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PubMed1989

Cesarean birth for failed progress in labor.

"Failure to progress" is the leading indication for primary cesarean section and has a major impact on the escalating cesarean birth rate in the United States. We investigated the labor and delivery records of nulliparous women at term with vertex presentations admitted to the clinic and private services of our hospital to determine the importance of different management strategies associated with operative deliveries. Birth weights and immediate neonatal outcome were identical between the clinic and private services. The cesarean birth rate on the clinic service was 5.2%, compared with 17.1% on the private service; 80% of the abdominal deliveries on the private service were for "failure to progress." Epidural use rates were similar on both services and were associated with a 70% incidence of oxytocin augmentation. Once oxytocin augmentation became part of labor management, a 14-fold increase in cesarean sections was observed for the private service, but oxytocin had no impact on the cesarean birth rate in the clinic service. The placement of an intrauterine pressure catheter and an approach to the use of oxytocin that might be characterized as "selective active management" were necessary to achieve efficient uterine action in a timely fashion, permitting a high likelihood of vaginal birth on the clinic service.

Anesthesia, Epidural↗
PubMed2000

Sexuality and cancer: conversation comfort zone.

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Psychosocial issues profoundly affect patients with cancer. Of the many complexities that make up the psychosocial dynamic, perhaps the medical profession is most uncomfortable with sexuality. Many elements of sexual behavior remain high-profile taboos. A number of diseases and treatments significantly affect sexual function. Male and female sexuality were discussed in two separate rounds with an emphasis on how to begin a dialogue about sexuality without jeopardizing other aspects of the relationship with patients. Three cases were presented. A patient with prostate cancer considering treatment options for early-stage disease and two patients with gynecologic malignancies; one with a colostomy following cytoreductive surgery for ovarian cancer and the other with a failed vaginal reconstruction for recurrent squamous cell carcinoma of the vagina. Staff discussed the wide diversity of response to sexual dysfunction and the difficulties that patients face. A sensitive and informed approach to discussing sexuality can provide effective support. The elements of successful dialogue are presented in the PLISSIT model.

Adult↗
PubMed1982

[CO2 laser coagulation of benign changes of the portio vaginalis in comparison with the endocoagulation technic (Semm's method)].

The CO2-COHERENT laser was therapeutically used by the authors on 31 cases of extensive erythroplakia associated with recurrent and therapy-resistant fluor formation and on cases of highly vascularised transformation zones with contact bleeding. The benign nature of the findings first had been established by repetitive Pap smears and thorough colposcopic examination. The authors suggest that for the time being the CO2 laser is not suitable yet for the treatment of dysplasia or carcinoma in situ, since no material for histological testing is obtainable from that therapeutic approach, and the presence of microcarcinoma with invasive growth cannot be ruled out with absolute safety. CO2 laser treatment was undertaken without hospitalisation of patients, just as endocoagulation of the vaginal portio was carried out on an outpatient basis. Postoperative follow-up checks have been made one, three, and six weeks as well as three and six months from treatment. The therapeutic results obtained from CO2 laser therapy were compared with those recorded from patients who had undergone endocoagulation of the vaginal portio, with the view to checking the advantages claimed for laser therapy in the literature [1, 4, 11, 12, 23, 24], such as no need for anaesthesia, effective destruction of much of the pathological tissue, high-accuracy identification of tissue for destruction by means of colposcopy, low rate of postoperative complications, soon healing, and good haemostatic action. All these advantages were found to be obtainable just as well from the technique of endocoagulation without the need for the great amount of technical input and equipment definitely required for laser therapy [16, 18, 19, 20, 21].

Adult↗
PubMed1994

Endoscopic assessment of the integrity of the postcesarean uterine wall before a trial of labor. Transcervical Endoscopy Registry.

Endoscopic examination of the uterine scar site was performed on 52 women prior to a trial of labor after a previous cesarean section. A sterilized intraoperative fiberscope was introduced into the amniotic cavity after rupture of the fetal membranes under constant visual guidance. In 45 cases the site of the previous incision appeared unremarkable, and a scar from the previous surgery could not be identified. "Compromised" scars were detected in three patients, and scars were identified as vertical in four patients with no record of the type of uterine incision used for the previous surgery. Endoscopic data were confirmed postpartum in all cases. This approach seems beneficial in selected cases.

Adult↗
PubMed1996

[Contribution of Doppler color ultrasonography to the screening and surveillance of ovarian hyperstimulation syndrome].

Color and power Doppler producing ovarian vascular mapping allows to realize a new functional approach of ovarian hyperstimulation syndrome (OHS); local vascular factors (ovarian angiogenesis, increase in cappillary permeability) released by hCG injection (LH effect) have in fact an important part in this syndrome. Vaginal Doppler sonography allows: -before induction, to predict potential risk of hyperstimulation: polycystic ovaries, spontaneous stromal hypervascularization; -in monitoring of ovulation stimulation, to reduce risk of multiple pregnancy and to detect early hyperstimulation, decision of hCG injection depends on number of follicles able to be fertilized (> 15 mm) and luteinized (> 10 mm); -to assess severity of OHS and search complications: ascites, hydrothorax, ovarian torsion and deep venous thrombosis. So OHS prevention imposes a monitoring by Doppler sonography and estradiol assay of all cycles induced by gonadotropins.

Female↗
PubMed1993

[Value in gynecology of transvaginal pulsed and color Doppler. Study of ovarian vascularization].

Recently, pulsed Doppler has become available on high resolution vaginal ultrasound probes for studying ovarian blood flow. Doppler studies of ovarian blood flow are based on: semiquantitative analysis of Doppler flow waves recorded over the ovarian artery at its entry into the ovary; color Doppler mapping of intraovarian vessels. Semiquantitative analysis of the ovarian artery Doppler flow waves suffers from frequent difficulties at properly identifying the ovarian artery, particularly in multiparous women. Mapping of intraovarian vessels however, appears a most promising feature of vaginal Doppler for studying ovarian blood flow, provided that the proper ultrasound equipment is used. Specifically, transvaginal color Doppler mapping of intraovarian vessels allows for a positive visual detection of the onset of the ovulatory process prior to the actual follicular rupture. Thus, color Doppler mapping of ovarian vessels permits an improved and simplified approach for timing intercourses and inseminations in infertility patients. In controlled ovarian hyperstimulation (COH) used for in vitro fertilization (IVF), mapping of intraovarian vessels by color Doppler offers a fascinating new insight into normal and pathological responses of ovarian follicles to hCG. Finely, color Doppler appears a very promising asset to transvaginal ultrasounds for sorting suspicious ovarian cysts from their benign counter parts. In conclusion, we think that vaginal Doppler should be considered as a marvelous refinement of ultrasounds rather than as a truly new diagnostic tool. Yet vaginal color Doppler carries the potential for markedly improving the sensitivity and the specificity of vaginal ultrasound, particularly for diagnosing benign from potentially malignant ovarian conditions.

Arteries↗
PubMed2000

Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases.

OBJECTIVE: To evaluate the surgical feasibility and the long-term anatomic and functional results of a new procedure that uses the endoscopic approach to treat uterovaginal agenesis, known as Rokintansky syndrome. DESIGN: Evaluation of surgical feasibility and recording of clinical data over a 12-month follow-up. SETTING: Tertiary referral center for the treatment of female genital malformations. PATIENT(S): Fifty-two patients with vaginal agenesis. INTERVENTION(S): The laparoscopic version of the Vecchietti method was used to create a neovagina. MAIN OUTCOME MEASURE(S): Anatomic success was defined as a neovagina >/=6 cm long, allowing easy introduction of two fingers, within 6 months after corrective surgery. Functional success was considered achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery. RESULT(S): The surgical procedure was performed with no major complications and with 100% anatomic success; functional success was obtained in 98.1% of the study population. CONCLUSION(S): In patients with Rokitansky syndrome, the laparoscopic approach for creating a neovagina by the Vecchietti method is simple, safe, and effective.

Adolescent↗
PubMed1982

Combined therapy as an alternative to exenteration for locally advanced vulvo-vaginal cancer: rationale and results.

Locally advanced vulvo-vaginal cancer is a difficult therapeutic problem complicated by the fact that it is an uncommon clinical entity. Surgery for the vulvar (external genital) phase of this disease presentation was combined with radiotherapy for the internal genital phase (with adequate overlap of fields to protect surgical margins). The rationale is that this approach treats the cancer and its dual regional spread patterns, while at the same time preserves the bladder and/or rectum, and should be associated with less morbidity and mortality than exenterative surgery, especially in this predominantly geriatric patient population. During the period from 1968-1980, 33 cancers have been treated. There were 26 primary and seven recurrent cases. The apparent advantages of this combined therapeutic approach over exenterative surgery include bladder and/or rectal preservation, low primary mortality, low treatment morbidity, and good results in cancer control.

Adult↗
PubMed1996

Excellent outcome using selective criteria for rectocele repair.

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16-78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1-8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5-64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test, P < 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

Constipation↗
PubMed1995

Laparoscopically assisted transvaginal radical cystectomy.

Herein we describe 5 cases of anterior pelvic exenteration in females through a combined transvaginal and laparoscopic approach for bladder cancer. In 4 cases hysterectomy and bilateral ovariectomy were performed. As far as urinary diversion is concerned, a bilateral cutaneous ureterostomy was performed in the 1st case, and in the remaining 4 an ileal conduit was accomplished through a minilaparotomy at the stoma site. The surgical specimen was withdrawn 'en bloc' transvaginally in all cases except 1, in whom vaginal atrophy forced us to perform a midline minilaparotomy. Total operative time ranged between 6 and 9 h, and 4 patients were discharged after 7-11 days with no complications. One patient was discharged only after 18 days due to obesity and diabetic problems. A larger series is needed to confirm the advantages of the combined transvaginal and videolaparoscopic approach for anterior pelvic exenteration as compared to the conventional procedure, with special regard given to the oncological outcome. Our initial experience is surely encouraging.

Aged↗
PubMed1986

Regulation of cultured rat vaginal epithelial cells by 17 beta-estradiol and progesterone.

We have previously described a technique to obtain short-term cultures of epithelial cells from Wistar rat vaginae. In order to improve the efficiency and life span of these cultures, in the present study we have cultured the vaginal cells with lethally irradiated 3T3 cell feeder layers. Under this condition, cells can grow for several weeks while retaining epithelial characteristics and can eventually be subcultured. The proliferative effect of the ovarian hormones in these cultures was studied using two different approaches, [Methyl-3H]Thymidine (3HTdr) incorporation and increase in cell number. Both assays indicated a proliferative effect of 17 beta-estradiol and progesterone at physiological concentrations. This proliferative effect was also shown in feeder layer-free cultures, ruling out an indirect effect through the mesodermal cells. The capacity of the hormones to modify terminal differentiation in the culture was also studied, using colony stratification as an indicator of differentiation. Progesterone and fetal calf serum had an inhibitory effect on terminal differentiation, whereas 17 beta-estradiol induced a stimulatory action. This culture model allowed us to show a direct effect of the ovarian hormones on vaginal cells in vitro and seems to be a useful model to study hormone-cell interactions in vitro.

Animals↗
PubMed1998

Hospital- and patient-related characteristics determining maternity length of stay: a hierarchical linear model approach.

OBJECTIVES: The purpose of this study was to identify factors related to pregnancy and childbirth that might be predictive of a patient's length of stay after delivery and to model variations in length of stay. METHODS: California hospital discharge data on maternity patients (n = 499,912) were analyzed. Hierarchical linear modeling was used to adjust for patient case mix and hospital characteristics and to account for the dependence of outcome variables within hospitals. RESULTS: Substantial variation in length of stay among patients was observed. The variation was mainly attributed to delivery type (vaginal or cesarean section), the patient's clinical risk factors, and severity of complications (if any). Furthermore, hospitals differed significantly in maternity lengths of stay even after adjustment for patient case mix. CONCLUSIONS: Developing risk-adjusted models for length of stay is a complex process but is essential for understanding variation. The hierarchical linear model approach described here represents a more efficient and appropriate way of studying interhospital variations than the traditional regression approach.

Adult↗
PubMed2004

How useful are high vaginal swabs in general practice? Results of a multicentre study.

Vulvovaginal symptoms are a common reason for consultation with a general practitioner (GP). High vaginal swabs (HVS) are used to investigate symptoms, but their usefulness is poorly evaluated and microbiological tests performed vary between laboratories. In this multicentre study of 797 women with genital symptoms attending GPs, diagnostic yield of HVS was poor except for Candida spp. (22%). There is an urgent need to establish the most cost-effective approach for the management of these women.

Adolescent↗
PubMed2006

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial.

BACKGROUND: The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery. METHODS: We used a third-party-payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (< or = 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations. RESULTS: The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (7165 dollars v. 8042 dollars per mother and infant; mean difference -877 dollars, 95% credible interval -1286 dollars to -473 dollars). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth (7255 dollars v. 8440 dollars) and women having had at least one prior birth (7071 dollars v. 7559 dollars). Although the treatment effect was largest in the subgroup of women having their first child, there was no statistically significant interaction between treatment and parity since the 95% credible intervals for difference in treatment effects between parity equalling zero and parity of one or greater all include zero. INTERPRETATION: Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial.

Adult↗
PubMed2004

A practical approach to a multi-level analysis with a sparse binary outcome within a large surgical trial.

OBJECTIVES: To assess the potential source of variation that surgeon may add to patient outcome in a clinical trial of surgical procedures. METHODS: Two large (n = 1380) parallel multicentre randomized surgical trials were undertaken to compare laparoscopically assisted hysterectomy with conventional methods of abdominal and vaginal hysterectomy; involving 43 surgeons. The primary end point of the trial was the occurrence of at least one major complication. Patients were nested within surgeons giving the data set a hierarchical structure. A total of 10% of patients had at least one major complication, that is, a sparse binary outcome variable. A linear mixed logistic regression model (with logit link function) was used to model the probability of a major complication, with surgeon fitted as a random effect. Models were fitted using the method of maximum likelihood in SAS. RESULTS: There were many convergence problems. These were resolved using a variety of approaches including; treating all effects as fixed for the initial model building; modelling the variance of a parameter on a logarithmic scale and centering of continuous covariates. The initial model building process indicated no significant 'type of operation' across surgeon interaction effect in either trial, the 'type of operation' term was highly significant in the abdominal trial, and the 'surgeon' term was not significant in either trial. CONCLUSIONS: The analysis did not find a surgeon effect but it is difficult to conclude that there was not a difference between surgeons. The statistical test may have lacked sufficient power, the variance estimates were small with large standard errors, indicating that the precision of the variance estimates may be questionable.

Humans↗
PubMed2004

Clinical development of microbicides for the prevention of HIV infection.

The HIV/AIDS pandemic continues its spread at a rate of over 15,000 new infections every day. Sexual transmission of HIV-1 is the dominant mode of this pandemic spread. For the first time since the disease emerged in the early 1980s, about half the 42 million people now living with HIV/AIDS worldwide are women. Worldwide, more than 90 percent of all adolescent and adult HIV infections have resulted from heterosexual intercourse. The "feminization" of the pandemic largely driven by the social, economic, and biological factors warrants urgent attention particularly for the adolescent female population. In the absence of an effective prophylactic anti-HIV therapy or vaccine, current efforts are aimed at developing intravaginal/intrarectal topical formulations of anti-HIV agents or microbicides to curb the mucosal and perinatal HIV transmission. Microbicides would provide protection by directly inactivating HIV or preventing HIV from attaching, entering or replicating in susceptible target cells as well as dissemination from target cells present in semen or the host cells that line the vaginal/rectal wall. Thus, ideally, anti-HIV microbicides should be capable of attacking HIV from different angles. In addition, a contraceptive microbicide could help prevent unintended pregnancies worldwide. To be a microbicide, these agents must be safe, effective following vaginal or rectal administration, and should cause minimal or no genital symptoms following long-term repeated usage. A safe and efficacious anti-HIV microbicide is not yet available despite the fact that more than 60 candidate agents have been identified to have in vitro activity against HIV, 18 of which have advanced to clinical testing. Targeting HIV entry has been a favored approach because it is the first step in the process of infection and several readily available anionic polymeric products seem to variably interfere with these processes are the primary candidates for potential microbicides. Formulations of some anionic polymeric antiviral agents have been tested at various doses and various durations for safety, tolerability, and acceptability in Phase I/II clinical trials (vaginal, rectal, or penile studies) in HIV-uninfected and/or HIV-infected populations. Current multicenter Phase I/II safety and Phase II/III efficacy studies that are being conducted or planned in different geographical locations by various special interest groups are designed for rapid clinical development of candidate products. The currently marketed detergent-type spermicide, nonoxynol-9 (N-9), has failed in Phase III clinical trials, due to the drug-induced formation of localized genital lesions that might in fact actually promote virus transmission. Alternative "first-generation" microbicides that have undergone Phase I/II safety and tolerability studies in HIV-uninfected and/or HIV-infected volunteers include polymeric viral fusion inhibitors (dextrin sulfate/Emmelle, carrageenans [PC-213, PC-503, PC-515/Carraguard], cellulose sulfate/Ushercell, polystyrene sulfonate, naphthalene sulfonate [PIC 024-4/PRO 2000/5], acidifying gel [Carbomer 974P/BufferGel], Lactobacillus (L. crispatus) suppository/CTV-05, detergent-type dual-function barriers [ACIDFORM, GEDA Plus, SURETE, Glyminox/C31G/Savvy, Invisible Condom], herbal extracts [Praneem], and viral replication inhibitors [PMPA/Tenofovir]. For majority of these products, no information is available regarding their long-term mucosal safety, carcinogenicity potential, bioavailability, or efficacy following their extended vaginal or rectal exposure. The irritative genitourinary symptoms reported for a number of these first-generation products in Phase I clinical trials implies that the "soft" preclinical endpoints for mucosal safety established for the use and development of vaginal spermicides may not be rigorous enough for vaginal and rectal microbicides because of the efficient sexual tra virus diversity, and genetic environment. It is now apparent that sexually transmitted R5 HIV-1 viruses have less positive charge on their surface compared with the R4 HIV-1 viruses, which may limit the anionic polymers as topical microbicides despite extensive clinical trials. Nevertheless, their ongoing clinical trials, reviewed here, using optimized formulations, and special populations in various geographic locations are paving the way for future rigorous clinical testing of "mechanism-based" broad-spectrum anti-HIV microbicides that are currently under intense development. It is anticipated that future microbicide trials will focus on combination of products capable of attacking HIV life cycle at multiple steps intended to increase efficacy, limit cross-resistance as well as minimize microbicide-induced host toxicity.

Administration, Intravaginal↗