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PubMed1998

Characterization and prognostic significance of variable decelerations in the second stage of labor.

The characteristics of variable decelerations (VD) in the second stage of labor and the relationship between the number, frequency, or severity and neonatal outcome have not been studied. We have analyzed the characteristics of VD in the second stage of labor and their prognostic significance in the prediction of Apgar scores. In this descriptive study, fetal heart tracings containing VD from 250 singleton, vaginal deliveries between June 1994 and July 1996 were reviewed blinded to outcome information. Excluded were: (1) deliveries at <36 weeks, (2) uninterpretable tracing, (3) absence of VD in second stage of labor, and (4) absence of exam establishing beginning of second stage of labor. VD characteristics evaluated: shape (U, V, W); anterior and posterior "shoulders"; slow return to baseline (< or = 30-degree curve); cumulative depth of VD per 10 min, second stage oxytocin dose. Outcome information collected: method of delivery, birth weight and Apgar scores. Statistical analysis included regression and analysis of variance (ANOVA). The mean maternal age was 32+/-5 years and gestational age 39+/-1.3 week. In the second stage of labor, the mean oxytocin dose was 3+/-5 mu/min, length of the second stage 65+/-57 min, total number of VD averaged 21+/-17 and uterine contractions 26+/-22 per patient. The percentage of VD <100 bpm was 50+/-27%, VD <70 bpm 13+/-20%, anterior shoulders 76+/-30%, posterior shoulders 75+/-30% and slow return to baseline 12+/-17%. The number of VD significantly increased with the length of the second stage of labor (r=0.85, p <0.001). The total number and percentage of VD <70 bpm were inversely correlated with 5-min Apgar score (p=0.038, 0.015 respectively). The sum of the depth of VD/length of second stage as well as the percentage of VD with anterior and/or posterior shoulders and slow return to baseline were not significantly related to Apgar scores (p=0.08, 0.72, 0.73, 0.99, respectively). Patients with a higher percentage of decelerations with slow return to baseline had a higher rate of operative vaginal deliveries (20 vs. 11 %, p=0.002); but no significant differences in Apgar scores compared with those with spontaneous delivery (p=0.9). Second stage VD <70 bpm were significantly associated with lower 5-min Apgar scores. Although the presence of VD with a slow return to baseline was significantly associated with operative delivery, there was no difference in 5-min Apgar scores.

Adult↗
PubMed1980

Preliminary testing of the contraceptive collagen sponge.

The results of 3 years of developing the collagen sponge as an intravaginal contraceptive are presented. Postcoital tests were used to evaluate the efficacy of the sponge as a mechanical barrier. Results with the collagen sponge alone were compared to those of the sponge with spermicidal cream or spermicidal solution (acid buffer and zinc) and of spermicidal cream alone. The presence of any motile spermatozoa in the cervical mucus was considered a failure of the barrier method. The collagen sponge alone or with acid and zinc and spermicidal cream alone had failure rates of 22, 20, and 14%, respectively, whereas the collagen sponge with spermicidal cream had a 6% failure rate. The authors conclude that the combination of a mechanical and a chemical barrier is a more effective contraceptive method than a mechanical barrier or chemical agent alone.

Adolescent↗
PubMed2000

Inhibitory effect of melatonin on 7, 12-dimethylbenz[a]anthracene-induced carcinogenesis of the uterine cervix and vagina in mice and mutagenesis in vitro.

Forty female CBA mice aged 3-4 months were exposed twice a week during 2 months to intravaginal applications of polyurethane sponges impregnated with 0.1% solution of 7,12-dimethylbenz[a]anthracene (DMBA) in triethyleneglycol. Three hours after each application the sponges were taken out. Starting from the day of the 1st DMBA application a part of mice was exposed five times a week during 4 months with melatonin in tap water (20 mg/l) given at night time (from 18:00 to 09:00 h). Additional 20 female CBA mice were intact and served as a control. All mice were sacrificed in 6 months after start of the experiment. Seven of 20 mice exposed to DMBA alone developed malignancies in the vagina and cervix uteri and two mice developed benign cervical tumors. No malignancies in vagina and uterine cervix and three vaginal papillomas were observed in mice exposed to DMBA+melatonin. There were no any tumors in intact controls. Two in vitro tests were used for mutagenicity studies: the Ames test (strains TA 97 and TA 98 of Salmonella typhimurium) and the single cell gel electrophoresis assay (SCGE assay or COMET assay) performed on CHOK1 cells. In tested strains melatonin significantly reduced the mutagenicity of DMBA. In the SCGE assay preincubation with melatonin led to a strong inhibition of clastogenic activities of DMBA. Thus, our data indicate that pineal indole hormone melatonin inhibits cervical and vaginal carcinogenesis induced by DMBA in mice and possess antimutagenic and anticlastogenic effect in vitro.

9,10-Dimethyl-1,2-benzanthracene↗
PubMed2001

[Transcatheter arterial embolization in intractable postpartum hemorrhage].

OBJECTIVE: To asses the value of transcatheter arterial embolization treatment in intractable postpartum hemorrhage. METHODS: Fourteen patients of postpartum hemorrhage failed to the drugs treatment were performed transcatheter arterial embolization (TAE). Superselective catheterization to the bilateral uterial arteries or anterior branches of internal iliac arteries was carried out after intubation to single-side femoral artery by Seldinger's technique. When the catheter tip was proved in right place by digital substraction angiography (DSA) techniques, antibiotic solution was poured into arteries and then the arterial embolization with gelfoam particles was followed. RESULTS: All the patients were performed TAE successfully. The duration of TAE was 30-50 minutes [mean (41.8 +/- 6.4) minutes]. Bleeding was found in DSA mostly as diffuse intrauterine flow outward sign from one side or both side of uterial artery branches. After one time of TAE, the vaginal bleeding of all patients was stopped in 3-10 minutes [mean (6.1 +/- 3.6) minutes]. The follow-up showed that all patients had normal menstrual periods in 2-60 months and no serious complications were found. CONCLUSION: With the characteristic of fast homeostasis and less complications, TAE was proved to be an effective method for intractable postpartum hemorrhage.

Adult↗
PubMed2006

White sponge naevus with minimal clinical and histological changes: report of three cases.

White sponge naevus (WSN) is a rare autosomal dominant disorder that predominantly affects non-cornified stratified squamous epithelia: oral mucosa, oesophagus, anogenital area. It has been shown to be related to keratin defects, because of mutations in the genes encoding mucosal-specific keratins K4 and K13. We illustrate three cases diagnosed as WSN, following the clinical and histological criteria, with unusual appearance. They presented with minimal clinical and histological changes that could be misleading in the diagnosis. The patients showed diffuse irregular plaques with a range of presentations from white to rose coloured mucosae involving the entire oral cavity. In one case the lesion was also present in the vaginal area. The histological findings included epithelial thickening, parakeratosis and extensive vacuolization of the suprabasal keratinocytes, confirming WSN diagnosis. Clinical presentation and histopathology of WSN are discussed in relation to the differential diagnosis of other oral leukokeratoses.

Diagnosis, Differential↗
PubMedDate not supplied

Efficacy of nonoxynol 9 contraceptive sponge use in preventing heterosexual acquisition of HIV in Nairobi prostitutes.

OBJECTIVE: To determine the efficacy of the nonoxynol 9 contraceptive sponge in preventing sexual acquisition of the human immunodeficiency virus (HIV). DESIGN: Prospective, randomized placebo-controlled trial. SETTING: Research clinic for prostitutes in Nairobi, Kenya. PATIENTS AND INTERVENTIONS: One hundred thirty-eight HIV-seronegative women were enrolled, of whom 74 were assigned to nonoxynol 9 sponge use and 64 to placebo use. These two groups did not significantly differ with respect to demographic characteristics, sexual practices, or prevalence of genital infections at enrollment, except for a lower number of sex partners per week and a higher initial prevalence of genital ulcers among women assigned to nonoxynol 9 sponge use. Among the 116 women who returned for follow-up, the mean durations of follow-up were 14 and 17 months for the two groups, respectively. MAIN OUTCOME MEASURE: HIV seroconversion. RESULTS: Nonoxynol 9 sponge use was associated with an increased frequency of genital ulcers (relative risk [RR], 3.3; P less than .0001) and vulvitis (RR, 3.3; P less than .0001) and a reduced risk of gonococcal cervicitis (RR, 0.4; P less than .0001). Twenty-seven (45%) of 60 women in the nonoxynol 9 sponge group and 20 (36%) of 56 women in the placebo group developed HIV antibodies. The hazard ratio for the association between nonoxynol 9 sponge use and HIV seroconversion was 1.7 (95% confidence interval [CI], 0.9 to 3.0). Using multivariate analysis to control for the presence of genital ulcers at enrollment, the adjusted hazard ratio for the association between nonoxynol 9 sponge use and seroconversion was 1.6 (95% CI, 0.8 to 2.8). CONCLUSIONS: Genital ulcers and vulvitis occurred with increased frequency in nonoxynol 9 sponge users. We were unable to demonstrate that nonoxynol 9 sponge use was effective in reducing the risk of HIV infection among highly exposed women.

Adult↗
PubMed2006

The Maternal-Fetal Medicine Units Cesarean Registry: safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery.

OBJECTIVE: This study was undertaken to compare success rates of vaginal birth after cesarean (VBAC) delivery, and uterine rupture as well as maternal/perinatal outcomes between women with preterm and term pregnancies undergoing trial of labor (TOL), and to compare maternal and neonatal morbidities in those women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD). STUDY DESIGN: Prospective 4-year observational study of women with a singleton gestation and a prior cesarean delivery at 19 academic centers. Clinical characteristics, maternal complications and VBAC delivery success for those with a preterm (24(0)-36(6) weeks) TOL, preterm RCD and term TOL (> or = 37 weeks) were analyzed. RESULTS: Among 3119 preterm pregnancies with prior cesarean delivery, 2338 (75%) underwent a TOL. 15,331 women undergoing TOL at term were also analyzed as a control group. TOL success rates for preterm and term pregnancies were similar (72.8% vs 73.3%, P = .64). Rates of uterine rupture (0.34% vs 0.74%, P = .03) and dehiscence (0.26% vs 0.67%, P = .02) were lower in preterm compared with term TOL. Thromboembolic disease, coagulopathy and transfusion were more common in women undergoing a preterm TOL than those at term. Among women undergoing a preterm TOL, rates of uterine dehiscence, coagulopathy, transfusion, and endometritis were similar to those having a preterm RCD. After controlling for gestational age at delivery and race, neonatal outcomes such as Neonatal Intensive Care Unit (NICU) admission, intraventricular hemorrhage, sepsis, and ventilatory support were similar in both groups except for a higher rate of respiratory distress syndrome in those delivered after a TOL. CONCLUSION: The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture. Perinatal outcomes are similar with preterm TOL and RCD. TOL should be considered as an option for women undergoing preterm delivery with a history of prior cesarean delivery.

Adult↗
PubMed2004

Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.

BACKGROUND: The proportion of women who attempt vaginal delivery after prior cesarean delivery has decreased largely because of concern about safety. The absolute and relative risks associated with a trial of labor in women with a history of cesarean delivery, as compared with elective repeated cesarean delivery without labor, are uncertain. METHODS: We conducted a prospective four-year observational study of all women with a singleton gestation and a prior cesarean delivery at 19 academic medical centers. Maternal and perinatal outcomes were compared between women who underwent a trial of labor and women who had an elective repeated cesarean delivery without labor. RESULTS: Vaginal delivery was attempted by 17,898 women, and 15,801 women underwent elective repeated cesarean delivery without labor. Symptomatic uterine rupture occurred in 124 women who underwent a trial of labor (0.7 percent). Hypoxic-ischemic encephalopathy occurred in no infants whose mothers underwent elective repeated cesarean delivery and in 12 infants born at term whose mothers underwent a trial of labor (P<0.001). Seven of these cases of hypoxic-ischemic encephalopathy followed uterine rupture (absolute risk, 0.46 per 1000 women at term undergoing a trial of labor), including two neonatal deaths. The rate of endometritis was higher in women undergoing a trial of labor than in women undergoing repeated elective cesarean delivery (2.9 percent vs. 1.8 percent), as was the rate of blood transfusion (1.7 percent vs. 1.0 percent). The frequency of hysterectomy and of maternal death did not differ significantly between groups (0.2 percent vs. 0.3 percent, and 0.02 percent vs. 0.04 percent, respectively). CONCLUSIONS: A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. This information is relevant for counseling women about their choices after a cesarean section.

Adolescent↗
PubMed2005

Proteinase-activated receptors in ovine cervical function.

In sheep, inflammation not only functions in cervical dilation at parturition, but also plays an important part in the non-pregnant ewe cervix, as demonstrated by the high level of expression of interleukin (IL)-8 at oestrus. Ewes artificially induced to ovulate have significantly lower levels of IL-8 gene expression at oestrus compared with natural oestrus, indicating an inhibition of inflammation and function, offering an explanation for the low rates of conception in vaginally inseminated synchronised ewes. To identify potential pro-inflammatory agents to combat the anti-inflammatory effects of hormonal synchronisation of oestrus, we have investigated the role of proteinase-activated receptor (PAR)-1 and PAR-2. To localise and measure the level of expression of these receptors, ovine-specific probes were derived for PAR-1 and PAR-2 and used for quantitative in situ hybridisation in the ovine cervix. Both PAR-1 and PAR-2 were expressed in the luminal epithelium of the cervix throughout the oestrous cycle, with expression being highest at oestrus. The gene expression of PAR-2 at oestrus was approximately 30% higher than that of PAR-1. Artificial synchronisation of oestrus by either an intravaginal progesterone sponge or prostaglandin F2+/- injections did not inhibit PAR-1 or PAR-2 expression at oestrus; rather, in the case of PAR-2, progesterone synchronisation increased it. Both synchronising procedures increased the expression of PAR-1 and PAR-2 during the luteal phase of the cycle. Therefore, agonists of PAR-1 and PAR-2 may be potentially useful pro-inflammatory agents countering the inhibition of inflammation by hormonal synchronisation.

Analysis of Variance↗
PubMed2002

Anticipation of uterine bleeding in placenta previa based on vaginal sonographic evaluation.

OBJECTIVES: The aim of this study was to predict massive uterine bleeding during pregnancy and cesarean section in women with placenta previa using transvaginal ultrasonography. METHODS: Transvaginal ultrasonography was performed prospectively at and after 28 gestational weeks with follow-up scans at 5- to 7-day intervals until cesarean section in 35 women with placenta previa. The patients were classified into 3 groups based on the following sonographic features of the placental edge in relation to the internal cervical os: type A = two thirds of the placenta from the placental center overlapping the internal os (13 cases); type B = one third of the placenta from the periphery to outside overlapping the internal os (10 cases), and type C = echo-free space (EFS) in the placental edge overlapping the internal os (12 cases). In some cases of type-A placentas, lacunae with blood flow in the placenta from the basal plate to the chorionic plate were also observed. All types were further subdivided based on the presence or absence of associated sponge-like echo (S-echo) in the wall of the uterus adjacent to the placental location. In each type, the relation with the amount of bleeding during hospitalization and preterm delivery was examined. RESULTS: Incidences of sudden massive bleeding during hospitalization were 7.7% (1/13), 10.0% (1/10), and 83.3% (10/12), in types A, B and C, respectively, being significantly higher in type C (p < 0.01). The risk of antepartum massive bleeding was also significantly higher in type C (p < 0.01). The incidence of preterm delivery due to sudden massive bleeding and the amount of bleeding during cesarean section were significantly higher in type A + S and type A + S with lacunae, respectively. CONCLUSIONS: Sonographic EFS in the lower edge of the placenta overlying the cervix indicates the risk of sudden massive antepartum bleeding. Furthermore, lacunae with sponge-like echo may also reflect the risk of massive bleeding at cesarean section. These findings warrant further observational studies to verify their clinical implications.

Cesarean Section↗
PubMed1997

Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses.

Obstetric hemorrhage is still a potential cause of maternal mortality and morbidity. Angiographic embolization techniques have been described in cases of postcesarean bleeding, vaginal wall hematomas, cervical ectopic pregnancies, and postpartum bleeding to control persistent bleeding from pelvic vessels. We describe two cases of pregnancy complicated with placenta percreta. Balloon occlusion and embolization of the hypogastric arteries were performed during the cesarean section and hysterectomy, resulting in a remarkable reduction in intraoperative blood loss. Balloon occlusion and embolization of the internal iliac arteries significantly reduce intraoperative blood losses.

Adult↗
PubMed1994

Enhancement of regression of cervical intraepithelial neoplasia II (moderate dysplasia) with topically applied all-trans-retinoic acid: a randomized trial.

BACKGROUND: Retinoids enhance differentiation of most epithelial tissues. Epidemiologic studies have shown an inverse relationship between dietary intake or serum levels of vitamin A and the development of cervical dysplasia and/or cervical cancer. Pilot and phase I investigations demonstrated the feasibility of the local delivery of all-trans-retinoic acid (RA) to the cervix using a collagen sponge insert and cervical cap. A phase II trial produced a clinical complete response rate of 50%. PURPOSE: This randomized phase III trial was designed to determine whether topically applied RA reversed moderate cervical intraepithelial neoplasia (CIN) II or severe CIN. METHODS: Analyses were based on 301 women with CIN (moderate dysplasia, 151 women; severe dysplasia, 150 women), evaluated by serial colposcopy, Papanicolaou cytology, and cervical biopsy. Cervical caps with sponges containing either 1.0 mL of 0.372% beta-trans-RA or a placebo were inserted daily for 4 days when women entered the trial, and for 2 days at months 3 and 6. Patients receiving treatment and those receiving placebo were similar with respect to age, ethnicity, birth-control methods, histologic features of the endocervical biopsy specimen and koilocytotic atypia, and percentage of involvement of the cervix at study. Treatment effects were compared using Fisher's exact test and logistic regression methods. Side effects were recorded, and differences were compared using Fisher's exact test. RESULTS: RA increased the complete histologic regression rate of CIN II from 27% in the placebo group to 43% in the retinoic acid treatment group (P = .041). No treatment difference between the two arms was evident in the severe dysplasia group. More vaginal and vulvar side effects were seen in the patients receiving RA, but these effects were mild and reversible. CONCLUSIONS: A short course of locally applied RA can reverse CIN II, but not more advanced dysplasia, with acceptable local side effects. IMPLICATIONS: A derivative of vitamin A can reverse or suppress an epithelial preneoplasia, lending further support to the notion that chemoprevention of human cancer is feasible.

Administration, Intravaginal↗
PubMed2004

Role of CT-guided core needle biopsy in the diagnosis of a gossypiboma: case report.

A 66-year-old woman with previous hysterectomy had dysuria and vaginal spotting for 1 month. Computed tomography showed a heterogeneous presacral mass with eccentric calcification. Biopsies of the bladder and vagina and transrectal biopsy of the pelvic mass yielded only inflammation. T2-weighted magnetic resonance images revealed a heterogeneous mass with wavy hypointensities. Computed tomographically guided biopsy targeting at the calcified area disclosed thread-like materials, thus confirming the diagnosis of gossypiboma.

Aged↗
PubMed2005

Diagnosis and management of uterine arteriovenous fistulas with massive vaginal bleeding.

OBJECTIVE: To study the clinical manifestations, diagnosis, management, and prognosis of uterine arteriovenous fistulas with massive vaginal bleeding. METHODS: The clinical records of 15 patients who satisfied the diagnostic criteria were retrospectively analyzed. RESULTS: All patients had massive vaginal bleeding and a history of cesarean section, curettage, or gynecologic carcinoma. The disease was diagnosed by angiography or color Doppler ultrasonography. Vaginal bleeding can be aggravated by dilation and curettage. No complications occurred in the 14 patients who were treated with uterine artery embolization. Of the 11 patients who underwent successful embolizations, all returned to a normal menstrual cycle and 5 later became pregnant. CONCLUSION: Uterine arteriovenous fistula is a rare and potentially life-threatening condition. Uterine artery embolization is a safe and effective choice of treatment for this condition, and it can preserve both uterus and ovary function.

Adult↗
PubMed1977

Therapeutic embolization for intractable chronic bleeding.

Intractable, chronic vaginal and/or vesicle bleeding complicating pelvic cancers in five women was treated by transcatheter embolization of the hypogastric artery or its branches. Bleeding was presumed to be from hypervascular granulation tissue formed in response to irradiation in two patients and from tumor tissue in three. The embolic materials were Gelfoam and Oxycel reinforced autologous clots. Bleeding was stopped or reduced in volume by at least 90% in each patient. This form of therapy was useful even though bleeding site was not demonstrated angiographically.

Chronic Disease↗
PubMed2006

Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery.

OBJECTIVE: Assess effects of body mass index (BMI) on trial of labor after previous cesarean delivery and determine whether morbidly obese women have greater maternal and perinatal morbidity with trial of labor compared with elective repeat cesarean delivery. METHODS: Secondary analysis from a prospective observational study included all term singletons undergoing trial of labor after previous cesarean delivery. Body mass index groups were as follows: normal 18.5-24.9, overweight 25.0-29.9, obese 30.0-39.9, morbidly obese 40.0 kg/m2 or greater, and were compared for failure and maternal and neonatal morbidities. The morbidly obese trial of labor and elective repeat cesarean delivery were compared for maternal and neonatal morbidities. Multivariable logistic regression analysis controlled for confounding variables. RESULTS: There were 14,142 trial of labor participants and 14,304 elective repeat cesarean delivery participants. Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery: from 15.2% in normal weight (1,344) to 39.3% in morbidly obese (1,638), with combined risk of rupture/dehiscence increasing from 0.9% to 2.1% in morbidly obese women. Among morbidly obese women, trial of labor carried greater than five-fold risk of uterine rupture/dehiscence (2.1% versus 0.4%), almost a two-fold increase in composite maternal morbidity (7.2% versus 3.8%) and five-fold risk of neonatal injury (1.1% versus 0.2%) (fractures, brachial plexus injuries, and lacerations), but no neonatal encephalopathy. Morbidly obese women failing a trial of labor had six-fold greater composite maternal morbidity than those undergoing a successful trial of labor (14.2% versus 2.6%). CONCLUSION: Body mass index correlates with outcomes in trial of labor after previous cesarean delivery. Morbidly obese women undergoing a trial of labor were at increased risk for failure. Increased BMI was associated with greater composite morbidity and neonatal injury compared with elective repeat cesarean delivery, but absolute morbidities were small. Increased risks should be considered before trial of labor after previous cesarean delivery. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed1988

Transcatheter embolotherapy of massive bleeding after surgery for benign gynecologic disorders.

Transcatheter embolotherapy is a well-established technique for control of bleeding in patients with pelvic trauma and pelvic malignancies, but it has been rarely used in massive vaginal bleeding after surgery for benign gynecologic disorders. We report five patients with massive post-operative vaginal hemorrhage following total abdominal hysterectomy (n = 3), repeated dilatation and curettage (n = 1) and cesarean section (n = 1), all successfully controlled with transcatheter embolization after many operative procedures had failed to stop the hemorrhage. The age of the patients ranged from 21 to 36 years. All patients underwent embolization of both internal iliac arteries with Gelfoam alone or in combination with stainless steel coils. The bleeding stopped immediately in all patients. Four patients recovered completely and one patient died of disseminated intravascular coagulation and multi-organ failure.

Adult↗
PubMed1983

Effect of the suppository base on progesterone delivery from the vagina.

Inadequate levels of circulating progesterone (P) seen in clinical practice can be increased by P supplementation. When supplementation is via the vaginal route, its presentation may be in many different suppository bases. We have measured circulating P in the follicular phase to compare delivery from the vagina after P was presented in three different bases (glycerinated gelatin, cocoa butter, and polyethylene glycol). The mean peak level achieved and the area under the curve were highest after supplementation from polyethylene glycol-based suppositories. The duration of elevation above baseline was similar with all three suppositories. It is concluded that the suppository base is important in controlling the amount of this steroid absorbed from a given amount presented by this route.

Adolescent↗