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\begin{document}

\title{Nationwide population-based cohort study of adverse obstetric outcomes
in pregnancies with myoma or following myomectomy: Retrospective cohort
study}



\author[1]{Se Jin Lee}%
\author[2]{Hyun-Sun Ko}%
\author[1]{Sunghun Na}%
\author[3]{Jin Young Bae}%
\author[4]{Won Joon Seong}%
\author[5]{Jong Woon Kim}%
\author[2]{Jaeeun Shin}%
\author[6]{Hae Joong Cho}%
\author[7]{Gyu Yeon Choi}%
\author[8]{Geum Joon Cho}%
\author[2]{In Yang Park}%
\affil[1]{Kangwon National University Hospital}%
\affil[2]{Catholic University of Korea College of Medicine}%
\affil[3]{Catholic University of Daegu}%
\affil[4]{Kyungpook National University School of Medicine}%
\affil[5]{Chonnam National University Medical School}%
\affil[6]{Wonkwang University Hospital}%
\affil[7]{Soonchunhyang University Hospital Seoul}%
\affil[8]{Korea University College of Medicine and School of Medicine}%


\vspace{-1em}



  
  \date{May 20, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objectives: To evaluate risks of adverse obstetric outcomes in
pregnancies with myoma(s) or in pregnancies following myomectomy.
Design: Retrospective cohort Setting: The national health insurance
database Population: Women who had delivered in Republic of Korea,
between 2004 and 2015 Methods: We analyzed the risks of adverse
pregnancy outcomes in pregnancies with myoma(s) or in pregnancies
following myomectomy, compared to those in women without a diagnosed
myoma. Multivariate logistic regression analysis was performed. Main
Outcome Measures: The adverse obstetric outcomes. Results: There are
740,675 women who had never been diagnosed with myoma (Group A), 38,402
women who had diagnosed myoma(s) but no history of myomectomy (Group B),
and 9,890 women who had a history of myomectomy (Group C). Group B and
Group C had significantly higher risks of cesarean section and placenta
previa, compared to Group A. The risks of uterine rupture, preterm
birth, and low birth weight were significantly higher in Group C (aOR
12.78, 95\% CI 6.5-25.13, p \textless{} 0.001; aOR 1.64, 95\% CI
1.47-1.84, p \textless{} 0.001; and aOR 1.53, 95\% CI 1.39-1.68, p
\textless{} 0.001, respectively), but not in Group B, compared to Group
A. The incidence of uterine rupture was the highest at delivery within
one year after myomectomy and decreased over time after myomectomy.
Conclusions: When a woman who might become pregnant later on is
diagnosed with uterine myoma, she should be counseled about the risk of
myoma(s) and myomectomy on obstetric complications, especially including
the significant risk of uterine rupture in pregnancies following
myomectomy.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Uterine myomas (leiomyomata, fibroids) are the most common tumor of the
reproductive tract, with a prevalence of 20--25\%\textsuperscript{1} and
a cumulative incidence of 70\% in women of reproductive
age.\textsuperscript{2}

It has been reported that the presence of fibroids is associated with
infertility, spontaneous abortion, fetal malpresentation, placenta
previa, preterm birth, cesarean section, and peripartum
hemorrhage.\textsuperscript{3} Although surgical interventions such as
myomectomy have been tried in infertile women without specific causes,
it is unclear whether the treatment of uterine fibroids can improve
pregnancy outcomes, except for cavity-distorting myomas (submucosal, or
intramural with a submucosal component).\textsuperscript{4} The most
serious concern in pregnancies after myomectomy is the risk of uterine
rupture, which can result in significant increased morbidity and
mortality for both the mother and the fetus. The incidence of uterine
rupture after prior myomectomy has been reported to range from 0.2 to
3.7\% in women with prior myomectomy.\textsuperscript{5} There is no
consensus on the optimal interval between myomectomy and conception.

In US Census Bureau population projections, it was estimated that
myomectomies are predicted to increase 31\% between 2007 and
2050.\textsuperscript{6} In Korea, the number of women who underwent
myomectomy have increased 37.3\% between 2006 and
2010.\textsuperscript{7} Women in their 30s and 40s, who are a major
population for pregnancy, have been major candidates for myomectomy.
Because there is insufficient evidence that myomectomy improves
pregnancy outcomes, a practice committee of the American Society for
Reproductive Medicine (ASRM) reported that myomectomy is generally not
advised for improving pregnancy outcomes in asymptomatic women with
non-cavity-distorting myomas.\textsuperscript{8} The Society of
Obstetricians and Gynaecologists of Canada (SOGC) also recommended
against myomectomy in women with intramural fibroids (hysteroscopically
confirmed intact endometrium) and otherwise unexplained infertility,
regardless of their size.\textsuperscript{9}

The purpose of this study was to evaluate adverse pregnancy outcomes in
women with a history of diagnosed myoma or myomectomy, including
prevalence of uterine rupture in women with myomectomy, according to the
time interval after myomectomy.

\emph{}

\textbf{Methods}

The characteristics of the dataset

In Korea, 97\% of the population is enrolled in the Korea National
Health Insurance (KNHI) program. All claims information for these
individuals is contained within the KNHI claims database. Nearly all
information about the prevalence of different diseases and procedures
can be obtained from this centralized database, with the exception of
procedures not covered by insurance. As part of the KNHI system,
children aged 4--80 months are eligible for a National Health Screening
Program for Infants and Children (NHSP-IC). An NHSP-IC is composed of
seven consecutive health examinations based on age groupings. The first
to the seventh health examinations are performed at ages 4--9, 9--18,
18--30, 30--42, 42--54, 54--66, and 66--80 months. An NHSP-IC consists
of history taking, physical examination, anthropometric examination,
developmental screening, and visual acuity testing based on the child's
age. Women's data in the KNHI claims database were linked to the data of
their offspring contained within the NHSP-IC database.

Data on women's health conditions including obstetric diagnosis were
obtained from the KNHI claims database using ICD-10 codes. Data on
preterm birth and birth weight were corrected from the NHSP-IC database.
We have obtained the approval of this study by the Institutional Review
Board (no. 2020GR0012).

Outcomes

Using the KNHI claims database, we identified all women who had given
birth between January 1, 2014, and December 31, 2015. We also identified
whether these women had a diagnosis of uterine myoma based on ICD-10
codes before pregnancy and whether these women had a myomectomy using
procedure codes from the Health Insurance Medical Care Expenses.

The flow chart of study participants' enrollment is presented in Figure
1. For pregnancy outcomes, we extracted information on delivery mode,
nulliparity, multiple pregnancy, preeclampsia, PPH, placental abruption,
placenta previa, and uterine rupture using the KNHI claims database
(dataset 1). For the other outcomes, the KNHI claims database and the
NHSP-IC database were merged. Because data on preterm birth and birth
weight were corrected from the NHSP-IC database, women were excluded
from analysis if their offspring did not undergo at least one of the
seven consecutive NHSP-IC examinations or had missing data (dataset 2).
Data on preterm birth, low birth weight (LBW), and large for gestational
age (LGA) were extracted from dataset 2. Preterm birth was defined as
gestational age \textless{} 37 weeks. LBW was defined as birth weight
\textless{} 2.5 kg. LGA was defined as birth weight \textgreater{}
4.0 kg.

Statistical analysis

Continuous and categorical variables are expressed as the
mean \selectlanguage{ngerman}±\selectlanguage{english} standard deviation and percentages, respectively. Clinical
characteristics were compared using the ANOVA for continuous variables
and the chi-square test for categorical variables. Multivariate logistic
regression analysis was used to estimate the adjusted odd ratio (aOR)
and the 95\% confidence interval (CI)s for the association of a presence
of leiomyoma and myomectomy with adverse pregnancy outcomes. For
multivariate analyses, a fixed set of known risk factors for adverse
pregnancy outcomes was adjusted for potential confounding: maternal age
(continuous variable), and nulliparity (categorical variable).
Statistical analyses were done using SAS for Windows v9.4 (SAS, Inc.,
Cary, NC). The study protocol was approved by the Institutional Review
Board of the Korea University Medical Center

\emph{}

\textbf{Results}

From 2014 to 2015, 789,482 women delivered in Korea. After excluding
women with missing data (\emph{n} = 515), 788,967 remaining women were
included in dataset 1. Among them, 740,675 (93.88\%) women had no
diagnosed myoma, 38,402 (4.88\%) had diagnosed myoma(s) but no history
of myomectomy, and 9,890 (1.25\%) women had a history of myomectomy
before pregnancy. Dataset 2 included 534,259 women, excluding women
whose infants did not receive infant screening (\emph{n} = 254,693) or
showed missing values (\emph{n} = 15). There were 502,209 (94.00\%)
women who had never been diagnosed with myoma, 25,408 (4.76\%) women who
had diagnosed myoma(s) but no history of myomectomy, and 6,642 (1.24\%)
women who had a history of myomectomy, in dataset 2.

\begin{quote}
Maternal characteristics and adverse pregnancy outcomes of the study
population in dataset 1 as described in Table 1. There were significant
differences in maternal age, rates of nulliparity, multiple pregnancy,
cesarean section, and complications of preeclampsia, postpartum
hemorrhage, placenta previa, and uterine rupture, between the groups.
However, there was no significant difference in placental abruption
between the three groups.
\end{quote}

Obstetric characteristics in dataset 2 are presented in Table 2. There
were significant differences in neonatal birth weight and sex, and rates
of preterm birth, LBW, and LGA.

Multivariate logistic regression analysis for adverse obstetric outcomes
in pregnancies with myoma or following myomectomy

Both groups of women with a history of diagnosed myoma(s) and women with
a history of myomectomy had significantly higher risks of cesarean
section (aOR 1.13, 95\% CI 1.1-1.16, \emph{p} = 0.042; and aOR 7.46,
95\% CI 6.97-7.98, \emph{p} \textless{} 0.001, respectively) and
placenta previa (aOR 1.41, 95\% CI 1.29-1.54, \emph{p} = 0.042; and aOR
1.58, 95\% CI 1.35-1.83, \emph{p} \textless{} 0.001, respectively),
compared to women without a diagnosed myoma (Table 3). However, women
with a history of myomectomy had a significantly higher risk of uterine
rupture (aOR 12.78, 95\% CI 6.5-25.13, \emph{p} \textless{} 0.001). We
evaluated incidences of uterine rupture in women with myomectomy,
according to the time interval after myomectomy (Figure 2). The
incidence of uterine rupture was significantly higher at delivery within
one year after myomectomy (0.71\%) compared to any longer delivery
interval after myomectomy.

Finally, we compared obstetric outcomes in dataset 2 (Table 4). The
group of women with a history of myomectomy had significantly higher
risks of preterm birth (aOR 1.64, 95\% CI 1.47-1.84, \emph{p}\textless{}
0.001) and LBW (aOR 1.53, 95\% CI 1.39-1.68, \emph{p}\textless{} 0.001)
than did women without a diagnosed myoma. However, women with diagnosed
myoma(s) and women with a history of myomectomy had a significantly
lower risk of LGA (aOR 0.97, 95\% CI 0.90-1.04, \emph{p}= 0.002; and aOR
0.68, 95\% CI 0.597-0.79, \emph{p} \textless{} 0.001, respectively).

\textbf{Discussion}

Main Findings

The principal findings of this study are as follows: (1) In the study
population (dataset 2), 25,408 (4.76\%) women had a history of diagnosed
myoma(s) but no myomectomy, and 6,642 (1.24\%) women received myomectomy
before pregnancy.; (2) Women who have had a myomectomy had significantly
higher risks of cesarean section, placenta previa, preterm birth, LBW,
and uterine rupture, but a lower risk of LGA, than did women without a
history of diagnosed myoma.; (3) The incidence of uterine rupture was
significantly higher at delivery within one year after myomectomy
(0.71\%) than during any longer delivery interval after myomectomy.; (4)
Women with a history of diagnosed myoma had significantly higher risks
of cesarean section and placenta previa, but no significantly increased
risks of preterm birth, LBW, or uterine rupture, compared to women
without a history of diagnosed myoma.

Interpretation

Previous studies have also reported increased adverse pregnancy
outcomes, including abnormal placentation, such as placenta previa or
placenta accreta,\textsuperscript{10-12} preterm delivery, cesarean
delivery, uterine rupture, and postpartum bleeding, in women with a
history of myomectomy.\textsuperscript{13-16} The true incidence of
uterine rupture during subsequent pregnancy following myomectomy is
difficult to establish, because most of the studies have been cases,
case series, or small retrospective cohort studies that do not account
for the total number of pregnancies achieved after myomectomy and their
consequent outcomes. The incidences of preterm birth and uterine rupture
after myomectomy have been variously reported to range from 3.1\% to
35\% and from 0.2 to 3.7\%, respectively.\textsuperscript{17, 18} The
previous systematic review including all cohort studies with at least
five cases demonstrated that the overall incidence of uterine rupture
after myomectomy was 0.93\% (0.45--1.92\%) (\emph{n} = 7/756);
specifically, it was 0.47\% (0.13--1.70\%) (\emph{n} = 2/426) in women
undergoing a trial of labor after myomectomy, and 1.52\% (0.65--3.51\%)
(\emph{n} = 5/330) in women before the onset of
labor.\textsuperscript{5} However, the number of pregnancies and viable
deliveries after prior myomectomy were 2,367 and 1,284, respectively,
from a total of 23 studies. In our study, pregnancy outcomes were
available for 9,890 women with a history of myomectomy, which was the
largest population. In the previous studies, although uterine rupture
occurred at various gestation, it occurred more often before the onset
of labor, with a high rate of fetal
loss.\textsuperscript{18}.\textsuperscript{5} In this study, the
incidence of uterine rupture in women with a history of myomectomy was
0.22\%, which is less than the reported incidence of uterine rupture
(0.4-0.7\%) in a trial of labor after cesarean
section.\textsuperscript{19,20} Possible reasons can be a missing
diagnosis when uterine rupture is combined with abruptio placenta or
antepartum/postpartum bleeding in the middle of pregnancy. Also, uterine
dehiscence can be underdiagnosed, based on the data from diagnostic
code. However, in this study, women with a history of myomectomy had
more than a 12-fold risk of uterine rupture over that of women without a
diagnosed myoma. Therefore, counseling for myomectomy in women who
desire a pregnancy in the future should discuss the risk of adverse
pregnancy outcomes, especially uterine rupture during pregnancy, which
can be associated with fetal loss.

In a previous comparison study about delivery outcomes between
pregnancies following myomectomy and myoma-complicated pregnancies, the
latter showed better outcomes, including fewer cesarean sections,
preterm births, and less blood loss, than did pregnancies after
myomectomy, which were similar to the results of this
study\textsuperscript{21} A prospective, randomized, multicenter study
in couples with unexplained infertility demonstrated no significant
difference in conception, placenta previa, preterm labor, postpartum
hemorrhage, or live birth rates in women with non-cavity distorting
myomas and those without myomas.\textsuperscript{22} A recent
retrospective cohort study\textsuperscript{23} revealed that women with
a history of myomectomy were associated with a 180\% increased risk of
intraoperative transfusion, were 713\% more likely to experience a bowel
injury, and were 243\% more likely to undergo a cesarean hysterectomy.
These findings provide reassurance that pregnancy success is not
affected in couples with non-cavity distorting myomas undergoing
assisted reproductive treatment (ART) for unexplained infertility.

Previously, ACOG stated that myomectomy should be considered for a woman
with uterine leiomyomas who has undergone several unsuccessful IVF
cycles despite appropriate ovarian response and good-quality
embryos.\textsuperscript{24} SOGC, ASRM, and French guideline also
stated that intramural myomas may have a negative effect on fertility,
but treating them does not improve fertility, and myomectomy is
therefore indicated only for symptomatic
myomas,\textsuperscript{8,24,25} They emphasized that information should
be provided about the risk of uterine rupture during a future pregnancy,
before planning a myomectomy in women who might become pregnant later
on.

Strengths and Limitations

A limitation of this study was our lack of data on number, size, or type
of myomas, type of closure after myomectomy, number of suture layers,
and use of electrocauterization, which may have important clinical
significance. Also, there was no information on the type of myomectomy
(laparoscopic, open, hysteroscopic, or robot-assisted) or type of
conception (natural, OS, OS-IUI, or IVF). Last, data about gestational
age at uterine rupture was not available.

However, this study included the largest population in the group with a
history of diagnosed myoma(s) with and without myomectomy. In addition,
the nationwide design of the original database can provide more
generalized outcomes in pregnancies with diagnosed myoma(s) and with
previous myomectomy. In addition, to our knowledge, this is the first
study about incidence of uterine rupture in women with myomectomy,
according to delivery time interval after myomectomy. The incidence of
uterine rupture was highest within one year after surgery, which
suggests that pregnancy with or without ART should be delayed at least
3-6 months. Last, we compared pregnancy outcomes in three groups: women
with diagnosed myoma(s), with previous myomectomy, and without a
diagnosed myoma or myomectomy. Although both groups of women with myoma
and women with previous myomectomy showed adverse pregnancy outcomes,
women with a previous myomectomy demonstrated more risks of adverse
pregnancy outcomes, including preterm birth, low birth weight, cesarean
section, and uterine rupture. These results might be useful in
counseling when a woman, who might become pregnant later on, is
diagnosed with uterine myoma.

\textbf{Conclusion}

When a woman is diagnosed as having asymptomatic non-cavity distorting
myoma(s) before pregnancy, counseling should include information about
the risks of pregnancies with myoma(s) and after myomectomy. Especially,
if myomectomy is considered before pregnancy, a woman should be
counseled that her risk of uterine rupture, which can be accompanied
with fetal loss, during pregnancies after myomectomy can be increased.
In addition, pregnancy with or without ART after myomectomy should be
delayed at least 3-6 months.



\textbf{Acknowledgment}

We are grateful to the patients in the study. We thank our medical
staffs for their assistance. This research was supported by the Korean
society of Maternal Fetal Medicine Research Fund. (grant no.
KSMFM-2019-001)

\textbf{Disclosure of Interests}

The authors have no conflicts of interest to disclose.

\textbf{Contribution to authorship}

SJL, HSK, GJC and IYP conceived the study and designed the experiment.
SJL, HSK, SHN, JYB, WJS, JWK, JES, HJC, KYC, GJC and IYP contributed the
collection of data and performed the experiment. HSK, GJC and IYP
analyzed the data and contributed to the statistical analysis. SJL, HSK,
GJC and IYP wrote the article. All authors critically revised the
article and gave approval of the version to be published.

\textbf{Details of ethics approval}

The institutional review board of Korea University Guro Hospital
approved the collection and use of clinical information for research
purposes (No. 2020GR0012; Approval date, January 9, 2020). This study is
in compliance with the 2008 Helsinki World Medical Association
Declaration.

\textbf{Funding information}

This research was supported by the Korean society of Maternal Fetal
Medicine Research Fund. (grant no. KSMFM-2019-001)

\textbf{References}

1. Practice Committee of the American Society for Reproductive Medicine.
Myomas and reproductive function. Fertil Steril 2004.

2. Practice Committee of the American Society for Reproductive Medicine.
Myomas and reproductive function. Fertil Steril 2006; 86(5 Suppl 1):
S194.

3. Klatsky PC, Tran ND, Caughey AB, Fujimoto, Victor Y. Fibroids and
reproductive outcomes: a systematic literature review from conception to
delivery. Am J Obstet Gynecol 2008; 198(4): 357-66.

4. Whynott RM, Vaught KCC, Segars JH. The effect of uterine fibroids on
infertility: A systematic review. Semin Reprod Med; 2017: Thieme Medical
Publishers; 2017. p. 523-32.

5. Gambacorti\selectlanguage{english}-Passerini Z, Gimovsky AC, Locatelli A, Berghella,
Vincenzo. Trial of labor after myomectomy and uterine rupture: a
systematic review. Acta Obstet Gynecol Scand 2016; 95(7): 724-34.

6. Wechter ME, Stewart EA, Myers ER, Kho RM, Wu, Jennifer M.
Leiomyoma-related hospitalization and surgery: prevalence and predicted
growth based on population trends. Am J Obstet Gynecol 2011; 205(5):
492. e1-. e5.

7. Yuk J-S, Lee JH. Six-year survival of patients with unsuspected
uterine malignancy after laparoscopic versus laparotomic myomectomy: An
11-year national retrospective cohort study. Gynecol Oncol 2018; 151(1):
91-5.

8. Practice Committee of the American Society for Reproductive Medicine.
Removal of myomas in asymptomatic patients to improve fertility and/or
reduce miscarriage rate: a guideline. Fertil Steril 2017; 108(3):
416-25.

9. Carranza-Mamane B, Havelock J, Hemmings R, et al. The management of
uterine fibroids in women with otherwise unexplained infertility. J
Obstet Gynaecol Can 2015; 37(3): 277-85.

10. Miller DA, Chollet JA, Goodwin, T Murphy. Clinical risk factors for
placenta previa--placenta accreta. Am J Obstet Gynecol 1997; 177(1):
210-4.

11. Khong TY. The pathology of placenta accreta, a worldwide epidemic. J
Clin Pathol 2008; 61(12): 1243-6.

12. Milazzo GN, Catalano A, Badia V, Mallozzi M, Caserta D. Myoma and
myomectomy: Poor evidence concern in pregnancy. J Obstet Gynaecol Res.
2017; 43(12): 1789-804.

13. Fukuda M, Tanaka T, Kamada M, et al. Comparison of the perinatal
outcomes after laparoscopic myomectomy versus abdominal myomectomy.
Gynecol Obstet Invest 2013; 76(4): 203-8.

14. Fagherazzi S, Borgato S, Bertin M, et al. Pregnancy outcome after
laparoscopic myomectomy. Clin Exp Obstet Gynecol 2014; 41(4): 375-9.

15. Seracchioli R, Manuzzi L, Vianello F, et al. Obstetric and delivery
outcome of pregnancies achieved after laparoscopic myomectomy. Fertil
Steril 2006; 86(1): 159-65.

16. Flyckt R, Soto E, Nutter B, Falcone T. Comparison of long-term
fertility and bleeding outcomes after robotic-assisted, laparoscopic,
and abdominal myomectomy. Obstet Gynecol Int 2016; 2016.

17. Palomba S, Zupi E, Falbo A, et al. A multicenter randomized,
controlled study comparing laparoscopic versus minilaparotomic
myomectomy: reproductive outcomes. Fertility sterility 2007; 88(4):
933-41.

18. Pop L, Suciu ID, Oprescu D, et al. Patency of uterine wall in
pregnancies following assisted and spontaneous conception with
antecedent laparoscopic and abdominal myomectomies--a difficult case and
systematic review. J Matern Fetal Neonatal Med. 2019; 32(13): 2241-8.

19. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal
outcomes associated with a trial of labor after prior cesarean delivery.
N Engl J Med 2004; 351(25): 2581-9.

20. Guise J-M, Denman MA, Emeis C, et al. Vaginal birth after cesarean:
new insights on maternal and neonatal outcomes. Obstet Gynecol 2010;
115(6): 1267-78.

21. Kinugasa-Taniguchi Y, Ueda Y, Hara-Ohyagi C, Enomoto T, Kanagawa T,
Kimura T. Impaired delivery outcomes in pregnancies following myomectomy
compared to myoma-complicated pregnancies. J Reprod Med 2011; 56(3-4):
142-8.

22. Styer AK, Jin S, Liu D, et al. Association of uterine fibroids and
pregnancy outcomes after ovarian stimulation--intrauterine insemination
for unexplained infertility. Fertil Steril 2017; 107(3): 756-62. e3.

23. Gimovsky AC, Frangieh M, Phillips J, et al. Perinatal outcomes of
women undergoing cesarean delivery after prior myomectomy. J Matern
Fetal Neonatal Med 2018: 1-6.

24. Obstetricians ACo, Obstetrics GJ, gynecology. ACOG practice
bulletin. Alternatives to hysterectomy in the management of leiomyomas.
Obstet Gynecol 2008; 112(2 Pt 1): 387.

25. Marret H, Fritel X, Ouldamer L, et al. Therapeutic management of
uterine fibroid tumors: updated French guidelines. Eur J Obstet Gynecol
Reprod Biol 2012; 165(2): 156-64.

\textbf{Table 1.} Demographics and birth outcomes of study population
(Dataset 1)\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group A*} \textbf{(N = 502,209)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group B*} \textbf{(N = 25,408)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group C*} \textbf{(N = 6,642)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\emph{p}\textbf{-value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Preterm birth}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13,470 (2.68)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1,018 (4.01)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
327 (4.92)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Neonatal sex--male}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
258,518 (51.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13,066 (51.42)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3,430 (51.64)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Birth weight (kg)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.20 \selectlanguage{ngerman}± 0.46\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.17 \selectlanguage{ngerman}± 0.50\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.11 \selectlanguage{ngerman}± 0.50\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{LBW}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20,203 (4.02)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1,452 (5.71)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
459 (6.91)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{LGA}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17,390 (3.46)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
885 (3.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
165 (2.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*Group A, Women who had never been diagnosed with myoma; Group B, Women
who had diagnosed myoma(s) but no history of myomectomy; Group C, Women
who had a history of myomectomy

PPH, Postpartum hemorrhage

Values are given as mean \selectlanguage{ngerman}± standard deviation or number (\%).\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group A*} \textbf{(N = 502,209)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group B*} \textbf{(N = 25,408)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Group C*} \textbf{(N = 6,642)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\emph{p}\textbf{-value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Preterm birth}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13,470 (2.68)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1,018 (4.01)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
327 (4.92)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Neonatal sex--male}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
258,518 (51.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13,066 (51.42)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3,430 (51.64)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Birth weight (kg)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.20 \selectlanguage{ngerman}± 0.46\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.17 \selectlanguage{ngerman}± 0.50\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.11 \selectlanguage{ngerman}± 0.50\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{LBW}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20,203 (4.02)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1,452 (5.71)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
459 (6.91)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{LGA}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17,390 (3.46)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
885 (3.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
165 (2.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Demographics and birth outcomes of study population
(Dataset 2)

*Group A, Women who had never been diagnosed with myoma; Group B, Women
who had diagnosed myoma(s) but no history of myomectomy; Group C, \%)
women who had a history of myomectomy

LBW, Low birth weight; LGA, Large for gestational age

Values are given as mean \selectlanguage{ngerman}± standard deviation or number (\%).

\textbf{Table 3.} The obstetric outcomes in women with diagnosed
myoma(s) or a history of myomectomy (Dataset 1)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Obstetric outcomes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Odds ratio (95\% confidence interval)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Odds ratio (95\% confidence interval)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Unadjusted}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Adjusted \textsuperscript{a}}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\emph{p}\textbf{-value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Preterm birth}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group A}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group B}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.514 (1.419 -- 1.616)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.386 (1.297 -- 1.480)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.0713\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group C}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.879 (1.679 -- 2.103)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.644 (1.468 -- 1.841)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{LBW}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group A}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group B}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.446 (1.369 -- 1.528)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.313 (1.242 -- 1.388)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.0949\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group C}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.771 (1.609 -- 1.949)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.525 (1.385 -- 1.680)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{LGA}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group A}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group B}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.006 (0.939 -- 1.078)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.967 (0.902 -- 1.036)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.0019\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group C}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.711 (0.609 -- 0.830)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.676 (0.578 -- 0.790)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*Group A, Women who had never been diagnosed with myoma; Group B, Women
who had diagnosed myoma(s) but no history of myomectomy; Group C, \%)
women who had a history of myomectomy

PPH, Postpartum hemorrhage

\textsuperscript{a} Adjusted for age and parity

\textbf{Table 4.} The obstetric outcomes in women with diagnosed
myoma(s) or a history of myomectomy (Dataset 2)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Obstetric outcomes}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Odds ratio (95\% confidence interval)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Odds ratio (95\% confidence interval)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Unadjusted}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Adjusted \textsuperscript{a}}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\emph{p}\textbf{-value}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Preterm birth}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group A}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group B}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.514 (1.419 -- 1.616)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.386 (1.297 -- 1.480)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.0713\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group C}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.879 (1.679 -- 2.103)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.644 (1.468 -- 1.841)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{LBW}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group A}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group B}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.446 (1.369 -- 1.528)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.313 (1.242 -- 1.388)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.0949\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group C}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.771 (1.609 -- 1.949)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.525 (1.385 -- 1.680)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{LGA}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group A}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group B}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.006 (0.939 -- 1.078)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.967 (0.902 -- 1.036)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.0019\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group C}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.711 (0.609 -- 0.830)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.676 (0.578 -- 0.790)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}.0001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

*Group A, Women who had never been diagnosed with myoma; Group B, Women
who had diagnosed myoma(s) but no history of myomectomy; Group C, \%)
women who had a history of myomectomy

LBW, Low birth weight; LGA, Large for gestational age

\textsuperscript{a} Adjusted for age and parity



\textbf{Figure legends}

\textbf{Figure 1.} Flow chart of study participants' enrollment

\textbf{Figure 2.} Incidence of uterine rupture in women with
myomectomy, according to time interval after myomectomy.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-final/Figure-1-final}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2-final/Figure-2-final}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

