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Journal of Pediatric and Adolescent... Jun 2020
Topics: Dilatation; Female; Humans; Vagina
PubMed: 31987999
DOI: 10.1016/j.jpag.2020.01.005 -
The Cochrane Database of Systematic... Apr 2015Hysteroscopy is an operation in which the gynaecologist examines the uterine cavity using a small telescopic instrument (hysteroscope) inserted via the vagina and the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hysteroscopy is an operation in which the gynaecologist examines the uterine cavity using a small telescopic instrument (hysteroscope) inserted via the vagina and the cervix. Almost 50% of hysteroscopic complications are related to difficulty with cervical entry. Potential complications include cervical tears, creation of a false passage, perforation, bleeding, or simply difficulty in entering the internal os (between the cervix and the uterus) with the hysteroscope. These complications may possibly be reduced with adequate preparation of the cervix (cervical ripening) prior to hysteroscopy. Cervical ripening agents include oral or vaginal prostaglandin, which can be synthetic (e.g misoprostol) or natural (e.g. dinoprostone) and vaginal osmotic dilators, which can be naturally occurring (e.g. laminaria) or synthetic.
OBJECTIVES
To determine whether preoperative cervical preparation facilitates cervical dilatation and reduces the complications of operative hysteroscopy in women undergoing the procedure for any condition.
SEARCH METHODS
In August 2014 we searched sources including the Menstrual Disorders and Subfertility Group (MDSG) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and reference lists of relevant articles. We searched for published and unpublished studies in any language.
SELECTION CRITERIA
Two review authors independently selected randomised controlled trials (RCTs) of cervical ripening agents used before operative hysteroscopy in pre- and postmenopausal women. Cervical ripening agents could be compared to each other, placebo or no treatment.
DATA COLLECTION AND ANALYSIS
Data extraction and quality assessment were conducted independently by two review authors. The primary review outcomes were effectiveness of cervical dilatation (defined as the proportion of women requiring mechanical cervical dilatation) and intraoperative complications. Secondary outcomes were mean time required to dilate the cervix, preoperative pain, cervical width, abandonment of the procedure, side effects of dilating agents and duration of surgery. We calculated odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with 95% confidence intervals ( CIs). Data were statistically pooled where appropriate. Heterogeneity was assessed using the I(2) statistic. The overall quality of the evidence was assessed using GRADE methods.
MAIN RESULTS
Nineteen RCTs with a total of 1870 participants were included. They compared misoprostol with no treatment or placebo, dinoprostone or osmotic dilators.Misoprostol was more effective for cervical dilatation than placebo or no intervention, with fewer women requiring mechanical dilatation (OR 0.08, 95% CI 0.04 to 0.16, five RCTs, 441 participants, I(2)=0%, moderate quality evidence). This suggests that in a population in which 80% of women undergoing hysteroscopy require mechanical dilatation without use of preoperative ripening agents, use of misoprostol will reduce the need for mechanical dilatation to between 14% and 39%. Misoprostol was associated with fewer intraoperative complications (OR 0.37, 95% CI 0.18 to 0.77, 12 RCTs, 901 participants, I(2)=0%, moderate quality evidence). This suggests that in a population in which 3% of women undergoing hysteroscopy experience intraoperative complications without use of preoperative ripening agents, use of misoprostol will reduce the risk of complications to 2% or less.When specific complications were considered, the misoprostol group had a lower rate of cervical laceration or tearing (OR 0.25, 95% CI 0.11 to 0.57, nine RCTS, 669 women, I(2)=0%, moderate quality evidence) or false track formation (OR 0.34, 95% CI 0.12 to 0.97, seven RCTs, 560 participants, I(2)=0%, moderate quality evidence). There was no evidence of a difference between the groups in rates of uterine perforation (0.42, 95% CI 0.13 to 1.38, seven RCTs, 455 participants, I(2)=0%, low quality evidence) or uterine bleeding (OR 0.51, 95% CI 0.10 to 2.49, four RCTs, 340 participants, I(2)=0%, low quality evidence). Some treatment side effects (mild abdominal pain, vaginal bleeding, and increased body temperature) were more common in the misoprostol group.Compared with dinoprostone, misoprostol was associated with more effective cervical dilatation, with fewer women requiring mechanical dilatation (OR 0.58; 95% CI 0.34 to 0.98; one RCT, 310 participants, low quality evidence) and with fewer intraoperative complications (OR 0.32; 95% CI 0.12 to 0.83, one RCT, 310 participants, low quality evidence). However treatment side effects were more common in the misoprostol arm.Compared to osmotic dilatation (laminaria), misoprostol was associated with less effective cervical dilatation, with more women in the misoprostol group requiring mechanical dilatation (OR 5.96, 95% CI 2.61 to 13.59, one RCT, 110 participants, low quality evidence). There was no evidence of a difference between misoprostol and osmotic dilators in intraoperative complication rates (OR 5.14, 95% CI 0.24 to 109.01, three RCTs, 354 participants, low quality evidence), with only two events reported altogether.The overall quality of the evidence ranged from low to moderate. The main limitations in the evidence were imprecision and poor reporting of study methods.
AUTHORS' CONCLUSIONS
There is moderate quality evidence that use of misoprostol for preoperative ripening of the cervix before operative hysteroscopy is more effective than placebo or no treatment and is associated with fewer intraoperative complications such as lacerations and false tracks. However misoprostol is associated with more side effects, including preoperative pain and vaginal bleeding. There is low quality evidence to suggest that misoprostol has fewer intraoperative complications and is more effective than dinoprostone.There is also low quality evidence to suggest that laminaria may be more effective than misoprostol, with uncertain effects for complication rates. However the possible benefits of laminaria need to be weighed against the inconvenience of its insertion and retention for one to two days.
Topics: Cervical Ripening; Cervix Uteri; Dilatation; Dinoprostone; Female; Humans; Hysteroscopy; Laminaria; Misoprostol; Oxytocics; Pregnancy; Preoperative Care; Randomized Controlled Trials as Topic
PubMed: 25906113
DOI: 10.1002/14651858.CD005998.pub2 -
Supportive Care in Cancer : Official... Mar 2017Although vaginal dilator use after combined pelvic radiation therapy and brachytherapy (RT/BT) is recommended to prevent vaginal shortening and stenosis, women fail to...
PURPOSE
Although vaginal dilator use after combined pelvic radiation therapy and brachytherapy (RT/BT) is recommended to prevent vaginal shortening and stenosis, women fail to use them and experience sexual problems. A nurse-led sexual rehabilitation intervention targeting sexual recovery and vaginal dilatation was developed. Its feasibility was investigated during a prospective, longitudinal, observational pilot study.
METHODS
Four oncology nurses were specifically trained to conduct the intervention. Gynecologic cancer patients treated with RT/BT were assessed using (i) questionnaires on frequency of dilator use (monthly), sexual functioning, and sexual distress (at baseline and 1, 6, and 12 months) and psychological and relational distress (at 1, 6, and 12 months); (ii) semi-structured interviews (between 6 and 12 months); and (iii) consultation recordings (a random selection of 21 % of all consults).
RESULTS
Twenty participants were 26-71 years old (mean = 40). Eight participants discontinued participation after 3 to 9 months. At 6 months after RT, 14 out of 16 (88 %), and at 12 months 9 out of 12 (75 %), participants dilated regularly, either by having sexual intercourse or by using dilators. Sexual functioning improved between 1 and 6 months after RT, with further improvement at 12 months. Most participants reported that the intervention was helpful and the nurses reported having sufficient expertise and counseling skills.
CONCLUSIONS
According to the pilot results, the intervention was feasible and promising for sexual rehabilitation and regular dilator use after RT. Its (cost-)effectiveness will be investigated in a randomized controlled trial.
Topics: Aged; Brachytherapy; Constriction, Pathologic; Female; Genital Neoplasms, Female; Humans; Middle Aged; Nurse's Role; Pilot Projects; Prospective Studies; Radiation Injuries; Sexual Behavior; Surveys and Questionnaires; Vagina
PubMed: 27787681
DOI: 10.1007/s00520-016-3453-2 -
Journal of Cancer Survivorship :... Apr 2017We sought to evaluate patient adherence and response to simple vaginal and sexual health treatment strategies in female cancer patients receiving treatment at a female...
PURPOSE
We sought to evaluate patient adherence and response to simple vaginal and sexual health treatment strategies in female cancer patients receiving treatment at a female sexual medicine and health program and identify improvements of physical symptoms, per patient and clinical evaluation.
METHODS
Evaluability criteria included gynecologic exam at initial visit, at least one follow-up with gynecologic exam within 8 months of initial visit, and all consecutive follow-ups <6 months apart. Demographics, medical information, and clinical assessments from 175 evaluable patients with at least one follow-up from 09/12 to 10/14 were analyzed. The majority of patients were being treated for or had a history of breast (n = 90, 53 %), gynecologic (n = 54, 32 %), or colorectal/anal (n = 15, 9 %) cancers. An assessment form included a clinician evaluation, Vaginal Assessment Scale (VAS), Vulvar Assessment Scale (VuAS), and patient-reported outcomes. Compliance with treatment recommendations were summarized, and changes over time were compared for clinical outcomes.
RESULTS
Mean number of visits was 3.43. Mean age was 55.4 years; 92 % (n = 155/169) were in menopause. Treatment strategies included rationale and instruction for use of vaginal moisturizers, lubricants, pelvic floor exercises, and dilator therapy, in addition to psychosexual education regarding sexual changes (response, anatomy, and function) associated with cancer treatment and support. At last assessment, 89 % had complied with the clinical recommendation (moisturize 2-5+ times/week). Vaginal pH scores >6.5 declined over time (p = 0.03). VAS scores improved by last assessment (p < 0.001), as did VuAS scores (p = 0.001). Sexual function scores significantly improved (p < 0.001), confidence about future sexual activity increased (p = 0.004), and sexual/vaginal health concerns decreased (p = 0.00003).
CONCLUSION
Significant changes were observed in women using treatment strategies, with improvement in vulvovaginal symptoms, a decrease in elevated vaginal pH and pain with exams, enhanced sexual function, and increased intimacy confidence.
IMPLICATIONS FOR CANCER SURVIVORS
These findings have high clinical relevance for symptom management with improvement of sexual function using simple strategies and clinical tools in the oncology setting.
Topics: Exercise Therapy; Female; Humans; Middle Aged; Neoplasms; Quality of Life; Reproductive Health; Sexual Behavior; Surveys and Questionnaires; Survivors; Vagina
PubMed: 27868156
DOI: 10.1007/s11764-016-0585-9 -
Journal of Gynecology Obstetrics and... Nov 2023The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also... (Observational Study)
Observational Study
OBJECTIVE
The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also studied the severe maternal and neonatal morbidity and identify some prediction factors of vaginal delivery after labor induction after one previous cesarean section.
STUDY DESIGN
This was a retrospective observational monocentric study performed over the period from January 1st, 2016 to April 30th, 2020 at the university hospital of Rennes. Were included women with scar uterus because of one previous cesarean section with a viable singleton fetus in cephalic presentation and an induction of labor for medical reason, at term. Multivariate logistic regression analysis was used to analyze prediction of vaginal delivery after labor induction after one previous cesarean section. We also studied maternal (included uterine rupture, loss of blood, obstetrical injury of anus sphincter) and neonatal (APGAR score, arterial umbilical pH after 1 minute of life and eventual admission to neonatal unit) morbidity. We used a stepwise multivariate logistic regression model to select variables for multivariate analysis. The model with the lowest Akaike Index Criteria was chosen.
RESULTS
The study enrolled 353 women with scar uterus: 121 women were induced by balloon catheter, 57 by osmotic cervical dilatators, 91 by oxytocin alone, 84 by amniotomy. Vaginal delivery rate was 47,9%. There was 45% of vaginal delivery in the group with Bishop < 6 before induction of labor versus 62% in the group with Bishop ≥ 6. There was no statistically significative difference in neonatal and maternal severe morbidities between vaginal delivery and cesarean section: 4,5% of severe maternal morbidities (n = 16). Among their, we highlighted 7 uterine ruptures (3,8%). We observed also 3% of postpartum severe hemorrhage in vaginal delivery group (n = 5) against 1,6% in cesarian section group (n = 3) with no statistical significant difference (p = 0,632). Regarding to the obstetric perineal tears and lacerations we noticed 1,2% of OASIS 3 (n = 2) and 0,6% of OASIS 4 (n = 1). Severe neonatal morbidities were comparable by mode of delivery without significant difference: APGAR score at 5 min was similar (p = 1), as well as arterial umbilical pH after 1 min. (p = 0.719) and admissions to a neonatal unit (p = 1). Two variables were statistically associated with vaginal delivery after labor induction in women with scar uterus: Bishop score ≥ 6 (OR = 0,44; 95%CI: 0,25-0,81) and/or previous vaginal delivery after cesarean section (OR = 0,17; 95%CI: 0,08-0,35).
CONCLUSION
With 47,9% of vaginal delivery after labor induction in women with scar uterus, only 3.8% (n = 7/353) of uterine ruptures, less than 1% APGAR < 7 at 5 min (n = 3/353), induction on scar uterus should be consider in obstetrical practice. Bishop score ≥ 6 and/or previous vaginal delivery after cesarean section are associated to vaginal delivery after labor induction.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Cesarean Section; Uterine Rupture; Retrospective Studies; Cicatrix; Vaginal Birth after Cesarean; Labor, Induced; Uterus; Postpartum Hemorrhage; Hospitals
PubMed: 37595753
DOI: 10.1016/j.jogoh.2023.102641 -
European Journal of Obstetrics,... Jan 2023Objectives Digital examination has many uses in obstetrics and gynaecology, including cervical assessment in labour and measuring for vaginal pessaries. Clinicians must...
Objectives Digital examination has many uses in obstetrics and gynaecology, including cervical assessment in labour and measuring for vaginal pessaries. Clinicians must be adequately trained to perform accurate digital assessments and use this information to make decisions. We aimed to evaluate the accuracy of a clinician’s estimate for three different measuring tasks and assess whether there was any difference in the accuracy in relation to seniority or job role. Study design Doctors and midwives were recruited from two perineal trauma training events. Estimates and measurements for three different activities were recorded: length of own index finger, length of an anal sphincter model and cervical dilatation at two different dilatations (7 cm and 9 cm) using a pocket guide cervical dilatation tool. The results were analysed for accuracy of measurements according to job role and seniority. Results A total of 369 participants took part. Only 4.6% of participants accurately (to 0.1 cm) estimated the length of their index finger (0% of midwives and 5.5% of doctors). There was a significant difference (p < 0.05) when comparing average differences between estimated and actual lengths measured for doctors and midwives for almost all measurements. When comparing doctors based on seniority there was no significant difference in the accuracy of estimated lengths. A higher percentage of midwives than doctors were accurate at both 7 cm (22% vs 16.1%) and 9 cm (30.5% vs 29.5%) dilated. Conclusion We found that accuracy was poor for both doctors and midwives when asked to estimate various measurements. We suggest that training will improve awareness of finger length and therefore improve accuracy when performing digital examinations in clinical practice.
Topics: Humans; Certification; Educational Measurement
PubMed: 36495777
DOI: 10.1016/j.ejogrb.2022.11.026 -
Journal of Contemporary Brachytherapy Apr 2021The American Brachytherapy Association is attempting to develop standards for delivering brachytherapy, although differences in practice have been reported in the...
PURPOSE
The American Brachytherapy Association is attempting to develop standards for delivering brachytherapy, although differences in practice have been reported in the literature. This study evaluated vaginal cuff brachytherapy (VBT) practice and quality of life-related recommendations among Turkish radiation oncologists.
MATERIAL AND METHODS
A nationwide web-based 17-item survey was distributed to the members of the Turkish Society for Radiation Oncology. These members received e-mail notifications, and a link was posted on the Turkish Society for Radiation Oncology internet site to solicit voluntary responses The survey addressed the simulation processes, target volume, prescribed dose, delivery schedules, and recommendations related to vaginal side effects.
RESULTS
Fifty-seven radiation oncologists responded to the survey. The most used dose fraction schemes for adjuvant VBT were 7 Gy × 3 fractions (30%), 5.5 Gy × 5 fractions (26%), and 6 Gy × 5 fractions (28%). The preferred VBT scheme was 5 Gy × 3 fractions (50%) when the external beam radiotherapy (EBRT) dose was 45 Gy external radiotherapy, while the preferred schemes were 6 Gy × 3 fractions (30%) or 5 Gy × 3 fractions (32%) when the external radiotherapy dose was increased to 50.4 Gy. One-half of the respondents delivered VBT twice a week, and the dose was prescribed to 0.5 cm from vaginal mucosa by 86% of the respondents. There was no common definition for the dose prescription length, which was defined as 3 cm from the vaginal cuff in 33% of responses and as 4 cm in 35% of responses. For serous and clear cell histological types, 38% of the respondents targeted "full cylinder length". To prevent vaginal side effects, 78% of the respondents recommended using a vaginal dilator and/or sexual intercourse after VBT.
CONCLUSIONS
This survey revealed variations in the clinical practice of VBT among Turkish radiation oncologists, which suggests that standardization is necessary.
PubMed: 33897788
DOI: 10.5114/jcb.2021.105282 -
Facts, Views & Vision in ObGyn Sep 2023Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome has an incidence of 1 in 4000. The absence of the vagina and uterus results in sexual dysfunction and infertility. The...
BACKGROUND
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome has an incidence of 1 in 4000. The absence of the vagina and uterus results in sexual dysfunction and infertility. The first-line treatment is vaginal dilatation. There exists a number of second-line surgical options including the Uncu-modified Davydov procedure.
OBJECTIVE
To determine the complication rate, anatomical outcomes, and long-term sexual outcomes of MRKH syndrome patients after Uncu-modified Davydov procedure.
MATERIALS AND METHODS
Patients with MRKH syndrome who underwent paramesonephric remnant-supported laparoscopic double-layer peritoneal pull-down vaginoplasty (aka Uncu-modified Davydov procedure) between January 2008 and December 2021. The procedure involves laparoscopic circular dissection of the pelvic peritoneum followed by pulling down, through the opened vaginal orifice, and suturing the vaginal cuff with the support of uterine remnants. The long-term complication rate, anatomical outcomes, and sexual function outcomes (as measured by Female Sexual Function Index (FSFI)) were ascertained.
MAIN OUTCOME MEASURES
Main Outcome Measures: The long-term complication rate, anatomical outcomes and FSFI survey results.
RESULTS
A total of 50 patients with MRKH syndrome underwent the Uncu-modified Davydov procedure between Jan 2008- Dec 2021. There were four perioperative complications: three bladder injuries (6%) and one rectal serosa injury (2%). Four long-term postoperative complications were identified: one vesicovaginal fistula (2%), one recto-vaginal fistula (2%), and two vaginal stenoses (4%). All patients were physically examined at least one year after surgery. The mean vaginal length was 8.4 + 1.9 cm. The mean FSFI score was 31.5 + 3.9 (minimum score of 24, maximum score of 36).
CONCLUSION
Conclusion: The Uncu-modified Davydov procedure has been demonstrated to be a safe and effective treatment option with high female sexual function index scores for patients with MRKH syndrome.
WHAT IS NEW?
The long-term complication rate, anatomical and sexual outcomes of Uncu-modified laparoscopic peritoneal pull-down vaginoplasty were reported in this study. The results indicated that the surgical approach could be used in selective MRKH patients who failed first-line self-dilatation therapy.
PubMed: 37742200
DOI: 10.52054/FVVO.15.3.091 -
BMC Cancer Jul 2021
Correction to: Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial.
PubMed: 34266416
DOI: 10.1186/s12885-021-08543-8 -
Life (Basel, Switzerland) Oct 2023Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean...
Delivery Progress, Labor Interventions and Perinatal Outcome in Spontaneous Vaginal Delivery of Singleton Pregnancies between Nulliparous and Primiparous Women with One Previous Elective Cesarean Section: A Retrospective Comparative Study.
UNLABELLED
Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean section (LSCS), resulting in most cases being a successful vaginal birth after cesarean section (VBAC). The primary objective of this study was to examine if the progress and the duration of the active first stage and the second stage of labor in nulliparous women with singleton pregnancy, spontaneous start of labor and vaginal birth differ from primiparous women succeeding VBAC after one previous elective LSCS in a country with a low cesarean section and high VBAC rate. Secondary objectives were to compare labor interventions and maternal-neonatal outcomes between the two groups.
METHODS
This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally.
RESULTS
The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal-neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used.
CONCLUSIONS
Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC.
PubMed: 37895398
DOI: 10.3390/life13102016