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Objectives: To introduce a two‐dimensional sonographic method to assess the fetal anus, and to evaluate the feasibility of this method to diagnose anal atresia prenatally and identify the presence or absence of anoperineal fistula (in males) and anovestibular fistula (in females). Methods: This was an observational study of suspected cases of anal atresia referred to a single center in Israel between August 2018 and October 2023. In addition to conventional evaluation of the perineum in the axial plane, fetuses referred to our center for suspected malformation were scanned with a new method termed the 'infracoccygeal/transperineal window'. This window consisted of a midsagittal view of the fetal pelvis, including the distal rectum and the anal canal. Normal anatomy was confirmed when the anal canal was continuous with the rectum and terminated at the expected location on the perineum. In female fetuses, the normal anal canal runs parallel to the vaginal canal and diverges posteriorly, terminating at the perineal skin, distant from the vestibule. In male fetuses, the normal anal canal diverges posteriorly in relation to the corpora cavernosa, terminating at the perineal skin, distant from the scrotum. High anal atresia was identified when a blind‐ending rectal pouch was demonstrated in the pelvis without a fistula to the perineum or vestibule. Low anal atresia was determined when a rectal pouch was continuous with an anteriorly deflected fistula. In females, the fistula converges with the vaginal canal, terminating at the vestibule; in males, the fistula deflects anteriorly, terminating at the base of the scrotum. Postnatally, the diagnosis and type of anal atresia were confirmed through physical examination with direct visualization of the fistula, radiographic studies, surgical examination and/or postmortem autopsy. Results: Of the 16 fetuses diagnosed prenatally with anal atresia, eight were suspected to have low anal atresia and eight were suspected to have high anal atresia. The median gestational age at diagnosis was 23 (range, 14–37) weeks. All cases showed additional structural malformation. Eleven patients opted for termination of pregnancy, of which four had low anal atresia and seven had high anal atresia. Postnatal confirmation was not available in four cases due to curettage‐induced mutilation or in‐utero degradation following selective termination of the affected twin, leaving 12 cases for analysis, of which seven were diagnosed with low anal atresia and five with high anal atresia. In these 12 cases, all prenatal diagnoses were confirmed as correct, rendering 100% sensitivity and 100% specificity in this high‐risk fetal population. Conclusions: The infracoccygeal/transperineal window is an effective method to detect and classify the level of anal atresia prenatally. This may improve prediction of postnatal fetal continence and optimize prenatal counseling. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background and Aims: Obstetric fistula is a severe birth injury that profoundly impacts women's health, social well‐being, economic stability, and psychological state. While it can be prevented with timely emergency obstetric care, a significant barrier in many developing regions, including the study area, is the lack of awareness among women. This study aimed to evaluate the level of awareness about obstetric fistula and the factors influencing it among the Women Health Development Army in the South Gondar zone of the Amhara region, Ethiopia, in 2020. Methods: A community‐based cross‐sectional study was done from July to December 2020, involving 633 women. Participants were selected using a multistage stratified sampling method. Data were collected using a pretested, interviewer‐administered structured questionnaire. Data entry was performed using EpiData version 3.1, and analysis was conducted with SPSS version 23.0. Multivariable logistic regression models were employed to identify influencing factors, with a p < 0.05 considered statistically significant. Results: This study found that 55.3% (95% CI, 51.6%–57.2%) of study participants had a good awareness of obstetrics fistula. Significantly associated factors include; no history of ANC (AOR = 0.52: 95% CI, 0.31, 0.86), living >30 min away from a health facility (AOR = 0.43: 95% CI, 0.23, 0.81), no history of abortion (AOR = 0.37: 95% CI, 0.19, 0.72), Injectable and implant users (AOR = 3.60: 95% CI, 1.98, 6.53), having four to six pregnancy (AOR = 1.87: 95% CI, 1.22, 2.87) and lack of communication material in the house (AOR = 0.19: 95% CI, 0.10, 0.37). Conclusions: This study found that 55.3% of women have a good awareness of obstetrics fistula. ANC follow‐up history, abortion history, type of family planning, type of communication, number of pregnancies, availability of health facility, and distance of health facility were significantly associated with awareness of obstetric fistula. Hence, local and national efforts should be made to enhance access to information at home and basic maternal health services including antenatal care. [ABSTRACT FROM AUTHOR]

Objective: To present the contemporary evidence on transvaginal urogenital fistulae (UGF) repair with Martius fat pad (MFP), compared to direct graftless fistula repair. Methods: We reviewed all available studies reporting lower UGF repair via the transvaginal approach in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome of interest was the fistula closure rates. When available, patients' baseline characteristics, indications for surgery, and early and late postoperative complications with focus on MFP‐related complications are reported. Results and Discussion: In obstetric fistulae, tissue interposition has been almost completely abandoned, with contemporary large series reporting closure rates of >90% with graftless repair, even for complex fistulae. Similarly, most simple, non‐irradiated iatrogenic fistulae can be closed safely without or with tissue interposition with success rates ranging between 86% and 100%. However, MFP is valuable in fistulae with difficulty achieving tension‐free and layered closure, with significant tissue loss, urethral involvement and with poorly vascularised tissues after radiotherapy, with reported success rates between 80% and 97% in those challenging situations. Conclusion: A UGF repair should be individualised after considering the specific characteristics and complexity of the procedure. MFP interposition is probably unnecessary for the majority of low (obstetric) fistulae within otherwise healthy tissues. However, MFP may still have a place to maximise outcomes in low‐income settings, in select cases with higher (iatrogenic) fistulae, and in most cases with radiotherapy. [ABSTRACT FROM AUTHOR]

Objective Design Setting Methods Results Conclusions Globally, obstetric fistula is a tragic outcome following obstructed labour. Failure of complex repair and post‐operative incontinence are common. We describe an innovative surgical technique incorporating the rectus abdominus flap at the time of fistula repair.Retrospective case series.Malawi, Fistula Care Centre.Patients were followed for 3 months after discharge to determine continence and healing.Five of six patients were continent at 3 months and one was lost to follow‐up by dry at a one month post‐operative phone call. There were no major complications.The rectus abdominus flap may be a useful adjunct to repair of complex obstetric fistula. [ABSTRACT FROM AUTHOR]

Objective: Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long‐term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS. Methods: A Swedish nationwide cohort study including singleton term vaginal births during 2005–2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub‐analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC). Results: In all, 988 804 births were included. The rate of OASIS in Swedish‐born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60–1.83), as did women born in Sub‐Saharan Africa (aRR 1.60, 95% CI 1.49–1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56–0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60–3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92–0.98), but not significantly more protective among women with female genital mutilation. Conclusions: Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub‐Saharan Africa are at significantly increased risk as compared with Swedish‐born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS. Synopsis: Maternal country of birth plays an important role in the risk of sphincter injuries. Female genital circumcision is associated with increased risk of sphincter injuries. [ABSTRACT FROM AUTHOR]

Background: Obstetric fistula develops from obstructed labor and is a devastating condition with significant consequences across several domains of a woman's life. This study presents a narrative review of the evidence on the economic consequences of obstetric fistula. Methods: Three databases were searched, and search results were limited to English language papers published after 2003. Search results were reviewed for relevance based on title and abstract followed by full text review using specific inclusion and exclusion criteria. Bibliographies of papers were also scanned to identify relevant papers for inclusion. Data were extracted under three categories (defined a priori): the economic consequences of having the condition, the economic consequences of seeking care, and the macroeconomic impacts. Results: The search returned 517 unique papers, 49 of which were included after screening. Main findings identified from the studies include women losing their jobs, becoming dependent on others, and losing financial support when relationships are lost. Seeking care was economically costly for families or unaffordable entirely. There were no studies describing the impact of fistula on national economies. Conclusion: Economic consequences of obstetric fistula are multifaceted, pervasive, and are intertwined with the physical and psychosocial consequences of the condition. Understanding these consequences can help tailor existing fistula programs to better address the impacts of the condition. Further research to address the dearth of literature describing the macroeconomic impact of obstetric fistula will be critical to enhance the visibility of this condition on the health agendas of countries. Synopsis: Women experiencing obstetric fistula lose income, become financially dependent on others, and face economic barriers and hardships when seeking care for the condition. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether perineal infiltration of ropivacaine after episiotomy would decrease the incidence of postpartum pain compared with placebo. Design: Two‐centre, double‐blind, randomised, controlled trial. Setting: Two French maternity units, October 2017 to April 2020. Population: 272 women undergoing epidural analgesia with vaginal singleton delivery and mediolateral episiotomy at term (≥37 weeks) were randomly allocated perineal infiltration of ropivacaine (n = 135) or placebo (n = 137) in a 1:1 ratio before episiotomy repair. Methods: Patients were followed at short term (12, 24, 48 h), mid‐term (day 7) and long‐term (3 and 6 months). Main outcome measures: The primary outcome was the rate of perineal pain, defined by a Numerical Pain Rating Scale (NPRS) exceeding 3/10, in the mid‐term (day 7) postpartum period. Secondary outcomes were perineal pain (NPRS) and analgesic intake, quality of life (SF‐36), postpartum depression (EPDS), pain neuropathic component (DN4) and sexual health (FSFI). Results: Perineal pain occurred to an equal extent in the ropivacaine and placebo groups at day 7 (34.2% versus 30.4%, odds ratio 1.1, 95% confidence interval 0.7–1.8, p = 0.63). Similar results were recorded in the short and long term. High rates of dyspareunia and postpartum depression were documented in both groups. No differences were highlighted between the groups in terms of analgesic intake, adverse events, pain neuropathic component and postpartum quality of life. Conclusions: This study did not demonstrate any benefit of ropivacaine infiltration over placebo. [ABSTRACT FROM AUTHOR]

Summary: The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri‐operative cardiac arrest. Additional inclusion criteria for obstetric anaesthesia were: cardiac arrest associated with neuraxial block performed by an anaesthetist outside the operating theatre (labour epidural analgesia); and cardiac arrest associated with remifentanil patient‐controlled analgesia. There were 28 cases of cardiac arrest in obstetric patients, representing 3% of all cardiac arrests reported to NAP7, giving an incidence of 7.9 per 100,000 (95%CI 5.4–11.4 per 100,000). Obstetric patients were approximately four times less likely to have a cardiac arrest during anaesthesia care than patients having non‐obstetric surgery. The single leading cause of peri‐operative cardiac arrest in obstetric patients was haemorrhage, with underestimated severity and inadequate early resuscitation being contributory factors. When taken together, anaesthetic causes, high neuraxial block and bradyarrhythmia associated with spinal anaesthesia were the leading causes overall. Two patients had a cardiac arrest related to labour neuraxial analgesia. There were no cardiac arrests related to failed airway management or remifentanil patient‐controlled analgesia. [ABSTRACT FROM AUTHOR]

Objective: Surgery for obstetric fistula is a highly effective treatment to restore continence and improve quality of life. However, a lack of data on the cost‐effectiveness of this procedure limits prioritization of this essential treatment. This study measures the effectiveness of fistula surgeries using disability‐adjusted life years (DALYs) averted. Methods: In 2021 and 2022, the Fistula Foundation funded 20 179 fistula surgeries and related procedures at 143 hospitals among 27 countries. We calculated DALYs averted specifically for vesicovaginal fistula and rectovaginal fistula procedure types (n = 13 235 surgeries) by using disability weights from the 2019 Global Burden of Disease study. We based cost calculations on direct treatment expenses, including medical supplies, health provider fees, and preoperative and postoperative care. We measured effectiveness using data on the risk of permanent disability, country‐specific average life spans, and treatment outcomes. Results: The total treatment cost was $7.6 million, and a total of 131 433 DALYs were averted. Thus, the cost per DALY averted—the cost to restore 1 year of healthy life—was $58. For this analysis, we took a cautious approach and weighted only surgeries that resulted in a closed fistula with restored continence. We calculated DALYs averted by country. Limitations of the study include data entry errors inherent in patient logs and lack of long‐term outcomes. Conclusion: The current study demonstrates that obstetric fistula surgery, along with having a significant positive impact on maternal health outcomes, is highly cost‐effective in comparison with other interventions. The study therefore highlights the benefits of prioritizing fistula treatment as part of the global agenda for maternal health care. Synopsis: Obstetric fistula treatment is highly cost‐effective. The current study highlights the benefits of prioritizing fistula treatment as part of the global agenda for maternal health care. [ABSTRACT FROM AUTHOR]

The quest to ensure maternal health has long been in focus, mainly since the Safe Motherhood Initiative of the 1980s. Maternal health is contingent, among other things, on the availability of maternal health care services and the context in which the services are available. Therefore, we conducted rapid ethnographic research at four public hospitals in Southwest Ethiopia to gain anthropological insights into maternal health, maternal health‐seeking behavior, and healthcare services. We collected data from maternal near‐miss patients, patients with obstetric fistula, and health professionals working in maternity and labor wards. Our data reveal that there has been a huge effort to promote institutional delivery and ensure maternal health in the study area. However, failure to consider socioculturally embedded issues undermined the outcome of these efforts. We suggest that maternal health‐seeking for institutional delivery and, hence, ensuring maternal health should be understood as a process that should take into account these socioculturally embedded issues. [ABSTRACT FROM AUTHOR]

Objective: Our aim is to describe the epidemiological, anatomoclinical and therapeutic profile of obstetric fistula (OF) in the Democratic Republic of the Congo (DRC). Methodology: This was a descriptive retrospective study that collected 1416 obstetric fistulas in 1267 patients in seven provinces of the DRC, treated between January 2017 and December 2022. The variables studied were epidemiological, anatomoclinical and therapeutic. Results: The mean age of patients at the time of surgical repair was 33.2 years (range: 15 and 77 years) and 32.8% of patients were aged between 20 and 29 years. The mean age of the fistula at repair was 10 years (range: 3.5 months and 56 years). At the time of fistula, 61.7% of patients had delivered vaginally and 28.7% by caesarean section and 8.2% of patients had a haemostasis hysterectomy. Labour lasted at least 3 days in 47.3% of these patients for the fistula birth. Deliveries took place either at home (27.4%) or in a health facility (72.6%); 83.6% of newborns resulting from these births had died. Taken as a whole, urogenital fistulas are more common than genito‐digestive fistulas. Urethro‐vaginal (26.2%) and vesico‐uterine (24.7%) anatomoclinical entities were predominant among urogenital fistulas. A total of 1416 fistulas were surgically repaired in 1267 patients. These repairs were successful for 1226 (86.6%) fistulas. The main surgical route used was transvaginal (68.8%). Conclusion: In the DRC, obstetric fistula is common in young adult women. It often results from vaginal delivery, after prolonged labour. Fistula births often result in the death of newborns. Uro‐genital obstetric fistulas are the most frequent with predominance of urethro‐vaginal and vesico‐uterine anatomoclinical entities. Fistulas remain untreated for a long time. Mostly done transvaginally, surgical repair gives a good result. [ABSTRACT FROM AUTHOR]

Introduction: For women presenting with breast cancer during pregnancy, treatment guidelines were historically restricted to only surgical treatment. Over the past decades, chemotherapy administered during pregnancy has been gradually introduced. Although breast cancer treatments during ongoing pregnancy have been deemed safe, detailed information on potential obstetric risks is lacking. We aimed to assess the risk of adverse obstetric and perinatal outcomes of breast cancer in pregnancy and within 1 year postpartum and in relation to trimester at breast cancer diagnosis, tumor stage, and cancer treatment during pregnancy. Material and methods: Population‐based matched study. Women diagnosed with breast cancer during pregnancy in 1973–2017 were identified in the Swedish Cancer Register and the Medical Birth Register, with additional information from the National Quality Register for Breast Cancer. Each birth with maternal breast cancer (n = 208 pregnant, n = 672 postpartum) was matched by age, calendar year, and birth order to 10 unexposed births from cancer‐free women in the population (n = 2080 and n = 6720). Adjusted conditional logistic and multinomial regression models were used to estimate odds ratios and relative risk ratios, commonly denoted relative risks (RR) with 95% confidence intervals (CI), of adverse obstetric and perinatal outcomes. Results: Breast cancer during pregnancy was associated with higher risks of preterm birth, both planned (RR 67.1, 95% CI 33.2–135.6) and spontaneous preterm birth (RR 3.8, 95% CI 2.0–7.5), and low birthweight (<2500 g: RR 7.5, 95% CI 4.9–11.3). The associated risks were higher if the breast cancer was diagnosed in the second trimester, and of similar magnitude irrespective of stage and treatment groups. There was a higher risk of low birthweight for gestational age (<25th centile) if breast cancer was diagnosed in the first trimester (RR 2.8, 95% CI 1.1–7.3). Risks of other pregnancy complications were similar to those of unexposed women, as were risks of neonatal mortality and malformations. Postpartum breast cancer was only associated with bleeding during pregnancy (RR 1.6, 95% CI 1.0–2.8). Conclusions: Preterm birth and related adverse outcomes were more common in women diagnosed with breast cancer during pregnancy. Reassuringly, breast cancer was not associated with other maternal pregnancy complications or adverse outcomes in children. [ABSTRACT FROM AUTHOR]

Objective: To retrospectively assess changes in economic status, psychosocial status and empowerment among women who participated in Beyond Fistula reintegration programming following fistula repair. Methods: We conducted a retrospective study among 100 Beyond Fistula program participants capturing sociodemographic characteristics, obstetric and fistula history, program participation, and our primary outcomes: economic status, psychosocial status, and empowerment via quantitative survey at two time points: before program participation and currently. Data were collected from November 2020 to July 2021 from 2013 to 2019 program participants. We compared outcomes across these two time points using paired t tests or McNemar's tests. Results: The proportion of individuals owning property (28.0% vs. 38.0%, P = 0.006), having a current source of income (19.0% vs. 56.0%, P < 0.001), and saving or investing income (11.0% vs. 37.0%, P < 0.001) increased significantly from pre‐ to post‐programming. We also identified statistically significant increases from pre‐ to post‐programming in self‐esteem (5.0 [IQR 4.0–5.0] vs. 5.0 [IQR 5.0–5.0], P < 0.001), reintegration (53.0 [IQR 43.0–69.0] vs. 65.0 [IQR 51.0–72.0], P < 0.001) and level of input into household economic decision making (2.0 [SD 1.0] vs. 2.3 [SD 1.0], P = 0.004). Conclusion: Beyond Fistula programming likely improved economic status, psychosocial status, and empowerment of participants. Post‐surgical interventions incorporating a holistic approach can advance recovery through supporting psychosocial and economic wellbeing and should be offered to women undergoing genital fistula repair. Synopsis: A retrospective impact evaluation of the Beyond Fistula post‐surgical reintegration program in Kenya identified significant improvements in economic status, psychosocial status and empowerment. [ABSTRACT FROM AUTHOR]

Background: An ongoing barrier to sustainable obstetric fistula (OF) care is the lack of trained fistula surgeons. Despite a standardized training curriculum, data regarding OF repair training remain limited. Objectives: To assess the availability of literature on the case numbers or training duration required for OF repair competency and whether these data are stratified by trainee background or repair complexity. Search strategy: A systematic search of MEDLINE, Embase, and OVID Global Health electronic databases and gray literature. Selection criteria: All English sources from all years from low‐ and middle‐income and high‐income countries were eligible. Identified titles and abstracts were screened and full‐text articles were reviewed. Data collection and analysis: Data collection and analysis included a descriptive summary organized by training case numbers, training duration, trainee background, and repair complexity. Results: Of the 405 sources retrieved, 24 were included in the study. The only concrete recommendations were in the International Federation of Gynecology and Obstetrics 2022 Fistula Surgery Training Manual, which proposes 50 to 100 repairs (Level 1), 200 to 300 repairs (Level 2), and trainer discretion for Level 3 competency. Conclusions: More case‐ or time‐based data, particularly if stratified by trainee background and repair complexity, would be useful at the individual, institutional, and policy level for fistula care implementation or expansion. Synopsis: More research is required regarding the number of cases and time duration needed to achieve competency in obstetric fistula repair. [ABSTRACT FROM AUTHOR]

Background: Stillbirth and (obstetric) fistula are traumatic life events, commonly experienced together following an obstructed labour in low‐ and middle‐income countries with limited access to maternity care. Few studies have explored women's experiences of the combined trauma of stillbirth and fistula. Aim: To explore the lived experiences of women following stillbirth and fistula. Methods: Qualitative, guided by Heideggerian phenomenology. Twenty women who had experienced a stillbirth were interviewed while attending a specialist Hospital fistula service in urban Kenya. Data were analysed following Van Manen's reflexive approach. Results: Three main themes summarised participants' experiences: 'Treated like an alien' reflected the isolation and stigma felt by women. The additive and multiplying impacts of stillbirth and fistula and the ways in which women coped with their situations were summarised in 'Shattered dreams'. The impact of beliefs and practices of women and those around them were encapsulated in 'It was not written on my forehead'. Conclusion: The distress women experienced following the death of a baby was intensified by the development of a fistula. Health professionals lacked an understanding of the pathophysiology and identification of fistula and its association with stillbirth. Women were isolated as they were stigmatised and blamed for both conditions. Difficulty accessing follow‐up care meant that women suffered for long periods while living with a constant reminder of their baby's death. Cultural beliefs, faith and family support affected women's resilience, mental health and recovery. Specialist services, staff training and inclusive policies are needed to improve knowledge and awareness and enhance women's experiences. Patient or Public Contribution: A Community Engagement and Involvement group of bereaved mothers with lived experience of stillbirth and neonatal death assisted with the review of the study protocol, participant‐facing materials and confirmation of findings. [ABSTRACT FROM AUTHOR]

Objective: To present clinical and instrumental sequelae after obstetric anal sphincter injuries (OASIS), evaluating correlations between intrapartum severity of lesions, postpartum symptoms, and sonographic and manometric findings; outcomes during subsequent deliveries were also evaluated. Methods: This retrospective study evaluated all consecutive women who sustained an OASIS between 2015 and 2020. Postpartum symptoms, anorectal manometry (ARM), and three‐dimensional endoanal ultrasonography (3D‐EAUS) were analyzed. Results: A total of 107 women underwent OASIS primary repair; 84 (78.5%) of them were asymptomatic after 1 month. The presence and severity of symptoms showed a great correlation with instrumental outcomes in terms of maximum resting pressure, squeeze pressure increment (SPI), circumferential extension of defect for both external anal sphincter (EAS) and internal anal sphincter (IAS), and EAS, IAS and total Starck scores. There was a significant correlation between ARM and 3D‐EAUS findings, with the exception of SPI, for which the abnormalities were not predictable based on EAUS results. Conclusion: Both ARM and EAUS findings after OASIS are directly related to each other, and associated with symptoms. These instrumental tools may be useful for OASIS assessment and counseling. Synopsis: Endoanal ultrasound and anal manometry after obstetric anal sphincter injuries are directly related to each other, and are associated with symptoms and quality of life. [ABSTRACT FROM AUTHOR]

The purpose of this State‐of‐the‐Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two‐dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high‐quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost‐effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high‐quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first‐line approach as long as the residual myometrial thickness is at least 2.5–3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: To assess the association between episiotomy and severe obstetric anal sphincter injury (OASIS) in nulliparous women at term according to the use of an instrument for delivery with control confounding by indication. Methods: This was an observational retrospective cohort study including 12 346 women from 2004 to 2020. All nulliparous women with a cephalic singleton pregnancy were included. The primary outcome was the occurrence of OASIS. Association between episiotomy and OASIS was assessed by multivariate logistic regression with adjustment for confounding factors and stratification on the use of an instrument at delivery. Propensity score matching was used to account for indication bias. Results: Among 12 346 women included, 7803 (63.2%) had an episiotomy and 4543 (36.8%) did not have an episiotomy; the rate of OASIS was similar in both groups (0.7%). After stratification on use of instrument, an association between episiotomy and OASIS was shown in the case of instrumental delivery (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26–0.80) but not if the delivery was spontaneous (OR 0.76, 95% CI 0.29–1.98). The result was similar after matching on propensity score (in the case of operative vaginal delivery: OR 0.20, 95% CI 0.10–0.75). Conclusion: Episiotomy seems to be a protective factor for OASIS in nulliparous woman at term only in the case of operative vaginal delivery. Synopsis: Episiotomy seems to be a protective factor for OASIS in nulliparous woman at term only in the case of operative vaginal delivery. [ABSTRACT FROM AUTHOR]

Introduction: Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum. Material and methods: This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs). Results: At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5–7.7) and 3.6 (95% CI 1.6–8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1–11.5) and 8.3 (95% CI 3.8–18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1–13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1–3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3–4.5). Conclusions: This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying. [ABSTRACT FROM AUTHOR]

Objective: The aim of the current study was to assess whether Low Anterior Resection Syndrome (LARS) score could provide additional unique information to the Wexner score when assessing fecal incontinence (FI) in women with previous obstetric injury, thus providing a better foundation for treatment decisions. Methods: This was a retrospective cohort study with intraindividual comparison of two scoring systems. Women with previous obstetric injury and diagnosed with FI between January 1, 2015, and December 31, 2018, with valid LARS and Wexner scores were included. Statistical methods used were Spearman rank correlation, Kendall τ, scatterplot, and ratios. Results: Seventy women were included. Correlation coefficients varied from 0.42 to 0.66 (Spearman rank correlation) and 0.44 to 0.51 (Kendall τ). Cohen κ values varied from 0.33 to 0.67. No strong association was seen in the correlation analyses or the scatterplot. Conclusion: LARS score was shown to provide extra relevant information when assessing FI in women with previous obstetric injury. All symptoms should be considered relevant when assessing FI since it is a complex condition and should be approached accordingly. The authors suggest a combination of LARS and Wexner scores when assessing FI among women with previous obstetric injury. Synopsis: Assessment of fecal incontinence should focus on all aspects of its symptoms. Low Anterior Resection Syndrome score provides unique information when assessing fecal incontinence in women after obstetric injury. [ABSTRACT FROM AUTHOR]

Introduction: Perinatal management of extremely preterm births in Sweden has changed toward active care from 22-23 gestational weeks during the last decades. However, considerable regional differences exist. This study evaluates how one of the largest perinatal university centers has adapted to a more active care between 2004-2007 and 2012-2016 and if this has influenced infant survival. Material and methods: In this historical cohort study, women admitted with at least one live fetus and delivered at 22-25 gestational weeks (stillbirths included) at Karolinska University Hospital Solna during April 1, 2004-March 31, 2007, and January 1, 2012-December 31, 2016, were compared regarding rates of obstetric and neonatal interventions, and infant mortality and morbidity. Maternal, pregnancy and infant data from 2004-2007 were obtained from the Extreme Preterm Infants in Sweden Study while data from 2012-2016 were extracted from medical journals and quality registers. The same definitions of interventions and diagnoses were used for both study periods. Results: A total of 106 women with 118 infants during 2004-2007 and 213 women with 240 infants during 2012-2016 were included. Increases between the study periods were seen regarding cesarean delivery (overall rate 14% [17/118] during 2004-2007 vs. 45% [109/240] during 2012-2016), attendance of a neonatologist at birth (62% [73/118] vs. 85% [205/240]) and surfactant treatment at birth in liveborn infants (60% [45/75] vs. 74% [157/211]). Antepartum stillbirth rate decreased (13% [15/118] vs. 5% [12/240]) and the proportion of live births increased (80% [94/118] vs. 88% [211/240]) while 1-year survival (64% [60/94] vs. 67% [142/211]) and 1-year survival without major neonatal morbidity (21% [20/94] vs. 21% [44/211]) among liveborn infants did not change between the study periods. At 22 gestational weeks, interventions rates were still low during 2012-2016, most obvious regarding antenatal steroid treatment (23%), attendance of a neonatologist (51%), and intubation at birth (24%). Conclusions: Both obstetric and neonatal interventions at births below 26 gestational weeks increased between 2004-2007 and 2012-2016 in this single center study; however, at 22 gestational weeks they were still at a low level during 2012-2016. Despite more infants being born alive, 1-year survival did not increase between the study periods. [ABSTRACT FROM AUTHOR]

Primary outcome was pregnancy loss (miscarriage, neonatal death, termination, stillbirth), secondary outcomes included pregnancy prolongation, preterm birth, and maternal and neonatal outcomes. 24 Reducing inequalities in preterm birth and stillbirth through personalised risk-assessment an... Jenny Carter 1; Jane Sandall 1; Tommy's National Centre for Maternity Improvement 2 1 King's College London, London, UK; 2 Royal College of Obstetricians and Gynaecologists, Lon... B Abstract b B Background: b The Tommy's App (a web-based, CE-marked medical device) assesses risk of placental dysfunction and preterm birth much more accurately than current methods, and instantly recommends personalised evidenced-based care pathways. The model included mothers age, height, parity, smoking status, ethnicity, and any history of hypertension, pre-eclampsia, previous stillbirth or SGA baby, and gestational age at delivery. Longitudinal maternal cardiac adaptation in hypertensive disorders of pregnancy Hua Zen Ling; Gavin Guy; Kypros H. Nicolaides; Nikos A. Kametas Fetal Medicine Research Institute, King's College London, London, UK B Abstract b Preeclampsia (PE), compared to gestational hypertension (GH) has traditionally been considered the most severe hypertensive disorders in pregnancy, with worse outcomes and future cardiovascular morbidities. The model included mothers age, height, weight, mode of conception, parity, smoking status, ethnicity, and any history of diabetes, hypertension, pre-eclampsia, previous stillbirth or SGA baby, and gestational age at delivery. [Extracted from the article]

Objective: To determine the effect of vaginal scarring on the recovery from surgical repair of obstetric fistula in Northern Ethiopia from 2015 to 2020. Methods: A hospital‐based retrospective cohort study was conducted among 224 women who had obstetric fistula repair surgery in Northern Ethiopia from March 1 to March 31, 2020. Cox proportional hazards regression model was used to determine the adjusted predictors of recovery for each main baseline predictor variable, using 95% confidence interval (CI) and P < 0.05 to declare statistical significance. Results: The overall recovery rate was 57 of 1000 women (43 of 1000 and 73 of 1000 for women with and without vaginal scar, respectively), with an overall median time to recovery from obstetric fistula repair surgery of 15 days. Vaginal scarring (adjusted hazard ratio [aHR], 1.58 [95% CI, 1.13–2.21]), age of the patient (aHR, 4.05 [95% CI, 1.56–10.5]), mode of delivery (aHR, 2.14 [95% CI, 1.31–3.49]), place of delivery (aHR, 1.91 [95% CI, 1.17–3.12]), prior repair (aHR, 1.90 [95% CI, 1.08–3.35]), and duration of catheterization (aHR, 12.91 [95% CI, 7.21–23.13]) were independent predictors of recovery. Conclusions: In the present study, we found that women who had no vaginal scar, age older than 30 years, facility and spontaneous vaginal delivery, first attempt repair, and shorter duration of catheterization had a shorter recover time. Synopsis: Vaginal scarring is an important factor for predicting the time to recovery after surgical repair of obstetric fistula. This will guide health professionals and health policy makers to identify indicators for monitoring women with obstetric fistula and applying necessary preventive and appropriate measures to decrease time to recovery of patients. [ABSTRACT FROM AUTHOR]

Introduction: Interventional radiology (IR) is a technique for controlling hemorrhage and preserving fertility for women with serious obstetric conditions such as placenta accreta spectrum (PAS) or postpartum hemorrhage. This study examined maternal, pregnancy and hospital characteristics and outcomes for women receiving IR in pregnancy and postpartum. Material and methods: A population‐based record linkage study was conducted, including all women who gave birth in hospital in New South Wales or the major tertiary hospital in the neighboring Australian Capital Territory, Australia, between 2003 and 2019. Data were obtained from birth and hospital records. Characteristics and outcomes of women who underwent IR in pregnancy or postpartum are described. Outcomes following IR were compared in a high‐risk cohort of women: those with PAS who had a planned cesarean with hysterectomy. Women were grouped by those who did and those who did did not have IR and were matched using propensity score and other factors. Results: We identified IR in 236 pregnancies of 1 584 708 (15.0 per 100 000), including 208 in the delivery and 26 in a postpartum admission. Two‐thirds of women receiving IR in the birth admission received a transfusion of red cells or blood products, 28% underwent hysterectomy and 12.5% were readmitted within 6 weeks. Other complications included: severe maternal morbidity (29.8%), genitourinary tract trauma/repair (17.3%) and deep vein thrombosis/pulmonary embolism (4.3%). Outcomes for women with PAS who underwent planned cesarean with hysterectomy were similar for those who did and did not receive IR, with a small reduction in transfusion requirement for those who received IR. Conclusions: Interventional radiology is infrequently used in pregnant women. In our study it was performed at a limited number of hospitals, largely tertiary centers, with the level of adverse outcomes reflecting use in a high‐risk population. For women with PAS undergoing planned cesarean with hysterectomy, most outcomes were similar for those receiving IR and those not receiving IR, but IR may reduce bleeding. [ABSTRACT FROM AUTHOR]

This article discusses different surgical techniques for the treatment of rectovaginal fistula. The video vignette demonstrates two cases: one involving a modified LIFT procedure and the other involving a Martius flap procedure. The choice of technique depends on the anatomical characteristics determined by clinical findings and imaging. The authors conclude that the modified LIFT procedure is the procedure of choice for patients with a linear fistula tract, preserved anatomical muscles, and no previous vaginal delivery, while the Martius flap procedure should be used in cases of recurrence. Both techniques have shown good results. [Extracted from the article]

Objective: To implement a Flexible Operational Research Training (FORT) course within the Fistula Care Plus Project, Democratic Republic of Congo, from 2017 to 2021. Methods: A descriptive study using design and implementation (process and outcome) data. Two to four members of medical teams from three supported sites were selected for the training based on their research interests and level of involvement in the program. Results: Two courses (13–14 months each) involving nine facilitators and 17 participants overall were conducted between 2017 and 2021. Most participants in both courses were medical doctors (67% and 71%, respectively) from the supported hospitals (83% and 77%, respectively). About half were women. In addition to classic face‐to‐face didactic modules, the courses integrated online platforms to cope with the changing contexts (Ebola virus and COVID‐19). Most participants reported having gained new skills in developing research protocols, collecting, managing, and analyzing data, and developing research manuscripts. The two courses resulted in six scientific manuscripts and three presentations at international conferences. Participants subsequently published five papers from their research after the first course. The total direct costs for both courses were representing a cost of $3669 per participant trained. Conclusion: The FORT model proved feasible, efficient, and successful. However, scaling up will require more adaptation efforts from programs and participating sites. Synopsis: Integration of operational research capacity building in fistula care programs using the FORT model was feasible and successful. However, scaling up will require adaptation efforts. [ABSTRACT FROM AUTHOR]

Objective: Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade‐3a or ‐3b obstetric anal sphincter injury (OASI) in a tertiary‐referral perineal clinic. Methods: This was a retrospective observational study of all women referred to a tertiary‐referral perineal clinic after primary repair of OASI (Grade 3a–c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30–90° or > 90°) on endoanal imaging in the axial plane. Results: In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade‐3a/3b injury. In women referred with a Grade‐3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade‐3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26–15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25–6.45); P < 0.001). Conclusions: One in 11 women diagnosed with a Grade‐3a or ‐3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Aim: The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events. Method: Prospective data were collected within a 2 year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed. Results: Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow‐up of 23.4 months postpartum. Patients with secondary repair failure had lower anal resting (p = 0.006) and maximum squeeze pressures compared with patients with intact repairs (p < 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p = 0.157). Conclusion: Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow‐up periods is required to assess the validity of the findings. [ABSTRACT FROM AUTHOR]

Objective: To determine whether screening for gestational diabetes mellitus (GDM) in the third trimester and managing those who are screen positive on a diabetes pathway affects obstetric and neonatal outcomes. Design: Retrospective study of prospectively collected data. Setting: London Teaching Hospital. Population or sample: A total of 14 366 women delivering between 1 January 2018 and 31 December 2020. Methods: Retrospective chart analysis. Main outcome measures: Diagnosis of late‐onset GDM, obstetric and neonatal outcomes. Results: Five hundred and thirty‐one women were tested by home glucose monitoring for late‐onset GDM from 33 weeks of gestation. In all, 244 were diagnosed as having GDM (group 1) and managed accordingly, and 287 (group 2) were returned to normal care. A total of 1415 women had GDM diagnosed by oral glucose tolerance test before 33 weeks of gestation (group 3). Of the women in group 2, 49.5% had a spontaneous onset of labour compared with only 25.8% and 27% in groups 1 and 3. However, women in group 2 were significantly more likely to have a macrosomic baby (≥4000 g, 25.4%) than groups 1 (16.0%) or 3 (7.2%), and their babies were more likely to be admitted to special care (5.2% versus 2% in group 1). Macrosomic babies were associated with significantly higher rates of shoulder dystocia, third‐ and fourth‐degree tears and postpartum haemorrhage. Conclusions: Apparent late‐onset GDM affects a significant proportion of women, and targeted intervention was associated with better obstetric and neonatal outcomes. These results suggest that all pregnancies with risk factors for late‐onset GDM might benefit from active GDM management irrespective of specific glucose thresholds. Women with risk factors for GDM in the third trimester, and their babies, would probably benefit from active management of their blood sugars irrespective of threshold values. Women with risk factors for GDM in the third trimester, and their babies, would probably benefit from active management of their blood sugars irrespective of threshold values. Linked article: This article is commented on by Jane Hirst, pp. 2184 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.17184 [ABSTRACT FROM AUTHOR]

Objective: To describe the incidence and causes of severe maternal outcomes and the unmet need for life‐saving obstetric interventions among women admitted for delivery in a referral hospital in Somaliland. Methods: A prospective cross‐sectional study was conducted from April 15, 2019 to March 31, 2020, with women admitted during pregnancy or childbirth or within 42 days after delivery. Data were collected using the World Health Organization (WHO) and sub‐Saharan Africa (SSA) maternal near‐miss (MNM) tools. Descriptive analysis was performed by computing frequencies, proportions, and ratios. Results: The MNM ratios were 56 (SSA criteria) and 13 (WHO criteria) per 1000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric hemorrhage (13%), pregnancy‐related infection (10%), and hypertensive disorders (7.9%) according to the SSA MNM criteria. Most women giving birth received prophylactic oxytocin for postpartum hemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after 3 h. Conclusion: There is a need to improve the quality of maternal health services through implementation of evidence‐based obstetric interventions and continuous in‐service training for healthcare providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low‐resource contexts. [ABSTRACT FROM AUTHOR]

I always remember that day: Access to services for survivors of gender-based violence in Ethiopia's Tigray Region. The impact of war on the health system of the Tigray region in Ethiopia: an assessment. We implore the international community of obstetricians and gynaecologists to raise their voices to demand an end to the blockade of humanitarian aid to Tigray. I don't know if they realized I was a person:' rape and other sexual violence in the conflict in Tigray, Ethiopia: London, Amnesty International; 2021, Available from: https://www.amnesty.org/en/documents/afr25/4569/2021/en/ 6 Human Rights Watch. [Extracted from the article]

Urinary incontinence (UI) is highly prevalent amongst women around the world. In this review article we explore UI, its consequences and treatment in sub‐Saharan Africa, providing specific examples from Uganda and Malawi. In sub‐Saharan Africa the prevalence of UI is difficult to assess because of the wide variation in reporting resulting from patients hiding their condition due to the associated stigma in many communities. Whilst much of the literature from low‐ or low‐middle‐income countries focuses on UI from pelvic floor fistula, recent evidence demonstrates that non‐fistulous stress, urgency and mixed UI are highly prevalent in sub‐Saharan Africa. Incontinence secondary to vesico‐vaginal fistula can be related to obstetric causes, mainly obstructed labour. The risk factors for non‐fistulous incontinence are similar to those identified in high‐income countries, including high parity, vaginal and assisted delivery, gestational age, constipation, obesity, chronic cough and ageing. Urinary incontinence has significant social and emotional consequences, with a high proportion of women in African countries reporting relationship problems, depression and suicidal ideation. There is poor understanding of the perceived aetiology of incontinence in sub‐Saharan Africa, which may, in part, act as a barrier for women to seek medical advice. Innovative solutions have been found to manage the large number of obstetric fistulas that are prevalent across Africa, but a lack of capacity in specialists trained to treat women with UI means that more doctors, medical officers and better resource prioritization will be required to help the, as yet unquantified, number of women with non‐fistulous leakage. Better patient peri‐natal education may reduce the incidence of fistula still further, especially if the stigma felt by women with incontinence is overcome and they are encouraged to seek treatment. [ABSTRACT FROM AUTHOR]

Background: Conservative measures are first‐line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery. Methods: We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in‐hospital and 30 days post‐operative complications and pre‐ and post‐operative symptoms. Key results: The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in‐hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow‐up was 12.7 months (SD 13.9, range 1.4–71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS‐related symptoms improved in 58% of cases. Conclusions & inferences: The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms. [ABSTRACT FROM AUTHOR]

This article, titled "Ileoanal pouch excision: How multiple technical failures can lead to pouch dysfunction—a video vignette," discusses the case of a 56-year-old woman who was referred to a pouch center after experiencing complications from a previous surgery. The patient had undergone an open restorative proctocolectomy with loop ileostomy, which was complicated by an anastomotic leak, pelvic sepsis, and a pouch vaginal fistula. After a thorough evaluation and multidisciplinary team discussion, the patient underwent a pouch excision and redo pouch procedure. During surgery, it was discovered that the chronic ischaemia and severe atrophy of the small bowel were caused by an unexpected twist in the ileostomy mesentery. Another technical issue was the improper positioning of the loop ileostomy relative to the ileoanal pouch, which prevented the creation of a new pouch. The article emphasizes the importance of patient centralization in inflammatory bowel disease to ensure better outcomes and highlights the potential consequences of multiple technical failures in nonreferral IBD centers. The authors also mention that they obtained consent from the patient for the publication of footage and videos, and ethical committee approval was not required. [Extracted from the article]

Objective: To compare, in terms of anatomical, functional, and sexual aspects, two types of treatment for women with vaginal agenesis: progressive dilation or surgical neovaginoplasty. Methods: Women with vaginal agenesis underwent either dilation treatment using the Frank method or surgical treatment using the modified Abbé-McIndoe technique with oxidized cellulose. Patients were evaluated 3–6 months after treatment for a follow-up including medical history, physical examination, general satisfaction, clinical aspect of the vagina, Female Sexual Function Index, and three-dimensional pelvic floor ultrasound. Results: In total, 20 women with vaginal agenesis were included in the present study; nine in the dilation group and 11 in the surgical group. A comparison between the groups (vaginal dilation and surgical neovaginoplasty) showed efficacy in neovagina formation after both treatments, with a statistically significant difference between the pre- and post-treatment periods (P value pre- × post-dilation group <0.0001 and P value pre- × post-surgical group <0.0001). There were no statistical differences in total vaginal length measurements (P value post-dilation × post-surgical = 0.09) or Female Sexual Function Index scores (P = 0.72) after both treatments. Conclusion: Both treatments had satisfactory efficacy and positive outcomes for patients with vaginal agenesis concerning anatomical, functional, and sexual aspects, with minimum complications in the surgical group. Dilation treatment can remain the first-line therapy. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether obstetric complications prior to systemic sclerosis (SSc) diagnosis are more common in SSc patients compared to the general obstetric population. Methods: A case–control study was performed at Kaiser Permanente Northern California to compare prior obstetric complications in adult women who later developed SSc (cases) with women from the general obstetric population who did not develop SSc (controls; matched 10:1 by age and year of delivery) from 2007 to 2016. Exposures included past hypertensive disorders of pregnancy (preeclampsia, eclampsia, gestational hypertension), premature rupture of membranes (PROM), intrauterine growth restriction (IUGR), maternal infections, neonatal intensive care unit (NICU) admission, and preterm birth. Fischer's exact tests were used to compare categorical variables. Conditional logistic regression models estimated the odds ratio (OR), and corresponding 95% confidence intervals (95% CIs) for the outcome SSc. Results: Seventeen SSc cases and 170 non‐SSc controls were identified, with median maternal age at delivery 34 years (range 23–46 years) and median time from delivery to SSc diagnosis 2 years (range 0.2–7.3 years). Women with SSc were more likely to be Hispanic and Black. Prior obstetric complications appeared higher in women with an eventual SSc diagnosis compared to controls (70.6% versus 50%), including hypertensive disorders (17.7% versus 9.4%), PROM (11.8% versus 4.1%), IUGR (5.9% versus 1.8%), maternal infection (29.4% versus 14.1%), NICU admissions (23.5% versus 7.7%), and preterm delivery (29.4% versus 21.8%). Women with SSc had a higher odds of delivering infants requiring NICU admission (OR 4.7 [95% CI 1.2–18.8]). Conclusion: Women who eventually develop SSc had trends toward more complicated pregnancy histories before overt diagnosis. [ABSTRACT FROM AUTHOR]

Withdrawal: Harkiran Narang, Surindra Maharaj, Unsuspected late presentation of post cesarean section vesico‐peritoneal fistula, International Journal of Gynecology & Obstetrics, 17th April 2023, Volume 162, Issue 1, https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.14789. The above article, published online on 17th April 2023, on Wiley Online Library (https://doi.org/10.1002/ijgo.14789) and in Volume 162, Issue 1, has been withdrawn by agreement between the authors, Harkiran Narang and Surindra Maharaj, the Editor‐in‐Chief Michael Geary, the International Federation of Gynecology and Obstetrics, and John Wiley & Sons Ltd. The article has been withdrawn because the required consent for publication of a research's subject's case is missing. [ABSTRACT FROM AUTHOR]

Background: Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings. Aims: This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long‐term outcomes. Materials and Methods: A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14‐year period by one operative group. Results: A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n = 32). Obstetric cause was implicated in 26.8% (n = 11) and other causes include 26.8% (n = 11) from vaginal and abdominal surgery, 14.6% (n = 6) from perianal abscess, 7.32% (n = 3) as complications of Crohn's disease and 2.44% (n = 1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n = 33). Post‐operative symptoms were limited to flatal incontinence in 4.88% (n = 2), faecal incontinence in 2.44% (n = 1), and persistent perineal pain in 7.32% (n = 3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique. Conclusions: This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post‐operative symptoms. [ABSTRACT FROM AUTHOR]

Aim: Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over‐the‐scope (OTS) clips. Method: A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported. Results: Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157 ± 98 days, the mean defect diameter was 4.5 mm (range 2–10 mm) and the mean fistula length was 15 mm (range 2–25 mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long‐term success (mean follow‐up 218 days, range 25–673 days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long‐term success after four interventions; three patients have not undergone a repeat procedure after initial failure. Conclusion: Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long‐term success rates are similar to other gastrointestinal tract applications of OTS clips. [ABSTRACT FROM AUTHOR]

Objective: To examine the ability of a previously published risk score to predict incontinence at discharge in women with vesicovaginal fistulas (VVF) and to examine how the score correlates with an independent assessment of surgical skill. Methods: This is a retrospective cohort study including cases from January to June 2018. We evaluated operative records for factors associated with incontinence at hospital discharge, as well as relationships between a risk score cut‐point of 20 or more and surgical skill level. All women with VVF undergoing vaginal repair were included. Results: A total of 176 individuals underwent repair; 23 were performed by beginner, 85 by intermediate, 47 by advanced, and 21 by expert surgeons. Factors found significantly associated with incontinence at hospital discharge included Goh classification, fistula size, circumferential fistula, and vaginal scarring. A score of 20 or more predicted residual incontinence with a negative predictive value of 92% (odds ratio 7.75, 95% confidence interval 2.95–22.34). Applying the score cut‐point of 20 or more, we found an increased proportion of "high‐risk" cases allocated to surgeons with an increasing level of expertise. Conclusion: The correlation we observed between a risk score cut‐point of 20 or more, continence status, and an independent assessment of surgical skill is promising. Although the risk score is not meant to replace clinical judgment, it may provide a surgical trainee with an objective method of determining whether to operate or refer for optimal outcomes. A risk score predicting postoperative incontinence among women with obstetric fistula may be able to inform referral of high‐risk patients to experienced surgeons. [ABSTRACT FROM AUTHOR]

Aim: To present an anatomical pathogenesis parallel with the 2002 International Continence Society Lower Urinary Tract (LUTS) definitions standardization Report 2002. Methods: Each LUTS section is discussed using the same numbers as the Report. Results: Normal function Bladder control is binary, with two reflexes alternating, either closure (dominant) or open (micturition), with the same cortical and peripheral components: three directional muscle forces contracting against pubourethral (PUL) and uterosacral (USL) ligaments for closure, two against uterosacral ligaments for micturition. Dysfunction OAB symptoms reflect a prematurely activated micturition; PUL/USL weakness prevents muscle forces from controlling afferent urothelial emptying signals. Stress urinary incontinence is a consequence of weak PULs allowing posterior muscle forces to open the urethra during effort. Lax USLs weaken contractile force of the posterior urethral opening vectors, so detrusor has to contract against an unopened urethra. This is experienced as "obstructive micturition." Conclusions: Anatomical analysis indicates the ICS definitions are fundamentally sound, except for "OAB" which implies detrusor causation. Minor changes, OAB to "overactivated" bladder allow causation outside of bladder. This construct supports OAB and its component symptoms as a syndrome, as intuited by the Committee, (albeit as a prematurely activated micturition), retains the acronym, explains OAB cure by ligament repair, and incontinence pathogenesis from two post‐2002 syndromes which need an addition to the definitions, Posterior Fornix Syndrome (of which OAB is a component) and Tethered Vagina Syndrome, which is the basis for skin‐grafting cure of the 30%–50% of women who continue leaking urine massively after successful obstetric fistula closure. [ABSTRACT FROM AUTHOR]

Aims: To report on the follow‐up of obstetric fistula repair using vascularized surgical flaps, namely the Singapore fasciocutaneous flap, the gracilis muscle flap, or a combination of both. Methods: This cross‐sectional study reports on the follow‐up of 60 patients after fistula repair with a vascularized surgical flap at the Fistula Care Center in Lilongwe, Malawi. The primary outcome was fistula closure based on patients' self‐reported continence grade. Secondary outcomes were urinary incontinence based on a 1‐h pad‐weight test, quality of life based on the Incontinence Quality of Life (I‐QOL) questionnaire, surgical complications, and the indication for additional surgery after repair. Results: Successful closure was achieved in 62% of cases and full continence was achieved in 12% of cases. Incontinence based on a 1‐h pad weight test improved between surgery and follow‐up. QOL scores based on the I‐QOL were low but patients indicated moderate to great improvement in quality of life. Twenty‐two (37%) patients experienced surgical complication, mostly minor wound breakdowns. No major complications were reported. Six (10%) patients were indicated for additional surgery during follow‐up. Conclusion: The relative safety of the surgical procedures is shown in the findings of this study, including no reports on major complications during follow‐up. Vascularized flaps should be considered in complex fistula cases, especially in repeat cases and before considering urinary diversion as a last resort. [ABSTRACT FROM AUTHOR]

Introduction: Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC).Material and Methods: Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2-O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004-2016.Results: The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (β 0.49) and 6.2% (β -1.15) (trend, all p < 0.001) in 2016.Conclusions: This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy. [ABSTRACT FROM AUTHOR]

Vaginal obliteration surgery for prolapse - a retrospective cohort study B Graham, M SP 1 sp ; Doherty, N SP 1 sp ; Wylie, J SP 2 sp ; McCracken, G SP 2 sp ; Boggs, E SP 2 sp ; Prendergast, C SP 1 sp b SP 1 sp Altnagelvin Hospital, Derry, UK; SP 2 sp Craigavon Hospital, Craigavon, UK B Objectives b The aim of this study is to determine outcomes following obliterative vaginal surgery for prolapse focusing on recurrence and complications. Fine and Gray regression models were used to estimate hazard ratios (HRs) for the overall risk of reoperation by initial surgery type whilst adjusting for characteristics of patients and concurrent procedures done at time of initial surgery. [i] Urinary incontinence and pelvic organ prolapse in women: management NICE guideline 123 https://www.nice.org.uk/guidance/ng123 [ii] Surgery for stress urinary incontinence Patient decision aid https://www.nice.org.uk/guidance/ng123/resources/surgery-for-stress-urinary-incontinence-patient-decision-aid-pdf-6725286110 [iii] https://improvement.nhs.uk/documents/5122/MESH letter - Extension of pause on the use of vaginal mesh 29 March 2019.pdf The overall rate of LAM in patients with OASI, in these 8 studies, was 34.75% (nearly one third of patients who sustained OASI). [Extracted from the article]

Objectives: Female urethral stricture is a rare disease. Urethroplasty with different techniques using grafts or flaps are successful treatment options. The objective of this study was to present our experience with ventral onlay buccal mucosa graft urethroplasty for the treatment of female urethral stricture disease. Methods: Eight female patients treated with ventral onlay buccal mucosa graft urethroplasty were identified retrospectively. Patient evaluation included physical examination, uroflowmetry with postvoid residual urine measurement, videourodynamics and urethrocystoscopy. Stricture was identified by videourethrography and/or urethrocystoscopy. Urodynamic evidence of stricture was considered as a persistent low maximum flow rate of <12 mL/s combined with detrusor pressure at maximum measured flow rate of >20 cmH2O in the pressure flow study. Results: The mean age was 50.5 ± 4.14 years. Stricture etiology was idiopathic (62.5%) or iatrogenic (37.5%). Two patients (25%) had undergone prior urethral dilations before buccal mucosa graft urethroplasty. Mean stricture length was 1.62 ± 0.44 cm. Stricture location was as follows: four distal urethra (50%), two mid‐distal (25%) and two mid‐urethra (25%). The mean postoperative follow‐up period was 16.37 ± 5.75 months, and the during follow‐up success rate was 100%. No complication, such as incontinence or vaginal fistula, was noted, except dyspareunia developed in one patient (12.5%). Conclusions: Ventral onlay buccal mucosa graft urethroplasty is a safe and effective treatment option for female urethral stricture. Unnecessary dilation should not be carried out and buccal mucosa graft urethroplasty in expert centers should be recommended to these patients. [ABSTRACT FROM AUTHOR]

Objective: This study aims to establish the postoperative success rates of midvaginal versus juxtacervical obstetric vesicovaginal fistula (VVF) repairs. In addition, we aim to quantify the impact of patient sociodemographic variables, fistula classification, and surgical repair techniques associated with postoperative outcomes. Methods: A retrospective cohort study was conducted involving 420 women who had undergone a primary obstetric VVF repair. All data were collected from the Panzi Hospital, Democratic Republic of Congo between 2015 and 2017. Patient notes were analyzed to determine sociodemographic variables, symptoms, fistula classification, surgical repair techniques, and postoperative follow up. Binary logistic regression presented as χ2 for trend was used to establish P values. Results: Overall, 95.6% and 96.2% of midvaginal and juxtacervical VVF, respectively, underwent a successful repair. The principal prognostic factor associated with a statistically significant likelihood of a successful repair was the degree of fibrosis noted preoperatively (P =0.004, 95% confidence interval [CI] 2.38–94.61). Furthermore, VVF were more likely to have a successful repair if they were closed in two layers (P = 0.004, 95% CI 1.86–25.81) and sutured vertically (P = 0.005, 95% CI 1.16–2.52). Conclusion: Overall, high postoperative success rates of obstetric VVF repair can be expected among well‐trained surgeons but a complex interplay of factors means that the ability to preoperatively foreshadow individual outcomes remains difficult. Synopsis: Postoperative success rates are high for vesicovaginal fistulas. Repair is more likely to be successful if there was no or mild fibrosis, and if the fistula was closed in two layers and in a vertical fashion. [ABSTRACT FROM AUTHOR]

Obstetric anal sphincter injuries are a common cause of faecal incontinence in women. Traditionally, postpartum women with known sphincter defects underwent immediate or delayed surgical repair of their anal sphincter muscles with an end-to-end reapproximation. The prevalence of occult obstetric anal sphincter injury following childbirth-literature review. [Extracted from the article]

Aim: Ileoanal pouch–vaginal fistula (PVF) is a relatively common complication of restorative proctocolectomy with ileal pouch–anal anastomosis. There are several operative approaches in the management of PVF. There is currently no consensus as to which approach is the most effective or which should be attempted first. Method: A systematic review was undertaken following a publicly available protocol registered with PROSPERO (CRD42019133750) in accordance with PRISMA guidelines. Online searches of databases MEDLINE and Embase, Cochrane Library, ClinicalTrials.gov, EU Clinical Trials and ISRCTN registry were performed. Results: Twenty‐seven articles met the criteria for inclusion in the study: 13 retrospective cohort studies, two prospective cohort studies, eight case series, three case reports and a case–control study. A narrative synthesis was performed due to heterogeneity between included articles. Our study included 577 PVFs, and the incidence rate was 2.1%–17.1%. Both local and abdominal approaches were used in the management of PVF. The overall success of local and abdominal procedures was 44.9% and 60.2% respectively. ROBINS‐I assessment revealed a critical risk of bias. GRADE assessment indicated a very low certainty in effect size and evidence quality. Conclusion: Local interventions and abdominal approaches have a high failure rate. The results of this review will aid the counselling of patients with this condition. Furthermore, we provide an algorithm for discussion on the management of PVF based on experience at our local centre. The studies available on the management of PVF are low quality; a large prospective registry and Delphi consensus are required to further this area of research. [ABSTRACT FROM AUTHOR]

Background: Negative life events in childhood can increase the susceptibility to autoimmune and inflammatory diseases. Hidradenitis suppurativa (HS) is a systemic inflammatory disease affecting the apocrine sweat glands, characterized by abscesses, fistulas and inflammatory nodules. It is unknown whether adult HS is associated with traumatic events. Objective: To investigate the association between childhood and total lifetime traumatic events and the presence of HS. Methods: We conducted a matched (1 : 3) case–control study with 71 HS patients and 213 controls. Patients were matched on age, gender and level of education. Questionnaires on general and demographic information, as well as the Traumatic Experience Checklist and the Hospital Anxiety and Depression Scale, were completed. Results: The number of traumatic events (OR: 1.20 per trauma, P value < 0.05), and childhood traumatic events (yes vs. no, OR 3.59, P value < 0.05) and the number of childhood traumatic events (OR 1.35 per trauma, P value < 0.05) were correlated with an increased risk of developing HS. Detailed analysis showed that childhood emotional traumatic events (OR 5.03, P value < 0.05) were significantly associated with the development of HS. Conclusion: Number of lifetime traumatic events and childhood traumatic events are associated with HS. This association is strongest for emotional childhood traumas. The increased prevalence of childhood traumas in HS patients can be one of the underlying mechanisms leading to systemic inflammation in these patients. Linked Commentary: C. Szabó. J Eur Acad Dermatol Venereol 2020; 34: 2689–2690. https://doi.org/10.1111/jdv.17030. [ABSTRACT FROM AUTHOR]