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Maedica Sep 2019Hysteroscopy is a diagnostic and therapeutic modality, while cervical ripening before hysteroscopy is an issue of concern and different agents have been used for this...
Hysteroscopy is a diagnostic and therapeutic modality, while cervical ripening before hysteroscopy is an issue of concern and different agents have been used for this purpose. The goal of this study is to compare the effectiveness of misoprostol and isosorbide mononitrate (IMN) for cervical ripening before hysteroscopy. In this randomized clinical trial, 56 women who were candidates for hysteroscopy were randomly assigned to misoprostol or isosorbide mononitrate groups. During the early follicular phase of the cycle, a gynecology expert performed the hysteroscopies. Cervical dilation was measured by insertion of Hegar dilators up to size 9 without force. Vaginal bleeding, headache, abdominal pain, nausea, and vital signs were recorded by a specialized nurse. There was no significant difference regarding age, systolic and diastolic blood pressure in the two groups. Heart rate was significantly higher in the IMN group. Bleeding rate was not significantly different between the two groups (25.8% in the misoprostol group and 24% in the isosorbide mononitrate group, p=0.8). Headache was significantly more frequent in the isosorbide group, while abdominal pain, nausea, vomiting were significantly prevalent in the misoprostol group. The mean Hegar number used in the misoprostol and IMN groups was 7.3±1.1 vs 6.7±0.8 (p=0.03) Isosorbide mononitrate (IMN) is more effective than misoprostol for cervical ripening before hysteroscopy and complications are more frequent in the misoprostol group.
PubMed: 31798742
DOI: 10.26574/maedica.2019.14.3.260 -
AJOG Global Reports May 2023The use of epidural analgesia represents the gold standard for pain management during labor, but the influence of the use of epidural analgesia on delivery mode is not...
BACKGROUND
The use of epidural analgesia represents the gold standard for pain management during labor, but the influence of the use of epidural analgesia on delivery mode is not fully understood.
OBJECTIVE
This study aimed to analyze the impact of epidural analgesia on the delivery mode, namely, cesarean delivery, vaginal delivery, and operative vaginal delivery rates, in Robson class 1 women.
STUDY DESIGN
A retrospective cohort study was conducted on all Robson class 1 women who delivered from January 1, 2019, to December 31, 2019, in the University Hospital of Modena. The primary outcome was the delivery mode (cesarean delivery, vaginal delivery, and operative vaginal delivery rates), and the secondary outcomes were maternal, anesthesiologic, and neonatal effects of epidural analgesia (duration of labor, duration of the second stage of labor, Apgar score, and neonatal intensive care unit admission).
RESULTS
A total of 744 women were included in the final analysis, of which 198 (26.6%) underwent epidural analgesia on request and 546 (73.4%) did not. In women with and without epidural analgesia, the cesarean delivery rate was 8.1% vs 7%, the vaginal delivery rate was 79.3% vs 81.1%, and the operative vaginal delivery rate was 12.6% vs 11.9%, respectively. A significant increase in both the first stage of labor (66.3±38.5 vs 43.8±38.8 minutes; <.0001) and total duration of labor (328.0±206.7 vs 201.7±168.3 minutes; <.0001) was found in women receiving epidural analgesia. No change was recorded in the second stage of labor. A shorter duration of labor was observed (<.0001) when epidural analgesia was started earlier (dilation: 2-4 cm vs >4 cm). No significant difference in Apgar score and neonatal intensive care unit admission was found.
CONCLUSION
The use of epidural analgesia was not associated with an increased risk of cesarean delivery or operative vaginal delivery in Robson class 1 women. Further investigations are needed to evaluate its impact on the duration of labor, namely the duration of the first stage of labor, and on the possible advantages of starting epidural analgesia at an early stage.
PubMed: 37168548
DOI: 10.1016/j.xagr.2023.100207 -
American Family Physician Aug 2015Most of the nearly 4 million births in the United States annually are normal spontaneous vaginal deliveries. In the first stage of labor, normal birth outcomes can be...
Most of the nearly 4 million births in the United States annually are normal spontaneous vaginal deliveries. In the first stage of labor, normal birth outcomes can be improved by encouraging the patient to walk and stay in upright positions, waiting until at least 6 cm dilation to diagnose active stage arrest, providing continuous labor support, using intermittent auscultation in low-risk deliveries, and following the Centers for Disease Control and Prevention guidelines for group B streptococcus prophylaxis. Most women with a low transverse uterine incision are candidates for a trial of labor after cesarean delivery and should be counseled accordingly. Pain management during labor includes complementary modalities and systemic opioids, epidural anesthesia, and pudendal block. Outcomes in the second stage of labor can be improved by using warm perineal compresses, allowing women more time to push before intervening, and offering labor support. Delayed pushing increases the length of the second stage of labor and does not affect the rate of spontaneous vaginal delivery. A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, or the baby may be delivered using a somersault maneuver in which the cord is left nuchal and the distance from the cord to placenta minimized by pushing the head toward the maternal thigh. After delivery, skin-to-skin contact with the mother is recommended. Beyond 35 weeks' gestation, there is no benefit to bulb suctioning the nose and mouth. Postpartum maternal and neonatal outcomes can be improved through delayed cord clamping, active management to prevent postpartum hemorrhage, careful examination for external anal sphincter injuries, and use of absorbable synthetic suture for second-degree perineal laceration repair. Practices that will not improve outcomes and may result in negative outcomes include discontinuation of epidurals late in labor and routine episiotomy.
Topics: Adult; Delivery, Obstetric; Education, Medical, Continuing; Female; Humans; Labor, Obstetric; Middle Aged; Practice Guidelines as Topic; Pregnancy; United States; Young Adult
PubMed: 26280140
DOI: No ID Found -
Neurourology and Urodynamics Aug 2022To determine the outcomes and mechanisms of microenergy acoustic pulse (MAP) therapy in an irreversible rat model of female stress urinary incontinence.
OBJECTIVE
To determine the outcomes and mechanisms of microenergy acoustic pulse (MAP) therapy in an irreversible rat model of female stress urinary incontinence.
MATERIALS AND METHODS
Twenty-four female Sprague-Dawley rats were randomly assigned into four groups: sham control (sham), vaginal balloon dilation and ovariectomy (VBDO), VBDO + β-aminopropionitrile (BAPN), and VBDO + β-aminopropionitrile treated with MAP (MAP). MAP therapy was administered twice per week for 4 weeks. After a 1-week washout period, all 24 rats were evaluated with functional and histological studies. The urethral vascular plexus was examined by immunofluorescence staining with antibodies against collagen IV and von Willebrand factor (vWF). The urethral smooth muscle stem/progenitor cells (uSMPCs) were isolated and functionally studied in vivo and in vitro.
RESULTS
Functional study with leak point pressure (LPP) measurement showed that the MAP group had significantly higher LPPs compared to VBDO and BAPN groups. MAP ameliorated the decline in urethral wall thickness and increased the amount of extracellular matrix within the urethral wall, especially in the urethral and vaginal elastic fibers. MAP also improved the disruption of the urethral vascular plexus in the treated animals. In addition, MAP enhanced the regeneration of urethral and vaginal smooth muscle, and uSMPCs could be induced by MAP to differentiate into smooth muscle and neuron-like cells in vitro.
CONCLUSION
MAP appears to restore urethral wall integrity by increasing muscle content in the urethra and the vagina and by improving the urethral vascular plexus and the extracellular matrix.
Topics: Acoustics; Aminopropionitrile; Animals; Disease Models, Animal; Female; Rats; Rats, Sprague-Dawley; Urethra; Urinary Incontinence, Stress
PubMed: 35451520
DOI: 10.1002/nau.24939 -
Medicine Apr 2023Endogenous fungal endophthalmitis is a challenging condition. There are no universally accepted diagnostic or management protocols. We share a case of endogenous fungal...
RATIONALE
Endogenous fungal endophthalmitis is a challenging condition. There are no universally accepted diagnostic or management protocols. We share a case of endogenous fungal endophthalmitis who was successfully treated, focusing on the diagnostic and treatment procedures.
PATIENT CONCERNS
A 31-year-old female with a history of fungal vaginitis and tinea corporis presented with progressive visual decrease in both eyes after having an induced abortion. Her best corrected visual acuity at presentation was 20/1000 in her right eye and 20/250 in her left eye. Upon slit lamp examination, mild inflammatory reaction in the anterior chamber was found. Dilated fundus examination revealed a hazy view of the optic disc and posterior retina, and there was a whitish mass with "string and pearls" just in front of the macular region in each eye.
DIAGNOSES
Bilateral fungal endogenous endophthalmitis was diagnosed empirically, which was confirmed later by deoxyribonucleic acid sequencing and culture of intraocular fluid.
INTERVENTIONS
Oral itraconazole and intravitreal voriconazole were administered to the patient at first. The intraocular inflammation was partially responsive to the medication, yet the visual acuity persisted to deteriorate and the vitreous whitish masses became more prominent. Then vitrectomy procedures were carried out and oral itraconazle was switched to intravenous fluconazole. The antifungal treatment lasted for 8 weeks.
OUTCOMES
The intraocular inflammation alleviated and visual acuity improved after vitrectomy. At the 9-month follow-up visit, the patient's best corrected visual acuity was 20/40 in the right eye and 20/30 in the left eye. There was no intraocular inflammatary reaction, and retinal scar was noticed in each eye.
LESSON
Early and correct diagnosis, coupled with prompt and aggressive treatment, is crucial for cases of fungal endogenous endophthalmitis. Deoxyribonucleic acid sequencing techniques can contribute to early diagnosis, while vitrectomy may be necessary when antifungal medication is insufficient in controlling the condition.
Topics: Humans; Pregnancy; Female; Adult; Antifungal Agents; Endophthalmitis; Voriconazole; Vitrectomy; Eye Infections, Fungal; Inflammation; DNA
PubMed: 37083776
DOI: 10.1097/MD.0000000000033585 -
Geburtshilfe Und Frauenheilkunde Dec 2023Mechanical methods have gained growing interest for pre-induction cervical ripening in women with an unripe cervix, since they have a better safety profile compared to...
Mechanical methods have gained growing interest for pre-induction cervical ripening in women with an unripe cervix, since they have a better safety profile compared to prostaglandins. Balloon catheters have been the gold standard method for decades, while there was a lack of data on synthetic osmotic cervical dilators. Not until 2015, when Dilapan-S was approved by the Food and Drug Administration (FDA) for induction of labor, numerous studies have been published on the use of Dilapan-S in this field. The rate of vaginal deliveries associated with the use of Dilapan-S ranges from 61.6 to 81.7%, and no serious complications needing further interventions have been reported to this date. Dilapan-S was shown to be as effective as the Foley balloon catheter as well as the 10 mg PGE vaginal insert and orally applied misoprostol (25 µg every 2 hours) in achieving vaginal delivery, but patient's satisfaction during the cervical ripening process was significantly higher compared to the other methods and the rate of uterine hyperstimulation was significantly lower compared to prostaglandins (PGs). Minor complications (e.g. vaginal bleeding) associated with the use of Dilapan-S were < 2%, and maternal infectious morbidity was not higher compared to Foley balloon and vaginal PGE or misoprostol. Due to these beneficial properties Dilapan-S might be an ideal option for outpatient cervical ripening, as shown in a recent randomized clinical trial comparing inpatient to outpatient cervical ripening. Furthermore, according to the manufacturers' product information, Dilapan-S is the only cervical ripening method that is not contraindicated for induction of labor in women with a previous cesarean section. Upcoming guidelines should consider synthetic osmotic cervical dilators as an effective and safe method for cervical ripening/induction of labor acknowledging that more evidence-based data are mandatory, particularly in patients with a previous cesarean section.
PubMed: 38046527
DOI: 10.1055/a-2103-8329 -
Obstetrics & Gynecology Science May 2020This study aimed to compare the effects of vaginal misoprostol, laminaria, and extra-amniotic saline infusion (EASI) on cervical ripening.
OBJECTIVE
This study aimed to compare the effects of vaginal misoprostol, laminaria, and extra-amniotic saline infusion (EASI) on cervical ripening.
METHODS
This randomized controlled trial was conducted on 195 women with singleton pregnancies and unripe cervices. Participants were randomly allocated to 3, 65-person groups: a misoprostol, a laminaria, and an EASI group. The interventions in the misoprostol, laminaria, and EASI groups included a single 25-µg vaginal misoprostol suppository, an intracervical laminaria, and a transcervical Foley catheter, respectively. The groups were compared with each other regarding time intervals from labor induction to labor active phase and delivery, cervical dilation, Bishop scores 6 hours after induction, delivery type, length of hospital stay, and complications.
RESULTS
There were no significant differences among the groups regarding maternal ages, gestational ages, body mass indices, baseline cervical dilations, and Bishop scores (>0.05). Six hours after induction, the Bishop score and cervical dilation were significantly greater in the EASI group than in the other 2 groups (<0.001). Moreover, time intervals from labor induction to labor active phase and delivery in the EASI group were significantly short (<0.001). The rates of cesarean section, fetal distress, placental abruption, and meconium staining in the misoprostol group were significantly high (<0.05), and the length of hospital stay in the EASI group was significantly short (<0.001).
CONCLUSION
EASI is a safer and more effective method for cervical ripening. Considering its inexpensiveness, easy accessibility, and greater effectiveness, EASI is recommended for cervical ripening.
TRIAL REGISTRATION
Iranian Center for Clinical Trials Identifier: IRCT20170513033941N39.
PubMed: 32489970
DOI: 10.5468/ogs.2020.63.3.261 -
Acta Oncologica (Stockholm, Sweden) May 2015The purpose of this study was to examine whether or not vaginal elasticity or lack of lubrication is associated with deep or superficial dyspareunia. We investigated...
PURPOSE
The purpose of this study was to examine whether or not vaginal elasticity or lack of lubrication is associated with deep or superficial dyspareunia. We investigated gynecological cancer survivors treated with radiation therapy.
METHODS
In a population-based study with 616 women answering a questionnaire (participation rate 78%) and who were treated with radiotherapy for gynecological cancer, we analyzed information from 243 women (39%) who reported that they had had intercourse during the previous six months. Analyses included log-binomial regression (relative risks) and multiple imputations by chained equations in combination with Bayesian Model Averaging, yielding a posterior probability value. Age range of this cancer recurrent-free group of women was 29-80.
RESULTS
Dyspareunia affected 164 of 243 of the women (67%). One hundred thirty-four women (55%) reported superficial pain, 97 women (40%) reported deep pain, and 87 women (36%) reported both types of dyspareunia. The relative risk (RR) of deep dyspareunia was 1.87 (CI 1.41-2.49) with impaired vaginal elasticity compared to normal vaginal elasticity. Age and lower abdominal swelling were separate risk factors for deep dyspareunia. However, effects remain after adjusting for these factors.
CONCLUSION
The relative risk of deep dyspareunia was almost twice as high with impaired vaginal elasticity compared to normal vaginal elasticity. If we wish to treat or even prevent deep dyspareunia in women with gynecological cancer, we may use our knowledge of the pathophysiology of deep dyspareunia and increasingly provide dilators together with instructions on how to use them for stretching exercises in order to retain vaginal elasticity. Results highlight the need for studies with more precise questions distinguishing superficial from deep dyspareunia so that in the future we may be able to primarily try to avoid reduced vaginal elasticity and secondarily reduce the symptoms.
Topics: Adult; Aged; Bayes Theorem; Coitus; Dyspareunia; Elasticity; Female; Genital Neoplasms, Female; Humans; Middle Aged; Radiation Injuries; Regression Analysis; Risk; Surveys and Questionnaires; Survivors; Time Factors; Vagina
PubMed: 25761090
DOI: 10.3109/0284186X.2014.1001036 -
Journal of Obstetrics and Gynaecology... Aug 2018Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to...
BACKGROUND
Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient's preexisting demographic and clinical factors.
OBJECTIVE
To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.
METHODS
Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.
RESULTS
A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.
CONCLUSION
Both prediction models, the FLAMM and the "close to delivery" nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.
PubMed: 30065542
DOI: 10.1007/s13224-017-1031-2 -
Frontiers in Global Women's Health 2021Approximately 40% of cases of spontaneous preterm birth (sPTB) are associated with ascending intrauterine infections. The cervix serves as a physical and immunological... (Review)
Review
Approximately 40% of cases of spontaneous preterm birth (sPTB) are associated with ascending intrauterine infections. The cervix serves as a physical and immunological gatekeeper, preventing the ascent of microorganisms from the vagina to the amniotic cavity. The cervix undergoes remodeling during pregnancy. It remains firm and closed from the start until the late third trimester of pregnancy and then dilates and effaces to accommodate the passage of the fetus during delivery. Remodeling proceeds appropriately and timely to maintain the pregnancy until term delivery. However, risk factors, such as acute and chronic infection and local inflammation in the cervix, may compromise cervical integrity and result in premature remodeling, predisposing to sPTB. Previous clinical studies have established bacterial (i.e., chlamydia, gonorrhea, mycoplasma, etc.) and viral infections (i.e., herpesviruses and human papillomaviruses) as risk factors of PTB. However, the exact mechanism leading to PTB is still unknown. This review focuses on: (1) the epidemiology of cervical infections in pregnant patients; (2) cellular mechanisms that may explain the association of cervical infections to premature cervical ripening and PTB; (3) endogenous defense mechanisms of the cervix that protect the uterine cavity from infection and inflammation; and (4) potential inflammatory biomarkers associated with cervical infection that can serve as prognostic markers for premature cervical ripening and PTB. This review will provide mechanistic insights on cervical functions to assist in managing cervical infections during pregnancy.
PubMed: 35118439
DOI: 10.3389/fgwh.2021.777643