Managing couples with recurrent miscarriage: A narrative review and practice recommendations.

There is significant variation in practice when managing couples with recurrent miscarriage (RM), with guidelines differing on the definition of RM, recommended investigations, and treatment options. In the absence of evidence-based guidance, and following on from a paper by the authors-FIGO Good Practice Recommendations on the use of progesterone in the management of recurrent first-trimester miscarriage-this narrative review aims to propose a global holistic approach. We present graded recommendations based on best available evidence.

A systematic review and meta-synthesis of qualitative studies on childbirth perineal trauma for the development of a Core Outcome Set.

OBJECTIVES: Perineal injury occurs in 85% of cases during vaginal childbirth. This study aimed to synthesize qualitative data on women's perceptions of perineal trauma during vaginal childbirth. STUDY DESIGN: Thematic synthesis was applied utilizing a structured three-step framework. First, line-by-line coding strategy was applied to the included studies. Secondly, related codes were grouped together to develop descriptive themes to emphasize what matters most for women suffering from childbirth perineal trauma. Thirdly, analytical themes were developed. The quality of the included studies was high based on the assessment using the Critical Appraisal Skills Programme tool. RESULTS: Ten eligible studies were included in the meta-synthesis. Twenty-three codes encompassing multiple aspects of childbirth trauma from women's perspective were organised into a set of eight descriptive themes: psychosocial effects, communication, recovery, pain, support, knowledge of childbirth perineal trauma, sexuality, and prioritization. CONCLUSIONS: Among the descriptive themes, psychosocial effects, communication, and recovery exhibited the highest prevalence. The findings of this meta-synthesis may serve as a reporting guideline for future studies investigating the consequences of childbirth perineal trauma, ensuring that women's priorities are accurately reflected in reported outcomes.

Surgical and Quality of Life Outcomes Following Robotic-Assisted (da Vinci) Laparoscopic Repair of Vesicovaginal Fistula: A Case Report and Video Demonstration.

This report presents the case of a 63-year-old woman who developed a vesicovaginal fistula as a complication of a previous total hysterectomy. The fistula was treated with the use of the da Vinci X surgical system by a multi-disciplinary operating team, including senior Robotic Urological and Gynecological Surgeons at St. Luke's Hospital in Thessaloniki, Greece. The patient was monitored up to 12 months post-op at the time of writing and she was asked to evaluate post-op quality of life using the SF-36 and ICIQ-SF-UI questionnaires. The robotic surgical procedure was completed successfully. The total operation duration was 105 minutes, without any intra-operative complications. The patient was hospitalized for two days and made a swift, uneventful recovery. Regarding the quality of life, the patient reported satisfactory improvement in almost every domain assessed compared to her pre-op assessment; an improvement that was maintained throughout the reported follow-up period. At the time of writing, the patient reports no long-term complications and satisfactory urinary continence. Robotic-assisted laparoscopic vesicovaginal fistula repair is an effective and safe treatment option for this rare complication, as indicated by both post-operative data and the patient's own self-evaluation in this report. Further research is warranted, focusing on refining the surgical technique and comparing this to other alternative methods aiming to further improve patient outcomes.

Three-Dimensional Volume Rendering of Pelvic Floor Anatomy with Focus on Fibroids in Relation to the Lower Urogenital Tract Based on Cross-Sectional MRI Images.

We aimed to assess the feasibility of developing three-dimensional (3D) models of pelvic organs using cross-sectional MRI images of patients with uterine fibroids and urinary symptoms and of obtaining anatomical information unavailable in 2D imaging modalities. We also aimed to compare two image processing applications. We performed a feasibility study analysing MRI scans from three women, aged 30 to 58 years old, with fibroids and urinary symptoms. Cross-sectional images were used to render 3D models of pelvic anatomy, including bladder, uterus and fibroids, using 3D Slicer and OsiriX. Dimensions, volumes and anatomical relationships of the pelvic organs were evaluated. Comparisons between anatomical landmarks and measurements obtained from the two image processing applications were undertaken. Rendered 3D pelvic models yielded detailed anatomical information and data on spatial relationships that were unobtainable from cross-sectional images. Models were rendered in sufficient resolution to aid understanding of spatial relationships between urinary bladder, uterus and fibroid(s). Measurements of fibroid volumes ranged from 5,336 to 418,012 mm3 and distances between the fibroid and urinary bladder ranged from 0.10 to 83.60 mm. Statistical analysis of measurements showed no significant differences in measurements between the two image processing applications. To date, limited data exist on the use of 3D volume reconstructions of routine MRI scans, to investigate pelvic pathologies such as fibroids in women with urinary symptoms. This study suggests that post-MRI image processing can provide additional information over standard MRI. Further studies are required to assess the role of these data in clinical practice, surgical planning and training. Three-dimensional reconstruction of routine two-dimensional magnetic resonance imaging provides additional anatomical information and may improve our understanding of anatomical relationships, their role in clinical presentations and possibly guide clinical and surgical management.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders.

AIMS: The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus. METHODS: This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus. RESULTS: A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible. CONCLUSION: A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Short-Term Refractive Outcomes of Pseudomyopia Induced by Ocular Blunt Trauma.

A teenage female patient visited the ophthalmology emergency department reporting blunt ocular trauma from a stretched elastic band, accompanied by blurred vision. At presentation, uncorrected visual acuity (VA) was 6/60 in the affected eye, improving to 6/7.5 with pinhole. A slit lamp examination showed a mild anterior chamber reaction and iridoplegia with pupil shape irregularity. Gonioscopy revealed partial cyclodialysis with angle recession. Fundoscopy revealed focal commotio retinae with blot hemorrhages. B-scan ultrasonography yielded no pathology. Follow-up examination, the day after the injury, included detailed refraction, which showed a myopic shift in the affected eye. Uncorrected VA improved to 6/15 and the patient achieved 6/7.5 with correction. Clinical findings indicated myopia, which resolved within one week from the incident, and refractive error rapidly decreased to prior emmetropic values.

A rapid systematic review of postpartum bladder care guidelines and recommendations in the context of the COVID-19 pandemic.

New pathways for the management of postpartum voiding dysfunction and postpartum urinary retention should be considered to shorten hospital stays and promote early discharge during the COVID-19 pandemic. This rapid systematic review aimed to identify relevant national and international guidelines, and summarise available recommendations on postpartum bladder care that are relevant to women's care and management at the time of the pandemic. We searched Medline, Embase and Cochrane from inception till September 2021. Hand-searching of national and international specialist societies' websites was performed. We identified one international technical consultation, one international society's report of recommendations and two national guidelines. Guidelines stated that postnatal women should not be left more than 6 hours without voiding and assessed for postpartum urinary retention. As the cut-off of 150 ml for the diagnosis of significant postvoid residual volume is commonly used with no reported adverse outcomes, it could be beneficial to adopt this instead of 100 ml as further unnecessary interventions can be avoided. Such changes can reduce the number of women staying in the hospital. Clean intermittent self-catheterisation for the management of postpartum urinary retention could be considered as an option during the COVID-19 pandemic aiming to shorten hospital stays and avoid further attendances. Optimised bladder care has become more relevant during the coronavirus pandemic by striving towards self-care, community-based and remote care. We propose consideration of intermittent self-catheterisation in cases of postpartum urinary retention enabling self-care and avoidance of hospital visits.

Incidence and Risk Factors of Bilateral Herpetic Keratitis: 2022 Update.

Simultaneously occurring bilateral herpetic keratitis is a rare clinical manifestation of ocular herpes. Immunocompromised patients are more susceptible to develop bilateral disease. The purpose of this study is to review recent literature on the topic and to highlight latest updates, regarding risk factors and possible correlations to the disease, as well as new therapeutic options.

Vulvodynia: What is available online? A systematic review of information on the internet.

AIM: This review aimed to evaluate the quality of medicalinformation online for patients relating to vulvodynia. To our knowledge no evaluation of online patient information exists regarding vulvodynia and, at present, there is no standardized or validated method of evaluating medical information on the internet. METHODS: A clearly defined protocol was developed to generate keywords relating to vulvodynia. The three most popular search engines worldwide; google.com, yahoo.com, and bing.com, were searched in September 2020. Three assessors evaluated eligible webpages for accuracy, credibility, readability, and reliability. RESULTS: Forty-five webpages were eligible with 38% given HON certification or Information Standard approval. Only one webpage achieved a DISCERN score of ≥63 indicating excellent reliability. No webpages scored a maximum 10 points for credibility. Eleven percent of webpages were rated "accurate" with score 17 or above. The modal Flesch Kincaid Grade Level was 9 with only 15.6% having a readability grade level of 8 or less. CONCLUSIONS: It has been shown in previous studies that patient information available online pertaining to gynecological conditions is frequently inaccurate, with limited regulation and low reliability, and our findings are in agreement with this. As patients increasingly look to the internet for medical information and education, we as clinicians, need to ensure the resources available are of a high standard and regulated. Without ensuring safe and effective healthcare resources, we risk misinformation which can negatively impact clinical care.

A systematic review highlighting poor quality of evidence for content validity of quality of life instruments in female chronic pelvic pain.

OBJECTIVES: To evaluate the content validity of 19 patient-reported outcome measures (PROMs) used to measure quality of life (QoL) in women with chronic pelvic pain (CPP). STUDY DESIGN AND SETTING: We searched Embase, MEDLINE, PsycINFO databases and Google Scholar from inception to August 2020. We included records describing the development or studies assessing content validity of PROMs. Two reviewers independently assessed the methodological quality of PROMs using the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. Evidence was synthesized for relevance, comprehensiveness, and comprehensibility. Quality of evidence was rated using a modified Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS: PROM development was inadequate for all instruments included in this review. No high-quality evidence ratings were found for relevance, comprehensiveness, and comprehensibility. QoL was measured using generic instruments (68.42%, 13/19) rather than those specific to chronic pain (21.04%, 4/19) or pelvic pain (10.53%, 2/19). Quality of concept elicitation was inadequate for 90% of PROMs. Half of PROMs did not include patients in their development and only 40% were devised using a sample representative of the target population for which the PROM was developed. Cognitive interviews were conducted in one-fifth of PROMs and were mostly of inadequate/doubtful quality. CONCLUSION: There is poor quality of evidence for content validity of PROMs used to measure QoL in women with CPP.

Influence of previous delivery mode on perineal trauma risk.

OBJECTIVE: To evaluate the impact of a previous pregnancy and delivery on perineal trauma rates in the subsequent vaginal birth. METHODS: Retrospective cohort study. The perineal outcomes of secundiparous women with history of previous (first) delivery in one of three categories: failed operative vaginal delivery (FOVD) and second-stage emergency cesarean section (EmCS); elective cesarean section (ElCS), and vaginal delivery (VD) with intact perineum, were compared with a control primiparous group. RESULTS: The percentage obstetric anal sphincter injuries (OASIS)at first vaginal delivery was 17.3% (n = 9) after previous FOVD+EmCS, 12.9% (n = 18) after previous ElCS, and 0.6% (n = 9) after previous VD maintaining an intact perineum, compared with 6% (n = 1193) in the control primiparous group of women. Multivariate regression analysis demonstrated that previous FOVD+EmCS and ElCS were associated with a statistically significant increased risk of OASIS of 180% and 110% when compared with control (odds ratio [OR] 2.80; 95% confidence interval [CI] 1.35-5.78 and OR 2.10; 95% CI 1.27-3.48, respectively). Previous VD with intact perineum was associated with a statistically significantly reduced risk of OASIS (OR 0.09; 95% CI 0.04-0.17). CONCLUSIONS: Previous FOVD+EmCS and ElCS were associated with increased risk of OASIS in subsequent vaginal delivery compared with control, whereas previous VD with intact perineum was associated with decreased risk.

Which patient reported outcomes (PROs) and patient reported outcome measures (PROMs) do researchers select in stress urinary incontinence surgical trials? - a systematic review.

INTRODUCTION AND HYPOTHESIS: The mesh controversy has highlighted the need for robust evidence of treatment safety and efficacy, particularly in the surgical treatment of stress urinary incontinence (SUI). Current trials demonstrate heterogeneity in outcomes reported as well as outcome measures used, restricting the ability to synthesize data and produce robust research evidence (Doumouchtsis et al. 5). Patient-reported outcomes (PROs) should be a focus when evaluating SUI surgery given the quality-of-life nature of this condition affecting 25-45% women worldwide (Milsom and Gyhagen 1). As part of the first step in developing a core outcome set (COS) and measures set (COMS), we aimed to systematically review RCTs evaluating SUI surgery and extract PROs and outcome measures (PROMs) used. MATERIALS AND METHODS: We searched databases including MEDLINE and Cochrane for RCTs evaluating SUI surgical treatments from inception to January 2020. Eligibility criteria included English language and female-only subjects. PROs and PROMs were extracted and grouped into a structured inventory. PROMs were assigned to domains based on predominant theme. RESULTS: Of 123 eligible RCTs, 116 (94%) included PROs. Forty-four different PROMs were utilized; most frequent was Patient Global Impression of Improvement (PGI-I). Fifteen PROMs were used once. The top five PROMs have evidence of validity and are highly recommended. CONCLUSIONS: There is no consensus amongst relevant stakeholders regarding PROs or PROMs used in SUI surgery research. We propose that this consensus is required to standardize measurements and reporting and promote use of validated and reliable outcome measures. This systematic review forms the first step in the development process.

Maternal and neonatal outcomes associated with delivery techniques for impacted fetal head at cesarean section: a systematic review and meta-analysis.

OBJECTIVES: Late first-stage or second-stage cesarean section is commonly associated with fetal head impaction, leading to maternal and neonatal complications. This situation requires safe delivery techniques, but the optimal management remains controversial. The aim of this meta-analysis was to compare maternal and neonatal outcomes associated with delivery techniques via cesarean section. METHODS: An electronic search of three databases, from inception to June 2021, was conducted. Cohort and randomised comparative studies on maternal and neonatal outcomes associated with techniques to deliver an impacted fetal head during cesarean section were included. The methodological quality of the primary studies was assessed. Review Manager 5.4 was used for statistical analyses. RESULTS: Nineteen articles, including 2,345 women were analyzed. Three fetal extraction techniques were identified. Meta-analyses showed that the "pull" technique carries lower risks as compared to the "push" technique and the "Patwardhan" technique is safer compared to the "push" or the "push and pull" technique. CONCLUSIONS: In the absence of robust evidence to support the use of a specific technique, the choice of the obstetrician should be based on best available evidence. Our study suggests that the "pull", as well as the "Patwardhan" technique represent safe options to deliver an impacted fetal head.

Outcome reporting in randomized controlled trials (RCTs) on the pharmacological management of idiopathic overactive bladder (OAB) in women; a systematic review for the development of core outcome sets (COS).

INTRODUCTION AND HYPOTHESIS: Evidence on OAB management remains suboptimal and methodological limitations in randomized control trials (RCTs) affect their comparability. High quality meta-analyses are lacking. This study aimed to compare selection and reporting of outcomes and outcome measures across RCTs as well as evaluate methodological quality and outcome reporting quality as a first stage in the process of developing core outcome sets (COS). METHODS: RCTs were searched using Pubmed, EMBASE, Medline, Cochrane, ICTRP and Clinicaltrials.gov from inception to January 2020, in English language, on adult women. Pharmacological management, interventions, sample size, journal type and commercial funding were documented. Methodological and outcome reporting quality were evaluated using JADAD and MOMENT scores. RESULTS: Thirty-eight trials (18,316 women) were included. Sixty-nine outcomes were reported, using 62 outcome measures. The most commonly reported outcome domains were efficacy (86.8%), safety (73.7%) and QoL (60.5%). The most commonly reported outcomes in each domain were urgency urinary incontinence episodes (UUI) (52.6%), antimuscarinic side effects (76.3%) and change in validated questionnaire scores (36.8%). A statistically significant correlation was found between JADAD and MOMENT (Spearman's rho = 0.548, p < 0.05) scores. This indicates that higher methodological quality is associated with higher outcome reporting quality. CONCLUSIONS: Development of COS and core outcome measure sets will address variations and lead to higher quality evidence. We recommend the most commonly reported outcomes in each domain, as interim COS. For efficacy we recommend: UUI episodes, urgency and nocturia episodes; for safety: antimuscarinic adverse events, other adverse events and discontinuation rates; for QoL: OAB-q, PPBC and IIQ scores.

A meta-synthesis of qualitative studies on stress urinary incontinence in women for the development of a Core Outcome Set: A systematic review.

OBJECTIVE: Given the high variation of perceptions of women with stress urinary incontinence (SUI), qualitative meta-synthesis in this field appears warranted. We aimed to synthesize evidence on women's experiences of SUI by analyzing qualitative data. METHODS: A literature search of Medline, Embase, Scopus, PsycInfo, and CINAHL databases was performed by a CHORUS Working Group, from inception to August 2020. Qualitative studies on women's perspectives on SUI were included. Thematic analysis was used as a conceptual approach to analyze the data and develop a set of overarching themes. The quality of studies was assessed based on the Critical Appraisal Skills Program tool. RESULTS: Seven studies were included. Six themes encompassing women's perspectives on SUI emerged: experiencing SUI, awareness of SUI, treatments for SUI, sexuality, communication, and psychosocial effects. The quality appraisal of the studies showed good coherence. CONCLUSION: This study revealed six overarching themes, of which treatment had the highest prevalence. Assessment of women's perceptions of SUI in the context of a qualitative meta-synthesis may inform policy and practice around this condition, may guide and help set research priorities, and will ideally contribute to the development of a Core Outcome Set for SUI.

Impact of COVID-19 in gynaecological oncology care: a systematic rapid review.

PURPOSE: Synthesis of available evidence on clinical practice in gynaecological oncology during the COVID-19 pandemic is highly warranted, as women with cancer are at increased risk due to their systemic immunosuppressed state and changes in their care are inevitable. Rapid review of available data is a quick way of providing useful information and insight into the way medical practice has been affected by the COVID pandemic. METHODS: We conducted a systematic rapid review, based on a literature search of MEDLINE/PubMed, Embase, and Cochrane CENTRAL. We considered all studies on gynaecological oncology care during the COVID-19 pandemic using relevant keywords and MeSH terms. Selection criteria were English language, studies with more than five cases and publication in peer-review journal. RESULTS: Nine retrospective studies, one systematic review and five questionnaire surveys were included. Quality of the studies has been assessed. Development of higher quality evidence is warranted. Mortality of COVID-19 infection is higher in patients with gynaecological cancer than in non-cancer patients. Reported delays in diagnosis and management of cancer and changes in treatments, may affect the natural history of cancer and increase patients' anxiety and fear of disease progression while causing concerns to healthcare professionals affecting their clinical practice. The number of new diagnoses has declined. Prioritization is important, face-to-face interactions should be limited, and appropriate protective measures are essential. Cancer surgery, chemotherapy, and radiotherapy should continue as high priority practices. CONCLUSION: The COVID-19 pandemic has affected clinical practice significantly. Adaptations in clinical practice may improve mortality and complication rates.

Reversal of colpocleisis-A surgical technique for recurrent pelvic organ prolapse.

Given the rarity of recurrent pelvic organ prolapse after obliterative procedures and the paucity of data in the literature on this topic, optimal management is challenging. We describe a technique of reversal of colpocleisis in an 81-year-old woman with recurrent prolapse as the first step in a staged, reconstructive procedure. Basic principles underlying our approach include multidisciplinary team involvement, detailed preoperative planning, and a series of investigations including different imaging modalities and a meticulous stepwise surgical technique. The distortion of anatomical planes, anticipated scarring, and close proximity of pelvic organs specifically bladder and rectum are important considerations. In our case, the multidisciplinary surgical team included urogynecologists, a urologist, and a colorectal surgeon. Detailed preoperative planning was agreed following multiple patient and team consultations. Preoperative investigations included ultrasound and videourodynamics. Intraoperatively, cystoscopy and sigmoidoscopy were performed to identify anatomical landmarks and planes, rule out fistulae, and evaluate for anatomical distortions involving pelvic organs. Subsequently, reversal of the colpocleisis was undertaken and uneventful. Postoperative recovery was uncomplicated and a sacrospinous fixation, anterior vaginal repair, and perineorrhaphy were performed as a secondary restorative procedure for the correction of recurrent prolapse.