Objective: Child marriage forces a girl into adult roles before physical and psychological maturity, which can take a toll on women’s health over the life course. This paper aims to assess whether child marriage and adolescent childbearing are associated with elevated risk of gynecologic disorders leading to hysterectomy. Design: Cross-sectional and survival analysis. Setting: India, nationally representative survey. Population: 528,816 ever married women, aged 20-49 years. Methods: Women were grouped in four mutually exclusive categories – i) married adult – not an adolescent mother (reference category), ii) married adult – adolescent mother, iii) married child – not an adolescent mother, and iv) married child – adolescent mother. Multivariable logistic regressions were fitted to assess the odds of hysterectomy for these groups. Non-parametric Kaplan-Meier survivor functions were estimated to evaluate survival rates across the groups. Main outcome measures: Whether had a hysterectomy and age when hysterectomy was performed. Results: Compared to women married as adult – not an adolescent mother, women married in childhood and who gave birth in adolescence were 1.87 (95% CI: 1.78–1.96) times more likely to have a hysterectomy and had the lowest survival rate for hysterectomy. Women married as children but not an adolescent mother also had higher odds of hysterectomy (AOR = 1.40, 95% CI: 1.31–1.50). These results were robust across sub-groups including geographic regions, urban/rural residence, education, and income. Conclusions: Our results, showing a strong relationship between child marriage and hysterectomy, contribute to the literature on later-life health consequences of child marriage and call for strengthening efforts to eradicate child marriage.

Delivering in or out of water, the OASI rates in the POOL cohort study are disturbingly highDear Dr Papageorghiou,We have read with interest the POOL study report by Sanders et al. published in your journal.1 We acknowledge that the results of this study are based on a large obstetric cohort of low-risk women.The mere conclusion of the authors is that birth in water is not associated with increased risks for mothers and babies. However, in doing so, they seem to have overlooked an important issue related to the event rate in their comparator group. Indeed, the reported obstetric anal sphincter injury (OASI) rates of 5.0% in nulliparous and 1.3% in multiparous women are remarkably, if not unacceptably high. Particularly, given the risk for serious, often untreatable complications strongly associated with such injury.The reported event rates in the pool study are an outlier when compared to the 1.6% reported in other studies.3 The reported rates in the POOL study are comparable to those reported by Gurol-Urganci et al.4 Nonetheless, 20% of the women in the Gurol-Urganci et al study had operative vaginal births, a strong risk factor for OASI. In contrast, the POOL study cohort were all low-risk spontaneous births.The POOL study describes women delivering in and out of water, but the authors do not comment if manual perineal protection was used or not in either of the groups. Applying interventions, like manual perineal protection at the time of water birth may be challenging and does not tend to be attempted in some healthcare settings.Manual perineal protection was earlier associated with a significant reduction in OASI risk in Norway and Denmark and the UK. Fodstad et al. describe that the OASI prevalence in Norway in all vaginal deliveries has reduced from 4.2% in 2004 to 1.6% in 2023, after introduction of a national program with manual perineal protection.3Gurol-Urganci et al. have also demonstrated a significant reduction OASI rates in a healthcare setting comparable to that of Saunders et al. Moreover, the RCOG and, more recently, the published report from the All-Party Parliamentary Group on Birth Trauma have recommended the roll out and implementation, underpinned by sufficient training, of the OASI care bundle to all hospital trusts to reduce risk of perineal injuries in childbirth.4 Hence, it would have been expected that a UK based study using perineal trauma as its primary outcome would address and discuss what interventions were undertaken to mitigate the risk of trauma.We believe that there is a high risk that the exceptionally high OASI rate in the comparator arm has introduced bias in this non-inferiority RCT. Sanders et al conclude that their “Study findings provide reassurance that birth in water, in the context of UK midwifery practice, is not associated with increased risks for mothers or their babies. However, given the 2015 Supreme Court Montgomery ruling stating that “clinicians should disclose risks of childbirth” one should question, why the risk of childbirth in the POOL study was so unacceptably high and still remained undiscussed?Jan Willem de Leeuw, Department of Obstetrics and Gynaecology, Ikazia Ziekenhuis Rotterdam, the NetherlandsKatariina Laine, Norwegian Research Centre for Women’s Health, Oslo University Hospital, Oslo, Norway, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, NorwayMargareta Manresa, Clinic Institute of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, SpainSari Raisanen, Laurea University of Applied Sciences, Vantaa, FinlandVladimir Kalis, Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Center for Pelvic-floor Disorders, Pilsen, CzechiaZdenĕk Rušavý, Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles UniversityRenaud de Tayrac, Obstetrics and Gynaecology Department, Nimes University Hospital, University of Montpellier, Nimes, France

Obstetric anal sphincter injuries during instrumental vaginal deliveryPrathamesh Lanjewar1, Avir Sarkar11 – Department of Obstetrics and Gynecology, Noida International Institute of Medical Sciences, Noida, Uttar Pradesh, IndiaCorresponding author: Avir SarkarE mail: [email protected]: 6280765384Type of article: Letter to the EditorShort Title: Obstetric anal sphincter injuryInstitutional Ethics Committee Approval: Not requiredFinancial disclosure: No financial support has been obtained for this articleConflict of interest between authors: None declared

Evaluating Waterbirth Risks: A Deep Dive into the POOL Cohort Study’s Research GapsWei-Zhen Tang a, Tai-Hang Liu a,**, Xia Lan a,*

Objective: To investigate the prevalence and experience of symptom flares in women with Chronic Pelvic Pain (CPP) as well as their triggers Design: Cross-sectional questionnaire within the Translational Research in Pelvic Pain clinical cohort study. Setting: Women with CPP, with subgroups of women with endometriosis (EAP), interstitial cystitis/bladder pain syndrome (BPS), comorbid endometriosis and interstitial cystitis/bladder pain syndrome (EABP), and those with pelvic pain without endometriosis or interstitial cystitis/bladder pain syndrome (PP). Population or sample: 100 participants across subgroups. Methods: Questionnaire within large cohort study. Main Outcome Measures: The prevalence and characteristics of short, medium and long symptom flares in CPP. Results: 76% of women with CPP experience symptom flares of at least one length (short, medium and/or long). Flares are associated with painful and non-painful symptoms. There is large variation amongst those with CPP for the frequency, duration, symptoms and triggers for these flares. Participants reported flares as stopping them from doing things they would usually do, participants thinking about symptoms of flares as well as flares being bothersome. Conclusions: Flares are prevalent and clinically very important in the context of CPP. More research is needed to elucidate the mechanisms and characteristics underlying flares. Clinical practice should include an enquiry of flares with the aim of finding strategies to lessen their burden. Funding: This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777500. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA Companies.

Globally, obstetric fistula is a tragic outcome following obstructed labor. Failure of complex repairs and post-operative incontinence are common. We describe an innovative surgical technique incorporating the rectus abdominis muscle flap at the time of fistula repair. We report outcomes from six patients at the Fistula Care Center in Lilongwe, Malawi in October 2023. At three months following discharge, five patients (80.0%) were continent; one patient was unable to follow-up but was continent at a one-month phone follow-up. There were no major complications. The rectus abdominis muscle flap may be considered in challenging obstetric fistula repairs.

A document by Sabthagi Sivathasan. Click on the document to view its contents.

Objective To investigate the association between postpartum haemorrhage (PPH) and subsequent cardiovascular disease. Design Population-based retrospective cohort study, using record linkage between Aberdeen Maternity and Neonatal Databank (AMND) and Scottish healthcare datasets Setting Grampian region, Scotland Population or Sample 70,904 women who gave birth after 24 weeks of gestation, 1986-2016 Methods We used extended Cox regression models to investigate the association between PPH in any first or later births and subsequent cardiovascular disease, adjusted for sociodemographic, medical, and pregnancy and birth-related factors. Main outcome measures Cardiovascular disease identified from prescription of selected cardiovascular medications, hospital discharge records or death from cardiovascular disease. Results Compared with not having a PPH, having at least one PPH was associated with an increased risk of developing cardiovascular disease in the first year after birth [adjusted hazard ratio (aHR) 1.96, 95% confidence interval (CI) 1.51-2.53, p<0.001]. The association was attenuated over time, but strong evidence of increased risk remained 2-5 years (aHR 1.19, 95% CI 1.11-1.30, p<0.001) and 6-15 years after giving birth (aHR 1.17, 95% CI 1.05-1.30, p=0.005), with the direction of association reversed beyond 15 years (aHR 0.64, 95% CI 0.55-0.75, p<0.001). Conclusions Compared with women who have never had a PPH, women who have had at least one episode of PPH are twice as likely to develop cardiovascular disease in the first year after birth and some increased risk persists for up to 15 years. Keywords Postpartum haemorrhage, cardiovascular disease, health outcomes, Scottish data

Massive waste in obstetric prediction research

Prevention, the way to go.

Objective To identify a diagnostic microbial signature for endometriosis. Design Prospective cohort study Setting Nepean Hospital and UNSW Microbiome Research Centre, St George Hospital, Australia Population 64 age- and sex-matched subjects ( n=19 HC; n=24 N-ENDO and n=21 ENDO). All study participants, besides healthy controls, underwent laparoscopic surgical assessment for endometriosis, and histology was performed on excised lesions. Methods Oral, stool, and vaginal samples were self-collected at a single time point for healthy controls, and pre-operatively for patients undergoing laparoscopy. Samples underwent 16S rRNA amplicon sequencing, followed by bioinformatics analysis. Main Outcome Measures Compositional differences between cohorts as identified by diversity analyses, and differentially abundant microbial taxa, as identified by LEfSE analysis. Results The composition of the oral, stool, and vaginal microbiota is different between healthy controls and patients with and without endometriosis. Differentially abundant taxa are present within each cohort. Particularly , Fusobacterium was enriched in the oral samples from patients with moderate/severe endometriosis. Conclusions Distinct taxonomic and compositional differences were found between the microbiota in the mouth, gut and vagina of patients with and without endometriosis and healthy controls. Fusobacterium is noted as a key pathogen in periodontal disease, a common comorbidity in endometriosis. These findings support a role for the oral, vaginal, and stool microbiome in endometriosis, and present potential for microbial-based treatments and the design of a diagnostic swab.

Objective: to assess the effectiveness and acceptability of a pillow-like position modification device to reduce supine sleep during late pregnancy, and to determine the impacts on the severity of sleep-disordered breathing (SDB) and fetal wellbeing. Design: Randomised cross-over study Setting and population: Individuals in the third trimester of pregnancy receiving antenatal care at a tertiary maternity hospital in Australia. Methods: Participants used their own pillow for a control week and an intervention pillow for a week overnight, in randomized order. Sleep position and total sleep time for each night of both weeks was objectively monitored, with a sleep study and fetal heart rate monitoring performed on the last night of each week. Main Outcome Measures: Percentage of sleep time in the supine position, apnoea-hypopnoea index, fetal heart rate decelerations and birthweight. Results: Forty-one individuals were randomized with data collected on 35 participants over 469 nights. There was no difference in percentage of total sleep time in the supine position overnight between the control or intervention pillow week (13.0% [6.1, 25.5] v 16.0% [5.6, 27.2], p = .81), and no difference in the severity of SDB or fetal heart rate decelerations across weeks. However, increased supine sleep was significantly related to a higher apnea-hypopnea index (r s = .37, p = .003), lower birthweight (r s = -.45, p = .007) and lower customised birthweight centile (r s = -.45, p = .006). The proportion of supine sleep each night of the week varied widely both within and across participants, despite awareness of side-sleeping recommendations. Conclusions: The adoption of a pillow designed to discourage supine sleep was not effective in late pregnancy, with women spending an average of one hour per night supine. Supine sleep was associated with SDB and lower birthweight. Alternative devices should be investigated, incorporating lessons learnt from this study to inform trials of supine sleep minimisation in pregnancy. Clinical Trial Registration Number – ACTRN12620000371998 (Australia New Zealand Clinical Trials Registry)

Time to standardise terminology in the ultrasound study of the pelvic floor of pregnant women Joelene Murdoch-Ward, Irmina Nahon, Sally De-Vitry Smith, Eliza Bernardi, Tamara WoodsUniversity of Canberra, Faculty of Health, Canberra ACT, Australia. The Physiotherapy Clinic, Sydney NSW, AustraliaUniversity of Canberra, Faculty of Health, Canberra ACT, Australia 2610University of Canberra, Faculty of Health, Canberra ACT, Australia 2610The Physiotherapy Clinic, Sydney NSW, AustraliaThe Physiotherapy Clinic, Sydney NSW, Australia

Objective: Pregnancy with complicated type B aortic dissection is a rare but devastating scenario. And there are no definitive guidelines for management and therapy. We report our exploration and experiences of managing five pregnant with complicated TBAD in the second or third trimesters, aiming to propose an appropriate management strategy. Design: Retrospective study. Setting: Zhongnan Hospital of Wuhan University. Population: Pregnant women with TBAD Methods: The clinical data of 5 pregnant women with TBAD who were admitted to the Zhongnan Hospital of Wuhan University from January 2022 to June 2023 were collected. The clinical features, diagnostic procedures, treatment strategies and corresponding maternal and infant outcomes were retrospectively analyzed. Main Outcome Measures: The survival of mother and fetus. Result: All five pregnant women with TBAD were diagnosed with complicated TBAD. The average age of the patients was (34.8±8.13) years, and the range of gestational weeks at admission was 27 weeks plus 3 days to 36 weeks plus 6 days. The first patient intending to receive a cesarean section and subsequent TEVAR died of rupture of aortic dissection during cesarean section. Her neonate was successfully rescued. The remaining four patients who underwent TEVAR first survived. Three underwent single-stage aortic repair and delivery, and one patient underwent cesarean section 27 days after TEVAR. Three preterm live births of these four patients were recorded. During late follow-up, no maternal and fetal deaths occurred. Neither device-related nor systemic complications post TEVAR were observed in the mother. Routine physical examinations of four live births showed no abnormalities. Conclusion: When a pregnant woman in the second or third trimester has thoracic back pain and highly suspected aortic dissection, CTA should be performed to avoid missed diagnosis, misdiagnosis and diagnostic delay. Once diagnosed, maternal survival should be prioritized over fetal concerns. TEVAR is safe and feasible for such patients. For complicated TBAD in the third trimester single-stage delivery and TEVAR are preferred, and TEVAR followed by cesarean section performed in one operative session is the treatment of choice.

Aim: To develop evidence-based clinical algorithms for the assessment and management of spontaneous, uncomplicated labour and vaginal birth. Population: Pregnant women at any stage of labour, with singleton, term pregnancies considered to be at low risk of developing complications. Setting: Health facilities in low- and middle-income countries. Search Strategy: We searched for relevant published algorithms, guidelines, systematic reviews and primary research studies on Cochrane Library, PubMed, and Google on terms related to spontaneous, uncomplicated labour and childbirth up to 01 June 2023. Case scenarios: Three case scenarios were developed to cover assessments and management for spontaneous, uncomplicated first, second and third stage of labour. The algorithms provide pathways for definition, assessments, diagnosis, and links to other algorithms in this series for management of complications. Conclusions: We have developed three clinical algorithms to support evidence-based decision making during spontaneous, uncomplicated labour and vaginal birth. These algorithms might help guide health care staff to institute respectful care, appropriate interventions where needed, and potentially reduce the unnecessary use of interventions during labour and childbirth.

Objectives: To investigate psychological correlates in women referred with suspected ovarian cancer via the fast-track pathway, explore how anxiety and distress levels change 12 months post-testing and report cancer conversion rates by age and referral pathway. Design: Single arm prospective cohort study Setting: Multicentre. Secondary care including outpatient clinics and emergency admissions. Participants: 2596 newly presenting symptomatic women with a raised CA125 level, abnormal imaging or both. Methods: Women completed anxiety and distress questionnaires at recruitment and at 12 months for those who had not undergone surgery or a biopsy within 3 months of recruitment. Main outcome measures: Anxiety and distress levels measured using STAI-6 and IES-r questionnaires. OC conversion rates by age, menopausal status and referral pathway. Results: 1355/2596 (52.1%) and 1781/2596 (68.6%) experienced moderate-to-severe distress and anxiety at recruitment. Younger age and emergency presentations had higher distress levels. Clinical category for anxiety and distress remained unchanged/worsened in 76% at 12 months despite a non-cancer diagnosis. OC rates by age were 1.6% (95% CI 0.5 to 5.9) under 40 and 10.9 % (95% CI 8.7 to 13.6) over 40 years. In women referred through fast-track pathways, 3.3% (95% CI 1.9 to 5.7) of pre- and 18.5% (95% CI 16.1 to 21.0) of postmenopausal women were diagnosed with OC. Conclusions: Women undergoing diagnostic testing display severe anxiety and distress. Younger women are especially vulnerable and should be targeted for support. Women under 40 have low conversion rates and we advocate reducing testing in this group to reduce harms of testing.

Objective: Approximately 50% women who give birth after Obstetric Anal Sphincter Injury (OASI) develop anal incontinence (AI) over their lifetime. We review current evidence for protective benefit of planned cesarean section (CS) to prevent AI after OASI. Design and setting: Systematic review and meta-analysis according to prospectively published methodology. Population and methods: All studies reporting outcomes after an OASI and subsequent birth by any mode. Main outcome measures: AI measurement after OASI and subsequent birth. Total AI, new/worsening AI, quality of life, satisfaction, regret. Results: 86 of 2472 screened studies met inclusion criteria. All studies contributing to meta-analyses were at high risk of bias. There was no evidence of difference in new or worsening AI after subsequent vaginal birth (VB) compared to subsequent CS after OASI across all time periods (p=0.53: CI 0.72-1.19; 9 studies, 2104 participants); ≤2y (p=0.83: CI 0.65-1.72; 7 studies, 569 participants) or ≥5y after subsequent birth (p=0.39: CI 0.65-1.18; 2 studies; 1535 participants). There was no difference between subsequent CS or VB in asymptomatic women or for other AI or QOL outcomes. There was no evidence of difference in AI in women who subsequently delivered vs those who did not (p=0.9: CI 0.71-1.34; 10 studies, 970 participants); or pre- subsequent birth vs post-subsequent birth (p=0.31; CI 0.51-1.25, 13 studies, 5496 participants). Conclusions: Due to evidence quality (majority non-randomised studies) we are unable to determine whether planned cesarean is protective against AI after OASI. Higher quality data is required to guide practice in this area, specifically in asymptomatic women and for long-term outcomes.

COVID-19 vaccination and pregnancy: getting the word outVictoria Male, Senior Lecturer in Reproductive Immunology, Imperial College LondonPregnancy is a risk factor for severe COVID-19, doubling the likelihood that an unvaccinated individual requires intensive care, invasive ventilation, or ECMO. Between March 2020 and December 2021 in the UK, COVID-19 emerged as the leading cause of death during pregnancy: among the 33 women who succumbed to the virus, none had been fully vaccinated (Knight et al, ISBN: 978-1-7392619-4-8). Furthermore, in unvaccinated individuals, SARS-CoV-2 during pregnancy can adversely affect infants, increasing the odds of preterm birth by 1.5-fold and those of stillbirth or neonatal death by approximately 3-fold (Male, Nat Rev Immunol, 2022, 22:277-82).In the face of these concerning statistics, COVID-19 vaccination in pregnancy seems a sensible precaution. Clinical trials and subsequent observational studies demonstrated that COVID-19 vaccination is safe and effective in the general population, but expectant parents naturally have an important additional question: is it safe for my baby?In the clinical trials of the COVID-19 vaccines, pregnancy was an exclusion criterion but nonetheless 102 participants became pregnant during mRNA vaccine trials, with miscarriage rates no different between the vaccinated and control groups. Early observational studies focussed on outcomes at birth which, during the pandemic, have been somewhat better in vaccinated individuals, particularly with respect to outcomes influenced by SARS-CoV2 infection (Prasad, Nat Comms, 2022, 13:2412*). A population-based cohort study published in this issue of BJOG (please add reference) is the latest in a mounting number of observational studies that examine the risk of early pregnancy loss following COVID-19 vaccination, controlling for gestational age and relevant medical and social confounders. This is the first to formally consider termination of pregnancy at the patient’s request as a competing risk, but whether or not this was including in the analysis, the authors found no increased risk of miscarriage associated with COVID-19 vaccination either during or before pregnancy.The evidence is now clear: COVID-19 vaccination is safe in pregnancy, but infection is not. Despite this, COVID-19 booster uptake among those eligible due to pregnancy remains low, peaking at 19% in the 2022-23 booster season. Some people are not aware their pregnancy makes them eligible for a booster and, among those who are, not all are informed of the extensive evidence on the safety and benefits of COVID-19 vaccination in pregnancy. Others believe their primary course of vaccination, or a previous infection, is sufficient to protect them. Although a primary course of vaccination continues to protect against severe disease, evidence on how long protection lasts, particularly in the face of new variants, is not yet available: as time elapses the benefit of a booster is expected to increase. Pertinently, people continue to die of flu during and shortly after pregnancy, despite having been exposed to the virus throughout their lives. In the UK, two women recently died this way: neither had received the recommended flu booster during pregnancy (Knight et al, ISBN: 978-1-7392619-4-8).While ongoing research remains important for confirming the safety of COVID-19 vaccination during pregnancy, it is unlikely that any new study will overturn the wealth of evidence we have already amassed. The challenge now is to get the word out.* For a regularly updated list of studies concerning the safety of COVID-19 vaccination in pregnancy, please see http://bit.ly/pregnancysafety