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Vaginal pessaries are widely considered to be a safe alternative to surgery in older women. We report a case of near fatal septicaemia in a 75-year-old woman associated with a shelf pessary, the presence of which was identified during an exploratory laparotomy. This case highlights the importance of the gynaecological history and examination when assessing older women with septicaemia of unknown source.
BACKGROUND: The course of second-trimester abortions with the intention to use gemeprost as the only abortifacient is described. METHODS: The report is based on 278 consecutive second-trimester abortions, excluding missed abortions, during a 12-year period in a tertiary referral center. The women were treated with 1 mg gemeprost pessaries every fourth hour with a maximum of five applications during 24 h. If abortion had not occurred, a new treatment of gemeprost was prescribed after an interval of 12 h. RESULTS: The median number of gemeprost pessaries used was 4 (range 1-16) and the mean number (+/-SD) 4.09 (+/-1.90). Abortion occurred within 24 h in 78% of the women and within 48 h in 96%. The efficiency of gemeprost was highly dependent on previous vaginal deliveries (p<0.001), with a mean number of applications of 4.63 (+/-2.04), 3.93 (+/-1.74), and 3.13 (+/-1.26) in those with none, one, and two or more previous vaginal deliveries, respectively. Previous spontaneous abortions were associated with a lower number of applications. Including previous vaginal deliveries and spontaneous abortions in a two-way analysis of variance (anova), only the number of spontaneous abortions was marginally significant (p=0.05). After excluding four patients with three or more spontaneous abortions from the analysis, the number of previous vaginal deliveries was significant (p=0.010) whereas that of spontaneous abortions became nonsignificant. Postprocedure complications were reported in 13% of the women. CONCLUSION: The course of the abortions was dependent on previous vaginal deliveries and spontaneous abortions.
Experience with the use of Gemeprost pessaries (prostaglandin E1 analogue), in a group of 60 consecutive patients for second trimester termination in a Scottish District General Hospital, is presented. Gestation ranged from 12 to 20 weeks; there were 29 nulliparous (48%) and 31 (52%) multiparous women. Fifty-seven (95%) aborted within 36 hours; 29 (48%) aborted completely and did not require further uterine curettage. Nulliparous patients required more pessaries and the abortion was more often incomplete. Side effects were minimal. There were no serious problems; and antiemetics were required by 17% and parenteral analgesics by 13% of patients.
The frequency of clinical infection of the vaginal vault after hysterectomy was compared in two groups of patients, a study group treated with povidone-iodine vaginal pessaries for 36 hours pre-operatively and prepared with povidone-iodine preparations at the time of operation, and a control group given no preliminary treatment and prepared with chlorhexidine preparations at the time of operation. No significant difference was demonstrated between the two groups. Vault infection occurred in 32% of the entire series of patients (severe infection 14%) and infection correlated with the presence of pathogenic bacteria in the vagina. No significant differences in bacterial colonisation of the vagina between the two groups were demonstrated at any stage of the investigation. Preliminary preparation of the vagina with povidone-iodine pessaries is not recommended.
Using a double blind administration protocol, the effect on the cervix of prostaglandin E2 (PGE2) vaginal pessaries inserted one to six hours before aspiration termination of pregnancy has been assessed. Pessaries containing 10 mg of PGE2 produced significant cervical softening and dilatation compared with those containing only 5 mg of PGE2 or placebo, the effect was almost as good as 15 mg of PGE2 but the lower dose caused fewer gastro-intestinal side-effects and uterine cramps. Blood loss at abortion and in the early post-abortal recovery period was significantly reduced following PGE2 treatment compared with placebo. The method described is simple and effective in reducing difficult cervical dilatation and is appropriate for day-care abortion management.
A pessary containing the prostaglandin analogue, 16,16-dimethyl-trans-delta 2 prostaglandin E1 methyl ester (Cervagem) was inserted into the vagina of primigravid women 2 h before suction termination of pregnancy. The cervix was softer, easier to dilate and more widely dilated at the start of the procedure than in a control group of women who received placebo pessaries containing the vehicle alone. Intra-operative blood loss was diminished. The incidence of pre- and post-operative abdominal cramps was increased in the Cervagem-treated group. No gastrointestinal side-effects were noted.
In a randomized, single-blind trial, 78 women having vaginal termination of pregnancy were treated with either a 1-mg gemeprost (Cervagem) pessary or a Lamicel tent inserted 3-4 h before operation. Both agents produced satisfactory cervical softening but dilatation was significantly easier after gemeprost. Pre-operative side-effects were more frequent after gemeprost but did not increase the need for analgesia. There were no differences between the two groups with regard to either postoperative symptoms and analgesic requirements or pre-operative and postoperative temperature, pulse rate and blood pressure. Gemeprost pessaries are easier, faster and less uncomfortable to administer.
OBJECTIVE: To compare the efficacy within 24 hours of a three-times-a-day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming. DESIGN: Randomised controlled trial. SETTING: Department of Obstetrics and Gynaecology, Singapore General Hospital. PARTICIPANTS: One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score < or = 5) requiring induction of labour. METHODS: Eligible women were randomly assigned the standard regimen (3000 microg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 microg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of > or = 6) or the onset of active labour occurred. MAIN OUTCOME MEASURES: Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval. RESULTS: Forty-nine women were assigned to the standard regimen and 51 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty-two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6.2, 95% CI 2.3-17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty-five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2.92, 95% CI 1.19-7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens. CONCLUSIONS: Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.
An extremely rare complication of cervical entrapment of a polythene ring pessary within an epithelial 'tunnel' of the cervix is reported. The pessary was removed by dividing a segment of it with bone cutting forceps.
The results of a study of 101 consecutive second trimester terminations by Dilatation and Evacuation (D & E) under ultrasound control is presented. All had a Cervagem pessary inserted into the vagina prior to the procedure. The PGE1 analogue was assessed as 'effective' in 97% of patients. Concomitant ultrasound resulted in no patient leaving the operating table with retained products. The high efficacy of the single pessary associated with a low incidence of side-effects makes this combination the method of choice for nearly all second trimester terminations.
The routine method of induction at Queen Charlotte's Maternity Hospital is now by the use of prostaglandin E2 pessaries. The first 502 consecutive patients thus induced are presented: the caesarean section rate for a failed induction with an unfavourable cervix has fallen to 2%. The prostaglandin E2 pessary is highly efficient and acceptable for all cases in which a simple amniotomy will not suffice.
Urinary incontinence and pelvic organ prolapse are common conditions affecting the elderly. A careful evaluation of urinary incontinence, including history and physical examination, will often determine the etiology of this condition. Vaginal pessaries are a safe and efective treatment for both urinary incontinence and pelvic organ prolapse. They should be considered a viable alternative to surgery especially in the elderly with complicated medical histories. This article reviews the etiology of urinary incontinence, offers a guide in the evaluation of the incontinent woman, and reviews the use of pessaries for the treatment of incontinence and pelvic organ prolapse.
A prospective randomized study of 267 pregnant women was undertaken to compare the efficacy of a pharmacy-prepared 3-mg prostaglandin E2 (PGE2) vaginal suppository with a 3-mg PGE2 vaginal tablet for induction of labor and cervical ripening. No statistically significant difference in success frequency was found between the two groups, either on the first day (72% and 74%, respectively; p greater than 0.05) or on the second day (89% in both groups). There was an equal proportion of women requiring oxytocin augmentation in the two groups, but the slower releasing properties of the vaginal tablet were reflected in a longer mean induction--delivery interval of about 4 h for this group. In both the pessary and the vaginal tablet groups, women who had not gone into labor on the first day showed a statistically significant increment in the Bishop score on the morning of the second day. The frequency of cesarean section was the same in both groups, but instrumental deliveries were more frequent in the vaginal tablet group. It is concluded that PGE2 vaginal tablets--a chemically stable alternative to pharmacy prepared pessaries--appear to be effective as regards cervical ripening as well as for labor induction.
An 81-year-old woman with a solitary left kidney presented with uraemia due to ureteric obstruction by a vaginal ring pessary. She made a complete recovery following removal of the pessary.
In a randomized, double-blind clinical trial from general practice, 500 mg metronidazole pessaries applied once daily for seven days were compared with placebo in the treatment of bacterial vaginosis. Seventy-five women completed the study. At the follow-up visit immediately after completion of treatment, none of the patients on metronidazole fulfilled the criteria for bacterial vaginosis, compared with 12 (35%) in the placebo group (p less than 0.001). Nine (22%) of the patients treated with metronidazole harboured Gardnerella vaginalis after treatments, compared with 31 (91%) in the placebo group (p less than 0.001). Symptoms had improved or disappeared in 33 (80%) on metronidazole, and in 18 (53%) on placebo therapy (p less than 0.05). Four weeks after the follow-up visit, symptoms were reported by 28% in the metronidazole group and by 44% in the placebo group (p greater than 0.05). Metronidazole pessaries are effective in the treatment of bacterial vaginosis.
OBJECTIVE: Determination of the efficacy and side-effects of the synthetic prostaglandin analog gemeprost for termination of pregnancy in the third trimester. PATIENTS: Retrospective record study of 40 women who had undergone third trimester termination of pregnancy before term by serial administration of gemeprost because of intrauterine fetal death or hopeless fetal prognosis. Patients with multiple pregnancy, a Bishop score > 5, contractions or contraindications to prostaglandins were excluded. METHODS: Gemeprost vaginal pessaries (1-mg) were given at 6-hourly intervals until labor intervened. The main parameter studied was the induction-delivery interval, the length of time between administration of the first dose and delivery. Statistical analysis was performed with the chi-square and the Mann-Whitney U-test. RESULTS: The median induction-delivery interval was 14.4 h (range 3-48 h). Delivery occurred within 12 h in 17 women (42.5%), within 24 h in 27 women (67.5%) and within 36 h in 37 women (92.5%). An average of 2.6 doses were given per patient. Multigravidae had a significantly shorter induction-delivery interval than primigravidae (p < 0.01). A total of 87.5% women required analgesia. Side-effects were infrequent. CONCLUSIONS: The administration of gemeprost vaginal pessaries represents an efficient method with few side-effects for the induction of labor in the third trimester, provided patients are chosen carefully and monitored closely.
The available literature between 1990 and 2004 was reviewed to determine if the nurse's role in the use of vaginal pessaries to treat pelvic organ prolapse and/or urinary incontinence is well defined. Forty-five articles were reviewed, including one written by a physician's assistant, two written by both a physician and a registered nurse, seven written by registered nurses, 34 written by physicians, and one unpublished manuscript. Nurses could make a valuable contribution to the bank of information available on the use of vaginal pessaries to treat stress urinary incontinence and pelvic organ prolapse.
A uterine pessary containing penicillin, streptomycin, formosulphathiazole and ethinyloestradiol, was assessed for its efficacy in reducing the frequency and severity of uterine infections in cows after parturition. Fifteen pluriparous Holstein Friesian cows had pessaries inserted into the uterus within 24 hours after calving. Compared with 14 similar untreated cows there were significant reductions in the number infected by Actinomyces pyogenes and in the number exhibiting abnormal uterine discharges.