Primary repair of rectovaginal fistulas complicating pelvic surgery by gracilis myocutaneous flap

Objectives

Complex rectovaginal fistulas repair are extremely challenging. Various surgical options have been suggested; nevertheless, none had been universally accepted as the procedure of choice. This prospective study discusses a novel surgical technique using gracilis myocutaneous flap interposition.

Methods

Eleven patients had fistulas post-resection of pelvic malignancy (n = 10) and rectal endometriosis (n = 1). Primary treatment was pelvic resection; nevertheless, 6 cases had adjuvant chemo-irradiation, 2 cases had post-operative irradiation and 2 patients had chemotherapy only. Fistulas mean diameter was 2 ± 0.24 cm (1-3) and 8 patients (72.7%) had their fistulas in the middle vaginal third.Repair was wide debridement of fistulas margins followed by gracilis myocutaneous flap interposition with synchronous diverting stomas. Success was defined as healing of fistula after stomal closure.

Results

Five patients were repaired by single gracilis myocutaneous flaps, 2 cases by simple gracilis muscle and 4 cases by double gracilis myocutaneous flaps. Patients had a mean follow-up time of 34.8 ± 5.03 months (12-67) and all patients had definitive healing of their fistulas (100%). Median time to stoma closure was 2 months (1-5). Four women (36.4%) had at least one early postoperative complications including temporary leak (n = 3), vaginal sepsis (n = 1), partial skin paddle necrosis (n = 1) and donor limb deep venous thrombosis (n = 1). Late morbidities were seen in 3 cases (27.3%) including vaginal stricture, anorectal anastomotic stricture and anastomotic tumor recurrence.

Conclusion

Rectovaginal septum repair requires adequate debridement of necrotic devascularized tissues, tissue transposition and reconstruction of vaginal wall. Gracilis myocutaneous flaps are ideal for this issue.     

Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair

Objective

To determine if a wide genital hiatus is a risk factor for recurrence of anterior vaginal wall prolapse following anterior vaginal repair.

Methods

A retrospective cohort study was performed on patients who had undergone an anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide genital hiatus (≥ 5 cm) or normal genital hiatus (< 5 cm). The wide genital hiatus group (n = 35) was compared with the normal genital hiatus group (n = 30) for surgical failure.

Results

There were no significant differences between the 2 groups in demographic data, additional operative procedures, or apical suspensions. The rate of postoperative anterior vaginal wall prolapse was greater in patients with a wide genital hiatus compared with those with a normal genital hiatus (34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0-24.1]; P = 0.02).

Conclusion

The rate of recurrent anterior vaginal wall prolapse is higher in patients with a wide genital hiatus.     

Transobturator suburethral tapes in the management of urinary incontinence: success, safety and impact on sexual life

This study aims to assess transobturator tension-free vaginal tapes (TOT) in regard to subjective cure rates, patient satisfaction, long-term morbidity and impact on patients’ sexual life. It also aims to compare the safety profile of two TOTs: Obtape (outside-in technique) vs. TVT-O (inside-out technique). This is a retrospective study of all patients who had a TOT procedure for the management of urodynamic stress incontinence (USI) in a tertiary referral centre between July 2002 and January 2005. All patients identified from theatre records were sent an anonymous validated assessment questionnaire including the urinary domain of Birmingham Bowel and Urinary Symptoms Questionnaire, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), Sexual Impact Questionnaire and a visual analogue scale (VAS) to assess patients’ satisfaction. Case notes were examined to ascertain preoperative urodynamic diagnosis and perioperative complications. Two hundred and seventy-six women were identified from theatre records: 94 patients underwent TVT-O and 182 underwent Obtape . Mean age was 49 (range 34–78) years, and mean parity was two (range: 0–6). There was no difference between groups in regard to body mass index, urodynamic diagnosis and previous incontinence surgery. Intraoperative complications included bladder injury 0.4%, urethral injury 0.7%, lateral vaginal tears 4.3% and blood loss >200 ml in 5.4%. There was no statistically significant difference in intraoperative (p = 0.2) and early postoperative (p = 0.65) complications between groups. Late postoperative complications were mainly related to the tape material and included de novo urgency (6.9%), vaginal erosions (5.1%) and ischiorectal abscess (1.1%). A significantly higher rate of late postoperative complications occurred in the Obtape group (p = 0.047). Median follow-up was 28  ± standard deviation (SD) 4.8 (range 10–40) months. Subjective success rate, defined as absent or occasional episodes of incontinence according to the ICIQ-SF was 86% in the USI group compared with 52.4% in the mixed incontinence group (p < 0.001). Following the operation, there was no significant change in patients’ sexual life as regards frequency of intercourse and pleasure and/or pain during penetration (p = 1.000), whereas there was significant decrease in coital incontinence (p < 0.0001). TOT is a relatively safe procedure in the treatment of USI and is associated with a high subjective success rate with a median follow-up of 28 months. Coital incontinence is likely to be cured, and the vast majority of women described an improvement or no change in their sexual life following the TOT procedure. There was no significant difference in the complication rates between the outside-in vs. the inside-out techniques; however, significantly more “tape-related complications” occurred in the Obtape group. Both techniques of TOT are safe in the treatment of USI and are associated with high subjective success rate and improvement or on change in patients’ sexual life.     

A high Nugent score but not a positive culture for genital mycoplasmas is a risk factor for spontaneous preterm birth

Objective.?This study was performed to evaluate the relationship among the Nugent score for the diagnosis of bacterial vaginosis (BV), the results of vaginal fluid culture for genital mycoplasmas, and the subsequent occurrence of preterm birth.

Methods.?The Nugent score and culture for genital mycoplasmas were performed in vaginal fluid obtained from 977 pregnant women (gestational age 13–30 weeks). Vaginal samples were obtained with sterile cotton swabs. The relationship among the Nugent score, vaginal fluid culture results and the occurrence of spontaneous preterm birth was examined.

Results.?(1) Of the 977 women, 14% (137) had a Nugent score of ≥8; (2) The prevalence of a positive vaginal culture for genital mycoplasmas was 30% (288); Ureaplasma urealyticum was isolated in 252 (88%), Mycoplasma hominis in 9 (3%), and both in 27 (9%) women; (3) Cases with a Nugent score of ≥8 had a higher rate of a positive vaginal culture for genital mycoplasmas than those with the lower Nugent score (55%vs. 25%; p < 0.001); (4) Women with a Nugent score of ≥8 had a significantly higher rate of spontaneous preterm birth <37 (10%vs. 4%), <34 (5%vs. 2%), and <32 (4%vs. 1%) weeks of gestation than those with the lower Nugent score (at each gestational age, p < 0.05); (5) In contrast, a positive vaginal culture for genital mycoplasmas was not associated with an increased risk for spontaneous preterm birth; (6) Among patients with a positive culture and a Nugent score of ≥8, the frequency of spontaneous preterm delivery (<37 weeks) was 10% (7/72); (7) There was no difference in the incidence of spontaneous preterm delivery according to the results of vaginal culture in patients with a Nugent score of ≥8, as well as in those with a lower Nugent score.

Conclusion.?A high Nugent score (≥8) for the detection of BV but not a positive vaginal culture for genital mycoplasmas is a risk factor for spontaneous preterm birth.     

Congenital adrenal hyperplasia: long-term results following vaginal reconstruction

Forty-two women with virilizing congenital adrenal hyperplasia who had attempted coitus were studied retrospectively a mean of 23.6 years after vaginal repair. Satisfactory intercourse, as defined by the patient, was observed in 62% of the subjects. The functional success rate was higher if repeat operations were performed after the age of 16 years (61% versus 12%, P less than 0.05) or if the patient suffered from the non-salt-losing variety of the disorder (87% versus 46%, P less than 0.05). The outcome of the initial attempt to exteriorize the vagina did not differ significantly by age at surgery. In cases of moderate virilization, vaginal repair may be delayed until the patient's menarche, maturity, and desires for sexual activity are well established. Clitoroplasty should be performed as soon as possible.     

Surgical repair of genital fistulae — analysis of 62 cases in a tertiary hospital

Objectives

To determine the etiology of genital fistulae and the outcome of treatment.

Methods

A total number of 62 women with genital fistulae were managed during the period of January 2001 to December 2007. Fifty seven cases were urogenital and five cases were rectovaginal fistulae. They were analyzed with regards to the age, parity, etiology, mode of treatment and outcome. The route of repair was individualized according to the appropriate access of fistulae.

Results

Obstetric complications were the leading cause (79.03) of genital fistula. Majority (78.94%) of urogenital fistulae were treated surgically through vaginal route. Out of 57 cases of urogenital fistulae, 51 cases were repaired successfully in the first attempt and three patients were cured at the second repair. The overall cure rate achieved was 94.8%. All of the five rectovaginal cases were closed after a single attempt.

Conclusions

A high percentage of patients with genital fistulae can be repaired by the experience of surgeon, team work and meticulous surgery with conventional approach.     

Oviduct contractile response to vaginal distension: identification of vagino-tubal reflex

Objective The effect of vaginal distension on the oviduct contractile activity during penile thrusting at coitus could not be traced in the literature. We investigated the hypothesis that vaginal distension effects oviduct contraction, which assists in ovum transport along the oviduct.Methods Oviduct pressure was measured upon vaginal condom distension in 16 women (mean age 32.2±1.2 years) scheduled for abdominal hernia repair and oviduct ligation for sterilization. The test was repeated after individual anesthetization of the vagina and oviduct.Results Ten milliliters vaginal distension effected pressure elevation of the ampullary (AO) and isthmic (IO) parts of the oviduct (p<0.01, p<0.01 respectively) and a decrease in intramural oviduct (IMO; p<0.01). Twenty milliliters distension further increased the pressure in the AO and the IO (p<0.001, p<0.001) and decreased it in IMO (p<0.001). Vaginal distension with greater volumes produced an oviduct pressure response similar to that with 20 ml distension (p>0.05). Vaginal distension of anesthetized vagina or oviduct did not evoke the oviduct pressure response, but saline infusion did.Conclusions Vaginal distension seems to produce oviduct motile activity as evidenced by oviduct pressure changes, which appear to assist in sperm–ovum transport and fertilization. These oviduct changes are suggested to occur reflexly through the vagino-tubal reflex. Pathologic changes of the oviduct presumably interfere with this reflex action, a point that needs to be investigated.     

Vaginal hysterectomy in generally considered contraindications to vaginal surgery

Objective The objective was to evaluate the feasibility and complication rate of vaginal hysterectomy with or without adnexectomy in women with enlarged uteri and/or other considered contraindications to the vaginal route.Study design Over a period of 2 years, a total of 204 women underwent vaginal hysterectomy for benign pathology. Normally considered contraindications to the vaginal route were: moderate to excessive uterine enlargement, nulliparity or no prior vaginal delivery, previous cesarean or pelvic surgeries and adnexal pathologies. Laparoscopy was used only if it became necessary. Patients with uterine prolapse were excluded. The clinical outcomes and complication rate were analyzed even with regards to the type of contraindication.Results The mean age of the patients was 46.96±4.8 years (range: 38–68). The mean uterine weight was 427.74±254.75 g (range: 150–2,000). The operative time ranged from 30 to 140 min (mean: 61.59±21.80 SD) for vaginal hysterectomy alone, increasing up to 170 min (mean: 83.6±38.28 SD) in case of adnexectomy or laparoscopic assistance. The patient characteristics, the uterine weight and the postoperative results and clinical outcome did not differ among the groups of contraindications. Overall, the complication rate was 9.8%. No patient required a transfusion for surgical blood loss, a return to the operating room or readmission to the hospital. During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology) and was technically impossible in 9.3%. In 4 cases (1.9%) it was not possible to complete vaginal hysterectomy owing to the presence of thick adhesions obliterating the cul-de-sac, of severe endometriosis or other unforeseen circumstances. In these few cases with a difficult access to the ovaries (2.9% of all VH) or with difficulties in mobilizing the uterus, we resorted to laparoscopy. The pneumoperitoneum was achieved by means of an insufflation tube inserted via the vagina into the abdominal cavity and packing the vagina. Thus, the risks associated to the insertion of the Veress needle were avoided. In all but two cases in which conversion to laparotomy was necessary, laparoscopy was successfully completed.Conclusions Vaginal hysterectomy appears to be feasible in about 97% of cases in which this approach would have been judged unsuitable. This figure decreases to 94.2% when oophorectomy is indicated.     

Genital injury and implied consent to alleged rape

A review of 440 cases of reported rape was undertaken to see if sustaining injury to the genital area was an inevitable consequence of being raped. Injuries to areas other than the genital were taken as objective evidence that the victim did not consent to the encounter, while sperm found in her vagina that could not be accounted for by voluntary coitus was taken as objective evidence that penile penetration of the vagina had occurred. Of the 75 victims with objective evidence of both noncompliance and vaginal penetration, 28% sustained genital injury. The absence of genital injury does not imply consent by the victim or the absence of vaginal penetration by the assailant.     

Effect of vaginal intercourse on spontaneous labor at term: a randomized controlled trial

Objective

This study aimed at evaluating the effect of vaginal intercourse on spontaneous labor onset at term.

Methods

In a randomized controlled trial, patients with singleton, cephalic, term, and low-risk pregnancy were assigned to either vaginal intercourse at least twice a week or abstinence. The following data were assessed: demographics, parity, vaginal coitus frequency before and during pregnancy, Bishop score at 38th weeks, gestational age at delivery, mode of delivery, and days between recruitment and delivery. The primary outcome was spontaneous labor onset.

Results

Of the 123 patient analyzed, 63 were assigned to study group and 60 to control group. Mean interval between study recruitment and delivery was higher in sexually active women (15.05 days ± 0.8 compared with 14.17 days ± 0.8, p = 0.45) as well as the rate of cesarean delivery (14.3 % compared with 10 %, p = 0.58), but the differences were not statistically significant. The rate of spontaneous labor was similar in both groups (84.1 % in vaginal coitus group; 75 % in control group, p = 0.26).

Conclusion

Our results showed that vaginal intercourse does not hasten spontaneous labor onset at term.     

Maternal and perinatal outcome in pregnancies complicated with hypertensive disorder of pregnancy: a seven year experience of a tertiary care center

Objective: The aim of the study was to determine the risk factors, prevalance, epidemiological parameters and maternal-perinatal outcome in pregnant women with hypertensive disorder. Materials and methods: A retrospective analysis was undertaken on 255 consecutive cases of hypertensive disorder in pregnancy who were managed at Kocaeli University, School of Medicine, Department of Obstetrics and Gynecology from June 1997 to November 2004. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally delivery route, indications of cesarean section, fetal and maternal complications were determined. Statistical analysis was performed by SPSS programme using Kruskal Wallis nonparametric test, ANOVA (Analysis of variance) and chi-square tests. Results: Of 5,155 deliveries in our clinic during the defined period, 438 cases (8.49%) were managed as hypertensive disorder of pregnancy. Medical records of 255 cases could be avaliable. Of 255 cases, 138 patients (54.11%) were found to have severe preeclampsia while 88 cases (34.50%) were diagnosed as mild preeclampsia. Twenty-nine patients (11.37%) were suffering from chronic hypertension. Of 138 severely preeclamptic cases, 28 cases (11%) had eclamptic convulsion and another 28 patients (11%) were demonstrated to have HELLP syndrome. Intrauterine growth restriction, oligohydramnios, placental ablation were the obstetric complications in 75 (29.4%), 49 (19.2%), 19 (7.5%) cases, respectively. Additionally multiple pregnancy and gestational diabetes mellitus were noted in 5.9% (n:15) and 3.9% (n:10) of the patients. Delivery route was vaginal in 105 patients (41.2%) while 150 patients (58.8%) underwent cesarean section with the most frequent indication to be fetal distress in 69 cases (46%). Cesarean section rate seemed to be the lowest (48.3%) in chronic hypertensive women while the highest (63.8%) in severe preeclamptic patients. Maternal mortality occured in 3 cases (1.2%) and all of those cases were complicated with HELLP syndrome. Intracranial bleeding was the cause of maternal death in one case while the other two cases were lost due to acute renal failure and disseminated intravascular coagulation, respectively. Intrauterine fetal demise was recorded in 24 cases on admission. Ten fetuses died during the intrapartum period. Mean gestational age and birth weight were 28±3.5 and 1000±416 g, respectively in this group. In these ten women, five cases were diagnosed as HELLP syndrome, two were severely preeclamptic and three were eclamptic. Perinatal mortality rate was found to be 144/1,000 births Conclusion: Hypertensive disorder of pregnancy is associated with increased risk of maternal-perinatal adverse outcome. The complications of severe preeclampsia and eclampsia could be prevented by more widespread use of prenatal care, education of primary medical care personnel, prompt diagnosis of high-risk patients and timely referral to tertiary medical centers.     

Nonobstetrie Lower Genital Tract Trauma

EDITORIAL COMMENT": We accepted this paper for publication to remind readers of the different types of nonobstetric trauma to the lower genital tract. The mechanism of tearing in the upper vagina during coitus is debated; this report does not favour the theory that tearing in the unsupported upper vagina results from levator spasm rather than direct injury (A).
A. Ahnaimugan S, Asuen MI. Coital laceration of the vagina. Aust NZ J Obstet Gynaecol 1980; 20: 180–181.
Summary: In a 4-year-period there were 31 admissions to Nehru Hospital, because of nonobstetrie injuries of the female genital tract. This constituted 0.8% of all gynaecological admissions over this period. The injuries were caused by voluntary coitus, automobile accidents and various types of astride injuries. Seven of the 18 patients with noncoital injuries presented with vulval haematomas and all were managed by evacuation under general anaesthesia. Two of the 13 patients with coital injury were admitted with haemorrhagic shock and required initial resuscitation with blood transfusion. The vaginal vault, especially the right and posterior fornices were the frequent sites of coital injury for parous women; on the other hand lower vaginal and introital injuries were caused by first acts of coitus. Except for trivial superficial lacerations with minimal bleeding, primary definitive surgical repair other than vaginal packing was favoured for better healing and to reduce morbidity.     

Transvaginal repair of the posthysterectomy vesicovaginal fistula using a peritoneal flap: the gold standard

OBJECTIVE: To evaluate the transvaginal approach to management of vesicouterine fistulas. STUDY DESIGN: Over a 10-year period, 7 cases of simple posthysterectomy vesicovaginal fistulas were identified. The surgical technique involved resection of the fistulous tract completely, performance of layered closure and placement of a peritoneal flap between the bladder and vaginal suture lines. RESULTS: One fistula closed spontaneously, and the remaining 6 were repaired transvaginally. Primary repair was successful in all cases, with no complications. CONCLUSION: The transvaginal repair described is the preferred method of repair, associated with an extremely high success rate, low morbidity and cost savings. Its approach should be considered the gold standard.     

Predictors of Obstetric Fistula Repair Outcomes in Lubango,Angola

ObjectiveObstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.MethodsIn this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).ResultsA total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).ConclusionAlthough fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.     

Is V-NOTES Hysterectomy as Safe and Feasible as Outpatient Surgery Compared with Vaginal Hysterectomy?

Study ObjectiveThe vaginal approach is the reference surgical route to perform hysterectomy for benign pathologies. Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) is a new technique that would overcome the limitations of vaginal surgery by allowing a complete exploration of the peritoneal cavity and a constant visual control of the adjacent structures. The aim of this study is to assess the V-NOTES technique compared with vaginal hysterectomy (VH).DesignA retrospective cohort study.SettingFrench teaching hospital.PatientsThe first 50 V-NOTES hysterectomies were included successively and compared with the last 50 VH performed from March 2019 to November 2020. The study concerned all patients requiring hysterectomy unless it was for endometriosis or cancer (except for grade 1 endometrioid adenocarcinoma).InterventionsThe baseline characteristics and the surgical outcomes were compared. The main outcome assessed was the performing of outpatient surgery. Secondary end points were uterine weight and intraoperative and postoperative complications.Measurements and Main ResultsThe rate of outpatient surgery did not differ between the 2 surgical techniques (p = .23). The success rate of outpatient management was 77% in the V-NOTES group versus 75% in the VH group (p = .85). There was no difference in surgical outcomes between the 2 groups, except for the rate of salpingectomies or adnexectomies, which was significantly higher in the V-NOTES group, with 100% of patients undergoing one of these procedures, compared with 60% of patients in the vaginal route group (p < .001). There were 2 cases of re-admission in the month following the intervention in the vaginal group and 0 cases in the V-NOTES group.ConclusionHysterectomy by V-NOTES can be performed as a safe and adequate alternative to VH. This surgical route is a good candidate for outpatient management. However, more studies need to be conducted to confirm these findings.     

Genital appearance satisfaction in women: the development of a questionnaire and exploration of correlates

The aims of this study were to develop a new Genital Appearance Satisfaction (GAS) scale, to use this to describe genital appearance satisfaction in a general population sample, and to explore its relationship to self‐esteem, body satisfaction, and appearance schemas. This was prompted by a clinical need to respond appropriately to women requesting surgery to reduce the size of their labia minora. The questionnaire measures were completed by a general population sample of 135 women (63% response rate). Responses to individual GAS items covered the full range of the rating scale, confirming that there are measurable differences in women's reported satisfaction with all aspects of genital appearance. Principal components factor analysis revealed three factors, ‘Appearance of genitals’, ‘Impact on daily living’ and ‘Impact on sex’. Total GAS scores were very significantly correlated with appearance schemas (r = .28, p<.01), body satisfaction (r = .30, p<.01) and self‐esteem (r = ?.41, p<.01), but multiple regression analysis showed that when all three variables were entered, only self‐esteem significantly predicted Genital Satisfaction (beta = ?.38, p = .002). Dissatisfaction may be linked to psychosocial factors such as self‐esteem, and surgery may not appropriately address these concerns.     

Comparison between tension-free vaginal tape and transobturator tape in treating stress urinary incontinence after vaginal mesh surgery

Objective

A midurethral sling is the gold standard surgical treatment for stress urinary incontinence (SUI), however a lower success rate has been reported in the treatment of SUI after pelvic organ prolapse surgery. The aim of this study was to compare the success rates, quality of life, and complications with treatment using tension-free vaginal tape (TVT) and transobturator tape (TOT) in these patients.

Intraamniotic ethacridine lactate instillation versus vaginal PGE1 in second trimester termination of pregnancy

Objective

To report on our experience with intraamniotic injection of ethacridine lactate (EL) for second trimester termination of pregnancy (TOP) and to compare its effectiveness with vaginal PGE₁ in this setting.

Study design

(a) Retrospective analysis of 54 intraamniotic EL-induced TOP. (b) Matched pair analysis of 50 second trimester TOP, using intraamniotic EL in group A (n = 25) and vaginal PGE₁ suppositories in group B (n = 25). Main outcome measures: success rate, induction-delivery interval, analgesic use, drop in maternal hemoglobin, complications.

Results

(a) TOP with EL alone was successful in 50 cases (93%). Mean duration from instillation to delivery was 40.5 h (range 14–58, S.D.: ±9.0). Mean analgesic need was low. Mean drop in hemoglobin was low (1.0 g/dl, S.D.: ±1.1). (b) The matched pair analysis revealed a significantly shorter induction-delivery interval in the vaginal PGE₁ group (mean 26.9 h, range 8–80, S.D.: ±16.8 versus 41.0 h, range 24–55, S.D.: ±7.3, p < .05). There were no significant differences in analgesic use or drop in hemoglobin. In both groups one case of post partum hemorrhage occurred.

Conclusion

Intraamniotic instillation of ethacridine lactate in second trimester TOP is safe, cheap and successful in the vast majority of cases. Disadvantages are the longer induction-delivery interval compared to modern prostaglandins and the invasive mode of application. However, by the use of EL the side effects of repeated prostaglandin application can be avoided as well as multiple vaginal examinations. Furthermore, the time of delivery can be predicted in a narrower interval.     

Management of vesico-vaginal fistulas in women.

OBJECTIVE: Urinary fistulas resulting from obstetric trauma remains a major problem in developing countries. Surgical success rates, however, range from 61% to 95%. This study reviews the main causes of fistulas, and the surgical techniques and success rates of surgical closure. METHOD: A total of 1086 cases of urinary fistulas resulting from obstetric trauma over 25 years were reviewed. All women received surgical intervention. Various types of fistulas as well as specific surgical techniques are described, and patient age, parity, and probable cause of fistula were compared with findings from studies in Africa. RESULTS: The highest number of cases (47.6%) occurred in women aged between 26 and 35 years; moreover, 54.43% of the women were para 6 and higher. Obstructed labor contributed to 72.78%, cesarean hysterectomy to 7.60%, cesarean section to 7.30%, and other obstetrical traumatic procedures to 12.28% of the cases. Surgical success was achieved in 84.5% of the cases. The major residual problem of stress incontinence was noted in 5% of the cases. CONCLUSION: Besides prevention, the basic principles of fistula repair are the most important factors in achieving surgical success. Better preoperative preparation and rigorous measures for preventing postoperative infection can help increase the success rate of fistula repair.     

Idiopathic vaginal bleeding during pregnancy as the only clinical manifestation of intrauterine infection

Objective.?To determine the frequency and clinical significance of microbial invasion of the amniotic cavity (MIAC) in patients with vaginal bleeding in the absence of placenta previa, preterm labor or preterm premature rupture of membranes (PROM).

Study design.?This retrospective cohort study included patients who presented with vaginal bleeding between 18 and 35 weeks, and underwent an amniocentesis shortly after admission for the assessment of the microbiologic status of the amniotic cavity and/or fetal lung maturity. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients presenting with preterm labor, preterm PROM, placenta previa, overt placental abruption, and an intrauterine device in situ were excluded, as well as those with local cervical bleeding. MIAC was defined as a positive amniotic fluid culture. Analysis was conducted with non-parametric statistics.

Results.?One hundred and fourteen patients met the entry criteria. MIAC was detected in 14% of cases (16/114). Patients with vaginal bleeding and a gestational age <?28 weeks at the time of amniocentesis had a significantly higher frequency of MIAC than those with a gestational age ??28 weeks [25% (13/52) vs. 4.8% (3/62), respectively; p?<?0.01]. Ureaplasma urealyticum was the microorganism most frequently isolated from the amniotic fluid. Except for one case admitted at 33 weeks, all patients with MIAC?had an early preterm delivery ??32 weeks. Patients with vaginal bleeding and MIAC?had a shorter procedure-to-delivery interval than those without MIAC [MIAC, median survival 19 days (95% CI 10–27 days) vs. no MIAC, median survival 50 days (95% CI 37–62 days); p?<?0.0001]. Patients with vaginal bleeding and MIAC?had a significantly lower gestational age at delivery and lower birth weight than those with vaginal bleeding and negative amniotic fluid cultures (for gestational age, median 25 weeks, range 21–33 weeks vs. median 37 weeks, range 19–42 weeks, respectively; p?<?0.01, and for birth weight, median 750?grams, range 520–1820?grams vs. 2800?grams, range 520–4880?grams, respectively; p?<?0.01), as well as a higher frequency of subsequent preterm PROM [81.3% (13/16) vs. 9.2% (9/98); p?<?0.01].

Conclusions.?MIAC was detected in 14% of patients with ‘idiopathic’ vaginal bleeding and was associated with subsequent preterm PROM and early preterm delivery. Vaginal bleeding may be the only clinical manifestation of MIAC, and it predisposes to adverse outcome.