Risk of singleton preterm birth after prior twin preterm birth: a systematic review and meta-analysis.

OBJECTIVE DATA: The purpose of this study was to conduct a systematic review and meta-analyses of literature regarding the risk of preterm birth in singleton pregnancies after a preterm twin birth. STUDY: We conducted a literature search of Embase, Ovid Medline, and Cochrane from inception until February 28, 2019. Studies that evaluated women with a previous twin birth followed by a singleton birth were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Data were abstracted in duplicate, and summary odds ratios and confidence intervals were calculated with the use of random effects model. Risk of bias was assessed with the use of the Newcastle-Ottawa Scale, and quality of evidence was evaluated with the use of the Grades of Recommendation, Assessment, Development, and Evaluation approach. The primary outcome was a preterm singleton birth (<37 weeks gestational age); secondary outcomes included risk of late preterm birth (34-36+6 weeks gestation), preterm birth between 30 and 33+6 weeks gestation, and preterm birth at <30 weeks gestation. Subanalysis of risk of singleton preterm birth after spontaneous twin birth was also performed. A priori, the protocol was developed and registered with PROSPERO (2016; registration number: CRD42017053382). RESULTS: We included 8 cohort studies at low risk-of-bias met inclusion criteria for the systematic review and 6 for the meta-analysis. Compared with women with previous term twin births, women who had previous preterm (<37 weeks gestation) twin births were at increased odds of preterm singleton birth in subsequent pregnancy (odds ratio, 4.34; 95% confidence interval, 2.83-6.65). Gestational age at birth of previous twin pregnancy was an effect modifier. Compared with previous term twin births, the odd ratios of subsequent preterm singleton birth were 2.13 (95% confidence interval, 1.21-3.74) if twins were born between 34 and 36+6 weeks gestation, 5.18 (95% confidence interval, 2.78-9.64) if twins were born between 30 and 33+6 weeks gestation, and 9.78 (95% confidence interval, 4.99-18.98) if twins were born at <30 weeks gestation. A similar trend was seen for the risk of singleton preterm birth after spontaneous twin preterm birth. CONCLUSION: A history of preterm twin birth is associated with higher odds of subsequent preterm singleton birth. The odds increase with decreasing gestational age of previous twin birth.

Nomogram to Predict Risk of Postoperative Urinary Retention in Women Undergoing Pelvic Reconstructive Surgery.

OBJECTIVE: To develop a nomogram that determines an individual's risk of postoperative urinary retention (POUR) following pelvic floor reconstructive surgery. METHODS: We performed a retrospective chart review of women who underwent reconstructive surgery for pelvic organ prolapse and/or stress urinary incontinence. Short-term POUR was defined as failure of the trial of void (post-void residual >150 mL with a void of >200 mL) on postoperative day one or the need for re-catheterization in the first 2 postoperative days. Potential pre- and intraoperative risk factors for POUR were compared between patients with and without POUR. Multivariate binary logistic regression analysis with best-subsets variable selection was used to create a predictive nomogram. RESULTS: Most patients (275 of 332) had concomitant or combined procedures. The overall incidence of POUR was 31% (103 of 332 patients). The risk of POUR was higher for patients with high-grade anterior prolapse and those who had undergone anterior vaginal repair, vaginal hysterectomy, or a laparoscopic sling procedure. Patients who did not experience POUR tended to have fewer co-morbidities and were more likely to have undergone laparoscopic colposacropexy. Risk factors for POUR in the nomogram were diabetes, multiple medical co-morbidities, laparoscopic sling procedure, anterior vaginal repair, laparoscopic colposacropexy, and vaginal hysterectomy. The nomogram allows clinicians to calculate a patient's risk of POUR (range <10% to >80%). CONCLUSION: While the predictive nomogram in this study was developed using a single surgeon's case series and may not be generalizable to all surgeons, it demonstrates that the risk of POUR may be predicted based on clinical characteristics and the type of surgery performed. This kind of prediction model could help guide clinicians in preoperative patient counseling.

Does low-dose gapapentin reduce opioid use postoperatively?: A randomized controlled trial in women undergoing reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: Pre-emptive gabapentin has been shown to decrease postoperative pain in abdominal and vaginal hysterectomy. However, the effect of pre-emptive low-dose gabapentin has not been studied in vaginal hysterectomy combined with concomitant pelvic reconstruction. METHODS: A randomized double-blind placebo-controlled trial assessed all women seen for symptomatic prolapse requiring vaginal hysterectomy with concomitant pelvic reconstruction with or without midurethral sling. Gabapentin dosing was 600 mg (<65 years) or 300 mg (>65 years). The primary outcome was reduction in opioid consumption in the first 24 h after surgery. Secondary outcomes included sedation and prolongation of recovery room stay. Sample-size calculations indicated a need for 22 participants/group. Student's t test was used to compare differences in oral administration of morphine equivalents in the first 24 h postoperatively, time from end of surgery to leaving the recovery room, and length of recovery room stay. Mann-Whitney U test was used to compare visual analog scale (VAS) scores for anxiety, drowsiness/sedation, pain, and nausea. RESULTS: Twenty-one patients received gabapentin and 26 a placebo capsule. Groups were similar with respect to age, menopause status, parity, American Society of Anesthesiologist (ASA) class, and concomitant procedures. There were also no significant differences between groups in opioid requirements within the first 24 h after surgery, time from end of surgery to leaving the recovery room, length of time in recovery room, or VAS scores. CONCLUSIONS: Pre-emptive gabapentin at our institutional low doses did not significantly affect postoperative pain and opioid requirements in women undergoing vaginal hysterectomy with concomitant reconstruction. TRIAL REGISTRATION: www.clinicaltrials.gov , #NCT02999724.

The Effect of Medical Consultation on Patients' Concerns Regarding Vaginal Mesh Use in Pelvic Reconstructive Surgery.

OBJECTIVE: This study sought to determine patients' background knowledge and attitudes towards the use of mesh in pelvic floor reconstructive surgery (PFRS) and the effect of medical consultation on their knowledge and attitudes about mesh use. METHODS: New urogynecology patients seen for pelvic organ prolapse and/or stress urinary incontinence were asked to complete pre-consultation questionnaires involving 12 questions on demographics and knowledge, attitudes, and concerns about the use of vaginal mesh. If PFRS was discussed, a post-consultation questionnaire was administered. RESULTS: A total of 202 new patients were surveyed. Of these patients, 73.8% had heard of vaginal mesh, and most of this information came from a media source followed by their health care provider. A total of 102 of 202 patients completed both the pre- and post-consultation questionnaire. Before medical consultation, patients' "level of concern" on a Likert scale (1 = not at all concerned, 10 = very concerned) was 5.98 ± 3.04. After consultation, the level of concern decreased significantly to 4.25 ± 2.68 (P = 0.00005). Before consultation, 33.3% of patients stated that they would be willing to proceed with surgery using mesh; however, after receiving standardized information on vaginal mesh risks and complications on the basis of the most current information available, 62.8% stated that they would be willing to proceed with mesh if required (P = 0.00001). CONCLUSION: Almost 75% of patients presenting for urogynecologic consultation had heard of vaginal mesh use, and 55.7% cited the media as their source of information. Medical consultation significantly reduced the patients' level of concern regarding the use of mesh in PFRS and significantly increased the proportion of patients willing to have mesh placed if appropriate.

Laparoscopic implantation of electrodes for bilateral neuromodulation of the pudendal nerves and S3 nerve roots for treating pelvic pain and voiding dysfunction.

INTRODUCTION AND HYPOTHESIS: The objective of this video is to describe the technique for laparoscopic implantation of electrodes for bilateral neuromodulation of S3 and pudendal nerves. We report a successful case of a 48-year-old woman with spina bifida occulta referred with a 14-year history of intense acyclic pelvic pain, urinary hesitancy, and intermittent flow refractory to various conservative measures. METHODS: The procedure began with the removal of two previously placed InterStims. A quadripolar electrode was then laparoscopically inserted into Alcock's canal and attached to the pelvic pectineal line. Another lead was placed juxtaneurally to S3. Lead contacts were then exteriorized, and the peritoneum closed. The same procedure was then performed on the contralateral side. The leads were connected to a 16-pole rechargeable pulse generator. Postoperatively, the patient developed an acute dissection and partial thrombosis of the external iliac artery, which was treated endovascularly. RESULTS: Complete pain resolution was observed with simultaneous S3 and pudendal stimulation, with pudendal stimulation turned off for voiding. CONCLUSIONS: We conclude that laparoscopic implantation of neuromodulation electrodes allows simultaneous stimulation of S3 and pudendal nerves, providing more programming options and possibly increasing success rates in complex pelvic floor dysfunction cases.

Effect of increased MRI and CT scan utilization on clinical decision-making in patients referred to a surgical clinic for back pain.

BACKGROUND: We sought to determine the association between radiologic and clinical diagnoses and to measure the impact of more magnetic resonance imaging (MRI) and computed tomography (CT) scans on clinical decision-making in patients referred to a surgical clinic for back pain. METHODS: We conducted a 7-week prospective study of patients referred for back pain to spine surgeons in 1 health care centre. Patients were included if they had not previously been seen by a surgeon for their back problems and if their back pain was related to the thoracic or lumbar spine. We collected demographic data, imaging findings, clinical diagnoses as determined by the surgeons and visit outcomes and compared our results with those of a similar study conducted in 1996. RESULTS: Of 160 patients, 8 (5%) were no-shows and excluded from further analysis owing to incomplete data. There were more MRI scans and fewer plain radiographs ordered in 2009 compared with 1996 (73% v. 11% and 39% v. 68%, respectively). Degenerative disc disease was a more common radiologic diagnosis (n=78, 63%) than clinical diagnosis (n=41, 27%). Disc herniation was a more common radiologic diagnosis (n=69, 56%) than clinical diagnosis (n=25, 16%). With regards to visit outcomes, there were fewer second opinions sought in 2009 compared with 1996 (3% v. 11%). Although not statistically significant, the number of surgical candidates remained relatively stable (19% in 1996 v. 16% in 2009, p=0.44). CONCLUSION: The clinical diagnosis had a poor association with radiologic abnormalities. Despite an increase in the number of MRI and CT scans, the number of patients deemed surgical candidates has not changed.

Intrapelvic entrapment of sacral nerve roots by abnormal bundles of the piriformis muscle: description of an extra-spinal cause of sciatica and pudendal neuralgia.

Piriformis syndrome is a well-known extra-spinal cause of sciatica characterized by the entrapment of the sciatic nerve by variant bundles of the piriformis muscles in the deep gluteal space. In this case series, we describe the entrapment of intrapelvic portions of the sacral nerve roots by a variant bundle of the piriformis muscle originating medially to the sacral foramina, the surgical technique for the laparoscopic treatment of this condition, and the outcomes of the first eight cases treated with this technique. Five female and three male patients presenting with sciatica, pudendal pain and lower urinary tract symptoms underwent a laparoscopic exploration of the intrapelvic portion of the sacral nerve roots and transection of the abnormal piriformis bundle. Surgical technique is demonstrated in the Supplementary Video. Clinical success was achieved in seven of the eight patients, with a reduction of pain numeric rating scale from 8.5 (±1.2; 7-10) pre-operatively to 2.1 (±2.6; 0-7), 1-year following surgery. In conclusion, entrapment of intrapelvic portions of the sacral nerve roots by variant bundles of the piriformis originating medially to the sacral foramina are an extraspinal cause of sciatica, which can be treated though a laparoscopic approach.

Changes in referral pattern to a surgeon for low back pain: 1996 versus 2009.

The high prevalence of low back problems and increasing demand for surgery necessitate an efficient use of resources. The current study repeated a 1996 study to determine any changes in referral patterns. A seven-week prospective study included patients referred for back pain to spine surgeons in one centre. Demographic data, referral letters, wait times, investigations prior to the visit and visit outcomes were collected. Of 160 patients, 5% were excluded from the study due to incomplete data. The mean age was 53 years, 53% were female and 11% had ongoing workers' compensation cases. Compared with 1996, family physicians continue to refer the majority of patients and the average wait time increased from 10 to 13 weeks currently. The proportions of patients with pain in the leg or back were similar to 1996. The most common investigation ordered prior to the visit was magnetic resonance imaging (MRI, 73%), then computed tomography (CT, 41%) and radiography (39%), whereas in 1996, radiography was the most common (68%), then CT (37%) and MRI (11%). However, the number of surgical candidates remained relatively stable, at 19% in 1996 and 16% currently. The most common visit outcome was a diagnosis of chronic pain not amenable to surgery (34%), which had increased from 25% in 1996. Imaging is not an effective method of screening for surgical candidates as the decision to offer surgery is based more on the clinical picture. More resources should be dedicated to chronic pain management and improved screening to redirect the increased number of non-surgical patients with chronic pain.

Risk of singleton preterm birth after prior twin preterm birth: a cohort study.

Objective: To determine whether preterm birth in a twin pregnancy increases the risk of subsequent preterm birth (PTB) in a singleton pregnancy and to identify predictors for singleton PTB in women with previous twin PTB.Method: A retrospective cohort study of women with prior twin birth followed by a singleton birth in two tertiary referral centres between 2000 and 2016 was conducted. Rate of PTB in subsequent singleton pregnancy was compared between women who experienced previous preterm versus term twin birth. Analysis was further stratified by gestational age at twin and singleton birth, etiology for PTB and chorionicity in the twin pregnancy.Results: A total of 378 women met the inclusion criteria, of whom 252 (66.7%) experienced PTB in the index twin pregnancy. The overall rate of PTB in the subsequent singleton pregnancy was 11.6% (44/378). Women with prior twin PTB had a higher rate of PTB in the subsequent singleton pregnancy compared with women with prior term twin birth (17.5 versus 6.3%, p = .003, or 3.12, 95%-CI 1.42-6.85), mainly due to a higher rate of late singleton preterm birth (13.1 versus 4.0%, p = .005). Findings of higher odds of PTB in the subsequent singleton pregnancy was limited to women who gave birth before 340/7 weeks in the twin pregnancy and was related to the degree of prematurity (prior twin PTB at 300/7-336/7 weeks: OR 3.09, 95%-CI 1.12-8.51; prior twin PTB at <300/7 weeks: OR 5.8, 95%-CI 2.46-13.68). The association between previous twin PTB and subsequent singleton PTB was limited to women with prior spontaneous twin PTB (OR 3.34, 95%-CI 1.50-7.45).Conclusion: Women with a history of spontaneous PTB in a twin pregnancy are at increased odds of PTB in subsequent singleton pregnancies compared to women with prior term twin birth, and the risk is related to the severity of prematurity in the index twin pregnancy.

Superior gluteal vein syndrome: an intrapelvic cause of sciatica.

The role of malformed or dilated branches of iliac vessels in causing pelvic pain is not well understood. Such vessels may entrap nerves of the lumbosacral (LS) plexus against the pelvic sidewalls, producing symptoms not typically encountered in gynecological practice, including sciatica and refractory urinary and/or anorectal dysfunction. We describe cases of sciatica in which laparoscopy revealed compression of the LS plexus by variant superior gluteal veins (SGVs). In demonstrating an improvement in patient symptoms after decompression, we identify this neurovascular conflict as a potential intrapelvic cause of sciatica. This study is a retrospective case series (Canadian Task Force Classification II-3). Nerve decompression laparoscopies were performed in São Paulo, Brazil. Thirteen female patients undergoing laparoscopy for sciatica with no clear spinal or musculoskeletal causes were included in this study. In all cases, we identified LS entrapment by aberrant SGVs, and performed decompression by vessel ligation. The average preoperative visual analog scale score of 9.62 ± 0.77 decreased significantly to 2.54 ± 2.88 post-operatively (P < 0.001). The success rate (defined as ≥ 50% improvement in visual analog scale score) was 92.3%, over a follow-up of 13.2 ± 10.6 months. Our case series demonstrates a high success rate and significant decrease in pain scores after laparoscopic intrapelvic decompression, thereby identifying pelvic nerve entrapment by aberrant SGVs as a potential yet previously unrecognized cause of sciatica. This intrapelvic neurovascular conflict-the SGV syndrome-should be considered in cases of sciatica with no identifiable spinal or musculoskeletal etiology.

Surgical management of a giant condyloma of Buschke-Löwenstein in a patient with Netherton syndrome using the pedicled anterolateral thigh flap--a case report.

The surgical management of a giant condyloma of Buschke and Löwenstein poses particular reconstructive challenges, given the wound size, depth, and infection risk. We present a case where a pedicled anterolateral thigh flap is used to reconstruct a complex wound following resection of a giant condyloma of Buschke and Löwenstein arising in a patient with Netherton syndrome. Our operative technique re-iterates the utility of this flap in perineal reconstruction and demonstrates the possibility for an 18 cm wide arc of rotation. To our knowledge, this is the first report of a successful complex excision of a giant condyloma in Netherton syndrome, the subsequent reconstruction, and periodic maintenance with topical therapies.

Effectiveness of pain management following electrical injury.

The purpose of this study was to evaluate the effectiveness of pain management after electrical injury. A retrospective hospital chart review was conducted among electrically injured patients discharged from the outpatient burn clinic of a rehabilitation hospital (July 1, 1999, to July 31, 2008). Demographic data, numeric pain ratings (NPRs) at initial assessment and discharge, medications, nonpharmacologic modalities, and their effects before admission and after rehabilitation were collected. Pain management effects were compared between high (> or =1000 v) and low (<1000 v) voltage, and between electrical contact and electrical flash patients, using Student's t-test and chi, with a P < .05 considered significant. Of 82 electrical patients discharged during the study period, 27 were excluded because of incomplete data, leaving 55 patients who had a mean age +/-SD of 40.7 +/- 11.3 years, TBSA of 19.2 +/- 22.7%, and treatment duration of 16.5 +/- 15.7 months. The majority were men (90.9%), most injuries occurred at work (98.2%), mainly caused by low voltage (n = 32, 58.2%), and the rest caused by high voltage (n = 18, 32.7%). Electrical contact was more common (54.5%) than electrical flash (45.5%). Pain was a chief complaint (92.7%), and hands were the most affected (61.8%), followed by head and neck (38.2%), shoulders (38.2%), and back torso (38.2%). Before rehabilitation, the most common medication were opioids (61.8%), relieving pain in 82.4%, followed by acetaminophen (47.3%) alleviating pain in 84.6%. Heat treatment was the most common nonpharmacologic modality (20.0%) relieving pain in 81.8%, followed by massage therapy (14.5%) alleviating pain in 75.0%. During the rehabilitation program, antidepressants were the most common medication (74.5%), relieving pain in 22.0%, followed by nonsteroidal antiinflammatory drugs (61.8%), alleviating pain in 70.6%. Massage therapy was the most common nonpharmacologic modality (60.0%), alleviating pain in 75.8%, and then cognitive behavioral therapy (54.5%), alleviating pain in 40.0%. There were pain improvements in all anatomic locations after rehabilitation except for the back torso, where pain increased 0.7 +/- 2.9 points. Opioids were more commonly used in high voltage (P < .05), and cognitive behavioral therapy in low-voltage injuries (P < .05). Opioids were used in both electrical flash and electrical contact injuries. Pain in electrically injured patients remains an important issue and should continue to be addressed in a multimodal way. It is hoped that this study will guide us to design future interventions for pain control after electrical injury.