Spontaneous Uterine Rupture in the Second Trimester: A Case Report

1.1. Introduction This study compares the impact of two surgical treatments for endometriosis—hysterectomy with laparoscopic salpingo-oophorectomy (radical surgery) versus conservative laparoscopic surgery—on chronic pelvic pain and sexual quality of life in women aged 40 to 50. 1.2. Methods In a prospective cohort study, 145 women diagnosed with stage 4 endometriosis were recruited from the endometriosis clinic at Hazrat Rasool Hospital, Tehran. Participants were randomly assigned to undergo either radical surgery (75 patients) or conservative surgery (70 patients). Data were collected through physical exams, interviews, surveys, and lab tests. Primary outcomes included chronic pelvic pain measured by the Visual Analog Scale (VAS) and sexual quality of life assessed using the Sexual Quality of Life Questionnaire for Women (SQOL-F). Patients were evaluated at baseline, and then at 6 and 12 months post-surgery. 1.3. Result Baseline comparisons showed significant differences between the two groups in terms of age, BMI, and number of children. Radical surgery resulted in greater long-term pain reduction but was associated with lower overall patient satisfaction compared to conservative surgery. Six and twelve months post-operation, the radical surgery group reported zero dissatisfaction, whereas the conservative group had higher dissatisfaction rates (25.7% and 27.1%, respectively). The conservative group showed a significant improvement in sexual quality of life scores one year post-surgery, despite initial lower scores. Radical surgery was more effective in reducing chronic pelvic pain over the study period. 1.4. Conclusion While radical surgery offers superior pain relief for stage 4 endometriosis, conservative surgery may provide better outcomes in terms of sexual quality of life and patient satisfaction. The findings highlight the importance of individualized treatment plans for women with severe endometriosis.

Objective: To evaluate the impact of twin dating by ultrasound-measured crown-rump length (CRL) of the larger (CRL-L), smaller (CRL-S) or mean twin measurement (CRL-M) on the rates of preterm birth (PTB) and detection of fetal growth restriction. Design: A cohort study. Setting: A tertiary fetal medicine centre (London, UK). Population or sample: All twin pregnancies between 1998 and 2023 who underwent ultrasound assessment of first trimester CRL and fetal growth. Methods: Data collection included CRL measurement, estimated fetal weight (EFW), pregnancy outcome and birthweight (BW) for each twin. Pregnancies were retrospectively re-dated by CRL-S, CRL-L and CRL-M. Main outcome measures: Small for gestational age (SGA) <10 th centile and PTB rates. Results: Of the 1129 twin pairs median CRL was 61mm (IQR:56.0-66.0) and 63mm (IQR:58.4-68.9) for the smaller and larger twin respectively with a mean discordance of 4.0%. Prenatal SGA diagnosis occurred in 19.8% and 23.1% of smaller twins when dated by CRL-S and CRL-L respectively. When pregnancies were dated by CRL-M versus CRL-S or CRL-L there was no difference in prenatal SGA diagnosis (p=0.275 and p=0.419); SGA at birth (p=0.132 and p=0.325); or PTB (p=1.00 and p=0.765 respectively). Conclusions: Dating by the smaller, larger or mean-twin CRL doesn’t significantly alter rates of extreme preterm birth, SGA detection or SGA birth. Dating by the mean twin CRL reduces stigmatisation of the smaller twin, alleviating parental anxiety, whilst retaining the utility of accurate gestational age assessment without impacting on clinical outcomes.

Objective: We examined the cost-effectiveness of conservative management (CM) compared to planned cesarean hysterectomy (CH) for placenta accreta spectrum (PAS). Design: A cost-effectiveness analysis in a theoretical cohort of patients. Setting : A decision analytic model. Population : A theoretical cohort of 1000 pregnant patients with PAS greater than 20 weeks gestation. Methods : In base case analysis, we assumed that between 20-40% of individuals would be eligible for CM. Model inputs were derived from the literature. Analysis was conducted from a healthcare system perspective with a one year analytic horizon. Outcomes included hysterectomy, surgical site infection (SSI), length of hospitalization, intensive care unit (ICU) admission, and death. An incremental cost-effectiveness ratio (ICER) of $50,000 per quality-adjusted life year (QALY) defined cost-effectiveness. Sensitivity analyses were performed. Main outcome measures: The cost gained per life year and per QALY. Results: For base-case estimates, CM was the cost-saving strategy with an ICER of $9330.51 USD. Compared to CH, CM resulted in 905 fewer hysterectomies, 80 fewer instances of SSI, and 5 fewer deaths. CM resulted in 149 more admissions with length of stay >5 days and 25 more ICU admissions . In probabilistic sensitivity analysis, CM was the cost-effective strategy in 71% of runs and the dominant strategy in 42% of runs. Conclusion: CM was the cost-effective strategy for management of PAS in greater than 70% of iterations of our model. Modeling demonstrated significant uncertainty in the comparative effectiveness of the two strategies, highlighting the need for prospective research evaluating the effectiveness of CM.

Objectives. To estimate postpartum depression at two months (PPD) prevalence and its related risk factors. Design. Multicentre prospective cohort study. Setting. France. Population or sample. Representative sample of 7,133 women participating to the French National Perinatal Survey (ENP) over one week in March 2021. Methods. Data on maternal characteristics, course of pregnancy/delivery, and child’s health were collected from face-to-face interviews in maternity wards and/or medical records, and a self-questionnaire (including the Edinburgh Postnatal Depression Scale (EPDS)) at two months postpartum. Women with an EPDS score >=13 were considered to have PPD. Poisson regression models with robust variance were used to estimate adjusted prevalence ratios (aPR) for PPD. Main Outcome Measures. PPD Results. PPD prevalence at two months was 16.7% (95%CI[15.7-17.7]). Factors significantly associated with PPD were: i/ age<=29 or >=40 years (maximum aPR=1.41 95%CI[1.12-1.77] obtained for 15-24 year-olds vs 35-39 year-olds), ii/ being born in North Africa (1.29[1.02-1.64] vs France), iii/ having a lower level of health literacy (1.23[1.14-1.35]), iv/ having a history of psychological (1.45[1.24-1.69]) or psychiatric (1.52[1.23-1.88]) care since adolescence (vs none), v/ receiving little/no support or good support during pregnancy (1.80[1.52-2.14] and 1.31[1.15-1.48] vs. receiving very good support), vi/ reporting feelings of sadness (1.92[1.65-2.25]), anhedonia (1.69[1.36-2.11]) or both (2.61[2.26-3.01]) during pregnancy (vs none of these feelings), vii/ having had an instrumental vaginal delivery (1.18[1.01-1.38] vs spontaneous vaginal delivery). Conclusions. Our findings on PPD (prevalence and risk factors) could guide policies on early identification and preventive support for women in the perinatal period.

Objective: Retained placenta is a serious complication of vaginal birth. The ability to predict retained placenta may have positive effect on timely management. We aimed to evaluate the maternal and obstetric risk factors associated with retained placenta after singleton live vaginal birth Methods: A retrospective cohort of women who had retained placenta after singleton live vaginal birth ≥ 24 weeks, compared in 1:2 ratio with women who had normal vaginal delivery without complications. Study and control group were matched for maternal age, gestational age and parity. Multivariate regression analysis was performed to evaluate the potential risk factors for retained placenta including maternal and obstetrical characteristics Results: Fifteen thousand two hundred sixty women underwent vaginal delivery at our medical center between 2015-2022. One hundred seventy women (1.1%) were diagnosed with retained placenta. Ninety-nine women (0.65%) who met the inclusion criteria, were matched with 198 women (1.3%) as controls. Multivariate logistic regression revealed various potential risk factors not previously described as associated with retained placenta including: IVF pregnancy (OR 3.8, 95% CI [1.3- 11.7], P 0.018), preeclampsia (OR 4.5, 95% CI[1.1- 17.5 ],P 0.0315), women with large for gestational age fetus (OR 28.2, 95% CI [5.4- 148.5], P 0.0298),labor Induction (OR 21.8, 95%CI [5.5- 86.8],P <0.001), vacuum assisted vaginal delivery (OR 2.3 .95% CI [1.2- 4.5], P 0.011), and Duration of second stage > 3 hours (OR 3.9,95%CI [1- 15.1], P <0.001) Conclusion: Our study highlights unreported risk factors associated with retained placenta such as macrosomia , in vitro fertilization and endometriosis. This emphasis on early risk identification and the exploration of possible preventive measures holds promise for enhancing antenatal care practices, ultimately improving outcomes for both mothers and infants .

Objective: To determine the optimal leading follicle size for triggering final oocyte maturation in POSEIDON groups 3 and 4 poor responders undergoing ART cycles. Design: Retrospective cohort study. Setting: University based Infertility Centre. Population: Data of 294 POSEIDON groups 3 and 4 poor responders aged between 20 and 42 years who underwent ICSI following a GnRH antagonist cycle between January 2015 and July 2021 were reviewed. Methods: Among the 342 patients eligible in our database, 294 fulfilling inclusion criteria were assessed for final analyses. Cycles were categorized into two groups according to occurrence of premature ovulation. Premature ovulation was defined as visualization of rupture of at least one of the leading follicles on the day of oocyte retrieval. In addition, number of oocytes retrieved, number of MII oocytes, MII/antral follicle count (AFC) ratio and follicle-oocyte index (FOI) were compared between different leading follicle sizes. Main Outcome Measures: Number of oocytes retrieved, number of MII oocytes, MII/antral follicle count (AFC) ratio and follicle-oocyte index (FOI). Results: Among all, 47 (16.2%) had premature ovulation between the trigger and oocyte pick-up days. The mean size of the leading follicle on the day of trigger was significantly higher in the premature ovulation group than the controls (19.8±2.4 mm vs.18.7±2 mm, respectively; P<0.001). Multivariate logistic regression analyses identified baseline LH (Odds ratio {OR} 1.144, 95% confidence interval {CI} 1.052-1.243; P=0.002), number of follicles >11 mm on the day of trigger (OR 0.580, 95% CI 0.438-0.767; P<0.001), and leading follicle size (OR 1.361, 95% CI 1.130-1.641; P=0.001) as independent predictors of premature ovulation. According to the one-way ANOVA test and non-linear curve estimation model the FOI and MII/AFC ratios peaked when the leading follicle size was between 16-17 mm, respectively. Conclusion: Individualized trigger based on leading follicle size can provide maximum efficiency in ovarian stimulation in POSEIDON expected poor responders. While late trigger may result in premature ovulation, early trigger may also result in less MII. Triggering when the leading follicle size is between 16.5 and 17 mm can help to prevent these negative outcomes and achieve optimal cycle outcome.

Serious concerns have been raised over safety of vaginal mesh tapes for stress urinary incontinence (SUI). Autologous rectus fascial sling and the more recent “sling on a string” through a laparotomy are gaining popularity as native tissue options for SUI. We describe a novel technique of laparoscopic mid-urethral autologous rectus fascial sling for SUI. Ten patients underwent this new technique safely. At six months, all subjects reported cure of SUI with normal voiding. The advantages of this technique include the minimal access approach, introduction of the sutures under laparoscopic guidance, and avoidance of over tightening of the sling.

Objective: To assess whether, in those requiring ongoing uterine stimulation after cervical ripening with oral misoprostol and membrane rupture, augmentation with low dose oral misoprostol is superior to intravenous oxytocin. Design: Open-label, superiority randomised trial Setting: Government hospitals in India Population: Women induced with oral misoprostol for hypertensive disease in pregnancy and requiring ongoing induction after membrane rupture Methods: Participants received misoprostol (25mcg orally two hourly) or titrated oxytocin through an infusion pump. Main Outcome Measure: Caesarean birth Results: 520 women were randomised and the baseline characteristics were comparable between the groups. The caesarean section rate was not reduced by the use of misoprostol (misoprostol 32.3% vs oxytocin 27.3%; adjusted odds ratio 1.226 (95% CI 0.81-1.85, p=0.33)). There were no differences in rates of hyperstimulation, fetal heart rate abnormalities, or maternal side effects, although the geometric mean time from randomisation to birth was 31 minutes longer with misoprostol. Fewer babies in the misoprostol arm were admitted to the special care unit (10 vs 21 in the oxytocin group) and there were no neonatal deaths in the misoprostol group, compared to 3 in the oxytocin arm. Women’s acceptability ratings were high in both study groups. Conclusion: Following cervical preparation with oral misoprostol and membrane rupture, the use of ongoing oral misoprostol for augmentation did not significantly reduce caesarean rates compared to oxytocin. The method, however, was safe for both mother and baby.

Abstract Background: Maternal mental health influences the metabolism and growth of fetal brain structures affecting their skills up to adulthood. Objective: Main objective is whether music interventions improve modifiable maternal health outcomes. Search Strategy: Up to July 2023, randomized controlled trials (RCTs) investigating music during pregnancy were identified using MEDLINE, CENTRAL, WEB OF SCIENCE. Selection Criteria: Using COVIDENCE reviewers screened for RCTs with >3 interventions applying the Perceived Stress Scale (PSS), State-Trait-Anxiety Inventory (STAI), Edinburgh Postnatal Depression Scale (EPDS), or blood pressure (BP) as outcome measures. Data Collection and Analysis: The revised Cochrane risk-of-bias tool (RoB2) and the reversed Cohen’s d were applied to investigate the impact of target groups, frequency, type and selection of music programs. The review was registered via PROSPERO CRD42022299950. Main Results: From 251 records, 14 RCTs (16 intervention arms) and 2375 pregnancies were included. Music interventions varied from 3 to 84 active or passive music sessions per pregnancy or 10 to 60 minutes per day and significantly decreased PSS in 2/4, STAI in 8/9, EPDS in 3/4 and BP in 3/4 RCTs. RoB2 was high in 5/14, or “with concerns” in 9/14 studies. Stratifying the Cohen’s d in 14 interventions arms suggested a big effect in 234/469 mothers on BP, and in 244/489 mothers on maternal anxiety. Conclusion: The findings show the dretailed potential of music interventions on maternal BP, stress resilience or anxiety complementing our research on complex music interventions throughout pregnancy in times of pandemics, violent conflicts, or natural catastrophes. Funding: Clara Angela Foundation. Key words: Music in pregnancy, systematic review, maternal stress, anxiety, and depression.

Objective: To investigate postnatal contraception use amongst physician women, who would be expected to be health-literate and therefore a possible “best case” scenario of postnatal contraception behaviours. Design: Secondary analysis of cross-sectional survey data Setting: United Kingdom Population or Sample: Registered physicians in the United Kingdom less than two years postpartum, aged 30-55 years old, who reported spontaneous conception. Methods: Secondary analysis of online, anonymous, survey data collected April - June 2021. Chi-squared or Fisher’s exact tests were used to compare efficacy of postnatal contraception by socio-demographics and experience of contraception counselling. A Sankey plot presents timing of initiation and type of postnatal contraception used. Main Outcome Measures: Postnatal contraception use; time postpartum at which contraception initiated; contraception efficacy. Results: Among the 146 women who had had sex postpartum, only 11.6% used a very effective method (LARC/ sterilisation) as first contraception, and 16.4% had had sex without appropriate postnatal contraception. Postnatal contraception-efficacy was associated with timing of initiation (p<0.001); 92.3% of women initiating contraception up to 3 weeks postpartum used effective or very effective methods. Contraception counselling at the place of birth was associated with initiation of effective or very effective postnatal contraception (p=0.041). Conclusions: Uptake of effective or very effective postnatal contraception in the first 6 months postpartum was low, despite a highly health-literate population. However, the significantly high proportion of women choosing these options less than 3 weeks postpartum indicates their acceptability where services are available.

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Recommendations for müllerian anomalies classificationSi Su1,2, Lan Zhu1*1 Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China2 Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China*Corresponding Author: Lan Zhu, MD, Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, No. 1 Shuaifuyuan, Dongcheng District, 100730, Beijing, China (zhu_julie@vip.sina.com)The word count for the main text: 506.In 2021, a new müllerian Anomalies Classification was proposed by American Society for Reproductive Medicine (ASRM 2021), 1 which was based on the American Fertility Society (AFS) 1988 2 and combined the benefits of existing classifications. However, mullerian anomalies is a group of complex diseases with various manifestations. And no consensus has been reached about the classification and diagnosis in clinical practice. The purpose of this study is to test the clinical application value of this new classification through the analysis of the cases from Peking Union Medical College Hospital in the past 20 years, and put forward valuable recommendations.A retrospective study was conducted using clinical data of hospitalized patients from January 2003 to December 2022 from Peking Union Medical College Hospital. Inclusion criteria included patients with 46, XX karyotype, diagnosed of müllerian anomalies, and clearly identified alterations of the uterus, cervix, and vagina. Clinical data of patients were collected through the hospital information system, and classification was performed based on the ASRM 2021. SPSS 25.0 version was used for data analysis.2671 patients were included, with an average visiting age of 28.9±10.0 years. The most common is septate uterus with 1144 cases (42.8%), followed by MRKH syndrome (20.4%), Herlyn-Werner-Wunderlich syndrome (HWWS) (10.4%), unicornuate uterus (7.4%), cervical agenesis (6.5%), uterus didelphys (5.6%), bicornuate uterus (2.9%), longitudinal vaginal septum (without uterine malformation) (2.0%), transverse vaginal septum (1.2%), complex anomalies (0.5%) and other anomalies (0.3%) (Table 1). It should be emphasized that HWWS was taken as an independent classification for statistical analysis, with reference to the clinical definition (uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis).3,4 13 cases of complex anomalies were identified and 8 cases that could not be classified were classified as other anomalies (Supplement table 1).ASRM 2021 was proposed based on the AFS 1988, which is the most widely used classification in the past 30 years. We found ASRM 2021could distinguish most clinical patients well, but there are still some shortcomings. First, the classification of patients with uterine malformations and longitudinal/transverse/oblique vaginal septum is not clear. We recommend that patients with longitudinal vaginal septum and uterine anomalies should be classified into the uterine anomalies respectively, while others without uterine anomalies should be included in longitudinal vaginal septum. All transverse vaginal septum should be included in transverse vaginal septum, because the symptoms of transverse septum are prominent. A new type of HWWS should be added. Because the obstructive symptom is prominent. Second, we found several cases of complex anomalies. For these patients, multidisciplinary and individualized treatment should be carried out. The anomalies we found that are not currently classified include T-shaped uterus, congenital vaginal stenosis, and accessory and cavitated uterine masses (ACUM). With the deeper insight into this field, there may be a better way to classify them. The limitation of this study is that as a single-center retrospective study, there could be statistical biases.In conclusion, we put forward following suggestions for ASRM 2021 classification: 1) Minimize overlaps of classification and add a type of HWWS; 2) Update complex anomalies timely; 3) Add other anomalies classification.

Cesarean Section Rates in India: A Retrospective Analysis of Districts and States from 2011 to 2019

Objective: Increased rates of pro-inflammatory and metabolic-related disorders, plus perinatal death and other pregnancy complications such as gestational diabetes (GDM), are consistently reported among women of Indian ethnicity. This study compares lipid profiles and early pregnancy biomarkers associated with metabolic dysfunction between healthy nulliparous pregnant women of Indian and European ethnicity. Design: a prospective cohort study. Setting: Australia, Ireland, New Zealand and the United Kingdom; 2004-2011. Population: 138 and 5,240 women of Indian and European ethnicity were included from the prospective Screening for Pregnancy Endpoints cohort study. Methods: Early pregnancy biomarkers were selected a priori on the basis of a potential association with the metabolic syndrome, diabetes/GDM or obesity, and compared between ethnic groups. Biomarkers that differed significantly between ethnic groups were adjusted for maternal age, body mass index, smoking, alcohol use and socioeconomic status. Main outcome measures: Mean values for 21 placental, metabolic, inflammatory and cardiovascular biomarkers, plus blood lipids, measured at 15±1 weeks gestation. Results: Ten biomarkers were significantly different by ethnicity, mostly consistent with a pro-inflammatory and less favourable metabolic profile in Indian women: PlGF (p=0.02), adiponectin (p<0.01), NGAL (p<0.01), TNFR1A (p<0.01), CXCL10 (p=0.01), ICAM-1 (p<0.01), ST2 (p<0.01), angiogenin (p<0.01), and proANP (p<0.01). We additionally found increased triglycerides (1.6±0.6 vs 1.5±0.6, p<0.01) and reduced HDL cholesterol (1.7±0.4 vs 1.9±04, p<0.01) in Indian mothers, compared with European. Conclusions: Low-risk mothers of Indian ethnicity have an overall less favourable metabolic health profile at early gestation compared with European women. Future research should investigate the association with pregnancy outcomes.

Objective: Few studies have examined whether number of births is associated with women’s aging. This study aims to evaluate the association of number of births with women’s biological aging, premature mortality and life expectancy. Methods: A total of 272,494 participants from UK biobank who completed the questionnaire on number of live births were enrolled at baseline. The number of births was categorized into 6 groups, and participants with one live birth was the reference group. General linear regression model and cox proportional hazards model were performed to evaluate the association of number of births with women’s biological aging and premature mortality. Restricted cubic spline (RCS) was used to visualize dose-response relationship. Moreover, the latest Office for National Statistics life tables rom was used to calculate the life expectancy. Results: During a median follow-up of 11.9 years, a total of 10,992 cases of all-cause premature death were documented. After adjustment for potential confounders, compared to women had one birth, childless women had greater premature death (hazard ratio, HR=1.17, 95%CI: 1.09-1.25), whereas women with two or three children had lower risk of premature death (HR=0.87, 95%CI:0.82-0.93, HR=0.90, 95%CI: 0.82-0.99), which showed a U-shaped relationship visualized by RCS (P<0.05 for non-linearity). Further, at age 40, childless women had 1.41 years lower life expectancy, and women with two children was related to 1.10 years higher life expectancy. Moreover, compared to women had one birth, the women with two or three children had lower corrected estimated values of FI, ΔKDM-biological age and HD, and the women with five or more children had higher corrected estimated values of FI, ΔKDM-biological age, and HD (all the P<0.05). Conclusions: The association of number of live births with women’s biological aging, premature mortality and life expectancy had a U-shape relation. The childless or five more child women were more likely to be aging with increased risk of premature death and decreased life expectancy years. The double-child women decreased aging process with lower risk of premature death and high life expectancy.

Objective: To explore the potential factors that contribute to the occurrence of medical abortion(MA) through a Mendelian randomization(MR) study. Design: Univariate MR(UVMR) and multivariate MR(MVMR) analyses. Setting: Genetic variants from European populations. Population or Sample: Instrumental variants for MA were obtained from FinnGen with 36,232 cases and 149,622 controls. Methods: The inverse variance weighting method was adopted as the primary analysis. Main outcome measures: The associations of MA with household income(HI), education attainment(EA), cognitive performance(CP), risky behaviors: smoking behavior(SB), alcohol consumption(AC), and reproductive traits: age at first sexual intercourse(AFS), lifetime number of sexual partners(LNSP), age at first birth(AFB), age at last birth(ALB). Results: In the UVMR, increasing HI, EA, AFS and AFB appeared to reduce MA risk(HI, OR=0.569, P = 7.93E-08; EA, OR=0.875, P = 6.02E-21; AFS, OR=0.439, P = 5.17E-25; AFB, OR=0.815, P = 5.46E-12), whereas SB and LNSP appeared to add to MA risk((SB, OR=1.424, P =8.32E-11; LNSP, OR=2.777, P =2.14E-11). In the MVMR, EA, SB, LNSP and AFS seems to be the predominant risk factor for MA risk with the independent effect, while HI had no effect after controlling EA(HI in model 1, OR=0.890, P = 5.78E-01). AFB functioned as mediators in the causal chain of MA risk reduction by EA, with the mediated proportion of AFS and AFB being 57.8%. Conclusions: Our MR study demonstrated the causal potential of the associations of HI, EA, SB, LNSP, AFS and AFB with medical abortion.

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