OBJECTIVE:To determine pre-procedure maternal, pregnancy and fetal factors associated with survival until 6 months of age and evaluate temporal trends in survival outcomes over a 25-year period following fetoscopic laser ablation (FLA) of placental anastomoses in monochorionic twin pregnancies with twin-twin transfusion syndrome (TTTS). DESIGN:Retrospective observational study. SETTINGS:A tertiary care fetal centre in Canada. POPULATION OR SAMPLE:One thousand and five patients undergoing TTTS between 1998 and 2023. METHODS:Patient demographics, pregnancy, procedural and outcome details were collected. Predictors for single and dual survival were identified using multivariable logistic regression. Temporal trends in survival outcomes across the study period were also examined. MAIN OUTCOME MEASURES:Fetal/neonatal survival at 6 months and predictors for single and dual survival. RESULTS:Of 915 included fetoscopies, 597 pregnancies (65.2%) achieved dual survival, 217 (23.9%) had a single survivor, and 101 (11%) resulted in dual demise. Survival rates improved significantly over the 25-year study period for both single and dual survival (p = 0.03 and p = 0.0004, respectively). Three significant pre-procedural predictors of dual demise versus one or two survivors were: cervical length ≤ 15 mm (adjusted odds ratio [AOR] 6.1, 95% CI 2.7-14.1), earlier gestational age (GA) at intervention (AOR 1.2 per earlier week, 95% CI 1.1-1.3), and abnormal donor umbilical artery Doppler flow (AOR 5.1, 95% CI 1.7-15.6). A prediction calculator using this model achieved an area under the curve of 0.65. CONCLUSION:Short cervical length (≤ 15 mm), presence of abnormal donor umbilical artery Doppler waveform, and early GA at time of intervention are significant predictors of fetal/neonatal survival at 6 months following FLA in TTTS and thus, are valuable parameters to consider for pre-procedural counselling.
BACKGROUND:Cervicovaginal agenesis with functional uterine remnants is a rare Müllerian anomaly that may cause obstructed menstrual flow, pelvic pain, haematometra, haematosalpinx and endometriosis. Uterus-preserving reconstruction is challenging because it requires both neovaginal creation and durable uterine drainage. AIMS:To describe a uterus-preserving laparoscopic technique combining peritoneal pull-down neovaginoplasty with catheter-guided uterovaginal anastomosis in patients with cervicovaginal agenesis and obstructed functional uterine remnants. MATERIALS AND METHODS:Seven patients with cervicovaginal agenesis and functional uterine remnants underwent laparoscopic reconstruction between 2019 and 2024. The procedure included laparoscopic-guided vesicorectal dissection, peritoneal pull-down neovaginoplasty, opening and drainage of the obstructed uterine remnant, intrauterine Foley catheter placement and circumferential uterovaginal anastomosis. In patients with bilateral remnants, cavity unification was performed before anastomosis. Postoperative mould use and intrauterine catheterisation were used to maintain patency during healing. RESULTS:Menstrual drainage was restored in all patients. Office hysteroscopy confirmed a patent uterovaginal anastomosis and accessible endometrial cavity. No intraoperative bladder, rectal, ureteric or vascular complications occurred. One patient underwent two unsuccessful frozen embryo transfer attempts. One patient required hysterectomy for recurrent pelvic inflammatory disease, with preservation of the neovagina. No late stenosis was observed during available follow-up. DISCUSSION:This technique may provide a feasible uterus-preserving approach for selected patients with cervicovaginal agenesis and functional uterine remnants. However, the presence of an accessible cavity does not prove normal biological uterine function, implantation potential or pregnancy safety. The findings should be interpreted with caution because of the small sample size and limited reproductive follow-up. CONCLUSION:Laparoscopic peritoneal pull-down neovaginoplasty combined with catheter-guided uterovaginal anastomosis may restore menstrual drainage and anatomical patency in carefully selected patients. Further multicentre experience with objective imaging, hysteroscopic follow-up and reproductive outcome data is required to assess fertility potential, pregnancy safety and long-term durability.
OBJECTIVE:To describe the temporal trends in Preterm prelabour rupture of membranes (PPROM) in metropolitan France and the geographical distribution at the administrative division level. DESIGN:Exploratory population-based study using administrative data of the French National Health Data System. SETTING:Metropolitan France, 2015 to 2023. POPULATION:Pregnancy with a diagnosis of PROM before 37 SA. METHODS:Annual crude incidence of PPROM was calculated by dividing the number of pregnancies with PPROM diagnosis by the number of live births recorded during the same period. Annual trend was estimated by a binomial negative mixed model. Smoothed standardised incidence ratios were estimated based on a BYM2 model, which accounts for spatial variability between departments. MAIN OUTCOME:PPROM cases, defined as pregnancies with first hospitalizations with a diagnosis of PROM before 37 weeks. RESULTS:Over the study period, we included 150 615 PPROM cases representing 16 735 (±596) per year. Incidence of PPROM cases showed an ascending trend over time (incidence rate ratio 1.023 per year; 95% CI: 1.017-1.030) with an annual crude incidence ranging from 2.2% in 2015 to 2.7% in 2023. A decrease in the incidence was observed in 2020 relative to other years (incidence rate ratio 0.903, 95% CI: 0.887-0.920). A map of smoothed SIRs of PPROM cases at the French administrative division level revealed geographical inequalities. CONCLUSIONS:This first population-based study describing PPROM cases in metropolitan France paves the way for further studies to explore environmental hypotheses. Identifying temporal and geographical disparities in PPROM incidence is relevant to public health policy and practice as such disparities argue for the development of targeted prevention strategies in high-risk areas.
OBJECTIVE:To compare pregnancy outcomes following high versus low vaginal cerclage in women at high risk of preterm birth. DESIGN:Secondary analysis of a multi-centre randomised control trial. SETTING:Obstetric units across the UK. SAMPLE:Women participating in the C-STICH trial who received a transvaginal cerclage. METHODS:Cerclage height was classified as high (with bladder dissection) or low (without bladder dissection). Cerclage technique was determined by clinician preference. For each outcome, regression models were fitted adjusting for pre-specified prognostic variables. MAIN OUTCOME MEASURES:The primary outcome was pregnancy loss defined as miscarriage and perinatal mortality (stillbirth or neonatal death within 7 days). Secondary maternal outcomes included miscarriage and previable neonatal death, stillbirth, gestational age at delivery, preterm pre labour rupture of membranes and sepsis. Secondary neonatal outcomes included early and late neonatal death and sepsis. RESULTS:Of the 2048 women randomised to C-STICH, 1995 had details of cerclage height available: 24% received a high and 76% a low vaginal cerclage. Pregnancy loss rates were similar between the groups (6.5% vs. 7.3%; adjusted risk ratio 0.88, 95% CI: 0.57-1.34). High vaginal cerclage was associated with an increase in mean gestational age of 0.5 weeks and a lower rate of births before 32 weeks (adjusted risk ratio 0.57, 95% CI: 0.37-0.86). CONCLUSION:Pregnancy loss rates do not differ significantly between high and low vaginal cerclage techniques. High cerclage may be associated with a small prolongation of pregnancy in women at high risk of preterm birth and reduction in preterm births < 32 weeks.
OBJECTIVE:To determine whether adding electrical stimulation (ES) biofeedback to supervised pelvic floor muscle training (PFMT) provides additional long-term benefit in prolapse anatomy among women with symptomatic pelvic organ prolapse (POP). DESIGN:Randomised controlled trial. SETTING:A tertiary hospital in Beijing, China. POPULATION:Primiparas (20-40 years) with symptomatic pelvic organ prolapse quantitation (POP-Q) stage II to III at 42-60 days postpartum following a full-term, vaginal singleton delivery. METHODS:We randomised 220 participants (1:1) to the intervention group (PFMT+ES+biofeedback) or control group (PFMT-only) for a 12-week intervention. The PFMT-only group received supervised PFMT (15 min/session, three times/week). The PFMT+ES+biofeedback group received two weekly sessions of ES (10 min) with biofeedback-mediated PFMT (15 min), and one session of supervised PFMT. MAIN OUTCOME MEASURES:Primary outcome was POP-Q stage at 24 months. Secondary outcomes included Pelvic Floor Impact Questionnaire Short Form-7 (PFIQ-7) score, pelvic floor muscle (PFM) strength, PFM electromyography values, and economic analysis. RESULTS:At 24 months, the proportion of participants with improved POP-Q stage was not significantly different between PFMT+ES + biofeedback and PFMT-only groups. PFM strength demonstrated significant improvement in PFMT+ES + biofeedback group. No significant differences were observed in PFIQ-7 score or PFM electromyography values. Adding ES cost more, but had similar quality-adjusted life years. No adverse events were reported. CONCLUSIONS:A single course of ES biofeedback plus supervised PFMT provides limited long-term benefit in postpartum prolapse. TRIAL REGISTRATION:Chinese Clinical Trial Registry: ChiCTR1900021719; https://www.chictr.org.cn/showproj.html?proj=35452.
OBJECTIVE:To understand agreement between definitions of severe maternal morbidity (SMM), the reasons for disagreement and the impact the outcome definition may have on the measurement of ethnic and socioeconomic inequalities. DESIGN:A national cohort study using administrative data. SETTING:The English National Health Service. POPULATION:Maternities leading to birth between 1st January 2013 and 31st March 2023 at a gestational age at birth of ≥ 20 weeks. METHODS:The characteristics of maternities were described overall and according to SMM definition. Agreement and chance-adjusted agreement between definitions were calculated. Poisson regression was used to estimate relative risks (RRs) with 95% confidence intervals (95% CI) for SMM across ethnic and socioeconomic groups. MAIN OUTCOME MEASURES:SMM definitions were the USA's Centers for Disease Control and Prevention (CDC) without blood transfusion, the Canadian Perinatal Surveillance System (CPSS) definition, and the English Maternal Morbidity Outcome Indicator (EMMOI). RESULTS:There were 5 939 919 included maternities. Overall, SMM occurred in 1.4% (80 191/5 939 919), 2.7% (158 759/5 939 919) and 1.1% (67 745/5 939 919) of maternities according to the CDC, CPSS and EMMOI definitions, respectively. Chance-adjusted agreement was K = 0.67 for the CDC and EMMOI; 0.50 for the CPSS and EMMOI; and 0.52 for the CDC and CPSS, with 0.55 between all three definitions. Ethnic and socioeconomic inequalities varied by definition, with RR 1.96 (95% CI 1.90-2.01), 1.71 (1.67-1.74) and 1.98 (1.92-2.04) for the CDC, CPSS and EMMOI definitions, respectively, for Black women compared to White, and RR 1.37 (1.33-1.40), 1.18 (1.16-1.21) and 1.22 (1.19-1.26), respectively, for women living in most vs. least deprived areas. Among maternities with SMM, 55% (44 193/80 191), 41% (64 982/158 759) and 35% (23 905/67 745) had a diagnostic code for sepsis within the CDC, CPSS and EMMOI definitions, respectively. Sepsis was the only component of the SMM indicator for 51%, 44% and 33% of maternities within each of the definitions, respectively. Only 0.3%-0.6% of sepsis codes were associated with a code for shock. The same percentages for acute renal failure overall were 18% (14 159/80 191), 9% (14 842/158 759), and 22% (14 842/67 745), respectively, with acute renal failure representing the only component of the SMM indicator for 13%, 5% and 17%, respectively. Only 1.1%-1.2% of renal failure codes were associated with a procedural code for dialysis. CONCLUSIONS:The prevalence of SMM differed between national definitions and chance-adjusted agreement was only moderate. The majority of maternities defined as having SMM had only a single diagnostic code for either sepsis or acute renal failure. Only a small minority of maternities with a diagnosis of sepsis or acute renal failure had additional diagnoses or procedures indicative of life-threatening disease. Validation of the common diagnostic codes is needed to ensure that the measurement of SMM reliably captures and can inform the equitable prevention of severe complications.
OBJECTIVE:To investigate the association between postpartum haemorrhage (PPH) severity and the subsequent risk of premature ovarian failure (POF), with blood transfusion used as a marker of severe PPH: DESIGN: Nationwide population-based retrospective cohort study. SETTING:Korean National Health Insurance Service (KNHIS) database. POPULATION:Women who delivered in Korea between 2015 and 2016. METHODS:Women were followed from delivery until diagnosis of POF, attainment of 40 years of age, or 31 December 2021. PPH was identified using International Classification of Diseases, 10th Revision (ICD-10) codes. Red blood cell (RBC) transfusion during the delivery hospitalization was used as the primary indicator of PPH severity. POF was defined as ovarian failure before 40 years of age. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). MAIN OUTCOME MEASURES:Incident premature ovarian failure. RESULTS:Among 745 125 women, 78 225 (10.5%) experienced PPH and 3552 (0.48%) developed POF during follow-up. When stratified by transfusion status, women with PPH requiring RBC transfusion had a markedly higher risk of POF (adjusted HR 2.058, 95% CI 1.668-2.539, p < 0.0001), whereas PPH without transfusion was associated with only a borderline association (adjusted HR 1.108, 95% CI 0.993-1.237, p = 0.066). A significant dose-response relationship was observed between RBC transfusion volume and POF risk, with adjusted HRs increasing progressively from 1.749 (95% CI 1.314-2.329) for 1 unit to 2.507 (95% CI 1.792-3.507) for 2-3 units and 2.894 (95% CI 1.439-5.820) for ≥ 4 units (p < 0.0001). CONCLUSIONS:Severe PPH requiring blood transfusion is associated with a substantially increased risk of premature ovarian failure in this nationwide population-based cohort. These findings support the importance of long-term endocrine surveillance and reproductive counselling for women who experience transfusion-requiring PPH.
BACKGROUND:Hypertensive disorders of pregnancy (HDP) are associated with increased long-term risk of maternal cardio-metabolic disease, but links with future retinal diseases remain unclear. OBJECTIVE:The objective of this study is to synthesise the published literature on HDP and subsequent retinal and other ophthalmic disease. SEARCH STRATEGY:Databases including PubMed, Embase, Web of Science, and Cochrane Library were searched to March 2026 following a pre-registered PROSPERO protocol, CRD42024589508. SELECTION CRITERIA:These included: a population of parous women, exposure to HDP at least once, at least one primary outcome (retinal disease) or secondary outcome (other ophthalmic disease). Women with pre-pregnancy retinal/ophthalmic diseases were excluded. DATA COLLECTION AND ANALYSIS:Two reviewers independently screened studies, extracted data, and assessed bias using an adapted Newcastle-Ottawa tool. Random-effects meta-analyses were performed. RESULTS:Of 5673 studies retrieved, 13 were eligible for inclusion (2 450 072 participants). HDP was associated with increased risk of diabetic retinopathy (aRR 3.54, 95% CI 2.19-5.74), particularly after preeclampsia (aRR 4.24, 95% CI 3.51-5.12). HDP-exposed women were also at higher risk of non-diabetic retinopathy (aRR 3.65, 95% CI 1.18-11.33), retinal detachment (aRR 1.54, 95% CI 1.28-1.86), and retinal vascular occlusion (aRR 2.09, 95% CI 1.55-2.81). HDP-exposed women may also be at risk of hypertensive retinopathy and central serous chorioretinopathy, but aRRs did not reach statistical significance. Across individual studies, HDP-exposed women were reported to be at increased risk of cataract extraction, non-infectious uveitis, and choroidal neovascular age-related macular degeneration. CONCLUSION:Women who experience HDP may be at future risk of retinal and other ophthalmic diseases, particularly diabetic retinopathy. Further observational research is required to confirm these associations.
OBJECTIVE:To evaluate the long-term impact of a structured, multidisciplinary CS reduction strategy in a high-complexity Italian hospital. DESIGN:Retrospective ecological time-trend study. SETTING:Tertiary obstetric care Italian centre. SAMPLE:28 577 deliveries, ≥ 22 weeks' gestation, from 2014 to 2024 were analysed. METHODS:In 2014, a multifaceted improvement program including standardised protocols, continuous staff training, Robson Ten-Group Classification audits, and tailored intrapartum care (revised dystocia criteria, updated induction methods, intrapartum ultrasound, dedicated VBAC clinic, and physiology-based CTG interpretation) was introduced. MAIN OUTCOME MEASURE:Temporal trend in CS rate, maternal morbidity (postpartum haemorrhage > 1000 mL, obstetric anal sphincter injuries, hysterectomy) and neonatal morbidity (cord pH < 7.0, resuscitation, therapeutic hypothermia). Temporal trends were assessed using segmented regression. RESULTS:Segmented regression analysis of CS rates identified 2016 as a breakpoint. Prior to 2016, the annual change in CS rate was not significant (-0.24 percentage points per year; p = 0.75), whereas after 2016 a significant downward trend was observed (-1.64 percentage points per year; p < 0.001). Conversely, VBAC rates showed a significant increasing trend over time, while uterine rupture rates remained consistently below 0.3% throughout the study period. Maternal outcomes were overall stable, although a modest increase in postpartum haemorrhage was observed. Neonatal outcomes did not show significant changes over time, including the rate of arterial cord pH < 7.0 at birth. CONCLUSIONS:The implementation of a structured, multifaceted strategy aimed at containing CS rates was associated with a significant change in their temporal trend, with a sustained post-2016 decline identified by segmented regression analysis. This trend was not associated with clinically significant detrimental effects on maternal or neonatal outcomes.
OBJECTIVE:To evaluate long-term failure rates and complications after retropubic and transobturator midurethral sling procedures for primary stress urinary incontinence (SUI). DESIGN:Retrospective cohort study. SETTING:Academic medical centre. POPULATION:A previously described cohort of patients (n = 1881) who underwent midurethral sling procedures (2002-2012) and a covariate-matched cohort of patients with retropubic (n = 570) or transobturator (n = 317) slings. METHODS:Health record review with follow-up extended by 9 years (through December 31, 2022). MAIN OUTCOME MEASURES:Treatment failure (reoperation for recurrent SUI) and procedure-associated complications. RESULTS:The duration of assessment was extended by 6.9 years for the retropubic group and by 6.4 years for the transobturator group. The median (IQR) follow-up was 11.1 (5.1-14.5) years (retropubic, 11.4 [5.9-14.6]; transobturator, 9.6 [2.6-13.7]). Higher risk of reoperation was observed with transobturator (8.8%) than retropubic (4.4%) slings (unadjusted hazard ratio [HR], 2.29 [95% CI, 1.49-3.54]; p < 0.001; covariate-matched analysis HR, 1.91 [95% CI, 1.15-3.17]; p = 0.01). The increased risk of reoperation with a transobturator sling was higher when the procedure was combined with prolapse repair (unadjusted HR, 6.34 [95% CI, 3.09-13.02]; p < 0.001; covariate-matched analysis HR, 3.96 [95% CI, 1.35-11.58]; p = 0.01). Higher rates of reoperation for urinary retention were observed for the retropubic group than for the transobturator group (covariate-matched analysis HR, 8.39 [95% CI, 1.11-63.22]; p = 0.04). CONCLUSION:In this long-term follow-up study, midurethral slings had a low failure rate. Women with SUI undergoing transobturator sling placement plus prolapse repair had a greater risk of reoperation. However, women with retropubic slings had a greater risk of urinary retention requiring intervention.
