Background A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which has been identified as an important research priority. Objectives To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. Search strategy Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. Selection criteria Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention. Data collection and analysis Interventions, outcomes reported, definitions and outcome measurement tools were extracted. Main results 40 randomised and 200 non-randomised studies were included. 58 different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. 242 outcome measurement instruments were used, with 0-22 tools per outcome. Conclusions Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.

BJOG-20-0640.R1 The evolving definition of pre-eclampsia

Objective: to describe the impact of COVID-19 on the management of patients with ectopic pregnancy. Design: a multicentre study comparing outcomes from a prospective cohort during the pandemic [Covid-ectopic pregnancy registry (CEPR)] compared to an historical pre-pandemic cohort [non-Covid ectopic pregnancy registry (NCEPR)]. Setting: five London university hospitals. Population and Methods: consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March/2020-Aug/2020) were entered into the CEPR and an exploratory matched analysis was performed comparing results to NCEPR patients (January/2019-June/2019). Main outcome measures: patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non-surgical management), length of stay (surgical management) and 30-day complications. Results: 341 patients met inclusion: 162 CEPR and 179 NCEPR. A significantly higher percentage of women underwent non-surgical management versus surgical management in the CEPR versus NCEPR (58.6% [95/162] vs 72.6% [130/179]; p= 0.0084]. Amongst patients managed with expectant management the CEPR had a significantly lower mean number of hospital visits compared to NCEPR [3.6 [SD 1.4] vs 13.7 [SD 13.4], p= 0.0053]. Amongst patients managed with medical management, the CEPR had a significantly lower mean number of hospital visits [NCEPR 6.4 [SD 2.3] vs 8.8 [SD 3.9], p= 0.0014]. There was no observed difference in complication rates between cohorts. Conclusion: women were found to undergo significantly higher rates of non-surgical management during COVID-19 first wave vs NCEPR cohort. Women managed non-surgically in CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complications rates.

We describe a novel surgical technique of 31 patients with histopathologically–confirmed placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team using prophylactic infrarenal abdominal aortic cross-clamping technique during cesarean hysterectomy. We conclude that this new surgical procedure is a safe and effective technique to reduce operative blood loss. Hopefully, our pioneer work will stimulate others to develop protocols assessing this innovative technique to improve surgical outcome of PAS disorders.

Objective: To estimate the association between maternal origin and obstetric anal sphincter injury (OASI), and assess if associations differed by length of residence. Design: Population-based cohort study. Setting: The Medical Birth Registry of Norway. Population: Primiparous women with vaginal livebirth of a singleton cephalic fetus between 2008 and 2017 (n=188 658). Methods: Multivariable logistic regression models estimated aORs for OASI with 95% CI by maternal region of origin and birthplace. We stratified models on length of residence and paternal birthplace. Main outcome measures: OASI. Results: Overall 6 373 cases of OASI were identified (3.4% of total cohort). Women from South Asia were most likely to experience OASI (6.2%; aOR 2.24, 95% CI 1.93–2.60), followed by those from Southeast/East Asian/Pacific (5.7%; 1.83, 1.64–2.04), and Sub-Saharan Africa (5.2%; 1.97, 1.72–2.26), compared to women originating from Norway. Among women born in the same region, those with short length of residence in Norway (0–4 years), showed higher odds of OASI. Migrant women across most regions of origin had reduced risk of OASI if they had a Norwegian compared to foreign-born partner. Conclusions: Primiparous women from Asian regions and Sub-Saharan Africa had up to two-fold risk of OASI, compared to women originating from Norway. Migrants with short residence and those with a foreign-born partner had higher risk of OASI, implying that some of the risk differential is due to sociocultural factors. Some migrants, especially new arrivals, may benefit from special attention during labour to reduce morbidity and achieve equitable outcomes.

A document by Isioma Okolo. Click on the document to view its contents.

Objective: To assess the incidence of serious complications and reoperations for recurrence after pelvic organ prolapse (POP) surgery and compare the three most common types of repair. Design: Prospective cohort study using a registry. Setting: 19 surgical centres in France. Population: 2309 women participated between 2017 and 2019. Methods: a multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups. Main outcome measures: Serious complications and subsequent reoperations for POP recurrence Results: Mean follow-up was 16.6 months. Surgeries included in the analysis were native tissue vaginal repair (N=504), transvaginal mesh placement (692), and laparoscopic sacropexy with mesh (1113). Serious complications occurred among 52 women (2.3%), and reoperation for recurrence was required for 32 (1.4%). At one year, the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair (95% confidence interval 0-3.9), 3.9% for transvaginal mesh (2.0-5.9), and 2.2% for sacropexy (1.1-2.6). Compared with the native tissue vaginal repair group, the risk of serious complications was higher in the transvaginal mesh group (weighted-HR 3.84, 2.43-6.08), and the sacropexy group (2.48, 1.45-4.23), while the risk of reoperation for prolapse recurrence was reduced in both groups (transvaginal mesh [0.22, 0.13-0.39] and sacropexy [0.29, 0.18-0.47]). Conclusions: Laparoscopic sacropexy with mesh appears to have a better risk profile (few serious complications and few reoperations for recurrence) than transvaginal mesh placement (more serious complications) and native tissue vaginal repair (more reoperations for recurrence). These results are useful for informing women and for shared decision making.

Letter to the Editor, BJOG Exchange

Intrapartum stillbirths and early neonatal deaths remain stubbornly high in low income countries. Fetal monitoring in labour can reduce these poor outcomes, but limited progress is being achieved in these settings. Intermittent auscultation and continuous electronic fetal monitoring (CEFM) can both be employed to monitor a fetus during labour. There are challenges and limitations with both modalities. We used AI augmented fetal monitoring in a hospital in Malawi and demonstrated substantial reductions in both intrapartum stillbirths and early neonatal deaths with a small increase in the cesarean delivery rate. AI-CEFM should be studied further to achieve better perinatal outcomes.

Dear Editor,Thank you for the opportunity to respond to Dr Sahu’s letter1. We would like to thank Dr Sahu and his team for their valuable points and ourselves recognise and acknowledge the gaps in our early commentary2 which reflected on the early practice at our hospital, with an aim to help fellow obstetricians with the management of COVID-19 at the start of the outbreak. Since then, more literature has been published providing us with greater knowledge regarding this new infection. Guidance from the Royal College of Obstetricians and Gynaecologists (RCOG)3 and International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG)4 amongst others help us streamline management of COVID-19 in pregnant patients.Both guidelines concur that radiographic investigations should be performed in pregnant patients – protecting the fetus by using a radiation shield over the gravid uterus. Chest CT has high sensitivity up to 97% for diagnosis of COVID-19 and may be considered as primary tool for COVID-19 detection.Both guidelines recommend the use of antenatal corticosteroids (ANC) for the usual indications but cautions use in critically ill women with COVID-19 infection as it may worsen their clinical condition. Importantly, urgent deliveries should not be delayed for the administration of ANC.Li et al5 compared clinical characteristics, maternal and neonatal outcomes of pregnant women with and without COVID-19. They found that COVID-19 infection generally causes mild respiratory symptoms in pregnant women, with no deaths or severe respiratory complications requiring critical care. They observed a higher rate of preterm deliveries in confirmed cases (33.3%) compared to control groups (¬5%). This study included two patients who had vaginal deliveries prior to COVID-19 diagnosis. Their newborns did not show any respiratory symptoms.New reports of SARS-COV-2 IgM in infants6 at birth suggest possibility of vertical transmission although COVID-19 infection in newborns is more commonly likely due to neonatal transmission.During breastfeeding, the main risk for infants lies in their close contact with mothers and transmission of infective respiratory droplets. Infected mothers wishing to breastfeed should do so with precautions such as wearing surgical masks, practising good hand hygiene and thorough cleaning of equipment after use. While the decision for separation of mother and baby has serious consequences on bonding and mental health, we continue to advise separation of baby from mothers infected with COVID-19 due to risk of neonatal transmission.Current data suggests that the adverse effects of COVID-19 in pregnancy are less severe than those of SARS-CoV and MERS-CoV. All presently reported patients were diagnosed in the third trimester and the potential effects of COVID-19 infections in the first and second trimesters remain to be investigated.As Dr Sahu mentioned, comparative studies are scarce. Establishment of international registries will improve our understanding of COVID-19 in pregnancy. Meanwhile, we shall continue to support one another and work together in the fight against this pandemic.We would like to thank the all departments from the Division of Obstetrics and Gynaecology, Infectious Diseases Department and all staff in KK Womens’ and Children’s Hospital for leading the COVID-19 fight locally.Monica Shi Qi Chua1, Jill Cheng Sim Lee2, Suzanna Sulaiman1, Hak Koon Tan31Department of Obstetrics and Gynaecology,2Department of Urogynaecology,3Division of Obstetrics and GynaecologyKK Women’s and Children’s Hospital, Singapore

Objective: To determine SARS-CoV-2 seroprevalence in a UK pregnancy cohort and assess associations with demographic factors and vaccination timing. Design: Observational cohort study. Setting: UK inner-city maternity centre. Sample: 960 pregnant women attending nuchal scans from July 2020-January 2022. Methods: Blood samples were tested for IgG antibodies against SARS-CoV-2 nucleocapsid (N) and spike (S) proteins. Self-reported demographics, vaccination status and previous Covid-19 infection were extracted from health records. Multivariable regression models determined factors associated with seroprevalence and antibody titers. Main outcome measures: IgG N- and S-protein antibody titers. Results: 196/960 (20.4%) women were SARS-CoV-2 seropositive from previous infection. Of these, 70 (35.7%) self-reported previous infection. Amongst unvaccinated women, black women were most likely to be SARS-CoV-2 seropositive (aRR 1.88 [95% CI, 1.35-2.61], P < 0.001). Women from black and mixed ethnic backgrounds were least likely to have a history of vaccination with seropositivity to S-protein (aRR 0.58 [95% CI, 0.40-0.84], P = 0.004 and aRR 0.56 [95% CI, 0.34-0.92], P = 0.021 respectively). Double vaccinated, previously infected women had higher IgG S-protein antibody titers than unvaccinated, previously infected women (mean difference: 4.76, 95% CI = [2.65, 6.86], P < 0.001). Vaccination timing before vs during pregnancy did not significantly affect IgG S antibody titers (F(1, 77) = [0.07], P = 0.785). Conclusions: This inner-city pregnancy cohort demonstrates high rates of asymptomatic SARS-CoV-2 infection with women of black ethnicity having higher infection risk and lower vaccine uptake. SARS-CoV-2 antibody titers were highest among double vaccinated, previously infected women.

Original Manuscript ID: BJOG-21-1723.R1 Descriptive: The Impact of Respectful and Compassionate Bereavement Care Following Stillbirth Running Title: Respectful Bereavement Care After Stillbirth Author information: Mehali Patel, Senior Research Officer, Saving Babies’ Lives Team, Sands Contact Details: 07709602633 [email protected] Sands Office, CAN Mezzanine, 49-51 East Road, London, N1 6AH

Objective To assess if delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode 3and neonatal outcome in the subsequent pregnancy. Study Design Retrospective analysis of prospectively collected data. Setting 15 Maternity units in North West London (1988 to 2000). Population 30,840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database. Methods Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2. Main Outcome Measures Gestational length, mode of delivery and neonatal unit admission in pregnancy 2. Results Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1% respectively, whereas following a spontaneous or instrumental birth in pregnancy 1 the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2. Conclusions Compared to vaginal birth, an emergency CS in the first term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy.

The surgical management of prolapse has undergone a meandering path, with innovation, controversy and legislation all being encountered en route. Some of the dust is now settling with respect to the role of mesh implant surgery, and whilst it continues to have albeit a contracted role, there is very much a new direction set on native tissue and non-mesh repairs with the advent of techniques such as laparoscopic suture hysteropexy, cervicopexy and colporrhaphy.The authors of this paper present the largest series of women undergoing autologous fascia sacrocolpopexy for the treatment of moderate-severe prolapse. Learning from the past, two key questions that must always be answered when evaluating any new procedure are safety and efficacy. For both these measures, the authors show encouraging results comparable with current gold-standard, mesh augmented repairs.The use of autologous fascia has been well established to treat women with urinary incontinence -the pubovaginal / rectus fascial sling (Mcguire EJ et al . Pubovaginal sling procedure for stress incontinence. J Urol.  1978;119:82–4) – the use of which has resurged following the widespread suspension of synthetic sling procedures. Reports of autologous fascial support of the vaginal vault however are limited to a few short-term case series.This series involves 132 women, followed up for a median of 2.2 years; the authors present five-year data with comparable success rates to those reported in the landmark CARE study (Nygaard I, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse.JAMA . 2013 May 15;309(19):2016-24) without the complication of mesh erosion.The mixed bag of patient types and concomitant surgery in this study underscores the myriad of pathology and presenting symptoms to the pelvic floor surgeon; sadly, this reality hinders forensic evaluation of the single procedure. It is noted that around three-quarters of the women in the study were having primary prolapse surgery, with a similar proportion undergoing some form of hysterectomy coupled with autologous fascial vault support. Other sacrocolpopexy series have involved women the majority who have already had primary procedures, are without a uterus and represent an already failed and perhaps more difficult to successfully treat group (Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016 Oct 1;10(10):CD012376.) The addition of a hysterectomy, as well as the harvesting of autologous fascia inevitably means a lengthening of procedure time compared to those usually quoted for women undergoing laparoscopic vault suspension procedures of hysteropexy or sacrocolpopexy.The complexities of pelvic floor patients and their symptoms mean that additionally nearly 2/3 of the patients had Burch colposuspensions performed at the time of index surgery. The unpredictability of pelvic floor surgery on bladder symptoms is amply demonstrated by around 1/3 of women complaining of stress incontinence and a third suffering overactive bladder symptoms following the procedure. It’s clear that functional improvements do not always go hand in hand with anatomical correction for the pelvic floor patient.Many women remain alarmed by the adverse reports of mesh augmentation surgery in gynaecology (Izett-Kay ML, et al ’What research was carried out on this vaginal mesh?’ Health-related concerns in women following mesh-augmented prolapse surgery: a thematic analysis. BJOG . 2021 Jan;128(1):131-139). Contemporary best practice involves distilling out irrefutable principles such as recognising the importance of appropriate apical support which is usually optimally achieved abdominally, as well as an awareness of risks of surgery, careful counselling regarding mesh and being able to offer evidence-based alternatives. This paper provides valuable long-term data for a further promising meshless surgical technique.

Mini Commentary – BJOG

A document by Franca Rusconi. Click on the document to view its contents.

SARS-CoV-2 has had a significant impact on pregnancy outcomes due to the effects of the virus and the altered healthcare environment. Stillbirth has been relatively hidden during the COVID-19 pandemic, but a clear link between SARS-CoV-2 and poor fetal outcome emerged in the Alpha and Delta waves. A small minority of women/birthing people who contracted COVID-19 developed SARS-CoV-2 placentitis. In many reported cases this was linked to intrauterine fetal death, although there are cases of delivery just before imminent fetal demise and we shall discuss how some cases are sub-clinical. What is surprising, is that SARS-CoV-2 placentitis is often not associated with severe maternal COVID-19 infection, and this makes it difficult to predict. The worst outcomes seem to be with diffuse placental disease and occurs within 21 days of COVID-19 diagnosis. Poor outcomes are often pre-dated by reduced fetal movements, but are not associated with ultrasound changes. In some cases, there has also been maternal thrombocytopenia, or coagulation abnormalities, which may provide a clue as to which pregnancies are at risk of fetal demise if a further variant of concern is to emerge. In future, multidisciplinary collaboration and cross-boundary working must be prioritised, to quickly identify such a phenomenon and provide clinicians with clear guidance for reducing fetal death and associated poor outcomes. Whilst we wait to see if COVID-19 brings a future variant of concern, we must focus on appropriate future management of women who have had SARS-CoV-2 placentitis. The histopathology reports with pathologies of chronic histiocytic villositis and/or massive perivillous fibrin deposition fill clinicians with concern about future pregnancy outcomes. However, we must remember, that in the context of a cause (SARS-CoV-2) and no other history of concern, it is not likely that SARS-CoV-placentitis will recur, and thus a measured approach to subsequent pregnancy management is needed.

Objective To determine the prevalence of genital mycoplasma infection and the risk of spontaneous preterm birth (sPTB) in asymptomatic pregnant women. Design Prospective cohort. Setting Public and private health services in Ribeirão Preto-SP, Brazil. Population 1.349 asymptomatic women with a singleton pregnancy at 20-25 weeks of gestation (WG) recruited between 2010 and 2011. Methods Baseline data was assessed using a questionnaire, in addition to cervicovaginal fluid and blood samples, to analyze lower reproductive tract infections (RTIs) and immune mediators, respectively. The association between variables and the risk of sPTB was evaluated using logistic regression analysis to estimate the odds ratios (ORs). Main outcome measures Genital mycoplasma infection and prematurity. Results The prevalence of the sPTB and genital mycoplasma was 6.8% and 18%, respectively. The infection was not a risk factor for sPTB (aOR 0.66; 95% CI 0.32-1.35), even when associated with bacterial vaginosis (BV). However, it was associated with a low socioeconomic status (p=0.0470), cigarette use (p=0.0009), number of sexual partners (p=0.0019), and BV (p<.0001). Regarding the risk factors associated with sPTB, previous history of PTB (aOR 12.06; 95% CI 6.21-23.43) and a cervical length ≤ 2.5 cm (aOR 3.97; 95% CI 1.67-9.47) were significant. Conclusions The risk of sPTB was independently associated with the history of PTB and the cervical length but not with the genital mycoplasma infection. Funding: This work was founded by CNPq, FAPESP and CAPES. Keywords: Preterm birth, pregnancy, genital mycoplasma, bacterial vaginosis, risk factor