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Background: Single intrauterine fetal death affects approximately 6% of twin pregnancies and can have serious sequelae for the surviving co-twin.Objectives: Determine the prognosis of the surviving co-twin following spontaneous single intrauterine fetal death to aid counselling patients and highlight future research areas.Search Strategy: Medline, Embase, Web of Science, and Cochrane Library, from 1980 to June 2017.Selection Criteria: Studies of five or more cases of spontaneous single intrauterine fetal death after 14 weeks gestation, in diamniotic twin pregnancies.Data Collection and Analysis: Summary event rates were calculated and stratified by chorionicity. Monochorionic and dichorionic twins, and sub-groups, were compared by odds ratios.Main Results: In monochorionic twins, when single intrauterine fetal death occurred at less than 28 weeks' gestation, this significantly increased the rate of co-twin intrauterine fetal death [odds ratio (OR) 2.31, 95% confidence interval (CI) 1.02-5.25, I2  = 0.0%, 12 studies, 184 pregnancies] and neonatal death (OR 2.84, 95% CI 1.18-6.77, I2  = 0.0%, 10 studies, 117 pregnancies) compared with when the single intrauterine fetal death occurred at more than 28 weeks' gestation. Neonatal death in monochorionic twins was significantly higher if the pregnancy was complicated by fetal growth restriction (OR 4.83, 95% CI 1.14-20.47, I2  = 0.0%, six studies, 60 pregnancies) or preterm birth (OR 4.95, 95% CI 1.71-14.30, I2  = 0.0%, 11 studies, 124 pregnancies). Abnormal antenatal brain imaging was reported in 20.0% (95% CI 12.8-31.1, I2  = 21.9%, six studies, 116 pregnancies) of surviving monochorionic co-twins. The studies included in the meta-analysis demonstrated small study effects and possible selection bias.Conclusions: Preterm birth was the commonest adverse outcome affecting 58.5 and 53.7% of monochorionic and dichorionic twin pregnancies. Outcomes regarding brain imaging and neurodevelopmental comorbidity are an important area for future research, but meta-analysis may be limited due to different methods of assessment.Tweetable Abstract: Preterm birth is the highest risk in single co-twin death. Abnormal antenatal brain imaging was found in 1/5 surviving MC twins. [ABSTRACT FROM AUTHOR]

Objectives: To assess the effect of timing of folic acid (FA) supplementation during pregnancy on the risk of the neonate being small for gestational age (SGA).Design: A population database study and a systematic review with meta-analysis including the results of this population study.Setting and Data Sources: A UK regional database was used for the population study and an electronic literature search (from inception until August 2013) for the systematic review.Participants and Included Studies: Singleton live births with no known congenital anomalies; 111,736 in population study and 188,796 in systematic review.Outcome Measures, Data Extraction and Analysis: The main outcome was SGA based on customised birthweight centile. Associations are presented as odds ratios (OR) and adjusted odds ratios (aOR), adjusted for maternal and pregnancy-related characteristics.Results: Of 108,525 pregnancies with information about FA supplementation, 92,133 (84.9%) had taken FA during pregnancy. Time of commencement of supplementation was recorded in 39,416 pregnancies, of which FA was commenced before conception in 10,036, (25.5%) cases. Preconception commencement of FA supplementation was associated with reduced risk of SGA <10th centile (aOR 0.80, 95% CI 0.71-0.90, P < 0.01) and SGA <5th centile (aOR 0.78, 95% CI 0.66-0.91, P < 0.01). This result was reproduced when the data were pooled with other studies in the systematic review, showing a significant reduction in SGA (<5th centile) births with preconception commencement of FA (aOR 0.75, 95% CI 0.61-0.92, P < 0.006). In contrast, postconception folate had no significant effect on SGA rates.Conclusion: Supplementation with FA significantly reduces the risk of SGA at birth but only if commenced preconceptually independent of other risk factors.Systematic Review Registration: This systematic review was prospectively registered with PROSPERO number CRD42013004895. [ABSTRACT FROM AUTHOR]

Objectives To assess the effect of timing of folic acid (FA) supplementation during pregnancy on the risk of the neonate being small for gestational age (SGA). Design A population database study and a systematic review with meta-analysis including the results of this population study. Setting and data sources A UK regional database was used for the population study and an electronic literature search (from inception until August 2013) for the systematic review. Participants and included studies Singleton live births with no known congenital anomalies; 111 736 in population study and 188 796 in systematic review. Outcome measures, data extraction and analysis The main outcome was SGA based on customised birthweight centile. Associations are presented as odds ratios (OR) and adjusted odds ratios (aOR), adjusted for maternal and pregnancy-related characteristics. Results Of 108 525 pregnancies with information about FA supplementation, 92 133 (84.9%) had taken FA during pregnancy. Time of commencement of supplementation was recorded in 39 416 pregnancies, of which FA was commenced before conception in 10 036, (25.5%) cases. Preconception commencement of FA supplementation was associated with reduced risk of SGA <10th centile (aOR 0.80, 95% CI 0.71-0.90, P < 0.01) and SGA <5th centile (aOR 0.78, 95% CI 0.66-0.91, P < 0.01). This result was reproduced when the data were pooled with other studies in the systematic review, showing a significant reduction in SGA (<5th centile) births with preconception commencement of FA (aOR 0.75, 95% CI 0.61-0.92, P < 0.006). In contrast, postconception folate had no significant effect on SGA rates. Conclusion Supplementation with FA significantly reduces the risk of SGA at birth but only if commenced preconceptually independent of other risk factors. Systematic review registration This systematic review was prospectively registered with PROSPERO number CRD42013004895. [ABSTRACT FROM AUTHOR]

Background: Approximately 50% of spontaneous miscarriages are associated with chromosome abnormalities. Identification of these karyotypic abnormalities helps to estimate recurrence risks in future pregnancies. Chromosomal microarray analysis (CMA) is transforming clinical cytogenetic practice with its ability to examine the human genome at increasingly high resolution.Objectives: The aim of this study was to determine whether CMA testing on the products of conception following miscarriage provides better diagnostic information compared with conventional karyotyping.Search Strategy: MEDLINE (from 1996 to December 2012), EMBASE (from 1974 to December 2012), and CINAHL (from 1996 to December 2012) databases were searched electronically.Selection Criteria: Studies were selected if CMA was used on products of conception following miscarriage, alongside conventional karyotyping.Data Collection and Analysis: Nine papers were included in the systematic review and meta-analysis. All statistical analyses were performed using stata 11.0 (Stata Corp., College Station, TX, USA).Main Results: There was agreement between CMA and karyotyping in 86.0% of cases (95% CI 77.0-96.0%). CMA detected 13% (95% CI 8.0-21.0) additional chromosome abnormalities over conventional full karyotyping. In addition, traditional, full karyotyping detected 3% (95% CI 1.0-10.0%) additional abnormalities over CMA. The incidence of a variant of unknown significance (VOUS) being detected was 2% (95% CI 1.0-10.0%).Author's Conclusions: Compared with karyotyping, there appears to be an increased detection rate of chromosomal abnormalities when CMA is used to analyse the products of conception; however, some of these abnormalities are VOUS, and this information should be provided when counselling women following miscarriage and when taking consent for the analysis of miscarriage products by CMA. [ABSTRACT FROM AUTHOR]

Objective: To perform a systematic review and meta-analysis of the effects on the surviving twin of single fetal death comparing monochorionic to dichorionic twins to report the rates of co-twin death, preterm delivery, and neurologic morbidity in the surviving fetus.Data Sources: MEDLINE (inception-December 2010), EMBASE (inception-December 2010), The Cochrane library (inception-December 2010), Web of Science (inception-December 2010), and British Nursing Index (inception-December 2010) were searched electronically.Methods Of Study Selection: Selected studies had more than five cases of single fetal death with reports of co-twin death, neurologic morbidity, or both co-twin death and neurologic morbidity. They also must have defined the gestational age of single fetal death and chorionicity.Tabulation, Integration, and Results: The search yielded 1,386 citations. Full manuscripts were retrieved for 204 and 22 were included in the review and meta-analysis. Twenty manuscripts were used to calculate overall summary statistics for monochorionic and dichorionic twins showing rates of co-twin death after single fetal death (15% compared with 3%), rates of preterm delivery after single fetal death (68% compared with 54%), the rate of abnormal postnatal cranial imaging after single fetal death (34% compared with 16%), and the rate of neurodevelopmental impairment after single fetal death (26% compared with 2%). Odds ratios (ORs) were calculated from 16 manuscripts. There was no significant difference reported between preterm delivery of monochorionic or dichorionic twins (OR 1.1, 95% confidence interval [CI] 0.34-3.51, P=.9). After single fetal death, monochorionic twins had higher odds of an abnormal cranial imaging after delivery, this was not significant (OR 3.25, 95% CI 0.66-16.1, P=.12). After single fetal death, monochorionic twins were 4.81-times more likely to have neurodevelopmental morbidity (95% CI 1.39-16.6, P<.05).Conclusion: Monochorionic twins are at significantly increased odds of co-twin demise and neurodevelopmental morbidity after single fetal death. [ABSTRACT FROM AUTHOR]

The results of two experiments comparing processing of function words and content words are reported. In Experiment 1, priming was present for both related function and related content word pairs, as measured in lexical decision response times. In Experiment 2, participants' eye movements were monitored as they read sentences containing either a high- or a low-frequency function or content target word. Average word length and word frequency were matched across the function and content word conditions. Function words showed frequency effects in first-fixation and gaze duration that were similar to those seen for content words. Clear differences in on-line processing of function and content words emerged in later processing measures. These differences were reflected in reading patterns and reading time measures. There was inflated processing time in the phrase immediately following a low-frequency function word, and participants made more regressions to the target word in this condition than in the other three conditions. The priming effects in lexical decision and the word frequency effects in initial processing measures in silent reading for both word types were taken as evidence of common lexical processing for function and content words. The observed differences in later processing measures in the eye-movement data were taken as evidence of differences in the role that the two word types have in sentence processing beyond the lexical level. [ABSTRACT FROM AUTHOR]

In two experiments, we found that readers are sensitive to manipulations of syntactically marked focus and that focus is an effective message level contextual priming mechanism. Changes in focus resulted in changes in sentence context effects on subsequent target word processing. This was demonstrated in latency to name the target word (Experiment 1) and in initial looking time on the target in silent reading (Experiment 2). Experiment 2 also revealed direct effects on the focused items, as readers made fewer regressions and spent less total time on a word that was focused than when it was not focused. However, no initial processing time effects were found on the focused word. [ABSTRACT FROM AUTHOR]

Introduction: The Fontan circulation palliates single-ventricle congenital heart disease by separating the systemic and pulmonary circulations. An increasing number of women with a Fontan circulation are wishing to become pregnant, however the ability to increase cardiac output during pregnancy is limited in many due to the chronic low output state. We describe pregnancy outcomes in these women at a large tertiary centre, including functional and imaging outcomes., Methods: We retrospectively investigated women with a Fontan circulation giving birth after 24 weeks' gestation between 1995 and 2023. Data collected included obstetric and neonatal complications, changes in cardiac volumes and ejection fraction (EF), and functional outcomes including change in NYHA class and exercise capacity pre- and post-pregnancy, compared to matched male controls., Results: Twenty-six pregnancies occurred among 23 women. Almost half experienced obstetric complications, primarily bleeding, which was the commonest indication for emergency C-section. Worsening cardiac symptoms complicated 50 % of pregnancies, with 4 requiring hospital admission for decompensation. Arrhythmias were not uncommon. Mean VO 2max declined post-pregnancy (p = 0.03), though not significantly compared to controls. Worsening of NYHA class was uncommon (15.4 %), suggesting that cardiovascular complications during pregnancy do not correlate with longer-term functional limitation. EF worsened post-pregnancy, declining significantly more so than in matched controls (p = 0.03), however there were no changes in cardiac volumes., Conclusions: Pregnancy in women with a Fontan circulation is associated with high rates of obstetric complications and worsening cardiac symptoms. However, successful pregnancies are possible, with little evidence of medium-term functional impairment. This data informs pre-pregnancy counselling of Fontan women of child-bearing age., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Twin-twin transfusion syndrome (TTTS) complicates approximately 10%-15% of all monochorionic twin pregnancies. The aim of this review was to evaluate the placental architectural characteristics within TTTS twins following laser and elucidate their impact on fetal outcomes and operative success., Material and Methods: Five databases were searched from inception to August 2023. Studies detailing post-delivery placental analysis within TTTS twins post-laser were included. Studies were categorized into two main groups: (1) residual anastomoses following laser and (2) abnormal cord insertion: either velamentous and/or marginal or proximate. The primary outcome was to determine the proportion of TTTS placentas with residual anastomoses and abnormal cord insertions post-laser. Secondary outcomes included assessing residual anastomoses on post-laser fetal outcomes and assessing the relationship between abnormal cord insertion and TTTS development. Study bias was critiqued using the Joanna Briggs Institute checklists and Cochrane risk of bias tool. Random-effects meta-analysis was used, and results were reported as pooled proportions or odds ratio (OR) with 95% confidence interval (CI). PROSPERO registration: CRD42023476875., Results: Twenty-six studies, comprising 4013 monochorionic twins, were included for analysis. The proportion of TTTS placentas with residual anastomoses following laser was 24% (95% CI, 0.12-0.41), with a mean and standard deviation of 4.03 ± 2.95 anastomoses per placenta. Post-laser residual anastomoses were significantly associated with intrauterine fetal death (OR, 2.38 [95% CI, 1.33-4.26]), neonatal death (OR, 3.37 [95% CI, 1.65-6.88]), recurrent TTTS (OR, 24.33 [95% CI, 6.64-89.12]), and twin anemia polycythemia sequence (OR, 13.54 [95% CI, 6.36-28.85]). Combined abnormal cord (velamentous and marginal), velamentous cord, and marginal cord insertions within one or both twins following laser were reported at rates of 49% (95% CI, 0.39-0.59), 27% (95% CI, 0.18-0.38), and 28% (95% CI, 0.21-0.36), respectively. Combined, velamentous and marginal cord insertions were not significantly associated with TTTS twins requiring laser (p = 0.72, p = 0.38, and p = 0.71, respectively) vs non-TTTS monochorionic twins., Conclusions: To the best of our knowledge, this is the first review to conjointly explore outcomes of residual anastomoses and abnormal cord insertions within TTTS twins following laser. A large prospective study is necessitated to assess the relationship between abnormal cord insertion and residual anastomoses development post-laser., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Introduction: The management of women with premature cervical dilatation and exposed unruptured fetal membranes remains uncertain and controversial. Treatment options may include expectant management or emergency cervical cerclage (ECC). Little is known regarding the effectiveness of individual interventions, or additional therapies. This systematic review aims to summarise all existing evidence to improve understanding of the treatment options and pregnancy outcomes for women presenting with premature cervical dilatation., Methods: Databases were searched using a prospective protocol (CRD42021286275). Studies were eligible for inclusion across five distinct comparison groups if they included women with premature cervical dilatation and reported clinical outcomes. Primary outcome was pregnancy loss (miscarriage, stillbirth, neonatal death and termination of pregnancy). Planned subgroups included singletons and twins, and low-cervical or high-cervical suture. Pairwise random effects meta-analysis calculated in RevMan5.4, single arm random effects proportional meta-analysis calculated using RevMan and R studio. Risk of bias was assessed using Cochrane Risk of Bias tool and Joanna Briggs Institute checklists., Results: 6781 abstracts were screened, and 177 (four randomised controlled trials) studies included in the five analysis groups. Women receiving ECC were significantly less likely to experience pregnancy loss (combined RR 0.48 95 %CI 0.39-0.59 singleton RR 0.48 95 %CI 0.34-0.67 twin only RR 0.39 95 %CI 0.26-0.58) compared to expectant management. Adjuvant amnioreduction with ECC was not found to reduce pregnancy loss (RR 1.12 (95 % CI 0.73-1.72) or any other outcomes compared to ECC without amnioreduction. Women were significantly more likely to experience pregnancy loss (RR3.85 95 %CI 3.13-4.74) after ECC compared to planned cerclage. The probability of intra-operative rupture of membranes at ECC insertion was 3.3 % (95 %CI 1.8-5.1) and the probability of an ECC attempt being abandoned was 2.6 % (95 %CI 1.1-4.6 %)., Discussion: ECC appears to reduce the risk of pregnancy loss for both singletons and twins although the overall quality of evidence is poor. It is important that women are counselled regarding the outcomes following cerclage according to indication. Pregnancy complications are common after ECC although the rates of intra-operative complications are lower than may be anticipated. Randomised trials remain imperative for understanding the role of ECC and adjunctive treatments in preventing pregnancy loss in this condition., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To predict birth weight at various potential gestational ages of delivery based on data routinely available at the first antenatal visit., Design: Individual participant data meta-analysis., Data Sources: Individual participant data of four cohorts (237 228 pregnancies) from the International Prediction of Pregnancy Complications (IPPIC) network dataset., Eligibility Criteria for Selecting Studies: Studies in the IPPIC network were identified by searching major databases for studies reporting risk factors for adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction, and stillbirth, from database inception to August 2019. Data of four IPPIC cohorts (237 228 pregnancies) from the US (National Institute of Child Health and Human Development, 2018; 233 483 pregnancies), UK (Allen et al, 2017; 1045 pregnancies), Norway (STORK Groruddalen research programme, 2010; 823 pregnancies), and Australia (Rumbold et al, 2006; 1877 pregnancies) were included in the development of the model., Results: The IPPIC birth weight model was developed with random intercept regression models with backward elimination for variable selection. Internal-external cross validation was performed to assess the study specific and pooled performance of the model, reported as calibration slope, calibration-in-the-large, and observed versus expected average birth weight ratio. Meta-analysis showed that the apparent performance of the model had good calibration (calibration slope 0.99, 95% confidence interval (CI) 0.88 to 1.10; calibration-in-the-large 44.5 g, -18.4 to 107.3) with an observed versus expected average birth weight ratio of 1.02 (95% CI 0.97 to 1.07). The proportion of variation in birth weight explained by the model (R 2 ) was 46.9% (range 32.7-56.1% in each cohort). On internal-external cross validation, the model showed good calibration and predictive performance when validated in three cohorts with a calibration slope of 0.90 (Allen cohort), 1.04 (STORK Groruddalen cohort), and 1.07 (Rumbold cohort), calibration-in-the-large of -22.3 g (Allen cohort), -33.42 (Rumbold cohort), and 86.4 g (STORK Groruddalen cohort), and observed versus expected ratio of 0.99 (Rumbold cohort), 1.00 (Allen cohort), and 1.03 (STORK Groruddalen cohort); respective pooled estimates were 1.00 (95% CI 0.78 to 1.23; calibration slope), 9.7 g (-154.3 to 173.8; calibration-in-the-large), and 1.00 (0.94 to 1.07; observed v expected ratio). The model predictions were more accurate (smaller mean square error) in the lower end of predicted birth weight, which is important in informing clinical decision making., Conclusions: The IPPIC birth weight model allowed birth weight predictions for a range of possible gestational ages. The model explained about 50% of individual variation in birth weights, was well calibrated (especially in babies at high risk of fetal growth restriction and its complications), and showed promising performance in four different populations included in the individual participant data meta-analysis. Further research to examine the generalisability of performance in other countries, settings, and subgroups is required., Trial Registration: PROSPERO CRD42019135045., Competing Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the National Institute for Health and Care Research Health Technology Assessment UK programme for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Fetal growth restriction is associated with perinatal morbidity and mortality. Early identification of women having at-risk fetuses can reduce perinatal adverse outcomes., Objectives: To assess the predictive performance of existing models predicting fetal growth restriction and birthweight, and if needed, to develop and validate new multivariable models using individual participant data., Design: Individual participant data meta-analyses of cohorts in International Prediction of Pregnancy Complications network, decision curve analysis and health economics analysis., Participants: Pregnant women at booking. External validation of existing models (9 cohorts, 441,415 pregnancies); International Prediction of Pregnancy Complications model development and validation (4 cohorts, 237,228 pregnancies)., Predictors: Maternal clinical characteristics, biochemical and ultrasound markers., Primary Outcomes: fetal growth restriction defined as birthweight <10th centile adjusted for gestational age and with stillbirth, neonatal death or delivery before 32 weeks' gestation birthweight., Analysis: First, we externally validated existing models using individual participant data meta-analysis. If needed, we developed and validated new International Prediction of Pregnancy Complications models using random-intercept regression models with backward elimination for variable selection and undertook internal-external cross-validation. We estimated the study-specific performance ( c -statistic, calibration slope, calibration-in-the-large) for each model and pooled using random-effects meta-analysis. Heterogeneity was quantified using τ 2 and 95% prediction intervals. We assessed the clinical utility of the fetal growth restriction model using decision curve analysis, and health economics analysis based on National Institute for Health and Care Excellence 2008 model., Results: Of the 119 published models, one birthweight model (Poon) could be validated. None reported fetal growth restriction using our definition. Across all cohorts, the Poon model had good summary calibration slope of 0.93 (95% confidence interval 0.90 to 0.96) with slight overfitting, and underpredicted birthweight by 90.4 g on average (95% confidence interval 37.9 g to 142.9 g). The newly developed International Prediction of Pregnancy Complications-fetal growth restriction model included maternal age, height, parity, smoking status, ethnicity, and any history of hypertension, pre-eclampsia, previous stillbirth or small for gestational age baby and gestational age at delivery. This allowed predictions conditional on a range of assumed gestational ages at delivery. The pooled apparent c -statistic and calibration were 0.96 (95% confidence interval 0.51 to 1.0), and 0.95 (95% confidence interval 0.67 to 1.23), respectively. The model showed positive net benefit for predicted probability thresholds between 1% and 90%. In addition to the predictors in the International Prediction of Pregnancy Complications-fetal growth restriction model, the International Prediction of Pregnancy Complications-birthweight model included maternal weight, history of diabetes and mode of conception. Average calibration slope across cohorts in the internal-external cross-validation was 1.00 (95% confidence interval 0.78 to 1.23) with no evidence of overfitting. Birthweight was underestimated by 9.7 g on average (95% confidence interval -154.3 g to 173.8 g)., Limitations: We could not externally validate most of the published models due to variations in the definitions of outcomes. Internal-external cross-validation of our International Prediction of Pregnancy Complications-fetal growth restriction model was limited by the paucity of events in the included cohorts. The economic evaluation using the published National Institute for Health and Care Excellence 2008 model may not reflect current practice, and full economic evaluation was not possible due to paucity of data., Future Work: International Prediction of Pregnancy Complications models' performance needs to be assessed in routine practice, and their impact on decision-making and clinical outcomes needs evaluation., Conclusion: The International Prediction of Pregnancy Complications-fetal growth restriction and International Prediction of Pregnancy Complications-birthweight models accurately predict fetal growth restriction and birthweight for various assumed gestational ages at delivery. These can be used to stratify the risk status at booking, plan monitoring and management., Study Registration: This study is registered as PROSPERO CRD42019135045., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/148/07) and is published in full in Health Technology Assessment ; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.

Background: Second trimester miscarriage and preterm birth is a significant global problem. Surgical cervical cerclage is performed to prevent pregnancy loss and preterm birth. It utilises either a monofilament or braided suture. It is hypothesised that a braided material becomes colonised with pathogenic bacteria that causes vaginal dysbiosis, infection and cerclage failure., Objectives: The primary objective of the study was to examine the effectiveness of using a monofilament suture material as opposed to a braided suture material on pregnancy loss in women requiring a vaginal cervical cerclage., Design: Superiority open randomised controlled trial., Setting: Seventy-five maternity sites across the UK., Participants: Women experiencing a singleton pregnancy requiring a cervical cerclage., Interventions: Monofilament suture or braided suture., Main Outcome Measures: The primary outcome was pregnancy loss (miscarriage and perinatal mortality, including any stillbirth or neonatal death in the first week of life). Secondary outcomes included the core outcome set for preterm birth., Methods: Women were randomised on a 1 : 1 basis to monofilament or braided cerclage utilising a bespoke randomisation service with minimisation dependent on the site, indication for cerclage, intention to use progesterone and planned surgical technique. The inclusion criteria were three or more previous mid-trimester losses or preterm births, insertion of a cerclage in a previous pregnancy, a history of a mid-trimester loss or preterm birth with a shortened cervical length in the current pregnancy or in women who clinicians deemed at risk of preterm birth. The exclusion criteria were an emergency or rescue cerclage, age of < 18 years, being unable to give informed consent or the cerclage having to be placed abdominally. The original sample size was calculated based on a relative risk reduction of 41% from a pregnancy loss rate of 19% in the braided group to 11% in the monofilament group with 90% power and alpha at p = 0.05. The independent data monitoring committee noted a lower-than-anticipated pooled event rate within the trial and recommended an increase in sample size to 2050. The outcome data were collected using clinical record forms from the maternal and neonatal medical records and reported to Birmingham Clinical Trials Unit., Results: A total of 2049 women were randomised, after withdrawals and loss to follow-up, data on 1005 women in the monofilament group and 993 women in the braided group were included. The baseline demographics between the groups were similar. There was no evidence of a difference in pregnancy loss rates between the monofilament and braided groups (80/1003 vs. 75/993; adjusted risk ratio: 1.05, 95% confidence interval: 0.79 to 1.40; adjusted risk difference: 0.002, 95% confidence interval: -0.02 to 0.03)., Limitations: The trial did not collect long-term paediatric outcomes. There were no safety concerns., Conclusions: There was no evidence of a difference in pregnancy loss between a monofilament suture and a braided suture., Future Work: Long-term follow-up of neonates born within the C-STICH (cerclage suture type for an insufficient cervix and its effects on health outcomes) trial., Trial Registration: This trial is registered as ISRCTN15373349., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/04/107) and is published in full in Health Technology Assessment ; Vol. 28, No. 40. See the NIHR Funding and Awards website for further award information.

Introduction: Childbirth-related perineal trauma (CRPT) is the most common complication of childbirth affecting 80% of women overall after vaginal birth. There remains a lack of comprehensive evidence relating to the prevalence of subsequent health problems. Current evidence is related to short-term outcomes, for example, pain, but there is less known about longer-term outcomes such as infection, wound dehiscence, pelvic floor function and psychological outcomes. This is a protocol for a cohort study assessing outcomes of women after CRPT., Methods and Analysis: A multicentre, prospective UK cohort study aiming to include 1000 women. All women who have sustained CRPT will be eligible for inclusion and will be followed-up for 12 months after childbirth. The primary outcome will be perineal infection at 6 weeks post-birth. Secondary outcomes will include antibiotic use for perineal infection, wound breakdown, use of analgesia, the requirement for admission or surgical intervention, urinary and faecal incontinence, anxiety and depressive symptoms, sexual function and impact on daily activities. Outcomes will be measured at 6 weeks, 6 months and 12 months post partum, with some outcomes being measured at all time points and others at selected most appropriate time points only. Outcome data will be obtained from a review of clinical notes and from patient questionnaires. Simple descriptive statistics will be used to summarise characteristics and outcomes, with categorical variables expressed as percentages and continuous variables as mean averages, alongside the corresponding standard deviatons., Ethics and Dissemination: Ethical approval has been granted by the Research Ethics Council with reference 23/WA/0169. Data collected from the Childbirth Acquired Perineal Trauma (CHAPTER) cohort study will highlight the prevalence and type of complications after CRPT and which women are more at risk. After the conclusion of this study, findings will be used to work with governmental organisations and Royal Colleges to target resources and ultimately improve care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To explore local induction of labour pathways in the UK National Health Service to provide insight into current practice., Design: National survey., Setting: Hospital maternity services in all four nations of the UK., Sample: Convenience sample of 71 UK maternity units., Methods: An online cross-sectional survey was disseminated and completed via a national network of obstetrics and gynaecology specialist trainees (October 2021-March 2022). Results were analysed descriptively, with associations explored using Fisher's Exact and ANOVA., Main Outcome Measures: Induction rates, criteria, processes, delays, incidents, safety concerns., Results: 54/71 units responded (76%, 35% of UK units). Induction rate range 19.2%-53.4%, median 36.3%. 72% (39/54) had agreed induction criteria: these varied widely and were not all in national guidance. Multidisciplinary booking decision-making was not reported by 38/54 (70%). Delays reported 'often/always' in hospital admission for induction (19%, 10/54) and Delivery Suite transfer once induction in progress (63%, 34/54). Staffing was frequently reported cause of delay (76%, 41/54 'often/always'). Delays triggered incident reports in 36/54 (67%) and resulted in harm in 3/54 (6%). Induction was an area of concern (44%, 24/54); 61% (33/54) reported induction-focused quality improvement work., Conclusions: There is substantial variation in induction rates, processes and policies across UK maternity services. Delays appear to be common and are a cause of safety concerns. With induction rates likely to increase, improved guidance and pathways are critically needed to improve safety and experience of care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Taylor et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)