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PubMed2004

Comparison of misoprostol and dinoprostone for elective induction of labour in nulliparous women at full term: a randomized prospective study.

BACKGROUND: The objective of this randomized prospective study was to compare the efficacy of 50 mcg vaginal misoprostol and 3 mg dinoprostone, administered every nine hours for a maximum of three doses, for elective induction of labor in a specific cohort of nulliparous women with an unfavorable cervix and more than 40 weeks of gestation. MATERIAL AND METHODS: One hundred and sixty-three pregnant women with more than 285 days of gestation were recruited and analyzed. The main outcome measures were time from induction to delivery and incidence of vaginal delivery within 12 and 24 hours. Admission rate to the neonatal intensive care unit within 24 hours post delivery was a secondary outcome. RESULTS: The induction-delivery interval was significantly lower in the misoprostol group than in the dinoprostone group (11.9 h vs. 15.5 h, p < 0.001). With misoprostol, more women delivered within 12 hours (57.5% vs. 32.5%, p < 0.01) and 24 hours (98.7% vs. 91.4%, p < 0.05), spontaneous rupture of the membranes occurred more frequently (38.8% vs. 20.5%, p < 0.05), there was less need for oxytocin augmentation (65.8% vs. 81.5%, p < 0.05) and fewer additional doses were required (7.5% vs. 22%, p < 0.05). Although not statistically significant, a lower Caesarean section (CS) rate was observed with misoprostol (7.5% vs. 13.3%, p > 0.05) but with the disadvantage of higher abnormal fetal heart rate (FHR) tracings (22.5% vs. 12%, p > 0.05). From the misoprostol group more neonates were admitted to the intensive neonatal unit, than from the dinoprostone group (13.5% vs. 4.8%, p > 0.05). One woman had an unexplained stillbirth following the administration of one dose of dinoprostone. CONCLUSIONS: Vaginal misoprostol, compared with dinoprostone in the regimens used, is more effective in elective inductions of labor beyond 40 weeks of gestation. Nevertheless, this is at the expense of more abnormal FHR tracings and more admissions to the neonatal unit, indicating that the faster approach is not necessarily the better approach to childbirth.

Adult↗
PubMed2004

Establishing valid AIDS monitoring and research in countries with generalized epidemics.

The authors present guidelines for valid HIV/AIDS surveillance and epidemiologic research, and for clarification of uncertainties in transmission dynamics, particularly in countries with generalized epidemics. The consensus assumption that most HIV/AIDS cases in many developing regions, particularly sub-Saharan Africa, are explained by 'heterosexual' transmission (interpreted, by default, to mean penile-vaginal intercourse) has been challenged by recent reviews demonstrating an important contribution from unsafe health care practices. Resolution of existing uncertainties about the proportions of HIV transmission accounted for by specific parenteral exposures and sexual practices (e.g., vaginal and anal intercourse, considered separately) is crucial for the design and implementation of efficacious prevention strategies. Accurate risk-factor information is the best foundation upon which people living in countries with generalized epidemics can learn to protect themselves and their families. Multimethod approaches for developing sound HIV/AIDS research are presented.

Africa South of the Sahara↗
PubMed2006

Delivery systems for hormone replacement therapy.

The steroid hormones used for hormone replacement therapy in the menopausal transition and postmenopause can be administered by several different routes using a variety of delivery systems. The conventional approach to administration has been oral, and this is still the standard against which other routes are compared. However, there is a steadily increasing research development and popularity for alternative systems. Such systems can be geared to ultra low-dose delivery for local vaginal effect or higher dosages for systemic effect. Different delivery systems have a range of attributes with varying appeal to different individual women. Such a range of choices can be important for acceptability and compliance. One of the most important attributes of many newer delivery systems is the potential to deliver hormones in a controlled manner over prolonged periods of time, allowing constant low dosages, as well as constant blood and tissue levels. They also have the potential for reducing side effects and metabolic effects. Transdermal, subdermal, intravaginal and intrauterine systems are particularly likely to undergo refinement and further development in the foreseeable future with subsequent increases in popularity.

Dosage Forms↗
PubMed2004

[Compression of the bulbar urethra by transobturator suburethral tape: anatomical study].

INTRODUCTION: The management of female stress urinary incontinence has been markedly improved by the suprapubic tension-free vaginal tape (TVT) and transobturator tape techniques. The objective of our study was to assess the feasibility of this type of technique in males based on cadavre dissection. MATERIAL AND METHOD: A 300 mm x 15 mm polypropylene tape was inserted via a transobturator approach on a cadavre stored in the refrigerator at 4 degrees C and on three cadavres stored in formalin. The technique was almost identical to that used in females. It requires a midline perineal incision in the raphe and two small lateral incisions. The deep transverse muscle of the perineum was opened with scissors. The needle was introduced via the lateral incisions and its progression was guided by a finger introduced into the perineal orifice. The cadavre was then sectioned sagittally to verify the course of the tape and its relations to adjacent structures. RESULTS: The operative technique did not raise any particular problems. Dissection revealed that the tape crossed the deep transverse muscle of the perineum and the levator ani muscle, before travelling towards the obturator foramen. The tape avoided the bladder, prostate, corpora cavernosa, and pudendal pedicle. CONCLUSION: The transobturator tape technique therefore appears to be feasible in males. It does not appear to comprise any particular risks for adjacent organs. This anatomical study appeared to be essential before considering an in vivo application.

Cadaver↗
PubMed1995

Laparoscopic-assisted hysterectomy in a rural Minnesota hospital.

Hysterectomy remains a commonly performed gynecologic surgery. An estimated 650,000 women in the United States undergo surgical removal of the uterus annually at a considerable cost to patients, payers, and society at large. Currently, two-thirds of hysterectomies are performed by abdominal surgery and approximately one-third by vaginal surgery. Most research supports laparoscopic-assisted hysterectomy as a safe, effective, and less intrusive alternative to open surgery. Laparoscopy is far less costly, results in less pain, and has a much shorter recovery period. This paper discusses such advantages of the laparoscopic approach over the standard abdominal hysterectomy and reviews 158 laparoscopic-assisted hysterectomies performed at a 100-bed rural Minnesota hospital. Techniques, equipment, patient mix, and complications are discussed. Patients experienced few complications, and most left the hospital in 48 hours.

Adult↗
PubMed1994

Duplicate cervix and vagina associated with infertility, endometriosis, and chronic pelvic pain.

BACKGROUND: Müllerian anomalies are associated with several gynecologic complications including endometriosis, infertility, and pelvic pain. CASE: A woman with duplicate cervix and a non-communicating longitudinal vaginal septum, but no other uterine anomalies, presented with pelvic pain, secondary infertility, and a long history of endometriosis. She was treated with operative laparoscopy and excision of the vaginal septum. CONCLUSION: A thorough evaluation, including history, physical examination, and appropriate imaging techniques (hysterosalpingography and magnetic resonance imaging) facilitates accurate diagnosis of anatomical defects and any associated disease in cases of unusual müllerian anomalies. An accurate preoperative diagnosis allows a planned, efficient surgical approach.

Abnormalities, Multiple↗
PubMed2002

Surgical management of stress urinary incontinence: consideration for an algorithmic approach.

Stress urinary incontinence is defined as the symptomatic loss of urine related to increases in intra-abdominal pressure. A variety of nonsurgical therapies with varying degrees of effectiveness and patient acceptance are available. If nonsurgical therapies fail, then multiple surgical options exist, including retropubic urethropexy, bulking agents, pubovaginal slings, and sling variants. A surgical algorithm based on the amount of anterior vaginal wall prolapse (including urethrovesical mobility) and urethral sphincter function utilizing these procedures is reported herein.

Algorithms↗
PubMed1982

Risk factors for infection at the operative site after abdominal or vaginal hysterectomy.

We studied risk factors for postoperative infections at the operative site after hysterectomies. Data were collected prospectively on all women undergoing vaginal hysterectomies (323 patients) or abdominal hysterectomies (1125 patients) at the Boston Hospital for Women between February 1976 and April 1978. Logistic-regression analysis indicated that factors significantly associated (P less than 0.05) with a higher risk of infection at the operative site were increased duration of operation, lack of antibiotic prophylaxis, younger age, being a clinic patient, and an abdominal approach. After these variables were accounted for, the variables of obesity, preoperative functional and anatomical diagnoses, postoperative anatomical and pathological diagnoses, estimated blood loss, menopausal status, and operation by a specific surgeon did not add predictive power. An increasing duration of operation was associated with a decreasing effect of antibiotic prophylaxis, the preventive fraction of which diminished from 80 per cent at one hour to an unmeasurable effect at 3.3 hours.

Adult↗
PubMed2001

Real-time intraoperative ultrasound guidance: the transrectal approach.

OBJECTIVE: To assess the role of real-time transrectal ultrasound guidance in complicated gynecologic procedures. DESIGN: In 1998-99, real-time guidance with transrectal ultrasound was utilized in our department to assist the gynecologic surgeon in two procedures: completing the evacuation of the uterine cavity after identification of uterine wall perforation during first trimester termination of pregnancy, and drainage of infected vaginal vault hematoma following hysterectomy. RESULTS: The technique was applied for 11 patients, six abortions and five infected hematomas. All the procedures were completed without any further complications and the patients were discharged on the following day. Follow-up was uneventful. CONCLUSIONS: On-line intraoperative transrectal ultrasound can effectively provide real-time assistance to the gynecologic surgeon during complicated pelvic procedures.

Abortion, Induced↗
PubMed2002

[The impact of some factors on obstetrical management in women with previous cesarean section].

Considering obstetrical management we should have always in mind advantages and disadvantages of vaginal birth after cesarean (VBAC) and elective cesarean section after a previous one, financial part of the elected mode of delivery in the particular case, psychological aspect of the matter (especially after an unsuccessful trial of labour--TOL) and not on the last position-patient's right to choose the way how to deliver. We performed an inquiry of 3-year-period and 50 women with a prior cesarean section, by which we studied the factors contributed in different extent to the choice of the following approach to delivery: patient's preliminary choice, the impact of medical staff during pregnancy and when entering the Department of Obstetrics, the impact of non-medical persons, complications after the previous cesarean section, patient's acquaintance with complications and consequences associated with the operative mode of delivery, as well as doctor's personal attitude to the different modes of delivery. The aim of our research is to show that by careful selection (according to the established indices) of women, who have a high probability (more than 80%) to deliver their babies vaginally and offering adequate information by educational literature and including the woman in the decision making process, the growing rate of cesarean section will be decreased by increasing the number of VBAC--undoubtedly one of the most important issue in modern obstetrics.

Attitude of Health Personnel↗
PubMed2002

[Effect of some factors on obstetrical care of women with previous cesarean section].

Considering obstetrical management we should have always in mind advantages and disadvantages of vaginal birth after cesarean (VBAC) and elective cesarean section after a previous one, financial part of the elected mode of delivery in the particular case, psychological aspect of the matter (especially after an unsuccessful trial of labour--TOL) and not on the last position-patient's right to choose the way how to deliver. We performed an inquiry of 3-year-period and 50 women with a prior cesarean section, by which we studied the factors contributed in different extent to the choice of the following approach to delivery: patient's preliminary choice, the impact of medical staff during pregnancy and when entering the Department of Obstetrics, the impact of non-medical persons, complications after the previous cesarean section, patient's acquaintance with complications and consequences associated with the operative mode of delivery, as well as doctor's personal attitude to the different modes of delivery. The aim of our research is to show that by careful selection (according to the established indices) of women, who have a high probability (more than 80%) to deliver their babies vaginally and offering adequate information by educational literature and including the woman in the decision making process, the patient resistance to vaginal delivery will be reduced. In this way, the growing rate of cesarean section will be decreased by increasing the number of VBAC--undoubtedly one of the most important issue in modern obstetrics.

Attitude of Health Personnel↗
PubMed1998

Integrated multimodality therapy for embryonal rhabdomyosarcoma of the lower genital tract in postpubertal females.

Embryonal rhabdomyosarcoma of the female lower genital tract is generally regarded as a neoplasm occurring in childhood, but has also been reported in adults. The philosophy of therapy, largely based on data obtained from pediatric patients, has evolved slowly from ultraradical surgery, without adjuvant therapy, to neoadjuvant chemotherapy followed by less radical surgery and postoperative radiation. We report here three cases of lower genital tract rhabdomyosarcoma in postpubertal females. A failure to observe complete responses from any single treatment modality suggests that for embryonal rhabdomyosarcoma in adult and adolescent women a multimodality approach to therapy is essential.

Adolescent↗
PubMed2006

Epidural labour analgesia in a parturient with Noonan syndrome: a case report.

PURPOSE: Noonan syndrome is a relatively uncommon genetic disorder with implications for anesthesia due to multiple organ system involvement. Pregnancy presents additional concerns and there are only four reported cases of anesthesia for Cesarean delivery in parturients with Noonan syndrome. We describe the first reported management of labour analgesia in a parturient with Noonan syndrome culminating in vaginal delivery. CLINICAL FEATURES: A 21-yr-old parturient with Noonan syndrome received patient-controlled epidural analgesia for labour at 39 weeks gestation. Meticulous attention to the anesthetic technique resulted in good analgesia, and a successful outcome for mother and child. The different approaches to labour analgesia in parturients, with particular attention to combined spinal epidural vs epidural analgesia in this setting are discussed. CONCLUSION: Parturients with Noonan syndrome can present with an array of anomalies that may present difficulties to the anesthesiologist including a difficult airway, cardiopulmonary abnormalities, exaggerated lumbar lordosis and short stature. Careful preoperative consultation and determination of the degree of associated anomalies will help to prepare the anesthesiologist for potential problems.

Adult↗
PubMedDate not supplied

Total laparoscopic radical parametrectomy.

Although the surgical approach to early invasive cervical carcinoma may result in a better functional quality of life, the majority of patients with occult cervical cancer posthysterectomy still are treated with radiation therapy. Obviously, a radical operation still is considered a technically difficult task. Recently, laparoscopic-assisted vaginal radical parametrectomy (LAVRP) has been reported as an alternative treatment for this situation. In laparoscopic-assisted vaginal radical hysterectomy (LARVH), parts of the procedure are performed vaginally. We modified LAVRP in treating cervical cancer as through the laparoscope completely total laparoscopic radical parametrectomy (TLRP). The major advantage of TLRP for occult cervical cancer is that the entire surgery is performed under direct observation. It may reduce the possibility of visceral organ injury during vaginal procedures and could minimize the vaginal bleeding from vaginal dissection. Our preliminary experiences suggest that TLRP is feasible for carefully selected candidates.

Endometrium↗
PubMed1997

The role of rectosigmoid neocolporrhaphy.

BACKGROUND: Vaginoplasty for congenital vaginal atresia, a component of the Mayer-Rokitansky-Kuster syndrome, or for gender confirmation, may be achieved by several techniques. This report focuses on the efficacy of rectosigmoid neocolporrhaphy (RSNC) performed either primarily or secondarily after failure of another procedure. METHODS: Sixty patients underwent isoperistaltic RSNC, three primarily and 57 secondarily. The indication was vaginal atresia in 1 patient and gender dysphoria in 59 patients. RESULTS: All 60 patients survived and have a functional neovagina. One major complication, an anastomotic leak with colovaginal fistula, was treated by a temporary colostomy and later reconstruction through a combined anterior and posterior approach. Late complications were reversible stomal stenosis (six patients), reversible conduit narrowing (five patients), transient rhabdomyoblastosis (one patient), and temporary mucosal bleeding from hyperplasia (three patients). Thirty patients have regular intercourse, 12 patients have occasional intercourse, and the others feel "whole," with their intact desired sexual anatomy awaiting a suitable partner. CONCLUSIONS: The number of patients seeking vaginoplasty is increasing. Primary or secondary RSNC is a safe and effective method.

Abnormalities, Multiple↗
PubMed1999

Newly available and future laboratory tests for sexually transmitted diseases (STDs) other than HIV.

BACKGROUND AND OBJECTIVES: The development and introduction of nucleic acid amplification (NAA) tests by commercial sources has improved our ability to diagnose chlamydial infections and other sexually transmitted diseases (STDs). A review of approaches to diagnosing STDs can provide a clearer picture of the present needs. GOALS: To review the advantage and disadvantages of current and future diagnostic approaches. STUDY DESIGN: Survey the literature and define current and future needs in developed and developing country settings. RESULTS: The increase in analytical sensitivity afforded by NAA has enabled the use of noninvasive specimens, such as first-void urine (FVU) and self-obtained vaginal swabs, for diagnostic testing and screening asymptomatic low-prevalence populations and hard-to-access populations. This technology allows multiplexing in which targets from multiple agents responsible for a particular syndrome can be amplified and detected. Although NAA tests have been designed to minimize contamination, there is some reluctance to replace less sensitive tests with this new technology. The concerns involve potential false positive and false negative results caused by the presence of inhibitors, even though the rates of false results are low. Other concerns are cost, through-put, hands-on time, and time necessary for results. CONCLUSIONS: Nucleic acid amplification tests are a great improvement and additional tests are needed for the diagnosis of STDs at the point of first encounter, with minimal delay between diagnosis and treatment. Affordable tests, which are rapid, sensitive, and specific are needed for use in resource-limited settings where most STDs are seen; this has been a major undertaking for the Sexually Transmitted Diseases Diagnostics Initiative.

Clinical Laboratory Techniques↗
PubMed1998

Reporting sexual risk behavior for HIV: a practical risk index and a method for improving risk indices.

OBJECTIVES: As a means of enhancing public health efforts to control sexual transmission of human immunodeficiency virus (HIV), methods were developed to report on risk behavior in a manner that is comparable and widely interpretable. METHODS: An elementary sexual behavior risk index (the vaginal episode equivalent index) that is in accord with some of the essential knowledge about sexual transmission of HIV is described, and a multivariate ordinal risk (MOR) method that can be used to improve such risk indices is introduced. RESULTS: An example shows that these approaches are applicable to observational studies of seroconversion. CONCLUSIONS: The MOR represents a powerful new tool to develop valid comparable measures of sexual risk behavior and, thereby, to advance HIV prevention research.

Female↗

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