The association between obesity and the success of trial of labor after cesarean delivery (TOLAC) in women with past vaginal delivery

OBJECTIVES

To evaluate the effect of overweight (body mass index; BMI 25.0-29.9 kg/m2), and obesity (BMI>30 kg/m2), on the success of trial of labor after cesarean delivery (TOLAC), with consideration of successful past vaginal birth.

METHODS

This retrospective cohort study was performed using electronic database of obstetrics department at a university-affiliated tertiary medical center. All women admitted for TOLAC at 37-42 weeks of gestational age, carrying a singleton live fetus at cephalic presentation, with a single previous low segment transverse cesarean delivery between 1/2015 and 5/2021 were included. Primary outcome was the rate of cesarean delivery during labor, and subgroup analysis was performed for the presence of past vaginal birth.

RESULTS

Of the 1200 TOLAC deliveries meeting the inclusion criteria, 61.9 % had BMI in the normal range, 24.6 % were overweight (BMI 25.0-29.9 kg/m2), and 13.4 % were obese (BMI of 30 kg/m2 and over). Using a multivariate analysis, BMI≥30 kg/m2 was associated with increased risk of cesarean delivery compared to normal weight. However, in the subgroup of 292 women with a history of successful vaginal birth BMI did not affect TOLAC success.

CONCLUSIONS

BMI does not affect the success of TOLAC in women with previous vaginal birth. This information should be considered during patients counselling, in order to achieve a better selection of mode of delivery and higher patients' satisfaction.

Evaluation of blood type as a potential risk factor for hemorrhage during vaginal hysterectomy

OBJECTIVE

To examine the association between the O blood type and bleeding tendency in patient undergoing vaginal hysterectomy.

METHODS

This was a retrospective cohort study including all women who had undergone vaginal hysterectomy at our institution between January 2015 and September 2020. All women underwent blood type and complete blood count testing pre- and post-operatively. The estimated intraoperative blood loss, the need for blood transfusion, pre- and postoperative hemoglobin and hematocrit measurements and surgical data were recorded for all patients. Patients with known coagulopathies or those taking antithrombotic medications were excluded from the study. Statistical analysis was performed using student t, χ2, Fischer exact, and ANOVA tests as well as a stepwise logistic regression model.

RESULTS

The study included 106 patients (35.2 %) with O and 195 patients (64.8 %) with non-O (i.e., A, B or AB) blood types. The O blood type was significantly associated with a higher risk for moderate blood loss (defined as a pre- to postoperative Hb or HCT drop >2gr or >6 %, respectively) (p = 0.012), but not with severe (defined as a Hb or HCT drop of >3gr or >9 %, respectively) perioperative bleeding, nor with the need for blood transfusion.

CONCLUSION

The O blood type was found to be significantly associated with moderate but not with severe intraoperative bleeding during and following vaginal hysterectomy.

The Value of Preoperative Multichannel Urodynamic Testing for Detecting Occult Stress Urinary Incontinence in Women Undergoing Prolapse Repair Surgery

BACKGROUND

Diagnosing occult stress urinary incontinence (OSUI) prior to surgical intervention for pelvic organ prolapse (POP) repair may allow for adding an anti-incontinence procedure and thus prevent postoperative SUI.

OBJECTIVES

To compare preoperative detection rates for OSUI by either a multichannel urodynamic investigation or by a plain pelvic examination.

METHODS

We retrospectively evaluated the medical charts of all women who underwent urodynamic investigation prior to surgical repair of advanced POP at our institution between 1 January 2006 and 31 December 2012.

RESULTS

In total, 720 women underwent surgical POP repair during the study period, of whom 54 (7.5%) were diagnosed with OSUI preoperatively. Of these patients, 54 (100%) were detected by multichannel urodynamic investigation while only 27 (50%) were detected by a plain pelvic examination (P = 0.001). Bladder fullness during the pelvic examination was associated with higher detection rates for OSUI (P = 0.001). Women with OSUI who underwent concomitant tension-free vaginal tape and POP repair procedures did not develop de novo SUI or obstructive voiding symptoms (OVS) postoperatively.

CONCLUSIONS

Preoperative multichannel urodynamic investigation has significantly higher detection rates for OSUI than a plain pelvic examination. Utilizing this modality resulted in no cases of de novo SUI or OVS postoperatively.

Group B Streptococcus real-time PCR may potentially reduce intrapartum maternal antibiotic treatment

BACKGROUND

Protocols for preventing early-onset group B streptococcal (GBS) neonatal infection may result in unnecessary antibiotics administration. Real-time polymerase chain reaction (PCR) can provide a result within 30-60 min and has been found to be specific and sensitive for defining intrapartum GBS status.

OBJECTIVE

To evaluate whether implementation of GBS fast real-time PCR to all women who require GBS prophylaxis may reduce the use of maternal prophylactic antibiotics.

METHODS

This prospective cohort study included women admitted to a single delivery ward who required prophylactic antibiotics either due to a positive antepartum GBS culture screening performed at 35-37 weeks or due to an unknown GBS status with an intrapartum risk factor. All the women were tested by a double vaginal swab (real-time PCR and culture) as soon as it became apparent, they required antibiotic prophylaxis and prior to its administration.

RESULTS

Between May 2019 and August 2020, 303 women met eligibility criteria and were enrolled, but four were excluded from the analysis due to failed culture or PCR tests. Of 299 women included in the study, 208 (69.5%) and 180 (60.2%) women, showed no evidence of GBS on intrapartum culture or PCR, respectively. Of 89 GBS antepartum carriers, 43 (48.3%) and 32 (35.9%) had negative intrapartum culture and PCR results, respectively. Of the 210 women with risk factors, 165 (78.5%) were culture negative and 148 (70.4%) had a negative PCR. Using intrapartum culture as the gold standard, intrapartum GBS real-time PCR was found to have a sensitivity of 97.8% (95% confidence interval [CI] 92.3, 99.7) and a specificity of 85.6% (95% CI 80.1, 90.1).

CONCLUSIONS

Compared with antepartum universal culture screening or intrapartum risk-factor assessment, the need for maternal antibiotic treatment may be substantially reduced by implementation of intrapartum GBS real-time PCR, without compromising the sensitivity of GBS detection.

P-664 The effect of LH levels on the day of trigger on the oocyte retrieval and maturation rates in GnRH-antagonist cycles with an agonist trigger

Study question

Are LH levels on day of trigger correlated with the number of oocytes retrieved and oocyte maturation rate in GnRH-antagonist cycles with an agonist trigger?

Summary answer

Low LH levels on the day of trigger were associated with a lower oocyte retrieval rate yet no correlation with oocyte maturation rates was found.

What is known already

The concept that a bolus of gonadotrophin-releasing hormone agonist (GnRHa) can replace human chorionic gonadotrophin (HCG) as a trigger of final oocyte maturation was introduced several years ago. GnRHa trigger offers important advantages including the prevention of ovarian hyperstimulation syndrome (OHSS) with the elicitation of an endogenous LH and FSH surge. Therefore, we sought to evaluate whether LH levels on the day of the trigger are associated with the efficacy of the trigger in eliciting endogenous LH surge and thereby influencing oocyte retrieval and oocyte maturation rates.

Study design, size, duration

This retrospective single center study included all GnRH antagonist cycles triggered with GnRHa trigger (Decapeptyl 0.2mg) performed at our IVF unit between July 2013 and December 2020. We studied the association between LH levels on the day of trigger and the number of oocytes retrieved. Additionally, we studied the effect of LH levels on oocyte maturation rates.

Participants/materials, setting, methods

All GnRH antagonist cycles triggered with GnRHa trigger were included. Data was acquired through individual review of medical records. Linear regression was used to study the correlation between LH levels and oocyte retrieval and maturation rates. Moreover, LH levels on day of trigger were divided ≤1 IU/L and > 1 IU/L to further investigate this correlation. The ratio between Basal LH and LH on day of trigger was investigated as well.

Main results and the role of chance

There were 211 GnRH antagonist cycles triggered with GnRH agonist trigger during the study period. The mean age of patients in the study group was 30.1±4.8 y/o, mean basal LH levels were - 6.8±3.4 IU/L, mean Basal FSH levels were - 6.7±1.9IU/L and the mean total dose of gonadotropin administered was 1633.4±680.6 Units. The mean E2 levels were 11,444±7018.5 pmol/L and the mean number of oocytes retrieved was 19.8±10.2. A correlation was found between lower LH levels on the day of trigger and the number of oocytes retrieved (p < 0.001). No correlation was found between LH levels on the day of trigger and oocyte maturation rates (p = 0.82). The ratio between Basal LH and LH on day of trigger was not found to be a significant factor influencing either the number of oocytes retrieved or oocyte maturation rate. When dividing the group by LH on day of trigger to below and above 1, a borderline difference was found relating to oocyte retrieval rate between the two groups (p = 0.06).

Limitations, reasons for caution

The retrospective nature of the study is the main limitation. Patients receiving GnRHa trigger are mainly a selective population of either high responders or patients for fertility preservation stimulated to retrieve many oocytes, therefore findings may not be applicable to normal or poor responders.

Wider implications of the findings

Low LH levels on day of trigger were found associated with lower oocyte retrieval rates. GnRHa has become an alternative to standard hCG triggering in certain situations. These are preliminary findings of an ongoing study designed to investigate the efficacy of GnRHa trigger according to cycle parameters including LH levels.

Trial registration number

not applicable

P-325 Endometriosis has no negative effect on embryo quality and morphokinetics. A retrospective case control study

Study question

Does endometriosis affect embryo quality assessed by a time-lapse morphokinetic model analysis?

Summary answer

Endometriosis does not seem to have a negative effect on embryo morphokinetics and embryo quality assessed by a time-lapse in-house model.

What is known already

Endometriosis is strongly associated with infertility. Clinical studies suggest lower implantation and pregnancy rates in women with endometriosis. Embryos of women with endometriosis exhibit a higher incidence of developmental delay and arrested development than those derived from women without the disease. Poor oocyte and embryo quality have been suggested as a possible cause.

It has been found that time-lapse systems which capture images of embryos at frequent time intervals allow continuous assessment of their quality. Developing an in-house model for embryo selection based on embryos with known implantation data (KID) enables detecting the highest quality embryos selected for transfer.

Study design, size, duration

A retrospective case control study between July 2013 and December 2020 which evaluated embryos from 58 ICSI cycles of women with endometriosis and 487 ICIS cycles of healthy women treated for male factor infertility. Morphokinetic parameters and rate of high-quality embryos were compared. High-quality was considered as: time to pronucleus fading (tPNf)<24.08, T2<26.6, S2<0.9, and t8<56 hours following insemination for cleavage embryos, and t2<26.6, S2<0.9, t8<56 and time to start blastulation (tSB)<96.6 hours for blastocysts.

Participants/materials, setting, methods

At a single infertility unit, women with endometriosis were compared to healthy women with male factor infertility as the control group. The main outcome was embryo kinetics which included: time to polar body extrusion (tPB2), time to pronucleus fading (tPNf), cleavage timings (t2-t8), synchrony of the second and third cycles (S2 and S3), duration of the second cycle (CC2) time to start blastulation (tSB). These parameters were set based on an in-house morphokinetic model.

Main results and the role of chance

We compared 154 embryos derived from 58 ICSI cycles of women with endometriosis to 1,387 embryos derived from 487 ICSI control cycles of couples with male factor as a single cause of infertility.There was a wider use of agonist protocol (48.3% vs 15.7%,p<0.001) and a higher rate of nuliparity (81% vs 61.5%, p = 0.003) in women with endometriosis compared to the control group. Demographic and treatment parameters were comparable including: maternal age, BMI, Gravidity, number of cycles, gonadotropins dosage, basal serum FSH, basal serum LH, estradiol and progesterone level at the day of ovum pick-up, number of oocytes aspirated, number of mature oocytes. There was no difference in tPB2, tPNf, t2-t8, S2 and S3, CC2, tSB between the groups. The rate of top quality embryos was comparable for both groups; for day 3 p = 0.25 and for day 5 p = 0.72. Pregnancy rate for the study and control group was 38.8% and 45%, respectively, p = 0.36.

Limitations, reasons for caution

One limitation is the retrospective methodology. Endometriosis severity was not taken into account which might be a confounding factor. The strengths are a single center study with embryos cultured under the same standardized laboratory conditions. However, a larger scale study might be needed.

Wider implications of the findings

Time lapse in-house model is an additive informative tool for embryo quality. Opposed to what was thought so far, the use of our time-lapsed system demonstrated that embryos of women with endometriosis had similar quality to healthy women. This can be used to reassure women with endometriosis before IVF treatment.

Trial registration number

not applicable

Changes in the obstetrical emergency department profile during the COVID-19 pandemic

BACKGROUND

The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection.

OBJECTIVES

To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department.

STUDY DESIGN

A retrospective cohort study in one medical center. The population was women > 20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department.

RESULTS

During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6, p = .001). Higher proportions of women in the COVID-19 cohort presented in active labor, defined by cervical dilation of at least 5 cm on admission to the labor ward [37 (9.3%) vs 28 (5.1%), p = .013)] and with premature rupture of membranes [82 (20.6%) vs 60 (11.0%), p < .001)], and consequently with more admissions to the delivery room [198 (49.7%) vs 189 (34.7%), p < .001)]. We also recorded a significant increase in urgent obstetrical events in the emergency department during the recorded COVID-19 pandemic [23 (5.8%) vs 12 (2.2%)), p = .004]. However, the rates of neonatal and maternal morbidity did not change. During the outbreak the proportion of visits during the night was higher than during the matched period of the previous year: [138 (34.7%) vs 145 (26.6%)), p = .008]. In a multivariate logistic regression, the higher rates of admission to the delivery room during active labor and of urgent events during the pandemic outbreak compared to the matched period in the previous year remained statistically significant.

CONCLUSIONS

The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

[Fibrinolysis of deep venous thrombosis on implantable perfusion devices. Apropos of a consecutive series of 57 cases of thrombosis and 32 cases of fibrinolysis]

The main complication of totally implantable venous access devices is deep venous thrombosis on catheter. It may dramatically reduce the already limited venous capacity of patients undergoing chemotherapy and obturate catheters, causing pulmonary embolism or functional disorders. These thromboses usually involve veins of the superior vena cava system where the catheters are implanted. Generally, they occur early, are extensive and often asymptomatic. Doppler ultrasonography is the diagnostic investigation of choice, phlebography being reserved for particular cases or to specify the limits of the thrombus. In a series of 412 vein access devices implanted and systematically monitored by Doppler ultrasonography, we found 57 thromboses (13.8%), 15 partial and 42 complete. The lowest thrombosis rate was observed in the right internal jugular vein (10% vs 20 to 23%, p = 0.006). Thirty-two patients received a systemic fibrinolytic treatment, 16 with streptokinase (SK), five with urokinase (UK), four with tissue plasminogen activator (rt-PA) and seven with SK/UK association. No serious side effects were observed. Sixteen repermeabilizations (50% of fibrinolysis) were obtained. There were no significant differences with respect to the fibrinolytic, the initial characteristics of thrombosis or the patients. Patients without fibrinolysis received 3 weeks of low molecular weight heparin (curative doses) then warfarin. Only one patient was repermeabilized with this treatment (significative difference with fibrinolysis: p = 0.009). Fibrinolysis is indicated in symptomatic thrombosis and/or in cases of extension to the innominate vein or the superior vena cava. Systematic monitoring by Doppler ultrasonography and prophylactic anti-thrombotic treatment are recommended in patients with implantable venous access devices in order to decrease the occurrence of thromboses, to detect asymptomatic patients at an early stage and to increase the effectiveness of fibrinolysis.

[Experimental prevention of deep venous thrombosis with low-molecular-weight heparin using implantable infusion devices]

We studied the effect of a fractionated heparin, Dalteparine Sodium, on the prevention of thrombosis of veins of the superior vena cava system catheterized by implantable infusion devices. Forty-six patients with solid or lympho-proliferative tumors, whose clinical condition required installation of a such device, were successively included into the study in 1991. The anticoagulant was administered for one month following implantation at the dosage of 2,500 anti-Xa units per day. The development of deep vein thrombosis was investigated by systematic Doppler ultrasound before the first and third months and at 1 year. Three early (D9, D12 and D16) and asymptomatic thrombosis were diagnosed (6.5%). This rate, although clearly more favourable, was not significantly different (p = 0.254) from the rate of 15.2% previously reported in a group of 72 comparable patients, but who did not receive preventive treatment. These results demonstrate the necessity and feasibility of a randomized study on a larger number of patients testing several protocols, before concluding on the efficacy of this type of preventive treatment.