Colposcopic acetowhitening of vulvar lesion: a validity study

Objective

To evaluate the acetowhite changes of the vulva as a predictor for high grade vulvar intraepithelial neoplasia.

Methods

We performed retrospective analysis from 344 patients referred to our gynecology oncology clinic for genital dysplasia. All patients underwent vulvar colposcopy. Vulvar biopsies were performed for acetowhite changes and visible vulvar lesions such as ulceration, hyperpigmentation, and thickening of the vulvar tissue. High grade vulvar dysplasia was defined as vulvar intraepithelial neoplasia 2 or worse. Results of the vulvar pathology were collected and sensitivity, specificity, negative and positive predictive values.

Results

Of the 344 women who underwent vulvoscopy 241 patients had acetowhite lesions, of whom 89 had true high grade dysplasia. Using colposcopic acetowhite changes as a marker for high grade vulvar dysplasia, the test’s sensitivity was 97 %, specificity was 40 %, negative predictive value was 98 %, and the positive predictive value was 37 %.

Conclusion

Acetowhitening of the vulva has high sensitivity but low specificity as a predictor of high grade vulvar intraepithelial neoplasia. The absence of acetowhite lesion can reassure that high grade vulvar lesion is absent.

     

Maternal physical activity,cervical length and its relation to spontaneous vaginal birth at term

Objective

Physical activity during pregnancy is known to be beneficial, however there are controversies about the risk of preterm labor, and there is no published data to assess the association between cervical length and maternal physical activity during pregnancy. Therefore, the objective of the study was to describe the cervical length in the second and third trimesters, correlating with physical activity, anthropometric characteristics, and obstetric results.

Methods

Prospective cohort with 56 pregnant women, allocated in two groups according to the answers obtained by a validating questionnaire on physical activity. It was considered significant p < 0.05.

Results

The length of the uterine cervix was similar between active and sedentary women, from the 22nd to the 24th week of pregnancy (p = 0.58), and from the 32nd to the 34th week (p = 0.59). Gestational age at delivery was lower among active women than among sedentary ones, although without clinical repercussion, 38.2 ± 1.2 vs. 39.1 ± 1.2 weeks, respectively (p = 0.02). Among active women, 33 (89.1 %) had natural labor, while among sedentary ones, only 13 (68.4 %) (p = 0.05). The Apgar score was higher among children of active mothers (p = 0.04).

Conclusion

Despite being the data still to small to allow final conclusions, maternal physical activity, cervical length and its relation to spontaneous vaginal birth at term is a relevant topic for the information of women in early pregnancy. More investigations directly after specific activities such as riding, walking, and biking are needed to answer the questions we receive from our pregnant patients.     

Frequency of cervical intraepithelial neoplasia grade II or worse in women with a persistent low-grade squamous intraepithelial lesion seen by Papanicolaou smears

Purpose

We investigated the frequency of cervical intraepithelial neoplasia (CIN) grade II or worse in low-income Brazilian women with persistent low-grade squamous intraepithelial lesions (LSIL).

Methods

A retrospective review of medical records was performed for all patients who underwent a loop electrosurgical excision procedure (LEEP) with "see and treat" strategy for persistent LSIL seen on Papanicolaou (Pap) smears (persisting >12 months in at least two consecutive tests, over a 50-month period. We assessed the colposcopy and histopathology results at the time of the procedure and at follow-up, using Pap and histopathology.

Results

Of 106 women, 48 (45.3 %) had no dysplasia by histopathology, 18 (17.0 %) had CIN I, 29 (27.4 %) had CIN II and 10 (9.4 %) had CIN III. Among the patients with CIN, 38 (66.7 %) performed the follow-up. Of these, only 4 (10.5 %) were classified as follow-up (+), all had CIN I. Women with initial CIN I had 16.7 % (n = 2) recurrences; those with initial CIN II had 5.9 % (n = 1); and those with initial CIN III had 11.1 % (n = 1) (p > 0.05).

Conclusions

A very high proportion of the women with persistent LSIL had CIN II/III on post-LEEP histopathology. Recurrence rates were equal to than those that originally caused the patients to be subjected to LEEP (LSIL). The benefits of the "see and treat" protocol by LEEP for persistent LSIL outweigh the risk of overtreatment, principally in low-resource settings where poor patient compliance is expected, as in Brazil.     

Effects of gender roles, child wish motives, subjective well-being, and marital adjustment on infertility-related stress: a preliminary study with a Hungarian sample of involuntary childless men and women

Purpose

The aim of the study is to investigate the infertility-related stress in a Hungarian infertile population and examine the effects of gender roles, child wish motives, subjective well-being, and marital relationship on the experience of infertility according to our self-constructed conceptual framework.

Methods

Validated self-report questionnaires measuring the factors of the conceptual framework were taken in the study carried out in a sample of 53 people attending the fertility unit of a Hungarian clinic.

Results

Infertility-related global stress, infertility-related social concerns, and general health problems have more intensive effect on women than on men (all p < 0.05). Women from the infertile group scored higher their femininity (p < 0.001) and lower their general health (p < 0.05) than the reference population. Infertile men believe deeper in meaning of life than women (p < 0.05) or reference population (p < 0.01). Femininity (β = 0.460, p < 0.05), traditional gender role concepts (β = ?0.248, p < 0.05), general health (β = ?0.474, p < 0.05), and marital relationship (β = ?0.251, p < 0.05) play the strongest role to predict stress caused by infertility.

Conclusions

The current study emphasizes the importance of interrelations of gender role attitudes, gender role identification, general health, and satisfaction in couple relationship with infertility-related stress. In further investigations, both social and personal aspects and their effect on experiencing infertility need to be measured in infertile people, particularly in different cultural settings.     

Comparison of clinical and perinatal outcomes in early- and late-onset preeclampsia

Purpose

To compare the clinical and laboratory findings and maternal–perinatal outcomes between women with early-onset preeclampsia (EO-PE) and late-onset preeclampsia (LO-PE).

Methods

One hundred and fifty-four women with preeclampsia (PE) who delivered in our clinic were included in the study. Perinatal and obstetric outcomes were evaluated.

Results

The incidence of abnormal uterine artery (UtA) velocity waveform was significantly higher in the EO-PE group (71.4 vs 30.1 %) (p < 0.001). The incidences of small-for-gestational age, oligohydramnios, Apgar score <7 at 5 min, stillbirth and early neonatal death rates were significantly higher in women with EO-PE compared to LO-PE (p < 0.01). Maternal complications were only recorded in women with severe PE.

Conclusion

EO-PE, especially with abnormal UtA Doppler findings defines a placentation abnormality with higher perinatal adverse outcomes.     

Patient satisfaction with childbirth after external cephalic version

Purpose

To assess acceptance and impact of external cephalic version (ECV) for breech presentation at term on maternal satisfaction with childbirth.

Methods

Retrospective study on n = 131 women with breech presentation comparing maternal satisfaction after ECV and consecutive childbirth (n = 66; 50.4 % of these successful attempts in n = 33; 50 %) against the group without ECV and primary caesarean section (CS) (n = 65; 49.6 %) instead using a questionnaire.

Results

Women with successful ECV tolerated side effects of the intervention better than after unsuccessful ECV (pain, tocolytics, mental and physical state, for all p < 0.001). They were not more satisfied with childbirth than women who experienced an unsuccessful ECV (p = 0.37). However, they would undergo the procedure again (p = 0.003) and would recommend it to other women (p < 0.001). Only women with spontaneous vaginal deliveries after successful version were more satisfied with childbirth than women with planned CS (p = 0.05). Women with version attempts tend to perceive childbirth as being less problematic with fewer complications (9.5 vs. 19 %, p = 0.12). Unsuccessful ECVs had no negative impact on satisfaction with childbirth (p = 0.072).

Conclusion

Attempting ECV seems to be an option for increasing the rate of vaginal births with breech presentation without negative impact on maternal satisfaction regarding consecutive childbirth.     

Misoprostol for cervical ripening prior to gynecological transcervical procedures

Purpose

Dilatation and curettage is frequently performed in gynecological practice. Aim of this prospective randomized double-blind placebo-controlled study was to evaluate the safety and efficacy of oral misoprostol to prime non-pregnant cervix before this procedure.

Method

Women requiring dilatation and curettage were included in the study. Exclusion criteria were visible growth in cervix or vagina, pregnancy, allergy to prostaglandins, some medical disorders. Each participant was instructed to take either 400 µg of misoprostol or placebo orally 12 h before the procedure. Primary outcome measure was: diameter of the largest negotiable Hegar’s dilator through internal os without any resistance at the beginning of the procedure. Secondary outcome measures were: percentage of women with initial cervical dilatation of ≥5 mm, time required for optimum cervical dilatation, percentage of failed procedures and complications. t test, Chi-square test and Fisher’s test were used to compare the variables.

Result

Misoprostol significantly increased baseline cervical diameter in the pre-menopausal group (p < 0.001), but not in post-menopausal subjects (p = 0.1) and reduced time required for cervical dilatation in both pre-and post-menopausal women. The number of patients achieving initial cervical dilatation ≥5 mm was significantly greater in pre-menopausal subjects receiving misoprostol, but not significant in post-menopausal ones. The drug was also found to be effective in both nulliparous and multiparous patients. Side effects were comparable between two groups. Only nausea and vomiting were more frequent in post-menopausal misoprostol group than placebo (p = 0.018).

Conclusion

Four hundred micrograms of oral misoprostol 12 h prior to dilation and curettage was found to be beneficial in cervical priming in pre-menopausal subjects. It was also found to be effective irrespective of the parity of the patients.     

The association of a cervical length of <25 mm in high-risk pregnancies on neonatal morbidity and mortality in preterm infants

Purpose

To evaluate and compare the effects of a short cervix (<25 mm) on neonatal morbidity and mortality as opposed to a normal cervical length (≥25 mm). The predictive value of a short cervix on neonatal outcome is also investigated.

Methods

Preterm infants who were admitted to the neonatal intensive care unit and whose mothers had undergone a pre-delivery evaluation for cervical length (CL) and cervical cultures were included in the study. Infants were stratified into two groups based on CL measurements (Group 1, CL < 25 mm; Group 2, CL ≥ 25 mm).

Results

A total of 203 infants were included in the final analysis. Group 1 consisted of 105 neonates while Group 2 had 98 newborns. Cervical culture positivity rate was 46.7 % (n = 49) in Group 1 compared to 19.4 % (n = 19) in Group 2 (p = 0.0001). Frequencies of early onset neonatal sepsis (EOS) in Group 1 and Group 2 were 31.5 and 18.4 %, respectively (p = 0.032), whereas respective frequencies of proven sepsis in the two groups were 18.1 and 8.2 % (p = 0.037). A CL < 25 mm was found to increase the risk of cervical culture positivity, EOS and proven EOS by odds ratios of 3.63, 2.03 and 2.48, respectively.

Conclusions

This is the first clinical study to demonstrate a significant link between CL and each of cervical culture positivity, EOS and neonatal morbidity and mortality. Preterm infants born to high-risk mothers with short CL should be monitored closely for the risk of EOS.     

Maternal death in the emergency department from trauma

Purpose

Trauma during pregnancy is among leading causes of non-pregnancy-related maternal death (MD). This study describes risk factors for MD from trauma during pregnancy in a large urban population.

Methods

We queried an urban Level One Trauma Center registry for the medical records of pregnant women suffering trauma from 1990 to 2007. Associations were examined between maternal demographics, injury mode details, injury characteristics, and risk of maternal death upon arrival to the emergency room.

Results

Overall, 351 patients were identified. Most traumas was caused by motor vehicle collision (71.8 %), accounting for 78.9 % of MD, followed by gun shot wound (10.3 %), stabbing (8.5 %), falls (4.3 %), and assaults (4 %). Abdominal and head injuries were more frequent in cases of MD compared with patients admitted to the hospital (33.3 vs. 25.1 % abdominal, 55.6 vs. 29.4 % head; p < 0.001). A greater proportion of MDs were characterized by lack of restraint use (66.7 %) compared to women admitted to the hospital (47.7 %) and women discharged after observation (43.1 %); p = 0.014. ER deaths had more negative base excess scores than women who were admitted or discharged (?14 vs. ?3 vs. ?2; p < 0.001), lower blood pH values (6.96 vs. 7.40 vs. 7.44; p < 0.001), greater Injury Severity Scores (ISS) (44.4 vs. 11.49 vs. 2.66; p < 0.001), and lower Revised Trauma Scores (RTS) (0.5 vs. 7.49 vs. 7.83; p < 0.001).

Conclusions

Lack of restraint use in the pregnant population is associated with increased MD. Although not validated in the pregnant population, the ISS and RTS were associated with maternal mortality outcomes.     

The role of apoptosis in preterm premature rupture of the human fetal membranes

Purpose

The present study was designed to examine apoptotic cell death via the caspase-dependent pathway in human fetal membranes.

Methods

Amniotic membrane samples were collected from three groups of women: group 1, women with preterm premature rupture of fetal membranes (PPROM) after cesarean delivery (n = 10), group 2, women with preterm labor (PTL) with intact membranes after cesarean delivery (n = 9) and group 3, women with term labor and vaginal delivery after an uncomplicated pregnancy (controls) (n = 11).

Results

Active caspase-3 immunopositivity (ACPI) of the PPROM group was significantly higher than that of the control group (p < 0.05). ACPI was higher in the PTL with intact membranes group as compared to the control group; however, it did not reach statistical significance (p > 0.05).

Conclusion

Active caspase-3 positivity is increased in the fetal membranes of those women with PPROM.     

Clinical significance of ptyalism gravidarum

Objective

The aim of this study was to identify the clinical significance associated with ptyalism gravidarum in Japanese singleton pregnancies.

Methods

Data were collected from 22 patients complicated by ptyalism gravidarum whose symptoms continued until delivery and from 7,743 unaffected controls.

Results

The incidence of ptyalism gravidarum in the Japanese pregnant women was about 0.3 %. Using multiple logistic regressions, ptyalism gravidarum was associated with history of hyperemesis gravidarum (p < 0.01), neonatal male sex (p = 0.02) and small for gestational age infants (p = 0.04).

Conclusions

Ptyalism gravidarum may be a distinctive condition leading to adverse perinatal outcomes.     

Need for episiotomy in a subsequent delivery following previous delivery with episiotomy

Purpose

To assess the need of episiotomy in a subsequent delivery in women with previous primiparous vaginal delivery with episiotomy.

Methods

In this historical prospective study, we followed primiparous women who had an episiotomy at a normal vaginal delivery. The study group included parturient women (n = 201) who underwent an episiotomy at a vaginal delivery during a 2-year period (2001–2002). Inclusion criteria were: primiparity, term singleton vaginal delivery, episiotomy, and a subsequent vaginal delivery in Edith Wolfson Medical Center. Exclusion criteria were instrumental delivery at the index delivery, preterm delivery or twins at the subsequent delivery. Episiotomy in the enrolled parturient women was done when it is thought that failure to perform episiotomy would result in perineal tears. The control group (n = 201) was formed from the same time period and included women who had a spontaneous vaginal delivery without episiotomy.

Results

Of the 201 women with episiotomy at the index delivery, 48 (23.9 %) had episiotomy at the subsequent delivery compared to only 20 women (10.0 %) out of the 201 women without an episiotomy at index delivery (p < 0.05). Having an episiotomy at the index delivery significantly increased odds of a subsequent episiotomy (OR 2.84, 95 % CI 1.62–4.99, p < 0.05) and the risk of spontaneous perineal tears (59.2 vs. 23.4 %, p < 0.05) at the subsequent delivery.

Conclusion

Episiotomy at first vaginal delivery significantly and independently increased the risk of repeated episiotomy and spontaneous perineal tears in a subsequent delivery.     

Fetal uvula: navigating and lightening the soft palate using HDlive

Background

Anaemia is the most common complication of pregnancy and a predictor of poor maternal and foetal outcomes. HIV infection is now recognized as one of the major contributors to anaemia in pregnancy. It is therefore important to determine the burden and risk factors of anaemia in maternal HIV infection in others to plan effective prevention strategies as well as optimize management outcomes.

Objective

To determine the prevalence and risk factors of anaemia in pregnant HIV positive Nigerians.

Methods

The prevalence and possible risk factors of anaemia were investigated in HIV positive pregnant Nigerian women at a large HIV treatment clinic in southwestern Nigeria using a cross-sectional design between January 2006 and December 2011.

Results

Nine hundred and eighty-five (42.5 %) women of 2,318 HIV positive pregnant women seen during the period were anaemic by WHO standard defined by haemoglobin <11 g/dl. Majority were of mild to moderate severity (97.9 %). Short inter birth interval (p = 0.002), presence of opportunistic infections (OIs), (p = 0.001), use of zidovudine containing regimen (p = 0.0005) and CD4 cell count <200 cells/mm³ (p = 0.001) were found to be independently associated with anaemia in HIV positive pregnant women after controlling for confounding variables.

Conclusion

Anaemia was found to be high at 42.5 % among the HIV positive women studied and was found to be independently associated with short inter birth interval, presence of OIs, advanced HIV disease and use of zidovudine containing HAART regimen.     

Genitourinary infection prevalence among women who used an intrauterine device or oral contraceptives

Purpose

The study aimed at investigating genitourinary infection prevalence among women who used an intrauterine device (IUD) and oral contraceptives (OC) in relation with their socio-demographic characteristics.

Methods

The study was conducted at the Mother and Child Health and Family Planning center between October 2011 and February 2012 and included 81 women who used IUD, 84 who used OC, and 84 who did not use artificial contraceptive methods (coitus interraptus).

Results

It was found that there was a difference between the three groups in terms of urinary system infection (X ² = 9.85, p = 0.000) and genital infection (X ² = 8.29, p = 0.001). It was also observed that urinary infection was more common in the OC group, whereas genital infection was more common in the IUD group. In urinary culture, it was seen that Enterobacter species was the most common microorganism among the group who used an IUD, while Escherichia coli was the most common microorganism in the group who used OC and the control. In vaginal cultures, Candida albicans was determined to be the first isolated microorganism among the group who used OC, IUD, and the control.

Conclusion

It is believed that the most significant reason for genitourinary infections among women was inadequate hygiene practices rather than use of different contraception methods.     

Minimally invasive sacrospinous ligament suspension: perioperative morbidity and review of the literature

Purpose

The objective of this study is to determine the perioperative outcomes of minimal invasive sacrospinous ligament suspension (SSLS) in women with apical prolapse.

Methods

This prospective randomized study included 1,464 patients for a 10-year period. SSLS was performed by Deschamps ligature carrier at 762 patients (Group 1) and automatic suturing instrument was applied at 702 patients (Group 2). Patients’ perioperative complications, blood loss, operative time, and hospital stay were recorded.

Results

Suturing took 46 s (range 31–63 s) in Group 2 and 775 s (range 585–965 s) in Group 1. Group 2 patients had shorter time for suturing process, less postoperative analgesic requirement, and shorter hospital stay (p < 0.0001, p < 0.01, p < 0.01, respectively). Also there were no bladder, ureteral, rectum or nerve injuries in Group 2.

Conclusion

Minimally invasive SSLS is a reliable procedure with less procedural complications, reduced postoperative pain, less hospital stay and shorter operation times.     

Sublingual versus vaginal misoprostol for cervical ripening before hysteroscopy: a randomized clinical trial

Purpose

To evaluate the efficacy of two routes of misoprostol (sublingual and vaginal) for cervical ripening before hysteroscopy.

Methods

One hundred and ten perimenopausal women who were referred to a tertiary hospital for surgical hysteroscopy enrolled in this double-blind randomized clinical trial. They were divided into two groups to receive 400 mg misoprostol either sublingually or vaginally 6 h before hysteroscopy. The duration of dilatation, Hegar number inserted into the cervix without resistance, and hysteroscopic and drug complications were recorded for all cases.

Results

Forty-nine women in sublingual and 51 in vaginal group participated in the study. Dilatation time was significantly lower in sublingual group (P < 0.001). Median Hegar number passed into the cervix without resistance was 5 in sublingual versus 4 in vaginal group (P = 0.002). Cramp followed by vomiting and diarrhea were the most common side effects of misoprostol in the sublingual group, while cramp followed by vomiting was the most frequent side effect in the vaginal group. Diarrhea was not reported in the vaginal group (P = 0.008).

Conclusion

Sublingual route of misoprostol could be considered as an effective medication before surgical hysteroscopy in perimenopausal women.     

Direct colposcopic vision used with the LLETZ procedure for optimal treatment of CIN: results of joint cohort studies

Purpose

To assess the value of direct colposcopic vision (DCV) for optimizing large loop excision of the transformation zone (LLETZ) for the treatment of cervical intraepithelial neoplasia (CIN).

Methods

Data from 648 patients who underwent excisional procedures for CIN and were included in two previously published cohort studies were retrospectively reviewed. Women who had a LLETZ were included for analysis (n = 436). Margin status, surgical specimen dimensions and volume were analysed according to the use of colposcopy during procedure.

Results

Compared to LLETZ guided by previous colposcopy report only, and to LLETZ performed immediately after colposcopy, DCV allowed for a significantly higher rate of clear margins: 33 (52.4 %), 104 (68.0 %) and 142 (84.5 %), respectively (p < 0.001). It also allowed for a significantly higher probability of achieving both negative margins and depth of specimen <10 mm: 10 (15.9 %) cases, 47 (30.7 %) cases and 125 (74.4 %) cases, respectively (p < 0.001). In multivariate analysis, when compared with the use of previous colposcopy report or with colposcopy immediately before the LLETZ, DCV allowed for a significantly higher probability of negative margins (AOR: 4.61; 95 % CI: 2.37–8.99 and AOR: 2.55; 95 % CI: 1.47–4.41), combined negative margins and depth <75th percentile (AOR: 3.67; 95 % CI: 1.97–6.86 and AOR: 3.05; 95 % CI: 1.91–4.87) and combined negative margins and volume <75th percentile (AOR: 12.96; 95 % CI: 5.99–28.05 and AOR: 6.16; 95 % CI: 3.75–10.14), respectively.

Conclusions

When used with the LLETZ procedure, DCV allows for optimal outcomes in terms of negative resection margins, and minimized depth and volume of the excised specimen; and should therefore be recommended.     

Anti-Mullerian Hormone: A New Marker of Ovarian Function

Objectives

The aim of this study was to determine day 3 Serum AMH, FSH, LH, Estradiol (E₂), Inhibin B levels, ovarian volume, and antral follicular count to assess ovarian function.

Methods

This study was conducted on 130 infertile women between age 18 and 43 years. Day 3 Serum AMH level was estimated by sandwich enzyme immunoassay; Serum FSH, S. LH, S. E₂, by solid-phase two-site chemiluminescent immunometric assay; Inhibin B by ELISA; and Ovarian volume and AFC, by transvaginal ultrasonography.

Results

With advancing age, Serum AMH level (p < 0.0001), AFC (p < 0.05), ovarian volume (>0.05), and Inhibin B (>0.05) were decreased, and Serum FSH (p < 0.05), LH (p > 0.05), and E₂ (p < 0.05) were increased. Serum AMH level was 4–6.8 ng/ml with optimal fertility in 26.15 % cases and 2.2–4.0 ng/ml with satisfactory fertility in 53.85 % cases. Serum AMH levels were more strongly correlated with AFC (p < 0.0001) and ovarian volume (p < 0.0001).

Conclusion

Serum AMH levels were more robustly correlated with AFC than FSH, LH, E₂, and Inhibin B on day 3 of the cycle. This suggested that serum AMH might be taken as single test to reflect ovarian reserve.     

Prognostic value of endocervical sampling following loop excision of high grade intraepithelial neoplasia

Objective

To assess the role of additional biopsies performed with loop electrosurgical excisional procedure (LEEP) in predicting the likelihood of persistent high grade intraepithelial neoplasia.