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Obstetrics & Gynecology Science May 2024This study aimed to describe the clinical features, associated extragenital anomalies, and management of Mayer- Rokitansky-Küster-Hauser (MRKH) syndrome in a Thai...
OBJECTIVE
This study aimed to describe the clinical features, associated extragenital anomalies, and management of Mayer- Rokitansky-Küster-Hauser (MRKH) syndrome in a Thai population.
METHODS
This retrospective study analyzed the medical records of 96 patients with MRKH syndrome diagnosed and treated at a university hospital and tertiary referral center in southern Thailand between 2000 and 2022.
RESULTS
The study included 96 patients with MRKH syndrome. The most common symptom was primary amenorrhea (88.5%), followed by difficulty or inability to engage in sexual intercourse (9.4%) and pelvic mass (2.1%). Notably, 80.3% of the patients did not have extragenital malformations and were diagnosed with MRKH type I (typical form), whereas 19.7% were categorized as MRKH type II (atypical form). Skeletal malformations were the most frequent extragenital anomalies and were present in 19.5% of patients, with scoliosis being the most common skeletal condition. Other extragenital malformations included renal (8.5%) and neurological (1.0%) abnormalities. Clinical vaginal examination revealed complete atresia in 21.8% and vaginal hypoplasia (median vaginal length, 3 cm) in 78.2% of the patients. Half of the patients did not receive treatment because they had not engaged in sexual intercourse. In this cohort, 41.7% of the patients had no difficulty performing sexual intercourse. Hence, self-dilation therapy or concomitant dilation was recommended. Only eight patients (8.3%) underwent surgical reconstruction of the vagina.
CONCLUSION
This study confirmed the complexity and heterogeneity of the phenotypic manifestations of MRKH, including the degree of vaginal atresia and types and rates of associated malformations.
PubMed: 38461809
DOI: 10.5468/ogs.23211 -
Birth (Berkeley, Calif.) Dec 2023We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital...
BACKGROUND
We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics.
METHODS
We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient.
RESULTS
Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%).
DISCUSSION
Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
PubMed: 38158784
DOI: 10.1111/birt.12809 -
American Journal of Reproductive... Sep 2023The exact biochemical mechanisms that initiate labor are not yet fully understood. Nitric oxide is a potent relaxant of uterine smooth muscles until labor starts, and...
PROBLEM
The exact biochemical mechanisms that initiate labor are not yet fully understood. Nitric oxide is a potent relaxant of uterine smooth muscles until labor starts, and its precursor is L-arginine. Asymmetric (ADMA) and symmetric (SDMA) dimethylarginines, are potent NO-inhibitors. However, arginines (dimethylarginines and L-arginine) are scarcely studied in relation to labor and childbirth. We aimed to investigate arginines in women with spontaneous (SLVB) and induced (ILVB) term labor with vaginal birth and in women undergoing elective caesarean section (ECS).
METHOD OF STUDY
Women at gestational week 16-18 were recruited to the population-based prospective cohort study BASIC at the Uppsala University Hospital, Sweden. Plasma samples taken at start of labor were analyzed for arginines, from SLVB (n = 45), ILVB (n = 45), and ECS (n = 45), using Ultra-High Performance Liquid Chromatography. Between-group differences were assessed using Kruskal-Wallis and Mann-Whitney U-test.
RESULTS
Women with SLVB and ILVB had higher levels of ADMA (p < .0001), SDMA (p < .05) and lower L-arginines (p < .01), L-arginine/ADMA (p < .0001), and L-arginine/SDMA (p < .01, respectively <.001) compared to ECS. However, ILVB had higher ADMA (p < .0001) and lower L-arginine (p < .01), L-arginine/ADMA (p < .0001), and L-arginine/SDMA (p < .01) compared to SLVB. Results are adjusted for gestational length at birth and cervical dilatation at sampling.
CONCLUSION
Our novel findings of higher levels of dimethylarginines in term vaginal births compared to ECS give insights into the biochemical mechanisms of labor. These findings might also serve as a basis for further studies of arginines in complicated pregnancies and labor.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Cesarean Section; Prospective Studies; Parturition; Delivery, Obstetric; Arginine
PubMed: 37641379
DOI: 10.1111/aji.13767 -
Acta Cirurgica Brasileira 2024To investigate inflammation and cell adhesion molecules in the vagina after ovarian ischemia-reperfusion (IR) injury.
PURPOSE
To investigate inflammation and cell adhesion molecules in the vagina after ovarian ischemia-reperfusion (IR) injury.
METHODS
20 Wistar albino female rats were divided into two groups: control, and IR groups. In IR group, blood flow was restricted for 2 hours for ovarian ischemia. Then, tissues were re-blood 2 hours for reperfusion. Vagina tissues were excised and processed for histopathological analysis. Histopathological and biochemical follow-ups were performed.
RESULTS
Both malondialdehyde and myeloperoxidase values were increased in IR group compared to control group. Glutathione content was decreased in IR group compared to control group. Epithelial degeneration, inflammation, dilatation, and nuclear factor-κB (NF-κB) expression were increased in IR group compared to control group. E-cadherin expression was significantly decreased in IR group. In the IR group, E-cadherin showed a positive reaction in adenomas, gland-like cryptic structures, cellular junctions with clustered inflammatory cells. In the IR group, NF-κB expression was increased in basement membrane, inflammatory cells, in blood vessels.
CONCLUSIONS
Ovarian ischemia caused degeneration of epithelial cells in the vaginal region and disruptions in the cell junction complex, which leads to activation of E-cadherin and NF-κB signaling pathway and alterations in reproductive and embryonal development in the vaginal region.
Topics: Animals; Female; Rats; Cadherins; Inflammation; Ischemia; NF-kappa B; Rats, Wistar; Reperfusion Injury; Ovary; Vagina
PubMed: 38629650
DOI: 10.1590/acb391724 -
International Journal of Surgery... Dec 2023When a disorder causes the absence of a healthy, full-size vagina, various neovaginal creation methods are available. Sometimes dilation or stretching of the vaginal...
BACKGROUND
When a disorder causes the absence of a healthy, full-size vagina, various neovaginal creation methods are available. Sometimes dilation or stretching of the vaginal cavity is sufficient, but intestinal or dermal flap tissue is generally required. However, different inherent tissue properties cause complications. Therefore, a lost body part should be replaced with a similar material. The use of organ-specific acellular vaginal tissue carries great potential, as its similar architecture and matrix composition make it suitable for vaginal regeneration.
METHODS
The authors developed an optimized protocol for decellularization of healthy human vaginal tissue. Resected colpectomy tissue from 12 healthy transgender patients was used. Successful decellularization was confirmed by applying acellular criteria from in-vivo remodeling reports. Suitability as a tissue-mimicking scaffold for vaginal reconstruction was determined by visible structural features, biocompatibility during stretching, and the presence of visible collagen, elastin, laminin, and fibronectin.
RESULTS
Histological examination confirmed the preservation of structural features, and minimal cellular residue was seen during fluorescence microscopy, DNA and RNA quantification, and fragment length examination. Biomechanical testing showed decreased peak load (55%, P <0.05), strain at rupture (23%, P <0.01), and ultimate tensile stress (55%, P <0.05) after decellularization, while the elastic modulus (68%) did not decrease significantly. Fluorescence microscopy revealed preserved Fibronectin-I/II/III and Laminin-I/II, while Collagen-I and Ficolin-2B were decreased but mostly retained.
CONCLUSIONS
The absence of cellular residue, moderately altered biomechanical extracellular matrix properties, and mostly preserved structural proteins appear to make our decellularized human vaginal matrix a suitable tissue-mimicking scaffold for vagina transplantation when tissue survival through vascularization and innervation are accomplished in the future.
Topics: Female; Humans; Tissue Engineering; Fibronectins; Tissue Scaffolds; Extracellular Matrix; Collagen; Laminin; Vagina
PubMed: 37755377
DOI: 10.1097/JS9.0000000000000727 -
Journal of Pediatric Urology Aug 2023Persistent cloaca, defined as confluence of the rectum, the vagina and the urethra into a single common channel, has an estimated incidence of 1/50,000 live births. We...
INTRODUCTION
Persistent cloaca, defined as confluence of the rectum, the vagina and the urethra into a single common channel, has an estimated incidence of 1/50,000 live births. We describe the buccal mucosa graft vaginoplasty for a 11 year old female with cloaca, who underwent at the age of 11 months a Peña repair. We performed the vaginoplasty after the onset of uterine pain due to the beginning of menstruation.
MATERIAL AND METHODS
We accessed the lower lip for superficial dissection to harvest the graft. The donor site has been kept with as much submucosal fat as possible to avoid damage to the buccinatoria muscles. A second graft was further obtained from the cheek. Both grafts were submitted to multiple small sections to produce a mesh graft and increase its size. A arciform incision anterior to the anal canal and posterior to the urethra was performed followed by consecutive dissection with eletrocautery to gain profundity. The mesh-graft was placed over the neovaginal cavity and sutured with 4.0 PDS monofilament suture used to suture and then quilt the graft in place. The vaginal capacity was confirmed by ease of a two-digit insertion. Haemostasis was confirmed before the insertion of a soft vaginal mold. The patient remained with an indwelling urinary catheter. The mold was equivalent to 24Fr and had 13 cm of profundity and Foley tube were removed after 14 days postoperatively.
RESULTS
Patient had an excellent postoperative course and had been instructed to perform vaginal dilatation every 3 h during the day. Current follow up is 10 months.
DISCUSSION
Buccal mucosal grafting has advantages over the use of keratinized skin flaps and intestinal flaps. Buccal mucosa is ideal for female genital reconstruction, given its color, texture, lack of hair and mild mucous production. In our particular case, we connected the neovagina after two months of adequate healing to the native 1⁄3 through laparoscopic approach.
CONCLUSIONS
BMG vaginoplasty is a viable alternative to treat females with cloaca at adolescence.
Topics: Adolescent; Humans; Female; Infant; Child; Mouth Mucosa; Plastic Surgery Procedures; Vagina; Surgical Flaps; Rectum
PubMed: 37120365
DOI: 10.1016/j.jpurol.2023.03.036 -
Urology Oct 2023To describe the authors' experience with surgical management of complications following intestinal vaginoplasty and review the literature on incidence of complications...
OBJECTIVE
To describe the authors' experience with surgical management of complications following intestinal vaginoplasty and review the literature on incidence of complications following gender-affirming intestinal vaginoplasty.
METHODS
Retrospective chart review identified patients presenting with complications following prior intestinal vaginoplasty requiring operative management. Charts were analyzed for medical history, preoperative exam and imaging, intraoperative technique, and long-term outcomes. Systematic literature review was performed to identify primary research on complications following gender-affirming intestinal vaginoplasty.
RESULTS
Four patients presented to the senior authors' clinic requiring operative intervention for complications following intestinal vaginoplasty, all of whom underwent surgical revision. Complications included vaginal stenosis (2 patients, 50%), vaginal false passage (1 patient, 25%), and diversion colitis (1 patient, 25%). Postoperatively all patients were able to dilate successfully to a depth of at least 15 cm. Systematic review identified 10 studies meeting inclusion criteria. There were 215 complications reported across 654 vaginoplasties (33% overall complication rate). Average return to operating room rate was 18%. The most common complications were stenosis (11%), mucorrhea (7%), vaginal prolapse (6%), and malodor (5%). Six intestinal vaginoplasty segments developed vascular compromise leading to flap loss. There were 2 reported mortalities.
CONCLUSION
Intestinal vaginoplasty is associated with a range of complications including vaginal stenosis, mucorrhea, and vaginal prolapse. Intra-abdominal complications, including diversion colitis, anastomotic bowel leak, and intra-abdominal abscess can occur many years after surgery, be life-threatening and require prompt diagnosis and management.
PubMed: 37479146
DOI: 10.1016/j.urology.2023.07.005 -
Minimally Invasive Therapy & Allied... Dec 2023Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions...
OBJECTIVE
Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs).
DESIGN
Prospective analysis.
SETTING
A teaching and university hospital.
PATIENTS
Women with RPOC.
INTERVENTIONS
Office -HM with 'Truclear 5 C'.
MATERIAL AND METHODS
Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed.
RESULTS
Mean procedure time was six minutes ( ± 5). Tissue samples had a mean collection size 2.5 cm+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any IUAs in any of the enrolled patients.
CONCLUSIONS
In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.
Topics: Pregnancy; Humans; Female; Cesarean Section; Morcellation; Pregnancy Complications; Uterine Diseases; Hysteroscopy; Retrospective Studies
PubMed: 37493491
DOI: 10.1080/13645706.2023.2227694 -
Journal of Pediatric and Adolescent... Dec 2023To describe surgical correction of vaginal agenesis via a modified laparoscopic Vecchietti procedure with the goal of disseminating knowledge and improving surgical...
OBJECTIVE
To describe surgical correction of vaginal agenesis via a modified laparoscopic Vecchietti procedure with the goal of disseminating knowledge and improving surgical technique CASE: An 18-year-old female presented with primary amenorrhea, age-appropriate secondary sex characteristics, a shallow vagina, and 46,XX karyotype. Imaging showed rudimentary uterine horns and normal ovaries, kidneys, and spine. Diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome type I was made. After an unsuccessful attempt at vaginal dilation and extensive counseling, the patient chose to have a laparoscopic Vecchietti procedure. Vecchietti vaginoplasty eliminates the need for grafts and creates a neovagina with accelerated vaginal dilation by stretching the introital mucosa with a spring mechanism.
RESULTS
A modified laparoscopic Vecchietti procedure was performed. Postoperatively, daily suture adjustments were made. When the device was removed after 7 days, the examination revealed a 9-cm vaginal canal, which was maintained with self-dilation.
Topics: Female; Animals; Humans; Adolescent; Vagina; Laparoscopy; Uterus; Plastic Surgery Procedures; 46, XX Disorders of Sex Development; Mullerian Ducts; Congenital Abnormalities; Treatment Outcome
PubMed: 37354985
DOI: 10.1016/j.jpag.2023.06.004 -
Obstetrics and Gynecology Dec 2023To compare the labor curve between individuals with induced labor and those undergoing spontaneous labor. (Comparative Study)
Comparative Study
OBJECTIVE
To compare the labor curve between individuals with induced labor and those undergoing spontaneous labor.
METHODS
This was a secondary analysis of the Consortium on Safe Labor database, including nulliparous and multiparous individuals with singleton vertex pregnancy who delivered vaginally after spontaneous labor or induction of labor at term. Labor that resulted in uterine rupture and neonates with a 5-minute Apgar scores less than 7, birth injury, or neonatal intensive care unit admission was excluded. We modeled the course of cervical dilation using repeated-measures analysis with a polynomial function. We compared traverse time , defined as the elapsed time between two given dilation measures, between induced and spontaneous labor using interval-censored regression.
RESULTS
Of 46,835 nulliparous individuals, 18,576 and 28,259 underwent induced and spontaneous labor, respectively. Of 77,503 multiparous individuals, 29,684 and 47,819 underwent induced and spontaneous labor, respectively. The start of the active phase on the labor curve was 6 cm in induced labor, regardless of parity. In nulliparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 1.8 hours [5th-95th percentile 0.4-8.6 hours] vs 2.3 hours [5th-95th percentile 0.6-9.4 hours]; P <.01). In multiparous individuals, induced labor compared with spontaneous labor had a significantly shorter traverse time from 6 to 10 cm (median 0.9 hours [5th-95th percentile 0.1-6.0 hours] vs 1.4 hours [5th-95th percentile 0.3-7.9 hours]; P <.01).
CONCLUSION
Similar to spontaneous labor, the start of the active phase of induced labor was at 6 cm of dilation. Comparatively, induced labor had a shorter active phase than spontaneous labor. These findings suggest that the current criteria for active phase arrest provided by the American College of Obstetricians and Gynecologists do not need to be lengthened for individuals in induced labor.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Labor Stage, First; Labor, Induced; Labor, Obstetric; Parity; Retrospective Studies; Time Factors
PubMed: 37826850
DOI: 10.1097/AOG.0000000000005407