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Objective: Isolated fallopian tube torsion (IFTT) presents a challenging preoperative diagnosis. This study investigated the specific sonographic characteristics of IFTT and compared them to the characteristics of ovarian and adnexal torsion., Design: Retrospective cohort study., Setting: Tertiary level gynecological ultrasound unit.: 225 women operated for suspected isolated ovarian, fallopian tube or adnexal torsion (ovary and tube) were included., Interventions: Electronic medical records of patients diagnosed with torsion at our ultrasound unit from 2001 to 2018 were retrieved. Inclusion criteria were women operated for suspicion of isolated ovarian, fallopian tube or adnexal torsion (involving both ovary and tube), with a preoperative sonogram performed in our tertiary level gynecologic ultrasound unit. Patients operated after a sonographic examination in the emergency department were excluded., Measurements: Patients were divided into 4 groups according to their laparoscopic diagnosis: IFTT, ovarian torsion, adnexal torsion or no torsion. The sonographic characteristics of the groups were compared and the diagnosis was confirmed according to laparoscopy findings., Main Results: IFTT was reported in 28/225 (12.4%) cases. Ovarian volume was significantly lower in IFTT (29.2 ± 44 cm 3) compared to ovarian torsion (111 ± 143 cm 3 , p=.037). There were fewer cases of ovarian edema in IFTT compared to ovarian torsion (12/22 (54.5%) vs. 54/63 (85.7%) respectively, p=.001). IFTT was associated with paraovarian cyst significantly more often than with ovarian torsion (13/24 (54.2%) vs. 4/75 (5.3%), respectively; p=.003). There was no difference between whirlpool sign and location in all forms of torsion. The sensitivity, specificity, Positive predictive value and Negative predictive value for IFTT were 88.4%, 83.3%, 95.8% and 62% respectively., Conclusion: IFTT has distinct sonographic characteristics, including normal ipsilateral ovary, paraovarian cyst, and whirlpool sign. Awareness of these features may improve the diagnosis of IFTT and promote faster and more efficient treatment. Further studies are needed to establish these characteristics., Competing Interests: Declaration of competinig interest The authors have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: To evaluate pain perception and analgesic use between patients who underwent endometriosis-specific laparoscopic surgery compared to laparoscopic hysterectomy., Material and Methods: This retrospective cohort study included women diagnosed with endometriosis who underwent laparoscopic surgery from 1/2019 to 11/2022. The control group consisted of premenopausal women who underwent laparoscopic hysterectomy, which was considered a similarly extensive surgery. Demographics, preoperative and post-operative data were compared between groups. Post-operative pain scores on a visual analogue scale (VAS) between 0 (no pain) and 10 (worst pain) were compared between groups for each post-operative day (POD). Standard pain relief analgesia on POD 0-1 included fixed intravenous treatment with paracetamol and intramuscular diclofenac. The need for additional analgesics (morphine or dipyrone) beyond the standard pain relief protocol was compared between groups., Results: Among 200 patients who underwent laparoscopic surgery, 100 (50%) were in the endometriosis group and 100 (50%) in the hysterectomy group. The endometriosis group was characterized by younger age and lower parity (both, p<0.001). There was no significant difference between the groups in mean VAS scores for each post-operative day. However, among patients who needed additional analgesics beyond the standard protocol on POD 1, a higher percentage of women in the endometriosis group used opioids rather than milder analgesics, as compared to controls (1% vs. 0.2%, respectively, p = 0.03)., Conclusion: Increased post-operative morphine use was observed in patients with endometriosis following laparoscopic surgery, despite no significant difference in mean VAS scores during the post-operative days. These findings suggest that personalized pain relief protocols should be adjusted for women with endometriosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Yagur 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.)

Objectives: This study aimed to evaluate the training and self-assessed proficiency of surgeons in the surgical management of pelvic organ prolapse (POP). We focused on the factors that influence decision-making, the surgical techniques employed, the training received, and the management of complications., Design: A cross-sectional survey., Setting: An electronic questionnaire., Population: European Urogynaecological Association (EUGA) and International Urogynecological Association (IUGA) members., Methods: A total of 33 questions evaluating surgeon preference regarding vaginal surgeries., Main Outcome Measures: Demographics, surgical selection, proficiency and technique, and training methods., Results: There were 471 respondents, of which 273 (58%) dedicated more than 50% of their week to urogynaecology. 250 (53%) had completed a fellowship, with 215 (86%) of those fellowships being in urogynaecology and pelvic floor reconstruction. A preference for hysterectomy in cases of uterine descent was noted by 297 (63%) respondents, influenced mainly by patient preference, age, and prolapse anatomical score. A total of 443 (94%) were proficient in vaginal hysterectomy, with two-thirds performing 30 or fewer procedures annually; 212 (45%) reporting a decrease in the number of procedures over the last decade. Additionally, 373 (79%) respondents believed that 10-30 cases were needed to achieve and maintain proficiency., Conclusion: Vaginal hysterectomy remains a key component in uterine prolapse repair. However, with the rise of uterine-sparing prolapse repairs, the decision-making process may be influenced by multiple factors, including surgical training. Emphasis should be placed on training and maintaining proficiency in both traditional and novel techniques., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Objective: This study aimed to compare duration of medication abortion after pretreatment with mifepristone versus misoprostol-only regimens at 22 + 0/7 to 30 + 0/7 weeks., Methods: This retrospective cohort study included patients admitted for medication abortion from 2014 to 2022. Patients underwent feticide due to genetic or anatomical abnormalities at gestational age of 22 + 0/7 to 30 + 0/7 weeks. Excluded from this study were patients admitted at gestational age < 22 + 0/7 or > 30 + 0/7 weeks, with multiple gestation, with diagnosis of intrauterine fetal demise before feticide, with contraindication for vaginal delivery, and who were administered a medical regimen other than the mifepristone-misoprostol or misoprostol-only protocol. Information collected included patients' demographics, clinical outcomes, additional procedural interventions, and complications. Data of patients treated with mifepristone-misoprostol versus misoprostol-only were compared., Results: The study group included 46 patients in the mifepristone-misoprostol group and 35 in the misoprostol-only group. Median interval from first dose of misoprostol to fetal expulsion was shorter in the mifepristone-misoprostol group (10.6 vs. 15.3 h; p = 0.007) with shorter duration of hospitalization (3.5 ± 1.1 vs. 4.1 ± 1.2 days; p = 0.013). Study groups did not differ in terms of complications. Patients in the mifepristone-misoprostol group had a younger gestational age (23.8 ± 1.69 vs. 25.37 ± 2.4 weeks; p = 0.002). However, multivariable Cox regression found that mifepristone was independently associated with shorter abortion time (OR 1.7, 95% CI 1.03-2.9, p = 0.03)., Conclusion: Medication abortion with mifepristone-misoprostol was associated with shorter time to fetal expulsion at gestational ages 22 + 0/7 to 30 + 0/7 weeks, compared with misoprostol-only regimen., (© 2024. The Author(s).)

In an epoch where digital innovation is redefining the medical landscape, electronic health records (EHRs) stand out as a pivotal transformative force. Urogynecology, a discipline anchored in intricate patient histories and meticulous follow-ups, is on the brink of profound transformation due to these digital strides. While EHRs have unified patient data, challenges related to data privacy, interoperability, and access persist. In response, we present Pelvic Health Place (PHPlace) - a multilingual, patient-centric application. Purposefully designed to bolster patient engagement, PHPlace provides clinicians with essential pre-consultation insights, streamlines the consent process, vividly delineates surgical pathways, and assures comprehensive long-term monitoring. This platform also establishes a foundation for global data amalgamation, promising to invigorate research and potentially harness artificial intelligence (AI) capabilities. With AI integration, we anticipate a more tailored treatment approach and enriched patient education, signaling a pivotal shift in urogynecology and emphasizing the imperative for ongoing academic inquiry., 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 Elsevier B.V. All rights reserved.)

Recently, the debate surrounding the use of mesh in urogynecological procedures has intensified, leading to FDA warnings and heightened safety concerns. This clinical opinion emphasizes the vital need to specify mesh types in these procedures, drawing attention to the risk profiles and clinical outcomes associated with various meshes and the procedures that utilize them. A significant issue identified in contemporary literature is the tendency to group diverse mesh types under the same umbrella, disregarding their unique characteristics and applications. We describe the range of mesh types, their application routes, and associated complications, highlighting the risks of this nonspecific approach to patient safety and informed decision making. We critically examine the generalization of mesh terminology in clinical and research dialogues. Concluding with specific recommendations for health care providers and researchers, the paper advocates for a more nuanced understanding and communication in the field, ultimately aiming to improve patient care and safety in urogynecological practice., (© 2024. The Author(s).)

Objective: Prevalence of obesity in reproductive age and pregnant women has been on the rise during the past several decades. The relationship between body mass index (BMI) and obstetric anal sphincter injuries (OASIS) or episiotomy has not yet been thoroughly investigated. The objective of this study was to shed light on this issue., Methods: This retrospective cohort study was performed using electronic database of an obstetrics department at a university-affiliated tertiary medical center. All spontaneous singleton vaginal deliveries at term between January 2015 and December 2021 were included. The primary outcome was the incidence of OASIS (third- and fourth-degree perineal tears) and obesity. These were compared across three BMI categories: normal (BMI below 25 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ), and obesity (BMI of 30 kg/m 2 and over)., Results: Of the overall 13,932 spontaneous vaginal deliveries identified, 34.7 % had BMI in the normal range, 43.1 % were overweight, and 25.4 % were obese. Multivariate analysis demonstrated lower rates of OASIS in obese (OR 0.2, 95 %CI 0.04-0.9) and in overweight (OR 0.3, 95 %CI 0.1-0.99) women, as compared to the normal-weight cohort. In addition, lower rates of episiotomy were noted in the obese cohort (OR 0.7, 95 %CI 0.6-0.8)., Conclusions: Decreased incidence of OASIS was noted in women with obesity, in conjunction with lower use of episiotomy. These findings imply that obstetrics clinics might consider a more conservative approach to episiotomy in obese patients., 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. Published by Elsevier B.V.)

Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p  = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p  = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery.

Stress urinary incontinence (SUI) is defined as a condition characterized by the involuntary leakage of urine during activities that increase intra-abdominal pressure which may decrease quality of life with a significant economic impact on health systems, necessitating the implementation of cost-effective management plans. Urodynamics (UDS) has been considered during the last decades as the gold standard for assessment of lower urinary tract symptoms (LUTS) due to their high reproducibility. At the same time, concerns about the systematic use of UDS before SUI surgery were raised due to a limited evidenced base to recommend their routine use. In uncomplicated female patients with SUI, UDS can offer further insights into LUTS, potentially assisting the physician in determining the appropriate therapeutic approach. However, it has not been shown that preoperative UDS can directly impact the surgical outcome for continence. Indeed, evidence supports the conclusion that pre-operative UDS in women with uncomplicated, clinically demonstrable, SUI does not improve the outcome of surgery for SUI. Nevertheless, asymptomatic detrusor overactivity (DO) identified by urodynamic testing or pre-existing voiding dysfunction are associated with an increased occurrence of postoperative overactive bladder (OAB) and voiding dysfunction, respectively. The EUGA Working Group concluded that the evidence does not support the systematic preoperative use of UDS for uncomplicated cases. However, in cases where mixed symptoms, voiding dysfunction, previous surgery, or concomitant prolapse are present, preoperative UDS are advised as they can be beneficial in anticipating postoperative outcomes. This aids in conducting comprehensive and thorough preoperative counseling. The Group recommend performing preoperative UDS considering the patient's specific clinical situation and the surgeon's judgment, with consideration given to the potential benefits, risks, and impact on treatment decisions and patient outcomes., 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 Elsevier B.V. All rights reserved.)

Purpose: Pelvic organ prolapse (POP) and overactive bladder (OAB) commonly affect the aging female population. We aimed to investigate the possible relationship between the two, as reflected by urodynamic studies., Methods: A retrospective analysis was conducted on women who underwent urodynamic studies at a university-affiliated tertiary medical center from January 2018 to January 2021. Women presenting with urge incontinence and diagnosed with detrusor overactivity (DO) were included in the study. Based on the presence or absence of a modified POP-Q ≥ grade 2, these women were categorized into two groups. Data on general demographics, clinical symptoms, and urodynamic findings were extracted and compared using SPSS., Results: During the study period, 949 urodynamic evaluations were performed. Of these, 303 (31.92%) reported urge incontinence. Out of this subset, 151 (49.83%) were diagnosed with DO. Within this group, 18 (11.9%) had POP, while 134 (88.1%) did not. The POP group had a notably higher incidence of prior vaginal hysterectomy and anterior colporrhaphy (p = 0.02 and p = 0.01, respectively). While most urodynamic parameters were similar between groups, there was a significant increase in hesitancy in the POP group (13 s vs 8 s, p = 0.03). There was a trend indicating a reduced median Q max (12 ml/s vs. 18 ml/s, p = 0.06) and an increased flow time (55 s vs 40 s, p = 0.08) in the POP group., Conclusion: The urodynamic profile of the POP group suggests an obstructive voiding pattern. Further longitudinal research is essential to fully understand the relationship between POP and OAB., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: This study evaluated age-related maternal outcomes of vacuum-assisted vaginal deliveries (VAD)., Methods: This retrospective cohort study included all nulliparous women with singleton VAD in one academic institution. Study group parturients were maternal age ≥ 35 years and controls < 35. Power analysis revealed that 225 women/group would be sufficient to detect a difference in the rate of third- and fourth-degree perineal tears (primary maternal outcome) and umbilical cord pH < 7.15 (primary neonatal outcome). Secondary outcomes were maternal blood loss, Apgar scores, cup detachment, and subgaleal hematoma. Outcomes were compared between groups., Results: From 2014 to 2019, 13,967 nulliparas delivered at our institution. Overall, 8810 (63.1%) underwent normal vaginal delivery, 2432 (17.4%) instrumental, and 2725 (19.5%) cesarean. Among 11,242 vaginal deliveries, 10,116 (90%) involved women < 35, including 2067 (20.5%) successful VAD vs. 1126 (10%) women ≥ 35 years with 348 (30.9%) successful VAD (p < 0.001). Rates of third- and fourth-degree perineal lacerations were 6 (1.7%) with advanced maternal age and 57 (2.8%) among controls (p = 0.259). Cord pH < 7.15 was similar: 23 (6.6%) study group and 156 (7.5%) controls (p = 0.739)., Conclusion: Advanced maternal age and VAD are not associated with higher risk for adverse outcomes. Older, nulliparous women are more likely to undergo vacuum delivery than younger parturients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To evaluate the efficacy and safety of non-ablative vaginal Er:YAG laser device in stress urinary incontinence (SUI) treatment., Methods: We conducted a multicenter blinded randomized sham-controlled trial in which women with urodynamic SUI were randomization to active arm using Er:YAG laser therapy, and sham arm using sham handpiece. Patients received two treatments 1 month apart. The primary outcomes measure was 1 h pad weight test measured at 6 months. Secondary outcomes were durability of treatment success at 12 months, and questionnaires for assessment of SUI severity (ICIQ-UI SF), sexual function (PISQ-12) and HRQoL (KHQ), and incidence and severity of device related adverse events and pain (VAS)., Results: A total of 110 participants with SUI were recruited; 73 in the active arm and 37 in the sham arm. Two participants were excluded; one was assigned the wrong treatment and one withdrew their consent. Treatment success was observed in 36% of the sham arm and 59% of the active arm; in the latter, odds of achieving treatment success were more than three-fold higher (OR 3.63, 95% CI: 1.3-11.2, P = 0.02). HRQoL by KHQ showed significant improvement in the active versus the sham arm (OR 0.36, 95% CI: 0.15-0.87, P = 0.003). Similarly, subjective patient assessment of general and sexual function improvement with PISQ-12 and PGI-I showed superior effect over sham (OR 2.8, 95% CI: 1.2-7.0, P = 0.02 and OR 0.13, 95% CI: 0.05-0.36, P < 0.001, respectively)., Conclusion: Non-ablative vaginal Er:YAG laser therapy significantly improves SUI symptoms versus sham treatment. Er:YAG laser therapy should be considered as a non-surgical treatment option for SUI patients., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Patients with endometriosis are known to have altered pain perceptions. Cesarean delivery (CD) is one of the most prevalent surgeries performed worldwide. Appropriate pain control following CD is clinically important to the recovery and relief of patients. This study assessed pain perception and analgesic use after CD among women with or without endometriosis., Methods: This retrospective case control study included women diagnosed with endometriosis, based on clinical or surgical findings, who underwent CD from 2014 to 2022. Controls were matched to the study group by maternal age, BMI (kg/m 2 ), parity, number of previous CDs and by CD indication, in a 2:1 ratio. Post-operative visual analogue scale (VAS) pain scores, on each post-operative day (POD) were compared between groups. Pain intensity was measured and compared using the VAS, range 0 (no pain) to 10 (worst pain). The standard pain relief analgesia protocol in our department includes fixed oral treatment with paracetamol and diclofenac, with the addition of morphine sulphate on POD 0. Analgesic dosages used and the percentage of patients not using the full standard analgesic protocol were compared between groups., Results: As compared to controls (n = 142), the endometriosis group (n = 71) was characterized by higher rates of in-vitro fertilization (IVF) pregnancies and previous abdominal surgeries other than CD (p < .001 for both). Other maternal characteristics between groups did not differ. On POD 0, mean morphine dosage was significantly higher in the endometriosis group compared to the control group (24 mg vs. 22.8 mg, respectively; p = .044). More patients in the endometriosis group used the full standard analgesia protocol or more, as compared to controls. VAS scores were not significantly different between groups., Conclusions: Increased use of analgesics after CD was more common among women with endometriosis. These findings imply that pain relief protocols should be personalized for women with endometriosis., 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 © 2023 Elsevier B.V. All rights reserved.)

Introduction and Hypothesis: Post-hysterectomy vault prolapse poses significant challenges to patients and surgeons alike. Despite numerous surgical interventions during initial vaginal hysterectomy to counteract this, a comparative analysis of their efficacy is limited. This study introduces a pioneering technique intended to avert vault prolapse during vaginal hysterectomy by harmoniously merging level 1 and level 2 support., Methods: After obtaining informed consent, we recorded a variation of the McCall technique performed during vaginal hysterectomy and anterior repair. Patient follow-ups were conducted up to 6 months post-operation to evaluate anatomical outcomes and quality of life., Results: A total of 46 women underwent the surgery. Anatomical evaluations at the 6-month mark were commendable, with no recurrence instances. Quality-of-life assessments, using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12), showcased substantial improvement., Conclusion: Our novel approach to vault suspension provides an uncomplicated, easily impartible, surgical procedure utilizing standard sutures. We believe that this approach is both enduring and safe., (© 2023. The International Urogynecological Association.)

Objectives: To assess the characteristics of patients with unilateral and bilateral tubo-ovarian abscess (TOA)., Methods: Women diagnosed with TOA during 2003-2017 were included in this retrospective cohort study. TOA was diagnosed using sonography or computerized tomography and clinical criteria, or by surgical diagnosis. Demographics, sonographic data, clinical treatment, surgical treatment, and post-operative information were retrieved., Results: The study cohort included 144 women who met the inclusion criteria, of whom 78 (54.2%) had unilateral TOA and 66 (45.8%) had bilateral TOA. Baseline characteristics were not different between the groups. There was a statistical trend that women with fewer events of previous PID were less likely to have with bilateral TOA (75.3% vs. 64.1%, respectively; p = 0.074). Women diagnosed with bilateral TOA were more likely to undergo surgical treratment for bilateral salpingo-oophorectomy compared to unilateral TOA (61.5% vs. 42.3%, respectively; p = 0.04). There was no difference in maximum TOA size between groups., Conclusions: This study detected a trend toward increased need for surgical treatment in women diagnosed with bilateral TOA. These findings may contribute to determining the optimal medical or surgical treatment, potentially leading to a decrease in the duration of hospitalization, antibiotic exposure, and resistance. However, it is important to acknowledge that the results of the current study are limited, and further research is warranted to validate these potential outcomes., (© 2023. The Author(s).)

Minimally invasive surgical techniques have become more common in pelvic floor reconstructive urogynaecological surgery, specifically, robotic-assisted pelvic floor surgery. Female pelvic floor anatomy is complex, and some repairs require highly experienced surgical skills that can be gained more easily using robotic-assisted surgery. A common application of the robotic platform in urogynaecological surgeries includes sacrocolpopexy, which has become the gold standard approach in the last decade for the correction of apical prolapse. Additional procedures include sacrohysteropexy, sacrocervicopexy, fistula repair, and complex procedures involving the bladder and other pelvic organs. Despite its increasing use and clear benefit in our field, data in the literature and, in particular, randomised controlled trials are sparse. This review provides an update, incorporating recently published literature and our personal experience in that field., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Background: The number of robotically assisted sacrocolpopexy procedures are increasing; therefore, experienced clinicians are needed. Simulation-based cadaver models are challenging in aspects of cost and availability. Therefore, we need to look at alternative and more cost-effective models., Objective: The objective of this video was to design a new surgical model for the training of robotic-assisted sacrocolpopexy, which is affordable and accessible., Methods: We used a whole chicken model to simulate the female pelvic floor. We used Medtronic's Hugo™ RAS system as the robotic console in that procedure. A vaginal cuff was prepared from the proventriculus (stomach), and a Y shaped mesh was secured to the ischium to simulate the sacrocolpopexy procedure., Conclusion: This model is easily constructed and in our view is cost-effective. We have demonstrated a new valuable education tool that can serve as a practical simulation model to teach the sacrocolpopexy procedure and to improve trainees' skills. A larger cohort study size is essential to demonstrate the learning curve among young trainees using this simulation model., (© 2023. The International Urogynecological Association.)

Purpose: This study evaluated the differences in treatment outcomes between misoprostol and surgical evacuation for the management of incomplete abortion., Methods: This retrospective cohort study compared patients with a clinical diagnosis of incomplete abortion who underwent surgical or pharmaceutical (misoprostol) intervention, 2014-2017. Demographics, sonographic results, treatment follow-up, and post-intervention data on retained products of conception were retrieved. Women with incomplete abortion who underwent surgical versus pharmaceutical intervention were compared., Results: Among 589 spontaneous abortions, 198 were included in the study, of which 123 (62.1%) underwent surgical evacuation and 75 (37.9%) pharmaceutical intervention with misoprostol. Baseline characteristics were similar between groups. During 130.8 ± 91.7 days of follow-up, no patient who underwent surgical evacuation had retained products of conception or needed surgical hysteroscopy. Four cases (5.3%) in the misoprostol group had retained products of conception and needed hysteroscopy (p = 0.02). Patients who underwent surgical evacuation had higher hemoglobin levels during follow-up (12.1 mg/dL vs. 11.7 mg/dL, p = 0.05). There were no differences in post-treatment pregnancy rates between groups., Conclusion: Long-term follow-up after incomplete abortion showed that hemodynamically stable patients treated with misoprostol achieved the desired results in 95% of cases without significant differences in pregnancy intervals compared to surgical management. Further prospective studies with larger sample sizes are required to confirm the outcomes described in this study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To evaluate potential risk factors for retained placenta in a first pregnancy., Method: This retrospective case-control study included all primigravida with a singleton, live, vaginal birth at 24 weeks or later, at a tertiary hospital, 2014-2020. The cohort was divided into those with retained placenta versus controls. Retained placenta was defined as the need for manual extraction of the placenta or portions of it, immediately postpartum. Maternal and delivery characteristics, and obstetric and neonatal adverse outcomes, were compared between groups. Multivariable regression was performed to reveal potential risk factors for retained placenta., Results: Among 10 796 women, 435 (4.0%) had retained placenta and 10 361 (96.0%) controls did not. Multivariable logistic regression revealed nine potential risk factors for retained placenta: abruption (adjusted odds ratio [aOR] 3.58, 95% confidence interval [CI] 2.36-5.43), hypertensive disorders (aOR 1.74, 95% CI 1.17-2.57), prematurity (<37 weeks, aOR 1.63, 95% CI 1.13-2.35), maternal age older than 30 years (aOR 1.55, 95% CI 1.27-1.90), intrapartum fever (aOR 1.48, 95% CI 1.03-2.11), lateral placentation (aOR 1.39, 95% CI 1.01-1.91), oxytocin administration (aOR 1.39, 95% CI 1.11-1.74), diabetes mellitus (aOR 1.35, 95% CI 1.01-1.79), and female fetus (aOR 1.26, 95% CI 1.03-1.53)., Conclusion: Retained placentas in first deliveries are associated with obstetric risk factors, some of which could be related to abnormal placentation., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: Postpartum retained products of conception (RPOC) can cause short- and long-term complications. Diagnosis is based on ultrasound examination and treated with hysteroscopy. This study evaluated the size of RPOC that can be related to a positive pathology result for residua., Materials and Methods: This retrospective cohort study included women who underwent hysteroscopy for postpartum RPOC diagnosed by ultrasound, 4/2014-4/2022. Demographics, intrapartum, sonographic, intraoperative, and post-operative data were retrieved. We generated a ROC curve and found 7 mm was the statistically sonographic value for positive pathology for RPOC. Data between women with sonographic RPOC ≤ 7 mm and > 7 mm were compared. Positive and negative predictive values were calculated for RPOC pathology proved which was measured by ultrasound., Results: Among 212 patients who underwent hysteroscopy due to suspected RPOC on ultrasound, 20 (9.4%) women had residua ≤ 7 mm and 192 (90.6%) had residua > 7 mm. The most common complaint was vaginal bleeding in 128 cases (60.4%); more so in the residua > 7 mm group (62.5% vs. 40%, p = .05). Among women with residua ≤ 7 mm, the interval from delivery to hysteroscopy was longer (117.4 ± 74.7 days vs. 78.8 ± 68.8 days, respectively; p = .02). Positive pathology was more frequent when residua was > 7 mm. PPV for diagnosis of 7 mm RPOC during pathology examination was 75.3% and NPV 50%., Conclusions: Sonographic evaluation after RPOC showed that residua > 7 mm was statistically correlated with positive RPOC in pathology and PPV of 75% and NPV of 50%. Due to the high NPV and low complication rate of office hysteroscopy, clinicians should consider intervention when any RPOC are measured during sonographic examination to reduce known long-term complications., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Artificial intelligence (AI) in medicine is a rapidly growing field aimed at using machine learning models to improve health outcomes and patient experiences. Many new platforms have become accessible and therefore it seems inevitable that we consider how to implement them in our day-to-day practice. Currently, the specialty of urogynecology faces new challenges as the population grows, life expectancy increases, and quality of life expectation is much improved. As AI has a lot of potential to promote the discipline of urogynecology, we aim to explore its abilities and possible use in the future. Challenges and risks are associated with using AI, and a responsible use of such resources is required., (© 2023. The International Urogynecological Association.)

Objective: Isolated posterior prolapse is a unique entity that was previously linked to chronic obstructive defecation. Our objective is to evaluate the relationship of low adherence to a Mediterranean diet (LAMD) with bowel dysfunction and isolated posterior compartment prolapse (IPCP)., Methods: This multicenter, cross-sectional study compared the dietary outcomes (validated Mediterranean diet [MD] questionnaire) of women who underwent pelvic organ prolapse (POP) repair surgery between August 2020 and October 2021., Results: Among 204 patients enrolled, 108 (52.9%) patients adhered to the MD and 96 (47.0%) did not. Among the LAMD patients, increased symptoms of constipation (P = 0.047) and higher body mass index (P < 0.001) were more prevalent. Surgical repairs of the posterior compartment, combined (P = 0.033) and isolated (P = 0.021), were more prevalent in the LAMD group. Prolapse of all compartments except the apical compartment was found to be more prevalent in the LAMD group. Multivariate logistic regression analysis was found to be significant as a protective factor for the primary outcome (IPCP)., Conclusion: Low adherence to a Mediterranean diet displays a higher prevalence of posterior vaginal defects, both isolated and combined. Hence, we can conclude that LAMD and subsequent bowel dysfunction are significant contributory factors to the prolapse of the posterior vaginal compartment., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: Uterine size is one of the essential factors determining the feasibility of a minimally invasive gynecologic surgery approach. A traditional electromechanical morcellator is a well-known tool but not without flaws. We aim to assess feasibility and safety of a novel intrauterine power morcellation device for uterine size reduction to overcome these limitations during hysterectomy., Methods: This single-arm, observational study was conducted in a single tertiary care medical center from April 2022 to July 2022. Feasibility and safety of a novel intrauterine morcellation device for uterine size reduction was tested in ten post-hysterectomy uteri (Ex-vivo)., Measurements and Main Results: Ten uteri were examined in this trial. No major complications occurred during the procedure. All ten (10) uteri were successfully reduced in size (size reduction range was between 9% to 54%). The average resection time using the Heracure Device was 4.3 minutes (range: 1min- 10min). Mean uterus weight reduction was 21%, with a mean circumference reduction of 25%. No leakage was observed from the outer surface of the uterus/serosa after the saline injection post-procedure examination., Conclusion: In this novel experiment, we verified the feasibility and safety of the Heracure device for vaginal intra-uterine morcellation for uterine size reduction. This technique could enable rapid and easy removal of the uterus through the vaginal orifice., Clinical Trial Registration: Name of the registry: ClinicalTrials.gov; Number Identifier: NCT05332132., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Pomeranz 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.)

Objective: To study mesh exposure rates among obese (BMI ≥ 30 kg/m 2 ) vs non-obese women after mid-urethral sling (MUS) operation., Study Design: This retrospective cohort study included all patients who underwent MUS surgery for stress urinary incontinence April 2014-April 2021 in a tertiary-level university hospital. Data from obese and non-obese patients were compared., Results: A total of 120 (41 %) obese patients and 172 (59 %) non-obese patients who had mid-urethral sling surgery were compared. Of the cohort, 265 (90.7 %) underwent TVT-obturator, 15 (5.1 %) mini-sling TVT, and 12 (4.1 %) retro-pubic TVT. Diabetes mellitus was significantly more prevalent in the obese group (p =.01), without other demographic differences. Mesh post-operative exposure rate was 5.4 % during the study. The obese group had lower incidence of mesh exposure than the non-obese group (1.6 % vs 8.1 % respectively, p =.018). Mean follow-up was 51 months (range 8-87 months) without significant differences between groups (49.9 ± 21.2 vs 51.5 ± 22.3, p =.548). Pelvic organ prolapse, cystocele, and rectocele stages were significantly higher in non-obese patients. Similar numbers of post-menopausal women were in each group., Conclusion: This follow-up after MUS surgery showed an association between obesity and lower rate of mesh exposure. Further research is needed to evaluate correlations between estrogen and mesh exposure., 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 © 2022 Elsevier B.V. All rights reserved.)

Clinical estimation of fetal weight is an integral component of obstetric care that might dictate the timing and mode of delivery. Inaccurate fetal weight estimation might result in unnecessary interventions or in underestimating potential risks, resulting in inappropriate intrapartum care. This retrospective study assessed factors associated with under- or overestimation of birthweight and evaluated the obstetric implications. It included singleton births ≥24 w with clinically estimated fetal weight (EFW) up to 1 week before delivery, during 2014−2020. Estimates >±10% of the actual birthweight were considered inaccurate and categorized as overestimation (>10% heavier than the actual birthweight) or underestimation (>10% smaller than the birthweight). Multivariable logistic regression was performed to reveal factors associated with inaccurate EFW. Maternal characteristics and obstetric outcomes were compared. The primary outcomes for the overestimation group were the neonatal composite adverse outcome, induction of labor and cesarean delivery rates. The primary outcomes for the underestimation group were rates of shoulder dystocia, 3rd- or 4th-degree perineal lacerations, and failed vacuum extraction. Among 38,615 EFW, 5172 (13.4%) were underestimated, 6695 (17.3%) were overestimated and 27,648 (69.3%) accurate. Multivariable logistic regression found increasing gestational age as an independent risk-factor for underestimation (odds ratio (OR) 1.15 for every additional week, 95% confidence interval (CI) 1.12−1.2). Major factors independently associated with overestimation were nulliparity (OR 1.95, CI 1.76−2.16), maternal obesity (OR 1.52, CI 1.33−1.74), smoking (OR 1.6, CI 1.33−1.93), and oligohydramnios (OR 1.92, CI 1.47−2.5). Underestimation was an independent risk-factor for shoulder dystocia (OR 1.61, CI 1.05−2.46) and 3rd- or 4th-degree perineal lacerations (OR 1.59, CI 1.05−2.43). Overestimation was an independent risk-factor for neonatal composite adverse outcome (OR 1.15, CI 1.02−1.3), induced labor (OR 1.30, CI 1.21−1.40) and cesarean delivery (OR 1.59, CI 1.41−1.79). Clinicians should be aware of factors and adverse obstetric implications associated with over- or underestimation of birthweight.

Objective: To evaluate the possibility of referring women with uterine polyps larger than 1.5 cm directly to surgical hysteroscopy., Methods: This retrospective cohort study included all women referred to a university-affiliated tertiary medical center for hysteroscopy, with the diagnosis of endometrial polyp, from 01/2013 to 05/2016. Women were referred for surgical hysteroscopy based on TVUS findings. PPV of TVUS for detecting intrauterine polyps was evaluated relating to pathology as gold standard, with sub-group analysis relating to polyp size and other parameters., Results: We selected 1.5 cm as a cutoff size for subgroup analysis of endometrial polyps. PPV of TVUS for the entire cohort of 295 cases eligible for analysis, was 79.3%. TVUS describing polyps ≥1.5 cm had PPV of 92.1%, higher than the PPV for smaller polyps. Among post-menopausal women in this group, PPV was as high as 96.2%. Use of doppler or saline was found to improve PPV in the entire cohort. Indication for performing TVUS did not affect the PPV., Conclusion: TVUS describing polyps ≥1.5 cm may suffice for direct referral of women to surgical hysteroscopy. A personalized approach based on the initial diagnosis may avoid unnecessary invasive procedures for patients., (© 2021 International Federation of Gynecology and Obstetrics.)

Objective: Obesity is a key factor for stress urinary incontinence. Our aim was to evaluate the long-term, subjective surgical satisfaction rate among obese (BMI ≥ 30) women after mid-urethral sling (MUS) procedure in a tertiary-level university hospital., Study Design: This retrospective, case-control study compared the outcomes of obese and non-obese patients who underwent MUS surgery for stress urinary incontinence (SUI), March 2014-January 2020. Patients were followed-up using Urogenital Distress Inventory-6 (UDI-6) and Patient Global Impression of Improvement (PGI-I) telephone questionnaires., Results: Among 264 patients who had MUS surgery, 107 (40.6%) patients with BMI ≥ 30 kg/m 2 were matched with 157 (59.4%) non-obese patients (BMI < 30 kg/m 2 ). Mean follow-up was 41.4 (8-73) months. Obese women had higher post-operative urinary symptom scores in UDI-6 (32.3 vs. 25.7, p =.015) and PGI-I questionnaires (2.9 ± 1.7 vs. 2.3 ± 1.7, p =.03). More patients in the obese group (p =.03) had urinary stress symptoms. Subjective failures (PGI-I ≥ 4) totaled 46 (17.4%), 18 in obese and 28 in non-obese patients, giving cure rates of 83.2% and 82.2%, respectively (p = 1)., Conclusion: Although obese patients had higher UDI-6 scores, an interpretation of this score did not show an increase in distress due to urinary incontinence symptoms (>33.33 points)., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: Estimated fetal weight (EFW) is crucial for clinical decision-making during pregnancy and labor. Maternal habitus impacts its accuracy. This study compared the accuracy of clinical versus ultrasound EFW in tall pregnant women (height ≥ 172 cm, 90th percentile)., Methods: In this prospective study, tall pregnant women at term, who arrived for a prenatal visit and delivered within a week, underwent clinical and ultrasound assessments of estimated fetal weight. Each woman served as her own control. After delivery, birth weight was compared to the clinical and ultrasound EFW. The primary outcome was the accuracy of each method in predicting the actual birth weight., Results: All 100 women included in this trial underwent clinical and ultrasound estimations of fetal weight. Mean maternal height was 175.7 ± 3.3 (172-185) cm. More clinical EFW swere inaccurate compared to ultrasound (25 (25%) vs. 6 (6%), respectively, p < 0.001). Both clinical (3583 g) and ultrasound (3490 g) evaluations underestimated the fetal weights compared to the birth weights (3664 g, p < 0.001). In the macrosomic fetal group, both the clinical (3983 g) and ultrasound (3767 g) estimates were significantly inaccurate compared to the birth weights (4237 g, p < 0.001)., Conclusion: Among tall women, ultrasound EFW is more accurate than clinical EFW., Trial Registration Number and Date of Registration: IRB-0016-17-MMC, Clinical-Trials.gov identifier NCT03206281., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Chromosomal microarray analysis (CMA) is preferred for genetic work-up when fetal malformations are detected prenatally., Objectives: To assess the detection rate of CMA after pregnancy termination due to abnormal ultrasound findings., Methods: CMA was successfully performed in 71 pregnancies using fetal DNA (mainly from skin) or placenta. Data regarding clinical background, pregnancy work-up, and CMA were analyzed., Results: Findings were abnormal in 17 cases (23.9%), of which 13 were detectable by karyotype. The incremental yield of CMA was 4/71 (5.6%); 1/32 (3.1%) for cases with an isolated anomaly and 3/39 (7.7%) for cases with nonisolated anomalies., Conclusions: CMA yield from terminated pregnancies was 23.9%. Although most chromosomal abnormalities are detectable by karyotype, CMA does not require viable dividing cells; hence, it is more practical for work-up after termination. In most cases, the diagnosis was followed by consultation regarding the risk of recurrence and recommendations for testing in subsequent pregnancies.

Objective: COVID-19 pandemic caused a dramatic decline in the gynecology emergency department (ED) visits. The Israeli government took a determined step of quarantine to suppress and control the spread. This study evaluates the effect of the COVID -19 quarantine on gynecology emergency department (ED) visits compared to the previous year., Materials and Methods: A retrospective case-control study was conducted during the first half-year of the COVID-19 pandemic and focused on the quarantine during April. In order to identify differences in the population's epidemiology and changes in the amount and type of emergency gynecological visits and surgeries, we compared patients during April 2020 (COVID-19 quarantine) to those who visited the gynecology ED during April 2019., Results: During January-June 2020 period, there was an overall 3707 patient visits in the gynecology ED, which represents a 22.8% decrease in patient visits compared to the previous year (2019, 4803 patients). There was a 36% decrease in the gynecology ED visits during the quarantine period. Patient demographics were similar between groups. Visits of nulliparous women were more common in the study group (p = .0001) and self-referral (p = .017). More post-operative complications and fewer patients with abdominal pain were admitted to the study group (p = .034 and p = .054, respectively). During the study, the hospitalization rate did not change 18.2% vs. 17.5% (p = 0.768). Hospitalization duration was significantly longer in the COVID-19 quarantine (2.8 ± 1.3 vs. 3.1 ± 1.5, p < 0.001). There was no significant difference among surgical procedure incidents., Conclusion: Visits in the gynecology ED service decreased during the COVID-19 quarantine without compromising the treatment of gynecology emergencies. Many gynecologic complaints can be managed in community care settings without referral to an ED., 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 © 2021 Elsevier Masson SAS. All rights reserved.)

Introduction: Missed abortion can be treated with medication or aspiration curettage. A Karman aspiration cannula is another option. We evaluated its success in evacuating retained products of conception (RPOC) based on symptoms, endometrial thickness, endometrial irregularity, and blood flow seen on Doppler ultrasound (indicative of placenta)., Material and Methods: This prospective, randomized, nonblinded trial was conducted in a university-affiliated medical center. It included 40 women diagnosed with missed abortion and two failed courses of 600 µg buccal misoprostol, one  week apart, randomly assigned to treatment or controls. One week after the second misoprostol course, immediately after evaluating endometrial thickness, endometrial irregularity using Doppler ultrasound, and with blood flow indicative of RPOC, women in the aspiration group underwent endometrial suction with a Karman aspiration cannula. The 5-6 mm cannula attached to a 60 mL syringe was inserted into the uterus under ultrasound guidance. The contents were aspirated until the uterus was empty. Control group patients did not receive additional treatment. All were scheduled for ambulatory, operative hysteroscopy under anesthesia 1 month later (departmental protocol). On that day, all women with RPOC on Doppler ultrasound underwent hysteroscopy. Bleeding days, days with pain, pain according to visual analog scale, length of hospitalization, and infection rate were recorded. NIH clinical trial registration number NCT02917785., Results: In the study group, 90% did not need hysteroscopy, compared with 50% of controls (p = 0.014). No complications were noted. At all visits, we used Doppler ultrasound to exclude or confirm RPOC. Pathology revealed RPOC in all women who underwent aspiration. Average visual analog scale score for office aspiration (n = 20) was 4.9 ± 3.6. vs. 6.3 ± 3.4 for the first (p = 0.157) and 4.7 ± 3.3 for the second (p = 0.836) misoprostol treatment cycle. The treatment group experienced 6.1 days of bleeding and the control group experienced 1.4 days (p = .006)., Conclusions: Based on our criteria of diagnosing RPOC according to symptoms, endometrial thickness, endometrial irregularity, and blood flow indicative of placental tissue seen on Doppler ultrasound and histo-pathological confirmation, aspiration using Karman cannula can be an effective therapeutic approach. It may be a safe alternative for women with RPOC after misoprostol failure., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To compare two pain management strategies: oral tramadol or a verbal analgesia technique during insertion of an intrauterine device (IUD) among nulliparous women., Study Design: In this randomized, controlled trial, 54 nulliparous women undergoing insertion of a levonorgestrel-releasing intrauterine device (IUD), from December 2015 to December 2018 were randomized to receive oral tramadol for analgesia or verbal analgesia prior to IUD insertion. Demographic data, clinical symptoms, visual analogue scale (VAS) and complications were reviewed from patient records., Results: There was no difference between the two groups regarding gravidity, age, smoking or body mass index. No significant differences were detected between the groups regarding the procedure, including ease of insertion (p = .415), number of insertion attempts (p = .514) and complications during the insertion (p = .150). Mean pain level by VAS was 4.5 ± 1.6 (range 2-8) for the tramadol group and 4.8 ± 2.4 (0-10) for the verbal analgesia group (p = .610). There was no spontaneous ejection of the IUD in either group, and no endometritis or discomfort that resulted in IUD removal., Conclusion: There was no benefit in using oral tramadol for analgesia prior to IUD insertion among nulliparous women. Verbal analgesia can be a suitable technique for this process and clinicians should become more familiar with its use., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Anticancer treatments, particularly chemotherapy, induce ovarian damage and loss of ovarian follicles. There are limited options for fertility restoration, one of which is pre-chemotherapy cryopreservation of ovarian tissue. Transplantation of frozen-thawed human ovarian tissue from cancer survivors has resulted in live-births. There is extensive follicular loss immediately after grafting, probably due to too slow graft revascularization. To avoid this problem, it is important to develop methods to improve ovarian tissue neovascularization. The study's purpose was to investigate if treatment of murine hosts with simvastatin or/and embedding human ovarian tissue within fibrin clots can improve human ovarian tissue grafting (simvastatin and fibrin clots promote vascularization). There was a significantly higher number of follicles in group A (ungrafted control) than in group B (untreated tissue). Group C (simvastatin-treated hosts) had the highest levels of follicle atresia. Group C had significantly more proliferating follicles (Ki67-stained) than groups B and E (simvastatin-treated hosts and tissue embedded within fibrin clots), group D (tissue embedded within fibrin clots) had significantly more proliferating follicles (Ki67-stained) than group B. On immunofluorescence study, only groups D and E showed vascular structures that expressed both human and murine markers (mouse-specific platelet endothelial cell adhesion molecule, PECAM, and human-specific von Willebrand factor, vWF). Peripheral human vWF expression was significantly higher in group E than group B. Diffuse human vWF expression was significantly higher in groups A and E than groups B and C. When grafts were not embedded in fibrin, there was a significant loss of human vWF expression compared to groups A and E. This protocol may be tested to improve ovarian implantation in cancer survivors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Magen, Shufaro, Daykan, Oron, Tararashkina, Levenberg, Anuka, Ben-Haroush, Fisch and Abir.)

Aim: To investigate characteristics and risk factors for recurrent adnexal torsion (AT)., Methods: Retrospective cohort study in a university-affiliated medical center included 320 Women with AT verified by laparoscopy, from January 2005 through January 2017. Demographic data, clinical symptoms, surgical findings and treatment were retrospectively reviewed from patient records. Data from primary and secondary AT of patients in the recurrent torsion group was compared to those with single torsion, to evaluate risk factors for recurrent AT., Results: Two hundred and sixty seven (83.4%) patients had a single event of AT and 53 (16.5%) had recurrent AT. Patients with recurrent torsion had significantly fewer previous non-gynecologic surgeries (4.3% and 9.8% of the study groups vs 32.2% of the control group, P = 0.001 for both). Ovarian size was significantly smaller in the recurrent torsion groups (47.5 mm and 48.3 mm vs 63.9 mm, P = 0.045 and P = 0.012, respectively). Polycystic ovary was significantly more common in the recurrent AT group (P = 0.028 and P = 0.005), with risk ratio 4.4 (95% confidence interval, 1.66 to 11.63). Ovaries without any specific findings were also more common among recurrent AT cases (P = 0.001 for both groups). Logistic regression analysis demonstrated that smaller ovarian size is an independent risk factor for recurrent AT., Conclusion: Recurrent torsion correlated with fewer previous surgeries, small ovarian mass, polycystic ovaries and ovaries without specific findings, which might indicate that additional pathophysiological factors contribute to the recurrent event. Ovarian fixation might be recommended in patients with primary torsion of normal or polycystic ovaries., (© 2020 Japan Society of Obstetrics and Gynecology.)

Purpose: To evaluate the effects of nuchal cord and the number of loops during labor and delivery on delivery outcomes among women with singleton pregnancy who delivered vaginally., Methods: This retrospective cohort study included 42,798 women with singleton, vertex, and vaginal deliveries at 24-43 weeks of gestation. We analyzed delivery outcomes based on the number of nuchal cord loops., Results: A total of 42,798 deliveries met the inclusion criteria, of which, 3809 (8.9%) had nuchal cord with 1 loop at delivery, 1035 (2.42%) had 2 loops, and 258 (0.6%) had 3 loops. Nuchal cord with 3 loops compared to no nuchal cord has been associated with higher incidence of intrauterine fetal death (1.9%), Apgar scores less than 7 at 1 and 5 min (7.4%, 2.3%), and higher rate of operative vaginal deliveries (17.5%). Nuchal cord with 2 or 3 loops was associated with higher incidence of intrauterine growth restriction (10.2%, 11.6%).  In a multiple logistic regression model, nuchal cord with 3 loops was an independent risk factor for operative vaginal delivery and Apgar score less than 7 in 1 min., Conclusions: In the case of vaginal delivery in the presence of nuchal cord, as the number of nuchal cord loops increased, so did the number of adverse delivery outcomes. While 3 loops were associated with higher incidence of intrauterine fetal death, intrauterine growth restriction, increased operative vaginal deliveries, and low Apgar scores, 1 loop was not associated with adverse perinatal outcomes.

Objective: This study measured cervical length (CL) at 14-16 and 21-24 weeks of gestation and assessed whether the difference between the measurements is predictive of preterm delivery (PTD)., Methods: This retrospective, cohort study included patients with two consecutive CL measured with transvaginal sonography at 14-16 weeks of gestation (CL 1 ) and 21-24 weeks (CL 2 ). Electronic medical records were reviewed for demographic, medical and obstetric history; complications during the current pregnancy and delivery data. CL 1 , CL 2 and the change between scans were evaluated and correlated to PTD prediction., Results: Among the 216 patients, 196 (90.7%) delivered at term (≥37 weeks) and 20 (9.3%) preterm (<37 weeks). CL 1 was not a good predictor of PTD (p = .70). CL 2 was significantly shorter in the PTD group (p < .05). The correlation between CL change and PTD was not significant (p = .55). Perinatal outcomes between term and preterm deliveries were similar., Conclusions: Sonographic measurement of CL at 14- to 16-week gestation and the difference between CL in the first and second scans are not reliable predictors of PTD. However, cervical length at 21-24 weeks in low-risk women is predictive of this complication.

Study Objective: The study aimed to evaluate whether there is an association between the ovarian ligament length and ovarian torsion., Design: This is a prospective cohort study. Design Classification: II.2., Setting: The study was conducted in the gynecology department of a university affiliated hospital., Intervention: We measured the length of the ovarian ligaments during laparoscopy., Patients: A total of 56 women were recruited, of which 28 women were operated for ovarian torsion (torsion group) and 28 others for other gynecologic conditions (control group)., Measurement and Main Results: The study found correlations between ovarian ligament length and ovarian torsion. The length of the right (2.2 ± 0.6 cm) and left ovarian ligament (2.3 ± 0.8 cm) in the control patients were similar. Ovarian torsions occurred mainly on the right side (67.9 %). The right ovarian ligament was significantly longer in the torsion group (3.2 ± 0.9 cm) than in the control group (2.2 ± 0.6 cm; p < 0.001). Even after exclusion of patients with ovarian cyst, the ovarian ligament was still significantly longer in the torsion group as compared to the control group (3.2 ± 1.1 vs. 2.2 ± 0.6 cm respectively, p = 0.01)., Conclusion: Our results suggest that increased length of ovarian ligament might be correlated with the development of ovarian torsion. This could be a basis for ovarian ligament fixation or oophoropexy at the time of conservative surgery for ovarian torsion., (© 2018 S. Karger AG, Basel.)

Purpose: Normal labor curves have not been assessed for women undergoing a trial of labor after cesarean delivery (TOLAC). This study examined labor patterns during TOLAC in relation to epidural analgesia use., Methods: Retrospective cohort study of deliveries of women undergoing TOLAC at a single, academic, tertiary medical center. Length of first, second and third stages of labor was compared between 424 women undergoing TOLAC in the current labor with no previous vaginal delivery (VD) and 357 women with at least one previous VD and current TOLAC., Results: Women in the TOLAC only group had significantly longer labors compared to women in the previous VD and TOLAC group. In both groups, women who underwent epidural analgesia had longer first and second stages of labor. In the TOLAC only group, more women who had epidural analgesia tended to deliver vaginally as compared to those who did not (P = 0.09). For women who delivered vaginally, the 95th percentile for the second stage duration with epidural was 3.40 h in the TOLAC only group and 2.3 h in the previous VD and TOLAC group. The 95th percentile for the second stage duration without epidural was 1.4 h in the TOLAC only group and 0.9 h in the previous VD and TOLAC group., Conclusions: Operative intervention (instrumental delivery/cesarean delivery (CD)) might be considered for women attempting TOLAC after a 2-h duration of second stage without epidural and 3-h duration with epidural, with an hour less for women who also had previous VD.

Study Objective: To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy., Design: A retrospective case-control study (Canadian Task Force classification II-2)., Setting: A tertiary care academic medical center., Measurements and Main Results: The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012)., Conclusion: Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Objective: To correlate the duration of Category II cardiotocograms (CTG) with adverse neonatal outcomes associated with perinatal asphyxia and determine the duration before fetal compromise., Study Design: This retrospective, observational study used electronic medical record data from a cohort of 271 patients, delivered by C-section due to non-reassuring fetal heart rate, at a tertiary medical center, from 2015 through 2017. Duration of Category II CTG, variability, tachycardia and deceleration frequency were analyzed and correlated to immediate postnatal outcomes. including cord pH ≤ 7, cord base excess >12, 1- and 5-min Apgar scores ≤7, need for ventilation, need for chest compressions, NICU admission, hypoglycemia and convulsions. Intrapartum fever and meconium stained amniotic fluid were correlated to the same outcomes. Categorical and continuous variables were analyzed using chi-square and t-tests, respectively. P < 0.05 was considered significant., Results: The mean duration of Category II CTG was 146 min (range 17-553). Longer duration did not result in increased rates of adverse neonatal outcomes. In contrast, reduced fetal heart rate (FHR) variability, fetal tachycardia and intrapartum fever did show increased rates of adverse neonatal outcomes, as follows: patients exhibiting reduced vs. normal (FHR) variability had 12.9% vs. 1.4% cord pH ≤ 7, P = 0.006 and 12.5% vs. 1.3% cord BE > 12, P = 0.004: patients with fetal tachycardia vs. normal baseline FHR exhibited 48% vs. 17.9% 1-minute Apgar score ≤7, P = 0.0004; 8% vs. 0.8% 5-minute Apgar score ≤7, P = 0.04; and 48% vs. 18.7% ventilation support, P < 0.001; patients with intrapartum fever vs. normal temperature, cord BE > 12 was seen in 9.7% vs. 1.7%, P = 0.035; 1-minute Apgar score was ≤7 in 35.5% vs. 18.7%, P = 0.03; 5-minute Apgar score ≤7 in 9.7% vs. 0.4%, P = 0.005; need for ventilation in 35.5% vs. 19.6%, P = 0.042; need for chest compressions in 6.45% vs. none, P = 0.013; and NICU admission in 12.9% vs. 2.5%, P = 0.018., Conclusions: Our results suggest that the duration of Category II CTG alone does not appear to predict perinatal asphyxia. Parameters associated with perinatal asphyxia are reduced FHR variability, fetal tachycardia and intrapartum fever. Therefore, when contemplating intervention during labor to avoid fetal asphyxia, these parameters should be strongly considered., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aim: To evaluate factors predictive of the success of dinoprostone slow release vaginal insert for cervical ripening., Methods: A total of 169 women who underwent cervical ripening with dinoprostone slow release vaginal insert were included in the study cohort. The correlation between parameters present before cervical ripening with dinoprostone slow release and its success, as well as complications and adverse outcomes were analyzed., Results: Dinoprostone slow release vaginal insert was successful in achieving vaginal delivery in 148 of 169 (87.6%), while sufficient ripening was achieved in 140 (83%) cases. Factors associated with successful vaginal delivery were multiparity and younger gestational age at delivery. Factors predictive of the success of cervical ripening with dinoprostone slow release vaginal insert were lower body mass index (BMI), higher parity and perceived contractions prior to insertion. Intrauterine growth restriction was associated with a significant risk for dinoprostone insert removal. Neonatal outcomes were similar in cases of successful or failed ripening., Conclusion: The success of cervical ripening with dinoprostone slow release vaginal insert can be predicted by factors that can be recognized at admission., (© 2018 Japan Society of Obstetrics and Gynecology.)

Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL., Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL., Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p < .05), although transfusion rates in each group were similar. Neonatal outcomes between groups did not differ. Induction and gestational age at delivery were risk factors for failed TOL., Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.

Background: The optimal choice of skin closure at cesarean delivery has not yet been determined., Objective: This study compared wound complications and scar healing following cesarean delivery between 2 methods of skin closure: glue (Dermabond; Ethicon, Somerville, NJ) and monofilament (Monocryl; Ethicon) epidermal sutures., Study Design: We conducted a randomized controlled trial in which pregnant women undergoing a scheduled cesarean delivery were randomly assigned to skin (epidermis) closure with glue or with a monofilament synthetic suture. The subcutaneous tissue was sutured for all patients. Outcome assessors were blinded to group allocation. Scars were evaluated >8 weeks. Primary outcome measures were Patient and Observer Scar Assessment Scale scores. Secondary outcome measures were surgeon satisfaction, duration of surgery, duration of hospitalization after the cesarean delivery, and complications of surgical site infection or wound disruption (hematoma or seroma). A sample of 104 women was needed to achieve a clinically significant effect with a power of 80%., Results: Demographic characteristics, patients' clinical background, prepregnancy body mass index, and subcutaneous thickness were similar in both groups. Length of surgery between the groups (37 ± 10 minutes for glue vs 39 ± 13 minutes for sutures, P = .515) was similar. Scores immediately after the wound closure were similar for both groups regarding surgeons' time estimate of closure (P = .181) and closure appearance (P = .082). Surgeons' satisfaction with the technique was significantly higher in the suture group (P = .003). No significant differences were found between the groups in blood loss, surgical site infection, length of postpartum hospitalization, or wound disruption. Glue and suture skin closure scores using Patient and Observer Scar Assessment Scale were similar 8 weeks after surgery, at P = .710 for patients and P = .568 for a physician observer., Conclusion: Skin closure using glue or a monofilament synthetic suture had similar results. Both methods were shown to be safe and successful for skin closure after a scheduled cesarean delivery and, therefore, can be used based on surgeon and patient preferences., (Copyright © 2017 Elsevier Inc. All rights reserved.)