Complications requiring medical interventions during childbirth are far from rare, even after uncomplicated pregnancies. It is often a challenge for maternity healthcare professionals to know how to prepare future parents for these eventualities without causing unnecessary anxiety. Studies on traumatic birth experiences have shown that feelings of loss of control, insufficient information, and lack of participation in medical decisions during childbirth are factors of difficult experiences. However, little is known about the information and communication needs of expectant parents about childbirth during the prenatal period. To gain a deeper understanding of the information and communication needs of first-time pregnant women and partners, we explored their perceptions and expectations for their upcoming childbirth, and the actions they initiated to prepare for it.Semi-structured interviews were conducted individually with first-time pregnant women and partners of pregnant women aged 18 years or older, with an uncomplicated pregnancy. Thematic analysis was used to identify themes and sub-themes.Twenty expectant parents (15 pregnant women and five partners of pregnant women) were interviewed. Six themes were identified: Childbirth event; Childbirth experience; Childbirth environment; Organisation of care; Participation in decision making; Roles within the couple and transition to parenthood.This study contributes to a better understanding of the information needs of future parents expecting their first child. Results highlighted that the notion of “childbirth risks” went beyond the prospect of complications during birth, but also encompassed concerns related to a feeling of loss of control over the event. Expectant parents showed an ambivalent attitude towards consulting risk information, believing it important to prepare for the unpredictability of childbirth, while avoiding information they considered too worrying. They expressed a desire to receive concrete, practical information, and needed to familiarise themselves in advance with the birth environment. Establishing a respectful relationship with the healthcare teams was also considered important. The findings suggest that information on childbirth should not be limited to the transmission of knowledge, but should primarily be based on the establishment of a relationship of trust with healthcare professionals, taking into account each person’s individual values and expectations. A significant number of women undergo unplanned medical interventions during childbirth, often performed in an emergency, to address unexpected complications. In Switzerland, for example, nearly 16% of women face an unplanned caesarean section, 11,1% an instrumental vaginal delivery (forceps or vacuum) and 17% an episiotomy. In more than 26% of cases, childbirth is induced. In addition, many women face a serious complication, the most important being postpartum haemorrhage 8%), preeclampsia (2%) –5. Prena%, preeclIn healthcare in general, the provision of information is widely recognised as an essential means of enabling patients to acquire the necessary knowledge to exercise autonomy and participate in decisions that affect their health . The neeIn a recent international review of qualitative studies, provision of information and informed consent about labour and childbirth was presented as an essential component of respectful maternity care . SeveralHowever, these positive findings are tempered by other studies that highlight the challenges of prenatal information and raise questions about how to best meet the expectations of future parents in the current context of maternity care organisation. Some research focusing specifically on the influence of information provision on knowledge retention, informed choice, and decision making has shown very limited results in terms of effectiveness –33. The Information needs should be considered globally, taking into account all sources of information available to expectant parents, such as family and friends, but also the media and online contents , 35. FutA qualitative study design using semi-structured interviews was used to explore the perceptions and information needs about childbirth of future parents expecting their first child. Thematic analysis was used to identify themes and sub-themes .Expectant parents, either pregnant women or partners of pregnant women, were recruited for this study. To be eligible for the study, participants had to fulfill the following inclusion criteria: (a) 21–36 weeks pregnancy, (b) no previous experience of childbirth, (c) pregnancy with no complications, (d) gave written consent. Exclusion criteria were (a) insufficient language skills to take part in a conversation in French.In Switzerland, maternity services are covered by the compulsory health insurance. They include seven check-ups performed by a doctor or a midwife during and after the pregnancy. A unique contribution is granted to the cost of antenatal classes, whether individual or in group CHF 150). Births at home, in the hospital or in a birthing centre benefit from the same insurance coverage. However, the vast majority of births take place in hospitals (98.3%) . It’s more afterwards, I’m afraid to say to myself, that I didn’t have the birth I wanted.” (W1)While most women said that they would do everything possible to promote a natural birth, sometimes seeing it as a form of challenge and a source of personal pride, several expressed to be very aware of the social pressure they were under, as a successful birth should be vaginal, ideally without an epidural. These women mainly reported protecting themselves from such injunctions, which they saw as harmful. However, two women expressed the sense of disappointment that could result from a birth that would not go as planned. The worst for them was not to face difficulties in the context of the birth, but to have to live with a sense of failure afterwards.“I would say confident. Reassuring. But I have the feeling that everything will go well. My state of mind is ‘everything will be fine’”. (P3)While they knew that childbirth could be a difficult experience, most women and partners indicated that they wanted to remain in a positive and confident state of mind when considering their upcoming birth. Some were well aware that this was based on a form of positive self-suggestion, which allowed them to approach childbirth with more serenity. This optimism seemed all the more possible, as the pregnancy had gone well up to that point and they had confidence in the competence of the professionals, in nature, or in their own ability to cope with the situation, whatever it might be.“I say to myself, the more I plan, the more I say to myself that this is what I want, the more in my opinion I have the impression that we’re going to get out of this theoretical plan because, I don’t know, a lot of things can happen, and if I plan too much, it’s going to frustrate me even more.” (W6)In addition to this positive mindset, most participants confided that they were prepared to be flexible and resilient, and therefore open to any situation, however difficult, that went against what they had hoped for. They reported that flexibility was necessary due to the unpredictable nature of childbirth and that the most important point, in the end, was that the mother and the baby were healthy. Some participants also expressed their reluctance to over-plan the event, to avoid frustration if their childbirth did not go according to expectations. In this respect, birth plans were sometimes perceived negatively because they gave the illusion that the birth could be planned in advance.Safety was perceived by women and partners as an essential criterion of the childbirth environment, which explained their choice for a hospital birth. At the same time, participants expressed the importance of having an attentive, respectful, and personalised environment, both in their relations with professionals and in the layout of the birthing facilities.everything was there in case of complications.“That there are instruments around, instruments that I don’t really know what they’re for, but it reassures me to have lots of high-tech instruments around me, saying to myself, we don’t know, but they’re there.” (P1)In line with their desire not to take risks, the majority of participants underlined the importance of choosing a place of birth that could guarantee the safety, both in terms of the equipment available and the qualifications of professionals. The participants confided that the choice of a hospital birth was mainly motivated by their need for security. The preference for a birth centre, when expressed, was only acceptable because of its proximity to a hospital. The university hospital, in particular, was seen as a highly reassuring place because “And then it’s true that I’m quite shy, so I’m also a bit afraid of finding myself with several people in front of me and not being at ease, of being inhibited, in fact, in relation to that.” (W8)Women in particular reported their need to give birth in a calm environment. The hospital was perceived as a potentially stressful place, due to the heavy workload for healthcare professionals and the emergencies that had to be managed. Several women expressed concern about the presence of a large number of professionals during their birth, because of the noise and bustle, but also because of the lack of privacy that this presence could bring.“… that they respect the fact that we are... I mean, we’re naked here, that they have respect for our bodies and that we’re not just women giving birth. That we are still a person.” (W13)The benevolence and kindness of the midwifery staff, as well as their ability to listen and to personalise care, were regularly mentioned by women and partners as important criteria for a positive experience of childbirth. Participants hoped that the teams would be welcoming and respectful, but also that the facilities could be adapted to their wishes. Hospital was a priori not perceived as a very flexible and hospitable environment. Through their comments, participants expressed their concerns about experiencing a form of dehumanisation and their need to be considered as people beyond the care of the body.“Presenting the places can help, the rooms. It’s like when you take an exam. I was always more comfortable when I took an exam in a room I knew.” (W9)In their preparation to childbirth, women and partners expressed the need to become familiar with the environment of their upcoming birth, although they were aware that this was not always possible. Depending on the individual, this need was expressed in different ways. Some participants felt it was important to get information about the professionals who would be present, and ideally to be able to meet them beforehand. For others, it was the visit to the birthing place in advance that was essential. Two women also reported that they had prepared a music playlist with their partner for the day of the birth. These different approaches were presented by the participants as ways of anticipating and mastering the context of an unknown and potentially difficult event.Participants observed a discontinuity in the organisation of maternity care and regretted not having the same reference person throughout their preparation and experience of childbirth. Discontinuity was also observed in terms of information, which participants perceived as insufficient and too fragmented to meet their needs in preparing for birth.“I think it would be nice (...) to have a person who is present from the beginning to the end. For example, that it is the same midwife who welcomes me when I arrive at the maternity hospital and who follows the whole birth process, and that even if there’s a problem or something that wasn’t foreseen, that this person is always present and gives me the information.” (W5)In their answers, some participants mentioned their difficulty in identifying reference professionals for questions related to the birthing process. Several women in particular indicated that their private gynaecologist was their primary trusted contact during pregnancy, but did not talk to them about the birthing phase, as they would not be involved. Midwives were seen as the professionals responsible for managing childbirth, and therefore essential in the preparation phase, but those encountered before childbirth would not, in principle, be those who would ensure the birth. In addition, the hospital was perceived as a complex, potentially overburdened system, with many professionals involved and regular turnover. For some, this discontinuity in the organisation of care added uncertainty to an already unpredictable event. In this context, being able to identify a reference person, at least on arrival at the hospital, was seen as a source of reassurance.“It is a whole thing actually. There is the pregnancy, the preparation for the baby, the administration, and then the childbirth. In fact, there are many things.” (W4)In terms of their understanding of care, some women expressed regrets that there was a lack of information on certain topics related to the normal course of childbirth, while much of the content focused on complications and medical interventions to manage them. They were surprised, for example, not to find explanations about the delivery of the placenta and the standard issues related to the postpartum period, such as heavy blood loss, the pain of breastfeeding, and the psychological distress that could be felt after the birth. They observed that professionals did not address these topics, but that information was equally difficult to obtain from their friends or relatives, as if such subjects were taboo. In addition, some women, particularly those who had recently arrived in Switzerland, expressed confusion about the organisation of maternity care and reported a lack of information about the available resources, health insurance coverage, and the administrative steps to be taken for the birth of their child. They suggested that a comprehensive, centralised approach to information needs on all aspects of birth preparation would be a great help, as concerns of future parents were extremely diverse at this stage of life.“I watch some videos too, on Youtube (...) I’m interested to know exactly what happens because it’s true that when someone tells me about their childbirth, it’s never in detail of what exactly happens.” (W12)Most participants indicated that they had sought or were seeking information about the different stages of childbirth to better understand its usual course. They were particularly eager for practical and realistic information that would allow them to anticipate their upcoming birth, to put it into context, and to better understand the care that would be provided to the mother and child. They perceived the birth preparation given by midwives as particularly valuable, especially when it was provided by their birthing facility because it conveyed information that was consistent with the reality they would experience. Some participants said they favoured feedback from family and friends because they were about real experiences. Several women and partners also mentioned watching information videos online, which gave them a more concrete and visual understanding of birth.Women and partners reported high confidence in the knowledge and experience of healthcare professionals and did not plan to question their decisions. However, they hoped to be respected in their expectations and to receive explanations about the medical procedures performed during childbirth. They confided that their latitude of choice in decision-making was unclear and needed to be clarified before birth.“I have no desire to impose things that will ultimately derail the system, in fact. That it would be too complicated for them to take charge and (...) that it would be a bit badly done in the end. That it could be harmful, when it was perhaps just an idea, a whim.” (W9)In general, participants reported a high level of trust in healthcare professionals, obstetricians, and midwives, whom they felt were in a better position to make decisions because of their knowledge and experience. For this reason, they did not consider questioning medical decisions, as long as such decisions were justified and not made for the comfort of the healthcare team. For some participants, going against medical choices could disrupt the system and affect the quality of care, or even endanger the mother and the child, which they wanted to avoid at all costs.Although they recognised that their involvement was limited because of the asymmetry in knowledge and experience, participants felt it was essential that some form of partnership took place around birthing decisions. They expected the teams to maintain communication with them throughout the birth and to consider them as full partners in care. It was especially important for them to be informed of any medical intervention performed and to know the reason for it. Indeed, even if they did not feel they had decision-making power, they expected the teams to justify the medical decisions, so that they could understand and accept them. It was for them a way to remain involved in the birth, to keep control, and to better accept the difficulties that may arise.“[I expect] to be heard in my questions, in my doubts, that they answer me if I have questions during the birth. That they respect the natural or biological rhythm, that they won’t want to accelerate the process.” (W11)In order to build trust with the teams, it was equally important to the participants that the preferences they had expressed were heard and respected. They hoped that the teams would accompany and support them in the way they wanted to foster. Some women, in particular, feared that they would be pressured by healthcare professionals to accept medical interventions to make the childbirth go faster.“Meeting the midwife beforehand, it’s more the idea that there is someone who knows. That the day I arrive, I don’t need to negotiate, that I know in fact that all that is possible, that I know how it is received. Because in reality (...) how do we make sure that everyone is on the same wavelength? Or even if it’s a possibility to be on the same wavelength?” (W15)Most women and partners expressed uncertainty about the degree of control they had over decisions about the birthing process. They therefore hoped to be able to discuss their preferences in advance with a professional at the maternity hospital where they planned to give birth. Although most of them were prepared for a potential need to re-specify their expectations to the team on the day of birth, they stated that such a discussion would be a way for them to verify that their wishes were acceptable, and to be able to anticipate with their partner the choices they might have to reconsider.Participants agreed that women had a central role in childbirth but that partner involvement was essential as a support and interlocutor with the healthcare team. It was necessary for them, and especially for the women, to be involved together in the preparation for the birth of their child. This preparation went beyond the birth event itself and also involved facing their new responsibilities as parents.“In 99% of cases, it is the mother who has to give her opinion. I just give my opinion but it is not me who chooses, it is not my body.” (P2)Women and partners agreed that mothers played a central role in the birthing process and therefore had priority within the couple for decision-making, even though their participation might be limited because of their vulnerability during childbirth. Their leading position was justified by the fact that their own body was at stake, and that they themselves were enduring the potential difficulties associated with the birthing experience, particularly pain.“And even if I were to be in a vulnerable position, I know that he would be there to be my voice if I wanted him to. I feel like it really takes a lot of stress out of dealing with this situation that’s probably going to be stressful, that’s not going to be the best time in life.” (W15)Although they sometimes felt they had a very limited role in the birth, partners reported being very concerned about providing support and reassuring the mother during the birth, so that she could have the best possible experience. Some noted the limitations in their support role, due to the fact that they themselves would be emotionally involved, and that the situation might not allow them to meet all their partner’s expectations. For their part, all the women interviewed stressed the importance of having their partner by their side during childbirth. They confided that this presence would give them indispensable support and also a form of security in the painful experience they might have to endure. In addition, several women reported that they were very reassured that their partner could be their advocate with the team in case they were no longer able to express their preferences.“The antenatal class, for example, I’m going to attend it especially so that my husband feels involved because, for the moment, every time he talks about it, he’s a spectator. I tell him that you can be a little more involved, so I tell myself that maybe this will allow him to see childbirth differently.” (W2)Participants indicated that it was important for them to be able to share their birth preferences with their partner before the birth, so that they would be in agreement for their discussions with healthcare teams. At the same time, several women reported that they felt their partner was not enough involved in childbirth preparation and that they were considering different approaches to get him to access the necessary information, such as sharing information resources with him or attending antenatal classes together.“But it’s something that I have to prepare, prepare for the arrival of the child in advance, that is to say to be ready for the arrival, to have a baby in the womb but to humanise it in advance.” (P5)Several participants were particularly concerned about preparing for their future role as parents. This preparation had different objectives. It focused in part on practical issues, particularly related to the choices to be made for the purchase of equipment for the baby. It also dealt with more psychological considerations related to their new responsibilities as parents and the balance to be found within the couple. The partners, in particular, said that it was important for them to prepare for their role as fathers and to make the arrival of their child more tangible by beginning to establish a bond with him/her during the pregnancy already, using techniques, such as haptonomy or communication through singing or speaking.The aim of our study was to explore the way in which first-time pregnant women and partners anticipated the birthing process and the actions they favoured to prepare for it. The qualitative approach was chosen to gain a more in-depth and comprehensive understanding of their information and communication needs in order to guide future communication strategies. The thematic analysis of the interviews allowed us to identify six themes that characterised the different areas of concern of future parents facing a first birth: Childbirth event; Childbirth experience; Childbirth environment; Organisation of care; Participation in decision making; Roles within the couple and transition to parenthood.In our study, pregnant women and partners described childbirth as an unpredictable event that could potentially require medical intervention to manage complications. Even those who were planning an out-of-hospital birth considered safety to be a key criterion in their decision making. These views are not surprising in a country like Switzerland where the medicalised model of childbirth care predominates, with 98.3% of births taking place in hospitals . At the This ambivalent attitude seems to influence how expectant parents seek and deal with information about childbirth risks. Most participants considered it important to be informed about possible complications, such knowledge allowing them to anticipate adverse events and to get involved in decisions. At the same time, however, they tried to avoid this type of information, preferring an optimistic or resilient attitude, sometimes suggesting that a negative state of mind could adversely influence the course of events. Research has shown that people are not passive recipients of risk information and that they do not respond to it rationally . They caA mismatch between expectations and experiences of childbirth has been found to have a negative impact on women’s satisfaction and their postpartum mental health , 50, 51.In addition, while participants expressed concerns about the prospect of a complication during childbirth, it appeared that beyond the event itself, they were particularly preoccupied with its impact on their own experience. The participants’ main concern was to ensure the health of the child and the mother, but they reported trusting the expertise of professionals to manage risky situations that could potentially threaten it. However, they were preoccupied that such adverse events would make them feel out of control of the situation. In addition, many pregnant women expressed worries that they would not be able to cope with the pain and duration of labour and therefore not feel fully involved in their childbirth. For some, it seemed that the risk of being somehow dispossessed of their birth could have consequences beyond the event itself, and give them a sense of failure that they would have to live with.Participants’ concerns are consistent with several studies that have shown that feeling in control during childbirth is a significant predictor of a positive childbirth experience , 54–57. In addition to familiarising themselves in advance with the birth environment, expectant parents wished to receive more concrete and practical information about the natural birthing process, as well as a more complete understanding of the services available to them. While antenatal classes and testimonials from family members or friends were particularly valued, it is interesting to note that these means were not felt to be sufficient, and that searching for information on the internet, particularly videos, was often cited as a useful way to visualise and anticipate concretely what they were about to live.The fact that the participants in our study were experiencing their first pregnancy may explain this strong need for concrete, practical information . HoweverSeveral studies on antenatal information and education have highlighted the importance of interaction with healthcare professionals and support to contextualise information, address personal concerns, and manage the emotional aspects of the birth experience , 60–62. Today, more than ever, expectant parents have access to a multitude of information resources on childbirth. Contrary to what one might think, this reality does not seem to undermine confidence in the expertise of healthcare professionals, who are still considered as the most valued sources of information , 61. In This does not mean that future parents planned to remain passive, but the partnership they expected seems to be characterised more by the quality of the relationship on which it would be built than by the decisions it would involve. Participants expressed a desire to clarify in advance how much of the decision making they would be involved in regarding birth-related choices, and whether their wishes were compatible with the usual procedures of the birthplace. Rather than unilaterally communicating their wish list or birth plan, it seems that their need was primarily to engage in a dialogue in order to adjust their own perspectives to the birthing context that would offer them the expected safety. We interpret this as a desire to initiate a relationship of trust with the professionals who will take care of them, thus preparing a model of partnership that would allow them to be involved in decision-making during the birth process, seeing their wishes respected and being informed to understand what is happening, without having to carry all the responsibility for decisions. From this perspective, the expectations of future parents seem to support the argument that the quality of the care relationship is an essential foundation for successful and collaborative shared decision-making , 20, 64.When considering how best to implement shared decision making in maternity care, it is essential to pay particular attention to the specific role and needs of the partners. In our study, we did not notice any major differences in the perceptions of future mothers and partners, which led us to believe that the variability of views was more related to individual characteristics than to gender criteria. However, some differences emerged in how they each anticipated the partner’s involvement in the birthing process. Although all shared the idea that the partner was a crucial support and advocate for the birthing woman, partners were apprehensive about the weight of this responsibility when they themselves would be emotionally involved in the event. In addition, they had difficulty imagining concretely the role they might play, an insecurity that was shown to persist during the birthing process and postnatal period , 66. On This study has several strengths. It addresses the question of information needs regarding the risks of childbirth in an innovative way by exploring them through the perceptions of expectant parents and the actions they take to prepare for childbirth. The qualitative approach allowed for a deeper and more subtle understanding of the needs of first-time parents through the nuances they provided during the interviews. The study also has the value of including partners, who have long been overlooked in studies addressing birth satisfaction. Finally, by focusing on future parents with uncomplicated pregnancies, our research also addresses new insights into the issue of risk information in non-pathological situations, an area in which knowledge is still very limited.The limitations of the study are primarily related to the lack of sociodemographic diversity among the participants. Proportionally, the sample had a higher level of education than the general population, which may have an impact on how information is sought and managed, and how relationships with care teams are viewed. The lack of cultural diversity is also a limit and future research should certainly involve more people with a migration background. In addition, although we tried to include as many partners as pregnant women, the latter participated in greater numbers. The difficulty of recruiting partners in perinatal studies has already been highlighted by other authors . HoweverOur results provide interesting insights for the development of information and communication strategies on childbirth for parents expecting their first child. First, they highlight the importance of redefining and broadening the concept of “childbirth risks” to take greater account of parental concerns. As the worries of future parents seem to be strongly linked to the fear of a loss of control, the question arises as to how prenatal information and communication could prepare them to participate more actively in the birth process and in decision making. Efforts should be made to provide pregnant women and partners with more concrete and comprehensive information to help them project themselves more easily into the upcoming birth, and to better manage the emotional issues associated with this unknown event. Visits to birthing facilities before the birth, presentations of the care teams and the organisation of care on site or via online video, or any other means enabling couples to familiarise themselves with the birthing environment in advance are also to be encouraged.how to communicate them seems essential. Our results suggest that the challenge is not simply to pass on knowledge to future parents to better prepare them for the reality of childbirth, but that this knowledge has to be contextualised and put into perspective with individual needs in order to make sense of it. The participants wished to be able to discuss their views and preferences with the team before the birth, in order to adjust their perspectives and establish a form of partnership adapted to the realities of the care environment. This prenatal exchange would seem to us to be an opportunity to initiate a collaboration between couples and healthcare teams before the birth. The aim would not be to pitch the “medical” against the “natural”, but rather to foster a flexible state of mind and mutual trust in anticipation of the birth to come, while respecting the constraints and values of each party.But beyond the issue of the topics to be transmitted to future parents, the question of To determine whether parents’ perception of their information needs changes after childbirth experience, it would be interesting to re-interview the same participants who have since given birth. Future research is also needed to compare the perceptions and expectations of future parents with those of healthcare professionals, in order to detect any discrepancies that could hinder communication. Finally, it would be useful to identify more concretely the elements to be considered in prenatal communication to encourage the establishment of a relationship of trust and support shared decision-making that meets the needs of everyone—women, partners, and professionals. In this respect, specific efforts should also be made to assess how to concretely tailor information provision and discussion on the individual needs of each future parent. To this end, we consider that it would be essential to involve all stakeholders—parents and professionals—in these research processes, in a co-development approach.This study contributes to a better understanding of the information needs of future parents expecting their first child. Results highlighted that the notion of “childbirth risks” goes beyond the prospect of complications during birth, but also encompasses concerns related to a feeling of loss of control over the event. Expectant parents showed an ambivalent attitude towards consulting risk information, believing it important to prepare for the unpredictability of childbirth, while avoiding information they considered too worrying. They expressed a desire to receive concrete, practical information, and a need to familiarise themselves in advance with the environment of their future birth. Establishing a respectful and caring relationship with the healthcare teams before labour starts was also seen as important to prepare for birth. The findings suggest that information on childbirth should not be limited to the transmission of knowledge, but should primarily be based on the establishment of a relationship of trust with healthcare professionals, taking into account each person’s individual values and expectations.


To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation.+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group.A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions  and in the neonatal hospitalization period . The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment.The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation. The administration of progesterone to high-risk women is associated with lower rates of spontaneous preterm birth and NICU admissions.Preterm birth is the leading cause of perinatal mortality and morbidity , 2. WomeCervical length measurement between 18 and 24 weeks of gestation is the most powerful predictive tool for sPTB , 6, 11, Some patients with prior preterm delivery do not receive any preventative treatment despite its wide recommendation, due to physician's preference, patient's preferences, or the patient's inability to comply. These patients may pose a management dilemma when referred for treatment after 24 weeks of gestation with the new diagnosis of a sonographic short cervical length.The aim of this study was to assess the effect of vaginal progesterone treatment on the prevention of sPTB and adverse neonatal outcomes in women with previous preterm birth and a short cervix newly diagnosed after 24 weeks of gestation.+0 to 33+6 weeks of gestation between 2010 and 2017  and the Samsung Accuvix A30 , both of which were equipped with vaginal probes.+0 weeks of gestation, had a progestogen prescription prior to 24+0 weeks, underwent pessary or cervical cerclage placement during the current pregnancy, and had either a medically indicated preterm delivery or delivered on the same day of the short-cervix diagnosis.Women were excluded from this study if they were diagnosed with a short cervical length measurement prior to 24Demographics and obstetrical history were obtained from the electronic medical records of the patients. The primary outcome measured was the rate of sPTB, defined as the spontaneous onset of labor resulting in birth before 37 weeks of gestation. Secondary outcomes consisted of sPTB by <34, <32, and <28 weeks of gestation; mean gestational age at diagnosis and delivery; lag from short cervical length diagnosis to delivery; and mode of delivery. Neonatal outcomes included the duration of the neonatal hospitalization period; Apgar score <7 at 5 min; birth weight; neonatal intensive care unit (NICU) admission; respiratory distress syndrome; intra-ventricular hemorrhage; necrotizing enterocolitis; retinopathy of prematurity; bronchopulmonary dysplasia; and neonatal mortality. The modes of delivery were categorized into vaginal delivery, operative delivery, or cesarean delivery. Neonatal hospitalization was measured in days from birth to discharge. The Apgar score after 5 mins was also reported in the study. Admission to the NICU was registered for any period during the primary period after birth. Respiratory distress syndrome was defined by cyanosis, tachypnea, and respiratory failure shown in blood gas and chest radiography . Intra-v+0 weeks and late preterm birth between 34+0 and 36+6 weeks of gestation) and the number of previous preterm births (single vs. multiple).We performed a sub-analysis according to the time of previous preterm birth .A Chi-square test or Fisher's exact test was used to test the association between two categorical variables. A two-sample t-test or the non-parametric Mann-Whitney test was used to compare quantitative variables between two independent groups. The non-parametric test was applied for non-normally distributed data. The Kaplan-Meier survival model, with the log-rank test for the comparison of survival curves, was applied to assess the effect of categorical variables in the event of premature birth, taking into account the time from cervical length measurement to delivery. The Cox regression model was used to assess the effect of quantitative variables on the event of premature birth, taking into account the time from cervical length measurement to delivery. The Cox regression model was also used as the multivariate model for simultaneously assessing the effect of several variables on premature birth, taking into account the time from cervical length measurement to delivery. All applied statistical tests were two-tailed, and a +0 and 33+6 weeks of gestation were identified through their medical records for this study. After exclusion criteria, 104 cases were eligible for the study cohort as presented in One-hundred and thirty-three women with a singleton pregnancy, a history of preterm birth, and a cervical length ≤ 25 mm measured between 24P = 0.14). No events of sPTB before 34 weeks occurred in the progesterone treatment group, whereas 7.1% (4/56) of the non-treatment group delivered before 34 weeks of gestation (P < 0.05). P = 0.21), and the aHR for the number of previous preterm deliveries was 2.01 .The Cox proportional logistic regression model for delivery before 37 weeks of gestation included five confounders: progesterone treatment; cervical length ≤ 15 mm; maternal age; the number of previous preterm deliveries; and occurrence of preterm delivery in the antecedent delivery. The adjusted hazard ratio (aHR) of progesterone treatment was 1.539 , and NICU admissions comprised three newborns (6%) in the treatment group and 14 newborns (25%) in the non-treatment group .Neonatal outcomes are shown in This study evaluated the effect of progesterone treatment in a high-risk population comprised of women with a history of preterm birth and a short cervix diagnosed after 24 weeks of gestation. The main findings are as follows: (1) administration of vaginal progesterone was associated with a lower rate of sPTB before 37 weeks (31% vs. 43%) and before 34 weeks (0% vs. 7%) of gestation as compared to no progesterone treatment; (2) NICU admissions and neonatal hospitalization stays were significantly lower in the progesterone treatment group, and (3) a subgroup analysis evaluating the number of previous preterm births and progesterone treatment demonstrated that multiple prior preterm deliveries significantly increase the recurrence risk of preterm birth, and those not treated with progesterone had a consistently higher rate of preterm birth.The two main risk factors for preterm birth are previous preterm birth , 3–6 andOur study demonstrated that, in a high-risk population cohort, 68.75% of the progesterone treatment group delivered at term, while only 57.2% of the non-treatment group delivered at term. This study may be underpowered to identify the statistically significant difference; however, this finding aligns with previous studies on recurrent preterm birth , 3–6, 27The study by McManemy et al. evaluated patients with a history of preterm delivery, reporting that those with two previous preterm births had a significantly higher risk for recurrent preterm birth when compared to women with one previous preterm birth  . Women iThe results of the Cox proportional regression model showed that while the adjusted hazard ratio of the treatment group was not statistically significant, indicating no difference in continued pregnancies between the two groups, the number of previous preterm deliveries was found to be a significant factor. This emphasizes the significance of considering a patient's prior obstetrical history when making treatment decisions regarding progesterone administration.A comparison of adverse neonatal outcomes reveals a significant decrease in NICU admissions and shorter neonatal hospitalization stays for the newborns of women who received progesterone treatment for diagnosed short cervical length. In fact, the parameters of earlier gestational age at cervical length measurement, tocolytic therapy, antepartum corticosteroid administration, and a cervical length ≤ 15 mm were more prevalent in the treatment group , 2. If tThis study has several strengths. (1) this is the largest cohort reported in the literature for the specific high-risk population ; (2) strict exclusion criteria were applied in this cohort, which resulted in a very specific sub-population to evaluate the research question; and (3) inclusion criteria specifically referred to vaginal micronized progesterone 200 mg daily, therefore unified type, route, and dosage of the preventive intervention administration. We excluded women who received other types of progestogens  to focus on a single proposed treatment.This study also has several limitations. First, its retrospective nature encompasses the possibility of information bias. The intervention group prescribed with vaginal micronized progesterone can present selection bias. For example, women who were diagnosed with a short cervix earlier in pregnancy and had a shorter cervical length were considered at higher risk; and this may have led the attending physician to provide progesterone treatment to the women at higher risk. In fact, parameters such as earlier diagnosis in pregnancy, tocolytic therapy, antepartum corticosteroid administration, and cervical length ≤ 15 mm were more prevalent in the progesterone treatment group , 2. TherThese findings need to be validated by prospective controlled trials. Additionally, further studies can examine patients with various high-risk conditions . Future studies can assess the benefit of vaginal micronized progesterone compared to no intervention and evaluate which subpopulation can benefit the most from such treatment.The impact of vaginal progesterone in patients with a history of preterm delivery had not been tested on women with a cervical length ≤ 25 mm diagnosed after 24 weeks of gestation . To thatIn conclusion, preventive treatment should be selected by evaluating specific characteristics for each population, in which the obstetrical history should be a leading factor . Patients with more than one prior preterm birth have a higher risk of recurrence, and this risk can be implicated in the management of future pregnancies by targeted preventive care . The efficacy of vaginal progesterone treatment for decreasing adverse neonatal outcomes suggests that this high-risk population may benefit from cervical assessments even after 24 weeks of gestation in addition to progesterone intervention, if necessary. Further prospective investigation might be necessary to evaluate the efficacy of late second and early third-trimester cervical length measurement.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Hadassah Review Board (0446-20-HMO). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The study was conceived and designed by DL, SP, RR, DR, and DK, with data acquisition assistance from DL, DR, and SP. The EMR database was built and the data was analyzed by DL, DR, and DK. RH, YS, HH, and YE contributed to the study design and interpretation of the results. The draft manuscript was written by DL, SP, RR, DR, and DK. All authors reviewed and provided critical feedback on the final version. All authors bear responsibility for the accuracy and integrity of the data and analysis and approved the final manuscript for submission.


Currently, there is no consensus on how to score Crohn disease (CD) activity assessed by intestinal ultrasound (IUS) in children. This study aimed to design an easy-to-use IUS score for disease activity in pediatric CD.Children undergoing ileo-colonoscopy for CD assessment underwent IUS the day before ileo-colonoscopy, assessed with simple endoscopic score for CD (SES-CD). IUS features were compared to the SES-CD on segmental level. Multiple regression analyses, separately for terminal ileum (TI) and colon, were done to assess predictors of disease activity and to develop a model.P < 0.001]. In colon, BWT  and mesenteric fat  were independent predictors. A pediatric Crohn disease IUS score (PCD-US) cut-off of 1 resulted in a sensitivity of 82%  and 85% (95% CI: 80%–89%) and a cut-off of 3 in a specificity of 88% (72%–97%) and 92% (87%–96%) for TI and colon, respectively. Inter-observer agreement was moderate for TI and colon .In 74 CD patients , 67 TI and 364 colon segments were assessed. Based on receiver operating characteristics curves, bowel wall thickness (BWT) was categorized into low [1 point: 2–3 mm (TI) and 1.6–2 mm (colon)], medium [2 points: 3.0–3.7 mm (TI) and 2.0–2.7 mm (colon)], and high [3 points: >3.7 mm (TI) and >2.7 mm (colon)]. In TI, only BWT was retained in the model [high BWT: odds ratio (OR) 11.50, The PCD-US score is an easy-to-use and reliable score to detect or rule out CD activity on segmental level in children. External validation is needed before applying this score in clinical practice. Transmural healing is increasingly recognized as treatment target for children with Crohn disease (CD).Transmural healing can be assessed with intestinal ultrasound (IUS).Studies in adults with CD show excellent accuracy for IUS.This is the first prospective study to design an activity index for IUS in children with CD.The pediatric CD IUS score (PCD-US) is an easy-to-score index.The PCD-US can be used both to detect and to rule out CD activity.Pediatric Crohn disease (CD) is a chronic debilitating condition, causing inflammation of the gastrointestinal tract . Due to In this prospective study, the RAINBOW study, consecutive children visiting the pediatric gastroenterology outpatient department of 2 tertiary care centers in Amsterdam were invited to participate between August 2019 and June 2021. Inclusion criteria were: 6–17 years of age, and undergoing an ileo-colonoscopy for diagnosis or follow-up of CD. Children were excluded in case of infectious gastro-enteritis, a histologically proven cytomegalo virus (CMV) infection, pregnancy, or a history of surgical resection of the intestine. In addition, children were excluded from the analysis if their final diagnosis was not CD according to the Porto criteria . Parts oParticipants underwent an IUS on the day before the ileo-colonoscopy, before start of the bowel preparation. In case this could not be realized, IUS was performed within 7 days before or after ileo-colonoscopy. The ileo-colonoscopy served as reference standard for the TI and colon. Baseline demographics, including age, gender, body mass index, Paris Classification, Pediatric Crohn Disease Activity Index (PCDAI), CRP, and FC were collected from the medical files.The IUS was performed by an ultrasonographer (EAW), who followed the International Bowel Ultrasound curriculum prior to the start of the study, and who had performed at least 100 IUS examinations under supervision. The ultrasonographer was unaware of the clinical details and was blinded for the results of the reference standard. Participants did not receive a specific bowel preparation, but were asked not to drink carbonated fluids or eat solid food 4 hours prior to the IUS, as is recommended by the ESPR-ESGAR guidelines . The IUShttp://links.lww.com/MPG/D73. We selected these items based on a study from IUS experts that used the Delphi method to identify the most important items of inflammation, and on 2 systematic reviews: 1 systematic review from 2019 evaluating all studies on diagnostic accuracy of IUS in children with IBD, and 1 systematic review summarizing all previously published IUS scoring indices for adult patients with IBD   ,13,17. TThe results of all measurements for each intestinal segment were recorded on a scoring form during the examinations.Participants were prepared for the ileo-colonoscopy with Kleanprep or Moviprep (Norgine BV) according to local protocol. The ileo-colonoscopy, the reference standard for TI and colon, was performed by experienced pediatric gastroenterologists , and video-recorded. Videos were centrally read and scored using the previously validated simple endoscopic score for CD (SES-CD)  per segm-No inflammation: 0 points-Mild inflammation: 1–3 points-Moderate-severe inflammation: >3 pointshttp://links.lww.com/MPG/D73 differed between the 3 endoscopic disease severity grades. Differences in continuous variables were assessed with Kruskal-Wallis test and differences in categorical variables with the X2 test. To simplify the interpretation of BWT measurements within the future model, BWT was subsequently categorized into 4 categories . As the rationale for cut-off values reported in previous pediatric studies is unclear, we based our cut-off values on receiver operating characteristics (ROC) curves. To assess the full range of diagnostic properties of BWT, we determined the cut-off associated with (1) around 10% false negatives, (2) optimal sensitivity and specificity, and (3) around 10% false positives.Analyses were performed separately for the TI and for all colon segments collectively. This was based on the difference in bowel wall characteristics for these segments, particularly bowel wall thickness (BWT). In case either the IUS or the endoscopy data was missing, the segment was excluded from the analyses. For all segments we tested whether each IUS item in Table 1, Supplemental Digital Content, P values and highest odds ratio (OR) 1 by 1 into the model . If the pseudo R2  or −2 log-likelihood (for logistic regression) improved by 10% after entering a new variable, the variable was added to final model.Next we performed either multiple ordinal regression analysis or—if group sizes were too small—multiple logistic regression analysis, again separately for the TI, and all colon segments collectively, using the categorized reference standards as dependent variable. In case of logistic regression, we dichotomized the reference standard into no inflammation  versus inflammation . We first performed univariate analyses and for item reduction, we subsequently entered variables with the lowest B values. To test the quality of this newly developed PCD-US score, we calculated sensitivity and specificity values and positive and negative likelihood ratios (LRs) for various cut-off values of the score, for differentiating active disease from remission, mild disease from remission, and moderate-severe disease from remission and mild disease.To further simplify our model into a score, we assigned points to the items in our final model, based on the rounded estimates or We further validated our score internally, using bootstrapping with 1000 samples, and by assessing the correlation of the sum of the segmental PCD-US scores with the SES-CD total score, using Spearman rank correlation. For reliability, we calculated weighted kappa values to test inter-observer agreement of the PCD-US score. Kappa values were interpreted as follows: ≤0, no agreement; 0.01–0.20, none to slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, substantial; and 0.81–1.00, almost perfect agreement . Baseline characteristics are displayed in Table A total of 74 children were included [median age of 15  years] . For TI there was a significant difference in all IUS items except for presence of lymph nodes. Complications were noted by IUS in only 8 patients .The IUS features per disease activity grade are displayed in Tables 2a and 2b. There was a significant difference in all IUS items between 3 disease activity grades for colon segments (http://links.lww.com/MPG/D73).The area under the receiver operating characteristic (AUROC) of BWT for detecting moderate-severe disease was 0.78 (95% CI: 0.67–0.90), and 0.78 (95% CI: 0.73–0.83) in TI and colon, respectively. The two cut-off values for BWT based on the ROC curve for each segment are displayed in Table 4a, Supplemental Digital Content, http://links.lww.com/MPG/D73). In the multivariate model, only BWT added to the predictive value of model for endoscopic TI disease activity  .For TI, the number of mildly inflamed segments was too low for ordinal regression; hence we performed logistic regression comparing no inflammation versus inflammation. Categorized BWT, Doppler signal, wall layer stratification, and peristalsis were predictors for endoscopic disease activity in univariate analyses . The items that were retained in the ordinal multivariate model for optimal prediction of colonic endoscopic disease activity were BWT  and presence of mesenteric fat proliferation  .For colon, all IUS items were independent predictors for endoscopic disease activity  are as follows:http://links.lww.com/MPG/D73. The score was calculated for each segment. The ROC curves of the PCD-US score and their area under the curves (AUC) are displayed in Figure Examples of IUS measurements are displayed in Figures 2 and 3, Supplemental Digital Content, B values resulting from the bootstrapping are displayed in Tables 5a and 5b, Supplemental Digital Content, http://links.lww.com/MPG/D73. The PCD-US total score correlated significantly with the SES-CD total score .The 95% confidence interval of the estimates and K: 0.42, SD: 0.13) and for colon . For TI, the first rater scored a PCD-US of 3 points in 3 of 43 segments while the second rater scored 0 points, and inversely, the second rater scored a PCD-US of 3 points in 1 of 43 segment where the first rater scored 0 points. For colon, the first rater scored a PCD-US of 3 points in 10 of 208 segments while the second rater scored 0 points, and inversely, the second rater scored a PCD-US of 3 points in 4 of 208 segments where the first rater scored 0 points.A total of 251 segments (43 TI and 208 colon) were evaluated by both the ultrasonographer and the radiologist. The inter-observer agreement was moderate for TI  and a cut-off of <1 to rule out disease activity .IUS is increasingly used and propagated as noninvasive and relatively cheap monitoring tool for children with CD , and an Interestingly, when included in multivariate analyses together with BWT, other IUS items did not improve the predictive value of the model except for mesenteric fat proliferation for colon, despite their predictive value for endoscopic disease activity in univariate analyses. This finding contrasts to other studies, describing for instance the presence of Doppler signal or abnormal wall layer stratification as independent predictors , but conIn our cohort, a PCD-US score of ≥3 points, that is, colonic BWT > 2.0 mm combined with fat infiltration, or a BWT > 3.7 or >2.7 mm for TI and colon respectively, had a high probability of endoscopic disease activity . If this high accuracy is confirmed following external validation, particularly for reassessment of disease during treatment, the PCD-US score could be applied as point-of-care test to predict endoscopically active disease in daily clinical practice. A negative score (0 points) demonstrated a low probability of active endoscopic disease . Specificity values of the PCD-US score were low for PCD-US scores of 1 and 2 points, implying that when active disease is suspected in these cases, these PCD-US scores are not sufficient to demonstrate disease activity. In our cohort, only one third of segments scored 1 or 2 points. Combination with other inflammatory markers, such as FC, might improve the accuracy in these cases. The effectiveness of this approach is supported by the results of Bots et al , who demA remarkable finding of our study was the moderate inter-observer agreement, which stresses the importance of standardized measurements . OperatoStrengths of this study are the prospective design, the short time period between IUS and reference standard, blinding procedures, central reading procedure of the reference standards, and adequate sample size, which is reflected by the small 95% confidence interval of the sensitivity and specificity, especially for the colon. There are, however, some limitations to this study as well. Ileo-colonoscopy and IUS are 2 completely different imaging methods and transmural healing cannot be assessed by ileo-colonoscopy, while all features of IUS, especially mesenteric fat proliferation, are indicators of transmural disease activity. This may have led to a number of incorrect false positives, as transmural activity can be present even in segments with a normal mucosa , and thuFuture research should focus on the external validation of the PCD-US score in an independent cohort. In addition, as IUS is increasingly used as a tool to monitor response to treatment, the sensitivity to change the PCD-US scores in relation to response to treatment needs to be assessed in a longitudinal cohort. The clinical added value of the PCD-US score, when using it in combination with other inflammatory markers and its predictive value for a flare is currently being studied.In conclusion, we developed the PCD-US score, an easy-to-use IUS score, which reflects moderate-to-severe CD activity on a segmental level. Further validation studies are warranted to assess the performance of this score during follow-up of CD and its wider application in clinical practice.We thank Hanneke van de Lee from the clinical research department of the Emma Children’s hospital for her contribution for the conception and design of this study.


Pelvic organ prolapse (POP) refers to symptomatic descent of the vaginal wall. To reduce surgical failure rates, surgical correction can be augmented with the insertion of polypropylene mesh. This benefit is offset by the risk of mesh complication, predominantly mesh exposure through the vaginal wall. If mesh placement is under consideration as part of prolapse repair, patient selection and counseling would benefit from the prediction of mesh exposure; yet, no such reliable preoperative method currently exists. Past studies indicate that inflammation and associated cytokine release is correlated with mesh complication. While some degree of mesh-induced cytokine response accompanies implantation, excessive or persistent cytokine responses may elicit inflammation and implant rejection.Here, we explore the levels of biomaterial-induced blood cytokines from patients who have undergone POP repair surgery to (1) identify correlations among cytokine expression and (2) predict postsurgical mesh exposure through the vaginal wall.Blood samples from 20 female patients who previously underwent surgical intervention with transvaginal placement of polypropylene mesh to correct POP were collected for the study. These included 10 who experienced postsurgical mesh exposure through the vaginal wall and 10 who did not. Blood samples incubated with inflammatory agent lipopolysaccharide, with sterile polypropylene mesh, or alone were analyzed for plasma levels of 13 proinflammatory and anti-inflammatory cytokines using multiplex assay. Data were analyzed by principal component analysis (PCA) to uncover associations among cytokines and identify cytokine patterns that correlate with postsurgical mesh exposure through the vaginal wall. Supervised machine learning models were created to predict the presence or absence of mesh exposure and probe the number of cytokine measurements required for effective predictions.PCA revealed that proinflammatory cytokines interferon gamma, interleukin 12p70, and interleukin 2 are the largest contributors to the variance explained in PC 1, while anti-inflammatory cytokines interleukins 10, 4, and 6 are the largest contributors to the variance explained in PC 2. Additionally, PCA distinguished cytokine correlations that implicate prospective therapies to improve postsurgical outcomes. Among machine learning models trained with all 13 cytokines, the artificial neural network, the highest performing model, predicted POP surgical outcomes with 83% (15/18) accuracy; the same model predicted POP surgical outcomes with 78% (14/18) accuracy when trained with just 7 cytokines, demonstrating retention of predictive capability using a smaller cytokine group.This preliminary study, incorporating a sample size of just 20 participants, identified correlations among cytokines and demonstrated the potential of this novel approach to predict mesh exposure through the vaginal wall following transvaginal POP repair surgery. Further study with a larger sample size will be pursued to confirm these results. If corroborated, this method could provide a personalized medicine approach to assist surgeons in their recommendation of POP repair surgeries with minimal potential for adverse outcomes. Pelvic organ prolapse (POP), defined as symptomatic descent of the vagina and surrounding pelvic organs, affects approximately 50% of parous women and 6% of nonparous women between ages 20 and 59 years , with alInflammatory responses are associated with mesh exposure due to asymptomatic mesh infection that inhibits the mesh from integrating with the surrounding environment . While sLeveraging a patient-specific, multifaceted immune response for the prediction of postsurgical complications is an ideal problem for the application of principal component analysis (PCA) and supervised machine learning models. In fact, this approach has been used to predict complications following other surgical procedures as well as progressive disease outcomes. In a liver transplant study, Raji and Vinod Chandra  applied PCA and supervised machine learning have also been applied to biological measurements for predicting medical outcomes. Tseng et al  built a The application of PCA and machine learning to predict postsurgical complications in women after POP surgery has also shown promising results. In the study of Jelovsek et al , statistIn this preliminary study, we explored the levels of baseline and stimulus-induced cytokines in blood isolated from patients who had undergone POP repair surgery with a polypropylene mesh. Proinflammatory and anti-inflammatory cytokine levels from these data were analyzed using PCA to establish the principal components (PCs) and to identify associative or opposing trends among cytokines. In addition, supervised machine learning models were applied to demonstrate predictive capabilities when models were trained with either all 13 cytokines or a smaller group of 7 cytokines determined most effective by a random forest method. The results demonstrate that leveraging PCA and supervised machine learning models to predict outcomes of vaginal mesh implantation has the potential to benefit future patients when they are faced with this surgical decision, which carries a relatively high risk of unsuccessful surgical outcome.t test based on an a priori power analysis, which indicates the number of patients for a given theoretical minimum study power as a function of the expected difference between patients with and those without mesh exposure, or the Cohen d. We assumed a conservative study power of 0.80 and a 100%, or 2-fold, difference in the level of a given cytokine between individuals with and without mesh exposure, equivalent to a Cohen d of 1. Here, 20 patients with equal distribution among the 2 groups are needed to observe the difference with a probability of .1. Participants with POP recurrence or taking medications that would alter inflammatory response were excluded from this study.In total, 20 healthy, nonpregnant female participants aged 56-89 years at Prisma Health Greenville Memorial Hospital with a history of surgical intervention to correct POP via a procedure that used polypropylene mesh were selected for the study. The participants, who were not matched, included 10 who experienced postsurgical mesh complication in which the implanted mesh protruded through the vaginal wall  and 10 participants who did not experience this complication post surgery. This sample size was estimated as an effective cohort for the pilot study using a 1-tailed The study protocol was approved by the institutional review board (IRB) of Prisma Health (Pro00067964). Informed consent from all study participants was obtained using an IRB-approved informed consent form. All samples collected and data analyzed were deidentified and followed IRB protocol.Blood samples were obtained from the 20 selected participants. Approximately 12 mL of blood was drawn from the upper extremity of each participant into 3 BD Vacutainer EDTA-coated tubes. Deidentified blood samples were then transferred on ice to a laboratory facility at the University of South Carolina School of Medicine Greenville for immediate processing. Each participant’s blood sample was divided into equal aliquots for 24-hour incubation at 37 °C under 3 distinct conditions: (1) incubation with inflammatory agent lipopolysaccharide (LPS) at 20 ng/mL (positive control), (2) incubation with sterile polypropylene mesh area of 2 cm × 2 cm , and (3) incubation alone (negative control). After incubation, the plasma layer was collected following centrifugation  and immediately stored at –80 °C.Cytokine levels in each blood sample were quantified using the bead-based MILLIPLEX Human Cytokine/Chemokine/Growth Factor Panel A—Immunology Multiplex Assay (EMD Millipore Corp), which is composed of analytes for target cytokines interleukin 1α (IL-1α), IL-1β, IL‑2, IL-4, IL-6, IL-8, IL-10, IL-12p40, IL-12p70, IL-17A, interferon-gamma , and granulocyte-macrophage colony-stimulating factor (GM-CSF). Frozen plasma samples were thawed at room temperature and analyzed following Milliplex protocol guidelines. Cytokine concentrations were measured using a Bio-Plex 200 (Bio-Rad) and Bio-Plex Manager software (Bio-Rad). Sample volume was doubled to ensure measurable levels of cytokines, and assay output data were adjusted to reflect concentrations in plasma samples. Each multiplex assay was performed in duplicate, and cytokine levels were evaluated in 3 independent measurements.Cytokine data gathered from the multiplex immunoassay were analyzed using data mining and predictive analytical methods. PCA was used to identify important cytokines by studying their contributions to each PC as well as to discern associations between cytokines. Supervised machine learning models were created to determine whether cytokine levels can accurately predict which patients are more likely to experience mesh exposure post surgery.The statistical programming language R  was used to analyze raw cytokine data values generated from the multiplex immunoassay. The imported data structure contained 60 observations (20 participants × 3 independent measurements) and 40 total variable fields (13 cytokines × 3 blood treatments + 1 target variable). The target variable was the participant’s outcome, which indicated a postsurgical complication that participants might have experienced following POP surgery. Observations marked “presence” represent participants who experienced mesh exposure through the vaginal wall. Observations marked “absence” represent participants who did not experience any mesh exposure through the vaginal wall. Univariate and multivariate methods were used to explore the data set, including identifying missing values, analyzing outliers, and visualizing frequency distributions.is the sample mean and ix and n are the individual observations and number of observations, respectively, within the sample [z-score standardization was also applied to scale each cytokine variable, thus ensuring that the mean was equal to 0 and SD equal to 1. Biplots were created to visualize PCs with the highest degree of variance explained. The eigenvectors were overlayed on the biplots to visualize correlations and identify hidden patterns between cytokines.PCA was performed using the FactoMineR package   to idente sample . Each cySupervised machine learning models were created using the caret package   in the RAdditionally, this process was replicated to study the effects of reducing the number of cytokines needed to predict a postsurgical mesh exposure. A random forest algorithm was used to select important cytokines for this study. These models were trained and tested for accuracy, sensitivity, and specificity as detailed above. The results are compared to models trained with all 13 cytokines.To identify significant associations among the cytokines, PCA was used to examine a total of 60 blood samples (20 participants × 3 blood treatments). Among the 20 participants, 10 experienced postsurgical mesh exposure through the vaginal wall and 10 did not. When PCA was used to examine only blood samples incubated with polypropylene mesh, PC 1 and PC 2 explained 60.1% and 13.1% of the total data variance, respectively B. FigureIn order to visualize associations between the participants presenting the absence or presence of postsurgical mesh exposure through the vaginal wall, a biplot illustrating individual participants was created . This biFour supervised machine learning models incorporating all 13 cytokines were trained using 70% (42/60) of the available 60 observations (20 participants × 3 independent measurements); the remaining 30% (18/60) was used to test the models’ accuracy when predicting the presence of mesh exposure through the vaginal wall. All 4 machine learning machines achieved at least 62% (26/42) training accuracy . ArtificAdditional models and predictive analyses explored whether a smaller set of cytokines could achieve similar predictive results. Feature selection using a random forest method identified a group of 7 cytokines capable of yielding effective predictive analysis: IL-1β, IL-8, IL-12p40, IL-12p70, TNF-α, IL-17A, and IL-6. Among patients with POP who undergo mesh implantation surgery, 17% of them experience mesh exposure through the vaginal wall . This raThe PCA analysis illustrated in The cytokines that contribute most to each PC segregate into proinflammatory and anti-inflammatory cytokines . When cyWhen juxtaposing the biplot of polypropylene-stimulated cytokine observations B with thWhen creating models trained with a subgroup of 7 cytokines , selecteThis study implemented rigorous research methods to identify physiological relationships among cytokine markers and developed robust machine learning models to predict mesh exposure; yet, some limitations should be noted. First, because this is a pilot study, the sample size is limited to 20 participants within a single hospital system. Nevertheless, this limited sample size predicted 83% (15/18) accuracy, a level that compares favorably with another predictive model study by Chu et al  that achWhile this preliminary study is limited to a sample size of just 20 participants, this novel approach to using cytokine response to predict POP surgical outcomes has successfully distinguished important cytokines and their correlations. Moreover, these relationships point toward prospective therapies that could promote better surgical outcomes. Supervised learning models also demonstrate a high level of accuracy, specificity, and sensitivity, even when a smaller group of cytokine data is used. This result suggests that blood cytokine analysis might be feasibly used in a clinical setting to predict POP surgical outcomes. Further study with a larger patient population will be needed to confirm the utility of this method. If successful at a larger scale, this approach has the potential to change perspectives in which surgeons would recommend and proceed with POP repair surgeries and to prevent undesired outcomes of mesh-related surgeries in patients.


This video demonstrates the purely endoscopic gross-total resection of a third ventricle colloid cyst that is partially covered by a large thalamostriate vein. To gain an ideal approach, the initial trajectory pointed to the interventricular septum above the cyst. After the head of the caudate nucleus is passed, it is retracted laterally by the endoscopic sheath for the ideal far lateral approach to the cyst. Using a pneumatic endoscope holder enables the surgeon to perform the procedure bimanually. After complete removal of the cyst, postoperative inspection confirms the intact fornix, veins, and caudate nucleus without signs of pressure-related damage.https://stream.cadmore.media/r10.3171/2023.1.FOCVID22140The video can be found here:  This case addresses the endoscopic transventricular resection of a colloid cyst of the third ventricle. On admission, the patient suffered from headache and intermittent nausea. In the preoperative MRI, you can see the third ventricle colloid cyst with a dilated right lateral ventricle.We decided to perform a purely endoscopic navigation-guided transventricular resection.1 We chose to access the cyst via the dilated right ventricle, where the cyst lies directly at the foramen of Monro. In the preoperative MRI, you already see a very prominent thalamostriate vein, rendering this case particularly challenging.For preoperative preparation, planning of the trajectory was carried out based on a thin-sliced T1-weighted MRI. Our aim was to gain an optimal trajectory, reaching the colloid cyst at the foramen of Monro from as far lateral as possible. To achieve this approach, the initial trajectory is pointed not to the cyst itself, but further medial to the interventricular septum. Once the head of the caudate nucleus is passed, the trajectory is shifted downward to reach the colloid cyst.2For endoscopic intraventricular procedures, we use the LOTTA system in combination with a pneumatic endoscope holder.For the approach, the patient is placed in a supine position. The head is slightly anteflected, so the planned burr hole is the highest point in order to minimize postoperative pneumocephalus. The correct entrance point is located with the help of our neuronavigation. For aesthetic reasons, the skin is incised in a straight fashion right behind the hairline.A burr hole is placed and the navigation-guided sheath for the endoscope is carefully inserted, following the preplanned trajectory, reaching the lateral ventricle with direct view to the interventricular septum and the head of the caudate nucleus. Once the caudate nucleus head is covered by the endoscope sheath, the sheath is used as a retractor to dislocate the head of the caudate nucleus a little bit laterally to get the ideal approach to the colloid cyst’s attachment at the roof of the third ventricle. The anatomical landmarks for orientation are the fornix, the choroid plexus, as well as the thalamostriate and the septal veins. This case is complicated by the high-caliber thalamostriate vein partially covering the cyst. The main difficulty here is to mobilize the cyst into the lateral ventricle, without injuring the thalamostriate vein or the fornix, both of which would result in severe consequences.At first, the choroid plexus covering the cyst’s surface is coagulated. After sharp incision, the content of the cyst is removed with a suction tube. Then the cyst is mobilized into the lateral ventricle. Using the pneumatic endoscope holder enables the surgeon to bimanually dissect the colloid cyst, exposing the cyst’s pedicle attached to the tela choroidea.3 Subsequently, the cyst can be removed.Bimanually, the vascularized pedicle is coagulated and sharply dissected from the choroid plexus.After complete removal of the cyst, the operative field is inspected. Here, you see the choroid plexus, where the cyst was attached; the intact fornix; and the unharmed caudate nucleus. Usually, we check the contralateral foramen of Monro and the aqueduct for blood clots, which may cause obstructive hydrocephalus. Here, this measure was waived due to the very narrow foramen of Monro to avoid injury to the fornix.Postoperatively, the patient is doing fine. In the postoperative MRI, the approaching canal placed relatively lateral can be seen without any caudate nucleus pressure-caused injury.In conclusion, a purely endoscopic procedure via the LOTTA ventriculoscope using a bimanual sharp dissection technique enables a gross-total resection of most colloid cysts.Dr. Schroeder reported personal fees from Karl Storz SE & Co. KG, Tuttlingen, Germany, during the conduct of the study.Primary surgeon: Schroeder. Editing and drafting the video and abstract: Lehmann. Critically revising the work: Schroeder. Reviewed submitted version of the work: Schroeder. Approved the final version of the work on behalf of both authors: Lehmann. Supervision: Schroeder.


The unpredictable nature of preterm labour can be a stressful experience for the mother. The occurrence of preterm birth can lead to the failure of the mother's previous expectations regarding the process of labour and birth leading to negative perception towards birth.This descriptive-analytical cross-sectional study was conducted in Tabriz, Iran. We employed convenience sampling to recruit eligible mothers with term birth (314 women) and preterm birth (157 women). Childbirth Experience Questionnaire 2.0, Preterm Birth Experiences and Satisfaction Scale, and Delivery Fear Scale were used to measure the woman’s fear of delivery during labour and birth experience. Data were analysed by general linear model.p = 0.414] in terms of childbirth experience. However, the fear of delivery had a significant relationship with the childbirth experience .The prevalence of negative birth experience in the term and preterm birth groups was 31.8% and 14.3%, respectively. The results of the multivariable general linear model, after the adjustment of demographic and obstetric characteristics, showed that there was no statistically significant difference between the two groups of mothers with term and preterm birth [β (95% CI): -0.06 (-0.22 to 0.09); There was no statistically significant difference in terms of women’s childbirth experience between the mothers with term and preterm births. The fear of delivery during labour was the predictor of childbirth experience. In order to improve women's childbirth experience, interventions should be made to reduce their fear during labour. Birth is one of the most important events in a woman's life. Women's emotional and cognitive experience of birth has a significant effect on the physical and mental state of the mother during the postpartum period  and her The World Health Organization (WHO) defines the positive birth experience as follows: “one that fulfils or exceeds a woman’s prior personal and sociocultural beliefs and expectations” . UsuallyGestational age and preterm labour have also been raised as other factors in association with birth experience . The preMost studies have focused on the birth experience of low-risk and full-term women. Whereas women with preterm infants may experience their birth differently from women with term infants. Considering the importance of having a positive birth experience as one of the important indicators of the quality of care , the higThis is a descriptive-analytical cross-sectional study that was conducted between March and August, 2022.Women with term birth  and preterm birth  were included in the study. Eligibility criteria included: residence in Tabriz city and suburban; healthy newborn; not having a history of depression based on the mother's self-report or medical record; not taking anti-depressants and not having a stressful event in life during the last three months prior to the study.Sampling method was convenient. Women admitted to the labour ward of Al-Zahra, Taleghani and 29 Bahman hospitals in Tabriz, Iran were examined in terms of eligibility criteria based on the checklist. After making sure of the eligible criteria, the objectives and method of conducting the study were explained to the women and written informed consent was obtained from them. The participants were assured that their information would remain confidential and anonymous. To complete the sampling of both groups at the same time, women were selected every day in the ratio of two term births to one preterm birth. In this way, first the preterm birth was identified and then simultaneously or immediately after this, the two term births were included in the study. Demographic and obstetric checklists were completed during labour and postpartum by reviewing medical records. Also, the fear of delivery questionnaire during labour and childbirth experience questionnaires within 24 h postpartum were completed by the interviewer.The participants from Al-Zahra educational, referral and specialized hospital, Taleghani general and educational hospital, and 29 Bahman organizational hospital of East Azerbaijan, Tabriz, Iran were included in the study. All three of these hospitals are level three hospitals.Data collection tools in this study included demographic and obstetric checklists, Childbirth Experience Questionnaire (CEQ 2.0), Preterm Birth Experiences and Satisfaction Scale (P-BESS) and Delivery Fear Scale (DFS).The questionnaire contains 23 items, including the following subscales: “Own capacity”, “Professional support”, “Perceived safety” and “Participation”. The responses range from completely agree (score 4), to relatively agree (score 3), relatively disagree (score 2) and completely disagree (score 1). A higher score in the CEQ 2.0 indicates a more positive birth experience . The CEQThis questionnaire has 17 questions within three subscales: , 29. TheThe DFS includes 10 questions, with the scores ranging from 1  to 10 (I completely agree). DFS was completed at the beginning of the active phase of labour . The PerThe sample size of 147 women was calculated based on the study of Najjarzadeh et al.  and cons.The study has been approved by the Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran (Code: IR.TBZMED.REC.1400.1200). Written informed consent was obtained from all participants. In order to keep the information confidential, the coding method of the questionnaire was used without mentioning the name and surname. In the case of the participants who were illiterate, the informed consent form was explained by the researcher in their own language and their fingerprints were takenp < 0.05) were entered into the general linear model, and by adjusting the effect of these variables, the birth experience was compared between the two groups.Data were analyzed, using Version 24.0 software for Windows . Qualitative data were reported as frequency (percentage) and quantitative data as mean (SD: standard deviation). In univariate analysis, demographic and obstetric characteristics between two preterm and term groups using Independent-Samples T Test; Chi-square for trend; Fisher's Exact; Chi-square and Mann–Whitney U were compared. In the next step, the variables that were significant (p < 0.05) (Table p < 0.05)  age of the women in preterm and term groups was 28.0 (7.1) and 27.2 (6.4) years, respectively. There was a statistically significant difference between the two groups in terms of education and occupation . The mean (SD) of the overall score of childbirth experience according to the CEQ 2.0 in the preterm and term labour groups was 2.7 (0.5) and 3.0 (0.4), respectively, out of the attainable score of 1–4. There was a statistically significant difference between the two groups in terms of overall score, “Own capacity”, “Participation” and “Perceived safety” subscales (p < 0.001). The prevalence of negative childbirth experience in the preterm labour and term groups was 31.8% and 14.3%, respectively, and there was a statistically significant difference between the two groups (p < 0.001)  of the overall score of childbirth experience according to the P-BESS for the women with preterm birth was 63.5 (12.4) out of the attainable score of 17 to 85. The mean (SD) of the “Staff professionalism and empathy” and “Information and explanation” subscales were 27.2 (5.8) and 24.4 (5.2), respectively, from the attainable score of 7 to 35 while the mean (SD) of the “Confidence in staff” subscale was 9.7 (1.6) out of the attainable score of 3 to 21 : -0.02 (-0.03 to -0.01); p < 0.001] : -0.06 (-0.22 to 0.09); To our knowledge, this is the first study to compare women's childbirth experience with preterm and term labours. The mean of the overall score of childbirth experience based on the CEQ 2.0 in preterm group (mean = 2.7) was lower than that in the term group (mean = 3.0). However, the results of the multivariate general linear model, after adjusting the demographic and obstetric characteristics, showed that there was no statistically significant difference between the two groups of mothers with preterm and term labour in terms of childbirth experience. Among the factors included in the general linear model, fear of delivery seemed to be negatively correlated with childbirth experience- the higher the fear of delivery, the lower the score of childbirth experience dropped.Fear of delivery during labour was a predictive factor of childbirth experience. In a previous study conducted in Iran, fear of delivery was also reported as one of the predictors of low birth satisfaction among term women . Fear ofThere was a strong and statistically significant association between the CEQ 2.0 and P-BESS. The mean overall P-BESS score was found to be 63.5 out of the maximum obtainable score of 85, which is almost similar to that reported for the UK (69.5 out of 85)  and SpaiThe results of multivariate general linear model showed that there was no statistically significant difference between the two groups of women with preterm and term labour in terms of childbirth experience. The results of this study are somewhat consistent with a study conducted in the Spanish context. These women expressed high satisfaction with maternity care during preterm birth. Women in Iran have also been reported to be satisfied with preterm birth , their eSome probable reasons for failing to find significantdifferences between preterm and term groups’ childbirth experience may includethe following: 1) Certainly, women in the preterm group may experiencehigher fear and stress due to the unexpected onset of labour . However. Inclusion of women only from teaching hospitals and one organizational hospital is probably one of the limitations of the study. However, due to the fact that advanced NICU equipment is usually available in such hospitals and due to the lack of insurance coverage of other hospitals in the event of a newborn being admitted to the NICU, most women refer to these hospitals in situations of threat to preterm labour. However, in the case of women who had a term labour, the results may not be generalizable to all women. Completing the questionnaires within 24 h after birth can be a limitation. Because women may give more positive responses due to the presence of staff or more negative responses due to lack of physical comfort. Future studies should investigate the effect of time on how women evaluate the childbirth experience, especially in the preterm labour group. Due to the comparison of childbirth experience, the CEQ 2.0 was used in both groups, and its results may not be precise in the preterm group. However, in order to increase the accuracy of the assessment, in addition to the CEQ, a specific and standard preterm questionnaire was also used in the preterm group. Being the first study of its kind in Iran, using standard tools are among the strengths of the study. The level of stress and the personality type of women may affect the perception of the birth experience. It is suggested these factors be examined in future studies. The preterm group may have a history of infertility treatment more than the term group, and this may affect the birth experience, however it was not investigated in this study.The comparison of birth experience between two preterm and term groups is one of the strong points of the stud whileAlthough the prevalence of negative birth experience in the preterm group was higher than that in the term group, there was no statistically significant difference in terms of women's childbirth experience during preterm and term labour. Finally, among all the factors examined in this study, the fear of delivery during labour was the predictor of childbirth experience. Healthcare providers, managers and policymakers can use the results of this study to improve the provision of services to women. Also, in order to improve women's childbirth experience, interventions should be made to reduce fear during labour.