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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 -
American Journal of Obstetrics and... Mar 2024Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor... (Review)
Review
Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Cesarean Section; Delivery, Obstetric; Fetus; Obstetrics; Labor, Obstetric
PubMed: 38462267
DOI: 10.1016/j.ajog.2022.10.037 -
Avicenna Journal of Phytomedicine 2023To determine whether addition of evening primrose to a misoprostol-based abortion regimen can increase the success of abortion.
OBJECTIVE
To determine whether addition of evening primrose to a misoprostol-based abortion regimen can increase the success of abortion.
MATERIALS AND METHODS
In this randomized clinical trial., 148 women referring to Niknafas Hospital in Rafsanajn with diagnosis of missed abortion were randomly allocated into two 74-subject groups. The intervention group used 2000 mg vaginal evening primrose capsules the night before the hospitalization, while the control group did not receive any medication. Both groups received an initial dose of 800 μg of vaginal misoprostol after admission and the next dose was given three hours later if necessary.
RESULTS
The two groups had significant differences in terms of full abortion, consistency and dilatation of cervix, duration between the first dose of misoprostol until the ejection of fetus, the misoprostol dose administered, and the level of vaginal bleeding during the hospitalization. They had no significant differences regarding curettage, duration of hospitalization, or side effects. The mean pain score had no significant difference between the two groups, though the score was lower in the intervention group (p>0.05).
CONCLUSION
Administration of vaginal evening primrose before vaginal misoprostol was found to be more effective compared to misoprostol alone in missed abortion.
PubMed: 38089421
DOI: 10.22038/AJP.2023.22179 -
AJOG Global Reports Aug 2023Labor progression curves are believed to differ between spontaneous and induced labors. However, data describing labor progression patterns with different modes of...
BACKGROUND
Labor progression curves are believed to differ between spontaneous and induced labors. However, data describing labor progression patterns with different modes of induction are insufficient.
OBJECTIVE
This study aimed to compare the progress patterns between labors induced with slow-release prostaglandin E vaginal analogue and those induced with a double-balloon catheter.
STUDY DESIGN
This retrospective cohort study included all nulliparous women who delivered at term and who underwent cervical ripening with prostaglandin E vaginal analogue or a double-balloon catheter from 2013 to 2021 in a tertiary hospital in Israel. Included in the analysis were women who achieved 10 cm cervical dilatation. The time intervals between centimeter-to-centimeter changes were evaluated.
RESULTS
A total of 1087 women were included of whom 786 (72.3%) were induced using prostaglandin E vaginal analogue and 301 (27.7%) were induced using a double-balloon catheter. The time from induction to birth was similar between the groups (32.5 hours for the prostaglandin E vaginal analogue group [5th-95th percentiles, 6.5-153.8] vs 29.2 hours for the double-balloon group [5th-95th percentiles, 9.1-157.1]; =.100). The median time of the latent phase (2-6 cm dilation) was longer for the double-balloon catheter group than for the prostaglandin E vaginal analogue group (7.3 hours [5th-95th percentiles, 5.6-14.5] vs 6.0 hours [5th-95th percentiles, 2.4-18.8]; =.042). The median time of active labor (6-10 cm dilatation) was similar between groups (1.9 hours [5th-95th percentiles, 0.3-7.4] for the prostaglandin E vaginal analogue group vs 2.3 hours [5th-95th percentiles, 0.3-6.5] for the double-balloon catheter group; =.307).
CONCLUSION
Deliveries subjected to cervical ripening with a double-balloon catheter were characterized by a slightly longer latent phase than deliveries induced by prostaglandin E vaginal analogue. After reaching the active phase of labor, the mode of cervical ripening did not influence the labor progress pattern.
PubMed: 37645656
DOI: 10.1016/j.xagr.2023.100198 -
AJOG Global Reports Nov 2023Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or...
INTRODUCTION
Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or inappropriate vaginal dilator use. Image-guided recanalization, especially for obstructed genitourinary tracts, is an emerging idea in interventional radiology. Although multiple surgical techniques have been reported to treat vaginal agenesis or obstruction, the idea of image-guided recanalization of vaginal stenosis is a relatively new management strategy for vaginal stenosis.
CASE
We present a challenging case of a patient who initially presented with the complaint of increasing pelvic pressure after the creation of a neovagina via vaginoplasty. She had a distal neovagina created after extensive surgical resection for a large infiltrating pelvic rectal adenocarcinoma. A computed tomography scan revealed a fluid-filled neovaginal abscess. Examination under anesthesia revealed complete stenosis of the neovagina with no identifiable tract for dilation.
INTERVENTION
A computed tomography scan and fluoroscopy-guided sharp recanalization of the stenosed neovagina was performed, followed by serial fluoroscopic balloon angioplasty to dilate the stenosed neovagina. Finally, the patient underwent a gynecologic surgery for the excision of remaining granulation tissue to produce a more permanent patent neovagina, followed by regular and proper use of vaginal dilators to ensure patency.
CONCLUSION
This case report demonstrates that image-guided techniques can be used to aid in vaginal recanalization in the postoperative setting.
PubMed: 37701754
DOI: 10.1016/j.xagr.2023.100257 -
Journal of Education & Teaching in... Apr 2024This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated...
AUDIENCE
This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC).
INTRODUCTION
Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality.
EDUCATIONAL OBJECTIVES
At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU).
EDUCATIONAL METHODS
This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: "I heard the team leader state that the platelets were normal, but then another resident disagreed. No one paused to come to a consensus. I'm wondering why this wasn't explored further in real time. Tell me more." This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows.
RESEARCH METHODS
Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.
RESULTS
Thirteen learners completed a feedback form out of seventeen participants. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores.
DISCUSSION
This is a cost-effective method for reviewing septic abortion and DIC. The case may be modified for appropriate audiences, such as simplifying the case to septic abortion without DIC. You can also consider not showing an initial temperature with the initial set of vitals unless it is specifically asked for by the participants. We encourage readers to utilize bleeding moulage techniques as a visual stimulus to increase psychological buy-in.
TOPICS
Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine.
PubMed: 38707944
DOI: 10.21980/J8GH1G -
Journal of Education & Teaching in... Apr 2024Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to...
UNLABELLED
Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to surrounding organ systems (eg, gastrointestinal, urological, vascular, etc.). Risk factors include advanced maternal age, prior gynecologic surgeries, and other anatomical features that impact the difficulty of accessing the uterine cavity. In this case report, we discuss a patient who presented to the emergency department (ED) with diffuse abdominal pain and vaginal bleeding that occurred after an elective dilation and curettage (D&C) for a termination of pregnancy. The diagnosis was suspected clinically and confirmed by imaging including ultrasound (US) and computed tomography (CT) of the abdomen and pelvis. The patient was managed operatively with a multidisciplinary approach including Gynecology, General Surgery, and Urology. The patient was stabilized and eventually discharged. Uterine perforation should be included in the differential for patients with a history of recent gynecologic instrumentation presenting with abdominal pain and vaginal bleeding. The stabilization of these patients requires aggressive volume resuscitation, controlling the source of bleeding, and emergent surgical consultation.
TOPICS
Gynecology, vaginal bleeding, ultrasound, computed tomography.
PubMed: 38707940
DOI: 10.21980/J83643 -
European Journal of Obstetrics &... Mar 2024This study aims to compare the perinatal outcomes of emergency and elective cervical cerclages.
OBJECTIVE
This study aims to compare the perinatal outcomes of emergency and elective cervical cerclages.
MATERIAL AND METHODS
This retrospective study included a total of 247 patients, with a total of 142 emergency (with a history of mid-trimester miscarriage or vaginal delivery of < 34 weeks and cervical length < 25 mm) and 105 electives cerclage patients (with painless cervical dilation and cervical length <25 mm) who had cerclage with the vaginal cervical McDonald technique between 1.1.2017-1.10.2022. Pregnant women with normal screening tests at weeks 11-14, normal fetal morphology, and singleton pregnancies were included in the study. The study was conducted in a tertiary center providing NICU care for < 1500 g, less than 32 weeks of age, and on a mechanical ventilator. Obstetric and perinatal outcomes were reviewed.
RESULTS
There was no statistical difference between the two groups regarding maternal age or BMI. It was observed that the week of delivery was greater for elective cerclages than for emergency cerclages (mean 34.6 GW versus 30.8 GW). The week of cerclage application was statistically higher in emergency cerclage (19.2 GW versus 16.3 GW p < 0.000). In addition, when we evaluated perinatal complications: prenatal Ex (n34 vs. n8 p < 0.001), C-reactive protein which is a marker of neonatal infection (12.7 mg/L vs. 2.5 mg/L p < 0.022), antibiotic use in the NICU (n 35 vs. n23 p < 0.050), the number of days of antibiotic use in the NICU (mean 15.3 days vs. 10.4 days p < 0.024), rate of NICU intubation (n 27 vs. n 11 p < 0.003), and neonatal sequelae (n 16 vs. n 6 p < 0.016) were significantly higher in the emergency cerclage group than in the elective cerclage group. There was no found significant difference between the progesterone given and not given progesterone after the procedure in term of the weeks of delivery ( 0.810 emergency cervical cerclage; p < 0681 elective cervical cerclage).
CONCLUSION
Considering the available information, the results of elective cerclage seem to be more beneficial for the patient than those of emergency cerclage. Therefore, it would be more reasonable to perform elective cerclage in patients with mid-trimester or preterm miscarriage and concomitant cervical shortening before emergency cerclage is required. Furthermore, the benefit of progestin, in addition after surgical intervention, has not been established.
PubMed: 38323103
DOI: 10.1016/j.eurox.2023.100276 -
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 -
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