Influence of ovarian torsion on reproductive outcomes and mode of delivery.

Purpose: To investigate differences in reproductive outcomes among patients before and following ovarian torsion. Study design: In this retrospective cohort study, we investigated the reproductive outcomes of patients who underwent surgery for ovarian torsion between 1988 and 2015 in a tertiary medical center. Data on deliveries before and after ovarian torsion were compared. Results: During the study period, 199 women underwent surgery due to ovarian torsion. The majority (91.4%; n = 182) underwent detorsion, and 8.6% (n = 17) underwent unilateral adnexectomy. At the time of the torsion, 27.6% (n = 55) of patients were pregnant. Among women who suffered from ovarian torsion, about half (52%) of the deliveries occurred before the torsion and 48% following the torsion. No significant difference in the live birth rate was noted (p = 0.19). The fertility treatment rate in our cohort was 7.5% before and 5% after the torsion (p = 0.01). In addition, live birth, cesarean delivery, and fertility treatment rates were similar in women who underwent detorsion vs. those who had adnexectomy. Conclusion: Surgically treated ovarian torsion does not appear to negatively influence fertility and live birth potential.

The impact of a previous cesarean section on the risk of perioperative and postoperative complications during vaginal hysterectomy.

OBJECTIVE: To investigate whether a previous cesarean section increases the risk of perioperative and postoperative complications during vaginal hysterectomy. METHODS: A retrospective cohort study of women who had undergone a vaginal hysterectomy for benign indications between 2014 and 2019 was conducted, comparing patients with or without a previous cesarean section. Perioperative and postoperative complications during vaginal hysterectomy were assessed according to the Clavien-Dindo classification system within 30 days of surgery. Duration of surgery, estimated blood loss, and postoperative hospitalization days were also recorded. A two-sided P value of less than 0.05 was considered significant. RESULTS: A total of 185 women were included, 25 (13.5%) patients had undergone a previous cesarean section (study group) and 160 (86.5%) had no history of cesarean section (comparison group). We found no significant differences in demographic and clinical characteristics as well as postoperative complications and interventions, duration of surgery, estimated blood loss, and postoperative hospitalization days (P > 0.05). However, patients who underwent two or more cesarean sections had a significantly (P = 0.01) higher rate and grade of complications during vaginal hysterectomy, compared with women with only one previous cesarean section. All women who underwent two or more cesarean sections had mild complications during vaginal hysterectomy (40% grade I and 60% grade II, P = 0.01). CONCLUSION: Vaginal hysterectomy is a safe procedure with few severe complications, regardless of a previous cesarean section. More than one previous cesarean section may increase the risk of minor complications during a vaginal hysterectomy. Patients who underwent a previous cesarean section could be reassured that they do not face an increased risk of complications during a vaginal hysterectomy.

Maternal and fetal outcomes among women with GDMA1 before and post-date.

OBJECTIVE: To investigate adverse pregnancy outcomes in patients complicated with GDMA1 who delivered at term before or after 40 weeks of gestation. STUDY DESIGN: A population-based cohort study including all women with GDMA1 during pregnancy was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. RESULTS: During the study period, 11,765 women with GDMA1 met the inclusion criteria. Of these, 1303 (11 %) delivered after 40 weeks (post-date, study group), while 10,462 (89 %) delivered at term before 40 weeks of gestation (before date, control group). Those who delivered after 40 weeks of gestation (the study group) had a significantly lower percent of cesarean deliveries (CD), higher rates of spontaneous vaginal deliveries and induction of labor in comparison to those who delivered before 40 weeks of gestation (the control group). The control group had significantly higher rates of preeclampsia and intrauterine growth restriction than the study group. Using a multivariable logistic regression model, delivery after 40 weeks was noted as an independent protective factor for CD (adjusted OR = 0.78, 95 %CI 0.66-0.92, p value = 0.001). Delivery after 41 + 0 weeks had a significantly higher rate of CD and LGA. CONCLUSION: No significant increase in adverse pregnancy outcomes at term post-date pregnancies complicated with GDMA1 was demonstrated. Furthermore, there was no increase in the rate of CD with the increase in gestational age until 41 weeks of gestation.

Is epidural analgesia an independent risk factor for OASIS? A population-based cohort study.

INTRODUCTION: To evaluate whether epidural analgesia is an independent risk factor for OASIS. METHODS: A population-based cohort study including all women who delivered by spontaneous vaginal delivery or by instrumental delivery beyond 24 weeks gestation was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. Women with multiple gestations and those lacking prenatal care were excluded from the analysis. RESULTS: During the study period, 252,542 women delivered at the Soroka University Medical Center and met the inclusion criteria. Of these, 583 (0.23%) were diagnosed with OASIS. Women with OASIS were more likely to be younger, nulliparous, with suspected fetal macrosomia, had higher rates of labor induction and vacuum extraction delivery, higher rates of conceiving after infertility treatments, more advanced gestational age at delivery, higher mean birth weight, higher rates of post-partum hemorrhage and need for blood transfusions. Use of epidural analgesia during pregnancy was significantly high among the OASIS group. Rates of episiotomy were not significantly different between the groups. Using a multimodal logistic regression model, after controlling for vacuum delivery, large for gestational age, nulliparity, gestational age, ethnicity, maternal age, induction of labor, fertility treatments, non-reassuring fetal heart rate and non-progressive second stage of labor, epidural analgesia was found to be significantly associated with OASIS. CONCLUSION: Epidural analgesia was found to be an independent risk factor for OASIS in our population.

The impact of cerclage placement on gestational length in women with premature cervical shortening.

OBJECTIVES: Cervical insufficiency (CI) is a condition consistent with painless cervical dilatation that can lead to preterm delivery. Cervical cerclage is a procedure in which cervical suture is performed for preventing preterm labor in several indications. Late emergency cerclage is technically more challenging compared to elective cerclage, performed earlier during pregnancy, prior to cervical changes. Pregnancy outcomes with emergency cerclage were found to be improved in previous reports, but there is still inconclusive data. To assess the effectiveness and safety of emergency cerclage vs. conservative management with progesterone and/or bed resting, in preventing preterm birth and improving neonatal outcomes in women with clinically evident cervical insufficiency. METHODS: This is a retrospective cohort study conducted on all women diagnosed with cervical insufficiency between the 16th and 24th gestational week who met the inclusion criteria, from January 2012 to December 2018. Obstetric and neonatal outcomes: time from diagnosis to delivery, duration of pregnancy, birth weight and Apgar score, were compared between women who underwent cerclage and those who treated conservatively. RESULTS: Twenty eight women underwent emergency cerclage (cerclage group) and 194 managed with a conservative therapy, progesterone and/or bed rest (control group). Time from diagnosis to delivery 13 weeks vs. 8 weeks and birth weight 2,418 g vs. 1914 g were significantly higher in the first cohort. Average pregnancy duration was three weeks longer in the cerclage group, but that was not significant. No complications occurred in the cerclage group and no difference in mode of delivery were found. CONCLUSIONS: Emergency cerclage is an effective and safe procedure in preventing preterm birth and prolongation of pregnancy, in women with cervical insufficiency in the late second trimester.

Increased Live Birth Rate with Dydrogesterone among Patients with Recurrent Pregnancy Loss Regardless of Other Treatments.

BACKGROUND: Recurrent pregnancy loss (RPL) is defined as the loss of two or more pregnancies. Several treatment options are available, including progesterone, which is one of the few treatments that improve live birth rates in RPL patients. OBJECTIVE: To compare the live birth rates, medical and obstetric characteristics, and RPL evaluation results of women with and without progesterone treatment. These women attended the RPL clinic at Soroka University Medical Center. METHODS: A retrospective cohort study based on 866 patients was conducted. The patients were divided into two groups and examined: the dydrogesterone treatment group consisting of 509 women and a group of 357 patients who did not receive the treatment. All the patients had a subsequent (index) pregnancy. RESULTS: The two groups were not statistically different in terms of their demographic and clinical characteristics or evaluation results. In a univariate analysis, no statistically significant differences were found between the groups in terms of live birth rates (80.6% vs. 84%; p-value = 0.209). In a multivariate logistic analysis adjusted for maternal age, the ratio of pregnancy losses to the number of pregnancies, other administered treatments, antiphospholipid syndrome, and body mass index, dydrogesterone treatment was found to be independently associated with a higher rate of live births than the control group (adjusted OR = 1.592; CI 95% 1.051-2.413; p-value = 0.028). CONCLUSIONS: Progesterone treatment is associated with an increased live birth rate in RPL patients. Studies with larger sample sizes are recommended to strengthen these results.

Positive pathological margins after loop electrosurgical excision procedure - Management and outcome.

OBJECTIVE: Pathological involvement of cervical conization margins is a risk factor for recurrence, although management of these patients is controversial. We aimed to define risk factors for positive margins and compare recurrence following additional surgical intervention compared to conservative management. METHODS: A retrospective study of all conizations at our center between 2010 and 2019. Univariate analysis identified characteristics associated with positive margins. Women were stratified by mode of management comparing three groups (surveillance, repeat conization or hysterectomy) then two groups (surveillance vs. additional surgery). Kaplan Meyer survival curves compared cumulative recurrence stratified by mode of management. Pathological results of subsequent surgical procedures were examined for residual disease. RESULTS: Of 448 conizations performed, 131 (29.2%) had positive margins which were associated with menopause, high-grade cytology and endocervical gland involvement. Women who underwent surveillance (n = 45) were more likely to be nulliparous, with low-grade histology and less endocervical gland involvement. Women who underwent hysterectomy (n = 61) were more likely to be postmenopausal and parous. Recurrence did not differ significantly in the three-group (p = 0.073) or two-group model (6.4% vs. 7.1% p = 0.869). Kaplan Meyer survival curves depicting cumulative recurrence did not differ significantly in either model (log rank test p = 0.642 for the three-group model, and p = 0.868 for the two-group model). Residual disease was found in 51.6% of hysterectomy specimens and 52.6% of repeat conizations. CONCLUSION: Surveillance is non-inferior to additional surgery in cases with positive conization margins and constitutes a valid option specifically for younger women at risk of future obstetric complications and those susceptible post-hysterectomy complications.

Factors associated with compliance to the recommendations for postpartum diabetes mellitus screening among women with gestational diabetes mellitus.

OBJECTIVE: Since women with GDM have an increased risk to develop type 2 DM, a 75 g OGTT is recommended 6-12 weeks postpartum for all women with GDM. However, screening rates remain low. The aim of this study was to find factors affect the rate of postpartum DM screening. MATERIALS AND METHODS: A retrospective cohort study between 2016 and 2017 at the Soroka Medical Center, comparing women with GDM who underwent postpartum DM screening test to those who did not. RESULTS: 257 women who had a diagnosis of GDM and met the inclusion criteria were included. 53 (20.6%) had a postpartum DM screening test and 204 (79.4%) did not complete the postpartum DM screening. Women who underwent a DM screening postpartum were more likely to be older, with significantly higher rates of vacuum-assisted delivery, more likely to be diagnosed with GDMA2 as compared to GDMA1 during pregnancy and, with high probability of receiving recommendations for screening at a postpartum visit. CONCLUSIONS: The rates of postpartum DM screening for women with GDM are low and need to increase. Age greater than 25, vacuum delivery, GDMA2, and having received a recommendation for postpartum screening increased the likelihood of undergoing a postpartum DM screening.

The Correlation Between the Sonographic Course of Transobturator Slings and Sling-Related Pain.

OBJECTIVES: To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain. METHODS: This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted. RESULTS: A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084). CONCLUSIONS: This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain.

Obstetric Outcomes after Perforation of Uterine Cavity.

We aimed to evaluate the pregnancy characteristics and obstetric outcomes in patients after perforation of the uterus. Study design: A retrospective cohort study was conducted and included all patients who were diagnosed with uterine perforation and treated in a tertiary referral medical center between the years 1996 and 2018. Up to two deliveries after perforations were investigated. Results: During the study period, 51 women were diagnosed with uterine perforation during gynecological procedures, including intrauterine device (IUD) insertion. The mean age of patients at the time of diagnosis was 27.9 (±4.7) years. The majority, 76.5% (n = 39), experienced perforation during IUD insertion, and 23.5% (n = 12) of the patients experienced perforation during surgical procedures. Most of the patients were multiparous or grand multiparous, 45.8. % (n = 22) and 39.6% (n = 19) respectively. Anteflexed uterus was found in 86.4% of the patients (n = 38). Five patients (9.8%) had pelvic abscesses after the IUD insertion. A total of 50 patients had 71 deliveries subsequent to uterine perforation. One patient experienced intrauterine fetal death due to fetal malformations. One patient experienced uterine rupture. No other major obstetric complications were noted. Conclusions: Uterine perforation may be associated with adverse obstetric outcomes. The possibility of uterine rupture must be considered while managing the deliveries of patients after uterine perforation. Moreover, a larger cohort and further studies are needed to establish an association between uterine perforation and adverse outcomes of the subsequent deliveries.

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.

Placental abruption: assessing trends in risk factors over time.

PURPOSE: To evaluate changes in the independent contribution of different risk factors for placental abruption over time. METHODS: In this retrospective nested case-control study, trends of change in ORs for known risk factors for placental abruption occurring in three consecutive 8-year intervals were compared. A univariate assessment of factors associated with placental abruption and two multivariable logistic regression models were constructed to identify independent risk factors for placental abruption. Trends of change in the incidence and specific contribution of various risk factors were compared along the study time-period. RESULTS: During the study period, 295,946 pregnancies met the inclusion criteria; of these, 2170 (0.73%) were complicated with placental abruption. Using logistic regression models, previous cesarean delivery, in vitro fertilization (IVF) pregnancy, hypertensive disorders, polyhydramnios, and inadequate prenatal care were recognized as independent risk factors for placental abruption. While the relative contribution of IVF pregnancy and polyhydramnios to the overall risk for abruption decreased over the course of the study, previous cesarean delivery became a stronger contributor for placental abruption. CONCLUSION: In our study, a change over time in the specific contribution of different risk factors for placental abruption has been demonstrated.

Does aging affect the elastic properties of the bladder and the urethra in nulliparous women: An ultrasound shear-wave elastography study.

OBJECTIVE: To investigate how aging and menopausal status in absence of pregnancy and childbirth affect the elasticity of the bladder and urethra. STUDY DESIGN: A single-center prospective observational study including nulliparous 10 pre- and 12 postmenopausal women. Data collection included baseline characteristics, physical examination data, questionnaire scores, PDFI and the Pelvic Floor Impact Questionnaire, and pelvic floor sonographic measurements as well as elastography measurements. The shear wave elastography (SWE) of tissue was measured using Kilopascal (kPa). The elastography measurements were taken over the rhabdosphincter, the suburethra smooth muscle, and the trigonal areas. RESULTS: A total of 22 nulliparous subjects were enrolled in the study. The cohort's mean age was 43.5 years, the mean body mass index (BMI) was 26.8, and 86% were of Caucasian ethnicity. The postmenopausal group was older and with higher BMI (p < 0.001 and p = 0.05). They also had higher scores in all the questionnaires (p < 0.05 for all) and did not demonstrate prolapse in any compartments. The SWE results for the whole group were 35.2 kPa in the rhabdosphincter measuring point, 40.2 kPa in the sub-urethra point, and 20.6 kPa in the trigone point. Comparing the premenopause and postmenopause groups, we found lower measurements in the rhabdosphincter area and equivocal measurements for the suburethral zone. No statistically significant differences were found between the groups CONCLUSIONS: The elastic properties of the different bladder components and the urethra change with age and menopause. Using elastic properties of the tissues, we can further explore both stress urinary incontinence and overactive bladder.

Validation of the hebrew version of the prolapse and incontinence knowledge questionnaire (PIKQ) during pregnancy.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery have a major effect on pelvic floor disorders. Assessing knowledge regarding pelvic floor disorders in childbearing age women and appropriate interventions will enable women to seek appropriate medical advice once pelvic floor disorders have developed. The purpose of this study was to validate the prolapse and incontinence knowledge questionnaire in the Hebrew language. METHODS: Translation of the prolapse and incontinence knowledge questionnaire to the Hebrew language according to international recommended guidelines. A study was conducted to validate the questionnaire. The study took place between June to September 2020 in a tertiary medical center in Israel. A total of 240 third trimester pregnant women completed the Hebrew version of the prolapse and incontinence knowledge questionnaire. Construct validity, criterion validity and reliability tests were performed. RESULTS: Factor analysis of the Hebrew version of the prolapse and incontinence knowledge questionnaire demonstrated 12 strong positive factor loadings to one principal factor in the prolapse and incontinence knowledge questionnaire-pelvic organ prolapse domain (FL > 0.3) and 10/12 in the prolapse and incontinence knowledge questionnaire-urinary incontinence domain. The Hebrew prolapse and incontinence knowledge questionnaire was found to have internal consistency, with Cronbach alpha coefficient of 0.745 for the urinary incontinence domain and 0.796 for the pelvic organ prolapse domain. CONCLUSIONS: The Hebrew version of the prolapse and incontinence knowledge questionnaire is a new, reliable, consistent, and valid instrument to examine the level of knowledge regarding pelvic floor disorders in Hebrew-speaking pregnant women.

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.

Antepartum vaginal Candida colonization and the risk for obstetrical tears.

OBJECTIVE: Vaginal Candida colonization is very common during pregnancy. An association between Candida colonization and obstetrical tears has not yet been investigated. We investigated whether vaginal Candida colonization during pregnancy is associated with an increased risk for obstetrical tears. STUDY DESIGN: A prospective cohort study was undertaken between the years 2014-2016, comparing pregnancy and delivery characteristics of women with and without Candida colonization during pregnancy. Clinical characteristics of Candida positive women and those with normal vaginal flora were collected. To test the statistical significance of the categorical variables, the chi-square test or Fisher's exact test were used, where appropriate. For continuous variables, the Student's t-test was used. RESULTS: During the study period, 102 women with vaginal Candida during pregnancy (of whom 70% had Candida albicans species) and 102 controls with normal vaginal flora were included in the analysis. No significant differences were observed between Candida positive women and those with normal vaginal flora. Pregnancy and delivery outcomes were comparable and no increased risk of obstetrical tears was found in the Candida group. CONCLUSIONS: Vaginal colonization with Candida species during pregnancy was not found to be associated with an increased risk of obstetrical tears.

A proposed prognostic prediction tool for a live birth among women with recurrent pregnancy loss.

PURPOSE: To develop a prognostic tool to predict the live birth rate in cases of repeated pregnancy losses. STUDY DESIGN: A retrospective cohort study including patients treated in the dedicated RPL clinic between 2000 and 2015. Background data was collected in the primary visit via questionnaires and medical records. The recurrent pregnancy loss workup includes a genetic testing, endocrine testing, and anatomic abnormalities as well as thrombophilia.The prognostic tool took into account the unique contribution of the different risk factors, including maternal age, number of pregnancy losses, primary vs. secondary RPL and positive RPL workup. RESULTS: A total of 675 women were included in the study. The live birth rate was 72% (484). It was significantly associated with age (p=.002), number of previous pregnancy losses (p=.016), primary and secondary RPL and positive RPL workup. Each variable was assigned points according to the odds ratio found in the logistic regression to create two prediction models, before and after the RPL workup. Both models show a rise in the live birth rate as the score increases. CONCLUSIONS: We constructed a proposed innovative prognostic tool to predict the chance of a live birth on the consecutive pregnancy following the visit to the RPL clinic. Locating, identifying and improving risk assessment can enable the provision of up-to-date information to couples and the treating staff. This knowledge will reduce stress among the patients and will allow the staff to constructed custom intervention programs.

Risk factors for antepartum death in term pregnancies.

OBJECTIVE: To identify risk factors for antepartum fetal death (APD) in term pregnancies while considering maternal, pregnancy and fetal characteristics. MATERIALS AND METHODS: Our study took place between the years 1988-2013. A total of 272,527 singleton births at term were recorded during this time period, including 524 cases of APD (0.2%). Cases of known chromosomal or other fetal abnormalities and cases with poor prenatal care were excluded. In order to identify independent risk factors contributing to antepartum fetal death in term we conducted a multivariate analysis using logistic regression. RESULTS: The main risk factors found to be significantly associated with APD in term were suspected intrauterine growth restriction (OR = 2.70, p < .001), diabetes (OR = 1.37, p = .05), hypertensive disorders (OR = 1.59, p = .01), advanced maternal age (OR = 1.03, p < .001) and grand-multiparity (OR = 1.79, p < .001). Advanced gestational age was not significantly associated with APD (38.95 vs. 39.44, p < .001). CONCLUSIONS: Most of the risk factors for antepartum fetal death in term pregnancies found in this study coincide with known risk factors for APD as described in previous studies. We believe that in the presence of these risk factors, closer surveillance and careful medical management of the pregnancy are required, in order to reduce the incidence of APD, including induction of labor at advanced gestational age.

The role of hydrodissection in native tissue repair of anterior vaginal wall defects.

AIMS: A variety of surgical techniques are available for vaginal prolapse repair, indicating a lack of consensus. A debate regarding the utility of hydrodissection for splitting the surgical plane of the vaginal wall exists. The aim of this study is to evaluate the impact of hydrodissection in anterior colporrhaphy (AC). MATERIALS: Patients undergoing primary AC were randomly assigned to an approach with (study group) versus without (control group) hydrodissection. Five surgeons performed both techniques, and the trimmed vaginal tissue was retrieved for histological analysis. Two pathologists, blinded to the surgical approach, evaluated the presence of a loose connective tissue at the surgical dissection plane (controversially deemed 'fascia', as explained in this article). In addition, we compared the operative time, pain score and haemoglobin levels. After statistical analysis, data were presented using percentile, and statistical significance was tested using the χ2 and Fisher's exact tests. RESULTS: Forty-six patients underwent primary elective AC, with 23 patients in each, the study and control groups. The groups were comparable regarding age (study group 60.33 ± 11.95 years and control group 59.86 ± 12.04, P = 0.90), menopausal status (study group 17 (73.9%) and control group 15 (68.2%), P = 0.67) and other characteristics. We found no difference in sample characteristics between the two groups. Connective tissue was found in only 13.6% (n = 3) of patients after hydrodissection and in 27.3% (n = 6) of patients without hydrodissection (P = 0.46). The hydrodissection group had significantly less bleeding than the control group (ΔHB 0.66 ± 0.66 vs 1.21 ± 0.84, P = 0.05). CONCLUSIONS: After hydrodissection, less bleeding was noted without compromise the surgical planes.

Exposure to metals and morbidity at eight years follow-up in women of childbearing age.

This exploratory study was aimed to investigate the link between toxic metal content in women's urine and their morbidity 2 years before and 6 years after the test. Concentrations of 25 metals in urine were analyzed for 111 pregnant women collected prior to delivery. All women were of Arab-Bedouin origin. Information on primary care and hospital visits during the study period was obtained. In a Poisson regression model, a health outcome was regressed over metal exposure and other factors. A Weighted Quantile Sum Regression (WQS) approach was used to indicate metals dominating in their possible impact on women's morbidity. Obesity was the most frequently diagnosed condition in this population (27.9%). Diagnoses in a neurological category accounted for 36.0%, asthma or respiratory-25.2%, psychiatric-12.6%, cardiovascular-14.4% and cancer or benign growth-for 13.5%. Based on WQS analysis, cancer and benign growth were mostly attributed to the increased levels of cadmium, cardiovascular outcomes were linked with lead, and obesity was found associated with elevated levels of nickel. Hematological, neurological and respiratory outcomes were attributed to multiple non-essential metals. The health and exposure profile of women in the study warrants a periodic biomonitoring in attempt to identify and reduce exposure to potentially dangerous elements.