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Kadah S, Soh SE, Morin M, Schneider M, Ang WC, McPhate L, Frawley H. Are pelvic pain and increased pelvic floor muscle tone associated in women with persistent noncancer pelvic pain? A systematic review and meta-analysis. J Sex Med 2023; 20:1206-1221. [PMID: 37507352 DOI: 10.1093/jsxmed/qdad089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/23/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND The association between pelvic pain and pelvic floor muscle (PFM) tone in women with persistent noncancer pelvic pain (PNCPP) is unclear. AIM To synthesize the evidence of the association between pelvic pain and PFM tone in women with PNCPP. METHODS A systematic review was conducted via MEDLINE, Emcare, Embase, CINAHL, PsycINFO, and Scopus to identify relevant studies. Studies were eligible if pelvic pain and PFM tone outcome measures were reported among women aged >18 years. The National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess study quality. Studies were pooled by assessment of PFM tone via a random effects model. Associations between the presence of pelvic pain and PFM tone were assessed with odds ratio (OR), while linear associations were assessed with Pearson or Spearman correlation. OUTCOMES Pelvic pain measures (intensity, threshold, and frequency) and resting PFM tone in women with PNCPP, as evaluated by any clinical assessment method or tool. RESULTS Twenty-four studies were included in this review. The presence of pelvic pain was significantly associated with increased PFM tone as assessed by digital palpation (OR, 2.85; 95% CI, 1.66-4.89). Pelvic pain intensity was inversely but weakly associated with PFM flexibility when evaluated through dynamometry (r = -0.29; 95% CI, -0.42 to -0.17). However, no significant associations were found between pelvic pain and PFM tone when measured with other objective assessment methods. CLINICAL IMPLICATIONS Pelvic pain and increased PFM tone may not be directly associated; alternatively, a nonlinear association may exist. A range of biopsychosocial factors may mediate or moderate the association, and clinicians may need to consider these factors when assessing women with PNCPP. STRENGTHS AND LIMITATIONS This review was reported according to the PRISMA guidelines. All possible findings from relevant theses and conference abstracts were considered in our search. However, nonlinear associations between pelvic pain and increased PFM tone were not assessed as part of this review. CONCLUSION Pelvic pain may be linearly associated with increased PFM tone and decreased PFM flexibility when measured with digital palpation or dynamometry; however, this association was not observed when other aspects of PFM tone were assessed through objective methods. Future studies are required using robust assessment methods to measure PFM tone and analyses that account for other biopsychosocial factors that may influence the association.
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Affiliation(s)
- Shaza Kadah
- Department of Physiotherapy, Monash University, Melbourne, Victoria 3199, Australia
- Department of Physical Therapy, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sze-Ee Soh
- Department of Physiotherapy, Monash University, Melbourne, Victoria 3199, Australia
| | - Melanie Morin
- School of Rehabilitation Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec J1K2R1, Canada
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria 3800, Australia
| | - W Catarina Ang
- Women's Health Services, Royal Women's Hospital, Melbourne, Victoria 3052 Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Lucy McPhate
- Department of General Medicine, The Royal Melbourne Hospital, Melbourne, Australia
| | - Helena Frawley
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria 3010, Australia
- Allied Health Research, The Royal Women's Hospital, Melbourne, Victoria 3052 Australia
- Allied Health Research, Mercy Hospital for Women, Melbourne, Victoria 3084, Australia
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da Silva JP, de Almeida BM, Ferreira RS, de Paiva Oliveira Lima CR, Barbosa LMÁ, Ferreira CWS. Sensory and muscular functions of the pelvic floor in women with endometriosis - cross-sectional study. Arch Gynecol Obstet 2023; 308:163-170. [PMID: 37042996 DOI: 10.1007/s00404-023-07037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/01/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE The aim of this study was to analyze the sensory and muscle functions of the pelvic floor in women with endometriosis, trying to improve overall knowledge/findings regarding pelvic floor muscle functions in patients with endometriosis. METHODS Sample size calculated as 92 patients with endometriosis, aged between 18 and 45 years, not virgin, without other causes of pain and could not be pregnant. Patients underwent the Pelvic Floor Sensorial and Muscle Function Exam (EFSMAP). Descriptive data were recorded with mean and standard deviation, median (range), and absolute and relative frequency. The Kolmogorov-Smirnov test was used to observe the normality of quantitative variables. The significance level adopted for this study was 5%. RESULTS Of 92 women assessed, 93.3% had pain and 75% had increased tone in the levator ani muscle; 50.4% had impaired pelvic floor relaxation with median strength of 3 by the Oxford scale and endurance of 2 s. CONCLUSIONS The patients had a high prevalence of pain and dysfunction of the pelvic floor muscles, such as low muscle endurance and difficulty to relax. It shows that these patients should be referred to a pelvic floor physiotherapist, as soon as they have the diagnosis of endometriosis, to be assessed to prevent and/or treat pelvic floor impairments.
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Affiliation(s)
- Joyce Pereira da Silva
- Department of Physiotherapy, Federal University of Pernambuco-UFPE, Av Prof. Moraes Rego, 1235. Cidade Universitária, Recife, Pernambuco, CEP: 50670-901, Brazil
| | - Bianca Maciel de Almeida
- Department of Physiotherapy, Federal University of Pernambuco-UFPE, Av Prof. Moraes Rego, 1235. Cidade Universitária, Recife, Pernambuco, CEP: 50670-901, Brazil
| | - Renata Santos Ferreira
- Department of Physiotherapy, Federal University of Pernambuco-UFPE, Av Prof. Moraes Rego, 1235. Cidade Universitária, Recife, Pernambuco, CEP: 50670-901, Brazil
| | | | - Leila Maria Álvares Barbosa
- Department of Physiotherapy, Federal University of Pernambuco-UFPE, Av Prof. Moraes Rego, 1235. Cidade Universitária, Recife, Pernambuco, CEP: 50670-901, Brazil
| | - Caroline Wanderley Souto Ferreira
- Department of Physiotherapy, Federal University of Pernambuco-UFPE, Av Prof. Moraes Rego, 1235. Cidade Universitária, Recife, Pernambuco, CEP: 50670-901, Brazil.
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Kadah S, Soh SE, Morin M, Schneider M, Heron E, Frawley H. Is there a difference in pelvic floor muscle tone between women with and without pelvic pain? A systematic review and meta-analysis. J Sex Med 2023; 20:65-96. [PMID: 36897234 DOI: 10.1093/jsxmed/qdac002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 09/06/2022] [Accepted: 09/15/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Alterations in pelvic floor muscle (PFM) function have been observed in women with persistent noncancer pelvic pain (PNCPP) as compared with women without PNCPP; however, the literature presents conflicting findings regarding differences in PFM tone between women with and without PNCPP. AIM To systematically review the literature comparing PFM tone in women with and without PNCPP. METHODS MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Scopus were searched from inception to June 2021 for relevant studies. Studies were included that reported PFM tone data in women aged ≥18 years with and without PNCPP. The risk of bias was assessed with the National Heart, Lung, and Blood Institute Quality Assessment Tool. Standardized mean differences (SMDs) for PFM tone measures were calculated via random effects models. OUTCOMES Resting PFM tone parameters, including myoelectrical activity, resistance, morphometry, stiffness, flexibility, relaxation, and intravaginal pressure, measured by any clinical examination method or tool. RESULTS Twenty-one studies met the inclusion criteria. Seven PFM tone parameters were measured. Meta-analyses were conducted for myoelectrical activity, resistance, and anterior-posterior diameter of the levator hiatus. Myoelectrical activity and resistance were higher in women with PNCPP than in women without (SMD = 1.32 [95% CI, 0.36-2.29] and SMD = 2.05 [95% CI, 1.03-3.06], respectively). Women with PNCPP also had a smaller anterior-posterior diameter of the levator hiatus as compared with women without (SMD = -0.34 [95% CI, -0.51 to -0.16]). Meta-analyses were not performed for the remaining PFM tone parameters due to an insufficient number of studies; however, results of these studies suggested greater PFM stiffness and reduced PFM flexibility in women with PNCPP than in women without. CLINICAL IMPLICATIONS Available evidence suggests that women with PNCPP have increased PFM tone, which could be targeted by treatments. STRENGTHS AND LIMITATIONS A comprehensive search strategy was used with no restriction on language or date to review studies evaluating PFM tone parameters between women with and without PNCPP. However, meta-analyses were not undertaken for all parameters because few included studies measured the same PFM tone properties. There was variability in the methods used to assess PFM tone, all of which have some limitations. CONCLUSION Women with PNCPP have higher PFM tone than women without PNCPP; therefore, future research is required to understand the strength of the relationship between pelvic pain and PFM tone and to investigate the effect of treatment modalities to reduce PFM tone on pelvic pain in this population.
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Affiliation(s)
- Shaza Kadah
- Department of Physiotherapy, Monash University, Melbourne, Victoria 3199, Australia.,Department of Physical Therapy, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sze-Ee Soh
- Department of Physiotherapy, Monash University, Melbourne, Victoria 3199, Australia
| | - Melanie Morin
- School of Rehabilitation Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec J1K 2R1, Canada
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria 3800, Australia
| | - Emma Heron
- School of Allied Health, Curtin University, Bentley, Western Australia 6102, Australia
| | - Helena Frawley
- School of Health Sciences, The University of Melbourne, Melbourne, Victoria 3010, Australia.,Allied Health Research, Royal Women's Hospital, Melbourne, Victoria 3052, Australia.,Allied Health Research, Mercy Hospital for Women, Melbourne, Victoria 3084, Australia
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Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature). Int J Mol Sci 2021; 22:ijms221910554. [PMID: 34638893 PMCID: PMC8508982 DOI: 10.3390/ijms221910554] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/22/2021] [Accepted: 09/26/2021] [Indexed: 12/11/2022] Open
Abstract
Endometriosis is a “mysterious” disease and its exact cause has not yet been established. Among the etiological factors, congenital, environmental, epigenetic, autoimmune and allergic factors are listed. It is believed that the primary mechanism of the formation of endometriosis foci is retrograde menstruation, i.e., the passage of menstrual blood through the fallopian tubes into the peritoneal cavity and implantation of exfoliated endometrial cells. However, since this mechanism is also observed in healthy women, other factors must also be involved in the formation of endometriosis foci. Endometriosis is in many women the cause of infertility, chronic pain and the deterioration of the quality of life. It also represents a significant financial burden on health systems. The article presents a review of the literature on endometriosis—a disease affecting women throughout the world.
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Abrao MS, Andres MP, Miller CE, Gingold JA, Rius M, Neto JS, Carmona F. AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score. J Minim Invasive Gynecol 2021; 28:1941-1950.e1. [PMID: 34583009 DOI: 10.1016/j.jmig.2021.09.709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility. DESIGN Multicenter study of patients treated at 3 recognized endometriosis centers. SETTING Three specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain. PATIENTS Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis. INTERVENTIONS Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed. MEASUREMENTS AND MAIN RESULTS A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system. CONCLUSION The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.
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Affiliation(s)
- Mauricio S Abrao
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain.
| | - Marina Paula Andres
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain
| | - Charles E Miller
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain
| | - Julian A Gingold
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain
| | - Mariona Rius
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain
| | - Joao Siufi Neto
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain
| | - Francisco Carmona
- Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain
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McNamara HC, Frawley HC, Donoghue JF, Readman E, Healey M, Ellett L, Reddington C, Hicks LJ, Harlow K, Rogers PAW, Cheng C. Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:729642. [PMID: 36303969 PMCID: PMC9580702 DOI: 10.3389/frph.2021.729642] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.
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Affiliation(s)
- Helen C. McNamara
- Royal Women's Hospital, Melbourne, VIC, Australia
- *Correspondence: Helen C. McNamara
| | - Helena C. Frawley
- Royal Women's Hospital, Melbourne, VIC, Australia
- School of Health Sciences, University of Melbourne, Parkville, VIC, Australia
- Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Jacqueline F. Donoghue
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Emma Readman
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Martin Healey
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Lenore Ellett
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Charlotte Reddington
- Royal Women's Hospital, Melbourne, VIC, Australia
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | | | - Keryn Harlow
- Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Peter A. W. Rogers
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Claudia Cheng
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
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