A 10- to 20-year follow-up after tension-free vaginal tape for stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Midurethral slings (MUS) have become the gold standard in the treatment of stress urinary incontinence (SUI). Some information is already available on the outcome of tension-free vaginal tape (TVT) after 10 years or more. Our objective was to assess the current outcome (efficacy, adverse events) of women who had been successfully operated upon for SUI by means of a TVT procedure 10 to 20 years ago. METHODS: We performed a retrospective cohort study including 291 women (mean age 69.4 years) who underwent a successful TVT procedure (retropubic bottom-to-top route) in a teaching hospital between January 2001 and December 2010. The main outcome measure was the incidence of SUI at 10-20 years' follow-up. Others were incidence of re-operation, tape exposure and de novo overactive bladder symptoms. We carried out a univariate logistic regression analysis to examine the relationship between outcomes and a set of clinical variables. RESULTS: After a median of 15 years, TVT remains highly effective: 272 women (94%) experienced either no leakage under any circumstance (214=74%) or leakage less than weekly (58=20%). Mesh exposure (8=2.7%; 1.8 events per 1,000 patient-years) and repeat surgery for SUI (11=3.8%; 2.5 events per 1,000 patient-years) were low. Three women (1%) needed to perform intermittent self-catheterisation. Bothersome overactive bladder symptoms (45=15%) were common and associated with polypharmacy, cardiovascular medication and obesity. CONCLUSION: The efficacy of TVT is demonstrated up to 20 years. The presence of bothersome OAB symptoms in the population may be an indicator of multimorbidity.

The Use of a Vaginal Pessary to Decide Whether a Mid Urethral Sling should be Added to Prolapse Surgery.

PURPOSE: Women with pelvic organ prolapse are at risk for stress urinary incontinence after prolapse surgery. Combining pelvic organ prolapse repair with anti-incontinence surgery reduces the incontinence rate but leads to overtreatment. Performing only pelvic organ prolapse repair leads to under treatment. Is a vaginal ring pessary a useful tool when deciding whether a mid urethral sling should be added to prolapse surgery? MATERIALS AND METHODS: We performed a retrospective cohort study in women with symptomatic pelvic organ prolapse but without bothersome stress urinary incontinence who underwent vaginal prolapse repair between January 1, 2008 and December 31, 2017. Preoperatively a pessary was inserted in all women to detect occult stress urinary incontinence. If the pessary revealed bothersome stress urinary incontinence, a concomitant mid urethral sling was proposed. The primary outcome at followup was de novo stress urinary incontinence. RESULTS: Included in study were 220 women. After pessary insertion 132 women (60%) remained continent, 20 (9%) reported nonbothersome stress urinary incontinence and 68 (31%) had bothersome stress urinary incontinence. The latter group was offered combined surgery. At followup bothersome stress urinary incontinence was present in 12 of the 132 women (9%) who had been continent preoperatively and in 7 of the 20 (35%) who had had nonbothersome stress urinary incontinence. In 132 women who were continent with the pessary a total of 11 mid urethral sling procedures would have been needed to prevent postoperative stress urinary incontinence in 1 (number needed to treat was 11). In the 20 women who had nonbothersome stress urinary incontinence only 3 mid urethral sling procedures would have been necessary (number needed to treat was 3). CONCLUSIONS: In women with symptomatic pelvic organ prolapse a pessary is a useful tool when deciding whether to add a mid urethral sling.

Mode of delivery and mortality and morbidity for very preterm singleton infants in a breech position: A European cohort study.

OBJECTIVE: Caesarean section (CS) may reduce mortality and morbidity for very preterm breech infants, but evidence is inconclusive. We evaluated neonatal outcomes for singleton breech infants by mode of delivery in a European cohort. STUDY DESIGN: Data come from the EPICE population-based cohort of very preterm births in 19 regions in 11 European countries (7770 live births). The study population was singleton spontaneous-onset breech births at 24-31 weeks gestational age (GA) without antenatal medical complications requiring caesarean delivery (N = 572). Mixed-effects regression models adjusting for maternal and pregnancy covariates and propensity score matching was used to examine the effect of (1) CS and (2) a unit policy of systematic CS for breech presentation by GA. The primary outcome was a composite of in-hospital mortality, intraventricular haemorrhage grades III & IV or cystic periventricular leukomalacia. Secondary outcomes were each component separately, five minute Apgar score below seven and mortality within six hours of delivery. RESULTS: 64.4% of infants were delivered by CS with a range across regions from 41% to 100%; these infants had higher GA and were more likely to be small for gestational age, receive antenatal steroids, and have mothers who were hospitalised for more than one day before delivery compared to those delivered vaginally. CS was associated with lower risks of all outcomes in mixed-effects adjusted models (odds ratio (OR) for the composite outcome: 0.50, 95% confidence interval (CI): 0.30-0.81), but not in propensity score matched models (OR: 0.72, 95% CI: 0.41; 1.29). A systematic CS policy was associated with lower mortality and morbidity in unadjusted, but not adjusted models (OR for composite outcome: 0.76, 95% CI: 0.44; 1.28). 35% of births 24-25 weeks were delivered by CS and protective effects were consistently stronger, but not statistically significant. CONCLUSIONS: Point estimates indicated protective effects of caesarean delivery for very preterm breech infants in conventional statistical models. However, analyses using propensity scores and based on unit policies did not confirm statistically significant associations. Prospective large-scale studies are needed to establish best practice and could be implemented in European regions where vaginal delivery remains an option.

GPs' attitudes on a healthy lifestyle: a survey of GPs in Flanders.

BACKGROUND: Patients often consider health professionals to be role models for leading a healthy lifestyle but no data is available on tobacco, alcohol, or substance use among GPs in Flanders (northern Belgium). AIM: To estimate the prevalence of smoking, alcohol, and substance use among GPs, in order to determine factors that influence these habits and to elucidate GPs' attitudes toward a healthy lifestyle. DESIGN AND SETTING: Online survey-based study in Flanders, Belgium. METHOD: Sociodemographic data and individual risk behaviour were collected by an anonymous self-administered questionnaire. GPs and family doctors in training were sent an email request between 1 April and 31 May 2011. RESULTS: Of 626 responders, 57% were male. The mean age was 45 years. Eight per cent (n = 50) were current smokers. Independent risk factors for smoking were: working alone, hazardous alcohol consumption, and smoking cannabis. Fourteen per cent (n = 86) consumed alcohol daily and 12% (n = 73) admitted at least one episode of binge drinking per month. Being male, cigarette smoking, cannabis use, and long working hours were associated with an increased likelihood of hazardous drinking. Sixteen per cent (n = 101) had used sleeping pills and 12% (n = 72) had used minor opiates as painkillers in the year before the study. Two-thirds (64%, n = 399) of GPs said they would be reluctant to seek medical help if they were misusing drugs or alcohol. CONCLUSION: Smoking is uncommon in Flemish GPs; in contrast, alcohol consumption is high. GPs who misuse substances will not seek help readily.

Common determinants of breech presentation at birth in singletons: a population-based study.

OBJECTIVE: To estimate common determinants of breech presentation at parturition. STUDY DESIGN: A population-based cohort study (between 1/1/2001 and 31/12/2010) was conducted among all women who delivered a singleton baby in breech presentation from 22 completed weeks of gestation. A binary logistic regression was used to determine independent feto-maternal characteristics of breech presentation at birth, adjusted odds ratios and 95% confidence intervals. Variables were: gestational age, birth weight, maternal age, parity and gender of the baby, presence or absence of a history of cesarean section, gestational diabetes, gestational hypertension, pregnancy after assisted reproduction technology and congenital malformations. RESULTS: From a population of 611,021 women; 28,059 were delivered in breech presentation (4.59%). Independent determinants of breech presentation at delivery were: gestational age and birth weight (the lower, the higher the incidence of breech at birth), parity (the frequency of breech decreased with increasing parity) and maternal age (the older the mother, the higher the odds for breech presentation). Women who had a scarred uterus, due to a previous cesarean section, women who gave birth to a female offspring and women whose baby showed a congenital malformation, were more prone to be delivered in breech presentation. CONCLUSION: Low gestational age and birth weight, advanced maternal age, a scarred uterus, a female baby and a baby with a congenital malformation increased the odds for singleton breech presentation at parturition. The latter gradually decreased with increasing parity.

Fetal and infant health outcomes among immigrant mothers in Flanders, Belgium.

OBJECTIVE: To compare fetal and infant mortality between immigrant and native-born mothers in Flanders, Belgium. METHODS: In a population-based study, data from 326 166 neonatal deliveries, collected by the Study Center for Perinatal Epidemiology and the Belgian Civil Birth Registration system between January 2004 and December 2008, were analyzed. Immigrant mothers were defined as women born in any country other than Belgium, and were grouped by country of origin according to the World Bank Atlas definition of low-, middle-, and high-income countries. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to evaluate the association between immigration and fetal/infant outcome. RESULTS: In univariate analysis, fetal and infant mortality rates were significantly higher among immigrants than among native-born mothers (fetal: crude OR, 1.50; 95% CI, 1.29-1.75; infant: crude OR, 1.47; 95% CI, 1.29-1.67). Fetal/infant death rates were highest among mothers originating from low-income countries. In multivariate analysis, however, most differences became non-significant: only the early neonatal death rate remained significantly higher (adjusted OR, 1.30; 95% CI, 1.06-1.60), whereas the fetal death rate appeared lower (adjusted OR, 0.67; 95% CI, 0.57-0.80), among immigrant mothers. CONCLUSION: After adjustment for relevant characteristics, fetal/infant mortality was comparable between immigrant women and native-born women in Flanders.

Knowledge about human papillomavirus and the human papillomavirus vaccine in Belgian students.

INTRODUCTION: The aim of this study was to examine the knowledge of Belgian university students about the human papillomavirus (HPV) and HPV-vaccination. MATERIAL AND METHODS: During a period of two months we administered an online questionnaire, which contained 29 questions, to 3332 students of the Free University of Brussels. Of the 433 completed questionnaires, 346 were included by age (18-30 years) and completeness of responded questionnaires. These formed the study group. RESULTS: Of the 346 included questionnaires (76% female), 48% were completed by medical students. The majority (65%) knew that both genders could be infected with HPV. Ninety-five percent of all medical students were aware of the existence of HPV, while 92% knew of the possibility to be vaccinated against the virus. Ninety percent of them were aware of the causal relationship between HPV infection and cervical cancer. 46% of the medical students were aware that HPV can cause anogenital cancers, and only 28% knew that HPV-vaccination could protect them against genital warts. Sixty percent of all female students were fully vaccinated against HPV, without any difference between medical and non-medical students. A very small part of all students (3%) believed that vaccination against HPV could enhance a promiscuous lifestyle. CONCLUSIONS: Almost 80% of respondents were aware of the existence of the human papillomavirus, its morbid potential and the HPV-vaccination.

Perceptions of fatigue - and perceived consequences - among Flemish obstetricians-gynaecologists: a survey.

OBJECTIVES: The effects of fatigue on the performance of medical trainees have been extensively studied. Much less is known about the effects of fatigue among doctors who have completed their training. The aim of this study was to inquire about the perception of fatigue and its consequences among certified obstetricians-gynaecologists (OGs). METHODS: A questionnaire was mailed to all certified OGs working in Flanders (Northern Belgium). Descriptive statistics as well as uni- and multivariate analyses for potential determinants of fatigue are presented. RESULTS: Of the 450 questionnaires mailed, 260 (58%) were returned. Half (52%) of the doctors worked more than 60 h/week. During an average working day, four out of ten respondents indicated they experienced a certain degree of fatigue, and one in ten felt really tired. Fatigue was associated with long working hours and led in a sizeable proportion of respondents to dissatisfaction (29%) and to medical/surgical errors (19%). None of the perceived errors resulted in loss of life. Academic OGs worked more hours/week but fewer during the night than their colleagues in private practice. The former reported having made significantly more medical errors (26%) than the latter (11%). CONCLUSIONS: Tired OGs have less job satisfaction, and perceive they make more errors. None of the perceived errors resulted in loss of life. Certified OGs working more than 60 h/week are more frequently tired.

Limiting the caesarean section rate in low risk pregnancies is key to lowering the trend of increased abdominal deliveries: an observational study.

BACKGROUND: As the rate of Caesarean sections (CS) continues to rise in Western countries, it is important to analyze the reasons for this trend and to unravel the underlying motives to perform CS. This research aims to assess the incidence and trend of CS in a population-based birth register in order to identify patient groups with an increasing risk for CS. METHODS: Data from the Flemish birth register 'Study Centre for Perinatal Epidemiology' (SPE) were used for this historic control comparison. Caesarean sections (CS) from the year 2000 (N = 10540) were compared with those from the year 2008 (N = 14016). By means of the Robson classification, births by Caesarean section were ordered in 10 groups according to mother - and delivery characteristics. RESULTS: Over a period of eight years, the CS rise is most prominent in women with previous sections and in nulliparous women with a term cephalic in spontaneous labor. The proportion of inductions of labor decreases in favor of elective CS, while the ongoing inductions of labor more often end in non-elective CS. CONCLUSIONS: In order to turn back the current CS trend, we should focus on low-risk primiparae. Avoiding unnecessary abdominal deliveries in this group will also have a long-term effect, in that the number of repeat CS will be reduced in the future. For the purpose of self-evaluation, peer discussion on the necessity of CS, as well as accurate registration of the main indication for CS are recommended.

Mothers' level of education and childbirth interventions: A population-based study in Flanders, Northern Belgium.

BACKGROUND: Interventions to influence the time and way to be born have been a global concern for decades. Yet, limited information is available on what drives these interventions and their variation in frequency among countries, institutions, and practitioners. The objective of this study was to examine to what extent first-time mothers' educational achievement contributes to the frequency of childbirth interventions. METHODS: Childbirth interventions, including induction of labor, cesarean section, instrumental delivery, and epidural analgesia, registered by the Flemish Study Center for Perinatal Epidemiology for Belgian-born nulliparous women from 1999 to 2006, were linked to the level of maternal education, recorded by the Belgian civil birth registration. Education was divided into four levels based on the highest diploma attained and adjusted for marital and occupational status. RESULTS: Frequencies of all interventions were inversely related to the level of maternal education. The effect remained after adjustment for birth year, maternal age, marital status, occupation, infant birthweight, gestational age, assisted conception, and type of hospital. Effect sizes between highest and lowest levels of education were relatively small for operative (31% vs 36%) and instrumental vaginal birth (20.7% vs 22.3%) compared with "initiated delivery" (defined as labor induction and prelabor cesarean section; 30.2% vs 40.3%) and epidural analgesia (66.8% vs 78.0%). The educational gradient in initiated delivery occurred at all gestational ages, contributing to lower gestational age and lower birthweight of term infants with decreasing levels of education. CONCLUSIONS: In an affluent society with universal and equitable access to maternity care, the more educated women are, the more likely they are to have a spontaneous labor and spontaneous birth without intervention. (BIRTH 38:3 September 2011).

Perinatal outcome of twins compared to singletons of the same gestational age: a case-control study.

Our objective was to determine the perinatal outcome of first- and second-born twins compared to singletons, born at the same gestational age. To that end we conducted a case-control study in Flanders (Northern Belgium). During a 10-year period (01.01.1999-31.12.2008), the entire twin population - 11,154 first- and 11,118 second-born twins (cases) - was compared to 22,228 singletons (controls) with respect to fetal and neonatal (0-27 days) mortality. Only case and control infants of ≥ 500 grams were included, which explained the unequal number of first- and second-born twins. Mothers and their infants of cases and of controls were derived from the Flemish perinatal database and were matched for maternal age and parity, gestational age and gender of the offspring. The main outcome measures were fetal and neonatal mortality according to gestational age. The frequency of fetal death was statistically significantly less frequent in preterm born twins than in singletons, except at term where the reverse was seen in second-born twins compared to controls. After adjustment for congenital malformations, the results stayed unchanged. Below 28 weeks gestation, singletons had a significantly lower neonatal mortality rate than twins that persisted after adjustment for congenital malformations: the first-born twin versus singleton OR 1.71 (1.17-2.51) and second-born versus singleton OR 2.09 (1.43-3.05). Between 28 and 32 weeks, the second-born twin showed a survival advantage over the control singleton. Between 32 and 36 6/7 weeks both twins had a significantly higher survival rate than the corresponding singleton controls. However, after adjustment for congenital malformations, the aforementioned differences between 28 and 36 6/7 weeks disappeared. When at term, twins and singletons had a comparable, though very low, neonatal death rate. These results confirm previous published data. In conclusion, we demonstrated that the neonatal death rate was lower for twins between 32 and 36 weeks (from 28 weeks for the second born twin) when compared to a singleton of the same gestational age. After adjusting for congenital malformations, there was no statistical significant difference.

Dramatic increase (1997-2007) in the number of procedures for stress urinary incontinence in Belgium.

INTRODUCTION AND HYPOTHESIS: We wondered if the tension-free vaginal tape approach, introduced in 1998, influenced the rate of anti-incontinence surgery. METHODS: We determined the rates of anti-incontinence surgery in Belgium between 1997 and 2007, using the Belgian National Health Insurance Fund register covering the entire adult female population of nearly 4,420,000 women in Belgium. RESULTS: The rate per 1,000 women of anti-incontinence surgery increased from 0.54 in 1997 to 2.03 in 2004, after which a plateau was reached (2.01 in 2007). This nearly fourfold increase coincided with the introduction in 1998 on the Belgian market of the tension-free vaginal tape (+66% more interventions between 1998 and 2001). After the introduction of the transobturator tape in 2001, the rate increased even more dramatically (+118% between 2001 and 2004). CONCLUSIONS: Rates of anti-incontinence surgery increased by 272% in Belgium between 1997 and 2007. This increase coincided with the availability of tension-free mesh sling operations.

The higher the educational level of the first-time mother, the lower the fetal and post-neonatal but not the neonatal mortality in Belgium (Flanders).

OBJECTIVE: To assess, in a homogenous population of primiparous women, how fetal and infant (=first year of life) mortality varied by the mothers' level of education. STUDY DESIGN: We conducted an observational study in Flanders (Northern Belgium) involving 170,948 primiparous women who delivered in Flanders during the period 1999-2006, and their 174,495 babies. We linked the maternal education (3 levels) with a series of obstetrical and perinatal events, with special emphasis on fetal and infant death. A logistic regression analysis was performed to adjust for confounders. RESULTS: The incidence of fetal (0.21% - high level of education; 0.35% - medium level; 0.84% - low level) and infant mortality (0.32%; 0.41%; 0.70%, respectively), followed an inverse maternal educational gradient: higher with a lower level of education. However, neonatal death (0-27 days) was independent of the educational level of the mother. The age of the woman at delivery, the use of assisted reproductive technology and the incidence of twin birth increased while the rates of preterm birth (7.7% - high level; 8.9% - medium level; 10% - low level) and low birth weight (7.2%; 9.5%; 11.8%, respectively) decreased with the mother's educational level. CONCLUSION: Perinatal and obstetrical outcome differ according to the level of the education of the mother, which is a determinant of the incidence of fetal and post-neonatal death but not of early and late neonatal death (0-27 days).

Factors predictive of outcome in tension-free vaginal tape procedure for urinary stress incontinence in a teaching hospital.

INTRODUCTION: A study was performed to determine which patients' characteristics before tension-free vaginal tape (TVT) for stress incontinence are predictive of a failed outcome. METHODS: A prospective cohort of 305 women with urinary stress incontinence underwent a TVT procedure in a teaching hospital. TVT was considered successful when the patient was fully satisfied and no leakage was seen at the standardized stress test. Logistic regression analysis examined the relationship between outcome and 32 pre-, intra-, and postoperative patient characteristics. All operations were done by trainees under supervision and assistance. RESULTS AND CONCLUSIONS: Eighty one percent was successfully treated. Independent predictors of TVT failure were previous surgery for incontinence (P = 0.006), >2 pads/diapers per day before treatment (P = 0.012), chronic use of psychotropic medication (P = 0.012), and a more advanced age of the patient (P = 0.005). Postoperative urgency was independently related to preoperative urgency (P < 0.001). Independent predictors of postoperative dissatisfaction were urgency symptoms (P < 0.001) and the need for a re-intervention (P < 0.001).

Who will benefit from pelvic floor muscle training for stress urinary incontinence?

OBJECTIVE: The purpose of this study was to determine which patient characteristics are predictive of outcome before pelvic floor muscle training for stress urinary incontinence. STUDY DESIGN: This was an observational study at a single-center outdoor patient clinic in Brussels, Belgium, that comprised 447 women, aged 26 to 80 years (mean, 52.7 years), who had urinary stress incontinence. All the women received individual pelvic floor muscle training under the guidance of the same physiotherapist. Twenty-two patient characteristics were considered for outcome measurements. RESULTS: Forty-nine percent of the women considered their treatment to be successful; 51% of the women had experienced only some improvement, no change, or a worsening of their condition or had interrupted therapy. Three independent predictors of treatment failure were > or =2 leakages per day before treatment ( P < .0001), the chronic use of psychotropic medication ( P = .002), and a baseline positive stress test result at first cough ( P = .042). The odds were only 15% for an individual patient to be treated successfully when these 3 predictors were present. CONCLUSION: Pelvic floor muscle training is beneficial in one half of the patients who are treated in this manner. Two or more leakages per day at baseline and the chronic use of psychotropic medication significantly predicted therapy failure.

Outcome after elective labor induction in nulliparous women: a matched cohort study.

OBJECTIVE: To determine whether elective induction of labor in nulliparous women is associated with changes in fetomaternal outcome when compared with labor of spontaneous onset. STUDY DESIGN: All 80 labor wards in Flanders (Northern Belgium) comprised a matched cohort study. From 1996 through 1997, 7683 women with elective induced labor and 7683 women with spontaneous labor were selected according to the following criteria: nulliparity, singleton pregnancy, cephalic presentation, gestational age at the time of delivery of 266 to 287 days, and birth weight between 3000 and 4000 g. Each woman with induced labor and the corresponding woman with spontaneous labor came from the same labor ward, and they had babies of the same sex. Both groups were compared with respect to the incidence of cesarean delivery or instrument delivery and the incidence of transfer to the neonatal ward. RESULTS: Cesarean delivery (9.9% vs 6.5%), instrumental delivery (31.6% vs 29.1%), epidural analgesia (80% vs 58%), and transfer of the baby to the neonatal ward (10.7% vs 9.4%) were significantly more common (P <.01) when labor was induced electively. The difference in cesarean delivery was due to significantly more first-stage dystocia in the induced group. The difference in neonatal admission could be attributed to a higher admission rate for maternal convenience when the women had a cesarean delivery. CONCLUSION: When compared with labor of spontaneous onset, elective labor induction in nulliparous women is associated with significantly more operative deliveries. Nulliparous women should be informed about this before they submit to elective induction.