Episiotomy: the final cut?

Objective

To investigate whether episiotomy prevents 3rd or 4th degree perineal tears in critical conditions such as shoulder dystocia, instrumental deliveries (vacuum or forceps), persistent occiput-posterior position, fetal macrosomia (>4,000?g), and non-reassuring fetal heart rate (NRFHR) patterns.

Methods

A retrospective study comparing 3rd and 4th degree perineal tears during vaginal deliveries with or without episiotomy, in selected critical conditions was performed. Multiple gestations, preterm deliveries (<37?weeks’ gestation) and cesarean deliveries were excluded from the analysis. Stratified analysis (using the Mantel–Haenszel technique) was used to obtain the weighted odds ratio (OR), while controlling for these variables.

Results

During the study period, there were 168,077 singleton vaginal deliveries. Of those, 188 (0.1?%) had 3rd or 4th degree perineal tears. Vaginal deliveries with episiotomy had statistically significant higher rates of 3rd or 4th degree perineal tears than those without episiotomy (0.2 vs. 0.1?%; P?<?0.001). The association between episiotomy and severe perineal tears remained significant even in the critical conditions. Stratified analysis revealed that the adjusted ORs for 3rd or 4th degree perineal tears in these critical conditions (Macrosomia OR?=?2.3; instrumental deliveries OR?=?1.8; NRFHR patterns OR?=?2.1; occipito-posterior position OR?=?2.3; and shoulder dystocia OR?=?2.3) were similar to the crude OR (OR?=?2.3).

Conclusions

Mediolateral episiotomy is an independent risk factor for 3rd or 4th degree perineal tears, even in critical conditions such as shoulder dystocia, instrumental deliveries, occiput-posterior position, fetal macrosomia, and NRFHR. Prophylactic use of episiotomy in these conditions does not seem beneficial if performed to prevent 3rd or 4th degree perineal tears.     

Vascular endothelial growth factor gene polymorphisms and endometriosis risk: a meta-analysis

Purpose

The vascular endothelial growth factor (VEGF) gene polymorphism has been reported to be associated with endometriosis risk. The purpose of the present study was to perform a comprehensive meta-analysis to explore whether VEGF gene polymorphisms confer risk to endometriosis.

Methods

By searching PubMed and EMBASE databases, a total of 11 studies were identified. Crude odds ratio (OR) and their corresponding 95% confidence intervals (CI) for VEGF gene polymorphisms and endometriosis risk were calculated.

Result

An association of VEGF gene +936TC polymorphism with endometriosis was found (Fixed-effect model: TT?+?TC vs. CC: OR 1.184, 95% CI 1.027?C1.366, P?=?0.020; TC vs. CC: OR 1.187, 95% CI 1.024?C1.375, P?=?0.023. Random-effcet model: TT?+?TC vs. CC: OR 1.203, 95% CI 1.003?C1.443, P?=?0.046; TC vs. CC: OR 1.188, 95% CI 1.021?C1.382, P?=?0.026). No association between VEGF genes ?460CT, +405CG, ?2578AC, ?1154GA polymorphisms and endometriosis was observed.

Conclusion

Our results indicate that VEGF +936TC gene polymorphism is a risk factor for endometriosis, and not ?460CT, +405CG, ?2578AC, ?1154GA.     

Once episiotomy,always episiotomy?

Objective

To investigate the association between episiotomy and perineal damage in the subsequent delivery.

Study design

A retrospective cohort study was conducted, comparing outcome of subsequent singleton deliveries of women with and without episiotomy in their first (index) delivery. Deliveries occurred between the years 1991–2015 in a tertiary medical center. Traumatic vaginal tears, multiple pregnancies, and cesarean deliveries (CD) in the index pregnancy were excluded from the analysis. Multiple logistic regression models were used to control for confounders.

Results

During the study period, 43,066 women met the inclusion criteria; of them, 50.4% (n?=?21,711) had subsequent delivery after episiotomy and 49.6% (n?=?21,355) had subsequent delivery without episiotomy in the index pregnancy. Patients with episiotomy in the index birth higher rates of subsequent episiotomy (17.5 vs. 3.1%; P?<?0.001; OR?1.9; 95% CI). In addition, the rates of the first and second degree perineal tears as well as the third and fourth degree perineal tears were significantly higher in patients following episiotomy (33.6 vs. 17.8%; P?<?0.001, and 0.2 vs. 0.1%; P?=?0.002, respectively). Nevertheless, there was no significant difference at the rates of CD and instrumental deliveries, between the groups. While adjusting for maternal age, ethnicity, birth weight, and vacuum delivery—the previous episiotomy was noted as an independent risk factor for recurrent episiotomy in the subsequent delivery (adjusted OR?6.7; 95% CI 6.2–7.3, P?<?0.001). The results remained significant for term (adjusted OR?6.8; 95% CI 6.2–7.4, P?<?0.001) as well as preterm deliveries (adjusted OR?4.5; 95% CI 3.3–6.3, P?<?0.001) in two different models.

Conclusion

Episiotomy is an independent risk factor for recurrent episiotomy in the subsequent delivery.

     

The impact of human papillomavirus (HPV) types 6, 11 in women with genital warts

Objective

Human papillomaviruses (HPV) are etiologically associated with the development of virtually all genital warts. HPV-6 and HPV-11 are the most commonly detected HPV genotypes, but at least 20 other HPV genotypes have occasionally been found in genital wart tissue specimens.

Study design

The aim of this study was to determine from 100 genital wart tissue specimens collected from female patients using multiplex gap-PCR technique the prevalence of various genital HPV among women with HPV genital warts in south of Iran. 100 genital wart tissue specimens were tested for the presence of HPV PG5/PG6 and also for HPV type using polymerase chain reaction (PCR).

Results

Based on the collected data, 73 (73?%) samples were detected positive for HPV DNA and 23 (23?%) samples out of 100 samples were detected negative for HPV DNA. 49 (49?%) and 67 (67?%) of patients were detected positive for HPV type 6 and 11, respectively. There was a significant association between marital status and HPV genotype 6 (OR?=?0.51, 95?% CI?=?0.37–0.70, P?=?0.01). Nevertheless, no significant association was found between marriage and HPV genotype 11 (OR?=?0.85, 95?% CI?=?0.58–1, 24, P?=?0.7). Similarly, this result was demonstrated, in combined marriage and HPV-general (OR?=?0.80, 95?% CI?=?0.62–0.05, P?=?0.4).

Conclusion

Concerning the prevalence of HPV in our study, determination of genital HPV prevalence and multiple infections among the normal population of women of Hormozgan Province is recommended.     

Clinical characteristics indicating adenomyosis at the time of hysterectomy: a retrospective study in 291 patients

Purpose

To better characterize adenomyosis as a disease entity.

Methods

We retrospectively reviewed the medical records of women undergoing hysterectomy with a histologic diagnosis of adenomyosis, adenomyosis and leiomyomas, and leiomyomas alone.

Results

The study included 291 women: 38 with adenomyosis alone, 56 with adenomyosis and leiomyomas, and 197 with leiomyomas alone. In univariate analysis, women with adenomyosis were younger (p?=?0.018) and had lower uterine weights (p?p?=?0.008). In multinomial logistic regression analysis, a lower uterine weight (OR 0.99, CI 95% 0.99–1.0), pelvic pain (OR 4.8, CI 95% 1.5–15.2), a history of smoking (OR 2.6, CI 95% 1.1–6.5) and at least one delivery (OR 4.3, CI 95% 1.5–12.3) were associated with a greater likelihood of having adenomyosis but not leiomyomas alone.

Conclusions

Women undergoing hysterectomy with adenomyosis alone have different clinical characteristics from women with adenomyosis and leiomyomas and from those with only leiomyomas.     

Is the risk of obstetric anal sphincter injuries increased in vaginal twin deliveries?

Objective: Vaginal twin deliveries have a higher rate of intrapartum interventions. We aimed to determine whether these characteristics are associated with an increased rate of obstetric anal sphincter injuries compared with singleton.

Study design: Retrospective study of all twin pregnancies undergoing vaginal delivery trial was conducted from January 2000–September 2014. Sphincter injury rate compared with all concurrent singleton vaginal deliveries. Multivariable analysis was used to determine twin delivery association with sphincter injuries while adjusting for confounders.

Results: About 717 eligible twin deliveries. Outcome was compared with 33?886 singleton deliveries. Twin pregnancies characterized by a higher rate of nulliparity (54.8% versus 49.5%, p?=?0.005), labor induction (42.7% versus 29.1%, p?<?0.001), and instrumental deliveries (27.5% versus 16.7%, p?<?0.001), lower gestational (34.6?±?3.3 versus 38.8?±?2.3, p?<?0.001), and lower birth weight. Total breech extraction was performed in 29.0% (208/717) of twin deliveries. Overall obstetric sphincter injury rate was significantly lower in the twins group (2.8% versus 4.4%, p?=?0.03, OR?=?0.6, 95% CI 0.4–0.9), due to lower rate of 3rd degree tears in twins versus singletons (2.2% versus 4.0%, p?=?0.02), rate of 4th degree tears similar among the groups (0.6% versus 0.4%, p?=?0.5). In multivariable analysis, sphincter injuries were associated with nulliparity (OR?=?3.9, 95% CI 3.4–4.5), forceps (OR?=?6.8, 95% CI 5.8–7.8), vacuum (OR?=?2.9, 95% CI 2.5–3.3), earlier gestational age (OR?=?0.2, 95% CI 0.1–0.3), episiotomy (OR?=?0.8, 95% CI 0.7–0.9), and birth weight over 3500?g (OR?=?1.8, 95% CI 1.6–2.0). However, the association between twins (versus singletons) deliveries and sphincter injuries was lost after adjustment for delivery gestational age (OR?=?0.7, 95% CI 0.4–1.2).

Conclusion: Despite a higher rate of intrapartum interventions, the rate of sphincter injuries is lower in twins versus singleton deliveries, mainly due to a lower gestational age at delivery.     

Practicability of vaginal washing fluid creatinine level in detecting premature rupture of membranes

Objective

The purpose of this study was to evaluate the reliability of vaginal washing fluid creatinine level for the diagnosis of premature rupture of membranes (PROM).

Method

A prospective diagnostic study performed in Shahid Sedoughi Hospital on 160 pregnant women (30 definite PROM, 30 no PROM and 100 suspected PROM) at 28?C40?weeks of gestation. The vagina was washed by injection with a syringe filled with 3?ml of saline solution, and the washing fluid was collected from the posterior vaginal fornix and send to laboratory. Creatinine values in vaginal washing were measured and compared.

Result

The mean vaginal fluid creatinine levels in definite PROM group, suspected PROM and no PROM were 0.40?±?0.20, 0.16?±?0.04 and 0.08?±?0.01?mg/dl, respectively, where the difference was statistically significant (P?=?0.001). The sensitivity, specificity, positive and negative predictivity values and accuracy were 98.7, 100, 100, 98.8 and 87.1%, respectively, in detecting PROM by evaluation of vaginal fluid creatinine concentration with cut-off value of 0.14?mg/dl.

Conclusion

This study showed that creatinine determination in vaginal washing fluid is a useful marker for PROM diagnosis. It is a reliable, simple, cheap and rapid test.     

Association of the Glutathione S-transferases M1 and T1 polymorphism with male infertility: a meta-analysis

Background

Genes of different pathways regulate spermatogenesis, and the complexity of the spermatogenic process indicates that polymorphisms or mutations in these genes could cause male infertility. Published data on the association between the GSTM1 and GSTT1 polymorphism and male infertility risk are inconclusive. To derive a more precise estimation of the relationship, a meta-analysis was performed.

Methods

A total of 11 studies regarding GSTM1 and 9 studies regarding GSTT1 between 1999 and 2012 were identified through researching MEDLINE, EMBASE and the Chinese Biomedical Database. It was performed to obtain summary estimated odd ratios and 95 % confidence intervals of GSTM1 and GSTT1 for male infertility, with attention to study quality and publication bias.

Results

Overall, a significant association was seen between GSTM1 (OR?=?1.20, 95 % CI?=?1.02–1.40, P_{heterogeneity}?=?0.000, P?=?0.027) genotypes and male infertility. Significant associations were also observed in subgroups of Caucasian populations (OR?=?1.65, 95 %CI?=?1.16–2.34, P_{heterogeneity}?=?0.006, P?=?0.005), but were not observed in Asian populations (OR?=?1.09, 95 % CI?=?0.72–1.65, P_{heterogeneity}?=?0.054, P?=?0.697) when stratified by ethnicity. While there was no significant association was seen between GSTT1 (OR?=?1.00, 95 % CI?=?0.74–1.35, P_{heterogeneity}?=?0.000, P?=?0.980) null genotypes and male infertility. Simultaneously, significant associations were not observed in subgroups of Caucasian populations (OR?=?0.94, 95 %CI?=?0.44–2.00, P_{heterogeneity}?=?0.000, P?=?0.867) and Asian populations (OR?=?0.93, 95 % CI?=?0.46–1.87, P_{heterogeneity}?=?0.002, P?=?0.838) when stratified by ethnicity.

Conclusion

Our results suggest the GSTM1 null genotype contributes to male infertility susceptibility, while GSTT1 gene polymorphisms are not associated with male infertility in our study.     

The Bishop Score as a determinant of labour induction success: a systematic review and meta-analysis

Purpose

To evaluate the association between the Bishop Score and successful induction.

Study strategy and selection criteria

We searched the PubMed and the lists of references of relevant studies to identify reports on the association between Bishop Score and achieving active phase of labour or vaginal delivery.

Data collection and analysis

We abstracted crude or adjusted measures of association from studies. Summary odds ratio (OR) and summary hazard ratio (HR), and 95?% confidence interval (95?% CI) were obtained by random effects meta-analysis. Study heterogeneity was assessed using the I ² test.

Results

Fifty-nine studies met the inclusion criteria. Analyses with crude ORs showed that women with higher versus lower Bishop Score were more likely to achieve vaginal delivery either with no time limit for this to occur, or within a certain time interval; the summary ORs according to the Bishop Score cutoff ranged from 1.98 (95?% CI: 1.58?C2.48; I ²?=?36.6?%) to 5.48 (95?% CI: 1.67?C17.96; I ²?=?0.0?%) and from 2.15 (95?% CI: 1.36?C3.40; I ²?=?0.0?%) to 4.22 (95?% CI: 2.48?C7.17; I ²?=?11.0?%), respectively. Summary estimates per unit increase in the Bishop Score, based on adjusted ORs, showed a positive association with achieving vaginal delivery, either with no time limit (OR_summary?=?1.33; 95?% CI: 1.13?C1.56; I ²?=?66.1?%) or within a certain time interval (OR_summary?=?1.52; 95?% CI: 1.37?C1.70; I ²?=?42.4?%). Summary HRs per unit increase in Bishop Score showed an association with induction to vaginal delivery (HR_summary?=?1.28; 95?% CI: 1.21?C1.36; I ²?=?0.0?%), but not with induction to active phase (HR_summary?=?1.21; 95?% CI: 0.88?C1.68; I ²?=?70.7?%) time interval.

Conclusions

Bishop Score seems be a determinant of achieving vaginal delivery and is associated with induction-to-vaginal delivery time interval.     

Association between polymorphisms in DNA repair genes (XRCC1 and XRCC7) and risk of preeclampsia

Purpose

Although the exact genes involved in preeclampsia (PE) are still not fully discovered, an important role for oxidative stress in its pathogenesis is accepted. XRCC1 (MIM: 194360) and XRCC7 (MIM: 600899) play a crucial role in the DNA repair pathways. Functional polymorphisms in XRCC1 (Arg194Trp and Arg399Gln) and XRCC7 (G6721T) may be risk factors for PE. In the present study, the association between the genetic polymorphisms of XRCC1 and XRCC7 and risk of PE is investigated.

Methods

The present case–control study was performed on 151 preeclapmtic patients, and a total of 344 normal pregnant women, as a control group. Control women had no history of pregnancies with PE.

Results

Neither polymorphism of Arg194Trp XRCC1 nor polymorphism of G6721T XRCC7 associated with the risk of PE. The Gln/Gln genotype of Arg399Gln XRCC1 polymorphism increased the risk of PE (OR?=?2.39, 95?% CI: 1.38–4.14, P?=?0.002). Statistical analysis revealed that the haplotype “194Arg-399Gln” showed higher frequency among PE patients compared to the controls (OR?=?1.65, 95?% CI: 1.23–2.19, P?=?0.001).

Conclusions

The present results suggest that the 399Gln allele of the XRCC1 is significant risk factor for PE development.     

Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases

OBJECTIVE: To assess the perinatal outcome in a series of macrosomic fetuses according to the intended mode of delivery, and to estimate the individual risk of shoulder dystocia and brachial plexus injury upon information available either prior the onset of labor or at delivery. STUDY DESIGN: Perinatal and postnatal information of 3356 women who delivered during a 10-year period a macrosomic fetus (>4500 g) in vertex presentation were analyzed. After the exclusion of cases with extraneous factors that may have affected the health of the neonate, patient and neonatal characteristics were compared according to the intended mode of delivery. The contribution of factors known prior labor and at the time of deliver on the occurrence of shoulder dystocia and brachial plexus injury was analyzed using multiple logistic regression analysis. RESULTS: During the study period, 2371 women were admitted to spontaneous labor, 778 underwent an induction of labor, and 207 had an elective cesarean section. All cases of shoulder dystocia (n=310), and brachial plexus injury (n=94) occurred among women who delivered vaginally. The rate of brachial plexus injury was higher in cases who had shoulder dystocia than in those who did not (58/310 versus 36/2329, P<0.001). The incidence of brachial plexus injury increases steadily from 0.8 in fetuses weighing 4500-4599 g to 2.86% in those weighing more than 5000 g (P<0.01) and from 2.1 in women taller than 180 cm to 12.5% in those shorter than 155 cm (P<0.05). After adjustment for confounding variables shoulder dystocia (OR 9.2, 95% C.I. 5.38; 15.59), operative vaginal delivery (OR 1.96, 95% C.I. 1.10; 3.49) and clavicular fracture (OR 2.9, 95% C.I. 1.31; 6.44) remained predictors of brachial plexus injury. CONCLUSION: Since some of these risk factors are known prior to delivery, each woman whose fetus is suspected to weight more than 4500 g should be counseled on her individual risk of severe perinatal morbidity before a decision on the mode of delivery is taken.     

Shoulder dystocia without versus with brachial plexus injury: A case–control study

Objective. To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI).

Study design. A case–control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

Results. From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88).

Conclusions. Neither antepartum nor intrapartum factors can differentiate the patient who will have shoulder dystocia with vs. without BPI.     

Risk factors for postpartum hemorrhage requiring transfusion in cesarean deliveries for Japanese twins: comparison with those for singletons

Objective

The aim of this study was to identify the factors associated with the increased risk of postpartum hemorrhage requiring transfusion in Japanese twin pregnancies in comparison with those in Japanese singleton pregnancies.

Methods

We reviewed the obstetric records of all singleton and twin deliveries after 22?weeks’ gestation at the Japanese Red Cross Katsushika Maternity Hospital from 2003 through 2011. Potential risk factors for transfusion due to hemorrhage after cesarean delivery were selected according to previous studies of postpartum hemorrhage or transfusion or both after delivery: maternal age, parity, previous cesarean deliveries, history of infertility therapies such as in vitro fertilization, gestational age at delivery, neonatal birth weight, placenta previa, uterine myoma ≥6?cm, hypertensive disorders, placental abruption, emergency cesarean deliveries and general anesthesia.

Results

Using multiple logistic regression, the independent risk factors for postpartum hemorrhage requiring transfusion in singleton pregnancies were preterm delivery [odds ratio (OR) 2.40, 95?% confidence interval (CI) 1.2–4.6, p?<?0.01], placenta previa (OR 8.08, 95?% CI 3.9–16, p?<?0.01) and placental abruption (OR 12.8, 95?% CI 2.3–76, p?<?0.01). In twin pregnancies, however, the independent risk factors for postpartum hemorrhage requiring transfusion were gestational age at ≥41?weeks (OR 8.20, 95?% CI 1.3–40, p?<?0.01) and hypertensive disorders (OR 5.45, 95?% CI 2.2–14, p?<?0.01).

Conclusions

The factors associated with postpartum hemorrhage requiring transfusion in cesarean deliveries of twins seemed to be different from those in singleton cesarean deliveries.     

Risk factors for emergency caesarean section in planned vaginal breech delivery

Purpose

To identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term.

Methods

Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared.

Results

Risk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09–3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87–4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04–1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003–2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58–83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort.

Conclusions

Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.

     

Utilisation of malaria preventive measures during pregnancy and birth outcomes in Ibadan, Nigeria

Background

To investigate the relation between maternal thyroid function and the outcome of external cephalic version (ECV) in breech presentation.

Methods

Prospective cohort study in 141 women (≥ 35 weeks gestation) with a singleton fetus in breech. Blood samples for assessing thyroid function were taken prior to ECV. Main outcome measure was the relation between maternal thyroid function and ECV outcome indicated by post ECV ultrasound.

Results

ECV success rate was 77/141 (55%), 41/48 (85%) in multipara and 36/93 (39%) in primipara. Women with a failed ECV attempt had significantly higher TSH concentrations than women with a successful ECV (p < 0.001). Multiple logistic regression showed that TSH (OR: 0.52, 95% CI: 0.30-0.90), nulliparity (OR: 0.11, 95% CI: 0.03-0.36), frank breech (OR: 0.30, 95% CI: 0.10-0.93) and placenta anterior (OR: 0.31, 95% CI: 0.11-0.85) were independently related to ECV success.

Conclusions

Higher TSH levels increase the risk of ECV failure.

Trial registration number

ClinicalTrials.gov: NCT00516555     

Brachial Plexus Birth Injury in Elective Versus Emergent Caesarean Section: A Cohort Study

Objective

Although Caesarean section (CS) is protective for brachial plexus birth injury (BPBI), the incidence is not zero. A trial of labour with unfavourable intrauterine positioning is hypothesized to result in excessive force on the brachial plexus. The purpose of this study was to determine the risk of BPBI in emergent CS versus elective CS.

Obstetric complications in grand and great grand multiparous women

Objective.?To investigate pregnancy and labour outcomes in grand and great grand multiparous women.

Study design.?A retrospective population-based study was conducted between the years 1988 and 2007. Parturients were classified into three groups: multiparous; 2–5 deliveries, grand multiparous; 6–9 deliveries, and great grand multiparous; 10+?deliveries. Stratified analyses included multiple logistic regression models.

Results.?A significant linear association was found between parity and adverse maternal and perinatal outcomes such as malpresentation, labour dystocia, caesarean delivery, postpartum haemorrhage, maternal anaemia (HB<10), congenital malformations and perinatal mortality. Using multivariable logistic regression models, grand multiparity was found an independent risk factor for labour dystocia, first stage (OR?=?1.5, P?<?0.001), and perinatal mortality (OR?=?2.0, P?<?0.001). Great grand multiparity was found an independent risk factor for labour dystocia, first stage (OR?=?2.6, P?<?0.001), labour dystocia, second stage (OR?=?2.1, P?<?0.001), and perinatal mortality (OR?=?2.5, P?<?0.001).

Conclusion.?Women with high birth order are at increased risk for adverse obstetric outcomes. The risk is higher for great grand multiparous women compared to grand multiparous women. Grand and great grand multiparity are independent risk factors for labour dystocia and perinatal mortality.     

Retention of Vaginal Breech Delivery Skills Taught in Simulation

Objective

The optimal frequency of conducting simulation training for high-acuity, low-frequency events in obstetrics and gynaecology residency programs is unknown. This study evaluated retention over time of vaginal breech delivery skills taught in simulation, by comparing junior and senior residents. In addition, the residents' subjective comfort level to perform this skill clinically was assessed.

Bevacizumab in the treatment of ovarian cancer: a meta-analysis from four phase III randomized controlled trials

Background

The aim of this meta-analysis was to summarize the efficacy and safety of bevacizumab in the treatment of ovarian cancer.

Methods

We sought to identify randomised controlled trials (RCTs) by searching PubMed and Web of Science. Outcomes were objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse events.

Results

Four studies with 4,246 patients were included. Combination of bevacizumab and chemotherapy resulted in a statistically significant improvement in ORR (OR 2.165, 95 % CI 1.511–3.103) and in PFS (HR 0.691, 95 % CI 0.517–0.865), compared with chemotherapy alone. There was no evidence of a significant improvement in OS (HR 0.934, 95 % CI 0.826–1.041). It also had significantly increased risk of gastrointestinal events (OR 2.743, 95 % CI 1.580–4.763; P < 0.001), hypertension (OR 4.630, 95 % CI 3.737 to 5.737; P < 0.001), proteinuria (OR 4.872, 95 % CI 2.617–9.069; P < 0.001), and arterial thromboembolism (OR 1.994, 95 % CI 1.210–3.286; P = 0.007).

Conclusion

This meta-analysis suggests that the addition of bevacizumab to chemotherapy offers meaningful improvement in objective response rate and progression-free survival in ovarian cancer treatment, but does not benefit overall survival. It also significantly increased the occurrence of gastrointestinal events, hypertension, proteinuria, and arterial thromboembolism.     

Shoulder dystocia without versus with brachial plexus injury: a case-control study.

OBJECTIVE: To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI). STUDY DESIGN: A case-control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88). CONCLUSIONS: Neither antepartum nor intrapartum factors can differentiate the patient who will have shoulder dystocia with vs. without BPI.