Perioperative opioid dispensing and persistent use after benign hysterectomy: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis was conducted to (1) assess the quantity and dose of perioperatively dispensed opioids for benign hysterectomy by procedure route and (2) identify the predictors of persistent opioid use after the procedure. DATA SOURCES: PubMed, Web of Science, and Embase were systematically searched from study inception to 25 March 2022. STUDY ELIGIBILITY CRITERIA: Studies reporting data on opioid dispensing among patients undergoing benign hysterectomy were considered eligible. The primary outcome was the dosage of opioids dispensed perioperatively (from 30 preoperative days to 21 postoperative days). The secondary outcome was the predictors of persistent opioid use after benign hysterectomy (from 3 months to 3 years postoperatively). Total opioid dispensing was measured in morphine milligram equivalents units. METHODS: The random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. RESULTS: A total of 8 studies presenting data on 377,569 women undergoing benign hysterectomy were included. Of these women, 83% (95% confidence interval, 81-84) were dispensed opioids during the perioperative period. The average amount of perioperatively dispensed opioids was 143.5 morphine milligram equivalents (95% confidence interval, 40-247). Women undergoing vaginal hysterectomy were dispensed a significantly lower amount of opioids than those undergoing laparoscopic or abdominal hysterectomies. The overall rate of persistent opioid use after benign hysterectomy was 5% (95% confidence interval, 2-8). Younger patient age (odds ratio, 1.38; 95% confidence interval, 1.17-1.63), smoking history (odds ratio, 1.87; 95% confidence interval, 1.67-2.10), alcohol use (odds ratio, 3.16; 95% confidence interval, 2.34-4.27), back pain (odds ratio, 1.50; 95% confidence interval, 1.10-2.05), and fibromyalgia (odds ratio, 1.60; 95% confidence interval, 1.39-1.83) were significantly associated with a higher risk of persistent opioid use after benign hysterectomy. However, there was no significant effect of hysterectomy route and operative complexity on persistent opioid use postoperatively. CONCLUSION: Perioperative opioid dispensing was significantly dependent on the route of hysterectomy, with the lowest dispensed morphine milligram equivalents of opioids for vaginal hysterectomy and the highest for abdominal hysterectomy. Nevertheless, hysterectomy route did not significantly predict persistent opioid use postoperatively, whereas younger age, smoking, alcohol use, back pain, and fibromyalgia were significantly associated with persistent opioid use.

Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects.

BACKGROUND: In utero repair of open neural tube defects using an open hysterotomy approach (hereafter referred to as "open") has been shown to reduce the need for ventriculoperitoneal shunting and to improve motor outcomes for affected infants. Laparotomy-assisted fetoscopic repair (hereafter referred to as "hybrid") is an alternative approach that may confer similar neurologic benefits while reducing the incidence of hysterotomy-related complications. OBJECTIVE: This study aimed to analyze procedure-related maternal and fetal complications of in utero repair using the Clavien-Dindo classification, and to compare the outcomes of the hybrid and open approaches. STUDY DESIGN: This was a retrospective cohort study conducted in a single center between September 2011 and July 2021. All patients who met the Management of Myelomeningocele Study criteria and who underwent either hybrid or open fetal surgery were included. Maternal complications were classified using a unique adaptation of the Clavien-Dindo scoring system, allowing the development of a comprehensive complication index score specific to fetal surgery. Primary fetal outcome was defined as gestational age at delivery and summarized according to the World Health Organization definitions of preterm delivery. RESULTS: There were 146 fetuses with open neural tube defects who were eligible for, and underwent, in utero repair during the study period. Of these, 102 underwent hybrid fetoscopic repair and 44 underwent open hysterotomy repair. Gestational age at the time of surgery was higher in the hybrid group than in the open group (25.1 vs 24.8 weeks; P=.004). Maternal body mass index was lower in the hybrid than in the open group (25.4 vs 27.1 kg/m2; P=.02). The duration of hybrid fetoscopic surgery was significantly longer in the hybrid than in the open group (250 vs 164 minutes; P<.001). There was a significantly lower Clavien-Dindo Grade III complication rate (4.9% vs 43.2%; P<.001) and a significantly lower overall comprehensive maternal complication index (8.7 vs 22.6; P=.021) in the hybrid group than in the open group. Gestational age at delivery was significantly higher in the hybrid group than in the open group (38.1 vs 35.8 weeks; P<.001), and this finding persisted when gestational age at delivery was analyzed using the World Health Organization definitions of preterm delivery. CONCLUSION: Use of our adaptation of the standardized Clavien-Dindo classification to assess the maternal complications associated with in utero open neural tube defect repair provides a new method for objectively assessing different fetal surgical approaches. It also provides a much-needed standardized tool to allow objective comparisons between methods, which can be used when counseling patients. The hybrid open neural tube defect repair was associated with lower rates of maternal adverse events , and later gestational age at delivery compared with the open approach.

Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis.

OBJECTIVE: Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES: PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA: We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS: The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS: We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION: Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.

Obstetrical outcomes following amniocentesis performed after 24 weeks of gestation: A systematic review and meta-analysis.

To evaluate obstetrical outcomes for women having late amniocentesis (on or after 24 weeks). Electronic databases were searched from inception to January 1st, 2023. The obstetrical outcomes evaluated were gestational age at delivery, preterm birth (PTB) < 37 weeks, PTB within 1 week from amniocentesis, premature prelabor rupture of membranes (pPROM), chorionamnionitis, placental abruption, intrauterine fetal demise (IUFD) and termination of pregnancy (TOP). The incidence of PTB <37 weeks was 4.85% (95% CI 3.48-6.56), while the incidence of PTB within 1 week was 1.42% (95% CI 0.66-2.45). The rate of pPROM was 2.85% (95% CI 1.21-3.32). The incidence of placental abruption was 0.91% (95% CI 0.16-2.25), while the rate of IUFD was 3.66% (95% CI 0.00-14.04). The rate of women who underwent TOP was 6.37% (95%CI 1.05-15.72). When comparing amniocentesis performed before or after 32 weeks, the incidence of PTB within 1 week was 1.48% (95% CI 0.42-3.19) and 2.38% (95% CI 0.40-5.95). Amniocentesis performed late after 24 weeks of gestation is an acceptable option for patients needing prenatal diagnosis in later gestation.

Fetoscopic laser photocoagulation versus expectant management for stage I twin-to-twin transfusion syndrome: A systematic review and meta-analysis.

To investigate the outcomes of asymptomatic stage I twin-to-twin transfusion syndrome (stage I TTTS) among patients treated with fetoscopic laser photocoagulation (FLP) versus expectant management. Databases such as PubMed, Web of Science and Scopus were systematically searched from inception up to March 1st, 2022. The primary outcome was at least one fetal survival at birth and secondary outcomes included gestational age at delivery, preterm premature rupture of membranes < 32 weeks, preterm birth < 32 weeks, and single and dual fetal survival. Five studies were included in the meta-analysis. There was no significant difference in terms of at least one survival (odds ratio (OR) = 1.40, 95%CI= (0.26, 7.43), P = 0.70), single survival (OR = 0.87, 95%CI= (0.51, 1.48), P = 0.60) and dual survival (OR = 1.63, 95%CI= (0.74, 3.62), P = 0.23) among FLP and expectant groups. Gestational age at delivery (mean difference = 1.19, 95%CI= (-0.25, 2.63), P = 0.10), the risk of PTB<32 weeks (OR = 0.88, 95%CI= (0.50, 1.54), P = 0.65), and pPROM<32 weeks (OR = 1.80, 95% CI= (0.41, 7.98), P = 0.44) were also comparable between the groups. Routine FLP of the placental anastomoses before 26 weeks of gestation is unlikely to be beneficial among asymptomatic stable stage I TTTS patients without cervical shortening as the procedure does not offer a survival advantage compared with expectant management.

Solomon versus selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: A systematic review and meta-analysis.

This meta-analysis aims to compare the perinatal outcome of twin-twin transfusion syndrome (TTTS) pregnancies undergoing selective versus vascular equator (Solomon) fetoscopic laser photocoagulation (FLP). We performed a systematic search in PubMed and Web of Science from inception up to 25 July 2021. Studies comparing the Solomon and selective techniques of FLP for treatment of TTTS pregnancies were eligible. Random-effects or fixed-effect models were used to pool standardized mean differences (SMD) and log odds ratio. Seven studies with a total of 1664 TTTS pregnancies (n = 671 undergoing Solomon and n = 993 selective techniques) were included. As compared to the selective FLP, Solomon was associated with a lower risk of recurrent TTTS compared to the selective technique (Log odds ratio [OR]: -1.167; 95% credible interval [CrI]: -2.01, -0.33; p = 0.021; I2 : 67%). In addition, Solomon was significantly associated with a higher risk of placental abruption than the selective technique (Log [OR]: 1.44; 95% CrI: 0.45, 2.47; p = 0.012; I2 : 0.0%). Furthermore, a trend for the higher risk of preterm premature rupture of membranes was observed among those undergoing Solomon (Log [OR]: 0.581; 95% CrI: -0.43, 1.49; p = 0.131; I2 : 17%). As compared to selective FLP, the Solomon technique for TTTS pregnancies is associated with a significantly lower recurrence of TTTS; however, it significantly increases the risk of placental abruption.

Pulmonary valve stenosis in a recipient twin in twin-to-twin transfusion syndrome with successful balloon valvuloplasty after birth: a case report.

BACKGROUND: Pulmonary stenosis (PS) is a congenital heart diseases (CHDs) with a spectrum of stenosis. Monochorionic (MC) twins are at increased risk of CHDs, especially acquired CHDs in twin-twin transfusion syndrome (TTTS). PS/Pulmonary atresia (PA) is a rare coincidence with TTTS. MC twin pregnancies have increased in last decades due to increasing in maternal age and extensive use of assisted reproductive technologies. Therefore, attention to this group is important for heart abnormalities, especially in twins with TTTS. Multiple cardiac abnormalities in MC twins with TTTS are to be expected due to cardiac hemodynamic changes and may be eliminated by Fetoscopic laser photocoagulation treatment. Prenatal diagnosis of PS is necessary given the importance of treatment after birth. CASE PRESENTATION: We here present a case of coexistence of TTTS with PS in a growth restricted recipient twin who successfully treated with balloon pulmonary valvuloplasty in neonatal period. Also, we detected infundibular PS after valvuloplasty that treated with medical therapy (propranolol). CONCLUSIONS: It is important to detect acquired cardiac abnormalities in MC twins with TTTS, and follow them up after birth to determine the need of intervention in neonatal period.

Prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States: a systematic review and meta-analysis.

This systematic review and meta-analysis assessed the risk of inadequate prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States. PubMed/MedLine, Embase, ClinicalTrials.gov and Web of Science were searched from inception up to March 30th, 2022. Studies were included if they reported the risk of inadequate prenatal care and/or pregnancy outcomes among incarcerated pregnant individuals in the United States jails or prisons. Adequacy of prenatal care was quantified by Kessner index. The random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs) using RevMan software. Nine studies were included in the final review. A total of 11,534 pregnant individuals, of whom 2,544 were incarcerated while pregnant, and 8,990 who were matched non-incarcerated pregnant individuals serving as control group, were utilized. Compared to non-incarcerated pregnancies, incarcerated pregnant individuals were at higher risk of inadequate prenatal care (OR 2.99 [95% CI: 1.60, 5.61], p<0.001) and were more likely to have newborns with low birthweight (OR 1.66 [95% CI: 1.19, 2.32], p=0.003). There was no significant difference between incarcerated and matched control pregnancies in the rates of preterm birth and stillbirth. The findings of the current systematic review and meta-analysis suggest that incarcerated pregnant individuals have an increased risk of inadequate prenatal care. Considering the limited number of current studies, further research is indicated to both assess whether the risk of inadequate prenatal care has negative impact on prenatal outcomes for this population and to determine the steps that can be taken to enhance prenatal care for all pregnant individuals incarcerated in the United States prisons.

Basal Plate Myofibers and the Risk of Placenta Accreta Spectrum in the Subsequent Pregnancy: A Large Single-Center Cohort.

OBJECTIVE: We aimed to evaluate whether there is a significant association between a placental pathology diagnosis basal plate myofibers (BPMF) in an index pregnancy with placenta accreta spectrum (PAS) in the subsequent pregnancy. STUDY DESIGN: We conducted a retrospective nested cohort study of all cases with a histopathological finding of BPMF between August 2012 and March 2020 at a single tertiary referral center. Data were collected for all subjects (cases and controls) with at least two consecutive pregnancies (the initial index pregnancy and at least one subsequent pregnancy) accompanied by a concomitant record of histopathological study of the placenta at our center. The primary outcome was pathologically confirmed PAS in the subsequent pregnancy. Data are presented as percentage or median, interquartile range accordingly. RESULTS: A total of n = 1,344 participants were included, of which n = 119 (index cases) carried a contemporaneous histopathological diagnosis of BPMF during the index pregnancy and n = 1,225 did not (index controls). Among the index cases, patients with BPMF were older (31.0 [20, 42] vs. 29.0 [15, 43], p < 0.001), more likely to have undergone in vitro fertilization (IVF) for conception (10.9 vs. 3.8%, p = 0.001) and were of a more advanced gestational age at delivery (39.0 [25, 41] vs. 38.0 [20, 42], p = 0.006). In the subsequent pregnancy, the rate of PAS was significantly higher among the BPMF index cases (6.7 vs. 1.1%, p < 0.001). After adjusting for maternal age and IVF, a histopathological diagnosis of BPMF in an index pregnancy was shown to be a significant risk factor for PAS in the subsequent gestation (hazard ratio: 5.67 [95% confidence interval: 2.28, 14.06], p < 0.001). CONCLUSION: Our findings support that a histopathological diagnosis of BPMF is an independent risk factor for PAS in the subsequent pregnancy. KEY POINTS: · BPMF may indicate morbid adherence of placenta.. · Patients with BPMF were older and more likely to have undergone IVF for conception.. · The BPMF in the current pregnancy is an independent risk factor for PAS in the subsequent pregnancy..

Fetal reduction of triplet pregnancies to twins vs singletons: a meta-analysis of survival and pregnancy outcome.

OBJECTIVE: This systematic review and meta-analysis aimed to compare the fetal survival rate and perinatal outcomes of triplet pregnancies after selective reduction to twin pregnancies vs singleton pregnancies. DATA SOURCES: PubMed, Web of Science, Scopus, and Embase were systematically searched from the inception of the databases to January 16, 2022. STUDY ELIGIBILITY CRITERIA: Studies comparing the survival and perinatal outcomes between reduction to twin pregnancies and reduction to singleton pregnancies were included. The primary outcomes were fetal survival, defined as a live birth at >24 weeks of gestation. The secondary outcomes were gestational age at birth, preterm birth at <32 and <34 weeks of gestation, early pregnancy loss (<24 weeks of gestation), low birthweight, and rate of neonatal demise (up to 28 days after birth). METHODS: The random-effect model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. To provide a range of expected effects if a new study was conducted, 95% prediction intervals were calculated for outcomes presented in >3 studies. RESULTS: Of note, 10 studies with 2543 triplet pregnancies undergoing fetal reduction, of which 2035 reduced to twin pregnancies and 508 reduced to singleton pregnancies, met the inclusion criteria. Reduction to twin pregnancies had a lower rate of fetal survival (odds ratio, 0.61; 95% confidence interval, 0.40-0.92; P=.02; 95% prediction interval, 0.36-1.03) and comparable rates of early pregnancy loss (odds ratio, 0.89; 95% confidence interval, 0.58-1.38; P=.61; 95% prediction interval, 0.54-1.48) and neonatal demise (odds ratio, 0.57; 95% confidence interval, 0.09-3.50; P=.55) than reduction to singleton pregnancies. Reduction to twin pregnancies had a significantly lower gestation age at birth (weeks) (mean difference, -2.20; 95% confidence interval, -2.80 to -1.61; P<.001; 95% prediction interval, -4.27 to -0.14) than reduction to singleton pregnancies. Furthermore, reduction to twin pregnancies was associated with lower birthweight and greater risk of preterm birth at <32 and <34 weeks of gestation. CONCLUSION: Triplet pregnancies reduced to twin pregnancies had a lower fetal survival rate of all remaining fetuses, lower gestational age at birth, higher risk of preterm birth, and lower birthweight than triplet pregnancies reduced to singleton pregnancies; reduction to twin pregnancies vs reduction to singleton pregnancies showed no substantial difference for the rates of early pregnancy loss and neonatal death.

Selective reduction in complicated monochorionic pregnancies: a systematic review and meta-analysis of different techniques.

OBJECTIVE: This systematic review and meta-analysis aimed to compare the perinatal outcomes of complicated monochorionic pregnancies after selective reduction by radiofrequency ablation, bipolar cord coagulation, and interstitial laser. DATA SOURCES: We searched PubMed, Scopus, and Web of Science, from the inception of the database up to April 26, 2021. STUDY ELIGIBILITY CRITERIA: Studies comparing at least 2 selective reduction techniques among complicated monochorionic pregnancies and presenting data on perinatal outcomes, including gestational age at procedure, gestational age at delivery, procedure to delivery interval, preterm premature rupture of membranes, preterm birth, survival rate, and birthweight, were eligible. METHODS: The random-effects model was used to pool the mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS: A total of 10 studies with 734 cases of fetal reduction met the inclusion criteria, of which 9 studies with 674 fetuses were eligible for quantitative synthesis. In 8 studies that compared radiofrequency ablation with bipolar cord coagulation, radiofrequency ablation was associated with increased procedure to delivery interval (days) (mean difference, 13.42; 95% confidence interval, 1.90-24.94; P=.02; I2=0.0%), decreased preterm birth (odds ratio, 0.50; 95% confidence interval, 0.29-0.85; P=.01; I2=3.0%), and decreased preterm premature rupture of membranes (odds ratio, 0.45; 95% confidence interval, 0.27-0.73; P=.001; I2=0.0%). Radiofrequency ablation and bipolar cord coagulation had comparable survival rates (odds ratio, 0.85; 95% confidence interval, 0.54-1.35; P=.49; I2=0.0%). In 3 studies that compared radiofrequency ablation with interstitial laser, there was no significant difference in gestational age at delivery (P=.07) or survival (P=.15). In 3 studies that compared bipolar cord coagulation with interstitial laser, bipolar cord coagulation was associated with a higher survival rate (odds ratio, 3.21; 95% confidence interval, 1.13-9.10; P=.03; I2=0.0%), but the gestational age at delivery was comparable between groups (P=.16). CONCLUSION: This study demonstrated that radiofrequency ablation has a greater procedure to delivery interval and decreased preterm premature rupture of membranes and preterm birth than bipolar cord coagulation. Although there was no difference in gestational age at delivery for either bipolar cord coagulation, radiofrequency ablation, or interstitial laser, survival was higher with bipolar cord coagulation than with interstitial laser.

The Society for Pediatric Pathology Task Force grading system for placenta accreta spectrum and its correlation with clinical outcomes.

BACKGROUND: The terminology and diagnostic criteria presently used by pathologists to report placenta accreta spectrum is inconsistent and does not reflect current knowledge of the pathogenesis of this disease. OBJECTIVE: In 2020, the perinatal subcommittee of the Society for Pediatric Pathology Placenta Accreta Task Force proposed a new pathologic grading system for placenta accreta spectrum. We sought to correlate the clinical outcomes with the classification into each group in the new placenta accreta spectrum grading system. STUDY DESIGN: The pathology reports of patients with histopathologic confirmation of placenta accreta spectrum were reviewed in 2 academic referral centers by placental pathologists. Pathologic grading was assigned based on the new grading system according to which placenta accreta spectrum is categorized into 5 groups depending on the depth of invasion, from grade p1 with no invasion into the uterine wall to grade p3E with invasion beyond the uterine wall to the adjacent organs. Patient characteristics and clinical outcomes were compared among these groups. A univariate analysis was performed, and a multivariate linear or binomial regression was employed when needed. RESULTS: A total of 683 patients with placenta accreta spectrum were identified. Of those, 407 were included for histology review. There were 92 patients (23%) categorized into the grade p1 group, 74 (18%) in the grade p2 group, 84 (20%) in the grade p3A group, 121 (30%) in the grade p3D group, and 36 (9%) in the grade p3E group. There was a significant association between the pathology grading and the number of red blood cells transfused (ß=1.14; 95% confidence interval, 0.48-1.79) and the postoperative complications including the rate of readmission (risk ratio, 1.93; 95% confidence interval, 1.26-2.94) and bladder injury (risk ratio, 1.81; 95% confidence interval, 1.23-2.68) after adjustment for antenatal diagnosis and other variables. The pathology grading was not associated with the estimated blood loss (P=.072). CONCLUSION: The new pathology grading system accurately reflects maternal outcomes and complications of placenta accreta spectrum. We encourage the utilization of this new pathologic grading system because it is designed to omit discrepancies in placenta accreta spectrum reporting and to standardize communication.

Intrapartum ultrasound measurement of angle of progression at the onset of the second stage of labor for prediction of spontaneous vaginal delivery in term singleton pregnancies: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to investigate the diagnostic performance of transperineal ultrasound-measured angles of progression at the onset of the second stage of labor for the prediction of spontaneous vaginal delivery in singleton term pregnancies with cephalic presentation. DATA SOURCES: We performed a predefined systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to February 5, 2021. STUDY ELIGIBILITY CRITERIA: Prospective cohort studies that evaluated the diagnostic performance of transperineal ultrasound-measured angles of progression (index test) at the onset of the second stage of labor (ie, when complete cervical dilation is diagnosed) for the prediction of spontaneous vaginal delivery (reference standard) were eligible for inclusion. Eligible studies were limited to those published as full-text articles in the English language and those that included only parturients with a singleton healthy fetus at term with cephalic presentation. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary receiver operating characteristic curves, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios were calculated using the Stata software. Subgroup analyses were done based on angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°. RESULTS: A total of 8 studies reporting on 887 pregnancies were included. Summary estimates of the sensitivity and specificity of transperineal ultrasound-measured angle of progression at the onset of the second stage of labor for predicting spontaneous vaginal delivery were 94% (95% confidence interval, 88%-97%) and 47% (95% confidence interval, 18%-78%), respectively, for an angle of progression of 108° to 119°, 81% (95% confidence interval, 70%-89%) and 73% (95% confidence interval, 57%-85%), respectively, for an angle of progression of 120° to 140°, and 66% (95% confidence interval, 56%-74%) and 82% (95% confidence interval, 66%-92%), respectively, for an angle of progression of 141° to 153°. Likelihood ratio syntheses gave overall positive likelihood ratios of 1.8 (95% confidence interval, 1-3.3), 3 (95% confidence interval, 2-4.7), and 3.7 (95% confidence interval, 1.7-8.1) and negative likelihood ratios of 0.13 (95% confidence interval, 0.07-0.22), 0.26 (95% confidence interval, 0.18-0.38), and 0.42 (95% confidence interval, 0.29-0.60) for angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°, respectively. CONCLUSION: Angle of progression measured by transperineal ultrasound at the onset of the second stage of labor may predict spontaneous vaginal delivery in singleton, term, cephalic presenting pregnancies and has the potential to be used along with physical examinations and other clinical factors in the management of labor and delivery.

Infantile neurodevelopmental outcome after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome: the first prospective experience from Iran.

OBJECTIVE: We sought to evaluate the neurodevelopmental outcomes at 12 months of age among infants with twin-to-twin transfusion syndrome (TTTS) undergoing fetoscopic laser photocoagulation (FLP). MATERIALS AND METHODS: In this prospective longitudinal study, neurodevelopmental assessment was performed among the infants at the corrected age of 12 months, who were diagnosed with TTTS and treated by FLP. The Ages and Stages Questionnaire (ASQ) was filled out by parents. In the next step in infants with abnormal ASQ, motor and cognitive developments were evaluated by Bayley's infant and toddler development scoring system (Bayley 3-Third edition). RESULTS: In 39 FLP procedures the rate of live birth of at least one twin was 73.8%. Four neonatal deaths were recorded, three of which were due to prematurity and one was due to heart anomaly. The ASQ was normal in 89.7% (35/39) of the infants (group I), 5.1% (2/39) had minor neurodevelopmental impairment (NDI) (group II), and 5.1% (2/39) had major NDI (group III). The 4 infants with abnormal ASQ had Bayley examination which showed two with mild to moderate cerebral palsy and two had delayed verbal skills and autistic spectrum disorder. No significant difference was noted between survivors with and without NDI with respect to donor or recipient status, birth weight, gestational age at birth, Quintero stage of TTTS. In addition, the relationship between gestational age at the time of undergoing FLC and NDI was not significant. CONCLUSION: In our population, minor and major neurodevelopmental impairment were seen in 10.2% of the infants. This information is useful for counseling our couples in this population prior the procedure.

A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century.

INTRODUCTION: Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates. MATERIAL AND METHODS: This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels. RESULTS: The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off. CONCLUSIONS: This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

Women's sexual function before and during COVID-19 pandemic: A systematic review and meta-analysis.

BACKGROUND: To systematically review and summarize the available literature regarding the women's sexual function during COVID-19 pandemic and compare it to pre-pandemic period. METHODS: We searched PubMed and Embase from the inception of the databases until 15th April 2021. Data regarding the sexual function, measured by female sexual function index (FSFI), of adult sexually active women were extracted from the eligible studies and compared between the before and during the COVID-19 pandemic. The secondary outcome was the frequency of intercourse during pandemic time. The random-effect model was used to pool the mean differences and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 value. RESULTS: Our search resulted in a sample of six eligible studies, which involved 1114 female participants. The total FSFI score among study participants during pandemic was 22.93 (95% CI: 19.26-26.59), which indicated a significant decrease in sexual function of women during pandemic as compared to pre-pandemic time (mean difference = -3.80, 95% CI: -6.48 to -1.12, p = 0.005, I2  = 96%). We also conducted a meta-analysis of individual FSFI domains. During pandemic, women had problems with arousal (p < 0.0001), orgasm (p = 0.0008), satisfaction (p = 0.0009), and pain (p = 0.009). No significant difference in frequency of intercourse was observed between pre- and during pandemic (p = 0.80). Furthermore, no significant publication bias was present among included studies. CONCLUSION: Overall, there was a significant decrease in sexual function of sexually active adult women during COVID-19 pandemic. The most affected areas of sexual function were arousal, orgasm, pain, and satisfaction. Physicians must be aware of COVID-19 impact on sexual life of women and provide proper counseling.

Placental Vascular and Inflammatory Findings from Pregnancies Diagnosed with Coronavirus Disease 2019: A Systematic Review and Meta-analysis.

We aimed to perform a meta-analysis of the literature concerning histopathologic findings in the placentas of women with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection during pregnancy. Searches for articles in English included PubMed, Web of Science, Google Scholar, and reference lists (up to April 2021). Studies presenting data on placental histopathology according to the Amsterdam Consensus Group criteria in SARS-CoV-2 positive and negative pregnancies were identified. Lesions were categorized into: maternal and fetal vascular malperfusion (MVM and FVM, respectively), acute placental inflammation with maternal and fetal inflammatory response (MIR and FIR, respectively), chronic inflammatory lesions (CILs), and increased perivillous fibrin deposition (PVFD). A total of 15 studies reporting on 19,025 placentas, n = 699 of which were derived from women who were identified as being infected with SARS-CoV-2 and 18,326 as SARS-CoV-2-negative controls, were eligible for analysis. No significant difference in incidence of MVM (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 0.73-1.90), FVM (OR: 1.23, 95% CI: 0.63-2.42), MIR (OR: 0.66, 95% CI: 0.29-1.52) or FIR (OR: 0.85, 95% CI: 0.44-1.63), and CILs (OR: 0.97, 95% CI: 0.55-1.72) was found between placentae from gravida identified as being SARS-CoV-2 infected. However, placenta from gravida identified as being infected with SARS-CoV-2 were associated with significantly increased occurrence of PVFD (OR: 2.77, 95% CI: 1.06-7.27). After subgroup analyses based on clinical severity of COVID-19 infection, no significant difference was observed in terms of reported placental pathology between symptomatic or asymptomatic SARS-CoV-2 gravidae placenta. Current evidence based on the available literature suggests that the only pathologic finding in the placentae of women who are pregnant identified as having been infected with SARS-CoV-2 was an increased prevalence of PVFD. KEY POINTS: · No association between SARS-CoV-2 and maternal or fetal placental malperfusion.. · No association between SARS-CoV-2 and maternal or fetal inflammatory response.. · SARS-CoV-2 is associated with increased perivillous fibrin deposition in placenta..

Intention to Receive COVID-19 Vaccine during Pregnancy: A Systematic Review and Meta-analysis.

OBJECTIVE: This meta-analysis aimed to assess the level of intent to receive coronavirus disease 2019 (COVID-19) vaccination and demographical factors influencing vaccine uptake among pregnant individuals. STUDY DESIGN: PubMed, Scopus, and archive/pre-print servers were searched up to May 22nd, 2021. Cross sectional surveys reporting the percentage of the pregnant individuals intending to get a COVID-19 vaccine were considered eligible for meta-analysis. This review was registered with PROSPERO (CRD42021254484). The primary outcome was to estimate the prevalence of COVID-19 vaccination intent among pregnant population. The secondary outcome was to evaluate the factors influencing the intention for vaccination. RESULTS: Twelve studies sourcing data of 16,926 individuals who were identified as pregnant were eligible. The estimated intention for the receipt of COVID-19 vaccine among women who were pregnant was 47% (95% CI: 38-57%), with the lowest prevalence in Africa 19% (95% CI: 17-21%) and the highest in Oceania 48.0% (95% CI: 44.0-51.0%). Uptake of other vaccines (influenza and/or TdaP) during pregnancy was associated with higher rate of intent to receive the COVID-19 vaccine (OR = 3.03; 95% CI: 1.37-6.73; p = 0.006). CONCLUSION: The intent to receive COVID-19 vaccine is relatively low among women who are pregnant and substantially varies based on the country of residence. In our meta-analysis, intent of women who were pregnant to receive the COVID-19 vaccine was significantly associated with the history of receiving influenza or TdaP vaccine during pregnancy. Given that in every country only a minority of gravidae have received the COVID-19 vaccine, despite known risks of maternal morbidity and mortality with no evidence of risks of vaccination, it highlights the importance of revised approaches at shared decision making and focused public health messaging by national and international advisories. KEY POINTS: · The estimated global intention for COVID-19 vaccination among pregnant women was 47%.. · The lowest intention was in Africa and the highest in Oceania.. · These findings highlight the importance of public health messaging by by different agencies..

Predictive role of Doppler indices of cerebral-placental-uterine ratio and umbilico-cerebral ratio for late-onset fetal growth restriction: a prospective cohort study.

Predicting late-onset foetal growth restriction (FGR) has proven to be rather challenging. In this study, we propose a new parameter, cerebral-placental-uterine (CPU) ratio and umbilico-cerebral (UC) ratio for this matter. Results of this study which included a total of 227 nulliparous women showed that an increase in CPU ratio (OR = 0.45; 95% CI: 0.23-0.88; p=.020) was associated with lower odds of foetal weight above the 10th percentile at birth. CPU ratio measured at 35-37 weeks of gestation had an AUC of 0.78 (95% CI: 0.58, 0.98), sensitivity of 0.62 (95% CI: 0.24, 0.91) and specificity of 0.90 (95% CI: 0.79, 0.96) for prediction of late-onset FGR, which showed higher accuracy than UC ratio. As some cases of the late-onset FGR are not diagnosed by foetal biometry, it is important to find Doppler parameters that can help us predict these cases and CPU ratio may help physicians in detection of high-risk foetuses that will benefit from earlier intervention. Impact StatementWhat is already known on this subject? Late-onset foetal growth restriction (FGR) defined by an FGR diagnosis after 32 weeks of gestational age, can lead to short- and long-term morbidities and early diagnosis is the key to prevent these complications.What do the results of this study add? Results showed that each unit increase in numeric variables including CP ratio (OR = 0.29, p=.006), and CPU ratio (OR = 0.40, p=.006) was associated with lower odds of the foetal weight above the 10th percentile in the second ultrasound at 35-37 weeks. In other words, CPU ratio can prove to be useful marker in prediction of late-onset FGR.What are the implications of these findings for clinical practice and/or further research? Our prospective cohort study confirms the added value of low CPU ratio, with higher predictive accuracy than UC ratio, in predicting late-onset FGR. Detection of late FGR remains poor, but it is important to prevent stillbirth so further studies on the role of CPU ratio in predicting FGR and perinatal outcomes are needed.

The effect of endocervical and catheter bacterial colonisation during in vitro fertilisation and embryo transfer (IVF-ET) on IVF success rate among asymptomatic women: a longitudinal prospective study.

The adverse effects of bacterial contamination during in vitro fertilisation and embryo transfer (IVF-ET) have been studied previously. However, data on asymptomatic women with positive bacterial culture and their IVF outcome are lacking. This prospective longitudinal study was conducted on 74 women undergoing IVF-ET, of whom specimens from the endocervix and ET catheter were taken and sent to a laboratory for microbiological assessment. Then, patients were followed up for evaluation of chemical pregnancy (ß-HCG > 25 mIU/mL) and clinical pregnancy (detected foetal heartbeat). The findings revealed that there was no significant difference in terms of biochemical (35.4% vs. 19.2%, p= .116) and clinical pregnancy rate (25.0% vs. 15.4%, p= .257) among ET catheter culture positive and negative women. This finding allows us to conclude that the positive culture in the absence of clinical signs of infection may not increase the risk of implantation failure.Impact StatementWhat is already known on this subject? There is growing evidence indicating that endometritis may decrease the endometrial receptiveness in in vitro fertilisation (IVF) cycles; however, there is a paucity of knowledge regarding IVF outcomes when the bacterial culture of embryo transfer (ET) catheter is positive.What the results of this study add? The present study demonstrates that positive ET catheter culture in asymptomatic women does not increase the risk of IVF failure.What the implications are of these findings for clinical practice and/or further research? Positive-culture, per se, may not be associated with poor IVF outcomes and further studies should be undertaken on this topic in various clinical settings using different protocols.