Tranexamic acid for preventing postpartum haemorrhage after vaginal birth

RATIONALE

Postpartum haemorrhage (PPH) is common and potentially life-threatening. The antifibrinolytic drug tranexamic acid (TXA) is thought to be effective for treating PPH. There is growing interest in whether TXA is effective for preventing PPH after vaginal birth. In randomised controlled trials (RCTs), TXA has been associated with increased risk of seizures and unexplained increased mortality when given more than three hours after traumatic bleeding. Reliable evidence on the effects, cost-effectiveness and safety of prophylactic TXA is required before considering widespread use. This review updates one published in 2015.

OBJECTIVES

To assess the effects of TXA for preventing PPH compared to placebo or no treatment (with or without uterotonic co-treatment) in women following vaginal birth.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, and WHO ICTRP (to 6 September 2024). We also searched reference lists of retrieved studies.

ELIGIBILITY CRITERIA

We included RCTs evaluating TXA alone or in addition to standard care (uterotonics) for preventing PPH following vaginal birth. For this update, we required trials to be prospectively registered (before participant recruitment), and we applied a trustworthiness checklist.

OUTCOMES

Critical outcomes were blood loss ≥ 500 mL and blood loss ≥ 1000 mL. Important outcomes included maternal death, severe morbidity, blood transfusion, receipt of additional surgical interventions to control PPH, thromboembolic events, receipt of additional uterotonics, hysterectomy, and maternal satisfaction.

RISK OF BIAS

We used the Cochrane risk of bias tool (RoB 1) to assess the risk of bias in the studies.

SYNTHESIS METHODS

Two review authors independently selected trials, extracted data, assessed risk of bias, and assessed trial trustworthiness. We used random-effects meta-analysis to combine data. We assessed the certainty of the evidence using GRADE.

INCLUDED STUDIES

We included three RCTs with 18,974 participants in total. The trials were conducted in both high- and low-resource settings and involved participants at both low and high risk of PPH. The trials compared intravenous TXA (1 g) and standard care versus placebo (saline) and standard care. After applying our trustworthiness checklist, we did not include any of the 12 trials in the previous version of this review.

SYNTHESIS OF RESULTS

Prophylactic tranexamic acid in addition to standard care compared to placebo in addition to standard care TXA results in little to no difference in blood loss ≥ 500 mL (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.81 to 1.06; 2 studies, 18,897 participants; 5 fewer per 1000, 95% CI 15 fewer to 5 more; high-certainty evidence). TXA likely results in little to no difference in blood loss ≥ 1000 mL (RR 0.86, 95% CI 0.69 to 1.07; 2 studies, 18,897 participants; 3 fewer per 1000, 95% CI 6 fewer to 1 more; moderate-certainty evidence). TXA likely results in little to no difference in severe morbidity (RR 0.88, 95% CI 0.69 to 1.12; 1 study, 15,066 participants; 2 fewer per 1000, 95% CI 6 fewer to 2 more; moderate-certainty evidence). TXA results in little to no difference in receipt of blood transfusion (RR 1.00, 95% CI 0.95 to 1.06; 3 studies, 18,972 participants; 0 fewer per 1000, 95% CI 10 fewer to 12 more; high-certainty evidence). TXA may result in little to no difference in receipt of additional surgical interventions to control PPH (RR 0.63, 95% CI 0.32 to 1.23; 2 studies, 18,972 participants; 1 fewer per 1000, 95% CI 2 fewer to 1 more; low-certainty evidence). In women with anaemia, TXA results in little to no difference in receipt of additional uterotonics (RR 1.02, 95% CI 0.94 to 1.10; 1 study, 15,066 participants; 3 more women per 1000, 95% CI 8 fewer to 24 more; high-certainty evidence). In women with no anaemia, TXA results in a slight reduction in receipt of additional uterotonics (RR 0.75, 95% CI 0.61 to 0.92; 1 study, 3891 participants; 24 fewer women per 1000, 95% CI 38 fewer to 8 fewer; high-certainty evidence). TXA likely results in little to no difference in maternal satisfaction. The evidence is very uncertain about the effect of TXA on maternal death, thromboembolic events, and hysterectomy (very low-certainty evidence): maternal death (RR 0.99, 95% CI 0.39 to 2.49; 2 studies, 15,081 participants; 0 fewer per 1000, 95% CI 1 fewer to 2 more); thromboembolic events (RR 0.25, 95% CI 0.03 to 2.24; 3 studies, 18,774 participants; 3 fewer women per 10,000, 95% CI 4 fewer to 5 more); hysterectomy (RR 0.89, 95% CI 0.36 to 2.19; 1 study, 15,066 participants; 1 fewer women per 10,000, 95% CI 9 fewer to 16 more).

AUTHORS' CONCLUSIONS

Adding prophylactic TXA to standard care of women during vaginal birth makes little to no difference to blood loss ≥ 500 mL and likely makes little to no difference to blood loss ≥ 1000 mL or the risk of severe morbidity, compared to placebo and standard care. TXA may result in little to no difference in additional surgical interventions to control PPH and results in little to no difference in blood transfusions. One trial found that TXA reduced the use of additional uterotonics in women without anaemia, whereas the largest trial found little to no difference in the use of additional uterotonics in women with anaemia. Although there were very few serious adverse events reported, the evidence is insufficient to draw conclusions about the effect of TXA on maternal death, thromboembolic events, hysterectomy, or seizures. TXA likely results in little to no difference in maternal satisfaction. These findings are based mainly on two large trials. In the smaller of these, less than 30% of study participants were at high risk of PPH. In the largest trial, all participants had moderate to severe anaemia. Those making decisions about routine administration of prophylactic TXA for all women having vaginal births should consider that current evidence does not show a benefit of TXA for blood loss outcomes and related morbidity, and the evidence is very uncertain about serious adverse events.

FUNDING

This review was partially funded by the World Health Organization (WHO).

REGISTRATION

Protocol (2009) DOI: 10.1002/14651858.CD007872 Original review (2010) DOI: 10.1002/14651858.CD007872.pub2 Review update (2015) DOI: 10.1002/14651858.CD007872.pub3.

Efficacy of N-Acetylcysteine in Polycystic Ovary Syndrome: Systematic Review and Meta-Analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects women of reproductive age and requires better treatment. N-acetylcysteine (NAC) is known to be beneficial under such conditions owing to its antioxidant potential and insulin-sensitizing properties. The effect of NAC on the reproductive outcomes of PCOS patients was examined in this meta-analysis.

METHODS

In accordance with PRISMA standards, this meta-analysis included studies that compared N-acetylcysteine, metformin, clomiphene citrate, and a placebo in patients with POCS. The main indicators were follicular growth, endometrial thickness, and hormone level. The risk of bias was evaluated using the Cochrane ROB2 tool.

RESULTS

Twenty-two studies (n = 2515) were included. NAC was associated with a statistically significant increase in progesterone (SMD 0.95, 95% CI: 0.13-1.77, p = 0.02) and endometrial thickness (SMD 0.58, 95% CI: 0.10-1.06, p = 0.02) compared to the placebo and other drugs (SMD 0.71, 95% CI: 0.48-0.94, p < 0.0001). LH levels were significantly increased by NAC compared to metformin (SMD 0.67, 95% CI: 0.23-1.12, p = 0.003). However, no significant differences were observed in the estradiol, SHBG, or FSH levels.

CONCLUSIONS

NAC had a major effect on progesterone, endometrial thickness, and LH levels in women with PCOS. Therefore, it may be a potential treatment option.

Gonadotropin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone (LH) surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth. We compared the benefits and risks of the different GnRHa protocols used.

OBJECTIVES

To evaluate the effectiveness and safety of different GnRHa protocols used as adjuncts to COH in women undergoing ART.

SEARCH METHODS

We searched the following databases in December 2022: the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, and registries of ongoing trials. We also searched the reference lists of relevant articles and contacted experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa, or variations of the protocol in terms of different doses or duration, used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcome measures were number of live births or ongoing pregnancies and incidence of ovarian hyperstimulation syndrome (OHSS) per woman/couple randomised. Our secondary outcome measures included number of clinical pregnancies, pregnancy losses, number of oocytes retrieved, amount of gonadotropins used, and cost and acceptability of the treatment protocols.

MAIN RESULTS

We included 40 RCTs (4148 women). The trials evaluated 10 different comparisons between protocols. The evidence is current to December 2022. Only half of the studies reported the primary outcome of live birth or ongoing pregnancy rates. We restricted the primary analysis of live birth and ongoing pregnancy to trials with low risk of selection and reporting bias. Nineteen studies compared long and short protocols. The primary analysis restricted to trials with low risk of bias included five studies reporting on live birth or ongoing pregnancy rates. Results showed little or no difference when the long protocol was compared with a short protocol (odds ratio (OR) 1.45, 95% confidence interval (CI) 0.83 to 2.52; I² = 0%; 5 studies, 381 women; low-certainty evidence). For the same comparison, there was evidence that the long protocol may improve clinical pregnancy rates when compared to the short protocol (OR 1.56, 95% CI 1.01 to 2.40; I² = 23%; 8 studies, 552 women; low-certainty evidence). No study in this comparison reported on OHSS. We are uncertain if there is a difference between groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort (OR 1.78, 95% CI 0.72 to 4.36; 1 study, 150 women; very low-certainty evidence); long luteal versus long follicular phase (OR 1.89, 95% CI 0.87 to 4.10; 1 study, 223 women; very low-certainty evidence); GnRHa reduced-dose versus GnRHa same-dose continued in the long protocol (OR 1.59, 95% CI 0.66 to 3.87; 1 study, 96 women; very low-certainty evidence); GnRHa administration for two versus three weeks before stimulation (OR 0.88, 95% CI 0.37 to 2.05; 1 study, 85 women; very low-certainty evidence); GnRHa continued versus discontinued after human chorionic gonadotropin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; 1 study, 181 women; very low-certainty evidence); and 500 µg dose versus 80 µg dose in the short protocol (OR 0.31, 95% CI 0.10 to 0.98; 1 study, 200 women; very low-certainty evidence). Clinical pregnancy rates may improve with a 100 µg dose compared to a 25 µg dose in the short protocol (OR 2.30, 95% CI 1.06 to 5.00; 2 studies, 133 women; low-certainty evidence). Only four of the 40 included studies reported adverse events. We are uncertain of any difference in OHSS rate in the GnRHa reduced-dose versus GnRHa same-dose regimen in the long protocol (OR 0.47, 95% CI 0.04 to 5.35; 1 study, 96 women; very low-certainty evidence) or when administration of GnRHa lasted for two versus three weeks before stimulation (OR 0.93, 95% CI 0.06 to 15.37; 1 study, 85 women; very low-certainty evidence). Regarding miscarriage rates, we are uncertain of any difference when the GnRHa long protocol was administered for two versus three weeks before stimulation (OR 0.93, 95% CI 0.18 to 4.87; 1 study, 85 women; very low-certainty evidence) and when a 500 µg dose was compared with an 80 µg dose in the short protocol (OR 3.15, 95% CI 0.32 to 31.05; 1 study, 131 women; very low-certainty evidence). No studies reported on cost-effectiveness or acceptability of the different treatment protocols. The certainty of the evidence ranged from low to very low. The main limitations were failure to report live birth or ongoing pregnancy rates, poor reporting of methods in the primary studies, imprecise findings due to lack of data, and insufficient data regarding adverse events. Only eight of the 40 included studies were conducted within the last 10 years.

AUTHORS' CONCLUSIONS

When comparing long and short GnRHa protocols, we found little or no difference in live birth and ongoing pregnancy rates, but there was evidence that the long protocol may improve clinical pregnancy rates overall. We were uncertain of any difference in OHSS and miscarriage rates for all comparisons, which were reported by only two studies each. There was insufficient evidence to draw any conclusions regarding other adverse effects or the cost-effectiveness and acceptability of the different treatment protocols.

The Impact of Oxidized Regenerated Cellulose Application during Cystectomy and Drainage in Endometrioma Patients: A Retrospective Cohort Study

Objectives

This study aims to determine the impact of oxidized regenerated cellulose (ORC) during cystectomy and drainage on recurrence and ovarian reserve.

Materials and Methods

Women aged 18-45 years with endometrioma (pathologically confirmed) who underwent conservative laparoscopy surgery (cystectomy and drainage) using ORC at Fatmawati General Hospital Jakarta, Indonesia, were included in this study. All surgeries were done by complete excision of all endometriosis lesions (especially for excision of deep infiltrating endometriosis and adenomyosis resection). All patients were followed up for 1 year, and the recurrence rate and postoperative anti-Mullerian Hormone (AMH) were evaluated.

Results

Twenty patients were included in the cystectomy group and 19 in the drainage group. The researchers found the result was not significant (P = 0.622) in recurrence rate. AMH was decreased from 3.0 ± 1.8 to 2.1 ± 1.5 in cystectomy with ORC group. Conversely, AMH decreased from 1.4 ± 1.25 to 1.1 ± 0.9 in the drainage with ORC group. The reduction of AMH level was more significant in the cystectomy group (P = 0.002) than in the drainage group (P = 0.124).

Conclusion

Cystectomy with ORC significantly reduces ovarian reserve. Drainage followed by insertion of ORC to the cyst cavity can be an option to maintain ovarian reserve with a risk of recurrence that is not significantly different from cystectomy.

Evidence-based cesarean delivery: intraoperative management from skin incision until placental delivery (Part 8)

The goal of standardizing the technique of the routine, uncomplicated cesarean delivery (CD) is to decrease maternal morbidity while optimizing neonatal outcomes. During the procedure, a family-oriented CD is recommended. The low transverse cesarean skin incision (created with either scalpel or diathermy) is preferred with either the Joel-Cohen or Pfannenstiel methods being acceptable. For patients with obesity (BMI > 35kg/m2), surgeons may also elect either the Cohen (including supraumbilical) or Pfannenstiel (infraumbilical or infrapannus) technique as there are similar outcomes, however the Cohen approach has been associated with lower Apgar scores and decreased surgeon satisfaction related to the feasibility of the incision. Diathermy may be preferred for subcutaneous tissue opening as compared to sharp dissection. Though postoperative recovery outcomes may be improved with an extraperitoneal approach to CD, a transperitoneal technique is the current standard of care. The initial fascial incision is made sharply, further extension can be carried out either sharply or bluntly. Inferior dissection of the rectus muscle can be omitted and routine cutting of the muscles is not needed. If necessary, a Maylard modification is acceptable. Though based on limited data, blunt peritoneal entry and extension should be considered. With regards to uterine entry and delivery: bladder flap creation should be omitted, a low transverse hysterotomy is recommended with blunt cephalo-caudad expansion, and manual delivery of the fetal head should be performed. If the fetal head is impacted, then reverse breech extraction may be preferred for maternal benefit. Delayed cord clamping is recommended for at least 30 seconds and up to 120 seconds (recommended for preterm deliveries) with either routine or selected umbilical cord gas collection being considered. In areas where available, carbetocin is more effective in prevention of postpartum hemorrhage (PPH). Otherwise, the combination of oxytocin plus either misoprostol or methergine should be utilized. There is insufficient evidence regarding the effectiveness of uterine massage for PPH prevention. Spontaneous removal of the placenta with gentle cord traction is recommended.

A prediction model for hemolysis, elevated liver enzymes and low platelets syndrome in pre-eclampsia with severe features

OBJECTIVE

The aim of the present study was to determine the risk factors for patients with pre-eclampsia (PE) with severe features to develop hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and to design a prediction score model that incorporates these risk factors.

METHODS

A retrospective cohort study was conducted at a tertiary university-affiliated medical center between 2011 and 2019. The study population comprised patients diagnosed with PE with severe features, divided into two groups: those with HELLP syndrome (study group) and those without (control group). A logistic regression was employed to identify independent predictors of HELLP syndrome. A predictive model for the occurrence of HELLP syndrome in the context of PE with severe features was developed using a receiver operating characteristic curve analysis.

RESULTS

Overall, 445 patients were included, of whom 69 patients were in the study group and 376 in the control group. A multivariate logistic analysis regression showed that maternal age <40 (OR = 2.28, 95% CI: 1.13-5.33, P = 0.045), nulliparity (OR = 2.22, 95% CI: 1.14-4.88, P = 0.042), mild hypertension (OR = 2.31, 95% CI: 1.54-4.82, P = 0.019), epigastric pain (OR = 3.41, 95% CI: 1.92-7.23, P < 0.001) and placental abruption (OR = 6.38, 95% CI: 1.29-35.61, P < 0.001) were independent risk factors for HELLP syndrome. A prediction score model reached a predictive performance with an area under the curve of 0.765 (95% CI: 0.709-0.821).

CONCLUSION

This study identified several key risk factors for developing HELLP syndrome among patients with PE with severe features and determined that a prediction score model has the potential to aid clinicians in identifying high risk patients.

A systematic review and meta-analysis of randomized trials comparing carbetocin to oxytocin in prevention of postpartum hemorrhage after cesarean delivery in low-risk women

OBJECTIVES

To evaluate the efficacy and safety of Carbetocin compared to oxytocin in prevention of postpartum hemorrhage (PPH) after low-risk cesarean delivery (CD).

SEARCH STRATEGY

Screening of Medline, Web Of Science, Scopus, Google scholar, and clinical trials registry till January 2024 using the key words related to carbetocin, blood loss, PPH, Cesarean section and their MeSH terms was done.

SELECTION CRITERIA

This study included all RCTs conducted on women with low risk for developing PPH after CD and compared the administration of carbetocin to oxytocin without any language limitation. These studies compared carbetocin to oxytocin alone or oxytocin combined with misoprostol. The review included all doses and routes of carbetocin and oxytocin administration.

DATA COLLECTION AND ANALYSIS

The extracted data included study settings, the participants' size and characteristics, intervention details of both the study and control groups especially data about the dose route and timing of drug administration, the outcome parameters and trial registration details The reported outcomes included the requirement of additional uterotonic agents or blood transfusion, the difference between preoperative and postoperative hemoglobin, the occurrence of PPH, blood loss and drug adverse effects.

MAIN RESULTS

Seventeen studies including 3667 participants were included. The need for additional uterotonic agents was evaluated in 14 studies with 3154 participants and revealed an OR of 0.53 with 95% CI of 0.39 and 0.72 (p < 0.001, I2 41%). The incidence of PPH was reported in 11 studies with 2228 participants and revealed an Odd ratio of 1.08 with 95%CI of [0.81, 1.44] (p = 0.61, I2 0%). The hemoglobin drop after the operation was evaluated in 3 studies with 1240 participants and revealed an MD of -0.08 with 95% CI of -0.10 and - 0.06 (p < 0.001, I2 0%). The need for blood transfusion was evaluated in 9 studies with 1936 participants and revealed an OR of 0.57 with 95% CI of 0.34 and 0.97 (p = 0.04, I2 0%).

CONCLUSION

Carbetocin administration during CD in women with low risk for PPH is associated with less need for additional uterotonic agents (moderate evidence), less need for blood transfusion (high evidence) and lower hemoglobin drop (high evidence) when compared to those who underwent oxytocin administration without an increase in adverse effects.

Engineering nanosystems for regulating reproductive health in women

Reproductive health-related diseases have a significant impact on the well-being of millions of women worldwide, severely compromising their quality of life. Women encounter unique challenges in terms of reproductive health, including gynecological diseases and malignant neoplasms prior to pregnancy, as well as complications during pregnancy that greatly undermine their physical and mental health. Despite recent advancements in the field of female reproduction, substantial challenges still persist. To address these challenges, nanotechnology-based diagnostic and therapeutic strategies have emerged to provide intelligent detection and treatment for pathologies related to women's reproductive health. Although some progress has been made with nanotherapeutics in this domain, its application is still nascent due to the delicate and intricate nature of the female reproductive system. This review comprehensively presents the latest advancements in nanomedicine for regulating woman's reproductive health. Firstly, based on the time period of onset, nanomedicine applications are categorized into four subcategories: 1) preconception diseases such as polycystic ovary syndrome, endometriosis, and gynecologic malignancy treatment; 2) pregastrulation period diseases including placenta accreta spectrum disorders and ectopic pregnancy; 3) mid-term pregnancy diseases like preeclampsia; and 4) late pregnancy diseases such as deep vein thrombosis during pregnancy. The systematic introduction covers the progress made by nanomedicine in various disease areas. Finally, this article discusses the challenges faced by these nanomedicines from research to clinical translation while also highlighting future directions.

Diagnostic Accuracy of Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

Objective:

To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) in diagnosing placenta accreta spectrum (PAS).

Methods:

We conducted a comprehensive literature search from database inception to November 2023 using terms such as placenta creta, increta, percreta, PAS, MRI, and their respective Medical Subject Headings terms. All prospective and retrospective cohort, case-control, and cross-sectional studies involving prenatal magnetic resonance imaging diagnosis of PAS with subsequent pathological confirmation were included.

Results:

A total of 40 studies encompassing 3664 women met the inclusion criteria, with 1894 cases confirmed pathologically as PAS. The overall sensitivity of MRI was 0.867 (95% confidence interval (CI): 0.807–0.910), and the specificity was 0.860 (95% CI: 0.799–0.905), with a correlation of 0.693 between sensitivity and specificity. The estimated odds ratio was 28.693 (95% CI: 14.463–56.924), the negative likelihood ratio was 0.178 (95% CI: 0.122–0.258), and the positive likelihood ratio was 4.316 (95% CI: 3.186–5.846). Analysis of individual MRI criteria revealed estimates of sensitivity, specificity, odds ratio, negative likelihood ratio, and positive likelihood ratio for abnormal placental bed vascularization as 0.500, 0.740, 2.788, 0.571, and 1.645 respectively; 0.384, 0.985, 6.270, 0.471, and 2.720 for bladder wall interruption; 0.766, 0.818, 13.638, 0.262, and 3.375 for the presence of dark intraplacental bands; 0.691, 0.913, 10.828, 0.352, and 3.361 for heterogeneous placenta; 0.688, 0.984, 34.886, 0.254, and 7.164 for indistinctive myometrium; 0.757, 0.864, 8.496, 0.362, and 2.778 for loss of retroplacental dark zone; 0.828, 0.593, 5.829, 0.329, and 1.766 for myometrial thinning; and 0.518, 0.916, 9.473, 0.411, and 3.526 for placental bulge, respectively.

Conclusion:

MRI demonstrates significant utility in diagnosing PAS and its severity. It is recommended for use in all cases with inconclusive ultrasonographic findings.

Registration:

Registration number CRD42021267501.

Feasibility, safety, and clinical outcomes of modified laparoscopic cervicoisthmic cerclage for refractory cervical insufficiency: A single-arm clinical trial-Part 1

AIM

To assess the feasibility, safety, and outcomes of modified laparoscopic transabdominal cerclage in patients with refractory cervical insufficiency.

METHODS

This single-arm clinical trial examined women with refractory cervical insufficiency who underwent modified laparoscopic transabdominal cerclage at a specialized center in Japan between December 2017 and May 2022. Various parameters related to patient demographics, surgical techniques, outcomes, and complications were evaluated.

RESULTS

The study enrolled 30 women with a median age of 36 years. The modified laparoscopic transabdominal cerclage was technically successful in all cases. The delivery rate and fetal survival rate at 28 days in the third trimester were both 93%. Surgical complication involving small bowel injury occurred in one case and was promptly repaired. No fetal complications or pregnancy losses occurred within 28 days of the procedure. Perinatal outcomes included a cesarean section rate of 93%, a neonatal intensive care unit admission rate of 30%, and an overall fetal survival rate of 93%. Additionally, no absence or reversal of end-diastolic flow in the uterine artery was identified at the time of cerclage in any of the cases.

CONCLUSIONS

This study demonstrated the feasibility and safety of modified laparoscopic transabdominal cerclage for refractory cervical insufficiency. The procedure achieved a high delivery rate in the third trimester and a good overall fetal survival rate. The study findings highlight the importance of anatomical precision during thread placement in modified laparoscopic transabdominal cerclage. This technique is promising for treating refractory cervical insufficiency and potentially preventing second-trimester losses and extreme preterm births.

Effect of Treatment with Progestins and Antiplatelet Agents on IVF in Women with Adenomyosis and Recurrent Implantation Failure

Background: This prospective study aims to identify the effect of the dienogest 2 mg/day and aspirin 150 mg/day combined treatment for two months before frozen ET on the assisted reproduction outcome in women with adenomyosis and recurrent implantation failure (RIF). Methods: Patients were selected based on specific criteria and divided into two groups (with and without treatment). Preimplantation biochemical parameters and ultrasonographic features (endometrial thickness, uterine peristalsis, and junctional zone thickness) were compared with pregnancy rate in a non-natural cycle frozen embryo transfer technique. A comparison between the two study groups indicated an increased successful implantation rate and clinical pregnancy rate (25% vs. 7.4%). Results: These results were attributed to the reduced uterine peristalsis and the reduction in thickness of the junctional zone following treatment. Available data were limited due to the nature of the study though maximal effort was exerted for the selected patients between groups to be as demographically similar and free from other potential pathology that may affect the results. Conclusions: In conclusion, it appears that the above stated treatment improves outcomes in women with adenomyosis and RIF; the parameters used may provide an insight as to the reasons why this occurs, though an explanation of the molecular mechanisms is still elusive.

Comparison of Surgical Interventions for Endometrioma: A Systematic Review of Their Efficacy in Addressing Infertility

Background: Endometriosis is characterized by the presence of endometrial tissue outside the uterus. Beyond medical treatment, surgical intervention is also a viable consideration. However, current guidelines do not clearly indicate whether laparoscopic cystectomy, ablative methods (CO2 laser vaporization, plasma energy), or sclerotherapy is the preferred option. Methods: We conducted searches in two databases (PubMed and Europe PMC) to retrieve articles containing the keywords 'surgical intervention for Endometrioma, ovarian reserve, pregnancy rates, fertility', published between 1 January 2000 and 31 December 2023. We included articles presenting information on surgical intervention for endometrioma and its correlation with infertility parameters. Articles describing conservative treatment were excluded. Data were extracted by two authors using predefined criteria. Results: The initial database search produced 1376 articles, which were narrowed down to 41 relevant articles meeting the eligibility criteria. Conclusions: Laparoscopic cystectomy appears to impact postoperative anti-mullerian hormone levels, showing a stronger correlation with larger cysts and individual factors. CO2 laser vaporization demonstrates favorable results compared to traditional cystectomy. Combining GnRH agonist treatment with assisted reproduction treatment after cystectomy could be considered an alternative method. Plasma energy causes less damage to ovarian function, with pregnancy outcomes comparable to cystectomy. Sclerotherapy shows promising results for ovarian reserve preservation, recurrence rates, and safety. Further studies comparing these techniques are necessary to provide guidance to clinicians.

Do nutritional interventions before or during pregnancy affect placental phenotype? Findings from a systematic review of human clinical trials

Background

Maternal nutritional interventions aim to address nutrient deficiencies in pregnancy, a leading cause of maternal and neonatal morbidity and mortality worldwide. How these interventions influence the placenta, which plays a vital role in fetal growth and nutrient supply, is not well understood. This leaves a major gap in understanding how such interventions could influence pregnancy outcomes and fetal health. We hypothesised that nutritional interventions influence placental phenotype, and that these placental changes relate to how successful an intervention is in improving pregnancy outcomes.

Methods

We searched PubMed, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform using pre-defined search terms for records published from January 2001 to September 2021 that reported on clinical trials in humans, which administered a maternal nutritional intervention during the periconceptional or pregnancy period and reported on placental phenotype (shape and form, function or placental disorders). These records were then screened by two reviewers for eligibility.

Results

Fifty-three eligible articles reported on (multiple) micronutrient- (n = 33 studies), lipid- (n = 11), protein- (n = 2), and diet-/lifestyle-based (n = 8) interventions. Of the micronutrient-based interventions, 16 (48%) were associated with altered placental function, namely altered nutrient transport/metabolism (n = 9). Nine (82%) of the lipid-based interventions were associated with altered placental phenotype, including elevated placental fatty acid levels (n = 5), altered nutrient transport/metabolism gene expression (n = 4), and decreased inflammatory biomarkers (n = 2). Of the protein-based interventions, two (66%) were associated with altered placental phenotype, including increased placental efficiency (n = 1) and decreased preeclampsia risk (n = 1). Three (38%) of diet and lifestyle-based interventions were associated with placental changes, namely placental gene expression (n = 1) and disease (n = 2). In studies with data on maternal (n = 30) or offspring (n = 20) outcomes, interventions that influenced placental phenotype were more likely to have also been associated with improved maternal outcomes (n/N = 11/15, 73%) and offspring birth outcomes (n/N = 6/11, 54%) compared to interventions that did not associate with placental changes (n/N = 2/15 (13%) and n/N = 1/9 (11%) respectively).

Conclusions

Periconceptional and prenatal nutritional interventions to improve maternal/pregnancy health associate with altered placental development and function. These placental adaptations likely benefit the pregnancy and improve offspring outcomes. Understanding the placenta's role in the success of interventions to combat nutrient deficiencies is critical for improving interventions and reducing maternal and neonatal morbidity and mortality globally.

Biochemical Mechanisms and Rehabilitation Strategies in Osteoporosis-Related Pain: A Systematic Review

BACKGROUND/OBJECTIVES

Osteoporosis causes a bone mass reduction and often determines acute and chronic pain. Understanding the biochemical and neurophysiological mechanisms behind this pain is crucial for developing new, effective rehabilitative and therapeutic approaches. This systematic review synthesizes recent advances in muscle-bone interactions and molecular pathways related to osteoporosis-associated pain.

METHODS

We carried out a systematic review including studies published from 2018 to 2024 using PubMed, Scopus, clinicaltrials.gov and Cochrane Library. The Cochrane Collaboration tool was used to assess bias risk. The review adhered to PRISMA guidelines and is registered with PROSPERO (CRD42024574456); Results: Thirteen studies were included. It emerged that osteoporosis causes progressive bone loss due to disruptions in biochemical processes and muscle-bone interactions. This condition is also closely associated with the development of pain, both acute and chronic. Key findings include the role of the miR-92a-3p/PTEN/AKT pathway and the impact of muscle-bone disconnection on bone health. Mechanotransduction is critical for bone maintenance. Effective pain management and rehabilitation strategies include physical therapy and physical exercise, yoga, Pilates, and cognitive behavioral therapy (CBT); they all improve pain relief and functional outcomes by enhancing muscle strength, flexibility, and balance. Pharmacological options such as NSAIDs, opioids, and new agents like SHR-1222, along with surgical interventions like percutaneous vertebroplasty, offer additional pain reduction, especially when included in individualized rehabilitation projects; Conclusions: This review highlights advancements in understanding osteoporotic pain mechanisms and identifies promising treatments. Integrating targeted therapies and rehabilitation strategies can enhance patients' pain relief.

Advancement in predictive biomarkers for gestational diabetes mellitus diagnosis and related outcomes: a scoping review

OBJECTIVE

Gestational diabetes mellitus (GDM) is a metabolic disorder associated with adverse maternal and neonatal outcomes. While GDM is diagnosed by oral glucose tolerance testing between 24-28 weeks, earlier prediction of risk of developing GDM via circulating biomarkers has the potential to risk-stratify women and implement targeted risk reduction before adverse obstetric outcomes. This scoping review aims to collate biomarkers associated with GDM development, associated perinatal outcome and medication requirement in GDM.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews was used to guide the study.

DATA SOURCES

This review searched for articles on PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature and the Web of Science from January 2013 to February 2023.

ELIGIBILITY CRITERIA

The eligibility criteria included analytical observational studies published in English, focusing on pregnant women with maternal plasma or serum biomarkers collected between 6 and 24 weeks of gestation. Studies were excluded if they evaluated drug effects, non-GDM diabetes types or involved twin pregnancies, microbiota, genetic analyses or non-English publications.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data. One reviewer extracted data from papers included in the scoping review using Covidence. From the 8837 retrieved records, 137 studies were included.

RESULTS

A total of 278 biomarkers with significant changes in individuals with GDM compared with controls were identified. The univariate predictive biomarkers exhibited insufficient clinical sensitivity and specificity for predicting GDM, perinatal outcomes, and the necessity of medication. Multivariable models combining maternal risk factors with biomarkers provided more accurate detection but required validation for use in clinical settings.

CONCLUSION

This review recommends further research integrating novel omics technology for building accurate models for predicting GDM, perinatal outcome, and the necessity of medication while considering the optimal testing time.

Case report: A rare but fatal complication of hysteroscopy-air embolism during treatment for missed abortion

Hysteroscopic procedures complicated by air embolism (AE) are exceptionally rare occurrences in clinical practice, and there have been no previously reported cases of AE associated with hysteroscopic dilation and curettage. While the overall incidence of this complication is low, the consequences can be devastating. During early pregnancy, the unique physiological changes, such as elevated hormonal levels and increased uterine blood supply, significantly heighten the risk of AE development. Therefore, the prompt recognition of early signs and symptoms, coupled with the implementation of timely and effective interventions, are crucial to improve patient survival rates and minimize the risk of long-term sequelae. This case report presents the characteristic clinical manifestations and imaging findings associated with AE, providing a valuable clinical reference for obstetricians and gynecologists to recognize this rare yet potentially life-threatening complication of hysteroscopic procedures. Early detection and appropriate management are essential to optimize patient outcomes and prevent catastrophic consequences.

MicroRNAs as Biomarkers and Therapeutic Targets in Female Infertility

The study of microRNAs (miRNAs) has emerged in recent decades as a key approach to understanding the pathophysiology of many diseases, exploring their potential role as biomarkers, and testing their use as future treatments. Not only have neurological, cardiovascular diseases, or cancer benefited from this research but also infertility. Female infertility, as a disease, involves alterations at multiple levels, such as ovarian and uterine alterations. This review compiles the latest studies published in humans that link female disorders that affect fertility with altered miRNA profiles. Studies on ovarian alterations, including diminished ovarian reserve (DOR), poor ovarian response to stimulation (POR), premature ovarian insufficiency (POI), and polycystic ovary syndrome (PCOS), are summarized and classified based on the expression and type of sample analyzed. Regarding uterine disorders, this review highlights upregulated and downregulated miRNAs primarily identified as biomarkers for endometriosis, adenomyosis, decreased endometrial receptivity, and implantation failure. However, despite the large number of studies in this field, the same limitations that reduce reproducibility are often observed. Therefore, at the end of this review, the main limitations of this type of study are described, as well as specific precautions or safety measures that should be considered when handling miRNAs.

The value of misoprostol administration before intrauterine contraceptive device insertion: a systematic review and meta-analysis

Objectives

To assess the value of misoprostol administration before IUD insertion.

Search strategy

Screening of PubMed, Scopus, Web Of Science, ScienceDirect, and clinical trials registry till April 2024 using the keywords misoprostol, prostaglandin E1 analogue, IUD, IUCD, intrauterine device, IUD insertion, and their MeSH terms.

Selection criteria

All RCTs that included misoprostol administration before IUD insertion. All doses, routes, and times of administration of misoprostol compared to placebo, analgesics, or other prostaglandins were included. This review included 19 RCTs including 2743 women (1333 had misoprostol administration and 1410 comparators (1281 received placebo, 16 received diclofenac, 43 received dinoglandin, and 70 received lignocaine).

Data collection and analysis

The extracted data included location setting, number of participants randomized and analyzed, participants selection criteria, the exact intervention details (including misoprostol dose, route and timing of administration, the comparator group details, and type of IUD inserted), primary and secondary outcomes of the trial ( including pain score, easiness of insertion score, the need for analgesics, the need for additional measures as cervical dilatation, failure of insertion, complications of the insertions process, and drug side effects), risk of bias of the included studies, and trial registration number and site.

Main results

Failure of IUD insertion was evaluated in 9 studies with 1350 participants and revealed an odd ratio (OR) of 0.87 with 0.39–1.98 95% CI, P value = 0.75, and I2 score = 45%.

The easiness score of insertion was evaluated in 7 studies with 780 participants and revealed an OR of − 1.12 with − 1.73 to 0.52 95% CI, P value < 0.001, and I2 score = 87%.

The pain VAS was evaluated in 13 studies with 1776 participants and revealed a mean difference (MD) of − 0.23 with − 0.77 to 0.31 95% CI, P value = 0.41, and I2 score = 90%.

The participants satisfaction score was evaluated in 3 studies with 366 participants and revealed a MD of 1.64 with 0.68–2.60 95% CI, P value < 0.001, and I2 score = 91%.

The need for analgesics and additional measures as cervical dilatation were evaluated in 7 and 4 studies with 813 and 295 participants respectively. The reported OR (95% CI), P values, and I2 scores were 0.58 (0.32–1.03) and 0.79 (0.33–1.92), 0.06 and 0.61, and 48% and 35% respectively.

Conclusion

Misoprostol administration before IUD insertion was associated with higher easiness score, higher women satisfaction score, and higher side effects named nausea, vomiting, cramps, shivering, headache, and fever compared to placebo administration.

Registration number

CRD42022364291.

Impact of haemostasis methods during ovarian cystectomy on ovarian reserve: a pairwise and network meta-analysis

BACKGROUND

Haemostasis during ovarian cystectomy is reported to damage the ovarian reserve, but the comparative impacts of three haemostasis methods (bipolar energy, suture and haemostatic sealant) on ovarian reserve in patients with ovarian cysts are not well known.

METHODS

The Cochrane Library, PubMed and Web of Science databases were searched from the date of inception of the database to June 2022 for literature exploring the impact of haemostasis methods during ovarian cystectomy on ovarian reserve. A traditional meta-analysis was performed using Review Manager software. A network meta-analysis (NMA) was performed using Stata and GemTC software.

RESULTS

The direct meta-analysis comparison indicated that the mean postoperative reduction of anti-Müllerian hormone (AMH) level was significantly higher in the electrocoagulation (bipolar) group than suture and haemostatic sealant group, both in the overall group and subgroup of women with ovarian endometrioma. In NMA, the reduction of postoperative AMH levels in the electrocoagulation (bipolar) group was higher than the suture group at 6 months with a statistical significance, and at 1, 3 and 12 months without a significant difference. The difference in the postoperative decrease of AMH level did not reach statistical significance between suture and sealant, coagulation and haemostatic sealant. The comprehensive ranking results revealed that suture treatment was, with the highest probability, beneficial to the protection of the ovarian reserve.

CONCLUSIONS

There was insufficient research to detect the optimal haemostasis method for ovarian reserve preservation in ovarian cystectomy. Nevertheless, haemostasis by electrocoagulation (bipolar) should be avoided when possible, and the suture might be considered as the best choice.

Recurrence after surgery for endometrioma: a systematic review and meta-analyses

IMPORTANCE

Endometriosis is an inflammatory disease, with different forms of expression and a variety of complaints. An endometrioma, an ovarian cyst with endometrium-like lining, is one of the most common expressions of abdominal endometriosis. These endometriomas can, in addition to medical treatment, be treated surgically. After surgery, hormonal therapy is still frequently used for the treatment of endometriosis in general and prevention of recurrence of endometriomas specifically. However, not all women want or can receive postoperative hormonal treatment. It is important for this group to determine the risk of anatomical recurrence of ovarian endometrioma after surgery for an endometrioma.

OBJECTIVE

To determine the recurrence rate for surgically treated endometrioma without postoperative hormonal treatment.

DATA SOURCES

We performed a systematic literature review and meta-analyses, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. MEDLINE, Embase, and the Cochrane library were searched until May 2023. The literature search was limited to women with endometrioma who received surgical treatment without postoperative hormonal treatment.

STUDY SELECTION AND SYNTHESIS

A distinction was made in study design including randomized controlled trials (RCTs) and cohort and retrospective studies. For assessment of risk of bias, the Cochrane Handbook for Systematic Reviews of Interventions and Risk of Bias in Non-randomized Studies - of Interventions assessment tool were used.

MAIN OUTCOMES

The outcome measure included in this review was endometrioma recurrence.

RESULTS

We screened 5,367 articles, of which 97 were systematically reviewed and 55 were included in this systematic review. Twelve of these were RCTs, 11 were prospective cohort studies, and 32 were retrospective studies. Nine RCTs had a low risk of bias. For non-RCTs, only 3 studies had a low risk of bias. Data of 23 studies were pooled in meta-analyses, performed for follow-up periods of 3, 6, 12, and 24 months. These studies showed recurrence rates of 4%, 14%, 17%, and 27%, respectively.

CONCLUSION AND RELEVANCE

In the meta-analysis, at 24 months after surgery, the endometrioma recurrence rate showed a weighted mean of up to 27%. In this study, we aimed to determine the recurrence rate of endometrioma after surgical treatment in women without postoperative hormonal treatment use. The recurrence rates were up to 27%.

REGISTRATION NUMBER

CRD42020216541.

Variation among venous thromboembolism risk assessment tools for postcesarean patients: a retrospective cohort study

Venous thromboembolism (VTE) risk in pregnant women is four to five-fold higher than in nonpregnant women, and the risk of VTE is an additional four-fold higher after Cesarean section compared to normal vaginal delivery. Recommendations regarding anticoagulant prophylaxis are inconsistent across international guidelines, and VTE remains one of the leading causes of maternal morbidity and mortality. This study aimed to compare the need for postcesarean anticoagulation for VTE prophylaxis based on three major guidelines and our own institutional protocol. It was a retrospective cohort study that reviewed the medical records of patients who underwent a cesarean section at a tertiary-level care hospital in the United Arab Emirates (UAE). The need for anticoagulation was assessed using clinical tools from the American College of Obstetricians and Gynecologists (ACOG), Royal College Obstetricians and Gynecologists (RCOG), American College of Chest Physicians (ACCP), and the study site hospital protocol. A total of 1134 postcesarean women, aged 18-55 years, were included in the study. Most patients (87%) were at moderate risk for VTE. According to the study site hospital tool, 90.7% qualified for anticoagulant prophylaxis, while the ACOG, RCOG, and ACCP tools indicated that 0.5, 90.9, and 36.7% qualified, respectively. Enoxaparin was the primary anticoagulant used in 95% of cases. Only one patient developed VTE during the follow-up period. Anticoagulation needs assessment tools vary extensively in their estimations, highlighting the need for a uniform tool across multiple societies to establish a consistent standard of care and guide the development of evidence-based, site-specific protocols.

Dual trigger versus human chorionic gonadotropin trigger for blastocyst quality and cumulative live birth

PURPOSE

To evaluate the difference in the number of euploid blastocysts and cumulative live birth rate (LBR) between dual and human chorionic gonadotropin (hCG) triggers in poor and normal ovarian responders undergoing preimplantation genetic testing (PGT) cycles.

METHODS

This retrospective cohort study was enrolled from July 2018 to December 2021 and followed up until June 2024 at a single reproductive medical center. Overall, 1040 in vitro fertilization (IVF)-PGT and 784 frozen-thawed embryo transfer (FET) cycles were assessed. Dual (triptorelin acetate 0.2 mg and recombinant hCG [rhCG] 250 µg) or hCG (rhCG 250 µg) trigger was used for oocyte maturation in the gonadotropin-releasing hormone antagonist protocol and PGT cycles. We assessed the embryo outcomes and FET cumulative pregnancy outcomes.

RESULTS

The number of oocytes retrieved (10.17 ± 5.22 vs 10.27 ± 5.14, P = 0.789), MII oocytes (8.24 ± 4.26 vs 8.28 ± 4.05, P = 0.888), blastocysts (2.16 ± 1.50 vs 2.12 ± 1.49, P = 0.729), euploid blastocysts (1.06 ± 1.14 vs 1.09 ± 1.23, P = 0.726), and the rate of cumulative LBR (24.9% vs 24.9%, P = 1.000) in the dual trigger group were comparable with those in the hCG group. The trigger method was not correlated with higher LBR based on logistic regression analysis (odds ratio[OR] = 1.040 [0.778-1.392], P = 0.790).

CONCLUSION

For poor and normal ovarian responders, the dual trigger, compared with the hCG trigger, did not improve the PGT embryo outcomes and FET cumulative pregnancy outcomes.

The Effect of Oxidative Stress and Antioxidants Treatment on Gestational Diabetes Mellitus Outcome: A Scoping Review

Diagnosing a pregnant woman's glucose intolerance is referred to as gestational diabetes mellitus (GDM). Diabetes has been linked to enhanced oxidative stress. In this condition, oxidative stress may damage nucleic acids, fats, and proteins, which in turn affects cell and tissue functions. The present study highlights the relationship between oxidative stress and GDM, with a particular focus on the role of hyperglycemia-induced processes during reactive oxygen species (ROS) oversupply, followed by it discusses the oxidative stress biomarkers and assesses the effects of antioxidant supplements on glycemic control, inflammatory processes, and oxidative stress among individuals with GDM. Two reviewers conducted a comprehensive literature search utilizing the PubMed®, Web of Science™, and Scopus® databases. Only items published in the English language up until June 2024 were taken into account. We conducted a thorough search of research databases to identify articles that had the terms "oxidative stress" or "antioxidant" and "GDM". From this search, we selected 55 relevant papers to be included in this narrative review. Pregnancy-induced hypertension, postpartum bleeding, lower birth weight, a higher risk of hyperbilirubinemia in their neonates, fetal growth retardation, and birth asphyxia were revealed to be outcomes of women enduring major oxidative stress during pregnancy. Furthermore, tight glycemic control both before and throughout pregnancy as well as oxidative stress treatment may help women highly prone to GDM.

Efficacy and safety of oral and vaginal administration of misoprostol for induction of labor in high-risk obese pregnant women with hypertension or diabetes mellitus

OBJECTIVE

This study aims to compare the safety and efficacy of misoprostol administered orally and vaginally in obese pregnant women at term with either gestational hypertension or diabetes.

METHODS

A total of 264 pregnant women were enrolled and categorized into two groups based on their primary condition: hypertension (134 cases) or diabetes mellitus (130 cases) and were further divided into subgroups for misoprostol administration: orally (Oral group) or vaginally (Vaginal group). The primary outcomes measured were changes in the Bishop score following treatment, induction of labor (IOL) success rates, requirement for oxytocin augmentation, duration of labor, mode of delivery, and cesarean section rates.

RESULTS

Significant enhancements in Bishop scores, decreased cesarean section rates and increased success rates of IOL were noted in both administration groups. The incidence of vaginal delivery within 24 h was significantly higher in the Vaginal group compared to the Oral group. Adverse effects, including nausea, uterine overcontraction, hyperfrequency of uterine contraction and uterine hyperstimulation without fetal heart rate deceleration, were significantly more prevalent in the Vaginal group than in the Oral group.

CONCLUSION

Misoprostol administration, both orally and vaginally, proves effective for labor induction in obese pregnant women with hypertension or diabetes. However, the oral route presents a lower risk of adverse maternal and neonatal outcomes, suggesting its preference for safer labor induction in this demographic.

Transcriptomic analysis identified novel biomarker in invasive placenta accreta spectrum

INTRODUCTION

Placenta accreta spectrum (PAS) disorders pose a grave threat to maternal life due to severe hemorrhage and the heightened risk of peripartum hysterectomy. Consequently, there's a pressing need for circulating biomarkers in clinical settings. MicroRNAs (miRNAs), being stable in peripheral circulation, hold promise as potential biomarkers for PAS.

METHODS

This study recruited singleton live pregnancies, including cases of invasive PAS, placenta previa (PP), and controls, across three phases. Initially, RNA-seq of peripheral blood identified 6 miRNAs in the screening phase. Subsequently, in the training and validation phases, miR-23a-5p, along with its target genes ASF1B and CHTF8, were validated using qRT-PCR. The diagnostic value of these markers for PAS and adverse outcomes was evaluated using Receiver Operating Characteristic (ROC) curves.

RESULTS

The results showed miR-23a-5p was down-regulated in PAS, whereas ASF1B and CHTF8 were up-regulated. miR-23a-5p had modest diagnostic efficiency for PAS and adverse outcomes, as the AUC were 0.689 and 0.711 respectively. However, when miR-23a-5p combined with CHTF8, the AUC can improve greatly to 0.869 in PAS diagnosis and 0.856 in prediction of adverse outcomes.

DISCUSSION

We propose the miR-23a-5p plays a role in PAS pathogenesis through regulating cell proliferation, migration, invasion, apoptosis by targeting various genes. This study confirmed its potential value of miR-23a-5p combined with target gene CHTF8 as novel biomarkers for PAS and adverse outcomes.

Magnitude and risk factors of khat, alcohol and cigarettes use among pregnant women in Africa: a systematic review and meta-analysis

BACKGROUND

The use of khat, alcohol, and cigarettes during pregnancy is a serious public health problem associated with harmful outcomes for the fetus and the mother's health. Studies that investigated khat, alcohol, and cigarettes usage during pregnancy yielded varied and contradictory results. This study used a systematic review and meta-analysis to estimate the pooled prevalence and associated factors of khat, alcohol, and cigarettes use among pregnant women in Africa.

METHODS

A review of eligible studies was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. This review has been registered in PROSPERO with protocol ID CRD42021289074. Literature published in English from January 1, 2002 to November 30, 2021 was retrieved from PubMed, Google Scholar, Cochrane, HINARI, African Journal Online, and Science Direct databases. The quality of included articles was assessed using the Joanna Briggs Institute's (JBI) critical appraisal checklist. The I2 statistic and Cochran's Q test were used to assess the presence of heterogeneity between studies. To assess publication bias, a funnel plot and Egger's regression test were utilized. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of risk factors for khat, alcohol, and cigarettes use.

RESULTS

Out of the 1509 studies identified, 71 met the inclusion criteria. The pooled prevalence of khat chewing, alcohol drinking, active smoking, and secondhand smoke exposure during pregnancy was 18.93%, 22.20%, 11.85%, and 43.45%, respectively. The subgroup analysis by UN sub-region showed the highest pooled prevalence of alcohol use during pregnancy in Middle Africa (25.69%) and the lowest in Northern Africa (1.10%). Several factors were identified as risk factors for alcohol use, including low educational level, younger age women, pre-pregnancy alcohol use, unplanned pregnancy, history of abortion, poor social support, mental distress, poor knowledge on alcohol risks, and partner alcohol use.

CONCLUSION

This review indicated that the pooled magnitude of khat, alcohol and cigarette use during pregnancy was higher in Africa. Substance use screening and brief interventions (SBI) should be routinely delivered in antenatal care settings to reduce pregnant women's substance use.

The use of misoprostol before hysteroscopy in Nulliparous women: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To assess the value of misoprostol intake before hysteroscopy in nulliparous women.

SEARCH STRATEGY

Databases screening was done from inception to July 2023 using "Misoprostol" AND "Hysteroscopy" AND "Nullipara" and their MeSH terms as keywords.

SELECTION CRITERIA

Thirteen studies were included in our analysis. Seven studies compared misoprostol to placebo, 3 studies compared it to dinoglandin, 1 study compared it to diclofenac and 4 studies compared different misoprostol doses and routes. These studies were conducted on 1528 participants,958 of them received misoprostol, 221 received dinoglandin, 51 received diclofenac and 308 received placebo.

DATA COLLECTION AND ANALYSIS

Extracted data included study place, participants number, inclusion and exclusion criteria, intervention details as dose, route, timing and comparotor, and hysteroscopy details.

MAIN RESULTS

Ease of cervical dilatation was reported in 3 studies (309 participants) and revealed an effect estimate mean difference (MD) of -0.57 [-1.72, 0.58] and a P value of 0.33. The time needed for cervical dilatation was reported in 6 studies (512 participants) and revealed a MD of -22.96 [-43.29, -2.62] and a P value of 0.03. The preoperative cervical width was reported in 4 studies (263 participants) and revealed MD of 1.69 [-0.09, 3.46] and a P value of 0.06. The number of women with failure of cervical dilatation or who needed further dilatation was reported in 4 studies (372 participants) and revealed a MD of 0.40 with [0.13, 1.17] 95% CI and a P value of 0.09. The preoperative pain was reported in 3 studies (351 participants) and revealed a MD of -0.56 [-2.30, 1.18] and a P value of 0.53. Total number of cases who experienced side effects and procedure complications were reported in 2 and 3 studies (249 and 252 participants) respectively and revealed an effect estimate Odd Ratio of 1.99 and 0.42 with [0.27, 14.67] and [0.14,1.32] 95% CI and a P value of 0.50 and 0.14 respectively. In the 3 studies comparing misoprostol to dinoglandin, The ease of cervical dilatation, time needed for cervical dilatation and preoperative cervical width were evaluated in 1,3 and 2 studies with 60, 436 and 376 participants respectively. The estimated MD were not estimated, 0.17 and 0.01; 95% CI were not estimated, [-4.70, 5.05], and [-0.78, 0.79]; P values of 0.94, 0.98 and 0.99 and I2 of 96%,95% and 74% respectively.

CONCLUSION

Misoprostol improved the time needed for cervical dilatation without affecting the rate of complications or drug side effects when compared to placebo but has similar outcomes to dinoglandin with higher side effects.

REGISTRATION NUMBER

CRD42023438432.

Endometrial scratching and intralipid treatment-no general recommendations

Objectives

Endometrial scratching (ES) and/or intravenous intralipid therapy (in cases of increased uterine natural killer cells, uNKs) are still conducted in several fertility centers as "add-on" treatments in patients undergoing ART, although convincing evidence for beneficial effects is lacking.

Study design

In this retrospective study, associations between ES treatment or additional intralipid therapy and pregnancy and live birth rates of 1,546 patients undergoing 2,821 IVF-/ICSI-treatment cycles with fresh or frozen embryo transfers in a German fertility-center between 1st January 2014 and 31th May 2017 were analyzed.

Results

Overall pregnancy and live birth rates for all 2,821 treatment cycles (468 cycles with ES) were 32.8% and 23.5%. There were no statistically significant differences in pregnancy or live birth rates between first treatment cycles with and without ES (p = 0.915 and p = 0.577) or between second cycles following an unsuccessful first cycle with and without ES (p = 0.752 and p = 0.623). These results were confirmed using multivariable generalized estimating equations (GEE) models accounting for non-independency of multiple treatment cycles per patients that included all cycles and showed no significant effect of ES on pregnancy (p = 0.449) or live birth rates (p = 0.976). Likewise, a GEE model revealed no significant effect of intralipid treatment on pregnancy (p = 0.926) and live birth rates (p = 0.727).

Conclusions

Our results reveal no evidence that ES increases the pregnancy or live birth rates in women undergoing their first or further IVF cycle with fresh or frozen embryo transfer. Intralipid treatment was also not beneficial. Even if patients explicitly ask for it, these procedures are not recommended outside of clinical studies.

Excisional surgery versus ablative surgery for ovarian endometrioma

BACKGROUND

Endometrioma are endometriotic deposits within the ovary. Laparoscopic management of endometriomas is associated with shorter hospital stay, faster recovery, and decreased hospital costs compared with laparotomy. The previous version of this systematic review (2008), including randomised controlled trials (RCTs) of surgical interventions for endometrioma, concluded that laparoscopic cystectomy (excision) was preferable to drainage and ablation of endometrioma. We aimed to update the evidence comparing excision with drainage and ablation for improving pain and fertility-related outcomes.

OBJECTIVES

To evaluate the safety and efficacy of laparoscopic excision (cystectomy) compared with laparoscopic drainage and ablation of endometrioma in women of reproductive age.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycInfo, two trials registries, grey literature sources, and conference proceedings on 19 December 2022. We also checked the reference lists of relevant papers and contacted leaders in the field of endoscopic surgery for any additional trials.

SELECTION CRITERIA

Eligible studies were RCTs that compared excision with drainage and ablation of endometriomas.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and applied the GRADE approach to rate the certainty of evidence.

MAIN RESULTS

We identified nine studies (involving 578 women) that investigated laparoscopic excision versus drainage and ablation of endometriomas measuring at least 3 cm in diameter. Participants were women of reproductive age who presented to an outpatient gynaecology clinic with pain, infertility, or both. For most outcomes, we downgraded the certainty of evidence for risk of bias due to lack of blinding and for imprecision due to low participant numbers. At up to two years after surgery, excisional surgery compared with ablative surgery may reduce the risk of dysmenorrhoea recurrence (OR 0.25, 95% CI 0.12 to 0.52; 2 studies, 140 women; low-certainty evidence;). Recurrence of dysmenorrhoea may occur in 49% of women after ablative surgery compared with 10% to 34% after excisional surgery. At up to two years after surgery, excisional surgery compared with ablative surgery may reduce the risk of dyspareunia recurrence (OR 0.09, 95% CI 0.03 to 0.22; 2 studies, 131 women; low-certainty evidence). Recurrence of dyspareunia may occur in 58% of women after ablative surgery compared with 4% to 23% after excisional surgery. At one year after surgery, excisional surgery may reduce the risk of endometrioma recurrence compared with ablative surgery (OR 0.17, 95% CI 0.09 to 0.34; 4 studies, 264 women; low-certainty evidence). Recurrence of endometrioma may occur in 37% of women after ablative surgery compared with 5% to 17% after excisional surgery. At one year after surgery, excisional surgery may reduce the need for further endometrioma surgery compared with ablative surgery (OR 0.16, 95% CI 0.07 to 0.41; 2 studies, 178 women; low-certainty evidence). Our results suggest that 32% of women require further endometrioma surgery after ablative surgery compared with 3% to 16% after excisional surgery. There may be little or no difference between excisional surgery and ablative surgery in terms of their effect on spontaneous pregnancy during the first year after surgery (OR 1.27, 95% CI 0.33 to 4.87; 3 studies, 101 women; low-certainty evidence). Five studies reported that there were no conversions to laparotomy. No studies provided data about any other surgical complications or adverse effects.

AUTHORS' CONCLUSIONS

Surgical management of endometrioma with excision (cystectomy) may be more effective than drainage and ablation for reducing painful menstrual periods, pain during sexual intercourse, endometrioma recurrence, and the need for further endometrioma surgery. However, there may be little or no difference between the techniques in their effect on subsequent pregnancy rates. We found limited evidence on the safety of excisional surgery compared with ablative surgery. Future trials should recruit adequate numbers of women and measure outcomes relating to adverse events and clinical pregnancy.

Novel Minimally Invasive Surgical Approaches to Endometriosis and Adenomyosis: A Comprehensive Review

Endometriosis and adenomyosis are chronic gynecological conditions that significantly impact women's quality of life, leading to symptoms such as pelvic pain, dysmenorrhea, and infertility. Despite ongoing research, a definitive cure for these conditions remains elusive, and treatment often focuses on managing symptoms. Minimally invasive surgery is considered the gold standard for surgical management, but novel surgical techniques are continuously being developed to enhance outcomes. These innovations aim to reduce disease recurrence, improve fertility rates, and provide better long-term symptom relief. In addition, techniques like robot-assisted laparoscopy (RAS) have revolutionized the treatment of complex cases, such as deep infiltrating endometriosis (DIE), offering improved precision and effectiveness. This review explores the latest advancements in surgical approaches, their clinical efficacy, and future directions, emphasizing the need for individualized multidisciplinary care to optimize patient outcomes.

Tranexamic acid for preventing postpartum haemorrhage after caesarean section

RATIONALE

Postpartum haemorrhage (PPH) is common and potentially life-threatening. The antifibrinolytic drug tranexamic acid (TXA) is recommended for treating PPH; it reduces the risk of death from haemorrhage by one-third when given soon after bleeding onset, but not overall risk of death. Interest in whether TXA may be effective in preventing PPH is growing. Evidence indicates that TXA given more than three hours after injury to bleeding trauma patients increases mortality. Potential harm becomes critical in prophylactic use of TXA. Reliable evidence of the effect and safety profile of TXA is required before widespread prophylactic use can be considered.

OBJECTIVES

To assess the effects of TXA for preventing PPH compared to placebo or no treatment (with or without uterotonic co-treatment) in women during caesarean birth.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and WHO ICTRP to 20 February 2024 and searched reference lists of retrieved studies.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) evaluating the use of TXA alone or plus uterotonics during caesarean birth for preventing PPH. Trials needed to be prospectively registered (i.e. before starting recruitment). We applied a trustworthiness checklist.

OUTCOMES

The critical outcome was blood loss ≥ 1000 mL, measured using estimated or calculated methods. Important outcomes included maternal death, severe morbidity, blood transfusion, the use of additional surgical interventions to control PPH, thromboembolic events, use of additional uterotonics, hysterectomy, maternal satisfaction, and breastfeeding at discharge.

RISK OF BIAS

We assessed risk of bias in the included studies using Cochrane's RoB 1 tool.

SYNTHESIS METHODS

Two review authors independently selected trials, extracted data, and assessed risk of bias and trial trustworthiness. We pooled data using random-effects meta-analysis. We assessed the certainty of the evidence using GRADE.

INCLUDED STUDIES

We included six RCTs with 15,981 participants. All 12 trials in the previous version of this review were not included after review of trial registrations and trustworthiness checklists. Most included studies involved women at low risk of PPH and were conducted in high-resource settings.

SYNTHESIS OF RESULTS

Prophylactic TXA in addition to standard care compared to placebo in addition to standard care or standard care alone TXA results in little to no difference in estimated blood loss ≥ 1000 mL (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.79 to 1.11; 4 RCTs; n = 13,042; high certainty evidence), resulting in 8 fewer per 1000 women having estimated blood loss ≥ 1000 mL (from 30 fewer to 16 more). TXA likely results in a slight reduction in calculated blood loss ≥ 1000 mL (RR 0.83, 95% CI 0.76 to 0.92; 2 RCTs; n = 4327; moderate certainty evidence), resulting in 53 fewer per 1000 having calculated blood loss ≥ 1000 mL (from 75 fewer to 25 fewer). The evidence is very uncertain about the effect of TXA on maternal death (one event in placebo group, none in TXA group). No trials measured severe morbidity. TXA likely results in little to no difference in blood transfusion (RR 0.88, 95% CI 0.72 to 1.08; 5 RCTs; n = 15,740; moderate certainty evidence), resulting in 4 fewer per 1000 women requiring a blood transfusion (from 10 fewer to 3 more). TXA results in little to no difference in additional surgical interventions to control PPH (RR 1.02, 95% CI 0.86 to 1.22; 4 RCTs; n = 15,631; high certainty evidence), resulting in 1 more per 1000 women requiring additional surgical intervention (from 4 fewer to 7 more). The evidence is very uncertain about the effect of TXA on thromboembolic events (RR 1.40, 95% CI 0.22 to 8.90; 4 RCTs; n = 14,480; very low certainty evidence), resulting in 1 more per 1000 women having a thromboembolic event (from 2 fewer to 17 more). TXA results in little to no difference in the need for additional uterotonics (RR 0.88, 95% CI 0.78 to 1.00; 4 RCTs; n = 15,728; high certainty evidence), resulting in 15 fewer per 1000 women requiring additional uterotonics (from 27 fewer to 0 fewer). The evidence is very uncertain about the effect of TXA on hysterectomy (RR 0.80, 95% CI 0.20 to 3.29; 2 RCTs; n = 4546; very low certainty evidence), resulting in 3 fewer per 10,000 women requiring a hysterectomy (from 11 fewer to 31 more). One trial measuring maternal satisfaction reported no difference between groups at day two postpartum. No data were available on breastfeeding. Overall, studies had low risk of bias. We downgraded the certainty of evidence mainly for imprecision.

AUTHORS' CONCLUSIONS

Prophylactic TXA in addition to standard care during caesarean birth results in little to no difference in estimated blood loss ≥ 1000 mL and likely results in a slight reduction in calculated blood loss ≥ 1000 mL compared to placebo. There were no data for severe morbidity due to PPH. Event rates for further interventions to control PPH were low and similar across groups. Prophylactic TXA thus results in little to no difference between groups for additional surgical interventions (32 versus 31 per 1000), and likely results in little to no difference between groups for blood transfusions (31 versus 36 per 1000) and use of additional uterotonics (107 versus 121 per 1000). There were very few events for the outcomes maternal death (1 in placebo group), thromboembolic events (2 versus 3 per 1000), and hysterectomy (1 per 1000 in each group). Evidence for these serious adverse events is therefore very uncertain. Decisions about implementing routine prophylactic TXA during caesarean birth should not only consider outcomes related to blood loss, but also the relatively low rates of PPH morbidity and uncertainty of serious adverse events. Most studies included women at low risk of PPH, thereby precluding any conclusions about women at high risk of PPH. Cost associated with routine use of an additional drug for all caesarean births needs to be considered.

FUNDING

This Cochrane review was funded in part by the World Health Organization.

REGISTRATION

The published protocol and updates to the review can be accessed: Protocol (2009) DOI: 10.1002/14651858.CD007872 Original Review (2010) DOI: 10.1002/14651858.CD007872.pub2 Review Update (2015) DOI: 10.1002/14651858.CD007872.pub3.

Maternal Serum SCUBE-1: A Novel Ischemic Marker in Preeclampsia

BACKGROUND

SCUBE-1 (Signal peptide-CUB (complement C1r/C1s, Uegf, and Bmp1)-EGF (epidermal growth factor)-domain-containing protein 1) is a novel marker of ischemia, which is a cell surface-secreted protein in the platelets and endothelial cells. The aim of the study is to measure serum SCUBE-1 levels and investigate their association with uteroplacental blood flow in patients with preeclampsia.

METHODS

The study was conducted on patients with preeclampsia. Maternal serum SCUBE1 and IMA levels were the main outcomes. The control group consisted of gestational-age-matched pregnant women. Fetal umbilical artery (UA) pulsatility index (PI), middle cerebral artery PI, cerebroplacental ratio (CPR), and maternal uterine artery (UtA)-PI were also examined, and correlation analysis was performed to reveal the association between maternal serum SCUBE1 levels and Doppler findings.

RESULTS

The study group consisted of thirty-two preeclamptic patients, and the control group consisted of thirty-two uncomplicated singleton pregnancies. Maternal serum SCUBE1 and IMA levels were significantly higher in preeclamptic women compared to the control group (p < 0.000, p < 0.004, respectively). Mean UtA-PI values and fetal UA-PI values were significantly higher in preeclamptic pregnant women compared to the control group (p < 0.05, p < 0.05, respectively). However, the average CPR was significantly lower in pregnant women with preeclampsia (p < 0.05). While no significant correlation was found between maternal serum SCUBE1 levels and UA-PI and CPR (p > 0.05, p > 0.05, respectively), a significant correlation was found between right and left UtA-PI (p < 0.004, p < 0.006, respectively).

CONCLUSIONS

The maternal serum SCUBE1 level is increased in patients with preeclampsia, and this increase is significantly correlated with the maternal uterine artery pulsatility index.

Cord Occlusion in Twin Reversed Arterial Perfusion Sequence: A Retrospective Study of Laser Photocoagulation versus Radiofrequency Ablation

INTRODUCTION

Twin reversed arterial perfusion (TRAP) sequence is a rare condition complicating monozygotic multiple gestations. Prenatal management via umbilical cord occlusion (UCO) of the anomalous twin has been shown to improve pump twin survival. We compared outcomes of gestations with high-risk TRAP sequence treated with mid-trimester UCO using laser photocoagulation versus radiofrequency ablation (RFA).

METHODS

This is a retrospective, single-center, cohort study of all patients with high-risk TRAP sequence who underwent UCO from 2006-2023. High-risk criteria were defined as follows: larger abdominal circumference of the anomalous twin, polyhydramnios, critically abnormal Doppler waveforms in the pump twin, hydrops in the pump twin, and/or monoamniotic twins. The primary outcome was 30-day survival of the pump twin.

RESULTS

The 74 patients were divided equally between the laser and RFA groups. For the 2 groups, mean gestational age (GA) at UCO (20.5 ± 2.3 vs. 20.7 ± 3.1 weeks, p = 0.987) and mean GA at delivery (35.2 ± 4.6 vs. 34.5 ± 5.7 weeks, p = 0.812) were similar. The 30-day neonatal survival rate did not differ (91.9% [34/37] vs. 89.2% [33/37], OR: 1.37 [0.29-6.61], p = 0.692).

CONCLUSION

No difference in 30-day neonatal survival was identified in patients with high-risk TRAP sequence who underwent mid-trimester UCO by laser versus RFA.

Impact of BMI on fertility in an otherwise healthy population: a systematic review and meta-analysis

BACKGROUND

An increased body mass index (BMI) can lead to subfertility; however, current literature fails to exclude the effect of other confounding medical conditions, raising questions regarding the direct link between increased BMI and fertility outcomes.

OBJECTIVES

To conduct a systematic review and meta-analysis to elucidate the effects of increased BMI on fertility outcomes in females with no other comorbidities.

SEARCH STRATEGY

A comprehensive search was conducted using EMBASE, MEDLINE and the Cochrane library from January 2000 until July 2023.

DATA COLLECTION AND ANALYSIS

Two authors independently conducted data extraction and assessed study quality. Odds ratio (OR) (dichotomous data), standardised mean difference (SMD) (continuous data) and 95% CIs were calculated.

MAIN RESULTS

Nine eligible studies were identified: one natural conception and eight assisted reproductive technology (ART). Aggregated data revealed women with BMI ≥25 were less likely to attain clinical pregnancy (OR 0.76, 95% CIs 0.62 to 0.93, p=0.007), with BMI ≥30 associated with a further decreased likelihood of clinical pregnancy (OR 0.61, 95% CIs 0.39 to 0.98, p=0.04). Women with raised BMI required longer duration of stimulation (SMD=0.08, 95% CIs 0.00 to 0.16, p=0.04) and obtained reduced oocytes (SMD=-0.11, 95% CIs -0.18 to -0.04, p=0.002).

CONCLUSIONS

These data demonstrate an adverse impact of being overweight/obese on ART outcomes in women with no other diagnosed medical comorbidities and highlight the distinct lack of data concerning the effects of isolated obesity on natural conception. Infertility represents an enormous burden for couples and society; it is essential to identify and tackle modifiable risk factors to improve chances of conception.

PROSPERO REGISTRATION NUMBER

CRD42022293631.

Additional Role of Magnetic Resonance Imaging to Ultrasound in Assessing Placenta Accreta Spectrum Disorders: A Retrospective Cross-sectional Study from Vietnam

Objectives

Placenta accreta spectrum (PAS) is commonly associated with adverse pregnancy outcomes. While ultrasound (US) is the primary imaging tool, magnetic resonance imaging (MRI) plays a crucial complementary role in assessing PAS disorders. This study aimed to evaluate the MRI features in PAS diagnosis and enhance the role of MRI in conjunction with US for better management. Additionally, the study examined the association between imaging findings and clinical outcomes.

Methods

This retrospective cross-sectional study was conducted between January 2017 and June 2022 at Tu Du Hospital, Vietnam. A total of 87 cases were eligible for inclusion. Antenatal MRI and US findings were compared to intraoperative diagnoses and/or histopathological confirmation, which is considered the gold standard. The diagnostic value of each MRI feature was calculated, and the association between MRI/US findings, estimated blood loss, and surgical methods was analyzed. Statistical significance was determined with a p-value < 0.05.

Results

Among the 87 women suspected of PAS on US, 83 were confirmed to have PAS through intraoperative diagnosis and/or histology. The mean maternal age was 35.9 5.7 years and the mean gestational age at cesarean section was 31.1 7.1 weeks. MRI sensitivity (Se) in detecting PAS ranged from 10.8-94.0%, while the specificity (Sp) ranged from 25.0-100%. Loss of retroplacental T2 dark zone demonstrated the highest diagnostic value. When combining three to six MRI signs, Se increased from 53.0-100%, and Sp from 25.0-100%. The highest Youden?(tm)s index (0.759) was observed with five MRI signs (Se = 75.9%, Sp = 100%). PAS diagnosed via MRI/US was associated with more significant blood loss during cesarean section (1000 (600-2000) mL vs. 500 (250-850) mL and 1000 (600-2000) mL vs. 300 (300-500) mL, respectively). Furthermore, the percreta type of PAS identified on MRI/US was linked to significantly higher rates of cesarean hysterectomy compared to conservative surgery (56.4% vs. 43.6% and 63.5% vs. 36.5%, respectively).

Conclusions

MRI provides a reliable diagnostic value for PAS, particularly following uncertain US findings. Depending on resource availability, a stepwise approach utilizing both imaging modalities should be considered. MRI can guide strict interdisciplinary management in cases of suspected PAS, especially percreta type. Further studies are needed to solidify the role of MRI in severe PAS cases.

Persistence of Uterine Artery Doppler Velocimetry Changes in Postpartum Mothers Following a Delivery Complicated by Preeclampsia: A Systematic Review

In preeclampsia, there occurs a defective trophoblastic invasion of spiral arteries, which is characterized by abnormal uterine artery wave parameter such as increased pulsatility index (PI) and early diastolic notch. This increased uterine artery PI is a good predictor of hypertensive disorder and small for gestational-age babies. Maternal hypertension and proteinuria resolve in the puerperium. Arterial Doppler changes in normal pregnancy were extensively studied. Doppler changes in uterine artery in hypertensive postpartum women were less researched and unclear. This review aimed to compare the uterine artery Doppler changes in preeclamptic and normotensive women during the puerperium through an extensive search of the available literature. It was found that even with the lengthiest follow-up of six weeks postpartum, the increased uterine artery PI persisted and the magnitude was higher in hypertensive than normotensive postpartum women.

Comparative study between the roles of intrauterine misoprostol versus the sublingual route for prevention of postpartum blood loss in elective cesarean sections: a randomized controlled trial

BACKGROUND

The prostaglandin E1 analog "misoprostol" is a drug that has powerful ecbolic effects and can be beneficial in the prevention and treatment of postpartum hemorrhage, which is the leading cause of maternal mortality worldwide.

OBJECTIVES

To assess the value of adding intrauterine misoprostol together with intravenous oxytocin injection compared with sublingual misoprostol together with intravenous oxytocin injection during elective cesarean section to reduce blood loss intraoperatively and prevent postpartum hemorrhage.

METHODS

A total of 192 pregnant women were counseled and recruited from the labor and delivery unit at Kasr Al Aini Hospital, Cairo University, and equally randomized into two groups. Group (A) included 96 women who received intrauterine misoprostol (400 mg) + oxytocin. Group (B) included 96 women who received sublingual misoprostol (400 mg) + oxytocin. The primary outcome of our study was estimation of the amount of blood loss during and after cesarean delivery. The secondary outcomes were the incidence of PPH within the first 6 h after labor, the need for blood transfusion, the need for any supplementary ecbolic drugs, the need for additional surgical intervention for PPH, changes in hematocrit and hemoglobin in both groups after delivery, and the incidence of side effects of the study medications.

RESULTS

We observed a significant discrepancy between the two groups in terms of postoperative Hb and Hct, postoperative differences (pre- and post-Hb and post-Hct) and EBL favoring the intrauterine group. However, no significant difference was observed between the groups with respect to excessive blood loss > 1000 ml in the 1st six hours, the need for supplementary ecbolics, the necessity for blood or blood prod, the need for additional surgical intervention (for PPH) or side effects.

CONCLUSION

Intrauterine misoprostol combined with oxytocin intravenous infusion is more effective than sublingual misoprostol combined with oxytocin intravenous infusion in lowering intraoperative blood loss and preventing postpartum hemorrhage in elective cesarean section.

TRIAL REGISTRATION

This trial was retrospectively registered with the ClinicalTrials.gov Registry on 12-April-2024 (registration number: NCT06364098).

Intrauterine infusion of autologous platelet rich plasma can be an efficient treatment for patients with unexplained recurrent implantation failure

The studies posits that there is not sufficient evidence to support the use of intrauterine platelet-rich plasma (PRP) infusion in patients with recurrent implantation failure (RIF). This study aims to investigate the effects of infusion of PRP on patients with unexplained-RIF in fresh and frozen embryo transfer (ET) cycles. A total of 80 participants were included in this study. The participants were randomly assigned to one of two groups with and without PRP infusion. Each of the PRP and control groups were also divided into fresh and frozen ET subgroups. ET outcomes were compared between groups. Clinical pregnancy rate was significantly higher in Frozen ET in PRP group than other subgroups (p < 0.0001). Miscarriage rate were significantly lower in PRP group than control group. Pregnancy complications and preterm labor were significantly higher in PRP group than control group (p < 0.0001). Live birth and healthy baby rate were significantly higher in PRP group than control group (p < 0.0001). The intrauterine infusion of 0.8-1 ml of PRP 48 h before blastocyst ET at fresh and frozen cycles can be an efficient treatment option for u-RIF patients. Also, results indicated that the clinical pregnancy rate was equal to the live birth rate at fresh ET cycles, whereas the live birth rate was lower than the clinical pregnancy rate at frozen ET cycles. Therefore, considering the superiority of fresh cycles over freeze cycles, the infusion of PRP into the uterus of patients with RIF is recommended to be done at fresh ET cycles.Trial registration: NCT, NCT03996837. Registered 25/06/2019. Retrospectively registered, http://www.clinicaltrial.gov/ NCT03996837.

The Utility of an Human Papillomavirus Genotype Assay for Cancer Screening in Self-Collected Urine and Vaginal Samples from Japanese Women

OBJECTIVES

The high incidence of invasive cervical cancer among those who have not undergone cancer screening is a serious problem. This study aimed to investigate the utility of human papillomavirus (HPV) test results from self-collected urine and vaginal samples as screening tools.

DESIGN

The study was conducted in two steps. First, the appropriate storage container, temperature, and time until urine HPV assay performance were verified. Second, the results of spot urine testing under those conditions and of gynecologist-collected cervical and self-collected vaginal samples were compared to verify the feasibility of using the BD Onclarity® HPV assay for individuals with abnormal cervical cytology.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were 121 women with abnormal cervical cytology. Self-collected urine and vaginal samples, along with gynecologist-collected cervical samples, were tested for HPV using the BD Onclarity® HPV assay. The optimal conditions for urine sample storage were identified by comparing the HPV detection rates under various conditions.

RESULTS

Urine stored in a BD Probe Tec™ (QxUPT) for less than 72 h at room temperature was found to have the highest HPV positivity rate. Under these conditions, the detection rates of HPV in urine, cervical, and vaginal samples were examined. HPV type 16 was detected in 41.7% of the cervical samples, type 18 in 10%, and types 31 and 52 in 12.6% each. The concordance rate for HPV testing between clinician-collected cervical and urine samples was 63.9% (kappa: 0.34; 95% CI: 0.21-0.47), and that between clinician-collected cervical and self-collected vaginal samples was 77.8% (kappa: 0.68; 95% CI: 0.53-0.83), indicating good concordance. In a population with an HPV-related lesion/tumor prevalence of approximately 70%, the sensitivity of HPV testing was 82.7% for the cervix, 46.4% for urine, and 75.7% for vaginal samples.

LIMITATIONS

The primary limitation is the lower detection rate of HPV in spot urine samples than in other sample types, indicating room for methodological improvement. The study's findings are based on a specific population, which may limit generalizability.

CONCLUSIONS

We investigated the optimal self-collected urine-to-testing time and temperature. Self-collected vaginal and urine HPV tests show moderate-high concordance with clinician-collected cervical HPV tests, suggesting their potential utility for women who do not undergo regular cancer screening. However, the sensitivity was not high in spot urine. Therefore, further large-scale studies are needed to verify these findings and optimize testing methods to encourage broader participation in cancer screening programs.

OBJECTIVES

The high incidence of invasive cervical cancer among those who have not undergone cancer screening is a serious problem. This study aimed to investigate the utility of human papillomavirus (HPV) test results from self-collected urine and vaginal samples as screening tools.

DESIGN

The study was conducted in two steps. First, the appropriate storage container, temperature, and time until urine HPV assay performance were verified. Second, the results of spot urine testing under those conditions and of gynecologist-collected cervical and self-collected vaginal samples were compared to verify the feasibility of using the BD Onclarity® HPV assay for individuals with abnormal cervical cytology.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were 121 women with abnormal cervical cytology. Self-collected urine and vaginal samples, along with gynecologist-collected cervical samples, were tested for HPV using the BD Onclarity® HPV assay. The optimal conditions for urine sample storage were identified by comparing the HPV detection rates under various conditions.

RESULTS

Urine stored in a BD Probe Tec™ (QxUPT) for less than 72 h at room temperature was found to have the highest HPV positivity rate. Under these conditions, the detection rates of HPV in urine, cervical, and vaginal samples were examined. HPV type 16 was detected in 41.7% of the cervical samples, type 18 in 10%, and types 31 and 52 in 12.6% each. The concordance rate for HPV testing between clinician-collected cervical and urine samples was 63.9% (kappa: 0.34; 95% CI: 0.21-0.47), and that between clinician-collected cervical and self-collected vaginal samples was 77.8% (kappa: 0.68; 95% CI: 0.53-0.83), indicating good concordance. In a population with an HPV-related lesion/tumor prevalence of approximately 70%, the sensitivity of HPV testing was 82.7% for the cervix, 46.4% for urine, and 75.7% for vaginal samples.

LIMITATIONS

The primary limitation is the lower detection rate of HPV in spot urine samples than in other sample types, indicating room for methodological improvement. The study's findings are based on a specific population, which may limit generalizability.

CONCLUSIONS

We investigated the optimal self-collected urine-to-testing time and temperature. Self-collected vaginal and urine HPV tests show moderate-high concordance with clinician-collected cervical HPV tests, suggesting their potential utility for women who do not undergo regular cancer screening. However, the sensitivity was not high in spot urine. Therefore, further large-scale studies are needed to verify these findings and optimize testing methods to encourage broader participation in cancer screening programs.

Impact of GnRH antagonist pretreatment on oocyte yield after ovarian stimulation: A retrospective analysis

The study investigates whether a 3-day pretreatment course with a GnRH antagonist in the early follicular phase has an impact on the number of retrieved COCs in a GnRH antagonist stimulation protocol. This is a retrospective single center crossover study involving women who did not conceive after one GnRH antagonist stimulation cycle ("standard cycle") and proceeded with another GnRH antagonist stimulation cycle preceded by early administration of GnRH antagonist for 3 days ("pretreatment cycle") with fresh embryo transfer or frozen embryo transfer. 430 patients undergoing 860 cycles were included. The mean female age was 34.4 ± 4.8 years. Indications for fertility treatment included unexplained infertility (34.3%), male-factor infertility (33.3%), age (16.9%), PCOS (8.2%), tubal (4.7) and endometriosis (2.6%). All cycles were divided into two groups: group 1 (standard, 430 cycles) and group 2 (pretreatment, 430 cycles). The mean duration of stimulation was similar in both groups (10.3 vs 10.3 days, p = 0.28). The starting dose of gonadotropin (234.9 vs 196.8 IU, p<0.001), total amount of gonadotropin used (2419 vs 2020 IU, p<0.001), the total number of retrieved COCs (10 vs 7.8 p<0.001) and the number of mature oocytes (8 vs 5.8 p<0.001) were significantly higher in group 2 than in group 1. The Generalized estimating equation (GEE) regression analysis showed that the pretreatment strategy had a significant positive effect on the number of COCs (coefficient 2.4, p <0.001 after adjusting for known confounders (age, indication, stimulation dose, type, and duration of stimulation). In conclusion, A 3-day course of GnRH antagonist pretreatment increases the number of COCs obtained after ovarian stimulation.

Prediction of adverse maternal and perinatal outcomes associated with pre-eclampsia and hypertensive disorders of pregnancy: a systematic review and meta-analysis

Background

Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal morbidity and mortality. If women at high risk for developing complications could be identified early, level of care could be triaged, limited resources could be correctly allocated and targeted interventions to prevent complications could be implemented.

Methods

We updated a systematic review and meta-analysis and added single outcomes. Women with hypertensive disorders of pregnancy were included. Exposures were tests predicting adverse maternal and/or perinatal outcomes. We searched Medline, Embase, CINAHL, and Cochrane library from January 2016-February 2024. We included studies identified from the previous review. We calculated effect measures. For similar predictive tests and outcomes, area under the receiver-operating-characteristic curve (AUROC) were pooled. This study was registered by PROSPERO: CRD42022336368.

Findings

Of the 2898 studies identified, 80 were included. Thirty were added from the previous review resulting in 110 included studies with 506,178 women. Despite more than 1500 tests being performed, most outcomes could not be pooled due to heterogeneity in populations, tests, and outcome definitions. For maternal outcomes, only studies reporting on the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) model could be pooled. For the composite outcome within 48-h the AUROC was 0.78 (95% CI 0.71-0.86, N = 8). There was significant heterogeneity (I 2  = 95.7%). For perinatal outcomes, data were pooled for pulsatility index in the umbilical artery and soluble FMS-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio. Biomarkers like the sFlt-1/PlGF ratio showed promising predictive performance for some outcomes but were not externally validated.

Interpretation

Despite including over 100 studies with more than 1500 predictors, we were unable to pool any single maternal outcomes and only a few individual perinatal outcomes. The fullPIERS model was externally validated, showing moderate accuracy which varied across studies and should be validated in each new population. Angiogenic biomarkers showed promise but need validation. Future studies should use standardized outcome measures and validate promising tests.

Funding

VB is supported by the Swedish Research Council, Grant number 2020-01481. University of Gothenburg.

Efficacy of intrauterine autologous blood cell derivatives in enhancing endometrial thickness and IVF outcomes for women with recurrent implantation failure: a retrospective cohort study

PURPOSE

The purpose of this study was to determine the effects of intrauterine infusion of autologous blood cell derivative (ABCD) on endometrial thickness and pregnancy outcomes in a group of patients who underwent IVF with recurrent implantation failure (RIF) and who had either a normal endometrium or thin endometrium.

METHODS

This retrospective study included 63 patients who experienced RIF at the Department of Reproductive Medicine and Surgery, KMC, Manipal, between January 2021 and March 2024 and who received three doses of intrauterine ABCD infusion to prepare the endometrium for frozen embryo transfer (FET).

RESULTS

We enrolled 63 RIF patients, 30 with a normal endometrium (NEM) and 33 with a thin endometrium (TEM). The endometrial thickness (EMT) significantly increased across all the groups. After 3 cycles of intrauterine ABCD infusion, the mean increases in EMT in the NEM and TEM groups were 0.77 mm and 1.36 mm, respectively, which were statistically significant. Among the 62 completed FET cycles, 40.3% were positive for beta-hCG. The clinical pregnancy rate was 33.8% (40% in the NEM group, 28.1% in the TEM group), and the live birth rate was 24.2% (30% in the NEM group, 18.8% in the TEM group). A total of 9.7% of pregnancies had spontaneous miscarriages. Moreover, the EMT did not differ between the pregnant and nonpregnant groups.

CONCLUSION

Intrauterine ABCD infusion improves the pregnancy outcomes of patients with RIF, regardless of the EMT. The results of this study revealed that endometrial receptivity improved significantly along with the EMT.

Optimizing intrauterine insemination: A systematic review and meta-analysis of the effectiveness and safety of clinical treatment add-ons

INTRODUCTION

Intrauterine insemination (IUI) is one of the most widespread fertility treatments. However, IUI protocols vary significantly amongst fertility clinics. Various add-on interventions have been proposed to boost success rates. These are mostly chosen arbitrarily or empirically. The aim of this systematic review and meta-analysis is to assess the effectiveness and safety of add-on interventions to the standard IUI protocol and to provide evidence-based recommendations on techniques used to optimize the clinical outcomes of IUI treatment.

MATERIAL AND METHODS

Systematic review and meta-analyses were performed in accordance with PRISMA guidelines. A computerized literature search was performed from database inception to May 2023. Randomized controlled trials (RCTs) were included reporting on couples/single women undergoing IUI with any protocol for any indication using partner's or donor sperm. A meta-analysis based on random effects was performed for each outcome and add-on. Three authors independently assessed the trials for quality and risk of bias and overall certainty of evidence. Uncertainties were resolved through consensus. Primary outcomes were ongoing pregnancy rate (OPR) or live birth rate (LBR) per cycle/per woman randomized. Registration number PROSPERO: CRD42022300857.

RESULTS

Sixty-six RCTs were included in the analysis (16 305 participants across 20 countries). Vaginal progesterone as luteal phase support in stimulated cycles was found to significantly increase LBR/OPR (RR 1.37, 95% CI 1.09-1.72, I2 = 4.9%) (moderate/low certainty of the evidence). Endometrial scratch prior/during stimulated IUI cycles may increase LBR/OPR (RR 1.44, 95% CI 1.03-2.01, I2 = 1.8%), but evidence is very uncertain. Results from two studies suggest that follicular phase ovarian stimulation increases LBR/OPR (RR 1.39, 95% CI 1.00-1.94, I2 = 0%) (low certainty of evidence). No significant difference was seen for the primary outcome for the other studied interventions.

CONCLUSIONS

The findings of this systematic review and meta-analysis suggest that vaginal luteal phase progesterone support probably improves LBR/OPR in stimulated IUI treatments. In view of moderate/low certainty of the evidence more research is needed for solid conclusions. Further research is also recommended for the use of endometrial scratch and ovarian stimulation. Future studies should report on results according to subfertility background as it is possible that different add-ons could benefit specific patient groups.

Hormonal contraception and medical readiness for female service members

Many female military service members choose to use hormonal contraception to prevent pregnancy and/or to control or suppress menses. Hormonal contraception, which comes in many different forms based on dose, estrogen/progestin type, and route of administration (oral, vaginal, transdermal, implant, intrauterine device, injectable), may cause side effects, some of which can influence military medical readiness, or the health status necessary to perform assigned missions. This expert review summarizes the evidence around common military-relevant side effects of hormonal contraception that could impact readiness, including effects on weight and body composition, bone health, psychological health, and physical performance, and serves as a tool for uniformed and civilian clinicians counseling female service members about hormonal contraception. Current evidence suggests some hormonal contraception can lead to weight and fat gain, may modulate susceptibility to mood or mental health disorders, and could impact bone mineral density and stress fracture risk; more research is needed on physical performance effects. Clinicians must be familiar with readiness considerations of each type of hormonal contraception to provide comprehensive patient education and allow for optimal shared decision-making about hormonal contraception use among female Service members. Considering the relative lack of data on the effects of nonoral hormonal contraception routes on readiness outcomes and the growing interest in long-acting reversible contraceptives among female service members, future research should continue to investigate effects of all hormonal contraception methods available to service members.

Potential damage to ovarian reserve from laparoscopic electrocoagulation in endometriomas and benign ovarian cysts: a systematic review and meta-analysis

PURPOSE

Laparoscopic cystectomy for ovarian endometriomas and benign ovarian cysts is often conducted through hemostatic methods, with bipolar electrocoagulation as a common approach. This study evaluated the impact of electrocoagulation, primarily through bipolar energy, versus nonthermal hemostatic methods on ovarian reserve in patients undergoing laparoscopic cystectomy for ovarian endometriomas and benign ovarian cysts.

METHODS

A systematic review with meta-analysis was conducted by searching the Cochrane Library, PubMed, EMBASE, and Web of Science databases. Randomized controlled trials (RCTs) comparing the impact of nonthermal hemostatic methods and electrocoagulation on the ovarian reserve during laparoscopic cystectomy were included. The Cochrane Risk of Bias Tool for Randomized Controlled Trials (ROB 2.0) was utilized to assess the quality of the included studies. The meta-analysis included 13 RCTs involving 1043 patients. Postoperative serum anti-Müllerian hormone (AMH) levels and antral follicle counts (AFCs) were analyzed using Review Manager ver. 5.4.

RESULTS

Compared with the bipolar group, patients with endometriomas in the nonthermal hemostatic group exhibited significantly higher postoperative AMH levels at 1, 3, 6, and 12 months. Conversely, no significant differences in AMH levels were observed in patients with benign ovarian cysts. Similarly, AFCs showed no significant differences, except for lower postoperative AFCs in patients with endometrioma in the electrocoagulation group.

CONCLUSION

Nonthermal hemostatic methods are associated with more effective preservation of the ovarian reserve compared with bipolar electrocoagulation in laparoscopic cystectomy for ovarian endometriomas. However, no significant impact of bipolar electrocoagulation on the ovarian reserve was observed in patients with benign ovarian cysts.

TRIAL REGISTRATION

Registered in PROSPERO on April 10, 2023; ID # CRD42023413158.

Diagnostic accuracy of magnetic resonance imaging to predict peripartum hysterectomy and neonatal mortality in total placenta previa: A retrospective cohort study

OBJECTIVES

To assess the reliability of placental magnetic resonance imaging measurements in predicting peripartum hysterectomy and neonatal outcomes in patients with total placenta previa.

STUDY DESIGN

This retrospective cohort study, conducted at a single tertiary center, identified 372 pregnant women diagnosed with placenta previa. 277 singleton pregnancies that met the inclusion criteria and were diagnosed with total placenta previa in the third trimester were divided into two groups according to whether a placental MRI was performed. Two radiologists analyzed the MRI findings of 150 pregnant women with total placenta previa. Measurements were conducted for the placental volume of the upper and lower uterine sectors, cervical canal length, and cervical canal dilatation. A comparison was made between the surgical progression of these pregnant women and 127 pregnant women with total placenta previa who did not undergo an MRI. After pathological examination, 122 (63.2%) of 193 pregnant women diagnosed with placenta accreta spectrum underwent peripartum total abdominal hysterectomy. The results were compared using logistic regression analysis.

RESULTS

Reduced placental volume in the upper uterine segment and increased volume in the lower uterine segment significantly correlated with a higher probability of peripartum hysterectomy (cut-off: ≤343.4 and ≥ 403.4 cm3; OR: 0.993, 95 % CI: 0.990-0.995 and OR: 1.007, 95 % CI: 1.005-1.009, respectively). Shortened cervical canal length and increased dilatation raise the risk of peripartum hysterectomy (cut-off: ≤34, ≥11 mm; OR: 0.82, 95 % CI: 0.77 - 0.88 and OR: 1.7, 95 % CI: 1.4 - 2.1, respectively). The risk of neonatal death is 32 times higher in those < 34 weeks than in those 34 weeks or higher (95 % CI: 4.2-250, p = 0.001).

CONCLUSIONS

Placental MRI significantly contributes to predicting peripartum total abdominal hysterectomy and neonatal mortality in patients with total placenta previa associated with placenta accreta spectrum.

Is Complete Excision Always Enough? A Quality of Sexual Life Assessment in Patients with Deep Endometriosis

Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision.

Inflammatory indices-Systemic Immune-Inflammation Index (SII) and Systemic Inflammatory Response Index (SIRI)-during Pregnancy and Associations with Gestational Diabetes Mellitus

Purpose

Gestational diabetes mellitus (GDM) is a prevalent complication during pregnancy. This study aimed to explore the associations between inflammatory indices during pregnancy and the development of GDM.

Methods

Data from the Fujian Birth Cohort Study between March 2019 and December 2022 were used. Participants who delivered a live-born singleton were included and categorized into GDM and non-GDM groups. Two inflammatory indices, the systemic immune-inflammation index (SII) and systemic inflammatory response index (SIRI), were calculated for each trimester of pregnancy via hematological parameters from complete blood count tests. The distributions of inflammatory indicators across trimesters were compared between the GDM and non-GDM groups. Additionally, multivariable logistic regression models were employed to investigate the associations between inflammatory indices and the incidence of GDM.

Results

A total of 17297 participants were included, 21.2% of whom were diagnosed with GDM. In the first trimester, the median SIIs for the GDM and non-GDM groups were 817.7×109/L and 756.9×109/L, respectively, whereas the median SIRIs were 1.6×109/L and 1.5×109/L, respectively. In both groups, the SII increased to its peak in the second trimester before declining, whereas the SIRI progressively increased throughout pregnancy. The SII and SIRI were greater in the GDM group than in the non-GDM group during the first two trimesters but lower in the third trimester. Nonlinear positive associations between first-trimester SII and SIRI levels and GDM were observed, with extreme quartile odds ratios of 1.32 (95% CI: 1.19, 1.48) and 1.39 (95% CI: 1.24, 1.55), respectively.

Conclusion

The SII and SIRI increased and reached their peak values in the second and third trimesters of pregnancy, respectively. Elevated levels of the SII and SIRI in early pregnancy were linked to an increased risk of GDM, suggesting their potential utility as screening tools for GDM.