Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study.

The primary aim was to assess the prevalence of levator ani muscle (LAM) avulsion after forceps- and vacuum-assisted deliveries, adjusting for indication for assisted vaginal delivery (AVD) and including spontaneous vaginal deliveries for comparison. The secondary aim was to compare neonatal injury between forceps and vacuum deliveries. This prospective observational cohort study was conducted at Haukeland University Hospital, Bergen, Norway. Primiparous women were recruited shortly after delivery, between June 2021 and April 2023, and LAM avulsion was assessed using transperineal ultrasound 9-12 months later. Delivery and neonatal data were collected from patient electronic health records. The risk of LAM avulsion was compared between forceps, vacuum and spontaneous vaginal deliveries using multivariable logistic regression analysis. Assisted deliveries were stratified by indication (fetal distress or protracted second stage of labor) and subgroup analyses were conducted for each indication, comparing forceps with vacuum delivery. A total of 736 women were examined using transperineal ultrasound at a median of 307 (interquartile range, 279-332) days after delivery. The 252 women who delivered by forceps had a higher prevalence of LAM avulsion (29.8%) compared with the 252 women who delivered by vacuum (17.5%) and the 232 women who underwent spontaneous vaginal delivery (11.2%). The adjusted oddsratio (aOR) of LAM avulsion after forceps vs vacuum delivery was 1.99 (95% CI, 1.26-3.18). After a protracted second stage of labor, the odds of LAM avulsion after forceps vs vacuum delivery were even greater (aOR, 3.09 (95% CI, 1.53-6.46)). Among those who underwent AVD for fetal distress, no significant difference in the odds of LAM avulsion was observed between forceps and vacuum deliveries (aOR, 1.63 (95% CI, 0.83-3.23)). The odds of neonatal trauma were lower after forceps compared with vacuum delivery (aOR, 0.49 (95% CI, 0.25-0.92)). There was no significant difference in the prevalence of LAM avulsion between forceps and vacuum deliveries when the indication for AVD was fetal distress, but the odds of LAM avulsion were 3-fold higher for forceps delivery when the indication was protracted second stage of labor. Forceps delivery was associated with a 51% reduction in the odds of neonatal injury compared with vacuum delivery, independent of indication for AVD. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

SummaryBackgroundAntithrombotic (anticoagulant or antiplatelet) therapy is withheld from some patients with cerebral cavernous malformations, because of uncertainty around the safety of these drugs in such patients. We aimed to establish whether antithrombotic therapy is associated with an increased risk of intracranial haemorrhage in adults with cerebral cavernous malformations.MethodsIn this population-based, cohort study, we used data from the Scottish Audit of Intracranial Vascular Malformations, which prospectively identified individuals aged 16 years and older living in Scotland who were first diagnosed with a cerebral cavernous malformation during 1999–2003 or 2006–10. We compared the association between use of antithrombotic therapy after first presentation and the occurrence of intracranial haemorrhage or persistent or progressive focal neurological deficit due to the cerebral cavernous malformations during up to 15 years of prospective follow-up with multivariable Cox proportional hazards regression assessed in all individuals identified in the database. We also did a systematic review and meta-analysis, in which we searched Ovid MEDLINE and Embase from database inception to Feb 1, 2019, to identify comparative studies to calculate the intracranial haemorrhage incidence rate ratio according to antithrombotic therapy use. We then generated a pooled estimate using the inverse variance method and a random effects model.FindingsWe assessed 300 of 306 individuals with a cerebral cavernous malformation who were eligible for study. 61 used antithrombotic therapy (ten [16%] of 61 used anticoagulation) for a mean duration of 7·4 years (SD 5·4) during follow-up. Antithrombotic therapy use was associated with a lower risk of subsequent intracranial haemorrhage or focal neurological deficit (one [2%] of 61 vs 29 [12%] of 239, adjusted hazard ratio [HR] 0·12, 95% CI 0·02–0·88; p=0·037). In a meta-analysis of six cohort studies including 1342 patients, antithrombotic therapy use was associated with a lower risk of intracranial haemorrhage (eight [3%] of 253 vs 152 [14%] of 1089; incidence rate ratio 0·25, 95% CI 0·13–0·51; p<0·0001; I2=0%).InterpretationAntithrombotic therapy use is associated with a lower risk of intracranial haemorrhage or focal neurological deficit from cerebral cavernous malformations than avoidance of antithrombotic therapy. These findings provide reassurance about safety for clinical practice and require further investigation in a randomised controlled trial.FundingUK Medical Research Council, Chief Scientist Office of the Scottish Government, The Stroke Association, Cavernoma Alliance UK, and the Remmert Adriaan Laan Foundation.

Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians

Urinary and anal incontinence after vacuum delivery

Reported case numbers and variability in delivery route and volume by obstetrics and gynecology residents from 2003 to 2019

ImportanceThe use of warfarin to prevent thromboembolism in patients with infective endocarditis (IE) remains controversial due to potentially increased bleeding risks. DesignPopulation-based retrospective cohort study. ParticipantsPatients aged 18 or older and diagnosed with IE in Hong Kong between January 1st, 1997 and August 31st, 2020 were included. Patients with use of any anticoagulant 30 days before IE diagnosis were excluded. Patients initiated on warfarin within 14 days of IE diagnosis and patients without warfarin use were matched for baseline characteristics using 1:1 propensity score matching. ExposureWarfarin use within 14 days of IE diagnosis. Main outcomes and measuresPatients were followed up to 90 days for the outcomes of ischemic stroke, all-cause mortality, intracranial hemorrhage, and gastrointestinal bleeding. Cox regression was used to determine hazard ratios (HRs) [95 % confidence intervals (CIs)] between treatment groups. Fine-Gray competing risk regression with all-cause mortality as the competing event was performed as a sensitivity analysis. In addition to 90-day analyses, landmark analyses were performed at 30 days of follow-up. ResultsThe matched cohort consisted of 675 warfarin users (57.0 % male, age 59 ± 16 years) and 675 warfarin non-users (53.5 % male, age 61 ± 19 years). Warfarin users had a 50 % decreased 90-day risk in all-cause mortality (HR:0.50 [0.39–0.65]), without significantly different 90-day risks of ischemic stroke (HR:1.04 [0.70–1.53]), intracranial hemorrhage (HR:1.25 [0.77–2.04]), and gastrointestinal bleeding (HR:1.04 [0.60–1.78]). Thirty-day landmark analysis showed similar results. Competing risk regression showed significantly higher 30-day cumulative incidence of intracranial hemorrhage in warfarin users (sub-HR:3.34 [1.34–8.31]), but not at 90-day (sub-HR:1.63 [0.95–2.81]). Results from Fine-Gray regression were otherwise congruent with those from Cox regression. Conclusions and relevanceWarfarin initiated within 14 days of IE diagnosis was associated with significantly decreased risks of mortality but higher risks of intracranial hemorrhage, with similar risks of ischemic stroke and gastrointestinal bleeding, compared with non-use of warfarin with 14 days of IE diagnosis. Key pointsQuestion: Is warfarin, initiated within 14 days of a diagnosis of infective endocarditis (IE), efficacious and safe?Findings: In this propensity score-matched, population-based, prospective cohort study from Hong Kong, warfarin use within 14 days of IE diagnosis was associated with a 50 % decrease in the risk of all-cause mortality, albeit with higher risk of intracranial hemorrhage, and without significant differences in the risk of ischaemic stroke and gastrointestinal bleeding.Meaning: In patients with IE, warfarin use within 14 days of diagnosis may have mortality benefits, despite increased risks of intracranial hemorrhage.

The optimum mode of delivery in a known carrier of a haemophilia A is still an issue of debate. This study was conducted to report a multicentre experience in Gulf Cooperation Council (GCC) on the incidence of intracranial haemorrhage (ICH) in newborns with severe haemophilia A delivered by different modalities. We have conducted a retrospective/prospective multicentre cohort study including a total of seven hospitals distributed in four GCC countries between 1998 and Jan 2015. A total of 163 patient with severe haemophilia A (factor VIII <1%) were enrolled in this study, age ranged between 2 weeks to 18 years. Most of the patients were born by spontaneous vaginal delivery (SVD) (131, 80.4%), whereas 26 patients (16%) were born by CS and only six patients were born by instrumental delivery (3.7%), five of them by vacuum and one was delivered using forceps. Five out of 163 patients developed ICH during the first 2 weeks of life (3.1%). Two of them were born by SVD (2/131; 1.5%) and two were born by instrumental delivery (2/6; 33.3%). Only one patient among those who were born by caesarean section developed ICH (1/26; 3.8%). Assisted vaginal delivery was associated with a significant risk of ICH, in comparison to SVD and CS (P = 0.0093). Normal vaginal delivery is still considered a safe journey through the birth canal for haemophilic newborns particularly in this area of the world. Larger prospective studies might be needed to define an evidence-based optimal mode of delivery for the haemophilia carrier expecting an affected child.

Risk of Hemorrhage and Obliteration Rates of LINAC-Based Radiosurgery for Cerebral Arteriovenous Malformations Treated After Prior Partial Embolization

Fetal and Neonatal Alloimmune Thrombocytopenia: Risk of ICH in Second Pregnancy and Treatments to Maintain an Adequate Platelet Count

Intracranial haemorrhage with bolus thrombolytic agents

2015 Background: Glioblastoma (GBM) is associated with a high rate of venous thromboembolism (VTE), but there is little data to guide anticoagulation in GBM patients, in whom the risks of VTE must be balanced against the risk of intracranial hemorrhage (ICH). Methods: We performed a single-institution retrospective cohort study of patients with GBM diagnosed with VTE from 2014-2021 who were treated with low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC). The cumulative incidence of ICH was compared between the LMWH and DOAC groups. The primary outcome was clinically relevant ICH within the first 30 days of anticoagulation, defined as any ICH that was fatal, symptomatic, required surgical intervention, and/or led to cessation of anticoagulation. Key secondary outcomes included clinically relevant ICH within 6 months, fatal ICH within 30 days and 6 months, any bleeding within 30 days and 6 months, and recurrent VTE within 6 months. Fisher’s exact test was used for comparison of primary and secondary endpoints between the two groups. Cumulative incidence curves were generated using the Kaplan-Meier method, and the cumulative incidence of clinically relevant ICH at both the 30-day timepoint and 6-month timepoint was compared between the DOAC and LMWH groups using the Gray test to account for death as a competing risk. Results: A total of 121 patients were identified in the primary cohort for 30-day outcome analyses (DOAC, n = 33; LMWH, n = 88). For 6-month outcome analyses, the cohort included only patients who were maintained on their initial anticoagulant (DOAC or LMWH) and did not switch anticoagulants during the 6 months following diagnosis of VTE (DOAC, n = 32; LMWH, n = 75). The cumulative incidence of clinically relevant ICH at 30 days was 0% (0/33) in the DOAC group and 9% (8/88) in the LMWH group (p = 0.11). The cumulative incidence of clinically relevant ICH at 6 months was 0% (0/32) in the DOAC group and 24% (18/75) in the LMWH group (p = 0.001), with 4 fatal ICHs in the LMWH group. Other outcomes are displayed in the Table. Conclusions: Our study suggests that DOACs are associated with a lower incidence of clinically relevant ICH in patients with GBM-associated VTE compared to LMWH. These data support the use of DOACs as a safe alternative to LMWH in patients with GBM.[Table: see text]

Statins are commonly prescribed for the secondary prevention of ischemic stroke, but there is conflicting evidence as to whether they increase the risk of intracranial hemorrhage. Lipophilic statins cross the blood-brain barrier more freely than hydrophilic statins and may therefore increase the risk of intracranial hemorrhage. To determine whether, in older patients following ischemic stroke, receipt of lipophilic statins was associated with differences in the risk of intracranial hemorrhage. We conducted a population-based nested case-control study linking multiple healthcare databases between 1 April, 2001 and 31 March, 2015 in Ontario, Canada. Cases were Ontarians aged 66years or older receiving a statin within100days preceding the development of intracranial hemorrhage within 1year following ischemic stroke. Each case was matched with up to four controls who experienced ischemic stroke not complicated by intracranial hemorrhage but who also received a statin. We classified statins as lipophilic (atorvastatin, simvastatin, lovastatin, fluvastatin, and cerivastatin) or hydrophilic (pravastatin and rosuvastatin) based on their octanol/water partition coefficients. We calculated the odds ratio for the association between intracranial hemorrhage and receipt of lipophilic statins, with hydrophilic statins as the reference group. We identified 2766 individuals who experienced intracranial hemorrhage during statin therapy after ischemic stroke and 11,060 matched controls. Relative to hydrophilic statins, lipophilic statins were not associated with an increased risk of intracranial hemorrhage (adjusted odds ratio 1.07; 95% confidence interval 0.97-1.19). Among patients treated with a statin following ischemic stroke, the risk of intracranial hemorrhage is not influenced by statin lipophilicity.

To the Editor. The study by Rimensberger et al1 suggests that early institution of high-frequency oscillation (HFO) for the treatment of respiratory distress syndrome improves the pulmonary outcome in ventilated very low birth weight infants. Unfortunately, there are flaws in study design that limit the validity of this conclusion. First, the 2 study cohorts were not concurrent. Most of the infants in the experimental cohort treated with HFO were born in 1997 and 1998, whereas those in the historical control cohort treated with conventional mechanical ventilation were born in 1994 and 1995. Subtle differences in clinical management might have been unavoidable in the 2-year period that separates these cohorts and contributed to the difference in the pulmonary outcome. Second, the statistical basis for selecting the specific number of infants in each cohort is not provided. Without appropriate power analysis, the statistical validity of comparisons between cohorts is difficult to confirm. Third, the retrospective nature of the study raises questions about uncontrolled data collection and problems with data retrieval, both inherent problems of a retrospective study design. Fourth, what is most striking is that there is no discussion of the common complications, such as symptomatic patent ductus arteriosus and airway infection, both of which are strong contributors to the development of chronic lung disease. And fifth, there is no discussion of the nutritional management of the infants. Nutrition plays a big role in the process of healing from lung injury. Thus, although the zero incidence of chronic lung disease in very low birth weight infants ventilated with HFO appears to be a remarkable achievement indeed, the enthusiasm for accepting this conclusion is dampened by the flawed study design. The subtle message that a single ventilation strategy can eliminate chronic lung disease, a disease of diverse causes, is misleading. What is …

Complications des accouchements assistés par ventouse

Observational studies demonstrate strong associations between blood pressure and bleeding complications of antithrombotic therapy. The objective was to determine whether blood pressure lowering reduces risks of bleeding in patients on antithrombotic therapy. This is a subsidiary analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial, a randomized, placebo-controlled trial. A total of 6105 patients with cerebrovascular disease were randomly assigned to either active treatment (perindopril ± indapamide) or placebo(s). The outcomes were intracranial and extracranial bleeding. There were 4876 (80%) patients on antithrombotic therapy at baseline. Over a mean follow-up of 3.9 years, 119 intracranial and 123 extracranial bleeding events were observed. Among patients with and without antithrombotic therapy, active treatment lowered blood pressure by 8.9/4.0 and 9.3/3.8 mm Hg and reduced the risks of intracranial bleeding by 46% (95% CI, 7%-69%) and 70% (39%-85%), respectively. However, active treatment did not reduce the risks of extracranial bleeding significantly in either group. Among patients on antithrombotic therapy, the lowest risk of intracranial bleeding was observed in participants with the lowest follow-up systolic blood pressure levels (median, 113 mm Hg). Blood pressure lowering provides protection against intracranial bleeding among patients with cerebrovascular disease including those receiving antithrombotic therapy.