Validation of a venous thromboembolism risk assessment model in gynecologic oncology

Objectives

Gynecologic oncology patients undergoing surgery are at an increased risk for venous thromboembolism (VTE). We attempted to validate a VTE risk assessment model in gynecologic oncology patients.

Methods

All gynecologic oncology patients who underwent a laparotomy for the diagnosis or suspicion of gynecologic malignancy from 2004 to 2010 were included. Demographic, surgicopathologic, and complication data were collected. VTE was based on the symptomatic diagnosis. Data for the Caprini risk assessment model (RAM) was used to score and stratify patients on their risk for VTE.

Results

1123 gynecologic oncology patients were included within this study. Ovarian cancer was the most common diagnosis (39%) with a median age of 56.1. All patients received SCDs with 40% receiving double prophylaxis. The overall incidence of VTE was 3.3%, with lower extremity deep venous thrombosis (DVT) n = 17 and pulmonary embolism (PE) n = 20. Complication rates were similar in each group. Based on the Caprini scoring model 92% of patients scored in the “Highest Risk” category. The Caprini RAM accurately predicted all 37 VTEs, all of which scored in the “Highest Risk” category. The percentage of patients that received double prophylaxis increased with time from 12% in 2004 to 63% in 2010. Importantly, 25 of the 37 VTEs (68%) did not receive double prophylaxis.

Conclusions

The use of the Caprini RAM accurately predicted patients at the highest risk of experiencing VTE. Considering accurate identification of patients allows proper administration of double prophylaxis, we recommend the use of this scoring model preoperatively in patients undergoing surgery for gynecologic malignancies.     

Temsirolimus with or without megestrol acetate and tamoxifen for endometrial cancer: A gynecologic oncology group study

Objectives

To determine the response, toxicities, and progression free survival of a regimen of temsirolimus with or without hormonal therapy in the treatment of advanced, or recurrent endometrial carcinoma.

Background

Preclinical evidence suggested that blockade of the PI3K/AKT/mTOR pathway might overcome resistance to hormonal therapy.

Methods

We performed a randomized phase II trial of intravenous temsirolimus 25 mg weekly versus the combination of weekly temsirolimus with a regimen of megestrol acetate 80 mg bid for three weeks alternating with tamoxifen 20 mg bid for three weeks in women with recurrent or metastatic endometrial carcinoma.

Results

There were 71 eligible patients who received at least one dose of therapy with 21 of these treated on the combination arm which was closed early because of an excess of venous thrombosis, with 5 episodes of deep venous thrombosis (DVT) and 2 pulmonary emboli. There were three responses observed in that arm (14%). A total of 50 eligible patients were treated on the single agent arm with 3 episodes of DVT and 11 responses (22%). Response rates were similar in patients with prior chemotherapy (7 of 29; 24%) and those with no prior chemotherapy (4 of 21; 19%). Two of four patients with clear cell carcinoma responded.

Conclusions

Adding the combination of megestrol acetate and tamoxifen to temsirolimus therapy did not enhance activity and the combination was associated with an excess of venous thrombosis. Temsirolimus activity was preserved in patients with prior adjuvant chemotherapy.     

Integrating a complementary medicine consultation for women undergoing chemotherapy

Objective

To explore oncology healthcare providers’ (HCPs’) patterns of referral of women undergoing chemotherapy to a complementary medicine (CM) consultation integrated within a conventional oncology service.

Methods

Oncology HCPs used a structured referral system for referral to an integrative physician (IP) for CM consultation. Referral goals were in accordance with a specified list of quality-of-life (QOL) outcomes.

Results

In total, the study HCPs referred 282 female patients, of whom 238 (84.4%) underwent CM consultation by the study IP: 59 (24.8%) with gynecologic cancer and 179 (75.2%) with non-gynecologic cancer. Use of CM for cancer-related outcomes was significantly higher among referred patients with gynecologic cancer than those with non-gynecologic cancer (69.5% vs 46.9%; P = 0.003). Oncologists initiated most of the referrals in the gynecologic oncology group, whereas oncologic nurses referred most patients in the non-gynecologic oncology group. Among patients with gynecologic cancer, the correlation between HCP indication and patient expectation was high for gastrointestinal concerns (κ 0.41).

Conclusion

The integration of a structured and informed process of referral to CM consultation may enhance patient-centered care and QOL during chemotherapy.     

Is venous thromboprophylaxis necessary in patients undergoing minimally invasive surgery for a gynecologic malignancy?

Objectives

Current recommendations for the use of venous thromboprophylaxis in patients undergoing minimally invasive surgery (MIS) for a gynecologic malignancy are derived from patients undergoing open surgery. Our objective was to determine the 30-day prevalence of symptomatic venous thromboembolism (VTE) after laparoscopic gynecologic oncology procedures in patients who received no thromboprophylaxis.

Methods

Between January 2006 and September 2013, women who underwent MIS for endometrial, cervical or ovarian cancer at a single institution were included. Data on patient demographics, diagnosis, comorbidities, perioperative characteristics, use of thromboprophylaxis, and diagnosis of VTE were collected retrospectively.

Results

Of the 419 patients who underwent MIS for a gynecologic cancer, 352 (84%) received no VTE prophylaxis. At least a total laparoscopic hysterectomy (simple or radical) or pelvic lymph node dissection was performed in 95% of these patients. The median length of surgery was 137 min and 95% of patients were discharged home within 1 day of surgery. The rate of VTE in the 352 untreated patients was 0.57% (1 pulmonary embolism and 1 deep vein thrombosis). There were no VTE diagnosed within 30 days of surgery in the 67 patients who received anticoagulant thromboprophylaxis.

Conclusion

The rate of VTE is low in patients undergoing minimally invasive surgery for a gynecologic malignancy despite no VTE prophylaxis. The benefits of routine use of VTE prophylaxis in this population are questionable.     

Synthetic cyanoacrylic glue in the prevention of post-operative lymphocele after pelvic lymphadenectomy in patients with uterine malignancies: A prospective,single-blind,preliminary study

Objectives

Lymphoceles are among the most common post-operative complications of pelvic lymphadenectomy, with a reported incidence of 1% to 29% in gynecology oncology. Several studies evaluated the effectiveness of biological glues on reducing lymphoceles, but no data on gynecological patients are available. We evaluated the effectiveness of cyanoacrylic glues (n-butyl cyanoacrylate) (Glubran 2 — GEM s.r.l., Italy) in preventing lymphocele on 30 patients who underwent pelvic lymphadenectomy for endometrial or cervical cancer.

Methods

Single-blind prospective randomized study. Patients were divided into 2 groups: pelvic lymphadenectomy plus n-butyl cyanoacrylate (treatment group: 44 patients) and pelvic lymphadenectomy without n-butyl cyanoacrylate (control group: 44 patients). Primary endpoint was incidence of pelvic lymphocele in the two groups 30 days after surgery, and evaluated with pelvic ultrasound and RMI examination. Secondary endpoints evaluated drainage volume of lymphorrhea 36, 48, 72 and 96 h after surgery.

Results

15% in the treatment group and 36.6% in the control group had lymphocele 1 month after the procedure (p < 0.03; RR 0.4 [95% CI 0.152–0.999]). Concerning the secondary outcome in group A the amount of lymphorrhea presented a constant significant decrease during evaluation; on the contrary, in group B, after an initial decrease at 48 h, the amount of lymphorrhea remained unchanged; at all considered times the amount of lymphorrhea resulted significantly greater in controls.

Conclusion

Intraoperative application of n-butyl cyanoacrylate seems to reduce lymph production after pelvic lymphadenectomy, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after pelvic lymphadenectomy.     

Velocimetría Doppler del flujo sanguíneo de la arteria uterina y riesgo de muerte perinatal en preeclámpsicas

Objective

To determine the association between Doppler velocimetry values of uterine artery blood flow with the risk of perinatal death in preeclamptic patients.

Materials and method

We selected 80 patients with a diagnosis of preeclampsia. Preeclamptic patients were divided into those with perinatal deaths and those without. The variables analyzed were the pulsatility index, the resistance index, and the systolic/diastolic flow ratio of the uterine arteries.

Results

There were no differences in maternal age, height or weight between preeclamptic patients with or without perinatal deaths (p = ns), or between gestational age at the time of Doppler ultrasound and systolic and diastolic blood pressure (p = ns). The pulsatility index (1.206 ± 0.140) and resistance index (0.684 ± 0.098) of the uterine arteries were significantly higher in women with perinatal deaths than in those without (1.113 ± 0.109 and 0.605 ± 0.116, respectively; P<.05). No significant differences were found in mean values of the systolic/diastolic flow ratio of the uterine arteries (p = ns).

Conclusion

A high value of the pulsatility index and resistance index of the uterine arteries on Doppler velocimetry in preeclamptic patients is associated with an increased risk of perinatal death.     

Risk stratification and prognosis determination using F-FDG PET imaging in endometrial cancer patients: A systematic review and meta-analysis

Objectives

In the current study, we systematically searched and analyzed the available literature on the prognostic value of semi-quantitative ¹⁸F-FDG PET imaging (SUVmax/mean) in patients with endometrial cancer and presenting the results in a meta-analytic format.

Methods

Pubmed, SCOPUS, and ISI Web of Knowledge were searched using “endometr* AND PET” as the search algorithm. All studies evaluating the ¹⁸F-FDG PET performance in pre-operative risk stratification or its prognostic value in patients with endometrial cancer were included. Statistical pooling of diagnostic accuracy indices was performed using random effects model. Cochrane Q test and I² index were used for heterogeneity evaluation.

Results

Ten studies (771 patients) were included in the systematic review. Pooled average SUVmax values in patients with risk factors [grade III, lymphovascular invasion (LVI), cervical invasion (CI), myometrial invasion (MI) ≥ 50%] were statistically higher than those in patients without risk factors. Pooled HR of pre-operative SUVmax for disease free survival was 7.415 [2.892–19.432] (p = 0.000046).

Conclusion

Despite higher average SUVmax in the high-risk group compared to the low-risk group of patients with endometrial cancer, the usefulness of ¹⁸F-FDG PET SUVmax in classifying patients into pre-defined risk groups seems to be limited. However, pre-operative SUVmax of endometrial tumors seems to be an independent prognostic marker of recurrence and death. Further large multicenter studies with adequate follow-up are needed to confirm our findings.     

Is bariatric surgery an option for women with gynecologic cancer? Examining weight loss counseling practices and training among gynecologic oncology providers

Objective

The objective of this study was to evaluate gynecologic oncology provider (GOP) practices regarding weight loss (WL) counseling, and to assess their willingness to initiate weight loss interventions, specifically bariatric surgery (WLS).

Methods

Members of the Society of Gynecologic Oncology were invited to complete an online survey of 49 items assessing knowledge, attitudes, and behaviors related to WL counseling.

Results

A total of 454 participants initiated the survey, yielding a response rate of 30%. The majority of respondents (85%) were practicing GOP or fellows. A majority of responders reported that > 50% of their patient population is clinically obese (BMI ≥ 30). Only 10% reported having any formal training in WL counseling, most often in medical school or residency. Providers who feel adequate about WL counseling were more likely to offer multiple WL options to their patients (p < .05). Over 90% of responders believe that WLS is an effective WL option and is more effective than self-directed diet and medical management of obesity. Providers who were more comfortable with WL counseling were significantly more likely to recommend WLS (p < .01). Approximately 75% of respondents expressed interest in clinical trials evaluating WLS in obese cancer survivors.

Conclusions

The present study suggests that GOP appreciate the importance of WL counseling, but often fail to provide it. Our results demonstrate the paucity of formal obesity training in oncology. Providers seem willing to recommend WLS as an option to their patients but also in clinical trials examining gynecologic cancer outcomes in women treated with BS.     

Robotic technology for pelvic exenteration in cases of cervical cancer

Background

Cervical cancer represents one of the most common types of neoplasia among women; the use of minimally invasive techniques in the treatment of cervical cancer is a challenge.

Objectives

To present evidence regarding robotic technology in the performance of pelvic exenteration in cases of cervical cancer.

Search strategy

PubMed and Scopus databases were searched.

Selection criteria

Articles examining the use of robotic technology for pelvic exenteration in cases of cervical cancer were included.

Data collection and analysis

Four studies were included.

Main results

Most cancers treated with robotic-assisted pelvic exenteration were squamous cell carcinomas of the cervix. The stage of primary cancer ranged from IB2 to IVA. In 7 of the 8 patients, anterior pelvic exenteration was performed; the other patient underwent total pelvic exenteration. Procedure duration ranged from 375 to 600 minutes; blood loss was 200–550 mL. Postoperative complications occurred in 2 of the 8 patients and included perineal abscess, Miami pouch fistula, and ureteral stenosis. Postoperative hospital stay ranged from 3 to 53 days, and postoperative follow-up ranged from 2 to 31 months.

Conclusions

The gold standard for pelvic exenteration remains the open surgical approach; however, the application of robotic technology could be an alternate choice associated with excellent results.     

Venous thromboembolism during primary treatment of ovarian clear cell carcinoma is associated with decreased survival

Objectives

To determine the impact of venous thromboembolism (VTE) during primary treatment of ovarian clear cell carcinoma (OCCC) on survival.

Methods

After Institutional Review Board approval, 74 cases of OCCC were retrieved from our pathology files. Clinical and pathological data were obtained by medical record and pathology review. Standard statistical analyses were performed.

Results

Among 74 patients with OCCC, VTE was diagnosed in 11 (15%) during primary treatment and 7 (9%) at time of cancer recurrence. 56 (76%) patients never developed VTE. Patients with VTE during OCCC primary treatment had shorter progression-free survival (PFS) and overall survival (OS) than OCCC patients without VTE (median PFS 11 vs. 76 months, p = 0.01, median OS 19 vs. 90 months, p = 0.001). Patients with VTE during OCCC primary treatment had a 3.9-fold increase in risk of recurrence (p = 0.007) and a 6.3-fold increase in risk of death (p < 0.001). After controlling for cancer stage, VTE during OCCC primary treatment remained an independent prognostic factor for death (HR = 3.6, p = 0.005). No patient died of VTE.

Conclusions

VTE during OCCC primary treatment is associated with a significantly higher risk of cancer recurrence and death. This increased risk is not attributable to VTE-related mortality and raises the possibility that a paracrine circuit involving thrombosis might contribute to a more aggressive tumor biology.     

Development and pilot of an advance care planning website for women with ovarian cancer: A randomized controlled trial

Objective

Few available tools facilitate cancer patients and physicians' discussions of quality of life and end-of-life. Our objective was to develop a web-based tool to promote advance care planning for women with ovarian cancer.

Methods

Women with ovarian cancer, their families, clinicians and researchers met to identify ways to improve cancer care. A prototype website was created to address advance care planning, focusing on advance healthcare directives (AHD) and palliative care consultation. Patients were recruited from a gynecologic oncology clinic for a pilot randomized controlled trial. Primary outcomes included completion of an AHD and palliative care consultation.

Results

At study completion, 53 women with ovarian cancer were enrolled and 35 completed the study. The mean age at enrollment was 57.9 ± 9.5 years; most were newly diagnosed or at first recurrence. There were no statistical differences in completion of AHD (p = 0.220) or palliative care consultation (p = 0.440) between intervention and control groups. However, women in the intervention group showed evidence of moving toward decision making regarding AHD and palliative care and lower decisional conflict. Women assigned to the intervention, compared to control website, were highly satisfied with the amount (p = 0.054) and quality (p = 0.119) of information and when they accessed the website, used it longer (p = 0.049). Overall website use was lower than expected, resulting from several patient-related and design barriers.

Conclusions

A website providing information and decisional support for women with ovarian cancer is feasible. Increasing frequency of website use requires future research.     

The influence of comorbidity on mortality in ovarian cancer patients

Background

Ovarian cancer is a severe disease with a peak incidence in the older age groups where concurrent morbidity is common and could potentially influence mortality rates.

Objectives

The aim was to study the influence of common comorbidity diagnoses on mortality in ovarian cancer patients.

Methods

The study population was patients with ovarian cancer in Sweden 1993–2006 (n = 11.139) identified in the national Cancer Register. Comorbidity data was obtained from the Patient Register and mortality from Cause of Death Register. Mortality was analyzed with Cox' proportional hazards models and subgroup analyses were performed by age and tumor histology.

Results

Almost all of the assessed comorbidities increased mortality in ovarian cancer patients. Thromboembolism was the most hazardous comorbidity (HR = 1.95, < 1 year after cancer diagnosis and HR = 7.83, 1–5 years after cancer diagnosis) followed by hematologic complications (HR = 1.84 and 7.11 respectively) and infectious disease (HR = 1.48 and 5.28 respectively). The occurrence of diabetes mellitus and hypertension had less impact on mortality.

Conclusion

Thromboembolism, hematologic complications and infections had a pronounced effect on mortality rates in women with ovarian cancer. The impact of comorbidity was mainly apparent among those with a more prosperous prognosis, such as longer time since cancer diagnosis, less aggressive tumors and younger age.     

Small-for-gestational-age fetuses with normal umbilical artery Doppler have suboptimal perinatal and neurodevelopmental outcome

Objective

To evaluate the perinatal and neurodevelopmental outcome of small-for-gestational-age fetuses with normal umbilical artery Doppler managed expectantly during pregnancy and delivery.

Study design

Perinatal and neurodevelopmental outcome was assessed from a cohort of singleton small-for-gestational-age fetuses with normal umbilical artery Doppler and normally grown controls matched by gestational age at delivery, parity and parental socio-economic level. Neurodevelopmental outcome was prospectively evaluated by means of the 24-month Age&Stage Questionnaire (ASQ).

Results

A total of 129 small-for-gestational-age fetuses and 259 controls were included. Small-for-gestational-age fetuses had a higher risk for neonatal intensive care unit admission (15.5% versus 3.9%; p < 0.001) and significant neonatal morbidity (2.3% versus 0%; p = 0.04) than controls. At 24-months, these fetuses showed significantly lower neurodevelopmental centile in the problem solving (42.8 versus 52.1; p = 0.001) and personal-social (44.4 versus 54.6; p < 0.001) areas than controls.

Conclusion

Perinatal and neurodevelopmental outcome in small-for-gestational-age fetuses with normal umbilical artery Doppler is suboptimal, which may challenge the role of umbilical artery Doppler to discriminate between normal-SGA and growth-restricted fetuses.     

Non-cancer life stressors contribute to impaired quality of life in ovarian cancer patients

Objectives

Diagnosis and treatment for a life threatening illness such as cancer are known to be psychologically impactful. However, little is known about the influence that non-cancer life stressors have on the quality of life (QOL) of ovarian cancer patients. The goal of the present study was to examine associations between non-cancer life stressors and QOL in 123 women with invasive epithelial ovarian cancer who were followed prospectively and longitudinally for one year.

Methods

Mixed models for repeated measures were used to examine the relationship between life stressors and QOL pre-surgery and one year later, while adjusting for age, cancer stage, depressive symptoms, anxiety, and chemotherapy status (at one year). Prospective associations between QOL pre-surgery and one-year QOL were also examined.

Results

Number and severity of life stressors were unrelated to QOL of participants before surgery. At one year, however, participants experiencing a greater number of life stressors reported poorer concurrent physical well-being (PWB) (p = 0.015), functional well-being (FWB) (p < 0.0001), social well-being (SWB) (p = 0.0003), and total QOL (p < 0.0001). Similar effects were found for life event severity. Finally, experiencing a greater number of life stressors pre-surgery predicted poorer overall QOL one year post-diagnosis (p < 0.0001).

Conclusions

Non-cancer life stressors can substantially impact long-term QOL of ovarian cancer patients, adjusting for medical variables such as chemotherapy and cancer stage, thus highlighting the importance of evaluating the stress burden of patients in ongoing cancer care.     

C-reactive protein serum levels are closely associated with lymph node status,but not with prognosis in patients with vulvar cancer

Objective

To evaluate whether C-reactive protein (CRP) serum levels can be used as prognostic parameter in patients with vulvar cancer.

Study design

CRP serum levels were measured at the time of first diagnosis of squamous cell vulvar cancer. Sixty-seven patients were enrolled; results were correlated to clinical data.

Results

Mean CRP serum levels in patients with vulvar cancer were 0.8 (0.80) mg/dL. CRP serum levels were significantly associated with lymph node involvement (p = 0.003), but not with tumor stage (p = 0.03), histological grade (p = 0.86) and patients’ age (p = 0.64). Univariate analysis showed lymph node involvement, tumor stage and histological grade, but not CRP serum levels and patients’ age to be associated with overall survival. A multivariable analysis determined only lymph node involvement as independent prognostic parameter for disease-free interval and overall survival.

Conclusion

CRP serum levels are closely associated with lymph node status but cannot be used as prognostic parameter in patients with vulvar cancer.     

Study of fetal tracheal fluid velocities using Doppler ultrasound

Objective

To characterize tracheal fluid flow during fetal breathing movements by Doppler ultrasound.

Study design

To use pulsed Doppler to measure flow velocity during inspiration and expiration in a cross-sectional study of 15 normal fetuses and determine the correlation, if any, between flow velocity and gestational age.

Results

Cyclic respiratory profiles – both regular and irregular – were observed. Intratracheal flow velocity was very elevated during inspiration, ranging from 10 to 80 cm/s and from 5 to 20 cm/s during expiration.

Conclusion

This technique enables the noninvasive semiquantitative evaluation of fetal breathing movements. This Doppler application opens the field for future studies to characterize the extent of pulmonary hypoplasia.     

A population-based study of venous thrombosis in pregnancy in Scotland 1980–2005

Objectives

Data on time trends in the incidence of pregnancy-related venous thromboembolism (VTE) are sparse. This report charts the incidence of pregnancy-related VTE over the period 1980–2005 in Scotland, and discusses the results in relation to potential risk factors.

Study design

1 475 301 maternity discharges from Scottish hospitals recorded on the Scottish Morbidity Record 2 (SMR2) were included. Incidences of pregnancy-related VTE, antenatal deep venous thromboembolism (DVT), postnatal DVT and pulmonary embolism (PTE) were derived relative to the number of deliveries, and risk factors were analysed using Poisson regression.

Results

Over the period, VTE incidence rose from 13.7 to 18.3 per 10 000 deliveries, antenatal DVTs from 8.8 to 12.2 per 10 000 deliveries and PTE from 1.5 to 3.0 per 10 000 deliveries. Postnatal DVTs, on the other hand, declined from 4.2 to 2.7 per 10 000 deliveries. Risk factors were: age over 35 years; three or more previous pregnancies; previous VTE; obstetric haemorrhage; and preeclampsia. Antenatal DVT risk was highest in the most deprived areas, where events started increasing before those in less deprived areas. Postnatal DVT risk was increased following caesarean delivery, especially when unplanned, although after 1996, events following emergency caesarean decreased.

Conclusion

During the 26-year period, pregnancy-related VTEs increased, with the greatest rise for antenatal DVTs. Postnatal DVTs, on the other hand, declined over the period, particularly following emergency section. Thromboprophylaxis use following emergency delivery may have led to the postpartum reduction. To continue to prevent events, risk assessment and intervention are required, particularly antenatally.     

Incontinencia anal postparto y control evolutivo hasta los doce meses

Objectives

To determine the prevalence of anal incontinence (AI) of faeces and gases, as well as the factors associated with the pregnancy, delivery and postpartum.

Design

Twelve-month follow-up study with visits at 2, 6 and 12 months.

Settings

Vic General Hospital as a basic general hospital in the Osona region (Central Catalonia, Spain).

Subject of the study

Women who had a live birth at full-term between the 1^st of January 2001 and the 31^st of March 2002.

Methodology

During admission for childbirth, data were collected on the mother (age, parity, body mass index, symptoms of incontinence during pregnancy), the type of delivery (vaginal, caesarean) and the foetus (weight, cranial circumference). Two months after parturition, the mothers were examined by a gynaecologist to detect and establish the clinical diagnosis of anal incontinence by means of a specific protocol. The women were asked whether they had symptoms of involuntary release of faeces or gases: women with symptoms of AI underwent a pelvic examination before being referred to a specialist in coloproctology for an assessment. Women with symptoms of AI at 2 months postpartum were recalled at 6 months for a new clinical assessment by the gynaecologist, and after 12 months all those who had shown persistence of symptoms at 6 months were contacted by phone. The prevalence of anal incontinence at 2 months postpartum was calculated and also the association of symptoms with maternal, foetal and delivery factors.

Results

A total of 531 women were visited at 2 months postpartum. Of these, 11 were diagnosed with anal incontinence. At 12 months post partum, 4 (36.4%) of these 11 women continued to have symptoms of incontinence. The prevalence of anal incontinence at 2 months after delivery was 2.1% (95% CI: 1.0-3.7) and was associated with primiparity (Odds ratio [OR] = 7.21, P = 0.029) and forceps use (OR = 5.54, P = 0.021).

Conclusions

The prevalence of AI symptoms at 12 months after parturition was low but in a half of the patients the symptoms were prevalent for more than 6 months. Primiparity and forceps use are associated with the AI symptoms at 2 months postpartum.