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The wide variety of available pessaries permits rather precise choice of pessary to meet a given patient's needs. Different approaches are reviewed. A paradigm for choosing a surgical repair based on the fascial and muscular support defects, as well as the functional demands and limitations of the patient is presented.
The objective of this work was to study the abortifacient effects of misoprostol, an orally active prostaglandin E1 (PGE1) analogue, in the second trimester. A randomized study of two prostaglandin regimens in women pre-treated with the antiprogesterone mifepristone was carried out in the gynaecological wards of Aberdeen Royal Hospitals, NHS Trust, and included 60 women at 13-20 weeks' gestation, in whom termination of pregnancy had been agreed. Following pre-treatment with mifepristone 600 mg women were randomly allocated to one of two prostaglandin regimens which started 36-48 h later. The first misoprostol 400 micrograms orally (up to three doses) followed by gemeprost vaginal pessary 1 mg up to two doses. The second was gemeprost vaginal pessary 1 mg up to five doses. The main outcome measures were success rate induction-to-abortion interval and side-effects. There were no significant differences between the two groups in any of the main outcome measures. We conclude that misoprostol is a stable, cheap PGE1 analogue with demonstrable efficacy and acceptable side-effects in the management of second trimester abortion. Further work is needed to establish the optimum dose and regimen.
OBJECTIVE: To compare the effectiveness of 200 mg mifepristone with 1 mg gemeprost vaginal pessary in achieving cervical dilatation and softening ('priming') before late first trimester pregnancy vacuum aspiration. DESIGN: A randomized, operator blind, placebo controlled trial. SETTING: UK teaching hospital. SUBJECTS: 90 primigravid women with 63-91 days amenorrhoea and ultrasonically confirmed single living fetus of correct size for gestational age. INTERVENTIONS: The women were allocated to receive 200 mg mifepristone orally or an identical oral placebo 36 h before operation or 1 mg gemeprost vaginal pessary 3-4 h preoperatively. MAIN OUTCOME MEASURES: Onset of new symptoms following drug administration, a proven objective measure of the force required to dilate the cervix, and estimated intraoperative blood loss. RESULTS: There were no significant differences in the baseline cervical dilatation, the force required to dilate the cervix or the volume of intraoperative blood loss between the active treatment groups. Both drugs were significantly more effective than placebo. Significantly fewer women in the mifepristone group had adverse side effects than in the gemeprost group. CONCLUSIONS: Mifepristone is a highly effective cervical priming agent, and has the advantages of being an oral preparation associated with few side effects.
OBJECTIVE: To determine the efficacy of a new regimen of the antiprogestogen mifepristone and gemeprost for midtrimester abortion. DESIGN: Prospective study. SETTING: Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh. SUBJECTS: One hundred women undergoing midtrimester abortion. INTERVENTIONS: Women were pretreated with 200 mg mifepristone 36 h before prostaglandin; 1 mg gemeprost was administered every 6 h for the first 24 h. If abortion had not occurred, 1 mg gemeprost was administered 3 hourly over the next 12 h. MEASUREMENT AND MAIN RESULTS: Ninety-six percent and 99% women aborted within 24 h and 48 h, respectively. The median prostaglandin-abortion interval was significantly shorter in multigravidae compared to primigravida (6.6 vs 8.2 h, P < 0.01). The median number of gemeprost pessaries to induce abortion was only two and 47% of women required one pessary. The incidence of vomiting and diarrhoea was 31% and 5%, respectively. Eighty-four percent of women required intramuscular diamorphine for analgesia. Thirty-three percent of women required an evacuation of the uterus following abortion. CONCLUSIONS: The shortened induction-delivery interval following pretreatment with mifepristone makes it possible to conduct midtrimester abortion on a daycare basis.
Prostaglandins have been increasingly used in obstetrical practice for cervical ripening and induction of labour. We set out to investigate the effectiveness of prostaglandin E2 (PGE2) vaginal pessaries in inducing labour in the Chinese population in Hong Kong. In the period August, 1991 to August, 1992, we recruited 206 pregnant Chinese women who required induction of labour for various obstetrical indications into the trial. The study group had induction of labour by PGE2 vaginal pessaries and the control group underwent amniotomy plus oxytocin infusion. These patients were alternately assigned either method of induction. They were further divided into primiparous and multiparous (parity 1 and 2 only) groups. Only 101 primiparas and 99 multiparas were available in the final analysis of the trial. Various aspects of labour, delivery, maternal and fetal outcome were compared. For primiparas, the traditional combined induction was the preferred method. For multiparas, both induction methods were quite satisfactory and there was a trend toward lesser blood loss and pethidine requirement in the PGE2 users.
OBJECTIVES: To compare the abortifacient efficacy and side effects of three doses of the antiprogestin mifepristone plus prostaglandin for termination of early pregnancy. DESIGN: Randomised, double blind multicentre trial. SETTING: 11 departments of obstetrics and gynaecology and of family planning, mostly in university hospitals, in seven countries. SUBJECTS: 1182 women with an early pregnancy (menstrual delay of 7-28 days) requesting abortion. INTERVENTIONS: Single doses of 200 mg, 400 mg, or 600 mg mifepristone followed, 48 hours later, by vaginal pessary of 1 mg of the prostaglandin E1 analogue gemeprost. MAIN OUTCOME MEASURES: Outcome of treatment; duration and subjective amount of menstrual bleeding; side effects and complications; and concentrations of haemoglobin. RESULTS: Outcome was similar with the three doses of mifepristone. Of the 1151 women with known outcome, 95.5% had a complete abortion (364 (93.8%) of those given 200 mg mifepristone, 368 (94.1%) of those given 400 mg, and 367 (94.3%) of those given 600 mg), 3.7% had an incomplete abortion (14 (3.6%), 15 (3.8%), and 14 (3.6%)), 0.3% had a missed abortion (three (0.8%), one (0.3%), and none), and 0.4% had a continuing live pregnancy (two (0.5%), two (0.5%), and one (0.3%)). Of the 43 women who had incomplete abortion, 23 underwent emergency uterine curettage (usually for haemostatic purposes) and three of these women were given a blood transfusion. The numbers of reported complaints, bleeding patterns, and changes in blood pressure and haemoglobin concentrations were similar with the three treatments. CONCLUSIONS: For termination of early pregnancy a single dose of 200 mg mifepristone is as effective as the currently recommended dose of 600 mg when used in combination with a vaginal pessary of 1 mg gemeprost.
A total of 273 Herford cross heifers were treated with intravaginal progestagen pessaries to determine some of the factors affecting oestrous response and fertility following long-term (20-day) and short-term (10-day) treatments. Oestrous response and degree of synchronization were high after treatment for 20 days, but the fertility rate was lower than that of control heifers. There was no difference in the fertility of heifers inseminated artificially and those mated naturally. When the treatment period was reduced to 10 days and 900 mg progesterone and 5 mg oestradiol valerate given intramuscularly at the start, a high oestrous response and a low degree of synchronization resulted, but the conception rate was similar to that of the control animals. Reducing the dose of progesterone to 250 mg resulted in a high oestrous response and a high degree of synchronization. The stage of the cycle at the start of the 10-day treatment did not affect the oestrous response. Retention of the progesterone pessary was low (79-9%) in heifers treated for 2- days, but was 100% in those treated for 10 days.
Estrous cycles of adult (n = 27), farm-flock, Suffolk ewes and Polypay range ewes (n = 224) were controlled with medroxyprogesterone acetate (MAP)-impregnated vaginal pessaries inserted (d 0) for 7 d in combination with prostaglandin F2 alpha (PGF2 alpha) injected on d 6. Descriptive criteria of the effects of this treatment regimen on endocrine characteristics of the estrous cycle were evaluated in the experiment with farm-flock ewes. The efficacy of this synchronization regimen on reproductive performance of range-bred ewes was tested in a second trial. Suffolk ewes bred at the second observed estrus after treatment to provide comparisons of cycle length between treated and control ewes. Polypay ewes were exposed to fertile rams at the controlled estrus. Eighty-nine percent of Suffolk ewes were in estrus within 3 d after pessary removal. All nonsynchronized Suffolk ewes (n = 24) were in estrus over a 21-d period. Estrous cycle lengths of treated ewes averaged 16.8 +/- .2 d. Plasma progesterone concentrations were similar for treated and control ewes during the luteal phase of the estrous cycle. Ninety-one percent of the range-bred, controlled ewes lambed. Sixty-two percent of these ewes lambed within 150 d after exposure to fertile rams compared with only 17% of nonsynchronized ewes (P less than .05). Lambing percentage was similar by 167 d for treated (87%) or control (88%) ewes. Lambs per ewe exposed averaged 1.68 and 1.80 for treated and nonsynchronized groups, respectively. These data indicate the effectiveness of this 7-d treatment method for control of the estrous cycle of ewes during the normal breeding season. Results further show that this treatment scheme has practical application for range breeding of ewes.
BACKGROUND: Earlier controlled clinical trials have demonstrated that combined treatment with the antiprogestagen, mifepristone and a suitable prostaglandin reduce the induction to abortion time in second trimester abortion. The aim of this study was to describe the results of the 197 consecutive second trimester terminations performed in routine clinical practice at our Department from 1996 to 1998. METHODS: The report is based on 197 consecutive second trimester abortions including live pregnancies and missed abortions, carried out in 192 women. The women were treated with 600 mg mifepristone followed 24 to 48 hours later by 1 mg gemeprost administered every 6 hours four times. If abortion had not occurred, 1 mg gemeprost was administered every 3 hours for the next 12 hours. After expulsion of the fetus a surgical evacuation of the uterus was routinely performed up to 18 weeks gestation and thereafter when needed. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and expulsion of the fetus. RESULTS: The median abortion time was 9.0 (1.4-40.5) hours for primigravidae and 7.2 (0-152.5) hours for multigravidae. The medium number of gemeprost pessaries to induce abortion was two and all except seven women aborted within 24 hours. Significantly more abortions occurred before 6, 7 and 8 hours in multigravidae than among primigravidae. The induction to abortion interval was also significantly shorter for nulliparous than for parous women. Except for one case of heavy bleeding, no serious complications occurred. CONCLUSION: The study confirms the efficacy and safety of mifepristone, together with gemeprost, for termination of second trimester pregnancy when routinely used in the clinic.
A prospective, randomized, single-blind study addressed the hypothesis that simple mechanical barriers are helpful in controlling urinary incontinence during exercise. Eighteen incontinent exercisers aged 33-73 participated in three 40-minute standardized aerobics sessions wearing either a Hodge pessary with support, a super tampon or no mechanical device. Urine loss was determined by a change in the weight of the pad worn while exercising. Statistical analysis of the log of urine loss revealed that women lost significantly less urine when exercising with either the pessary or the tampon than when exercising with no device. Thus, both devices studied are useful, nonsurgical alternatives for some women for the treatment of exercise incontinence.
BACKGROUND: Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. OBJECTIVES: To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except Misoprostol). SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled trials register and bibliographies of relevant papers. Last searched: November 2000. SELECTION CRITERIA: The criteria for inclusion included the following: (1) clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data was then extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. To avoid duplication of data in the primary reviews, the labour induction methods were listed in a specific order, from one to 23. Each primary review included comparisons between one of the methods (from two to 23) with only those methods above it on the list. MAIN RESULTS: In total, 94 studies were considered; 42 have been excluded and 52 included examining a total of 9402 women. Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18% vs. 99%, RR 0.19, 95% CI 0.14,0.25), the caesarean section rates were not different between groups although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.6% vs. 0.51%, RR 4.14, 95% CI 1.93, 8.90). Comparison of vaginal prostaglandin F2a with placebo showed no increase in caesarean section rates but the cervical score was more likely to be improved (15% vs. 60%, RR 0.25, 95% CI 0.13,0.49), and the risk of oxytocin augmentation reduced (53.9% vs. 89.1%, RR 0.60, 95% CI 0.43,0.84) with the use of vaginal PGF2a. There were insufficient data to make meaningful conclusions for the comparison of vaginal PGE2 and PGF2a. PGE2 tablet, gel and pessary appear to be as efficacious as each other. Lower dose regimes, as defined in the review, appear as efficacious as higher dose regimes. REVIEWER'S CONCLUSIONS: The primary aim of this review was to examine the efficacy of vaginal prostaglandin E2 and F2a. This is reflected by an increase in successful vaginal delivery rates in 24 hours, no increase in operative delivery rates and significant improvements in cervical favourability within 24-48 hours. Further research is needed to quantify the cost-analysis of induction of labour with vaginal prostaglandins, with special attention to different methods of administration.
ONO-802, a synthetic E1 prostaglandin, was administered intravaginally via pessaries to Dutch belted rabbits at doses of 250, 62.5, and 12.5 micrograms/kg on days 6 through 18 of gestation. Rabbits in a vehicle control group were treated with pessaries that did not contain ONO-802 during the same period. Another group of animals remained untreated throughout gestation. Necropsies were performed on rabbits found dead and on those killed on gestation day 30. Body weight, food and water consumption, and clinical signs were monitored during the experiment. Major organs were weighed when the dams were necropsied on gestation day 30, and litter and fetal data were collected. Abortion and maternal deaths occurred in drug-treated groups. Body weight gains and food and water consumption were adversely affected by treatment particularly at the 250 and 12.5 micrograms/kg dose levels. Wastage (postimplantation loss) was significantly increased among treated groups (all dose levels), while other litter and fetal parameters were unaffected. ONO-802 was not teratogenic at maternal and embryotoxic dose levels.
Management of vault prolapse in a patient who has previously undergone successful colposuspension has not been considered in the literature. The two cases presented highlight the risk of incontinence and illustrate measures that should help to reduce it. The approach aims to reveal potential stress incontinence and to prevent excessive stretching of the upper anterior vaginal wall during surgical correction. Potential stress incontinence is revealed by a cough stress test while reducing the prolapse without a speculum, a 'pessary test' for a few days, and urodynamics both with and without a pessary. Patients with potential incontinence undergo perineal ultrasound to assess bladder neck position. If sacrospinous fixation is used, epidural anesthesia is recommended so as to allow the patient to cough during the procedure to ensure accurate suture placement. When sacrocolpopexy is done, preoperative assessment of the degree of 'safe elevation' ensures accurate suture placement.
BACKGROUND: One of the etiologies of pelvic pain in women, often unrecognized, is the Masters-Allen syndrome, which was described in 1955 as the "universal joint cervix" syndrome. It has the following three elements: (1) etiology: obstetrics-related trauma; (2) clinical findings: uterine retroversion with hypermobile cervix following elongation or desinsertion of the uterosacral ligaments; (3) anatomy: visualization of a tearing of the posterior serosa and subperitoneal fascia of the ligamentum latum. METHODS: Forty-one laparoscopic Douglasectomies with uterosacral ligamentopexy were performed in the department of Gynecology at the University Hospital of Caen during the period between 1990 and 1995 in patients with painful retroverted uterus. The patient selection was made thanks to the "pessary test." The surgical endoscopic procedure, identical to the operation first promoted by Jamain and Letessier in 1976 by laparotomy, is described. RESULTS: Total pain relief was experienced by 31 patients (75%) and partial relief by five patients (5%). Two main complications occurred, requiring one laparotomy (bleeding from a pelvic varicose vein with a concomitantly occurring breakdown of the washing-aspiration system) and one second laparoscopy at day 15 (one case of hematoma below the peritonization revealed by pain). Twenty-three women became pregnant again, and had normal deliveries except for two cesareans, with no recurrence of pain. Douglasectomy is compared to alternative techniques in the literature. Other indications for Douglasectomy are discussed. CONCLUSION: Douglasectomy is the only definitive procedure for restoring normal anatomy of the pelvic floor in case of painful uterine retroversion occurring in a setting of Masters-Allen syndrome. Additionally, it provides for pathological analysis of the excised peritoneum. The results of this procedure are excellent when the indication is correctly set, particularly as concerns positive pessary testing.
A total of 67 female patients with pelvic relaxation (cystocele beyond the vaginal orifice) and with no urinary incontinence were clinically and urodynamically evaluated before and after a reconstructive surgical procedure. Of these, 24 patients had a significant decrease in abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of less than 1.0). All 24 had a revised Pereyra procedure in addition to the cystocele repair. The other 43 patients had adequate abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of greater than or equal to 1.0). These 43 patients underwent cystocele repair only with no surgical repair to the urethra or urethrovesical junction. Evaluation was repeated at 3 to 6 months after the operation. No patient developed urinary incontinence after operation. All 67 patients had urodynamically good abdominal pressure transmission to the urethra while coughing. Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence so that prophylactic measures can be undertaken.
Twenty-five 2-3-year-old cycling does weighing 17-25 kg were obtained from semi-nomadic farmers and managed under controlled conditions while simulating the traditional management system. Oestrus was synchronized using progestogen impregnated vaginal pessaries. Blood samples were collected daily for progesterone assay from the day of pessary withdrawal up to one complete oestrous cycle. Oestrus was checked twice daily using vasectomized bucks. Ovulation rate was determined by direct observation of the ovaries following laparotomy on day 5-7 of the oestrous cycle. Following oestrus synchronization, mean ovulation rate was 1.68 +/- 0.13. Mean oestrous cycle length and duration of oestrus were 21.30 +/- 0.28 days and 21.37 +/- 0.24 hours respectively. Plasma progesterone concentrations ranged from non-detectable levels on the day of oestrus to 5.2 +/- 0.28 ng ml at mid-cycle. The duration of elevated progesterone level (greater than 2 ng/ml) was about 12 days. The peak progesterone values did not differ between animals with different ovulation rates. However, the plasma progesterone concentration during the early cycle (days 0-6) was significantly lower in the single ovulators compared with others. There were no major differences in plasma progesterone levels during the oestrous cycle of Red Sokoto does with different ovulation rates.
Two experiments were conducted to evaluate the efficacy of a 3-mg ear implant of norgestomet, left in situ for 10 days, in conjunction with a single injection of 1.5 mg norgestomet and 0.5 mg estradiol valerate (EV) for controlling fertile estrus in the ewe. This treatment regime was compared with a 20-mg cronolone impregnated, intravaginal sponge left in situ for 14 days (Experiment 1) and a modification of the cronolone-sponge-treatment to include a single injection of 1.5 mg norgestomet and 0.5 mg EV (Experiment 2). The percentage of ewes synchronized was not significantly affected by progestin treatment (Experiment 1-cronolone pessary alone, 96%; norgestomet implant and injection of norgestomet and EV, 92%; Experiment 2-cronolone pessary + injection of norgestomet and EV, 84%; Norgestomet implant + injection of norgestomet and EV, 96%). In Experiment 1, the first service pregnancy rate (pregnant of ewes mated) of 80% for cronolone-treated ewes was significantly higher than the 59% observed in norgestomet-treated ewes (P<.05). In Experiment 2, no significant differences were observed in pregnancy rates between the two treatment groups (Cronolone, 57%; Norgestomet, 65%).
In a study of the time of ovulation following synchronization of estrus in the ewe, the effect of time of treatment with GnRH (24 vs 36 h after pessary removal) and dosage (6.25 to 100 ug per ewe) were examined. All treatments synchronized the time of ovulation irrespective of when untreated ewes commenced to ovulate. As part of an evaluation of GnRH treatment in artificial insemination programs, an assessment was made of the quality of eggs obtained from control ewes and ewes treated with GnRH at either 24 or 36 h after pessary removal. Treatment at 24 h increased the number of retarded embryos (P < 0.01) and unfertilized ova (P < 0.01) collected per ewe, reduced the number of embryos collected per ewe (P < 0.01), and reduced (P < 0.05) the percentage of pregnant ewes compared with other groups. However, there were no differences between control ewes and ewes treated with GnRH at 36 h. GnRH treatment at 36 h was consequently examined as a means of improving conception rates following the intrauterine insemination of frozen-thawed semen. Insemination of GnRH-treated ewes 8 to 12 h before the median time of ovulation resulted in a nonsignificant increase (range 5.7 to 7.3%) in the percentage of ewes of mature age which became pregnant. Insemination 0 to 4 h before the median time of ovulation resulted in a nonsignificant decrease in the percentage of pregnant ewes. GnRH treatment did not influence the number of fetuses per ewe. Reasons for the failure of this treatment to significantly improve ewe fertility are discussed.