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PubMed1977

[Perspectives of ultrasonic diagnosis for the localization of intrauterine pessaries. Ultrasonic presentation of various types of IUDs].

The authors report on their experiences with ultrasonic localization of several types of IUDs. The investigations were carried out with the ultrasonic equipment-B-scanning -- Vidoson S 635 (Siemens). The characteristics of the echosonic pictures of 6 IUDs (Szontágh-IUD, Lippes-Loop, Gravigard, Alza-T, Copper-T, Antigon were studied. It could be stated that the IUDs can be well identified by ultrasonics. In cases of IUD in situ and early pregnancy the amnion and the IUD can be exactly localized.

Amnion↗
PubMed1977

[Pregnancies in spite of intrauterine pessaries in situ].

Reviewing literature the fate of 3027 pregnancies with intrauterine devices in situ, included 43 own cases, is reported. The data strongly suggest to remove the intrauterine devices as early as possible in pregnancy, because otherwise the rate of spontaneous abortion, premature birth and stillbirth is negatively affected. The known elevated risk of extrauterine pregnancies is corroberated. The ratio of 1:4 with the progesterone-T is higher than with other IUDs (1:31 to 1:24,5). The observations do not support the view that intrauterine devices cause malformations. From the results instructions for the management of pregnancies associated with intrauterine devices are set up.

Abortion, Spontaneous↗
PubMed1995

Premature rupture of membranes in nulliparas at term with unfavorable cervices: a double-blind randomized trial of prostaglandin and placebo.

OBJECTIVE: To determine whether the use of a prostaglandin (PG) E2 3-mg pessary followed by a delay of 12 hours before stimulation of labor with oxytocin improves obstetric outcome compared with the use of a placebo pessary. METHODS: One hundred fifty-five nulliparas at term with poor cervical scores (modified Bishop score below 6 of 10) and premature rupture of membranes (PROM) were recruited for this double-blind, placebo-controlled randomized trial. On admission to the study, either a PGE2 pessary or an identical-appearing placebo pessary was inserted into the posterior fornix. If labor did not start in the next 12 hours or if symptoms and signs of infection were evident, labor was induced with oxytocin infusion. Assignment was unblinded at the end of the study, and details of the labor and maternal and neonatal outcome in women who received a PG pessary were compared with those who received a placebo pessary. RESULTS: Women receiving a PG pessary were significantly less likely to require stimulation of labor at the end of 12 hours than were those given a placebo pessary (37 versus 58%, P = .002). The mean time between admission to study and delivery was significantly shorter in the PG group compared with the placebo group (15 versus 19 hours, P = .01). The rate of cesarean delivery was not statistically different in the two groups (13.9% with PG versus 15.8% with placebo). CONCLUSION: In nulliparas with poor cervical scores who present with PROM at term and no evidence of infection or obstetric complications, use of a PGE2 pessary resulted in more women establishing labor earlier, with a resultant reduction in the admission-to-delivery interval, compared with the use of a placebo pessary. The cesarean delivery rates in the two groups were similar, and there were no significant differences in neonatal outcome.

Cervix Uteri↗
PubMed1999

Effect of stress-like concentrations of cortisol on follicular development and the preovulatory surge of LH in sheep.

Stress-like concentrations of cortisol increase the negative feedback potency of oestradiol in castrated male sheep. A similar cortisol-dependent response in female sheep might be expected to suppress gonadotrophin secretion and impair follicular development and ovulation. The oestrous activity of 21 female sheep was synchronized using progestogen-treated vaginal pessaries to test this hypothesis. Stress-like concentrations of cortisol (60-70 ng ml-1) were established by continuous infusion of cortisol (80 micrograms kg-1 h-1; n = 13) beginning 5 days before, and continuing for 5 days after, pessary removal. Control animals (n = 8) received a comparable volume of vehicle (50% ethanol-saline) over the 10 day infusion period. Serum concentrations of oestradiol increased progressively in control sheep during the 48 h immediately after pessary removal. This increase in serum oestradiol was blocked or significantly attenuated in sheep receiving stress-like concentrations of cortisol. Preovulatory surge-like secretion of LH was apparent in control animals 58.5 +/- 2.1 h after pessary removal. In contrast, surge-like secretion of LH was not observed during the 5 days after pessary removal in 54% (7 of 13) of sheep receiving cortisol. Moreover, the onset of the surge was significantly delayed in the cortisol-treated ewes that showed surge-like secretion of LH during the infusion period. The ability of episodic pulses of exogenous GnRH to override the anti-gonadal effect of cortisol was examined in a second study. Oestrous activity of 12 ewes was synchronized using progestogen-containing pessaries as described above. Ewes were randomly assigned to one of three treatment groups (n = 4 ewes per group). Animals received cortisol (100 micrograms kg-1 h-1; groups 1 and 2) or a comparable volume of vehicle (group 3) beginning 5 days before, and continuing for 2 days after, pessary removal. Pulses of GnRH (4 ng kg-1 h-1, i.v.; group 1) or saline (groups 2 and 3) at 1 h intervals were initiated at pessary removal and continued for 48 h. Serum concentrations of oestradiol were not significantly increased after pessary removal in sheep receiving cortisol alone. Conversely, serum concentrations of oestradiol increased progressively during the 48 h after pessary removal in control ewes and in ewes receiving cortisol and GnRH. At the end of infusion, serum concentrations of oestradiol did not differ (P > 0.05) between control (7.7 +/- 0.8 pg ml-1) ewes and ewes receiving cortisol and episodic GnRH (6.4 +/- 1.3 pg ml-1). Moreover, these values were significantly greater (P < 0.05) than the serum concentrations of oestradiol in animals receiving cortisol (1.0 +/- 0.4 pg ml-1) alone. Collectively, these data indicate stress-like concentrations of cortisol block or delay follicular development and the preovulatory surge of LH in sheep. In addition, episodic GnRH overrides cortisol-induced delay in follicular maturation.

Analysis of Variance↗
PubMed2004

[Genital prolapse; treatment and course in four general practices].

OBJECTIVE: To obtain insight into the treatment and course of genital prolapse in four general practices. DESIGN: Historical cohort study. METHOD: The files of patients in whom a prolapse was first diagnosed in the period 1976-2000 and who belonged to the four general practices associated with the General Practice Department of the UMC St Radboud in Nijmegen, the Netherlands, were studied. Data were collected concerning the management, course and symptoms arising from the use of pessaries and complications after operations. RESULTS: 324 patients were included with a median follow-up of 9 years; 15 of them had been treated by a gynaecologist. The initial treatment prescribed by the general practitioner (n = 309) was a wait-and-see policy in 29% of the cases, a pessary (40%), exercises of the muscles of the pelvic floor (15%) or medication (5%). A total of 192 of the 324 patients (59%) received a pessary in the course of time; 47% of them had no problems during the use of a pessary, 17% had increased vaginal discharge and 17% had a pressure ulcer. In 15% of the cases the pessary was ultimately lost because of insufficient support from the pelvic floor muscles. The pessary remained in situ for an average of 5.4 years (SD: 5.4). In 107 (56%) cases it was removed after a period of time; the most important reasons for this were complaints arising from the use of the pessary (54%) and ineffectiveness (24%). In case of a conservative approach (n = 299), the prolapse became worse in 15% of the cases. A total of 128 patients (40%) were referred to a gynaecologist. Of the 92 patients who were operated, 10% experienced a complication and 24% a recurrence. CONCLUSION: The pessary was a frequent and justified treatment in women with a genital prolapse. It is important that the complications of the pessary be reduced further.

Cohort Studies↗
PubMed2005

Noninvasive cerclage for the management of cervical incompetence: a prospective study.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of a noninvasive cerclage pessary in the management of cervical incompetence. METHODS: This is a prospective cohort study of all pregnant women treated for cervical incompetence during a 4-year period. Women with known risk factors for preterm delivery had transvaginal ultrasonography every 2-3 weeks after 17-19 weeks of gestation. Those with progressive shortening of cervix diagnosed before 30 weeks were treated with a cerclage pessary when the cervical length was < or = 25 mm. The pessary was electively removed at 34-36 weeks. The course and outcome of pregnancy were recorded. RESULTS: Thirty-two women were treated with a cerclage pessary. There were nine twin and two triplet pregnancies. Fifteen (47%) had two or more risk factors for preterm delivery. The mean gestational age at cerclage was 23 (17-29) weeks, cervical length 17 (5-25) mm. Two women required delivery before the onset of labor due to severe intrauterine growth restriction and one due to HELLP syndrome. These were excluded from further analysis. In the remaining 29 women, the interval between cerclage and delivery was 10.4 (2-19) weeks, mean gestational age at delivery 34 (22-42) weeks, and birth weight 2,255 (410-4,045) g. Thirteen (45%) women delivered before 34 weeks. There were a total of 35 live-born infants and four intrapartum fetal deaths (all between 22 and 25 weeks gestation). All women complained of increased vaginal discharge, but no other significant complications were observed that could be attributed to the use of pessary. CONCLUSION: Cerclage pessary may be useful in the management of cervical incompetence. Whether it can be a noninvasive alternative to surgical cerclage merits further investigation.

Adult↗
PubMed1991

FSH injections and intrauterine insemination in protocols for superovulation of ewes.

In Exp. 1, five injections of crude FSH (20 mg total), starting 36 h before removal of progestin pessaries or injection of prostaglandin F2 alpha (PGF2 alpha), were found to be as effective for superovulation of ewes as seven injections starting 72 h before removal of pessaries. Seven injections caused superovulation (more than three ovulations) in 13 of 15 ewes with an average (all ewes) of 12 +/- 2.3 ovulations. Five injections caused superovulation in 17 of 19 ewes with an average of 11.5 +/- 1.6 ovulations after pessary-regulated estrus in 12 of 16 ewes with an average of 12.4 +/- 2.2 ovulations after PGF2 alpha injection. In Exp. 2, intrauterine artificial insemination (IUAI) of naturally mated ewes provided ovum fertilization rates of 75.3% with an embryo recovery rate of 39.4%, whereas mating alone (MATED) provided fertilization rates of 64.2% with an embryo recovery rate of 72.1%. However, subsequent replications of the MATED protocol (MATED2) resulted in a low fertilization rate (34.2%). In Exp. 3, surgical IUAI at 22 h after removal of pessaries resulted in a low rate of superovulation (5 of 12 ewes), presumably as the result of pentobarbital anesthesia. Conducting IUAI at 46 h after removal of pessaries resulted in a high rate of superovulation (14 of 16 ewes) but a low embryo recovery rate (30.7%). In two subsequent trials, IUAI at 40 h after removal of pessaries resulted in most ewes superovulating (33 of 35 in April/May and 16 of 17 in September) with acceptable embryo recovery (65.2% and 71.3%) and high fertilization rates (82.8% and 96.4%).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2001

Ram-induced ovulation to improve artificial insemination efficiency with frozen semen in sheep.

Ram effect, defined as shortening of seasonal anestrus in ewes by exposure to the ram, is now well recognized but the underlying mechanisms are still unclear. Little information also exists whether the ram is able to influence the estrus cycle and ovulation. Three experiments were conducted to investigate endocrine response, time of ovulation and pregnancy rate of ewes in proestrus, exposed to the ram (treated) or an adult ewe (control). In the first experiment, ewes (n = 20) were treated with fluorgestone acetate pessaries for 12 days and were given eCG and cloprostenol one day before withdrawal of pessaries. On the day after removal of the pessaries ewes in the treated group (n = 10) were exposed to the ram and those in the control group (n = 10) were exposed to an adult ewe. Blood samples were taken for LH assay every 20 min from 2 h before to 24 h after ram exposure. In the second experiment, ewes (n = 120) were induced into proestrus and on the day after removal of the pessaries were exposed to either a ram (n = 60) or a ewe (n = 60) as described above and were laparoscoped 50, 60 or 70 h after pessary withdrawal (n = 20 at each time interval). In the third experiment ewes (n = 90) were induced and exposed to the ram (n = 45) or an adult ewe (n = 45) and inseminated via a laparoscope whit frozen-thawed semen at 50 or 60 h after pessary removal, respectively. Exposure to the ram was followed in 2 h by a marked rise in LH, equivalent to a preovulatory surge in duration and amplitude. It was also followed by concentrated ovulation within 25 to 30 h and by an increased pregnancy rate in exposed ewes (73.3 vs. 53.3%).

Anestrus↗
PubMed2005

Cardiotocographic abnormalities associated with dinoprostone and misoprostol cervical ripening.

OBJECTIVE: To characterize the frequency and timing of cardiotocographic abnormalities associated with the use of 3 commercially available prostaglandin analogues, misoprostol, dinoprostone gel, and dinoprostone pessary, as labor preinduction agents. METHODS: One-hundred and eleven women undergoing induction of labor with an unfavorable cervix were randomized to receive either misoprostol 50 microg every 6 hours x 2 doses, dinoprostone gel 0.5 mg every 6 hours x 2 doses, or dinoprostone pessary 10 mg x 1 dose for 12 hours intravaginally. Oxytocin induction was initiated per standardized protocol. Cardiotocographic tracings were blindly reviewed, with abnormalities coded using established definitions. RESULTS: Fifty-five percent of women treated with misoprostol demonstrated an abnormal tracing event within the initial 24 hours of induction, compared with 21.1% with dinoprostone pessary and 31.4% with the dinoprostone gel. The mean (+/- standard deviation) number of abnormal events was significantly greater in women treated with misoprostol (5.0 +/- 5.9) versus the dinoprostone pessary (1.6 +/- 2.5) and gel (2.2 +/- 3.1) (P < .05). In addition, these events occurred earlier after initial misoprostol dosing (5.0 +/- 4.0 hours), compared with the dinoprostone pessary (9.4 +/- 5.6 hours) and gel (7.7 +/- 6.6). Thirty-nine percent of the misoprostol-treated women had abnormal patterns within 6 hours of initial dosing, compared with those treated with the dinoprostone pessary (7.9%) and gel (17.1%). CONCLUSION: Cardiotocographic abnormalities are more frequent after misoprostol administration compared with the dinoprostone analogues. The early onset and frequent nature of the tracing abnormalities associated with misoprostol raises concern for the potential use of misoprostol for outpatient cervical ripening.

Adult↗
PubMed1988

Early pregnancy termination: a comparison between vacuum aspiration and medical abortion using prostaglandin (16,16 dimethyl-trans-delta 2-PGE1 methyl ester) or the antiprogestogen RU 486.

Three different regimens for termination of early pregnancy by medical means were compared to vacuum aspiration. Women seeking therapeutic abortion of pregnancy (less than or equal to 56 days amenorrhoea) were allocated to one of four treatment groups: (1) vacuum aspiration (n = 28); (2) 1 mg vaginal pessary of a prostaglandin analogue (gemeprost) every 3 h for up to 5 pessaries (n = 30); (3) the antigestogen (RU 486--mefipristone) 150 mg per day for 4 days by mouth (n = 20); (4) RU 486 in the same dose as group 3 together with 1 mg gemeprost on day 3 (n = 19). Complete abortion occurred more often in women treated with vacuum aspiration (96%), gemeprost alone (97%) and RU 486 plus gemeprost (95%) than in those treated with RU 486 alone (60%). In women receiving up to five gemeprost pessaries alone vomiting occurred in 7 (23%) and diarrhoea in 10 (33%); 16 (53%) required parenteral opiates for relief of pain. Side-effects and analgesic requirements were much reduced in the women who received RU 486 alone or in combination with a single gemeprost pessary. There was no difference in the number of days of vaginal bleeding after abortion between the four groups although there was wide individual variation (mean 10 days, range 1-34). These results confirm that medical induction of abortion in early pregnancy with prostaglandin vaginal pessaries is as effective as vacuum aspiration and that the dose can be reduced five-fold without loss of efficacy when used in combination with RU 486.

Abortion, Therapeutic↗
PubMed1999

Prediction of cervical response to prostaglandin E2 using fetal fibronectin.

BACKGROUND: To determine whether presence of fetal fibronectin in cervico-vaginal secretions at term will predict the cervical response to prostaglandin E2 (PGE2) pessaries and successful induction of labor amongst subjects with unfavorable cervices. METHODS: Cervico-vaginal secretion was tested for the presence of fetal fibronectin prior to cervical ripening with PGE2 pessaries in women with a singleton term or post-term pregnancy undergoing induction of labor. The total number of PGE2 pessaries, interval from induction to labor and induction to delivery, latent phase and active phase of labor and cesarean section rate were compared. RESULTS: Women with fetal fibronectin in their cervico-vaginal secretion had better cervical response to PGE2 pessaries and required fewer doses for induction of labor and they took a shorter time interval from induction to delivery. They tend to have a lower cesarean section rate but the figures did not reach statistical significance. CONCLUSIONS: The presence of fetal fibronectin from cervico-vaginal secretions in subjects with a Bishop score <5 is predictive of a favorable response to induction by prostaglandin pessary

Adult↗
PubMed1982

Induction of estrus and superovulation in seasonally anestrous ewes.

The induction of estrus in 17 previously cycling nulliparous ewes, 9 to 10 months of age, was attempted with Medroxyprogesterone acetate (MAP) pessaries during the early anestrous period (March-April). Ewes were verified to be anestrous by the lack of estrous behavior in the presence of a vasectomized ram and by a radioimmunoassay for serum progesterone in two samples taken 7 days apart showing less than 1 ng/ml serum progesterone. Superovulation was attempted with injections of either FSH or FSH + LH. MAP vaginal pessaries remained in place for a period of 12 days and FSH was administered to all ewes (IM) at 12 hr intervals over a 3 day period; 5 mg was injected twice on day 11 after pessary insertion, followed by 4 and 3 mg injections twice daily on each succeeding day, for a total of 24 mg per ewe. Nine ewes were given 25 mg LH (IV) within 8 hrs after the onset of behavioral estrus in addition to FSH. Ewes were hand-mated to several rams at 12 hr intervals throughout the estrus period. Ovulation and fertilization rates were recorded for each ewe following midline laparotomy and embryo collection. All ewes were in estrus between 36 and 48 hrs after removal of the MAP pessaries. In ewes injected with FSH only, 8 of 8 ovulated with a mean ovulation rate of 6.0 +/- 4.4 and a fertilization rate of 70%. Nine of 9 ewes receiving both FSH + LH ovulated with a mean ovulation rate of 13.9 +/- 13.1 and a fertilization rate of 72%. Statistical analysis by Students t-test resulted in differences in number of ova recovered (P<.05) between FSH only and FSH + LH treated ewes and a trend towards increased ovulation rate in FSH + LH treated ewes. These results show that early seasonally anestrous ewes can be successfully induced and synchronized for estrus with MAP pessaries and the number of ova recovered is increased with the inclusion of LH in the superovulation regime.

Journal Article↗
PubMed2000

[Laparoscopic treatment of symptomatic uterine retroversion].

STUDY AIM: The aim of this retrospective study was to demonstrate the feasibility of laparoscopic Jamain-Letessier procedure and to report its results. PATIENTS AND METHODS: Between August 1993 and September 1997, 19 patients (mean age: 29.7 years, range: 20-39 years) with painful uterine retroversion were operated on according to a laparoscopic Jamain-Letessier procedure. A preoperative pessary test was performed in 15 patients. The procedure included suture of the uterosacral ligaments to the midline and resection of the pouch of Douglas, followed by peritoneal suture. RESULTS: The pessary test was positive in 14 of the 15 patients. Mean operating time was 2 hours. There was no conversion to laparotomy. Postoperative urinary tract infection was observed in 3 cases. Mean postoperative hospital stay was 2.5 days. With a mean 3-year follow-up, 15 patients were completely pain-free and 2 patients were partially pain-free. The 14 patients with a positive pessary test obtained a good result. CONCLUSION: The pessary test is necessary for selection of patients. The Jalmain-Letessier procedure is easily performed laparoscopically and is associated with a low morbidity. With a mean 3-year follow-up, good results were obtained in 17 out of 19 patients (89%) and all patients with a positive pessary test obtained a good result.

Adult↗
PubMed2002

Embryo survival and recipient pregnancy rates after transfer of fresh or vitrified, in vivo or in vitro produced ovine blastocysts.

The aim of this study was to assess the effect of production system and of cryopreservation of ovine embryos on their viability when transferred to recipients. The experimental design was an unbalanced 2 x 2 factorial design of two embryo production systems (in vivo versus in vitro) and two embryo preservation conditions prior to transfer (transferred fresh versus transferred after vitrification/warming). For the production of blastocysts in vivo, crossbred donor ewes (n=30) were synchronised using a 13-day intravaginal progestagen pessary. Ewes received 1500 IU equine chorionic gonadotropin (eCG) 2 days before pessary withdrawal, and were mated 2 days after pessary withdrawal and embryos were recovered surgically (6 days after mating). Blastocysts were produced in vitro (IVP) using standard techniques. Recipients (n=95) were synchronised using a progestagen pessary and received 500 IU eCG at pessary removal and were randomly assigned to receive (two per recipient) in vivo fresh (n=10), in vivo vitrified (n=10), in vitro fresh (n=35) or in vitro vitrified (n=40) blastocysts. Recipients were slaughtered at day 42 of gestation and foetuses recovered. Pregnancy and embryo survival rates were recorded and analysed using CATMOD procedures. Foetal weights and crown-rump lengths were recorded and analysed using generalised linear model (GLM) procedures. There were no statistically significant interactions between the effects of embryo production system and preservation status at transfer on pregnancy rate and embryo survival. The pregnancy rate following transfer of fresh IVP blastocysts was lower (P<0.07) than that of in vivo embryos (54.3% versus 90.0%, respectively). Vitrification resulted in a decrease in pregnancy rate, the effect being more pronounced in the case of IVP embryos (54.3-5.0%, P<0.001) compared with in vivo embryos (90.0-50.0%), although the absolute change was similar (49.3% versus 40.0%). Transfer of fresh IVP blastocysts resulted in a higher proportion of single (78.9% versus 33.3%) and lower proportion of twin (21.1% versus 66.7%) pregnancies than those produced in vivo. This was reflected in a significant difference in embryo survival rate (fresh: 32.8% versus 75.0%, P<0.01; vitrified: 2.5% versus 35.0%, P<0.001, for IVP and in vivo blastocysts, respectively). Similarly, all pregnancies resulting from the transfer of vitrified/warmed IVP blastocysts were single pregnancies, while 40% of those from vitrified/warmed in vivo blastocysts were twin pregnancies; this was reflected in an embryo survival rate of 35.0% versus 75.0%, respectively. There was a significant effect (P=0.0184) of litter size on foetal weight but not on foetal length (P=0.3304). Foetuses derived from the fresh transfer of IVP blastocysts were heavier (6.4+/-0.2g versus 5.8+/-0.2g, respectively, P<0.05) and longer (5.2+/-0.1cm versus 4.8+/-0.1cm, respectively, P<0.01) than those derived from fresh in vivo blastocysts. There was no difference in these parameters as a consequence of vitrification of IVP embryos. However, in vivo blastocysts subjected to vitrification resulted in heavier (6.6+/-0.3g versus 5.8+/-0.2g, respectively, P=0.055) and longer (5.2+/-0.1cm versus 4.8+/-0.1cm, respectively, P<0.05) foetuses than their counterparts transferred fresh.

Animals↗
PubMed2001

Induction of labour: a comparison of two methods with particular concern to patient acceptability.

Induction of labour is a common obstetric intervention. When the cervix is unfavourable ripening agents are used, commonly prostaglandin E2. There are several methods of administration of prostaglandin E2 and little comparative work has been performed as to their acceptability by patients. Patients undergoing induction of labour by prostaglandin E2 were randomised to receive either intravaginal gel or an intravaginal slow-release pessary. Patient satisfaction with the method received was then assessed. Sixty-nine patients were randomised, 34 to receive gel and 35 to receive a pessary. Median scores for satisfaction of the induction process were the same for both methods; however, satisfaction with the labour was increased with those who had been randomised to the pessary group (median pessary=5, gel=4). There may be a marginal improvement in patient satisfaction when a slow-release intravaginal prostaglandin E2 pessary is used for the induction of labour.

Journal Article↗
PubMed1988

Recurrent vaginal candidosis: prospective study of effectiveness of maintenance miconazole treatment.

In a prospective study, 100 women with recurrent vaginal candidosis were treated with miconazole, using two 100 mg vaginal pessaries a day for one week, then one pessary twice a week for three months followed by one pessary a week for a further three months. Fifty four women elected to continue using one pessary a week for longer than six months. Symptomatic vaginal candidosis did not occur in any patient during regular maintenance treatment. Of the 46 women who discontinued treatment before six months, however, 22 had a recurrence. Maintenance prophylactic treatment with miconazole pessaries appears to be an acceptable and effective method of preventing recurrent episodes of vaginal candidosis.

Adolescent↗