Characterizing retained placenta : epidemiology and pathophysiology of a critical obstetric disorder

Background: Retained placenta is associated with severe postpartum hemorrhage but its etiology and pathophysiology are largely unknown. Certain studies have suggested that retained placenta is associated to defective placentation disorders- pregnancy disorders with an initial defective placentation resulting in increased oxidative stress. The aim of this thesis was to investigate risk factors for and consequences of retained placenta, determine whether retained placenta and defective placentation disorders are epidemiologically associated and to assess if this association is supported at the molecular and histological level. Methods and Main Results: Study I was a case-control study comparing pregnancy and deliveryrelated variables in women with retained placenta and controls (n=408 in each group) after singleton vaginal birth. The study found that retained placenta was associated with severe postpartum hemorrhage and that a history of abortion or recurrent miscarriage, pre-eclampsia, preterm delivery and prolonged oxytocin use in the current pregnancy were independent risk factors for retained placenta. Study II was a population based cohort study investigating the association between retained placenta and defective placentation disorders (pre-eclampsia, preterm birth, small-for-gestational-age birth and stillbirth) in primiparous women giving vaginal birth at 32-41 gestational weeks between 1997 and 2009 in Sweden (n=386 607). The study found that retained placenta was associated to pre-eclampsia, spontaneous preterm birth, small-for-gestational-age birth and stillbirth. The risk was further increased for women with these disorders among preterm deliveries. Study III was a cross-sectional pilot study investigating the antioxidative enzyme Glutathione Peroxidase 1 (GPX1) and the transcription factor Nuclear Factor Kappa-light-chain-enhancer of activated β-cells (NFκB), as markers of antioxidative defence capacity and inflammation, in 29 retained and 31 non-retained placentas. The study found that retained placentas showed a tendency of lower median concentrations GPX1 and were significantly more likely to have a low level of GPX1 protein concentration. There were no differences in expression ofNFκB. Study IV was a case-control study comparing histological signs of maternal underperfusion and inflammation in retained (n=49) and non-retained (n=47) placentas. The study found that retained placentas had a significantly smaller surface area, were more oblong in shape and showed overall more signs of maternal placental underperfusion compared to non-retained placentas. Conclusions: Retained placenta is epidemiologically associated to defective placentation disorders, a finding which is supported in part by signs of decreased antioxidative capacity in the placenta and increased histological signs of maternal placental underperfusion. Prolonged oxytocin use may exacerbate the risk of retained placenta. Risk awareness of retained placenta should guide preparedness during the third stage of labor given the high risk of severe postpartum hemorrhage that the disorder entails

Are sexual and reproductive health and rights taught in medical school? Results from a global survey

Our aim was to investigate the inclusion of sexual and reproductive health and rights (SRHR) topics in medical curricula and the perceived need for, feasibility of, and bar-riers to teaching SRHR. We distributed a survey with questions on SRHR content, and factors regulating SRHR content, to medical universities worldwide using chain referral. Associations between high SRHR content and independent variables were analyzed using unconditional linear regression or χ2 test. Text data were analyzed by thematic analysis. We collected data from 219 respondents, 143 universities and 54 countries. Clinical SRHR topics such as safe pregnancy and childbirth (95.7%) and contraceptive methods (97.2%) were more frequently reported as taught compared with complex SRHR topics such as sexual violence (63.8%), unsafe abortion (65.7%), and the vulnerability of LGBTQIA persons (23.2%). High SRHR content was associated with high- income level (P= 0.003) and low abortion restriction (P= 0.042) but varied within set-tings. Most respondents described teaching SRHR as essential to the health of society. Complexity was cited as a barrier, as were cultural taboos, lack of stakeholder recogni-tion, and dependency on fees and ranking

How the coronavirus disease 2019 pandemic is impacting sexual and reproductive health and rights and response: Results from a global survey of providers, researchers, and policy-makers

Introduction: We aimed to give a global overview of trends in access to sexual and reproductive health and rights (SRHR) during the coronavirus disease 2019 (COVID-19) pandemic and what is being done to mitigate its impact. Material and methods: We performed a descriptive analysis and content analysis based on an online survey among clinicians, researchers, and organizations. Our data were extracted from multiple-choice questions on access to SRHR services and risk of SRHR violations, and written responses to open-ended questions on threats to access and required response. Results: The survey was answered by 51 people representing 29 countries. Eighty-six percent reported that access to contraceptive services was less or much less because of COVID-19, corresponding figures for surgical and medical abortion were 62% and 46%. The increased risk of gender-based and sexual violence was assessed as moderate or severe by 79%. Among countries with mildly restrictive abortion policies, 69% had implemented changes to facilitate access to abortion during the pandemic, compared with none among countries with severe restrictions (P\u3c .001), 87.5% compared with 46% had implemented changes to facilitate access to contraception (P= .023). The content analysis showed that (a) prioritizations in health service delivery at the expense of SRHR, (b) lack of political will, (c) the detrimental effect of lockdown, and (d) the suspension of sexual education, were threats to SRHR access (theme 1). Requirements to mitigate these threats (theme 2) were (a) political will and support of universal access to SRH services, (b) the sensitization of providers, (c) free public transport, and (d) physical protective equipment. A contrasting third theme was the state of exception of the COVID-19 pandemic as a window of opportunity to push forward women\u27s health and rights. Conclusions: Many countries have seen decreased access to and increased violations of SRHR during the COVID-19 pandemic. Countries with severe restrictions on abortion seem less likely to have implemented changes to SRHR delivery to mitigate this impact. Political will to support the advancement of SRHR is often lacking, which is fundamental to ensuring both continued access and, in a minority of cases, the solidification of gains made to SRHR during the pandemic

How the coronavirus disease 2019 pandemic is impacting sexual and reproductive health and rights and response : results from a global survey of providers, researchers, and policy-makers

Introduction We aimed to give a global overview of trends in access to sexual and reproductive health and rights (SRHR) during the coronavirus disease 2019 (COVID-19) pandemic and what is being done to mitigate its impact. Material and methods We performed a descriptive analysis and content analysis based on an online survey among clinicians, researchers, and organizations. Our data were extracted from multiple-choice questions on access to SRHR services and risk of SRHR violations, and written responses to open-ended questions on threats to access and required response. Results The survey was answered by 51 people representing 29 countries. Eighty-six percent reported that access to contraceptive services was less or much less because of COVID-19, corresponding figures for surgical and medical abortion were 62% and 46%. The increased risk of gender-based and sexual violence was assessed as moderate or severe by 79%. Among countries with mildly restrictive abortion policies, 69% had implemented changes to facilitate access to abortion during the pandemic, compared with none among countries with severe restrictions (P < .001), 87.5% compared with 46% had implemented changes to facilitate access to contraception (P = .023). The content analysis showed that (a) prioritizations in health service delivery at the expense of SRHR, (b) lack of political will, (c) the detrimental effect of lockdown, and (d) the suspension of sexual education, were threats to SRHR access (theme 1). Requirements to mitigate these threats (theme 2) were (a) political will and support of universal access to SRH services, (b) the sensitization of providers, (c) free public transport, and (d) physical protective equipment. A contrasting third theme was the state of exception of the COVID-19 pandemic as a window of opportunity to push forward women's health and rights. Conclusions Many countries have seen decreased access to and increased violations of SRHR during the COVID-19 pandemic. Countries with severe restrictions on abortion seem less likely to have implemented changes to SRHR delivery to mitigate this impact. Political will to support the advancement of SRHR is often lacking, which is fundamental to ensuring both continued access and, in a minority of cases, the solidification of gains made to SRHR during the pandemic

Office hysteroscopy: A scientific overview

Office hysteroscopy, when defined as the vaginoscopic procedure, is a method which can be performed with very little discomfort for the patient and at an extremely low risk for serious complications. It has a low failure rate and high efficacy. It can be used for routine diagnostics but also for small operational interven tions and diagnosis of malignancy and pre-malignancy. It has proved to be superior to other diagnostic tools in the unique possibility of visualization and simultaneous visually-controlled biopsy. Primarily and foremost however, it represents an enormously beneficial gain in both time and psychological impact for the patients undergoing the procedure, who often obtain immediate diagnosis and treatment. There is a further advantage in minimizing the diameter of the hysteroscope, the so-called mini-hysteroscope of 3.3 mm sheath diameter being significantly better tolerated than the wider 4 mm hysteroscope. The use of mini-hysteroscopes may also obviate the need to restrict the patient population to those having undergone vaginal delivery or the need for a very experienced surgeon. At present, however, there seems to be no clear advantage in using a flexible scope, as the gain of greater patient comfort is outweighed by the fact of greater visibility, shorter procedure time and thus lower cost of rigid hysteroscopy. Given that this procedure is still more expensive, more time-consuming and somewhat less comfortable for patients than routine ultrasound it may at this time be premature to recommend, as suggested by some authors [29, 14], it as a screening tool for asymptomatic patients. Most asymptomatic patients will after all present to the clinic without uterine abnormality or cause for intervention. © 2011 Termedia Sp. z o.o. All rights reserved

Office hysteroscopy: A scientific overview

Office hysteroscopy, when defined as the vaginoscopic procedure, is a method which can be performed with very little discomfort for the patient and at an extremely low risk for serious complications. It has a low failure rate and high efficacy. It can be used for routine diagnostics but also for small operational interven tions and diagnosis of malignancy and pre-malignancy. It has proved to be superior to other diagnostic tools in the unique possibility of visualization and simultaneous visually-controlled biopsy. Primarily and foremost however, it represents an enormously beneficial gain in both time and psychological impact for the patients undergoing the procedure, who often obtain immediate diagnosis and treatment. There is a further advantage in minimizing the diameter of the hysteroscope, the so-called mini-hysteroscope of 3.3 mm sheath diameter being significantly better tolerated than the wider 4 mm hysteroscope. The use of mini-hysteroscopes may also obviate the need to restrict the patient population to those having undergone vaginal delivery or the need for a very experienced surgeon. At present, however, there seems to be no clear advantage in using a flexible scope, as the gain of greater patient comfort is outweighed by the fact of greater visibility, shorter procedure time and thus lower cost of rigid hysteroscopy. Given that this procedure is still more expensive, more time-consuming and somewhat less comfortable for patients than routine ultrasound it may at this time be premature to recommend, as suggested by some authors [29, 14], it as a screening tool for asymptomatic patients. Most asymptomatic patients will after all present to the clinic without uterine abnormality or cause for intervention. © 2011 Termedia Sp. z o.o. All rights reserved

Oxidative stress and inflammation in retained placenta : a pilot study of protein and gene expression of GPX1 and NF kappa B

Background: Retained placenta is associated with severe postpartum hemorrhage. Its etiology is unknown and its biochemistry has not been studied. We aimed to assess whether levels of the antioxidative enzyme Glutathione Peroxidase 1 (GPX1) and the transcription factor Nuclear Factor kappa beta (NF kappa beta), as markers of oxidative stress and inflammation, were affected in retained placentas compared to spontaneously released placentas from otherwise normal full term pregnancies. Methods: In a pilot study we assessed concentrations of GPX1 by ELISA and gene (mRNA) expression of GPX1, NF kappa beta and its inhibitor I kappa beta alpha, by quantitative real-time-PCR in periumbilical and peripheral samples from retained (n = 29) and non-retained (n = 31) placental tissue. Results: Median periumbilical GPX1 concentrations were 13.32 ng/ml in retained placentas and 17.96 ng/ml in nonretained placentas (p = 0.22), peripheral concentrations were 13.27 ng/ml and 19.09 ng/ml (p = 0.08). Retained placental tissue was more likely to have a low GPX1 protein concentration (OR 3.82, p = 0.02 for periumbilical and OR 3.95, p = 0. 02 for peripheral samples). Median periumbilical GPX1 gene expressions were 1.13 for retained placentas and 0.88 for non-retained placentas (p = 0.08), peripheral expression was 1.32 and 1.18 (p = 0.46). Gene expressions of NF kappa beta and I kappa beta alpha were not significantly different between retained and non-retained placental tissue. Conclusions: Women with retained placenta were more likely to have a low level of GPX1 protein concentration in placental tissue compared to women without retained placenta and retained placental tissue showed a tendency of lower median concentrations of GPX1 protein expression. This may indicate decreased antioxidative capacity as a component in this disorder but requires a larger sample to corroborate results

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review.

INTRODUCTION: The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls' access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs). METHODS: We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls' (15-49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings. RESULTS: We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs. CONCLUSION: Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies

Sexual and reproductive health and rights of refugee and migrant women: gynecologists\u27 and obstetricians\u27 responsibilities

Ensuring universal access to sexual and reproductive healthcare services is Target 3.7 of the United Nations Sustainable Development Goals (SDG). Refugee and migrant women and children are at particular risk of being forgotten in the global momentum to achieve this target. In this article we discuss the violations of sexual and reproductive health and rights (SRHR) of particular relevance to the refugee and migrant reality. We give context-specific examples of denial of health services to vulnerable groups; lack of dignity as a barrier to care; the vulnerability of adolescents; child marriage; weaponized rape; gender-based violence; and sexual trafficking. We discuss rights frameworks and models that are being used in response to these situations, as well as what remains to be done. Specifically, we call for obstetricians and gynecologists to act as individual providers and through their FIGO member societies to protect women\u27s health and rights in these exposed settings