Assessing menstrual equity amongst BAMER women fleeing gender-based abuse in Sheffield (UK): A cross-sectional study.

OBJECTIVES: Menstruation is not openly discussed in numerous Black, Asian, minority ethnic and refugee (BAMER) communities. Consequently, it is unclear if transitioning between cultures impacts BAMER women's menstrual health. This study aimed to evaluate menstrual equity and sanitary protection preference amongst BAMER abuse survivors displaced to Sheffield (UK). METHODS: Fifty participants were recruited from women's support services between December 2018 and May 2019. Selection criteria required participants to menstruate, identify as BAMER, be displaced, and have experienced gender-based abuse. Descriptive and inferential statistical analyses were performed using SPSS (IBM, USA) to assess menstrual equity. RESULTS: Many struggled to afford products (86 %), changed them infrequently (68 %) or improvised sanitary wear (40 %). Financially restricted women often changed products irregularly (p = 0.02) or used proxy items (p = 0.02). Participants disliked reusable pads (48 %) and vaginally inserted products (tampons 46 %, cups 78 %) without having tried them. Negativity surrounding reusable pads (p = 0.01) and cups (p = 0.04) was linked to menstrual taboo. Few women knew of menstruation prior to menarche (28 %). These participants were more likely to accept male doctors (p = 0.04), unlike those that regarded menstruation as taboo (p = 0.02), unclean (p = 0.02) or shameful (p = 0.001). CONCLUSION: We provide key information regarding the menstrual health status of marginalised women. Our findings suggest limited menstrual-health education at menarche and negative belief-systems may compromise access to products and healthcare in adulthood. This study advises policymakers to unify distribution of hygienic absorbents and menstrual-health education to normalise menstruation, thereby reducing menstrual shame and empowering women to make informed sanitary protective choices.

Factors that influence pregnant women's decision on mode of delivery after previous obstetric anal sphincter injury.

PURPOSE: Maternal request for caesarean section (CS) is increasing. One common reason is following a previous obstetric anal sphincter injury (OASI). We aim to understand which factors bear the greatest influence in driving this women's decision-making process once they are pregnant after having sustained an OASI. METHODS: Pregnant women with a previous OASIS who were attending their first antenatal appointment were deemed eligible and were asked to complete two questionnaires on their preferred mode of delivery (MoD) and ongoing pelvic floor symptomatology. Data were analysed with descriptive and inferential statistics using SPSS, and results were presented both quanti- and qualitatively. RESULTS: Data from 63 participants was included in the final analysis. Most women had experienced 3A/3B OASIS (n = 49, 77.78 %), and they were more likely to report bladder pain and difficulties with voiding than those with major tears (p < 0.05). The type of tear did not impact directly on the preferred MoD. However, women still experiencing bladder pain were more likely to request a CS (p < 0.05). Even though all participants who attended a perineal trauma clinic postpartum found it helpful, they reported that ultimately the decision on how to deliver was theirs, and their ideas and concerns played the greatest influence. CONCLUSION: Pregnant women with ongoing urinary symptoms rather than sexual or bowel dysfunction seem to favour a planned CS, regardless of the severity of their previous tear. Postpartum follow-up in a perineal trauma clinic is extremely valuable but even more is the need to understand women's motivations to support them make an informed decision.

Interventions for the prevention of spontaneous preterm birth: a scoping review of systematic reviews.

BACKGROUND: Globally, 11% of babies are born preterm each year. Preterm birth (PTB) is a leading cause of neonatal death and under-five mortality and morbidity, with lifelong sequelae in those who survive. PTB disproportionately impacts low/middle-income countries (LMICs) where the burden is highest. OBJECTIVES: This scoping review sought to the evidence for interventions that reduce the risk of PTB, focusing on the evidence from LMICs and describing how context is considered in evidence synthesis. DESIGN: We conducted a scoping review, to describe this wide topic area. We searched five electronic databases (2009-2020) and contacted experts to identify relevant systematic reviews of interventions to reduce the risk of PTB. We included published systematic reviews that examined the effectiveness of interventions and their effect on reducing the risk of PTB. Data were extracted and is described narratively. RESULTS: 139 published systematic reviews were included in the review. Interventions were categorised as primary or secondary. The interventions where the results showed a greater effect size and consistency across review findings included treatment of syphilis and vaginal candidiasis, vitamin D supplementation and cervical cerclage. Included in the 139 reviews were 1372 unique primary source studies. 28% primary studies were undertaken in LMIC contexts and only 4.5% undertaken in a low-income country (LIC) Only 10.8% of the reviews sought to explore the impact of context on findings, and 19.4% reviews did not report the settings or the primary studies. CONCLUSION: This scoping review highlights the lack of research evidence derived from contexts where the burden of PTB globally is greatest. The lack of rigour in addressing contextual applicability within systematic review methods is also highlighted. This presents a risk of inappropriate and unsafe recommendations for practice within these contexts. It also highlights a need for primary research, developing and testing interventions in LIC settings.

Impact of changing gloves during cesarean section on postoperative infective complications: A systematic review and meta-analysis.

INTRODUCTION: The cesarean section rate around the world, currently estimated at 21.1%, continues to increase. Women who undergo a cesarean section sustain a seven- to ten-fold greater risk of infective morbidity compared with those who deliver vaginally. MATERIAL AND METHODS: We aimed to assess the impact of changing gloves intraoperatively on post-cesarean section infective morbidity (PROSPERO CRD42018110529). MEDLINE, Scopus, Web of Science, CINAHL, WHO Global Index Medicus, and Cochrane Central were searched for randomized controlled trials until June 2020. Published randomized controlled trials that evaluated the effects of glove changing during cesarean section on infective complications were considered eligible for the review. Two reviewers independently selected studies, assessed the risk of bias, and extracted data about interventions and adverse maternal outcomes. Dichotomous variables were presented and included in the meta-analyses as risk ratios (RR) with 95% confidence intervals (CI). The quality of evidence was assessed using the GRADE approach in alignment with the recommendations from the Cochrane Review Group. RESULTS: We identified seven randomized controlled trials reporting data over 1948 women. Changing gloves during a cesarean section was associated with a statistically significantly lower incidence of wound infective complications (RR 0.41, 95% CI 0.26-0.65, p < 0.0001; GRADE moderate quality evidence). This intervention seemed to be effective only if performed after delivery of the placenta. No significant difference was seen in the incidence of endometritis (RR 0.96, 95% CI 0.78-1.20, p = 0.74; GRADE moderate quality evidence) and/or febrile morbidity (RR 0.73, 95% CI 0.30-1.81, p = 0.50; GRADE moderate quality evidence), regardless of the timing of the intervention. CONCLUSIONS: Changing gloves after delivery of the placenta during a cesarean section is associated with a significant reduction in the incidence of post-surgical wound complications compared with keeping the same gloves throughout the whole surgery. However, an adequately powered study to assess the limitations and cost-effectiveness of the intervention is needed before this recommendation can be translated into current clinical practice.

Does hysteroscopic resection of uterine septum improve reproductive outcomes: a systematic review and meta-analysis.

PURPOSE: Uterine septum in women with subfertility or previous poor reproductive outcomes presents a clinical dilemma. Hysteroscopic septum resection has been previously associated with adverse reproductive outcomes but the evidence remains inconclusive. We aimed to thoroughly and systematically appraise relevant evidence on the impact of hysteroscopically resecting the uterine septum on this cohort of women. METHODS: AMED, BNI, CINAHL, EMBASE, EMCARE, Medline, PsychInfo, PubMed, Cochrane register of controlled trials, Cochrane database of systematic reviews and CINAHL were assessed to April 2020, with no language restriction. Only randomised control trials and comparative studies which evaluated outcomes in women with uterine septum and a history of subfertility and/or poor reproductive outcomes treated by hysteroscopic septum resection against control were included. The primary endpoint was live birth rate, whereas clinical pregnancy, miscarriage, preterm birth and malpresentation rates were secondary outcomes. RESULTS: Seven studies involving 407 women with hysteroscopic septum resection and 252 with conservative management were included in the meta-analysis. Hysteroscopic septum resection was associated with a lower rate of miscarriage (OR 0.25, 95% CI 0.07-0.88) compared with untreated women. No significant effect was seen on live birth, clinical pregnancy rate or preterm delivery. However, there were fewer malpresentations during labour in the treated group (OR 0.22, 95% CI 0.06-0.73). CONCLUSION: Our review found no significant effect of hysteroscopic resection on live birth. However, given the limited evidence available, high-quality randomised controlled trials are recommended before any conclusive clinical guidance can be drawn.

Acute Villitis and Intravascular Microorganisms in Fetal Vessels: A Case Report and Literature Review of an Unusual Histopathological Finding.

Optimal management of intrauterine infection to avoid serious adverse perinatal outcomes entails prompt administration of antibiotics and consideration of early delivery of the fetus to remove the focus of infection. We report an unusual case of preterm chorioamnionitis which did not improve with sensitive antibiotics, or delivery of the fetus, and ultimately required an emergency hysterectomy to save the mother's life. Interestingly, subsequent histopathological analysis of the post-hysterectomy specimen did not reveal myometrial necrosis or infectious microorganisms. The placental pathological examination, on the other hand, showed evidence of necrotising chorioamnionitis accompanied by a rarely reported lesion: acute villitis with abundant intravascular Escherichia coli, a finding which is strongly associated with fetal demise and adverse maternal outcomes.

The impact of endometrioma on in vitro fertilisation/intra-cytoplasmic injection IVF/ICSI reproductive outcomes: a systematic review and meta-analysis.

BACKGROUND: Assisted reproductive technologies (ART) such as in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) are often used to aid fertility in women with endometrioma; however, the implications of endometrioma on ART are unresolved. OBJECTIVE: To determine the effect of endometrioma on reproductive outcomes in women undergoing IVF or ICSI. METHODS: A systematic review and meta-analysis was conducted to identify articles examining women who had endometrioma and had undergone IVF or ICSI. Electronic searches were performed in PubMed, BIOSIS and MEDLINE up to September 2019. The primary outcome was live birth rate (LBR). Secondary outcomes included clinical pregnancy rate (CPR), implantation rate (IR), number of oocytes retrieved, number of metaphase II (MII) oocytes retrieved, number of embryos and top-quality embryos and the duration of gonadotrophin stimulation and dose. RESULTS: Eight studies were included. Where significant heterogeneity between studies was identified, a random-effects model was used. The number of oocytes (weighted means difference; WMD-2.25; 95% CI 3.43 to - 1.06, p = 0.0002) and the number of MII oocytes retrieved (WMD-4.64; 95% CI 5.65 to - 3.63, p < 0.00001) were significantly lower in women with endometrioma versus controls. All other outcomes, including gonadotrophin dose and duration, the total number of embryos, high-quality embryos, CPR, IR and LBR were similar in women with and without endometrioma. CONCLUSION: Even though women with endometriomas had a reduced number of oocytes and MII oocytes retrieved when compared to women without, no other differences in reproductive outcomes were identified. This implies that IVF/ICSI is a beneficial ART approach for women with endometrioma.

Polarization-sensitive optical coherence tomography with a conical beam scan for the investigation of birefringence and collagen alignment in the human cervix.

By measuring the phase retardance of a cervical extracellular matrix, our in-house polarization-sensitive optical coherence tomography (PS-OCT) was shown to be capable of (1) mapping the distribution of collagen fibers in the non-gravid cervix, (2) accurately determining birefringence, and (3) measuring the distinctive depolarization of the cervical tissue. A conical beam scan strategy was also employed to explore the 3D orientation of the collagen fibers in the cervix by interrogating the samples with an incident light at 45° and successive azimuthal rotations of 0-360°. Our results confirmed previous observations by X-ray diffraction, suggesting that in the non-gravid human cervix collagen fibers adjacent to the endocervical canal and in the outermost areas tend to arrange in a longitudinal fashion whereas in the middle area they are oriented circumferentially. PS-OCT can assess the microstructure of the human cervical collagen in vitro and holds the potential to help us better understand cervical remodeling prior to birth pending the development of an in vivo probe.

Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis.

BACKGROUND: One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients. METHODS: We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES. RESULTS: Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy. CONCLUSIONS: The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.

Visualisation of the insertion of a membrane for the treatment of preterm rupture of fetal membranes using a synthetic model of a pregnant uterus.

Preterm premature rupture of fetal membranes is a leading cause of preterm delivery. Preterm labour can compromise fetal survival, and even if a pregnancy affected by preterm premature rupture of fetal membrane continues, major complications associated with leakage of amniotic fluid and risk of infection can affect the normal development and survival of the baby. There are limited management options for preterm premature rupture of fetal membrane other than delivery of the baby if ascending infection (chorioamnionitis) is suspected. We have previously reported the development and characterisation of an implantable membrane with the aim of using it to occlude the internal os of the cervix, in order to prevent amniotic fluid loss, allow fluid reaccumulation and reduce the risk of chorioamnionitis. For this, an electrospun biocompatible and distensible bilayer membrane was designed with mechanical properties similar to the human amniotic membrane. In this study, we consider the effects of sterilization on the membrane, how to insert the membrane and visualise it using routine clinical methods. To do this, we used e-beam sterilisation and examined the ability of the membrane to adhere to ex vivo human cervical tissues. We also studied its insertion into a custom-synthesised model of a 20-week pregnant uterus and imaged the membrane using ultrasound. Sterilisation produced minor effects on physical and mechanical properties, but these did not affect the capacity of the membrane to be sutured or to provide a fluid barrier. We demonstrated that fibrin glue can successfully adhere the bilayer membrane to cervical tissues. Finally, we demonstrated that the membrane can be inserted through the cervix as well as visualized in place using ultrasound imaging and an endoscope. In summary, we suggest this membrane is a candidate for further development in an appropriate animal model, supported by appropriate imaging, to precede possible future human studies if judged to demonstrate satisfactory safety and efficacy profiles.

Second Harmonic Generation microscopy reveals collagen fibres are more organised in the cervix of postmenopausal women.

BACKGROUND: During labour, the cervix undergoes a series of changes to allow the passage of the fetoplacental unit. While this visible transformation is well-described, the underlying and causative microscopic changes, in which collagen plays a major role, are poorly understood and difficult to visualise. Recent studies in mice and humans have shown that Second Harmonic Generation (SHG) microscopy, a non-destructive imaging technique, can detect changes in the cervical collagen. However, the question of whether SHG can identify changes in the arrangement of cervical collagen at different physiological stages still needs addressing. Therefore, this study aimed to compare the cervical collagen alignment between pre- and postmenopausal women using SHG and to generate proof-of-concept data prior to assessing this technique in pregnancy. METHODS: Cervical biopsies from premenopausal (n = 4) and postmenopausal (n = 4) multiparous women undergoing hysterectomy for benign conditions were cross-sectionally scanned using an upright confocal microscope. SHG images were collected in Z-stacks and qualitatively evaluated using semi-quantitative scoring (0-3 in ascending degree of alignment) by assessors who were unaware of the classification of the SHG images, and quantitatively, using 2D Fourier transformation analysis. The dominant orientation and difference in dispersion of collagen fibres in each z-stack (X ± SD) was calculated and compared between groups. RESULTS: Qualitatively, collagen fibres appeared more organised in postmenopausal women, [premenopausal: median 0, range (0-1), postmenopausal: median 1.25, range (1-3); X 2 (df = 5) = 19.35, p = 0.002]. Quantitatively, there was a statistically significant difference in collagen fibre dispersion between premenopausal (5.39° ± 12.68°) and postmenopausal women (-1.58° ± 8.24°), [Welch's t-test (245.54) = 5.54, p < 0.01], with no significant differences in dispersion within each group [premenopausal, Welch's F (7, 57.23) = 1.84, p = 0.098; postmenopausal, Welch's F (7, 57.28) = 1.39, p = 0.23]. CONCLUSION: These results suggest an increased alignment of cervical collagen in postmenopausal women which may result in increased stiffness and reduced compliance, confirm that SHG microscopy can provide qualitative and quantitative information about cervical collagen orientation without sample preparation, and support further research to explore SHG as a means of assessing cervical remodelling to predict the timing of term and preterm labour.