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PubMed2006

Minimizing the urological and psychological morbidity of urinary tract fistulae from VBAC.

BACKGROUND: Because of the relative rarity of the condition, there is no consensus for the timing of surgical repair of fistulae following vaginal birth after Caesarean section (VBAC). CASES: Three cases of urinary tract fistulae following VBAC are presented. Two patients had an early repair (24-48 hours after delivery), and the third had a repair at four months after delivery. The surgical approach and intraoperative findings for the early and late repairs are described, and the psychological effects of early and late repair are compared. The early repairs were not technically difficult and were associated with less psychological morbidity. CONCLUSION: In the absence of contraindications, early repair of urinary tract fistulae diagnosed within the first few days after VBAC delivery is preferred. If early repair is attempted, perioperative conditions must be optimized; urogynaecologic or urologic expertise and assistance should be considered.

Adult↗
PubMed1983

Malignant tumors of the vagina. Classification and approach to treatment.

While primary carcinoma of the vagina is relatively rare, metastatic lesions arising from the endometrium are more common, and extension from cervical or vulvar tumors can also affect the vagina. Adenocarcinoma related to diethylstilbestrol exposure in utero is a recently recognized type of vaginal lesion, and melanoma and sarcoma occur rarely in the vagina. Familiarity on the physician's part with these various presentations and their proper management will help ensure early treatment and preservation of normal vaginal function in affected patients.

Adenocarcinoma↗
PubMed1992

Natural oocyte retrieval with intravaginal fertilization: a simplified approach to in vitro fertilization.

To simplify in vitro fertilization (IVF), we have combined natural-cycle oocyte retrieval with intravaginal fertilization. Our subjects ranged in age from 28-40 years and were monitored by ultrasound and steroid hormone levels. Oocyte retrieval was carried out under vaginal ultrasound-guided aspiration 32-36 hours after the onset of the LH surge. The oocyte was identified and placed in a sealed capsule containing culture media and sperm. The capsule, in a sealed cryoflex envelope, was placed in the woman's vagina and removed 42-48 hours later. The embryo was then isolated and transferred to the woman's uterus. Fifty-one retrieval cycles were attempted in 45 patients. At least one oocyte was retrieved in 88% of cycles, and fertilization was achieved in 84% of oocytes. Of the five clinical pregnancies (10%), four have delivered and one is ongoing. The cost of this procedure is approximately one-third that of standard IVF. The advantages of our method are the elimination of the use of gonadotropins, the simplicity of monitoring and oocyte retrieval, and the lack of need for expensive laboratory equipment. Natural oocyte retrieval with intravaginal fertilization may prove appropriate for those women requiring IVF who fear multiple pregnancies, have side effects from controlled ovarian hyperstimulation, or cannot afford standard IVF.

Adult↗
PubMed1995

The polypropylene pubovaginal sling for the treatment of recurrent stress urinary incontinence.

PURPOSE: The significance of a 2-team approach to the problems of recurrent incontinence in patients with extensive pelvic scarring from previous surgery is emphasized. MATERIALS AND METHODS: We reviewed 88 consecutive patients who presented between January 1986 and November 1992. The demonstration of a scarred, wide open, proximal urethra or drain pipe urethra was the important selection criterion. Two teams, 1 operating abdominally and 1 vaginally, released the bladder neck from its bed of scar under direct vision and set the sling in place with minimal tension at the bladder neck. RESULTS: Of the women 75 (85.2%) were cured of the stress urinary incontinence and 8 (9.1%) had improvement with mainly urge incontinence, while 5 (5.7%) operations failed. There was a significant association between chronic chest disease and failure. CONCLUSIONS: The 2-team polypropylene (Marlex) mesh approach continues to be an effective treatment for women with complicated stress urinary incontinence.

Adult↗
PubMed1992

A controlled trial of a program for the active management of labor.

BACKGROUND: Over the past two decades, the rate of cesarean section in the United States has risen from 5 percent to 25 percent of deliveries, primarily because of the increased frequency of dystocia (arrest of labor). One strategy that has been proposed for increasing the rate of vaginal delivery is a program of active management of labor that encourages early amniotomy, early diagnosis of slow progress in labor, and the use of higher than usual doses of oxytocin; the efficacy and safety of this approach are uncertain, however. METHODS: We conducted a randomized trial in which nulliparous women in spontaneous labor at term were randomly assigned to either active management of labor or traditional management. With active management, amniotomy was performed within one hour of the diagnosis of labor, and when the rate of cervical dilation was less than 1 cm per hour, oxytocin was infused at an initial rate of 6 mU per minute. The dose was increased by 6 mU per minute every 15 minutes (to a maximum of 36 mU per minute) until there were seven contractions every 15 minutes. RESULTS: For the women assigned to active management (n = 351), the cesarean-section rate was 10.5 percent, as compared with 14.1 percent for those assigned to traditional management (n = 354, P = 0.18). The 26 percent reduction in the cesarean-section rate was due primarily to a decrease in dystocia. After we controlled for potential confounding variables, the reduction in the rate of delivery by cesarean section was statistically significant (odds ratio for women given active as compared with traditional management, 0.57; 95 percent confidence interval, 0.36 to 0.95). With active management, the average length of labor was shortened by 1.66 hours, principally because of earlier amniotomy and earlier use of oxytocin. There was no increase in maternal or neonatal morbidity, and there were significantly fewer infectious complications in the mothers. CONCLUSIONS: The program we studied for the active management of labor reduces the incidence of dystocia and increases the rate of vaginal delivery without increasing maternal or neonatal morbidity.

Adult↗
PubMed1989

[Vesicovaginal fistula. Still a daily reality in Africa. Apropos of 89 cases].

Vesico-vaginal fistulae (VVF) are still a daily occurrence in Africa. Obstetrical causes are the most frequent. This severe disability requires that everything be implemented to obtain a leak-free closure of the pathological opening. The authors report their experience with 89 cured cases of VVF. Except for 2 cases cured with an abdominal approach, the Moir technique gave good results in 78 cases, for midline, moderate size, fistulae. In 3 instances, closure of the vagina alone was satisfactory. There were 10 recurrences, cured 9 times at the second operation and once at the third. 3 recurrences came from other institutions and were cured after 4 and 5 successive procedures. In 6 instances, for fistulae close to 5 cm or larger and located in areas difficult to reach, the authors have developed a technique of vaginal closure alone using a turned-over, undetermined vaginal flap creating a leak-free diverticulum. No recurrences have been observed with this technique.

Adolescent↗
PubMed2005

ORG 33628 and ORG 31710 to control vaginal bleeding in progestin-only contraceptive regimens.

ORG 31710 and ORG 33628 were used in studies aiming to control vaginal bleeding in combination with progestagen-only contraception in primates. Preclinical evidence in monkeys with ORG 31710 has shown that a monthly supplementary administration to a progestagen-only contraceptive improves cycle control, probably as a result of a local endometrial effect (i.e., blocking of the progesterone receptor). In clinical trials ORG 31710 appeared to be effective for inducing vaginal bleeding after single-dose administration in the luteal phase of a normal cycle and for improving vaginal bleeding patterns of subjects using the 75 microg desogestrel progestagen-only pill (POP). Under POP treatment, ORG 31710 induced monthly bleeding and completely reduced intermittent (or breakthrough) bleedings, albeit for a limited number of days (+/- 10 days); thereafter, the incidence of spot bleedings returned to average levels with a POP, until the next monthly ORG 31710 administration. The temporary character of the effect was not predicted on the basis of the monkey studies, in which the improved bleeding pattern lasted a full cycle. Similar clinical results have been obtained with ORG 33628 both as administered in the luteal phase of the normal cycle and as given once (and twice) every 28 days in combination with the 75 microg desogestrel POP. Again, the improvement of the (POP-) bleeding pattern was not considered effective enough. In another approach, a continuous combined (daily) treatment of a progestagen (desogestrel) and the compound ORG 33628 was evaluated. It was hypothesized that if properly balanced, the progestagen would provide sustained ovulation inhibition, while the antagonistic activity of ORG 33628 would provide prevention of intermittent vaginal bleedings without antagonizing the inhibition of ovulation. This hypothesis is supported by the observation (from previous studies) that the antagonistic activity is higher at the level of the endometrium than at the level of the hypothalamus/pituitary. The continuous combined concept was studied in a single-center, double-blind, randomized trial of ORG 33628 at three different dosages in combination with the 75 microg desogestrel POP administered to healthy female volunteers. Effects on vaginal bleeding, endometrium, and ovarian function were evaluated. Vaginal bleeding was reduced with increasing doses of ORG 33628, but the inhibition of ovulation appeared to be compromised at the same time. In summary, the available studies suggest that there may be a progestagen/progesterone receptor-antagonist combination that provides the desired cycle control without compromising the inhibition of ovulation, but the ideal regimen or ratio has yet to be found.

Animals↗
PubMed1999

Two-year survey of Alberta laboratories processing of antenatal group B streptococcal (GBS) screening specimens: implications for GBS screening programs.

We evaluated specimen types received and methods used by laboratories to process screening GBS specimens from pregnant women. Surveys during 1995 and 1997 of all laboratories in the province of Alberta, Canada that culture GBS from screening genital specimens were completed. Between surveys, there was dissemination of information about appropriate culture techniques. Survey completion rates were 100% in both years (38/38 in 1995 and 20/20 in 1997). During 1995 as compared to 1997, laboratories were less likely to a) have a specific written protocol for identification of genital GBS screening specimens (1995: 78.2% versus 1997: 100%, p = 0.08) b) be receiving combined vaginal-anorectal swabs (1995: 18% of all swabs received versus 1997: 60.4%, p < 0.001), and c) be using selective GBS culture media (1995: 45.5% versus 1997: 86.7%, p = 0.01). Regions using screening based approaches for GBS prevention need to ensure that their laboratories are using adequate techniques for GBS detection.

Alberta↗
PubMed1989

[Eye diseases and control of labor. Studies of changes in the eye in labor exemplified by subconjunctival hemorrhage (hyposphagmas)].

The possible significance of subconjunctival bleedings (hyposphagmas) as a symptom for other pathological changes of the eye was studied in a group of 354 postpartum patients. They were found in 10.5% of the cases. A relatively higher frequency occurred in primiparas. No other maternal factors than parity were detected as of statistically significant influence. A slightly higher percentage in mothers with large newborn (above average cranial circumference) indicates a relationship to the necessary bearing-down effort. In a second study, 49 postpartum women with subconjunctival bleeding were examined by an ophthalmologist. Neither any intraocular or retrobulbar bleeding nor any other grievous damage to the eye were found. In accordance with the literature we recommend, that highly myopic pregnant women (even with a previous history of retinal detachment, but ophthalmologically sufficiently treated) should undergo induced delivery. However, the approach to pregnant women with retinal detachment occurring and treated during pregnancy, or to glaucoma-patients with risk to a small remaining visual field, should be more careful. In those cases, a vaginal operative delivery procedure (forceps, vacuum-extraction) is recommended. Nevertheless, one should consider individual wishes of the mother, when striving to diminish the risk to the foetus. The same applies to irrational fears related to previously damaged (and possibly only functional) eye.

Adult↗
PubMed2004

Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment.

OBJECTIVE: To test the efficacy of brief, safer-sex counseling by medical providers of HIV-positive patients during medical visits. SETTING: Six HIV clinics in California. DESIGN: Clinics were randomized to intervention arms evaluated with cohorts of randomly selected patients measured before and after the intervention. PARTICIPANTS: Five-hundred and eighty-five HIV-positive persons, sexually active prior to enrollment. INTERVENTIONS: Prevention counseling from medical providers supplemented with written information. Two clinics used a gain-framed approach (positive consequences of safer-sex), two used a loss-frame approach (negative consequences of unsafe sex), and two were attention-control clinics (medication adherence). Interventions were given to all patients who attended the clinics. OUTCOME MEASURE: Self-reported unprotected anal or vaginal intercourse (UAV). RESULTS: Among participants who had two or more sex partners at baseline, UAV was reduced 38% (P < 0.001) among those who received the loss-frame intervention. UAV at follow-up was significantly lower in the loss-frame arm [odds ratio (OR), 0.42; 95% confidence interval (CI), 0.19-0.91; P = 0.03] compared with the control arm. Using generalized estimating equations (GEE) to adjust for clustering did not change the conclusions (OR, 0.34; 95% CI, 0.24-0.49; P = 0.0001). Similar results were obtained in participants with casual partners at baseline. No effects were seen in participants with only one partner or only a main partner at baseline. No significant changes were seen in the gain-frame arm. CONCLUSIONS: Brief provider counseling emphasizing the negative consequences of unsafe sex can reduce HIV transmission behaviors in HIV-positive patients presenting with risky behavioral profiles.

Adult↗
PubMed2000

Pregnancy after medical management of a uterine arteriovenous malformation. A case report.

BACKGROUND: The natural history of conservatively managed uterine arteriovenous malformations is largely unknown, and the risks associated with subsequent pregnancy and vaginal delivery have not been established. CASE: A multiparous woman with a previously reported history of uterine arteriovenous malformation was monitored throughout pregnancy and vaginal delivery. Serial ultrasound studies were performed prior to a successful induction of labor for severe preeclampsia at 34 weeks' gestation. CONCLUSION: To our knowledge, this is the first report of pregnancy and vaginal delivery in a woman with a prior history of a medically managed uterine arteriovenous malformation. Noninvasive treatment of uterine arteriovenous malformations is rare, and the potential long-term risks of this approach, including pregnancy, remain uncertain.

Abortion, Therapeutic↗
PubMed1991

[Cervico-vaginal screening in the Abruzzo region].

This study focuses on cervical cancer and the importance of establishing a suitable screening programme. The results of a study carried out in the Abruzzo region during a 10-year sample period are reported. A Population of 36,663 patients, of which 3,372 had never been screened, was included in the study. All patients were attending the Centre of Cytology and Colposcopy at the Clinic of Obstetrics and Gynecology in L'Aquila. In order to make progress in both the diagnosis and treatment of this pathology, it is necessary not only to obtain an interdisciplinary approach with constant cooperation between professional colleagues (cytologist, colposcopist and histologist), but also an increased sensitivity of the population to the need for screening.

Female↗