Seroprevalence and placental transfer of SARS-CoV-2 antibodies in unvaccinated pregnant women.

PURPOSE: Pregnant women are at risk of severe SARS-CoV-2 infection, potentially leading to obstetric and neonatal complications. Placental transfer of antibodies directed to SARS-CoV-2 may be protective against neonatal COVID-19, but this remains to be studied. We aimed to determine the seroprevalence of SARS-CoV-2 antibodies in a population of unvaccinated pregnant women and to determine the placental transfer of these antibodies. METHODOLOGY: A total of 1197 unvaccinated women with mostly unknown pre-study SARS-CoV-2 infection status, were tested at delivery for SARS-CoV-2 spike protein IgG antibodies during the first year of the pandemic. Umbilical cord samples were collected and assessed for seropositivity if the mother was seropositive. Maternal characteristics, pregnancy and neonatal outcomes and data on SARS-CoV-2 infection were extracted from medical records. RESULTS: Specific IgG were detected in 258 women (21.6%). A significant placental transfer to the newborn was observed in 81.3% of cases. The earlier in the 2nd and 3rd trimesters that the mother had contracted the disease and the more symptomatic she was, the greater the likelihood of transplacental transfer of IgG to her newborn. CONCLUSION: Approximately one in five women had detectable anti-SARS-CoV-2 spike protein IgG antibodies at delivery during the first year of the pandemic, and these antibodies were significantly transferred to their fetuses. This research provides further evidence to better understand the dynamics of the placental transfer of SARS-CoV-2 IgG antibodies from mothers to their newborns, which is necessary to improve vaccination strategies.

A simulation study to assess the potential benefits of MRI-based fetal weight estimation as a second-line test for suspected macrosomia.

OBJECTIVE: To simulate the outcomes of Boulvain's trial by using magnetic resonance imaging (MRI) for estimated fetal weight (EFW) as a second-line confirmatory imaging. STUDY DESIGN: Data derived from the Boulvain's trial and the study PREMACRO (PREdict MACROsomia) were used to simulate a 1000-patient trial. Boulvain's trial compared induction of labor (IOL) to expectant management in suspected macrosomia, whereas PREMACRO study compared the performance of ultrasound-EFW (US-EFW) and MRI-EFW in the prediction of birthweight. The primary outcome was the incidence of significant shoulder dystocia (SD). Cesarean delivery (CD), hyperbilirubinemia (HB), and IOL at < 39 weeks of gestation (WG) were selected as secondary outcomes. A subgroup analysis of the Boulvain's trial was performed to estimate the incidence of the primary and secondary outcomes in the true positive and false positive groups for the two study arms. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for the prediction of macrosomia by MRI-EFW at 36 WG were calculated, and a decision tree was constructed for each outcome. RESULTS: The PPV of US-EFW for the prediction of macrosomia in the PREMACRO trial was 56.3 %. MRI-EFW was superior to US-EFW as a predictive tool resulting in lower rates of induction for false-positive cases. Repeating Boulvain's trial using MRI-EFW as a second-line test would result in similar rates of SD (relative risk [RR]:0.36), CD (RR:0.84), and neonatal HB (RR:2.6), as in the original trial. Increasing the sensitivity and specificity of MRI-EFW resulted in a similar relative risk for SD as in Boulvain's trial, but with reduced rates of IOL < 39 WG, and improved the RR of CD in favor of IOL. We found an inverse relationship between IOL rate and incidence of SD for both US-EFW and MRI-EFW, although overall rates of IOL, CD, and neonatal HB would be lower with MRI-derived estimates of fetal weight. CONCLUSION: The superior accuracy of MRI-EFW over US-EFW for the diagnosis of macrosomia could result in lower rates of IOL without compromising the relative advantages of the intervention but fails to demonstrate a significant benefit to justify a replication of the original trial using MRI-EFW as a second-line test.

External beam radiotherapy boost versus surgical debulking followed by radiotherapy for the treatment of metastatic lymph nodes in cervical cancer: A systematic review and meta-analysis.

OBJECTIVE: We aimed to assess disease-free survival (DFS), overall survival (OS) and treatment-related toxicity of two therapeutic strategies for treating bulky lymph nodes on imaging in patients with locally advanced cervical cancer (LACC): radiotherapy boost versus surgical debulking followed by radiotherapy. METHODS: We performed a systematic review of studies published up to October 2023. We selected studies including patients with LACC treated by external beam radiotherapy (EBRT) boost or lymph node debulking followed by EBRT (with or without boost). RESULTS: We included two comparative (included in the meta-analysis) and nine non-comparative studies. The estimated 3-year recurrence rate was 28.2% (95%CI:18.3-38.0) in the EBRT group and 39.9% (95%CI:22.1-57.6) in the surgical debulking plus EBRT group. The estimated 3-year DFS was 71.8% and 60.1%, respectively (p = 0.19). The estimated 3-year death rate was 22.2% (95%CI:11.2-33.2) in the EBRT boost group and 31.9% (95%CI:23.3-40.5) in the surgical debulking plus EBRT group. The estimated 3-year OS was 77.8% and 68.1%, respectively (p = 0.04). No difference in lymph node recurrence between the two comparative studies (p = 0.36). The meta-analysis of the two comparative studies showed no DFS difference (p = 0.13) but better OS in the radiotherapy boost group (p = 0.006). The incidence of grade≥3 toxicities (ranging 0-50%) was not different between the two approaches in the two comparative studies (p = 0.31). CONCLUSION: No DFS and toxicity difference when comparing EBRT boost with surgical debulking of enlarged lymph nodes and EBRT in patients with cervical cancer was evident. Radiotherapy boost had better OS. Further investigation is required to better understand the prognostic role of surgical lymph node debulking in light of radiotherapy developments.

Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study.

BACKGROUND: Trial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section. METHODS: We collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions. RESULTS: Of the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman' rho = 0.50 and 0.42, p value < 0.001). CONCLUSIONS: Organizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

Antenatal, Intrapartum and Postpartum Interventions for Preventing Postpartum Urinary and Faecal Incontinence: An Umbrella Overview of Cochrane Systematic Reviews.

Post-partum, women can suffer from urinary and faecal incontinence. It is important to assess interventions to prevent this problem. Cochrane systematic reviews summarize the data available from systematic reviews of randomized trials assessing interventions. We conducted an umbrella overview of Cochrane systematic reviews encompassing antenatal, intrapartum and postpartum interventions for preventing postpartum urinary and faecal incontinence. We searched the Cochrane Database of Systematic Reviews on the 9 May 2023. Results: Our search identified nine Cochrane reviews providing results. Data for urinary and faecal incontinence were available from 77 (72%) trials and included 51,113 women. The reviews assessed antenatal digital perineal massage, pelvic floor muscle training, techniques for repairing anal sphincter tears, routine use of episiotomy, use of endoanal ultrasound prior to repairing perineal tears, caesarean versus vaginal delivery (overall, for breech and for twins), and vaginal delivery with forceps or vacuum. Only the use of a vacuum instead of forceps if an assisted vaginal delivery is needed, the use of an endo-anal ultrasound prior to repairing perineal tears and postpartum pelvic floor muscle training suggest a reduction in postpartum incontinence. Due to the small number of relevant reviews, a consequence of the relatively small number of primary studies, the effect of almost all the tested interventions was found to be imprecise.

Late miscarriage and stillbirth in asymptomatic and symptomatic hospitalised pregnant women in Belgium during the first and second waves of COVID-19: a prospective nationwide population-based study.

BACKGROUND: Stillbirth has been recognized as a possible complication of a SARS-CoV-2 infection during pregnancy, probably due to destructive placental lesions (SARS-CoV-2 placentitis). The aim of this work is to analyse stillbirth and late miscarriage cases in unvaccinated pregnant women infected with SARS-CoV-2 during the first two waves (wild-type period) in Belgium. METHODS: Stillbirths and late miscarriages in our prospective observational nationwide registry of SARS-CoV-2 infected pregnant women (n = 982) were classified by three authors using a modified WHO-UMC classification system for standardized case causality assessment. RESULTS: Our cohort included 982 hospitalised pregnant women infected with SARS-CoV-2, with 23 fetal demises (10 late miscarriages from 12 to 22 weeks of gestational age and 13 stillbirths). The stillbirth rate was 9.5‰ for singleton pregnancies and 83.3‰ for multiple pregnancies, which seems higher than for the background population (respectively 5.6‰ and 13.8‰). The agreement between assessors about the causal relationship with SARS-Cov-2 infection was fair (global weighted kappa value of 0.66). Among these demises, 17.4% (4/23) were "certainly" attributable to SARS-CoV-2 infection, 13.0% (3/23) "probably" and 30.4% (7/23) "possibly". Better agreement in the rating was noticed when pathological examination of the placenta and identification of the virus were available, underlining the importance of a thorough investigation in case of intra-uterine fetal demise. CONCLUSIONS: SARS-CoV-2 causality assessment of late miscarriage and stillbirth cases in our Belgian nationwide case series has shown that half of the fetal losses could be attributable to SARS-CoV-2. We must consider in future epidemic emergencies to rigorously investigate cases of intra-uterine fetal demise and to store placental tissue and other material for future analyses.

Mechanical methods for induction of labour.

BACKGROUND: Mechanical methods were the first methods developed to ripen the cervix and induce labour. During recent decades they have been substituted by pharmacological methods. Potential advantages of mechanical methods, compared with pharmacological methods may include reduction in side effects that could improve neonatal outcomes. This is an update of a review first published in 2001, last updated in 2012. OBJECTIVES: To determine the effectiveness and safety of mechanical methods for third trimester (> 24 weeks' gestation) induction of labour in comparison with prostaglandin E2 (PGE2) (vaginal and intracervical), low-dose misoprostol (oral and vaginal), amniotomy or oxytocin. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (9 January 2018). We updated the search in March 2019 and added the search results to the awaiting classification section of the review. SELECTION CRITERIA: Clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with pharmacological methods. Mechanical methods include: (1) the introduction of a catheter through the cervix into the extra-amniotic space with balloon insufflation; (2) introduction of laminaria tents, or their synthetic equivalent (Dilapan), into the cervical canal; (3) use of a catheter to inject fluid into the extra-amniotic space (EASI). This review includes the following comparisons: (1) specific mechanical methods (balloon catheter, laminaria tents or EASI) compared with prostaglandins (different types, different routes) or with oxytocin; (2) single balloon compared to a double balloon; (3) addition of prostaglandins or oxytocin to mechanical methods compared with prostaglandins or oxytocin alone. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors independently extracted data and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: This review includes a total of 112 trials, with 104 studies contributing data (22,055 women; 21 comparisons). Risk of bias of trials varied. Overall, the evidence was graded from very-low to moderate quality. All evidence was downgraded for lack of blinding and, for many comparisons, the effect estimates were too imprecise to make a valid judgement.   Balloon versus vaginal PGE2: there may be little or no difference in vaginal deliveries not achieved within 24 hours (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.26; 7 studies; 1685 women; low-quality evidence) and there probably is little or no difference in caesarean sections (RR 1.00, 95% CI 0.92 to 1.09; 28 studies; 6619 women; moderate-quality evidence) between induction of labour with a balloon catheter and vaginal PGE2. A balloon catheter probably reduces the risk of uterine hyperstimulation with fetal heart rate (FHR) changes (RR 0.35, 95% CI 0.18 to 0.67; 6 studies; 1966 women; moderate-quality evidence), serious neonatal morbidity or perinatal death (RR 0.48, 95% CI 0.25 to 0.93; 8 studies; 2757 women; moderate-quality evidence) and may slightly reduce the risk of aneonatal intensive care unit (NICU) admission (RR 0.82, 95% CI 0.65 to 1.04; 3647 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious maternal morbidity or death (RR 0.20, 95% CI 0.01 to 4.12; 4 studies; 1481 women) or five-minute Apgar score < 7 (RR 0.74, 95% CI 0.49 to 1.14; 4271 women; 14 studies) because the quality of the evidence was found to be very low and low, respectively. Balloon versus low-dose vaginal misoprostol: it is uncertain whether there is a difference in vaginal deliveries not achieved within 24 hours between induction of labour with a balloon catheter and vaginal misoprostol (RR 1.09, 95% CI 0.85 to 1.39; 340 women; 2 studies; low-quality evidence). A balloon catheter probably reduces the risk of uterine hyperstimulation with FHR changes (RR 0.39, 95% CI 0.18 to 0.85; 1322 women; 8 studies; moderate-quality evidence) but may increase the risk of a caesarean section (RR 1.28, 95% CI 1.02 to 1.60; 1756 women; 12 studies; low-quality evidence). It is uncertain whether there is a difference in serious neonatal morbidity or perinatal death (RR 0.58, 95% CI 0.12 to 2.66; 381 women; 3 studies), serious maternal morbidity or death (no events; 4 studies, 464 women), both very low-quality evidence, and five-minute Apgar score < 7 (RR 1.00, 95% CI 0.50 to 1.97; 941 women; 7 studies) and NICU admissions (RR 1.00, 95% CI 0.61 to 1.63; 1302 women; 9 studies) both low-quality evidence. Balloon versus low-dose oral misoprostol: a balloon catheter probably increases the risk of a vaginal delivery not achieved within 24 hours (RR 1.28, 95% CI 1.13 to 1.46; 782 women, 2 studies, and probably slightly increases the risk of a caesarean section (RR 1.17, 95% CI 1.04 to 1.32; 3178 women; 7 studies; both moderate-quality evidence) when compared to oral misoprostol. It is uncertain whether there is a difference in uterine hyperstimulation with FHR changes (RR 0.81, 95% CI 0.48 to 1.38; 2033 women; 2 studies), serious neonatal morbidity or perinatal death (RR 1.11, 95% CI 0.60 to 2.06; 2627 women; 3 studies), both low-quality evidence, serious maternal morbidity or death (RR 0.50, 95% CI 0.05 to 5.52; 2627 women; 3 studies), very low-quality evidence, five-minute Apgar scores < 7 (RR 0.71, 95% CI 0.38 to 1.32; 2693 women; 4 studies) and NICU admissions (RR 0.82, 95% CI 0.58 to 1.17; 2873 women; 5 studies) both low-quality evidence. AUTHORS' CONCLUSIONS: Low- to moderate-quality evidence shows mechanical induction with a balloon is probably as effective as induction of labour with vaginal PGE2. However, a balloon seems to have a more favourable safety profile. More research on this comparison does not seem warranted. Moderate-quality evidence shows a balloon catheter may be slightly less effective as oral misoprostol, but it remains unclear if there is a difference in safety outcomes for the neonate. When compared to low-dose vaginal misoprostol, low-quality evidence shows a balloon may be less effective, but probably has a better safety profile. Future research could be focused more on safety aspects for the neonate and maternal satisfaction.

Induction of labour at or near term for suspected fetal macrosomia.

BACKGROUND: Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section. OBJECTIVES: To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials of induction of labour for suspected fetal macrosomia. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias. Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I2 = 89%).  For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates. AUTHORS' CONCLUSIONS: Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The observation of increased use of phototherapy in the largest trial, should also be kept in mind. Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents. Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.

Impact of the first wave of the COVID-19 pandemic on birth rates in Europe: a time series analysis in 24 countries.

STUDY QUESTION: Did the first wave of the COVID-19 pandemic have an impact on monthly birth rates in Europe? SUMMARY ANSWER: Using datasets on live births per month in Europe, collected from the Human Fertility Database, we found a -14.1% decline in live births in January 2021 (i.e. 9-10 months after the epidemic peaks and first lockdowns), compared to the average number of live births in January 2018 and 2019. WHAT IS KNOWN ALREADY: Previous pandemics in the 20th and 21st centuries have been associated with a decline in birth rates 9 months after their peak, and a rebound in births over time. Lockdowns were necessary to control the first wave of the COVID-19 pandemic and may have had an impact on subsequent birth rates. STUDY DESIGN, SIZE, DURATION: Monthly time series data on live births from January 2018 to March 2021 were extracted to provide a time-series analysis of birthrates during and after the first wave of the COVID-19 pandemic in 24 European countries. PARTICIPANTS/MATERIALS, SETTING, METHODS: We conducted a random-effect generalized least squares regression to assess the seasonality of births from January 2018 to March 2021, and to identify potential differences in monthly live births after the first wave of the COVID-19 pandemic, considering the seasonality of births. To quantify these potential differences, we estimated the variation rate between the monthly live births observed during 2020 and 2021 and the mean of the 2018-2019 monthly live births in Europe. Factors potentially associated with a variation in monthly birth rates were assessed using univariable and multivariable generalized linear regressions. MAIN RESULTS AND THE ROLE OF CHANCE: When considering the seasonality of births, January 2021 was the only month with a significant difference in live births. A drop of -14.1% was observed compared to the average number of live births in January 2018 and 2019. At the national level, this drop was observed 9-10 months after the epidemic peaks in 13 countries. The duration of lockdowns was the variable that had the stronger association with this decrease, whereas higher incomes per capita could be a factor limiting this decline. A rebound in births compared to the previous years occurred in March 2021 in 13 countries. LIMITATIONS, REASONS FOR CAUTION: Our data are based on national data, limiting the power in the multivariable models used and the identification of other potential factors contributing to a decrease or an increase in birth rates. In addition, we collected only live births up to April 2021, which precludes the identification of a difference in births seasonality in 2021. WIDER IMPLICATIONS OF THE FINDINGS: As with previous pandemics, the COVID-19 outbreak was associated with a decline in births 9 months after its first wave. This trend may be associated with the duration of the lockdowns. Although there was a rebound in births in the following months, it does not seem to compensate for this decline. STUDY FUNDING/COMPETING INTEREST(S): The authors receive no external funding and have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

The distribution of pelvic organ support defects in women undergoing pelvic organ prolapse surgery and compartment specific risk factors.

INTRODUCTION AND HYPOTHESIS: The objective of our study was to describe the distribution of pelvic organ prolapse (POP) in a population of women undergoing POP reconstructive surgery and to identify compartment-specific risk factors. METHODS: We conducted a retrospective observational study in a cohort of 326 women who underwent POP repair and had a standardized preoperative POP assessment using the Baden-Walker classification. The distribution of POP grade was described for each vaginal compartment. The association between the involvement of each specific compartment and predictors was evaluated with a logistic regression model. RESULTS: The frequency of significant POP (grade ≥ 2) was 79% in the anterior compartment, 49% in the middle/apical compartment and 31% in the posterior compartment. Combined significant anterior and apical defects were present in 25% of women. Increasing age was a significant risk factor for apical defect (between 60 and 70 years OR = 2.4, 95% CI 1.2-4.6; > 70 years OR = 3.4, 95% CI 1.7-6.6). Previous hysterectomy (OR = 2.2, 95% CI 1.0-4.6) was a significant risk factor for posterior defect. CONCLUSIONS: In a population undergoing POP surgery, anterior compartment involvement is the most common and serious defect and can often be associated with an apical defect, especially in older women. In case of previous hysterectomy, the posterior compartment may be weakened. These findings may help surgeons to select the appropriate POP reconstructive surgery, which often should address both anterior and apical defects.

Outcomes of robotically assisted laparoscopic lateral suspension (RALLS) with mesh for anterior and apical prolapse.

Abdominal sacral colpopexy/hysteropexy is the gold standard for the treatment of vaginal apex support. However, dissection of the promontory may expose to potentially life-threatening complications. To avoid this risk, laparoscopic lateral suspension with mesh is an alternative. Robotic assistance may be helpful in both techniques. The objective of our study was to evaluate outcomes of robotically assisted laparoscopic lateral suspension (RALLS) with mesh for anterior and apical pelvic organ prolapse (POP). From March 2012 to January 2018, 59 consecutive patients underwent RALLS using titanized polypropylene mesh. Between August 2017 and September 2019, all patients were contacted to assess outcome. We performed a clinical exam and asked them to complete the patient global impression of improvement (PGI-I) questionnaire. Fifty-four patients (91.5%) were available for follow-up. Mean age was 58.5 years (28.8-79.8). There were no perioperative complications. The mean follow-up was 33.6 months (11.2-74.1).The objective cure rate (no prolapse beyond hymen) and the subjective cure rate (PGI-I ≤ 2) were 83.3% and 77.2%, respectively. Five women (9.3%) were reoperated for POP recurrence. There was no erosion. Of the 20 women complaining of stress urinary incontinence (SUI) preoperatively, 12 (60%) were cured without any additional SUI procedure. Only two women (10%) required TVT for persistent grade 2 SUI. Two women (5.9%) developed de novo SUI, but none of them required an operation. RALLS repair for POP with mesh is safe and effective and may represent an alternative to sacral colpopexy/hysteropexy.

Fast-Track in Minimally Invasive Gynecology: A Randomized Trial Comparing Costs and Clinical Outcomes.

Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery. Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction. Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)]. Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04839263.

Physical activity and urinary incontinence during pregnancy and postpartum: A systematic review and meta-analysis.

To assess the association of physical activity and urinary incontinence, or its recovery, during pregnancy and postpartum. A search of publications indexed in five major electronic databases (CENTRAL, PubMed, EMBASE, CINAHL and PEDro) was performed from their respective inception dates to the 30 March 2020 with a combination of keywords to identify studies of interest. Google Scholar was used for non-indexed literature. All studies comparing physical activity with standard care in pregnant and postpartum women were selected. Two reviewers independently selected studies, assessed quality and extracted data. Odds ratios with 95% confidence intervals were calculated using fixed effects or random effects models, for low and moderate heterogeneity between studies, respectively. Seven studies (n = 12479) were included. Data of four studies could be pooled for meta-analyses; subgroup and sensitivity analyses were not possible. Physical activity, either during pregnancy or postpartum, is not associated with urinary incontinence, OR 0.90 (95% CI: 0.69-1.18) and OR 1.31 (95% CI: 0.74-2.34), respectively. Due to a lack of available data, urinary incontinence recovering could not be assessed. The available low evidence does not show that physical activity during pregnancy or postpartum is associated with urinary incontinence. Moderate physical activity should therefore be encouraged for the evidence-based benefits on other obstetrical outcomes.

Operative Complications and Outcomes Comparing Small and Large Uterine Weight in Case of Laparoscopic Hysterectomy for a Benign Indication.

Study Objective: This study was performed to evaluate the association between uterine weight and operative outcomes in women undergoing laparoscopic hysterectomy for a benign indication. Methods: This is a secondary analysis of a randomized trial with data collected prospectively and retrospectively. The data of 159 women undergoing laparoscopic hysterectomy for a benign indication were analyzed. Women were divided in two groups according to the postoperative uterine weight: small uterus group (<250 grams) and large uterus group (≥250 grams). Operative complications were compared between the two groups. Operative outcomes (need for uterine morcellation, operative duration, estimated blood loss), postoperative pain, and hospital length of stay were also analyzed. Main Results: Operative complications were not significantly different between the two groups (37% in the large uterus group versus 41% in the small uterus group). Operative outcomes showed a significantly increased use of uterine morcellation in the large uterus group (61% in the large uterus group versus 10% in the small uterus group). The operative duration was 150 min in the small uterus group and 176 min in the large uterus group, which corresponds to an increase of 17% in the large uterus group. The mean pain score on the day of surgery was identical in both groups (VAS pain score 5), but significantly in favor of the large uterus group on day 1 postoperatively (VAS pain score 4 in the small uterus group and 3 in the large uterus group). There was no statistical difference between groups in the mean hospital stay (62 ± 37 hours in the small uterus group versus 54 ± 21 hours in the large uterus group). In terms of surgical indication, the small uterus group comprised more patients with endometriosis/adenomyosis (36%) and the large uterus group more patients with leiomyoma (93%). Conclusion: The results from this study show that, even if a large uterine weight is associated with increased uterine morcellation requirement and operative duration, a laparoscopic approach is safe and does not increase operative complications nor pain and/or length of hospital stay in women undergoing hysterectomy for a benign indication.

A cross-sectional study on pelvic floor symptoms in women living with Female Genital Mutilation/Cutting.

BACKGROUND: Female Genital Mutilation/Cutting (FGM/C) concerns over 200 million women and girls worldwide and is associated with obstetric trauma and long-term urogynaecological and psychosexual complications that are often under-investigated and undertreated. The aim of this study was to assess the pelvic floor distress and the impact of pelvic floor and psychosexual symptoms among migrant women with different types of FGM/C. METHODS: This cross-sectional study was conducted between April 2016 and January 2019 at the Division of Gynaecology of the Geneva University Hospitals. The participants were interviewed on socio-demographic and background information, underwent a systematic gynaecological examination to assess the presence and type of FGM/C and eventual Pelvic Organ Prolapse (POP), and completed six validated questionnaires on pelvic floor and psychosexual symptoms (PFDI-20 and PFIQ7 on pelvic floor distress and impact, FISI and WCS on faecal incontinence and constipation, PISQ-IR and FGSIS on sexual function and genital self-image). The participants' scores were compared with scores of uncut women available from the literature. The association between selected variables and higher scores for distress and impact of pelvic floor symptoms was assessed using univariate and multivariable linear regression models. RESULTS: 124 women with a mean age of 31.5 (± 7.5), mostly with a normal BMI, and with no significant POP were included. PFDI-20 and PFIQ-7 mean (± SD) scores were of 49.5 (± 52.0) and 40.7 (± 53.6) respectively. In comparison with the available literature, the participants' scores were lower than those of uncut women with pelvic floor dysfunction but higher than those of uncut women without such disorders. Past violent events other than FGM/C and forced or arranged marriage, age at FGM/C of more than 10, a period of staying in Switzerland of less than 6 months, and nulliparity were significantly associated with higher scores for distress and impact of pelvic floor symptoms, independently of known risk factors such as age, weight, ongoing pregnancy and history of episiotomy. CONCLUSIONS: Women with various types of FGM/C, without POP, can suffer from pelvic floor symptoms responsible for distress and impact on their daily life. TRIAL REGISTRATION: The study protocol was approved by the Swiss Ethics Committee on research involving humans (protocol n°15-224).

Author Correction: Insulin-producing organoids engineered from islet and amniotic epithelial cells to treat diabetes.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Squatting position in the second stage of labor: A systematic review and meta-analysis.

OBJECTIVES: The influence of squatting during delivery on maternal and fetal outcomes remains unclear. We performed a systematic review and meta-analysis to evaluate the benefits and risks of adopting a squatting position during the second stage of labor. STUDY DESIGN: Search Strategy: A systematic search in the three major electronic databases (CENTRAL, PubMed and Embase) was performed, from their respective inception dates to the 14th of December 2019, using 'squatting', and a combination of keywords to identify delivery. Eligibility criteria: Randomized controlled trials comparing squatting position to any supine position during the second stage of labor. STATISTICAL ANALYSES: Risk ratio for dichotomous outcomes, mean difference for continuous outcomes, with 95 % confidence intervals. Fixed-effects meta-analysis (Mantel-Haenszel method) or random-effects model (inverse variance method), for low and high heterogeneity between trials, respectively. PROSPERO Registration number: CRD42018093244 RESULTS: Seven randomized controlled trials (n = 1219) were included. Three studies were assessed as low risk of bias, three others as moderate and one study as high risk of bias. The main limitation is the lack of reporting on the methods to achieve randomization and concealment of allocation in most of the studies. There was no difference in the duration of the second stage of labor (mean -11.09 min; 95 %CI -38.85 to 16.68). In the squatting group, the risk of caesarean section was increased (RR 2.26, 95 %CI 1.07-4.80) and the risk of instrumental delivery was decreased (RR 0.60, 95 %CI 0.45-0.81), which results in a similar probability of spontaneous delivery. There were no differences regarding the other maternal and fetal outcomes. CONCLUSIONS: The available evidence does not show the squatting position during childbirth to be beneficial. As there is no evidence for or against squatting, women should be able to choose the position they prefer.

Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data.

BACKGROUND: Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia. METHODS: The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV). RESULTS: In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234). Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4-4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM. CONCLUSION: The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

Augmentation of labour.

Augmentation of labour aims at improving the efficiency of uterine contractions in order to reduce maternal and foetal adverse outcomes associated with prolonged labour. This review covers the current best practice for different methods of augmentation of labour, namely, artificial rupture of membranes and oxytocin infusion as a prevention of, or therapy for, prolonged labour. The review highlights essential practice points and identifies knowledge gaps for future research in this important area of clinical obstetric practice.

Outcomes of drug exposition during pregnancy: Analysis from a teratology information service.

OBJECTIVE: We aimed to characterize drug exposures during pregnancy where the outcome was known that had benefited from counselling through our Teratology Information Service (TIS) between 1994-2016. STUDY DESIGN: This observational study analysed data collected through the drug exposures during pregnancy counselling. Data was analysed descriptively. RESULTS: Data from a total of 1'374 pregnant women were collected. Mean age was of 32 years. These women were exposed to more than ten drugs in 1.4 % (N = 19) of cases, with a mean drug intake of two. Analysis of the drugs altogether (N = 3'129) showed that FDA Pregnancy Category C drugs represented 42.9 % (N = 1'342) of drugs and ATC code N (nervous system) represented 36.4 % (N = 1'138). The onset of drug exposure was during the first trimester of pregnancy in 95.1 % (N = 2'982) of patients. Regarding outcomes, the rate of induced abortion was 10.8 % (N = 151), of pregnancy complications was 11.2 % (N = 157) and of malformations was 4.5 % (N = 49). CONCLUSION: Pregnant women counselled by our TIS take a mean of two drugs, ranging from one to 17. Drugs are from FDA Pregnancy Category C and ATC N drugs in most cases, 42.9 % and 36.4 % respectively. The rate of malformation of our cohort was of 4.5 %, close to the estimated spontaneous rate of malformation. This data gives a reassuring aspect of drug exposure in pregnancy but takes into account the outcome at birth only.