Background. Controversial evidence suggests a potential association between female genital mutilation (FGM/C) and adverse obstetric outcomes, with type III FGM/C (infibulation) carrying the greatest risk. Objectives: To assess current rate of adverse obstetric outcomes in women with type III female genital mutilation and cutting (FGM/C; infibulation) delivering across different settings worldwide. Search Strategy. Two authors searched relevant literature in the PubMed, Scopus, Embase, and ClinicalTrials.gov databases from inception to Jan 1, 2023, looking for articles reporting outcomes of women with type III FGM/C compared with women with no FGM/C. Selection criteria. Studies were selected if they included the main outcome of postpartum haemorrhage (PPH) or secondary outcomes, which included major conditions affecting maternal-neonatal health during labour and delivery. Data Collection and Analysis: DerSimonian-Laird random effects meta-analysis was performed and pooled effect estimates with corresponding 95% confidence intervals were computed. Heterogeneity was assessed using the I 2 statistic. Meta regression for relevant covariates was performed when data on relevant confounders were available. The Newcastle-Ottawa scale (NOS) was used to assess quality of observational studies. The level of evidence was assessed with the GRADE method. Main Results: 14 observational studies including 15,320 type III FGM/C women and 59,347 controls were eligible. The risk for postpartum haemorrhage was significantly increased in type III FGM/C, in the main analysis (OR 1.83, 95% CI 1.03 to 3.24, I 2=93%), in pooling of data adjusted for confounders (aOR 1.76, CI 1.42 to 2.17, I 2= 0%), and in sensitivity analysis of higher quality studies with NOS≥7 (OR 2.76, CI 1.38 to 5.51, I 2= 95%). Meta-regression showed that nulliparity was significantly and positively associated with postpartum haemorrhage. Similarly, analysis of data adjusted for confounders showed an increased risk of episiotomy in type III FGM/C (aOR 1.56, CI 1.03 to 2.35, I 2= 52%). Sensitivity analysis of studies with NOS≥7 revealed a significant increase for episiotomy (OR 7.53, CI 1.19 to 47.54, I 2= 96%), perineal tears (OR 4.24, CI 1.09 to 16.46, I 2= 66%), prolonged second stage of labour (OR 5.19, 95% CI 1.00 to 26.85, I 2= 66%), and Apgar score less than 7 (OR 4.19, CI 1.64 to 10.70, I 2= 0%). No difference was found regarding obstetric anal sphincter injuries and mode of delivery in these women. Deinfibulation achieved similar obstetric and neonatal outcomes to women who never had type III FGM. The overall quality of the studies was adequate (median NOS score: 7; IQR: 6-8), the level of evidence, according to the GRADE assessment, was low. Conclusions. These results consistently show an increased risk of adverse obstetric outcomes in women with FGM/C type III. Infibulation substantially increases the risk for PPH, particularly in nulliparae.

Objective: To evaluate the histological modifications of the vaginal mucosa after repeated microablative fractional CO2 lasers treatments. As secondary objectives we evaluated the clinical effects associated with repeated microablative fractional CO2 lasers treatments using validated questionnaires. Design: Prospective intervention study. Setting: Division of Gynecology and Obstetrics, Urogynecology Unit, IRCCS San Raffaele Scientific Institute Sample: 15 postmenopausal women complaining of genitourinary syndrome of menopause symptoms. Methods: one cohort of patients submitted to at least two previous laser treatment cycles in the past years. Main outcome measures: Vaginal Health Index (VHI), Visual Analog Scale (VAS), Female Sexual Function Index (FSFI), Urinary Distress Inventory-6 (UDI-6), International Consultation on Incontinence Questionnaire – Urinary Incontinence (ICIQ-UI) and 5-point Likert scale. Moreover an histological examinations were carried out on all samples. Results: At 4 weeks after the last treatment VHI score and all FSFI items resulted significantly increased compared baseline. We observed a statistically significant decrease both in frequency and severity for all urinary symptoms after the follow up. We observed a statistically significant increase in the number of epithelial cell layer with a consequent increase in epithelial thickness, in the number of glycogen filled cells, and in the number of papillae, after the laser treatment. No signs of fibrosis were observed since neovascularization was observed in each single woman. Conclusions: This is the first study demonstrating the histological persistency of efficacy in repeated annually laser treatment cycles, with tissue changes always leading to regenerative results without any sign of fibrosis.