Intermittent vs continuous catheterization for postpartum urinary retention: A multicenter randomized controlled trial.

BACKGROUND: Postpartum urinary retention is a common complication in the immediate postpartum period. However, there is no consensus regarding optimal management. OBJECTIVE: This study aimed to compare 2 catheterization strategies for the treatment of postpartum urinary retention. STUDY DESIGN: A multicenter prospective randomized controlled trial was conducted at 4 university-affiliated medical centers between January 2020 and June 2022. Individuals with postpartum urinary retention (bladder volume of >150 mL) up to 6 hours after vaginal or cesarean delivery were randomly allocated to 1 of 2 protocols: intermittent catheterization every 6 hours, up to 4 times, or continuous catheterization with an indwelling urinary catheter for 24 hours. If postpartum urinary retention was not resolved after 24 hours, an indwelling catheter was inserted for an additional 24 hours in both groups. The primary endpoint was the mean time to postpartum urinary retention resolution. The secondary endpoints included postcatheter urinary tract infection rate and length of hospital stay. The satisfaction rate was estimated using the 30-Item Birth Satisfaction Scale questionnaire. RESULTS: After randomization, 73 individuals were allocated to the intermittent catheterization group, and 74 individuals were allocated to the continuous catheterization group. The mean time to postpartum urinary retention resolution was significantly shorter in the intermittent catheterization group than in the continuous catheterization group (10.2±11.8 vs 26.5±9.0 hours; P<.001), with 75% and 93% resolution rates after 1 and 2 catheterizations, respectively. The number of individuals who achieved resolution at 24 hours was 72 (99%) in the intermittent catheterization group and 67 (91%) in the continuous catheterization group (P=.043). The satisfaction rate was higher in all categories in the intermittent catheterization group than in the continuous catheterization group (P<.001). No intercohort difference was found in the urinary tract infection rates (P=.89) or hospital stay length (P=.58). CONCLUSION: Compared with indwelling catheterization, intermittent catheterization for urinary retention after delivery was associated with quicker postpartum urinary retention resolution and a higher satisfaction rate without increasing the complication rates.

The impact of extending the second stage of labor on repeat cesarean section and maternal and neonatal outcome.

OBJECTIVE: To evaluate the effects of extending the second stage of labor in women attempting a trial of labor after a cesarean section (TOLAC). METHOD: A retrospective cohort study comparing maternal and neonatal outcomes following TOLAC over two periods: period I whose prolonged second stage was considered 2 h, and period II whose prolonged second stage was considered 3 h. The primary outcome was repeat cesarean delivery (CD) rate. RESULTS: Incidence of repeat CD was significantly lower in period II (18.1% vs 29.7%, P < 0.001). Incidence of uterine rupture was significantly higher in period II (P < 0.001). Instrumental delivery rates were significantly higher in period II (26.2% vs 15.6%, odds ratio [OR] 1.67, 95% CI 1.21-3.56, P < 0.001). Rates of third- and fourth-degree perineal lacerations, chorioamnionitis, and length of hospital stay were similar between groups. Incidence of fetal acidemia was significantly higher in period II (1.5% vs 0.7%, OR 2.14, 95% CI 1.32-5.63, P < 0.001), and incidence of neonatal intensive care unit (NICU) admission was significantly higher (2.5% vs 1.6%, P = 0.004). CONCLUSION: Extension of the second stage of labor is associated with a decrease in repeat CD rate with a concomitant increase in instrumental delivery rates, uterine rupture, fetal acidemia, and NICU admissions. These findings may warrant further consideration of allowing a prolonged second stage in patients attempting TOLAC.

COVID-19 Quarantine and Sexual Function after First Vaginal Delivery.

OBJECTIVES: Sexual function is an important part of quality of life at all ages. Childbirth brings many changes that may affect sexual function. During COVID-19 global pandemic, nuclear families were forced to stay home. The goal of this study was to evaluate sexual function during the COVID-19 quarantine, in postpartum couples in the first months following their first vaginal childbirth. DESIGN: This is a single-center, prospective study of females following their first vaginal delivery and their male partners. Participants were recruited in the maternity ward after their first delivery at Rambam Medical Center. Both spouses signed a consent form for answering the sexual function questionnaires. PARTICIPANTS: Participants were interviewed by telephone during the last week of the first COVID-19 quarantine, according to Arizona Sexual Experience Scale (ASEX). MAIN OUTCOME MEASURES: pre- and post-quarantine sexual function according to ASEX scores. ASEX is a survey that assesses sexual drive, arousal, vaginal lubrication, the ability to reach orgasm, and satisfaction from orgasm. Responses are scored on a 1-6 Likert scale with a potential range of 5-30, where the highest scores indicate worse sexual function. RESULTS: The participants were 38 women and 29 men. The average time from delivery to the interviews was 182.8 ± 84.7 days; 56% of the spouses were under quarantine. The median baseline total ASEX score was 13 (sexual drive 3, arousal 2.5, vaginal lubrication 2.5, ability to reach orgasm 2, orgasm satisfaction 2) for women and 11 (sexual drive 3, arousal 2, penile erection 1, ability to reach orgasm 2, orgasm satisfaction 2) for men. Sixteen percent of the women and none of the men had a baseline sexual dysfunction (ASEX score >19). Significant differences were not observed in total ASEX scores before and during the quarantine. LIMITATIONS: Sexual function at the end of the quarantine was evaluated prospectively and pre-quarantine sexual function was evaluated retrospectively, with the limitation of recall bias. CONCLUSIONS: COVID-19 quarantine did not seem to have a significant effect on female or male sexual function, three to 9 months after the first vaginal delivery. The current study is the first to describe primiparous postpartum sexual function as median ASEX score.

Continuous versus disrupted subcutaneous tissue closure in cesarean section: A retrospective cohort study.

OBJECTIVES: To compare rates of surgical-site infections following continuous, as compared with interrupted, subcutaneous tissue closure technique during cesarean delivery (CD). METHODS: A retrospective cohort study during 2008-2018. The study group included women who underwent either elective or emergent CD with continuous subcutaneous tissue closure, while the control group comprised those with interrupted subcutaneous tissue closure. We excluded women with suspected infectious morbidity before CD. The primary outcome was surgical-site infection (SSI) rate. RESULTS: The final analysis included 6281 women. We performed continuous subcutaneous tissue closure in 37.4% (1867/4988) of scheduled CD, and 45.8% (592/1293) of emergent CD. The rate of SSI was significantly lower following continuous than interrupted subcutaneous tissue closure, in both elective CD (2.7% versus 4.5%, respectively, P = 0.031) and emergent CD (3.2% versus 5.4%, respectively, P = 0.036) in nulliparous and multiparous women. Similarly, secondary outcomes such as re-admission rates, postoperative maternal fever, and need for antibiotic treatment were significantly lower following continuous subcutaneous closure. CONCLUSIONS: Continuous subcutaneous closure technique during CD yields a lower rate of surgical-site complications compared with the interrupted technique.

Postpartum cervical length as a predictor of subsequent preterm birth-novel insights on an old enigma.

BACKGROUND: Preterm birth poses one of the biggest challenge in modern obstetrics. Prediction of preterm birth has previously been based on patient history of preterm birth, short cervical length around midtrimester, and additional maternal risk factors. Little is known about cervical length and physiology during the postpartum period and any associations between postpartum cervical features and subsequent preterm birth. OBJECTIVE: This study aimed to determine the feasibility and utility of postpartum cervical length measurements in prediction of subsequent spontaneous preterm birth. STUDY DESIGN: This was a prospective cohort study in a single tertiary center, conducted during a 5-year period (2017-2021). We evaluated the mean postpartum cervical length in patients after both preterm birth and term deliveries at 4 time periods: 8, 24, and 48 hours, and 6 weeks postpartum, with follow-up in their subsequent pregnancies to evaluate gestational age at delivery. The mean postpartum cervical length in different populations stratified by gestational age at delivery was assessed in phase 1 of the study, and the gestational age at subsequent delivery was assessed in phase 2. RESULTS: A total of 1384 patients participated in phase 1. Mean postpartum cervical length was significantly shorter in the preterm birth (<34 weeks' gestation) group than in the term group at 8 hours (8.4±4.2 vs 22.3±3.5 mm; P<.0001), 24 hours (13.2±3.8 vs 33.2±3.1 mm; P<.0001), and 48 hours (17.9±4.4 vs 40.2±4.2 mm; P<.0001) postpartum. There was no significant difference in mean postpartum cervical length between the preterm birth group and the term group at 8, 24, and 48 hours postpartum. Cervical length was similar between the groups at 6 weeks postpartum. A total of 891 patients participated in phase 2. The area under the curve was higher for preterm birth screening based on a history of a short postpartum cervix alone than for a history of spontaneous preterm birth alone (0.66 [95% confidence interval, 0.63-0.69] vs 0.57 [95% confidence interval, 0.54-0.61]; P<.0001). Combining both a history of spontaneous preterm birth and a short postpartum cervix resulted in additional benefit, with an area under the curve of 0.74 (95% confidence interval, 0.73-0.84; P<.0001). CONCLUSION: Postpartum cervical length measurements may assist in detecting the group of patients at higher risk of subsequent spontaneous preterm birth. It may be beneficial to consider an increased follow-up regimen and earlier interventions in this group to reduce adverse perinatal outcomes.

Is 25 mm the correct mid-trimester cut-off for cervical shortening among asymptomatic women?

OBJECTIVES: To evaluate the impact of asymptomatic cervical shortening (ACS) at mid-trimester on maternal and neonatal outcomes. METHODS: This was a retrospective cohort study. Women with singleton gestations and an accidental finding of cervical length of 25 mm or less at mid-trimester were compared with women with symptomatic cervical shortening (SCS) and women with normal cervical length (NCL). Primary outcome was preterm birth (PTB) rate; secondary outcomes included total hospitalization length, betamethasone treatment rate, and a composite of PTB neonatal outcomes. RESULTS: In all, 1483 women were diagnosed with ACS. There was no difference in early and late PTB rate between the ACS and NCL groups (4.9% versus 3.8%, P = 0.25), though there was a significantly higher rate of antenatal corticosteroids use in the ACS group (78.2% versus 7.4%, P < 0.001). A CL of 15 mm or less was significantly associated with both early and late PTB, compared with the NCL group (47.2% versus 3.6%, P < 0.001, and 35.8% versus 3.8%, P < 0.001). CONCLUSIONS: An ACS of 15-25 mm is not associated with an increased risk of PTB. In contrast, women with a CL of 15 mm or less are more likely to delivery prematurely compared with women with a CL greater than 15 mm.

Which part of cervical length is predictive of preterm birth in women with cerclage?

OBJECTIVE: To evaluate the predictive value of transvaginal ultrasonography measures: total cervical length (TCL), length to internal OS (LIO) and external OS (LEO) from the cerclage following cerclage placement, for spontaneous preterm birth (PTB). METHODS: A retrospective cohort at a single tertiary care center (2010-2020). Women with McDonald cerclage were evaluated during the 2nd and 3rd trimesters for cervical measurements: TCL, LIO, LEO. The primary outcome was PTB < 37 weeks. Demographic data, obstetric history, delivery information and serial cervical length measurements were collected. Subgroup analyses were performed to evaluate cervical length parameters (as described) and PTB rates prior to 34, 32 and 28 weeks of gestation. RESULTS: Of 66 women enrolled, 36.4% (n = 24) had PTB. There were no differences in the obstetrical history and demographic information (p > .05) nor indication for cerclage (p = .369). Cervical length measurements at 20-24 weeks demonstrated a shorter TCL & LIO (22.69 vs. 33.86 mm, p = .001; 9.25 vs. 15.9 mm, p = .0042; respectively) in the preterm group. The LEO was similar in both groups. This pattern was also shown in a subgroup analysis (PTB < 34, 32 and 28 weeks). CONCLUSION: Cervical length from internal OS to cerclage and total cervical length have a predictive value for PTB in women with a cervical cerclage, regardless of the indication for cerclage/previous pregnancy outcomes. Our data emphasize the importance of follow-up cervical length measurements of women with a cervical cerclage, and especially cervical length from internal OS to cerclage as those women may need additional care.

Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial.

BACKGROUND: Vaginal looseness and decreased sensation during intercourse is prevalent in up to 30%-55% of premenopausal women. The efficacy and safety of CO2 laser have been demonstrated for these indications; however, the effect is temporary, up to 6-12 months. No studies regarding the efficacy and safety of adjuvant laser treatments have been conducted to date. AIM: To evaluate the efficacy and safety of a single maintenance CO2 laser treatment in women with vaginal looseness and a concurrent decline in sexual sensation during intercourse. METHODS: This prospective double-blinded randomized controlled trial included premenopausal women who experienced significant temporary improvement in symptoms following previous treatment with CO2 laser due to the abovementioned indications. Participants were randomized to either a single CO2 laser treatment or a single sham treatment. OUTCOMES: Treatment efficacy evaluated with the female sexual function index (FSFI) and the vaginal health index (VHI). RESULTS: Overall, 119 women were included in the study. Mean VHI and FSFI scores were significantly higher in the study group compared to the control group at three months post-treatment (17.34±1.39 vs 12.86±2.23, P = .023 and 30.93±1.79 vs 25.78±1.87, P = .044, respectively). In the study group, both VHI and FSFI returned to baseline at six months post-treatment. The median rate of sexual intercourse per month was increased in the study group at three months post-treatment (8 vs 4, P = .011), and returned to baseline at six months post-treatment. CLINICAL IMPLICATIONS: Maintenance laser treatment provides a temporary non-surgical alternative for women with vaginal looseness and associated sexual dysfunction, though treatment effect seems to be limited to less than 6 months, requiring additional maintenance sessions. STRENGTHS AND LIMITATIONS: The strengths of the current study include a randomized-sham controlled design. Furthermore, VHI was used as an objective evaluation tool, in addition to the FSFI, and assessment of the rate of sexual intercourse. The homogeneity and the relatively small sample size of the cohort is a limitation, and calls for caution in interpretation of the results, and the use of CO2 laser treatment in different age groups and populations. CONCLUSION: A single maintenance laser treatment in women who previously underwent successful treatment with laser is an effective, well-tolerated, and safe procedure for treating symptoms of vaginal looseness and sexual dysfunction, though effects are temporary. Lauterbach R, Aharoni S, Farago N, et al. Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial. J Sex Med 2022;19:1404-1411.

A randomized controlled trial of 2 techniques of salpingectomy during cesarean delivery.

BACKGROUND: Total salpingectomy during benign gynecologic surgery is recommended after completion of childbearing to reduce the risk of developing ovarian cancer. OBJECTIVE: This study aimed to assess operating time and complication rates of "traditional" salpingectomy using the "Knot and Cut" technique, compared with bipolar salpingectomy for sterilization at the time of cesarean delivery. STUDY DESIGN: This was a randomized controlled trial. Women undergoing planned cesarean delivery who desired sterilization were randomized to traditional salpingectomy or bipolar salpingectomy. The bipolar salpingectomy was performed using the LigaSure Precise. The primary outcome was the surgical time of the salpingectomy procedure. Secondary outcomes included total cesarean delivery time and associated bleeding parameters. We estimated that 42 patients would provide 80% power and a 2-sided alpha of 0.05 to identify a 10-minute difference in the primary outcome. RESULTS: A total of 26 women were randomized to bipolar salpingectomy and 25 to traditional salpingectomy. Baseline demographic characteristics were similar between the groups. Six procedures were converted from traditional to bipolar salpingectomy, and 2 traditional salpingectomies failed. The surgical time (16.16±9.53 vs 5.19±3.57 minutes; P<.001), estimated blood loss (928.08±414.66 mL vs 677.15±380.42 mL; P=.029), and need for blood transfusion (20% vs 0%; P=.016) were significantly greater in the traditional salpingectomy than in the bipolar salpingectomy group. The cesarean delivery time was similar (88.92±17.87 vs 88.23±19.85 minutes; P=.89). Hospitalization time was significantly longer following traditional salpingectomy than bipolar salpingectomy (5.24±2.27 vs 3.92±2.01 days; P=.034). CONCLUSION: "Traditional" salpingectomy is associated with longer surgical and hospitalization time, and greater blood loss and risk of blood transfusion compared with "bipolar" salpingectomy. In practices in which "bipolar" salpingectomy is available, it should be preferred over alternative methods of salpingectomy.

Vaginal fluid index - The fifth amniotic pocket.

OBJECTIVE: The forebag is a pocket of amniotic fluid preceding the fetal presenting part. Herein we describe the feasibility of transvaginal measurements of the forebag and assess its correlation with the standard amniotic fluid index (AFI). METHODS: A prospective study was carried out between January 2019 and July 2020. Eligible cases were women with singletons, vertex presentation, and normal AFI at term. We assessed the implementation and acceptance of a novel process in the clinical practice setting. Feasibility was assessed by using transvaginal ultrasound to measure the three orthogonal planes of the forebag. The vaginal fluid index (VFI) was defined as the volume composite of the three orthogonal planes. Correlations of the forebag measurements with both AFI and maximal vertical pocket were then calculated. RESULTS: In total, 292 out of 305 (95.7%) women were enrolled. All participants completed both transabdominal and transvaginal ultrasound, of which the vaginal pocket was demonstrated in 266 (91.1%) cases. We found significant correlations, in both nulliparas and multiparas, between the vaginal pocket measurements and the VFI to both the AFI and maximal vertical pocket measurements (R = 0.38, P < 0.001; R = 0.3, P < 0.001, respectively). CONCLUSION: We introduced a new ultrasound variable, the VFI, with a high feasibility rate. This may provide invaluable information for future decision making around the time of delivery.

Vaginal Dinoprostone Insert versus Cervical Ripening Balloon for Term Induction of Labor in Obese Nulliparas-A Randomized Controlled Trial.

Data regarding the preferred induction method in women with obesity is scarce. The current study was aimed at comparing pharmacological and mechanical induction in this population. This prospective randomized controlled trial was conducted between 2016−2020, in nulliparas with a pre-pregnancy body mass index >30. Inclusion criteria were singleton-term pregnancies, bishop score < 5, and indication for induction. Patients were randomized to induction by a cervical ripening balloon (CRB) or a 10 mg vaginal dinoprostone insert. The primary outcome was delivery rate within 24 h. Secondary outcomes included time to delivery, cesarean section rate, maternal and neonatal outcomes, satisfaction, and anxiety. The study population comprised of 83 women in the CRB group and 81 in the dinoprostone group. There was a significant difference in delivery rates within 24 h and time to delivery between the dinoprostone and CRB groups (45% vs. 71%, p = 0.017 and 49.3 ± 6.8 h vs. 23.5 ± 5.9 h, p = 0.003, respectively). There were no differences in cesarean delivery rates or maternal and neonatal outcomes, though CRB induction was associated with a significantly lower rate of tachysystole. Induction with CRB was accompanied by higher satisfaction and lower anxiety. In summary, CRB induction is associated with shorter time to delivery, higher satisfaction, and lower anxiety compared to PGE2 in women with obesity, without compromising maternal or neonatal outcomes.

An informative video before planned cesarean delivery and maternal anxiety-a multicenter randomized controlled trial.

BACKGROUND: Cesarean delivery is one of the most common procedures performed in obstetrics, and although cesarean delivery is a blissful occasion, it is commonly associated with fear and anxiety for the new mother. OBJECTIVE: We aimed to study the impact of watching a detailed, informative video on maternal anxiety levels, childbirth experience, and patient satisfaction in patients undergoing a primary cesarean delivery. STUDY DESIGN: We performed a multicenter randomized control trial. Women scheduled to undergo a primary nonemergent cesarean delivery were recruited. All participants in the intervention group watched an informative video on recruitment. This 4-minute video described in detail the expected cesarean delivery process: preparations before entering the operation room, regional anesthesia administration, sterile covering, the surgical procedure itself, and recovery (including mobilization and lactation). Situation-specific anxiety was measured at recruitment, before exposure to the video (S1), at the day of the operation (S2), and at postpartum day 1 (S3) using the State-Trait Anxiety Inventory score. In addition, participants answered a 10-item Childbirth Experience Questionnaire. A sample size of 63 per group was planned to achieve 80% power to detect a difference of 5 points in the primary outcome (State-Trait Anxiety Inventory score on the day of the operation). RESULTS: Overall, 154 participants from 4 medical centers were randomized, and 132 participants were analyzed after completing all questionnaires, 64 participants in the video group and 68 participants in the control group. The groups did not differ in demographics and delivery characteristics and had similar baseline anxiety levels (S1). On operation day (S2, the primary outcome), significantly lower anxiety levels were reported in the video group than in the control group (State-Trait Anxiety Inventory scores, 41.3±9.5 vs 49.3±10.3; P<.001). Moreover, anxiety levels in postpartum day 1 (S3) remained significantly lower in the video group (P<.001). No difference between the groups in childbirth experience score or patient satisfaction was demonstrated. CONCLUSION: A detailed informative video shown to patients before primary cesarean delivery decreased maternal anxiety levels before and after the procedure.

The efficacy and safety of a single maintenance laser treatment for stress urinary incontinence: a double-blinded randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: To evaluate the efficacy and safety of a single carbon dioxide (CO2) laser maintenance treatment in women previously treated successfully with laser for stress urinary incontinence (SUI), who have demonstrated a decline in treatment effect. METHODS: Women aged 40-70 years who experienced temporary significant improvement in symptoms following CO2 laser treatments for SUI were randomized to either the treatment group or the sham treatment control group. Cough test results, 1-h pad weights and scores on the Urogenital Distress Inventory (UDI6), the International Consultation of Incontinence Questionnaire (ICIQ-UI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were obtained at baseline and 3 and 6 months. RESULTS: Of 183 women screened, 131 were included in the final analysis. Demographic characteristics and baseline measures in the outcome tests were similar between the groups. Statistically significant improvements were demonstrated in the study compared to the control group at 3 months post-treatment in positive cough test (44.4% vs. 79.4%, P = 0.002), mean pad weight test (2.3 g ± 1.3 vs. 5.6 ± 1.1, P < 0.001), mean UDI-6(24.7 ± 12.1 vs. 45.1 ± 13.6 SD, P = 0.004), mean ICIQ-UI (16.5 ± 4.3 vs. 10.3 + 3.8, P = 0.003) and mean PISQ-12 (21.3 ± 6.8 vs. 36.6 ± 7.5, P = 0.003). However, values at 6 months post-treatment were similar to those at baseline. CONCLUSIONS: Our results suggest that a single maintenance laser treatment for reducing symptoms of SUI is transiently effective, well tolerated and safe. This treatment modality provides alternative non-surgical therapy for women with SUI.

Vaginal birth after cesarean in women with pre-labor rupture of membranes at term.

INTRODUCTION: Women with a successful vaginal birth after cesarean delivery (VBAC) have less morbidity than women undergoing repeat cesarean delivery. Although several scores and models predict VBAC success, none focus on pregnant women with pre-labor rupture of membranes (PROM). We evaluated different clinical variables that might predict the likelihood of VBAC success in women with PROM. STUDY DESIGN: A retrospective, 5-year study in a large referral center from December 2013 to December 2018. Inclusion criteria were women with singleton pregnancy, at or beyond 37 weeks' gestation, admitted with spontaneous PROM, with one previous cesarean delivery that consented trial of labor. Exclusion criteria were history of two cesarean deliveries, multiple gestations or obstetrical contraindications for TOLAC, including maternal request for repeat cesarean delivery. Variables associated with successful VBA C were identified using multivariate logistic regression. RESULTS: Of 302 women in the cohort, 74.8% (226/302) delivered vaginally (successful VBAC) and 25.2% (76/302) by repeat CD (failed TOLAC). Multiple logistic regression showed that duration of PROM-to-delivery time was the only significant factor associated with successful TOLAC (78% delivered vaginally within 24 h and 93.3% within 36 h), while none of the other variables (maternal age, gravidity, BMI, gestational and birthweight at delivery, effacement or station at admission, previous indication for cesarean delivery, time interval between previous and current delivery, presence of meconium-stained liquor, and documented temperature >38 °C) were associated with the prediction of successful VBAC. CONCLUSION: Women with spontaneous pre-labor PROM and previous cesarean delivery have high success rates of VBAC. The only significant variable associated with successful TOLAC in women with spontaneous PROM at term was the duration of PROM-to-delivery time. Our findings suggest that the success rate of VBAC is likely multifactorial, not-necessarily related to a specific underlying factor, and in the absence of contraindications, a fair trial of labor after cesarean delivery is justified.

Higher risk of hemorrhage and maternal morbidity in vaginal birth after second stage of labor C-section.

PURPOSE: This study evaluated the association between timing and indication for previous cesarean section (C-section) and its association with postpartum risks for adverse maternal outcomes, primarily postpartum hemorrhage (PPH) in vaginal birth after cesarean (VBAC). METHODS: This retrospective case-control study examined women following term vaginal delivery in a university-affiliated medical center between 2008 and 2018. Postpartum complications were compared between women who had their first VBAC and a control group comprised of women who had vaginal delivery without prior C-section. Additional analysis was performed to evaluate the association between the timing of previous C-section and the severity of postpartum adverse outcomes. RESULTS: Of the women meeting the inclusion criteria (n = 2879), 1,455 had VBAC and 1,424 were in the control group. Overall, significant postpartum complications, primarily PPH, were observed in the VBAC group compared to controls. Women who underwent C-section during second-stage of labor experienced higher PPH rates and increased drop in hemoglobin levels compared to women who underwent C-section during the first stage of labor or an elective C-Sect. (4.3 ± 0.9 g/dL vs. 2.8 ± 1.1 g/dL vs. 2.4 ± 0.8, p = 0.033). Concomitant increased need for blood transfusion (8.1% vs. 3.5% vs. 2.9%, respectively, p < 0.0001) and uterine atony (12.6% vs. 6.2% vs. 4.4%, respectively, p = 0.009) were also observed. No significant differences were demonstrated in other postpartum adverse effects evaluated. CONCLUSION: VBAC is associated with higher rates of postpartum complications, primarily PPH. The risk is significantly increased in VBAC following a second stage cesarean section. This data should be taken into consideration in the management of laboring women after C-section.

The impact of radiation therapy on vaginal biomechanical properties.

OBJECTIVE: In women with cervical cancer (CC), treatment with radiation causes changes in vaginal biomechanical properties, anatomy and function. The aims of the current study were to objectively assess effects of radiotherapy (RT) on vaginal elasticity, wall mobility and contraction strength; and to evaluate associations of these changes with sexual function. STUDY DESIGN: This prospective cohort study was approved by our Institutional Review Board. Between May 2018 and June 2020, women with CC who were candidates for RT were eligible to participate. Participants underwent vaginal tactile imaging (VTI) evaluation and were asked to fill the Female Sexual Function Index (FSFI) questionnaire at the time of first RT session and at a 6-month post-treatment follow up visit. Women who underwent radical hysterectomy, or had pelvic side-wall, pelvic or distant organ metastasis were not included. RESULTS: A total of 25 women with locally advanced CC were included in the final analysis. The mean age was 39 ± 2.7 years, the mean BMI was 24.8 ± 2.2 kg/m2 and the median parity was 2 (range: 1-5). Following RT, the mean scores for vaginal elasticity and vaginal tightening were significantly lower than at pre-treatment: 11.3 ± 2.5 vs. 28.3 ± 9, P < 0.0001 and 2.6 ± 0.7 vs. 16.7 ± 3, P < 0.0001, respectively. Following RT, significant decreases were demonstrated in vaginal wall mobility and pelvic muscle contraction strength: from 1.77 ± 0.34 to 0.36 ± 0.15, P < 0.0001 and from 2.55 ± 0.48 to 0.52 ± 0.23, P < 0.0001, respectively. Compared to pre-treatment, post-RT vaginal length was significantly shorter (3.30 ± 0.22 vs. 7.64 ± 0.63, P = 0.0023) and sexual intercourse frequency significantly lower: 1 (range 1-2) vs. 2 (range 1-4), P = 0.014). The mean total FSFI score was significantly lower following RT (6.7 ± 1 vs. 14.5 ± 2.7, P < 0.0001). CONCLUSIONS: Women with locally advanced CC who have been treated with RT exhibit persistent vaginal biomechanical changes that compromise sexual activity and result in considerable distress.

In Vitro Fertilization Entails a High Prevalence of Erectile and Male Sexual Dysfunction: A Prospective Case-Control Study.

PURPOSE: We evaluated the effect of in vitro fertilization (IVF) on sexual function in men, particularly for erectile dysfunction. MATERIALS AND METHODS: A prospective case-control study at a tertiary medical center. The study group comprised men of infertile couples that required IVF to conceive. The control group comprised men of couples who conceived spontaneously. The effects of IVF on sexual and erectile function were assessed based on the International Index of Erectile Function (IIEF-15) and the Self-Esteem and Relationship (SEAR) questionnaires. Participants were followed up to 1 year postpartum. RESULTS: Compared to the control group (378), for the IVF group (356), mean IIEF-15 scores were significantly lower: prior to pregnancy (31.7±4.5 vs 64.4±7.2, p <0.0001), at mid-pregnancy (37.3±5.1 vs 66.4±5.5, p <0.0001) and up to one year postpartum (42.3±4.9 vs 68.6±4.3, p <0.0001). Compared to the control group, in the IVF group, mean SEAR scores were significantly lower at these 3 respective time points (29.9±6.3 vs 66.5±8.3; 34.1±5.8 vs 66.9±7.2; and 40.9±6.7 vs 67.3±5.6; p <0.0001). At the 3 time points, for the IVF compared to the control group, the median monthly sexual intercourse rate was lower; and both the use of phosphodiesterase-5 inhibitor and psychologist/sexologist care were higher. CONCLUSIONS: The prevalence of erectile dysfunction among men participating in IVF in order to conceive is significantly higher compared to couples that conceived spontaneously, thus leading to an extremely high rate of phosphodiesterase-5 inhibitor use.

Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse.

OBJECTIVE: The objective of this study was to compare surgical and short-term postoperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) uterosacral ligament suspension (USLS) surgery. STUDY DESIGN: A retrospective cohort study was conducted on 135 patients who underwent hysterectomy with USLS via CV (n = 70) or via vNOTES (n = 65). Patients' baseline characteristics, surgical characteristics, and surgical outcomes were retrieved. The primary outcome was total operative time. Secondary outcomes include intra- and post-operative complications. RESULTS: Salpingectomy was performed in all vNOTES procedures and in only 27 % of conventional vaginal procedures (p < 0.005). Compared to the conventional vaginal procedures (n = 65), the vNOTES (n = 70) showed lower mean operative time and mean anesthesia time (101.4 ± 22.3 vs 125.5 ± 27.6 min and 141.4 ± 29.6 vs. 174.0 ± 32.9 min, respectively); and slightly longer median hospital stay (3 [range 2-4] vs. 2 [range 2-4] days, p < 0.05). Compared to women who underwent conventional vaginal hysterectomy with USLS, women who underwent vNOTES hysterectomy with USLS had lower incidences of intraoperative complications (6% vs. 18 %, p < 0.05) and intraoperative ureteral obstruction (0% vs. 8%, p < 0.05); and less estimated blood loss (58 ± 68 ml vs. 143 ± 87 ml, p < 0.05). CONCLUSION: vNOTES hysterectomy with USLS is associated with reduced incidence of intraoperative complications, shorter surgical and anesthesia time, and slightly longer hospital stay, compared to the traditional vaginal surgical approach. Post-operative complications during hospital stay were similar and infrequent following the two procedures.

Vaginal Fractional Carbon Dioxide Laser Treatment and Changes in Vaginal Biomechanical Parameters.

BACKGROUND AND OBJECTIVES: Vaginal fractional carbon dioxide (CO2 ) laser treatment has emerged in the past two decades as a non-surgical option for vaginal tightening. Mounting evidence supports the effectiveness and safety of this treatment for female sexual dysfunction. A newly developed vaginal tactile imaging (VTI) technique accurately evaluates the biomechanical parameters of the female pelvic floor and vagina, including tissue elasticity, pelvic support, and pelvic muscle function in high definition. In the current study, we evaluated changes in objective biomechanical parameters using VTI, following vaginal CO2 laser treatment for vaginal tightening and sexual dysfunction. STUDY DESIGN/MATERIALS AND METHODS: We conducted a prospective cohort between June 2018 and January 2020. Inclusion criteria were vaginal looseness, decreased local sensation during sexual intercourse, and sexual dysfunction. All the participants were treated with a vaginal carbon dioxide laser. They underwent a gynecological evaluation based on the Vaginal Health Index (VHI) and sexual function assessment according to the Female Sexual Function Index (FSFI). Vaginal biomechanical parameters were assessed by VTI. Initial evaluations were performed at the pre-treatment consult visit, 1 week prior to the first treatment and at a 6-month post-treatment follow-up visit. RESULTS: Twenty-five women were included in the final analysis. Compared with baseline, the post-treatment mean scores for vaginal elasticity and tightening were higher (54.8 ± 5.2 vs. 41.5 ± 6.3, P = 0.0027 and 1.97 ± 0.25 vs. 1.32 ± 0.31, P = 0.0014, respectively). Post-treatment increases were demonstrated in pelvic muscle contraction strength (25.9 ± 3.5 vs. 16.5 ± 4.2, P = 0.0011) and in reflex pelvic muscle contraction (2.93 ± 0.44 vs. 2.12 ± 0.47, P = 0.0022); the mean FSFI and VHI scores were higher following treatment (28.47 ± 1.73 vs. 21.12 ± 1.58, P = 0.036 and 19.15 ± 1.27 vs. 11.6 ± 0.97, P = 0.0032). CONCLUSIONS: The quantification of vaginal biomechanical parameters using VTI technology offers objective evidence of the beneficial effect of vaginal CO2 laser treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Association of Persistent Breech Presentation With External Cephalic Version Success.

OBJECTIVE: To evaluate a possible correlation between a new variable-persistent breech presentation-and the success rate of external cephalic version (ECV). METHODS: This was a retrospective study of ECVs performed from January 2008 through January 2019 in an Israeli tertiary care hospital. The study group included all pregnant women who underwent an ECV at or beyond 37 weeks of gestation. Persistent breech presentation was defined as persistent breech presentation during all ultrasound examinations performed between the anatomy scan at mid-pregnancy and the gestational week when ECV was attempted. Women in whom cephalic presentation was documented at least once on these ultrasound examinations were defined as not having persistent breech presentation. The primary outcome was defined as the success rate of ECV, and the secondary outcome was defined as the mode of delivery after a successful ECV. RESULTS: We identified 1,271 women with breech presentation during the study period. They had undergone median of five (range 2-7) ultrasound examinations. External cephalic version was attempted in 684 women (53.8%), with a success rate of 61.5%. External cephalic version succeeded in 19.6% of those with persistent breech presentation (44/224) compared with 82.0% (377/460) of those without persistent breech presentation (P<.001). Ultimately, women with persistent breech presentation and successful ECV experienced a lower rate of vaginal delivery (27.3% vs 79%, P<.001), and a higher rate of instrumental (29% vs 13%, P<.001) and cesarean deliveries (43% vs 7%, P<.001) compared with the nonpersistent breech presentation group. The rate of noninstrumental vaginal delivery among women with persistent breech presentation, regardless of ECV, was 5.4%. CONCLUSION: Women with persistent breech presentation experienced a high rate of ECV failure and a low rate of spontaneous vaginal delivery.