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To compare operative data and patient satisfaction between open and laparoscopic surgery for post-partum diagnosed uterine rupture.In this questionnaire-based cohort study we collected all cases of post-partum diagnosed uterine rupture after vaginal delivery, between 2016 and 2020 in a single academic tertiary center. The cohort was divided according to surgical method of repair; demographic, clinical, operative and post operative data were collected and compared between groups. A phone questionnaire on various satisfaction domains was conducted and satisfaction rates were compared between groups.Eight cases of uterine rupture following vaginal delivery were treated by laparoscopy, and eight were treated by laparotomy. The median operative time was 103 (IQR 86.3-129.0) minutes for the laparoscopy group and 61 (IQR 59.0-75.0) minutes for the laparotomy group (p=0.04). Blood transfusion was required in 25% of women who underwent laparoscopy, as compared to 88% of women who underwent laparotomy (p=0.010.05). Median hospitalization time was 3 (IQR 3-4) days in the laparoscopy group and 4 (IQR 4-4) days in the laparotomy group (p=0.2). Overall satisfaction, satisfaction from recovery, satisfaction from scars, satisfaction from ability to care for the neonate and post-operative pain and mood were all improved in the laparoscopy group, as compared to the laparotomy group.Minimally invasive surgery is a viable surgical option for patients with uterine rupture diagnosed after vaginal delivery, and may result in better patient recovery and satisfaction.

The aim of this study was to evaluate the effect of age on outcomes after uterine-preserving surgical treatment for apical prolapse.Retrospective cohort study.Female pelvic medicine and reconstructive surgery unit at a tertiary, university-affiliated teaching medical center.Women who underwent surgical management of apical prolapse with uterine preservation between 2010 and 2020. Excluded were women who had ≤1 month of follow-up and those for whom medical records were substantially incomplete.None.Included in the study were 140 women who underwent apical prolapse repair with uterine preservation and who met the inclusion criteria. The cohort was divided into 2 groups: (1) women aged 65 years and older (≥65 group) and (2) women younger than 65 years of age (65 group). Pre-, intra-, and postoperative data were compared between the groups. A total of 103 women (73.6%) were in the65 group and 37 women (26.4%) in the ≥65 group. Mean age for the entire cohort was 58 ± 9.8 years, body mass index 25.9 ± 4.8 kg/mUterine-preserving surgery is a safe and effective surgical treatment for women aged ≥65 years.

Pelvic organ prolapse (POP) is common among post-menopausal women and is associated with bladder, bowel, and sexual dysfunction. Surgical repair with the patients' native tissues is sub-optimal with high reoperation rates, potentially due to diminished age-related healing. We demonstrate that systemic transplantation of mesenchymal stem cells (MSCs) improves healing of full-thickness vaginal incision in the vaginal wall of old rats, as suggested by both histological and functional analysis. Transplanted MSCs homed and survived at the surgical vaginal site. Attenuation of the injury-induced inflammatory response, increased angiogenesis, and reduced matrix metalloproteinase 9 expression were observed at the surgical site of transplanted rats. Most importantly, the functional biomechanical properties of the healed vagina, at day 30 post-injury, were improved in MSC-transplanted, compared with sham-operated non-transplanted, old rats. These results may pave the way to further translational studies toward clinical transplantation of MSCs adjuvant to POP repair for the improvement of surgical outcome.

The aim of this study was to compare surgical outcomes in women undergoing vaginal uterosacral ligament suspension using permanent as opposed to absorbable sutures. We also aimed to assess for specific risk factors for suture complications.Retrospective cohort study.Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center.Women with apical prolapse who underwent vaginal hysterectomy with uterosacral ligament suspension during the study period.none.A total of 197 women were included in the study. Of them, 118 (59.9%) underwent the procedure using a permanent suture and 79 (40.1%) using an absorbable suture. Women in the permanent suture group were less sexually active and had less prolapse of point C on pre-operative exam. With regard to intra-operative and postoperative data, women in the permanent suture group had increased frequency of concomitant procedures, regional anesthesia, surgical time, duration of hospital stay, and change in hemoglobin. Clinical, anatomical, and composite success did not differ between groups. Patient satisfaction recorded using the Patient Global of Improvement Questionnaire was similar as well. Women in the permanent suture group had a higher frequency of suture exposure compared with the absorbable suture group (9.3% vs 0.0%, p = .006). In order to assess for risk factors leading to suture complications, a comparison was performed between women who had suture exposure or granulation tissue and those who did not. Increasing parity by 1 increased the odds of having suture exposure or granulation tissue by a factor of approximately 1.2 (adjusted odds ratio = 1.24; Confidence interval, 1.05-1.47). Women with stage IV prolapse had 3.4 times the odds of suture complication compared with women with stage III prolapse (adjusted odds ratio = 3.4; Confidence interval, 1.1-10.6).Use of an absorbable suture affords comparable success and lower frequency of suture exposure compared with permanent sutures in women undergoing vaginal uterosacral ligament suspension for treatment of apical prolapse.

To identify risk factors for increasing severity of OASI and evaluate its possible correlation with two known risk factors-birth weight (BW) and neonatal head circumference (HC).We performed a retrospective cohort study at a university affiliated hospital between 2003 and 2019. We compared five groups of patients - according to presence and degree of perineal laceration - 3a, 3b, 3c and 4 and patients without OASI. Additionally, four parameters were defined to assess their relation to the severity of OASI: (1) BW ≥ 90th and HC 90th percentiles; (2) BW 90th and HC ≥ 90th percentile; (3) BW and HC ≥ 90th percentile and (4) BW and HC 90th percentiles.During the study period, 150,221 deliveries were evaluated. Parturients were allocated according to OASI severity - 455 patients had a 3rd (3a, 3b or 3c) or 4th degree perineal tear, while 110,966 patients had no OASI. Allocation to subgroups according to offspring anthropomorphic measures showed that as fetal size parameters increased, the rate of more severe tears increased, particularly in women delivering neonates with HC ≥ 90th percentile. Multinomial regression analysis was performed for each 3rd degree OASI subgroup. This analysis demonstrated the odds for OASI gradually increase with tear severity for BW ≥ 90th percentile and the combined BW and HC ≥ 90th percentile parameters, as compared with neonates with HC and BW 90th percentile.Birth weight and head circumference above the 90th percentile are correlated with increased degree of OASI severity.

Study Objective To compare clinical and anatomic outcomes as well as patient satisfaction in women undergoing vaginal colposuspension using the Uphold Lite system (Boston Scientific Corporation, Marlborough, MA) and transvaginal hysterectomy with uterosacral ligament suspension (VUSLS) for the treatment of apical prolapse. Design Retrospective cohort study. Setting Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center. Patients Women with apical prolapse who underwent either vaginal colposuspension using the Uphold Lite system (uterine-preserving as well as after previous hysterectomy) or VUSLS from 2010 to 2019. Excluded were women with 1 month or less of follow-up. Interventions None. Measurements and Main Results A total of 164 women were included in the study: 112 women underwent VUSLS, and 52 underwent colposuspension using the Uphold Lite mesh system. Age, body mass index, maximal birth weight, comorbidity rates, and pelvic organ prolapse severity were similar between the groups. The clinical cure rate was similarly high in both groups, with 91.1% in the women who underwent VUSLS and 88.5% in those in the Uphold Lite group (p = .60). No differences were noted between the groups with regard to anatomic cure rate or composite outcome success rate (73.9% vs 76.0%, p = .77 and 70.3% vs 74.0%, p = .63, in the VUSLS and Uphold Lite groups, respectively). An advantage was noted in the VUSLS group with regard to patient satisfaction with 98.1% of the women stating that their condition was very much better (Patient Global Impression of Improvement questionnaire: A) or much better (Patient Global Impression of Improvement questionnaire: B) compared with 83.9% of the women in the Uphold Lite group (p = .023). In an attempt to assess the association between different variables and the composite outcome, a multivariate analysis was performed in which increased body mass index, menopausal status, and increased preoperative genital hiatus were found to decrease composite outcome success. Conclusion Vaginal colposuspension using the Uphold Lite system and VUSLS for the treatment of apical prolapse have comparable results with high clinical success rates.

In recent years uterine preservation has become a popular option in women undergoing pelvic organ prolapse repair. The aim of this study was to evaluate the effect of uterine volume on outcomes following uterine preserving surgical treatment for apical prolapse.We performed a retrospective comparative study at a tertiary university hospital. Included were women who had uterine preserving surgical treatment for apical prolapse. The cohort was divided into two groups: 1) Patients with a uterine volume ≥ 35 cmEighty-four patients were included in the final analysis. The large uterus group (≥35 cmWomen undergoing uterine preserving apical prolapse repair with uterine volume ≥ 35 cm

Obstetric anal sphincter injury (OASI) is a debilitating complication of vaginal delivery. The aim of this study was to identify risk factors for OASI in women with a previous vaginal delivery. We further attempted to detect specific risk factors for severe OASI in this subgroup. We conducted a retrospective cohort study between 2003 and 2019. The study group included women who had a singleton, live, vertex, vaginal delivery at term and who also had at least one previous vaginal delivery. The control group included women with at least one previous vaginal delivery without OASI. General medical history, obstetric history, and ante-, intra- and post-partum data were collected and compared between groups. Following implementation of the inclusion criteria, 79,176 women were included. Allocation to study groups was according to OASI occurrence: 135 patients (0.2%) had a third- or fourth-degree perineal tear, while 79,041 patients (99.8%) had no such injury. Multivariate analysis revealed that one previous vaginal delivery, birthweight ≥ 3900 g (90th percentile), vacuum-assisted vaginal delivery and episiotomy were associated with increased risk of OASI. Comparison of more severe OASI (3C and 4th-degree) cases to the control group showed similar results with the addition of prolonged second stage and younger age to risk factors associated with severe OASI while episiotomy was no longer significant. In women with a previous vaginal delivery, one vs. two or more previous vaginal deliveries, increased birthweight, vacuum-assisted vaginal delivery and episiotomy are risk factors for OASI.

Background Colorectal cancer is a condition which is associated with substantial morbidity and mortality. The aim of this study was to assess urinary dysfunction and its effect on quality of life in women who underwent total mesorectal excision compared to women treated by partial mesorectal excision for treatment of rectal cancer. Methods We performed a retrospective cohort study at a tertiary university hospital between January 2014 and December 2019. A comparison was performed between women who underwent total mesorectal excision as opposed to partial mesorectal excision for treatment of rectal cancer. Pre-operative, intra-operative and post-operative data were compared between groups. Data regarding radiation therapy was recorded and compared as well. Urinary dysfunction and its impact on quality of life were assessed using UDI-6 and USIQ questionnaires. Further univariate and multivariate analyses were performed in the attempt of assessing risk factors for urinary dysfunction. Results A total of 107 women were included in the study, 73 women underwent partial mesorectal excision as opposed to 34 women who were treated by total mesorectal excision. Twenty-five women in the TME group underwent radiation therapy prior to surgery as opposed to none in the PME group (p Conclusions Women undergoing total mesorectal excision have comparable results to partial mesorectal excision with regard to urinary dysfunction.

Obstetric anal sphincter injury (OASI) is a complication with substantial maternal morbidity. The aim of this study was to develop a machine learning model that would allow a personalized prediction algorithm for OASI, based on maternal and fetal variables collected at admission to labor. We performed a retrospective cohort study at a tertiary university hospital. Included were term deliveries (live, singleton, vertex). A comparison was made between women diagnosed with OASI and those without such injury. For formation of a machine learning-based model, a gradient boosting machine learning algorithm was implemented. Evaluation of the performance model was achieved using the area under the receiver-operating characteristic curve (AUC). Our cohort comprised 98,463 deliveries, of which 323 (0.3%) were diagnosed with OASI. Applying a machine learning model to data recorded during admission to labor allowed for individualized risk assessment with an AUC of 0.756 (95% CI 0.732–0.780). According to this model, a lower number of previous births, fewer pregnancies, decreased maternal weight and advanced gestational week elevated the risk for OASI. With regard to parity, women with one previous delivery had approximately 1/3 of the risk for OASI compared to nulliparous women (OR = 0.3 (0.23–0.39), p

Unintentional extension of uterine incision is a known complication during cesarean delivery estimated to occur in 4-8% of cesarean deliveries. The aim of this study was to examine risk factors associated with unintentional uterine incision extension and to assess which of them are independent risk factors for this condition.We conducted a retrospective cohort study at a large public university tertiary referral center between 2003 and 2017. Included were women who underwent cesarean delivery during this time period. Demographic, medical, obstetrical and surgical data were collected. The primary outcome was the presence of uterine incision extension during cesarean delivery. Secondary outcomes included detection of risk factors associated with uterine incision extension. A multivariate analysis was additionally performed to identify general and labor related risk factors for unintentional extension of uterine incision among patients that underwent cesarean delivery during second stage of labor.During the study period, 25,879 cesarean deliveries performed in our medical center were assessed. Out of them, 731 (2.8%) cases of unintended uterine incision extension were identified. Women in this group had high rates of full cervical dilatation and increased maternal hemorrhage. Assessment of incision extension direction revealed that two-thirds of extensions were lateral, mostly unilateral. Median size of the extension was 2.7 ± 1.2 cm.Independent parameters associated with unintended uterine incision extension included nulliparity, vertex presentation, epidural anesthesia and cesarean section indication. Further analysis including cesarean deliveries performed during the second stage of labor revealed 397 (15.3%) cesarean deliveries in which incision extension was noted and 2205 (84.7%) cesarean deliveries without incision extension. Following multivariate analysis performed in women who underwent cesarean delivery during second stage of labor, two independent parameters associated with unintended uterine incision extension remained significant - past cesarean delivery and failed vacuum attempt.Vacuum extraction attempt and previous cesarean delivery are independent risk factors for uterine incision extension in women undergoing cesarean delivery during the second stage of labor. We also showed the majority of these extensions to be lateral.

Study Objective The purpose of this study was to present the feasibility and potential clinical advantages of Apyx (Escala Medical, Israel), a minimally invasive incision-free anchoring device, for apical prolapse repair. Design An experimental prospective animal and cadaver study. Setting Animal facility and a cadaver laboratory of a tertiary care teaching hospital. Patients Included in this study were 7 ovine models, 2 porcine specimens, and 3 fresh unembalmed female human cadavers. Interventions The Apyx device for sacrospinous ligament (SSL) suspension was tested on ovine and porcine models. The pullout force needed to detach the Apyx anchor from the SSL was measured. Safety, reliability, and feasibility of this new incision-free procedure were also tested on an ovine model and human cadavers. The precision in deployment of the Apyx device to the SSL was tested via palpation by the surgeon, tissue dissection, and x-ray imaging. The efficacy was tested both by pullout forces and histologic analysis of the vaginal attachment to the SSL. Measurements and Main Results Forty-two anchors were inserted into the SSLs on ovine and porcine models and on cadaver SSLs. No abnormalities or malfunctions were noted in the functional performance of the anchors or the retrieval device. Mean pullout force for the ovine animal model was 38.64 ± 2.80 N. Pullout force in the porcine model was found to be in correlation with the values observed in the ovine model. None of the measured forces was below 20 N. Accuracy and safety tests showed good consistency when deploying the Apyx device to the SSL with no damage to surrounding organs in the ovine or the human cadaver model. Histology demonstrated biologic adhesion characterized by a gross assessment of a newly formed, firm fibrotic tissue 12 weeks after anchor deployment. Conclusion The Apyx anchoring system, a novel incision-free minimally invasive prolapse repair device, demonstrated an anatomically feasible, easy-to-use procedure for suspending the vaginal apex to the SSLs. Its clinical safety, efficacy, and impact on patient symptoms and quality of life should be further studied.

DNA methylation is a fundamental epigenetic mark that governs chromatin organization, cell identity, and gene expression. Here we describe a human methylome atlas, based on deep whole-genome bisulfite sequencing allowing fragment-level analysis across thousands of unique markers for 39 cell types sorted from 207 healthy tissue samples.Replicates of the same cell-type are >99.5% identical, demonstrating robustness of cell identity programs to genetic variation and environmental perturbation. Unsupervised clustering of the atlas recapitulates key elements of tissue ontogeny, and identifies methylation patterns retained since gastrulation. Loci uniquely unmethylated in an individual cell type often reside in transcriptional enhancers and contain DNA binding sites for tissue-specific transcriptional regulators. Uniquely hyper-methylated loci are rare and are enriched for CpG islands, polycomb targets, and CTCF binding sites, suggesting a novel role in shaping cell type-specific chromatin looping. The atlas provides an essential resource for interpretation of disease-associated genetic variants, and a wealth of potential tissue-specific biomarkers for use in liquid biopsies.Summary paragraphDNA methylation, a fundamental epigenetic mark, governs chromatin organization and gene expression1, thus defining the molecular identity of cells and providing a window into developmental processes with wide-ranging physiologic and clinical ramifications. Current DNA methylation datasets have limitations, typically including only a fraction of methylation sites, many from cell lines that underwent massive changes in culture or from tissues containing unspecified mixtures of cells2–6.We present a human methylome atlas based on deep whole-genome bisulfite sequencing of 39 sorted, primary cell types and use this dataset to address fundamental questions in developmental biology, physiology and pathology. Biological replicates are >99.5% identical, demonstrating unappreciated robustness to genetic variation and environmental perturbations. Clustering recapitulates key elements of tissue ontogeny, identifying methylation patterns retained since gastrulation. Loci uniquely unmethylated in individual cell types identify novel transcriptional enhancers and are enriched for tissue-specific transcription factors binding motifs. In contrast, loci uniquely hyper-methylated in specific cell types are rare, enriched for CpG islands and polycomb targets, and overlap CTCF binding sites, suggesting a novel role in shaping cell-type-specific chromatin looping. Finally, the atlas facilitates fragment-level deconvolution of tissue and plasma methylomes across thousands of cell-type specific regions to quantify their individual components at unprecedented resolution.The human cell-type-specific methylation atlas provides an essential resource for studying gene regulation by defining cell-type-specific distal enhancers and regulators of 3D organization, for identifying pathological changes in DNA methylation, and for the interpretation of methylation-based liquid biopsies.A deep methylation atlas of 39 human cell types, sorted from healthy samplesMethylomes record developmental history of cellsThousands of novel cell type-specific methylation markersHypo-methylation uncovers cell type-specific regulatory map of distal enhancersHyper-methylation across CTCF sitesCell type-specific biomarkers facilitate fragment-level deconvolution of tissues and cfDNA

While obstetric anal sphincter injury (OASI) is less frequent in parous compared to nulliparous women, it remains a major concern affecting quality of life of women worldwide. The aim of this study was to evaluate the association between birthweight (BW) difference between deliveries and risk of OASI in parous women.We performed a retrospective case-control study including parous women with at least one previous vaginal delivery who were diagnosed with OASI. The control group consisted of parous women who did not have OASI during vaginal delivery. Controls were matched in a 1:2 ratio by year of birth, maternal age, and parity. Medical history, obstetric background, and current labor-related data were compared. Further univariate and multivariable analyses were performed, assessing for risk factors for OASI.One hundred eight parous women who had a diagnosis of OASI and a control group of 216 parturients who delivered without OASI were included in the final analysis. Differences between the current BW and the preceding and maximal previous BW were evaluated. There were significantly higher rates of women who had a larger neonate with500 g difference between the current and previous BW in the OASI group than in those with no OASI (28.7% vs. 12.30%, respectively; p0.001). Following a multivariable analysis for the dependent parameter of OASI, the following parameters were found to be independently associated with OASI outcome: previous operative vaginal delivery, BW ≥ 90th percentile, and current BW ≥ 500 g compared to previous maximal BW.In parous women, neonatal BW increase between deliveries of500 g is associated with OASI.

Vaginal hysterectomy with uterosacral ligament suspension (VUSLS) is a common procedure for apical prolapse repair. Data regarding pelvic hematoma following this procedure is scarce. The aim of this study was to describe the occurrence of infected and non-infected pelvic hematoma in women following VUSLS and to assess for specific risk factors for infection.We performed a retrospective cohort study, including all women who underwent VUSLS for treatment of apical prolapse between 2010 and 2020. Patients with and without pelvic hematoma by ultrasound were compared. A subgroup analysis compared patients with infected vs non infected hematomas.During the study period, 316 women underwent VUSLS for treatment of apical prolapse. Sixty-six (20.9%) were diagnosed with a pelvic hematoma, and in seventeen (5.4%) women the hematoma became infected. The majority (76%) of pelvic hematomas were located above the vaginal cuff. Women in the hematoma group had increased rates of hypothyroidism and concomitant anterior colporrhaphy. However, following multivariate analysis, these differences were no longer significant. Subgroup analysis comparing women with infected versus non-infected pelvic hematoma was performed. No differences were noted with respect to surgical outcomes (clinical, anatomical, or composite). Women with infected hematoma had higher rates of posterior colporrhaphy during surgery (33.3% vs 9.5%, p = 0.039). This difference remained significant following multivariate analysis (aOR = 8.87, CI 1.1-73.0).Pelvic hematoma following VUSLS is common as opposed to infected pelvic hematoma which seldom occurs. Concomitant posterior colporrhaphy was associated with infection.

DNA methylation is a fundamental epigenetic mark that governs gene expression and chromatin organization, thus providing a window into cellular identity and developmental processes1. Current datasets typically include only a fraction of methylation sites and are often based either on cell lines that underwent massive changes in culture or on tissues containing unspecified mixtures of cells2–5. Here we describe a human methylome atlas, based on deep whole-genome bisulfite sequencing, allowing fragment-level analysis across thousands of unique markers for 39 cell types sorted from 205 healthy tissue samples. Replicates of the same cell type are more than 99.5% identical, demonstrating the robustness of cell identity programmes to environmental perturbation. Unsupervised clustering of the atlas recapitulates key elements of tissue ontogeny and identifies methylation patterns retained since embryonic development. Loci uniquely unmethylated in an individual cell type often reside in transcriptional enhancers and contain DNA binding sites for tissue-specific transcriptional regulators. Uniquely hypermethylated loci are rare and are enriched for CpG islands, Polycomb targets and CTCF binding sites, suggesting a new role in shaping cell-type-specific chromatin looping. The atlas provides an essential resource for study of gene regulation and disease-associated genetic variants, and a wealth of potential tissue-specific biomarkers for use in liquid biopsies.

Background Obstetric anal sphincter injury (OASI) is a debilitating complication of vaginal delivery which has yet to receive ample attention in adolescents. The aim of this study was to describe risk for OASI in adolescent mothers compared to adults. We further attempted to compare risk factors for OASI between these two age groups. Methods We performed a retrospective cohort study between 2003 and 2019. Primiparous women who delivered vaginally, 21 years and younger were compared to women ages 26–35. Excluded were preterm, multifetal, non-vertex, cesarean deliveries as well as intrauterine fetal death. Rate of OASI as well as obstetric and labor characteristics of women with OASI, were compared between groups. Finally, risk factors were assessed for each group separately. Univariate and multivariate logistic regression model were performed. Results Final analysis was performed on 5113 nulliparous adolescents and 13,845 nulliparous in the 26–35 age group. Allocation to study groups was according to OASI – Sixty-seven adolescents (1.3%) had a 3rd or 4th degree perineal tear and were defined as the OASI group, while 5046 patients (98.7%) did not have such a tear. In the adult group, 199 out of 13,845 patients (1.4%) were diagnosed with OASI. Occurrence of OASI did not differ between groups (p = 0.510). Comparison of women with OASI in the adolescent group vs. adult group found differences with regard to operative vaginal delivery, (20.9% vs. 36.2%, respectively; p = 0.023) and meconium stained amniotic fluid (9.1% vs. 21.3%, respectively; p = 0.027). Following multivariate analysis the only parameter independently associated with OASI in the adolescent age group was head circumference ≥ 90th percentile with an adjusted odds ratio of 3.08 (CI 1.48–6.38, p = 0.003). In the adult group the similar analysis revealed operative vaginal delivery (OR = 2.44, CI 1.72–3.47, p p = 0.012) to be independent risk factors for OASI. Conclusion Adolescents have similar risk for OASI compared to adults but differ in risk factors leading to OASI. Head circumference ≥ 90th percentile was found to be associated with OASI in this age group.

Obstetric anal sphincter injury (OASI) is a debilitating complication of vaginal delivery. The aim of this study was to identify risk factors for OASI in women with a previous vaginal delivery. We further attempted to detect specific risk factors for severe OASI in this subgroup.We conducted a retrospective cohort study between 2003 and 2019. The study group included women who had a singleton, live, vertex, vaginal delivery at term and who also had at least one previous vaginal delivery. The control group included women with at least one previous vaginal delivery without OASI. General medical history, obstetric history, and ante-, intra- and post-partum data were collected and compared between groups.Following implementation of the inclusion criteria, 79,176 women were included. Allocation to study groups was according to OASI occurrence: 135 patients (0.2%) had a third- or fourth-degree perineal tear, while 79,041 patients (99.8%) had no such injury. Multivariate analysis revealed that one previous vaginal delivery, birthweight ≥ 3900 g (90th percentile), vacuum-assisted vaginal delivery and episiotomy were associated with increased risk of OASI. Comparison of more severe OASI (3C and 4th-degree) cases to the control group showed similar results with the addition of prolonged second stage and younger age to risk factors associated with severe OASI while episiotomy was no longer significant.In women with a previous vaginal delivery, one vs. two or more previous vaginal deliveries, increased birthweight, vacuum-assisted vaginal delivery and episiotomy are risk factors for OASI.

Urinary bladder injury during cesarean delivery is an uncommon complication with substantial maternal morbidity. The aim of this study was to identify possible risk factors for bladder injury during cesarean delivery and to describe the role of retrograde bladder filling in the assessment of bladder wall integrity. A retrospective cohort study at a large tertiary referral center. Women who underwent cesarean delivery between 2003 and 2017 were included. Women diagnosed with urinary bladder injury were compared to women who did not have such injuries. Data retrieved included demographic characteristics, general medical history, obstetric history and intra-partum and intra-operative data. Information regarding use of retrograde bladder filling intra-operatively was retrieved as well. During the study period, 21,177 cesarean deliveries were performed of which 68 (0.3%) cases of urinary bladder injury were identified. Two-thirds of injuries were located at the urinary bladder dome with the remaining third located at the posterior bladder wall. Most injuries were formed during uterine incision extension (60.0%) followed by peritoneal entry (22.0%). Following uni- and multivariate analyses, three parameters remained independent risk factors for bladder injury: urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of the uterine incision extension. In 15.4% of cases in which retrograde bladder filling was utilized following bladder repair, leakage of fluid was evident. Urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of uterine incision extension are independent risk factors for urinary bladder injury during cesarean delivery.

Obstetric anal sphincter injury (OASI) is a complication with substantial maternal morbidity. The aim of this study was to develop a machine learning model that would allow a personalized prediction algorithm for OASI, based on maternal and fetal variables collected at admission to labor.We performed a retrospective cohort study at a tertiary university hospital. Included were term deliveries (live, singleton, vertex). A comparison was made between women diagnosed with OASI and those without such injury. For formation of a machine learning-based model, a gradient boosting machine learning algorithm was implemented. Evaluation of the performance model was achieved using the area under the receiver-operating characteristic curve (AUC).Our cohort comprised 98,463 deliveries, of which 323 (0.3%) were diagnosed with OASI. Applying a machine learning model to data recorded during admission to labor allowed for individualized risk assessment with an AUC of 0.756 (95% CI 0.732-0.780). According to this model, a lower number of previous births, fewer pregnancies, decreased maternal weight and advanced gestational week elevated the risk for OASI. With regard to parity, women with one previous delivery had approximately 1/3 of the risk for OASI compared to nulliparous women (OR = 0.3 (0.23-0.39), p 0.001), and women with two previous deliveries had 1/3 of the risk compared to women with one previous delivery (OR = 0.35 (0.21-0.60), p 0.001).Our machine learning-based model stratified births to high or low risk for OASI, making it an applicable tool for personalized decision-making upon admission to labor.

Urinary bladder injury during cesarean delivery is an uncommon complication with substantial maternal morbidity. The aim of this study was to identify possible risk factors for bladder injury during cesarean delivery and to describe the role of retrograde bladder filling in the assessment of bladder wall integrity.A retrospective cohort study at a large tertiary referral center. Women who underwent cesarean delivery between 2003 and 2017 were included. Women diagnosed with urinary bladder injury were compared to women who did not have such injuries. Data retrieved included demographic characteristics, general medical history, obstetric history and intra-partum and intra-operative data. Information regarding use of retrograde bladder filling intra-operatively was retrieved as well.During the study period, 21,177 cesarean deliveries were performed of which 68 (0.3%) cases of urinary bladder injury were identified. Two-thirds of injuries were located at the urinary bladder dome with the remaining third located at the posterior bladder wall. Most injuries were formed during uterine incision extension (60.0%) followed by peritoneal entry (22.0%). Following uni- and multivariate analyses, three parameters remained independent risk factors for bladder injury: urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of the uterine incision extension. In 15.4% of cases in which retrograde bladder filling was utilized following bladder repair, leakage of fluid was evident.Urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of uterine incision extension are independent risk factors for urinary bladder injury during cesarean delivery.

The objective was to compare clinical and anatomical outcomes between laparoscopic uterosacral ligament suspension (LUSLS) and vaginal colposuspension using the Uphold Lite™ mesh system for the treatment of apical prolapse. We performed a comparative, retrospective cohort study. All women who underwent either vaginal colposuspension with the Uphold Lite™ System or LUSLS for treatment of apical prolapse between 2010 and 2019 were included. The groups were compared with regard to demographic, pre-operative, intra-operative, and post-operative data. Outcome measures included clinical and anatomical cure, as well as a composite outcome. The PGI-I questionnaire was used to determine patient satisfaction. One-hundred and nineteen women met the inclusion criteria, including 70 women who underwent LUSLS and 49 women who underwent vaginal colposuspension with the Uphold Lite™ mesh system. At a mean follow-up of 31.7 (SD = 18.1) months, the clinical cure rate was high for both groups, reaching 98.6% in the LUSLS group compared with 89.8% in the Uphold group (NS). Anatomical cure rate was 83.6% in the LUSLS group compared with 69.7% for the Uphold group (NS). With regard to the composite outcome, no difference was found, although a trend towards a higher success rate was noted in the LUSLS group (83.6% vs 66.7%, p = 0.055). Patient satisfaction measured using the PGI-I questionnaire was high, at 98.6% in the LUSLS group and 87.8% in the Uphold group (NS). Laparoscopic uterosacral ligament suspension and vaginal colposuspension using the Uphold Lite™ mesh system both have high clinical cure rates.

Objectives To determine if PF-88, a reverse thermo-responsive polymer designed to create a gel at body temperature and liquefy at a lower temperature (21°C) can reversibly occlude the fallopian tubes in rabbits. Study design Mature female New Zealand White rabbits underwent laparotomy and placement of 22-gage catheter into the lumen of the distil uterine horns for evaluation of tubal patency by fluoroscopy using radio opaque contrast and treatment with PF-88. In the Acute Phase group (n = 5) after PF-88 treatment we immediately cooled the serosal surface of the tube with ice for 90 seconds to liquify the gel then reassessed patency. In the Survival Phase groups, animals recovered from the initial surgery and then underwent a second procedure for evaluation of tubal occlusion and reversibility at 4 (n = 3), 14 (n = 2), and 28 (n = 3) weeks after the initial procedure. We compared the histologic appearance of the treated fallopian tubes to untreated controls (n = 3). Results In the Acute Phase, we found all 10 fallopian tubes patent on initial evaluation, occluded following treatment with PF88, and patent following re-liquification by chilling. Animals in the Survival Group, all but one of the treated tubes appeared blocked at follow-up and patent following chilling. The treatment failure occurred in an animal in the 4-week group. Tubes treated with PF88 showed no histologic evidence of residual material or damage after removal of the polymer. Conclusion The PF-88 reverse thermo-responsive polymer demonstrated the ability to reversibly block fallopian tubes for up to 28 weeks. Implications The demonstration of reversible occlusion of the fallopian tube of rabbits using PF-88, a thermo-responsive reverse polymer, support additional studies to evaluate the potential of this polymer as a contraceptive in women.

Surgical treatment of pelvic organ prolapse often includes the use of patients’ vaginal connective tissue. Wound healing appears to play an important part in the success of such procedures. The aim of this study was to describe the effect of age on inflammatory processes, specifically macrophage response, involved in vaginal wound healing. Twenty-five young (12 weeks old) and 25 old (12 months old) virgin female Fischer rats underwent a standardized 9-mm posterior midline vaginal incision. Tissue samples were taken for histological analysis on days 1, 3, 7, 14 and 30 post-injury. Parameters evaluated included wound area, macrophage number and expression of inflammatory markers including tumor necrosis factor alpha (TNFa), inducible nitric oxide synthase (iNOS), CCR7/CD197, arginase I and CD163/M130. Microscopic examination of the vaginal wounds over time demonstrated a clear difference between young and old rats in spontaneous healing capacity. The average wound area in young rats 1 day after injury was significantly smaller than in old rats (16.5 ± 1.7 vs. 23.8 ± 1.5 mm2, P

Aim Parity and age are risk factors for urinary incontinence (UI). The aim of this study was to compare grand multipara women (GMP) to non-grand multipara (NGMP) women concerning UI types (stress urinary incontinence [SUI], urge urinary incontinence [UUI]), symptoms, and quality of life. Methods This correlation-comparative study used three tools: a demographic/health questionnaire, Questionnaire for Urinary Incontinence Diagnosis (QUID), and Incontinence Quality of Life (I-QOL). Results The sample included 132 women, from 50-88 years of age: 65 NGMP women (mean age: 67.23 years) and 67 GMP women (mean age: 65.04 years). The GMP group had a higher score, compared to the NGMP group, for UI type (by QUID) and a lower QOL (by I-QOL) , with none of the scores found to be statistically significant. By dividing the sample into age groups, 50-59 and ≥60 years, the interaction between the parity and the age groups was found to be significant for both the SUI and UUI. Conclusion The innovation of this study is the in-depth insight into the association between parity and age regarding UI type.

OBJECTIVES The aim of this study was to determine anatomical and clinical cure, as well as patient satisfaction in uterine-preserving laparoscopic uterosacral ligament suspension (LUSLS) in women with anterior and apical prolapse. METHODS This was a retrospective cohort study including all women who underwent LUSLS for anterior and apical prolapse between January 2012 and December 2015 at a tertiary-care university hospital. All women had LUSLS hysteropexy and anterior colporrhaphy. Pre- and postoperative pelvic organ prolapse quantification (POP-Q) measurements were taken. Prolapse symptoms were queried via standardized history. Patient satisfaction was measured by the Patient Global Impression of Improvement (PGI-I). RESULTS Fifty-three women underwent the procedure during the study period. Follow-up data were available for 48 women. The mean preoperative POP-Q Ba point was 2.7 ± 1.6 and C point was -0.8 ± 2.8. At a mean follow-up of 17.5 ± 16.0 months with a median of 12 months (range, 1-54 months), there was a significant improvement of POP-Q points Ba, C, and Bp (P < 0.001 for all comparisons). Anatomical cure, defined as no prolapse of any POP-Q point at or below 1 cm above the hymen (-1), was 85.4%. Clinical cure, defined as a composite outcome of no prolapse outside the hymen, C point above total vaginal length/2, no prolapse symptoms, and no need for further treatment, was 95.8%. At a mean of 22.2 ± 12.4 months postoperatively, patient satisfaction was high, with 95.5% stating their condition was very much better (PGI-I-A) or much better (PGI-I-B). CONCLUSION Laparoscopic uterosacral ligament suspension is a valid uterine-preserving option for women with anterior and apical prolapse, with high anatomical and clinical cure rates and patient satisfaction.

The process of informed consent is an integral part of the preoperative encounter. In theory, it has the potential to educate patients, enabling them to reach a true autonomous decision regarding the treatment offered. Unfortunately, in recent years informed consent has become overly complicated for the average patient. Questions have been raised regarding the ability of the process, as practiced nowadays, to actually increase knowledge and achieve its goals. In search of new ways to increase patient comprehension, researchers have suggested use of multimedia during the process of informed consent. Visualization of complex ideas, interactive learning and tailoring the procedure to fit patient needs are all advantages presented by use of multimedia during the process. Several randomized prospective trials have looked into this topic and have presented promising data in favor of multimedia use. Informed consent is a process with unfulfilled potential, and use of multimedia may be part of the solution. In our opinion, it is time to change the way we educate patients.

Aim We aimed to determine the importance of uterine position as a predicting factor of success rate in medically treated early pregnancy failure (EPF). Methods We carried out a retrospective cohort study at the Obstetrics and Gynecology Department of a tertiary medical center between January 2011 and June 2012. We included women diagnosed with EPF, which we defined as women diagnosed with missed abortion up to 13 gestational weeks. Patients were treated with one or two doses of 800 μg of misoprostol vaginally in accordance with the department's protocol. Demographic, clinical, and treatment success data were collected from patient electronic records. Results A total of 255 women were included in our study. The success rate after treatment with misoprostol for the anterior uterine group was 78.7% as compared to the non-anterior uterine group, which achieved a success rate of 88.1%. This difference was not statistically significant (P = 0.180). In a multivariate analysis comparing patients for whom treatment with misoprostol was successful as opposed to patients for whom treatment failed, only embryonic sac size showed a statistically significant difference, measuring shorter in the success group. Conclusion Uterine position has no effect on success rate of misoprostol treatment for EPF.

This case presents the work-up and management of a spina bifida patient with recurrent prolapse. Four international experts also provide their evaluation of and approach to this complex case. According to the literature, little is known regarding the approach to the management of this specific patient population.

Surgical repair of pelvic organ prolapse often includes native tissue repair during which the patient’s own vaginal connective tissue is used to achieve pelvic support. This method, based on plication and suspension often yields suboptimal anatomical outcomes, possibly due to inadequate healing of the vaginal connective tissue. We hypothesized that age might have a negative effect on the time course and tissue biomechanics of vaginal wound healing in a rat model. Fifty young (12 weeks) and old (12 months) female 344BN Fischer rats were subjected to a posterior midline vaginal incision. The time course of repair was determined by measuring the size of the wound on days 1, 3, 7, and 14 post-injury. These findings correlated with the immune response to injury using a marker of impaired wound healing, the inflammatory cytokine macrophage migration inhibitory factor in the vaginal muscularis. Biomechanical properties of the healed vaginal tissue were tested 30 days post-injury. Wound healing was assessed on days 1, 3, 7, and 14 post-injury. On day 3 post-injury, the wounds in the young animals had all closed whereas the wounds in the old animals remained open. Furthermore, on day 7, the wound gap was still filled with granulation tissue in the old rats, whereas for the young rats, the wound area was almost indistinguishable from the non-injured area. Macrophage migration inhibitory factor was highly expressed in the vaginal epithelium and in the vaginal muscularis after injury. When compared with young animals, macrophage migration inhibitory factor levels of old rats began to rise more than 2 days later and the increased tissue expression persisted for 7 days longer. The breakpoint force of the healed vagina of old rats was almost 4-fold weaker than in young rats. At 30 days post-injury, the healed vagina in old rats regained less of the original (healthy) force at breakpoint than the young rats. In this rat model, age impaired vaginal wound healing, which was reflected in the altered inflammatory response to injury and reduced tissue strength.

Obstetric anal sphincter injuries (OASIS) can have a very negative impact on women's health and quality of life. Literature exists concerning the role of the surgeon and physiotherapist after OASIS, but there is a dearth of literature pertaining to the role of the midwife in the management of women following an obstetric anal sphincter injury. This article examines the midwife's role and describes a new service instituted at Hadassah-Hebrew University medical centre, Jerusalem, utilised in the early postpartum period while the woman is still in hospital, entitled Special Services for Perineal Trauma.

Aim Leiomyomas, monoclonal tumors developed by the transformation of myometrium somatic stem cells, are a major health concern that can severely impair quality of life. Pathological alterations of signaling pathways have been recognized as a key feature in a variety of human diseases. Our objective was to analyze treatment with all-trans-retinoic acid (ATRA) by suppression of the phosphoinositide 3-kinase (PI3K) pathway on growth, signaling pattern and interactions among PI3K/B-cell lymphoma 2 (Bcl2)/retinol leiomyoma proteins. Methods Cultures of paired myometrium and leiomyoma cells from premenopausal women undergoing hysterectomy were collected. Western blot and analysis of variance were used for analysis. Results Significant differences were detected between treatment with ATRA alone or with LY294002 (a PI3K growth suppressor) in response to treatment and among cell samples and cell numbers. Leiomyoma cells were less affected. Immunochemical analysis of signaling patterns demonstrated that treatments affected most of the examined protein levels differently. Significant differences between the cell type responses to treatment in pyruvate phosphate dikinase 1 (pPDK1), Bad and pβ-catenin levels were identified. The pβ-catenin level showed highly significant interaction between response to treatment and cell type. Conclusions ATRA treatment on PI3K pathway suppression significantly affected growth, signaling pattern and interactions among PI3K/Bcl2/retinol proteins involved in the growth, survival and apoptosis of leiomyomas. Interpretation of our results suggests that increasing knowledge of the role of signaling interplay in the pathogenesis of leiomyomas may present an opportunity to use specific signal transduction inhibitors for treating and preventing this disorder.

Objective: While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare...

STUDY OBJECTIVE To compare anatomic and clinical cure rates as well as patient satisfaction between uterine-preserving laparoscopic uterosacral ligament suspension and total vaginal hysterectomy with uterosacral ligament suspension in women with apical and anterior prolapse. DESIGN Single-center clinical comparative retrospective cohort study. SETTING A female pelvic medicine and reconstructive surgery service at a tertiary teaching hospital. PATIENTS Women with pelvic organ prolapse who underwent surgical treatment for their condition between July 2010 and December 2015. INTERVENTIONS All women underwent laparoscopic uterosacral ligament suspension or total vaginal hysterectomy with uterosacral ligament suspension for apical and anterior prolapse. Concomitant procedures included anterior and posterior repair, as well as a midurethral sling when indicated. MEASUREMENTS AND MAIN RESULTS Preoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements were obtained. The primary outcome was clinical cure rate. Secondary outcomes included anatomic cure rate and outcomes of site-specific POP-Q points Ba, C, and Bp for the whole cohort. Patient satisfaction was measured using the Patient Global Impression of Improvement questionnaire. During the study period, 106 women underwent transvaginal hysterectomy with uterosacral ligament suspension, and 53 women had laparoscopic uterosacral ligament suspension. At a mean follow-up of 14.7 ± 13.23 months for the vaginal group and 17.5 ± 15.84 months for the laparoscopic group (p = .29), there were significant improvements of POP-Q points Ba, C, and Bp (p < .0001 for all comparisons in both groups). The clinical cure rate was 96% in the vaginal group and 98% in the laparoscopic group (p = .50). The anatomic cure rate was 85.4% in the vaginal group and 93.75% in the laparoscopic group (p = .11) Patient satisfaction was high in both groups. CONCLUSION In appropriately selected patients, laparoscopic uterosacral ligament suspension is a valid uterus-preserving option for women with anterior and apical prolapse, associated with high anatomic and clinical cure rates and patient satisfaction.

Study Objective The objective of this study was to describe prevalence and location of obstetric lacerations in adolescents. Design Retrospective cohort study. Setting We performed an analysis of the Consortium on Safe Labor database including tertiary care university-affiliated urban hospitals. Participants All primiparous women who delivered vaginally were included. Interventions Vaginal and perineal lacerations were compared between age groups 15 or younger, 16-21, 22-34, 35-39, and older than 40 years. Main Outcome Measures Outcome measures included vaginal, perineal, labial, and periurethral lacerations. χ2 and Fisher exact tests were used as appropriate, with P Results A total of 9777 patients were included in the analysis. Young adolescents and adolescents had significantly higher rates of labial and periurethral lacerations compared with individuals aged 22-34 years. The prevalence of third- and fourth-degree perineal tears increased with age. Conclusion Adolescent primiparous women are less likely to have severe perineal obstetric tears, but have higher rates of labial and periurethral tears.

Study Objective To evaluate reproductive and obstetric outcomes following operative hysteroscopy for treatment of retained products of conception (RPOC). We also investigated the effect of time interval between operative hysteroscopy and pregnancy on these outcomes. Design Retrospective cohort study. Setting The study was conducted at the gynecology department of a tertiary teaching hospital between January 2012 and December 2016. Patients or Participants Women who underwent operative hysteroscopy for treatment of RPOC and who became pregnant following the procedure. Interventions All women in the study underwent operative hysteroscopy with resection of RPOC. Measurements and Main Results Demographic, pre-operative, intra-operative, post-operative, reproductive and obstetric data were retrieved from electronic medical records. All patients were contacted via telephone questionnaire during which data regarding reproductive and obstetric outcomes of the pregnancy following the surgical procedure were collected. To determine the effect of time interval between operative hysteroscopy and pregnancy on reproductive and obstetric outcomes the cohort was divided into two groups: women who conceived 6 months or less following surgery and women who conceived more than 6 months after operative hysteroscopy. Eighty-two women who underwent operative hysteroscopy for treatment of RPOC and who conceived later were included. Mean time from women's attempt to conceive to conception was 4.32 (SD=5.31) months. Conception rate was 84.2% at 6 months and reached 92.7% at 12 months post-surgery. Miscarriage rate for the consecutive pregnancy following hysteroscopy was 16.7% and delivery rate was 83.3%. Two cases of obstetric complications including one case of retained placenta and one case of post-partum hemorrhage were noted. Time interval between operative hysteroscopy and pregnancy did not affect reproductive or obstetric outcomes. Conclusion Women treated by operative hysteroscopy for RPOC have positive reproductive and obstetric outcomes. Time interval between the procedure and pregnancy has no effect on these outcomes.