Láser CO2 vaginal, indicaciones y aplicaciones / Vaginal CO2 laser, indications and applications

El síndrome genitourinario es una entidad hoy en día cada vez más frecuente en la mujer posmenopáusica, con signos y síntomas muy característicos que llevan a la pérdida de calidad de vida de las pacientes, generados por la disminución de estrógenos. Su diagnóstico se realiza mediante una buena historia clínica, exámenes hormonales, estudios urodinámicos y de pH vaginal. Su clínica varía desde sequedad vaginal, atrofia de la misma, vaginitis a repetición, pérdida de orina al esfuerzo, nicturia y dispareunia. A los largo de los años se han protocolizado diferentes tratamientos como reemplazos hormonales, lubricantes y cirugías invasivas vaginales. Pero en los últimos años ha aparecido una nueva terapéutica de láser CO2 fraccionado. Materiales y método. Se realizó un estudio retrospectivo de seis años de evolución, entre los años 2017 y 2023, con más de 300 pacientes tratadas con tecnología láser CO2 fraccionado, con criterios de inclusión y exclusión, protocolizando 3 sesiones cada 30 días y controles hasta los 6 meses. Resultados. Para evaluar los resultados se diseñó una encuentra de satisfacción de 5 puntos, la cual fue presentada luego de cada sesión, encontrando un alto grado de satisfacción en la mejoría clínica a medida que transcurrían las sesiones, con un muy bajo índice de complicaciones. También biopsias con mejorías histológicas que demuestran resultados. Discusión. La aplicación de esta nueva tecnología láser nos abre una posibilidad terapéutica segura, rápida y efectiva para mejorar la sintomatología y calidad de vida de nuestras pacientes con síndrome genitourinario, sumando una nueva terapéutica a todo el arsenal de tratamientos médico-quirúrgicos disponibles a la fecha. Conclusiones. El síndrome genitourinario es una entidad prácticamente inevitable, con síntomas desde leves a graves, que afecta la calidad de vida personal, sexual y social. Los tratamientos hasta la fecha hormonales, tópicos o quirúrgicos han dado mediocres resultados sin estar exentos de complicaciones, por lo que la aparición de la tecnología láser CO2 fraccionada nos ha dado el plus necesario para aportar un tratamiento seguro, eficaz, con mínimas complicaciones y una curva de aprendizaje pequeña

Genitourinary syndrome is an increasingly frequent entity in postmenopausal women today, with very characteristic signs and symptoms that lead to a loss of quality of life in patients, generated by estrogen depletion, whose diagnosis is made through a good clinical history, hormonal tests, urodynamic and vaginal pH studies. Its symptoms vary from vaginal dryness, vaginal atrophy, repeated vaginitis, loss of urine on exertion, nocturia and dyspareunia. Over the years, different treatments have been protocolized, such as hormone replacements, lubricants, and invasive vaginal surgeries. But in recent years a new fractionated CO2 laser therapy has appeared. Materials and method. A retrospective study of six years of evolution was carried out, between the years 2017 and 2023, with more than 300 patients treated with fractionated CO2 laser technology, with inclusion and exclusion criteria, protocolizing 3 sessions every 30 days and controls until the 6 months. Results. To evaluate the results, a 5-point satisfaction score was designed, which was presented after each session, finding a high degree of satisfaction in the clinical improvement as the sessions progressed with a very low indication of complications. Also biopsies with histological improvements that demonstrate results. Discussion. The application of this new laser technology opens up a safe, fast and effective therapeutic possibility to improve the symptoms and quality of life of our patients with genitourinary syndrome, adding a new therapeutic option to the arsenal of medical-surgical treatments available to date. Conclusions. Genitourinary syndrome is a practically inevitable entity, with symptoms ranging from mild to severe, affecting the quality of personal, sexual and social life. The hormonal, topical or surgical treatments to date have given mediocre results, not being free of complications, so the appearance of fractionated CO2 laser technology has given us the necessary extra to provide a safe, effective treatment, with minimal complications. and a small learning curve.

The pain reported by postpartum women in rooming-in according to the mode of delivery / Dor relatada por puérperas no alojamento conjunto segundo a via de nascimento

ABSTRACT BACKGROUND AND OBJECTIVES: Pain is the most frequently reported symptom in the immediate puerperium. The aim of this study was to quantify pain levels and sociodemographic, obstetric, and care characteristics associated with severe pain and inadequate analgesia according to the mode of delivery. METHODS: Observational, descriptive, cross-sectional study conducted between October and December 2020, with a sample of 229 postpartum women considered eligible (baby born alive, weighing > 500 g and/or gestational age > 22 weeks) to answer the study questionnaire. RESULTS: The mean reported pain was 5.34 by Visual Analogue Scale (VAS) and there was a difference (p<0.001) between modes of delivery. Cesarean section was associated with severe pain (p=0.006) and pain above eight on the VAS (p=0.02). Vaginal delivery was associated with the perception of inadequate analgesia (p=0.04). Severe pain reported was associated with the admission of the baby to the ICU (p=0.01) and cases of postpartum hemorrhage (p=0.002). Among women who gave birth vaginally, there was an association between severe pain and instrumental delivery (p=0.05). Reported severe pain was associated with difficulties in self-care (p<0.001) and care of the newborn (p= 0.02), sensation of weakness (p<0.001), and fainting (p=0.002). The perception of inadequate analgesia was associated with vaginal birth (p=0.04) end non-white skin color (p=0,03). CONCLUSION: The average reported pain was moderate. Intense pain and the perception of inadequate analgesia were associated with instrumental delivery, newborns being referred to the NICU, postpartum hemorrhage, and non-white skin color.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor é o sintoma mais frequentemente relatado no puerpério imediato. O objetivo deste estudo foi quantificar os níveis de dor e as características sociodemográficas, obstétricas e da assistência associadas à dor intensa e à percepção de analgesia inadequada segundo a via de nascimento. MÉTODOS: Estudo observacional, descritivo, transversal, conduzido entre outubro e dezembro de 2020, com uma amostra de 229 puérperas consideradas elegíveis (nativivos com peso > 500g e/ou idade gestacional > 22 semanas) para responder ao questionário do estudo. RESULTADOS: A média de dor relatada foi 5,3 pela Escala Analógica Visual (EAV) e houve diferença (p<0,001) entre as vias de nascimento. A cesariana apresentou associação com dor intensa referida (p=0,006) e dor acima de oito pela EAV (p=0,02). O parto vaginal obteve associação com percepção de analgesia inadequada (p=0,04). Entre as mulheres que referiram dor intensa, houve associação com recém-nascido encaminhado à unidade de terapia intensiva neonatal (UTIN) (p=0,01) e nos casos de hemorragia pós-parto (p=0,002). Entre as mulheres que tiveram parto vaginal, também houve associação entre dor intensa e o parto instrumental (p=0,05). Dor intensa referida teve associação com dificuldades para o autocuidado (p<0,001) e do recém-nascido (p=0,02), sensação de fraqueza (p<0,001) e de desmaio (p= 0,002). A percepção de analgesia inadequada esteve associada a parto vaginal (p=0,04) e cor da pele não branca (p=0,03). CONCLUSÃO: A média de dor relatada foi moderada. Dor intensa e percepção de analgesia inadequada estiveram associadas com parto instrumental, recém-nascido encaminhado à UTIN, hemorragia pós-parto e cor de pele não branca.

Mucoadhesive polymeric systems for vaginal drug delivery: a systemic review / Sistemas poliméricos mucoadhesivos para la liberación vaginal de fármacos: revisión sistemática

ABSTRACT Intravaginal drug administration has many advantages in comparison to other delivery routes: its local and systemic effect, lower dosages, and easiness of administration. Furthermore, makes it a reliable and comfortable way of therapy. This route can be used to prevent and treat a wide range of conditions including, sexually transmitted infections (STIs), hormonal treatment, birth control, and cancer treatment. The dosage forms may vary from ovules, tablets, rings, gels, creams, films and many more; lately adding the mucoadhesiveness to the characteristics to reduce the waste of active molecules. This review focuses on the way mucoadhesive polymeric systems have been applied in vaginal delivery. This review presents a bibliographical compilation of results from various investigations published in scientific databases: Science Direct, SciELO, and PubMed Central. Results compiled demonstrate that the intravaginal drug administration can be an alternative form of medication for women with more stable and prolonged results than traditional routes requiring lower doses and avoiding the first-pass effect.

RESUMEN La administración de fármacos por vía intravaginal cuenta con múltiples ventajas a comparación de otras rutas, puede lograr un efecto tanto local como sistémico, las dosis requeridas son menores, facilidad de administración entre otras, hacen que esta forma de administración sea confiable y cómoda. Esta vía de administración puede ser empleada para prevenir y tratar diferentes trastornos, como enfermedades de transmisión sexual, desordenes hormonales, anticonceptivos y tratamiento contra el cáncer. La presentación de las dosis puede variar, desde óvulos, tabletas, anillos, geles, cremas, películas entre otros, agregando a esta, en los últimos tiempos, la característica de mucoadhesividad para reducir el desecho de moléculas activas. Este trabajo se enfoca en las aplicaciones que han tenido los sistemas poliméricos mucoadhesivos en la vía intravaginal. La bibliografía recolectada se obtuvo de bases de datos como Science direct, SciELO, y PubMed Central. Los resultados obtenidos demuestran que la administración de fármacos por vía intravaginal puede ser una forma alternativa para medicación en mujeres, con resultados más estables y prolongados que otras rutas, requiriendo menores dosis y evitando el efecto de primer paso.

Terapia de estrógenos vaginales y riesgo de recurrencia en mujeres con antecedente de cáncer de mama

El cáncer de mama sigue siendo la neoplasia maligna más frecuente y una de las mortales en mujeres, considerándose un importante objetivo de la salud global y prioridad en salud pública. Con el uso de terapias innovadoras, ha mejorado la supervivencia, apareciendo condiciones asociadas, como el síndrome genitourinario menopaúsico. La terapia hormonal, se utiliza para el manejo de esta condición, mejorando sustancialmente la sintomatología, e incluso, siendo en algunos casos la única solución. La más utilizada, es la terapia de estrógenos vaginales. Sin embargo, se ha descrito un posible riesgo de recurrencia de cáncer de mama con su uso. En habla hispana, no existe evidencia que haya discutido este tópico. Se llevó a cabo una búsqueda en las bases PubMed, ScienceDirect y MEDLINE, utilizando los términos "Terapia de estrógenos vaginales", "Recurrencia" y "Cáncer de mama". Se encontró, que, de forma global, la terapia de estrógenos vaginales es una opción terapéutica eficaz y segura en el manejo del síndrome genitourinario menopaúsico en mujeres con antecedente de cáncer de mama, sin incrementar el riesgo de recurrencia, a excepción de aquellas tratadas con inhibidores de la aromatasa, en quienes se recomienda el uso de otras terapias para evitar acarrear este riesgo.

Breast cancer remains the most common malignant neoplasm and one of the leading causes of mortality in women, making it a significant target for global health efforts and a public health priority. Through the use of innovative therapies, survival rates have improved, leading to the emergence of associated conditions such as genitourinary menopausal syndrome. Hormonal therapy is employed for managing this condition, significantly alleviating its symptoms and, in some cases, serving as the sole solution. The most commonly utilized approach is vaginal estrogen therapy. Nevertheless, there have been reports of a potential risk of breast cancer recurrence associated with its use. In the Spanish-speaking context, there is limited evidence discussing this topic. A search was conducted across PubMed, ScienceDirect, and MEDLINE databases, using the terms "Vaginal Estrogen Therapy", "Recurrence" and "Breast Cancer." It was determined that, on a global scale, vaginal estrogen therapy is an effective and safe therapeutic option for managing genitourinary menopausal syndrome in women with a history of breast cancer. This therapy does not appear to increase the risk of recurrence, with the exception of those undergoing treatment with aromatase inhibitors. For these individuals, alternative therapies are recommended to mitigate this potential risk.

Asociación entre la exposición a violencia íntima de pareja contra la mujer y el reporte de secreción y úlceras genitales

Objetivo: Evaluar la asociación entre la violencia íntima de pareja emocional, física y sexual con el auto reporte de secreción y úlcera genital en mujeres participantes de una encuesta poblacional. Métodos: Se realizó un análisis de la Encuesta Demográfica y de Salud Familiar del Perú, 2021. Los criterios de inclusión fueron tener 15 a 49 años, ser casadas o convivientes, y estar seleccionadas y entrevistadas para el módulo de violencia doméstica. Se estimó la prevalencia de auto reporte de secreción y úlcera genital. La asociación con la violencia íntima de pareja fue realizada mediante regresión logística binaria con la estimación de la razón de momios, considerando el diseño muestral complejo. Resultados: La prevalencia del reporte de úlcera o secreción genital fue 10,0%. La razón de momios para reportar secreción o úlcera genital entre las mujeres que sufrieron violencia física leve comparado con las no expuestas fue 2,25 (IC95%: 1,72 a 2,94), el riesgo incrementó a 3,42 (IC95%; 2,39 a 4,90) entre las mujeres que sufrieron violencia física severa. La razón de momios generada por la exposición a violencia sexual para reportar secreción o úlcera fue mayor (OR: 3,84, IC95%: 2,47 a 5,96). Conclusiones: Las mujeres expuestas a cada uno de los tres tipos de violencia íntima de pareja tuvieron mayor chance de reportar secreción o úlcera genital en los últimos 12 meses. El riesgo se incrementa cuando coexisten la forma física y sexual.

Objective: To assess the association between emotional, physical, and sexual intimate partner violence with self-reported discharge and genital ulcer in women from participants in a population-based survey. Methods: An analysis of the Demographic and Family Health Survey of Peru, 2021 was performed. Inclusion criteria were 15-49 years of age, married or cohabiting, and selected and interviewed for the domestic violence module. The prevalence of self-reported discharge and genital ulcer was estimated. The association with intimate partner violence was performed by binary logistic regression with odds ratio estimation, considering the complex sample design. Results: The prevalence of reporting genital ulcer or discharge was 10.0%. The odds ratio for reporting genital discharge or ulcer among women who suffered mild physical violence compared with those not exposed was 2.25 (95%CI: 1.72-2.94), the risk increased to 3.42 (95%CI: 2.39-4.90) among women who suffered severe physical violence. The odds ratio generated by exposure to sexual violence for reporting discharge or ulcer was higher (odds ratio: 3.84, 95% CI: 2.47-5.96). Conclusions: Women exposed to each of the three types of intimate partner violence had a higher chance of reporting genital discharge or ulcer in the last 12 months. The risk increases when physical and sexual violence coexist.

The Burden and Risk Factors of Reproductive Tract Infections among Married Women Aged 15-49 Years in Urban Slum of Agra Uttar Pradesh

Introduction: In developing countries, reproductive tract infection among women commonly goes undiagnosed and their sequel causes various complications. Objectives: To find out the prevalence of RTI/STI through a syndromic case approach and its correlates among women of reproductive age group. Material and Methods: A community-based cross-sectional study was carried out among 500 eligible married women residing in urban slums of Agra by using WHO Syndromic case approch for diagnosis of RTIs/STIs. Results: The overall prevalence of RTI/STD was found to be 32.80% where vaginal discharge (22.60%) and lower abdominal pain (8.20%) were the most common syndromes. On multivariate analysis, religion, caste, type of absorbent used during menses, and history of IUD use were found to be significantly significant. Conclusion: The result of this study highlights the high prevalence and potential risk factors that contribute to the occurrence of RTI. It also emphasizes the need of training and education session of the participants to identify the early symptoms of RTI.

Reparación quirúrgica por vía vaginal de fístulas vesicovaginales: una experiencia exitosa / Vaginal surgical repair of vesico-vaginal fistulas: a successful experience

OBJETIVO: Se presenta una serie de casos de reparación por vía vaginal de fístula vesicovaginal (FVV) de nuestro centro. MATERIAL Y MÉTODOS: Estudio observacional descriptivo. Se evaluaron todas las pacientes con reparación quirúrgica de FVV en el Centro de Innovación de Piso Pélvico del Hospital Sótero del Río entre 2016 y 2022. RESULTADOS: Se reportaron 16 casos, de los cuales el 81,3% fueron secundarios a cirugía ginecológica. En todos se realizó la reparación por vía vaginal, con cierre por planos. En el 94% (15/16) se logró una reparación exitosa en un primer intento. El tiempo de seguimiento poscirugía fue de 10 meses (rango: 3-29). No hubo casos de recidiva en el seguimiento. Una paciente presentó fístula de novo, la cual se reparó de manera exitosa en un segundo intento por vía vaginal. Se reportaron satisfechas con la cirugía 15 pacientes, con mejoría significativa de su calidad de vida. Una paciente reportó sentirse igual (6,3%), pero sus síntomas se debían a síndrome de vejiga hiperactiva que la paciente no lograba diferenciar de los síntomas previos a la cirugía. CONCLUSIÓN: Las FVV en los países desarrollados son secundarias a cirugía ginecológica benigna. La cirugía por vía vaginal en nuestra serie demostró una alta tasa de éxito, con mejora significativa en la calidad de vida de las pacientes.

OBJETIVE: We present a case series of vesico-vaginal fistulas (VVF) vaginal repair in our center. MATERIAL AND METHODS: Descriptive observational study. All patients with surgical repair of VVF at the Centro de Innovación en Piso Pélvico of Hospital Sótero del Río were evaluated between September 2016 and September 2022. RESULTS: 16 cases were reported. 81.3% were secondary to gynecological surgery. In all cases, a vaginal repair was performed, with a layered closure. 94% (15/16) had no contrast extravasation at the time of examination, confirming fistula closure. The follow-up time was 10 months (range: 3-29). There were no cases of recurrence during follow-up. 1 patient presented de novo fistula which was successfully repaired in a second attempt vaginally. 15/16 patients reported being satisfied with the surgery, with significant improvement in quality of life. 1 patient reported feeling the same (6.3%), but her symptoms were due to overactive bladder syndrome that the patient could not differentiate from the symptoms prior to surgery. CONCLUSION: VFV in developed countries are mainly secondary to benign gynecological surgery. Vaginal surgery in our series achieved a significant improvement in the quality of life of patients.

Conduta obstétrica em caso de hipoplasia materna da veia cava inferior / Obstetric management in case of the maternal inferior vena cava hypoplasia

A hipoplasia da veia cava inferior é uma patologia rara que integra o conjunto de anomalias do desenvolvimento da veia cava inferior. A sua incidência situa-se entre 0,3%-0,5% na população saudável e 5% nos adultos jovens sem fatores de risco para trombose venosa profunda, sendo considerada um importante fator de risco para o desenvolvimento de trombose dos membros inferiores. O principal objetivo deste trabalho é reportar a conduta obstétrica de um caso clínico de uma grávida diagnosticada com hipoplasia da veia cava inferior, prévia à gravidez. Trata-se de um caso clínico, de uma grávida, primigesta, com 37 anos, com hipoplasia da veia cava inferior e heterozigotia para o gene MTHFR677 diagnosticadas, na sequência de uma trombose venosa bilateral dos membros inferiores e do segmento infrarrenal da veia cava inferior. A gravidez foi seguida em consulta hospitalar na nossa instituição, tendo a grávida sido medicada com enoxaparina em dose profilática e ácido acetilsalicílico, com um período pré natal que decorreu sem intercorrências. Às 37 semanas e 6 dias de gestação, deu entrada no Serviço de Urgência de Obstetrícia por rotura prematura de membranas. Intraparto foram utilizadas meias de compressão pneumática intermitente, tendo o parto ocorrido às 38 semanas de gestação por via vaginal (parto eutócico), do qual nasceu um recém-nascido do sexo feminino, com 2620g e índice de Apgar 9/10/10. O presente caso clínico demonstra que em situações de hipoplasia da veia cava inferior com um seguimento obstétrico adequado é possível a realização de um parto vaginal, possibilitando um desfecho obstétrico favorável (AU).

Hypoplasia of the inferior vena cava is a rare condition that belongs to the group of developmental anomalies of the inferior vena cava. It has an incidence between 0.3% and 0.5% in the healthy population and 5% in young adults without risk factors for deep venous thrombosis, being considered an important risk factor for the development of lower limb thrombosis. This study aims to report the obstetric conduct of a clinical case of a pregnant woman diagnosed with hypoplasia of the inferior vena cava prior to pregnancy. This is a clinical case of a pregnant woman, primigravid 37 years old, with hypoplasia of the inferior vena cava and heterozygosity for MTHFR677, diagnosed following a bilateral venous thrombosis of the lower limbs and the infrarenal segment of the inferior vena cava. The pregnancy was followed up in our institution. The pregnant woman was medicated with a prophylatic dose of low molecular weight heparin and acetylsalicylic acid with an uneventful prenatal period. At 37 weeks and 6 days of gestation, she was admitted to the Obstetrics Emergency Service due to premature rupture of membranes. Intermittent pneumatic compression sockings were used intrapartum, and at 38 weeks of gestation, a female newborn was vaginally delivered (eutocic delivery) with 2620g and an Apgar score of 9/10/10. The present clinical case demonstrates that in situations of hypoplasia of the inferior vena cava with an adequate obstetric follow-up, it is possible to perform a vaginal delivery, enabling a favourable obstetric outcome (AU).

MODALITIES OF TREATMENT OF PELVIC ORGAN PROLAPSE IN A TERTIARY CARE HOSPITAL (GMCH) AND ITS SHORT TERM FOLLOW UP

Pelvic organ prolapse is an increasingly common condition seen in women with advancing age. The objective of this study is to observe the different modalities of treatment of pelvic organ prolapse and evaluate its outcome. In this study, all patients with pelvic organ prolapse, attending Gynae OPD or admitted in GMCH were included. In this study, 45(22.5%) patients were advised to use vaginal tampon, 9(4.5%) patients were advised Kegel's Results: exercise, 125(62.50%) patients were treated with VH + PFR, , 15 (7.5%) patients underwent vaginal hysterectomy (VH), 4(2%) patients underwent VH + PFR + Sacrospinous ?xation and 2 (1%) patients were treated with Fothergills' surgery. The feedback received revealed that 118(59%) were satis?ed and responded well to the treatment, 26 (13%) patients were not satis?ed and from the remaining 56(28%) patients, no feedback had been received. It was observed that satisfaction was higher in patients who had surgical intervention.

Corrección del prolapso de cúpula vaginal mediante colpopexia vía abdominal

Introducción: Las disfunciones del suelo pélvico se consideran un problema de salud en el mundo y constituyen una de las indicaciones de operaciones ginecológicas más comunes. Entre sus variantes está el prolapso de la cúpula vaginal. Objetivos: Evaluar los resultados de la corrección del prolapso de cúpula vaginal por la técnica de colpopexia, mediante fijación con tiras aponeuróticas a la pared abdominal anterior. Métodos: Se realizó un estudio observacional, descriptivo. Las variables utilizadas fueron la edad, presencia de comorbilidades, el número de cirugías previas y el grado de satisfacción subjetivo de las pacientes, luego del procedimiento. Resultados: Hubo predominio de edades avanzadas en la muestra estudiada con 89,5 % de pacientes mayores de 55 años. En la mayoría de las pacientes se encontró una o más comorbilidades que favorecieron la presencia de esta afección. Un total de 8 pacientes habían sido sometidas a una cirugía correctora previa para el prolapso (30,7 %). Al mes de la cirugía el 80,7 % tenía una puntuación de 1-3 de la escala de evaluación PGI-I, valor que fue en ascenso y alcanzó el 96,1 % a los 3 meses, el 100 % a los 6 meses y al año. Conclusiones: La corrección del prolapso de la cúpula vaginal, mediante colpopexia por vía abdominal es una alternativa de tratamiento para las pacientes, fundamentalmente jóvenes o que quieren conservar la funcionalidad vaginal y la vida sexual activa.

Introduction: Pelvic floor dysfunctions are considered a health problem in the world, and constitute one of the most common indications for gynecological surgery. Among its variants is the prolapse of the vaginal vault. Objectives: To evaluate the results of the correction of the vaginal vault prolapse by the colpopexy technique by means of fixation with aponeurotic strips to the anterior abdominal wall. Methods: An observational, descriptive, retrospective study was carried out. The variables used were age, presence of comorbidities, the number of previous surgeries and the degree of subjective satisfaction of the patients after the procedure. Results: There was a predominance of advanced ages in the sample studied with 89.5% of patients older than 55 years. In most of the patients, one or more comorbidities were found that favored the presence of this condition. A total of 8 patients had undergone previous corrective surgery for the prolapse (30.7%). One month after surgery, 80.7% had a score of 1-3 on the evaluation, a value that increased and reached 96.1% at 3 months, and 100% at 6 months, and one year. Conclusions: Vaginal vault prolapse correction by mean of abdominal way colpopexy is therapeutic alternative, mainly young, and those who want to preserve vaginal functionality, and active sexual life.

A cross-sectional study of reticulocyte count and hemoglobin content of umbilical cord blood with relation to maternal factors in newborns of Sikkim

Background: The hematological values of the new born is amenable to certain changes under the influence of fetal, maternal, and environmental factors. Aims and Objectives: The aims of this study was to study the effect of maternal factors on hemoglobin content and reticulocyte count in umbilical cord blood of newborns of Sikkim. Materials and Methods: A total of 150 cord blood samples from newborns delivered at CRH Hospital and STNM Govt. Hospital, Gangtok, Sikkim were analyzed. Two ml of cord blood was taken in an ethylene diamine tetra acetic acid tube under aseptic condition and within 6 h: Hemoglobin estimation and Reticulocyte count was done. Results: The mean reticulocyte count was 2.48 ± 0.87% in normal vaginal delivery (NVD) and in C/S was 3.06 ± 0.97%. The mean hemoglobin content was 13.9 ± 2.6 g/dL in NVD and in C/S was 16.1 ± 3.4 g/dL. P < 0.05 for cord hemoglobin and reticulocytes in relation to mode of delivery was found to be highly significant. The mean reticulocyte count was 2.85 ± 1.0% in normal pregnancy and in complication of pregnancy was 2.9 ± 0.70%. The mean hemoglobin content was 15.36 ± 3.31 g/dL in normal pregnancy and in complication of pregnancy was 16.1 ± 3.4 g/dL. The reticulocyte count was found to be statistically significant in relation to complication of pregnancy. The mean mother’s hemoglobin was 11.16 ± 1.27 when cord hemoglobin content was <14 g/dL and was 11.88 ± 1.24 g/dL when cord hemoglobin content was >14 g/dL. There was statistical significance between the cord hemoglobin content and the hemoglobin content of the mother. Conclusion: Maternal anemia leads to lower circulating hemoglobin in new born. Cord blood screening is a useful means for identification of anemia in neonatal period. High reticulocyte count in neonates denotes active erythropoiesis which might help to defer transfusion unless there were other special reasons for proceeding.

Factores predictores del éxito del parto vaginal posterior a cesárea

Objetivo : Determinar los predictores del éxito del parto vaginal posterior a cesárea segmentaria transversal primaria por causa no recurrente. Diseño : Estudio de casos y controles. Institución: Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Métodos : Gestantes con inicio espontáneo del trabajo de parto y antecedentes de cesárea con incisión transversal en el segmento inferior por causa no iterativa. La prueba de parto fue considerada exitosa si terminaba en parto vaginal. Principales medidas de estudio : Edad materna, paridad, frecuencia de trabajo de parto previo a la cesárea anterior, edad gestacional al momento del parto, estación de la presentación cefálica fetal al ingreso y peso fetal. Resultados : Se seleccionó 126 gestantes, de las cuales 85 (67,4%) tuvieron pruebas exitosas (parto vaginal), mientras que 41 (32,5%) tuvieron prueba fallida. No se encontraron diferencias en las características generales entre los grupos (p = ns). El análisis univariante mostró que el peso fetal igual o menor de 3,500 gramos, la estación de la presentación cefálica fetal fija o encajada y la edad gestacional menor de 40 semanas fueron predictores significativos del resultado exitoso de la prueba de parto (p < 0,05). El análisis de regresión logística demostró que el peso fetal igual o mayor de 3,500 gramos (p = 0,04) y la estación de la presentación cefálica fetal flotante insinuada (p = 0,03) conservaron importancia como predictores. Conclusión : Los predictores para una prueba exitosa de parto vaginal posterior a cesárea fueron peso fetal menor o igual a 3,500 gramos y la estación de la presentación cefálica fetal fija o encajada.

Objective : To determine predictors of successful vaginal delivery following primary transverse segmental cesarean section for non-recurring cause. Design : Casecontrol study. Institution: Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Methods : Pregnant women with spontaneous onset of labor and history of cesarean section with transverse incision in the lower segment for non-recurrent cause. The trial of labor was considered successful if it ended in vaginal delivery. Main study measures : Maternal age, parity, frequency of labor prior to previous cesarean section, gestational age at delivery, station of fetal cephalic presentation at admission, and fetal weight. Results : A total of 126 pregnant women were selected, of whom 85 (67.4%) had successful trials (vaginal delivery), while 41 (32.5%) had a failed trial. No differences in general characteristics were found between groups (p = ns). Univariate analysis showed that fetal weight equal to or less than 3,500 grams, station of fixed or engaged fetal cephalic presentation, and gestational age less than 40 weeks were significant predictors of successful trial of labor outcome (p < 0.05). Logistic regression analysis showed that fetal weight equal to or greater than 3,500 grams (p = 0.04) and station of floating insinuated fetal cephalic presentation (p = 0.03) retained significance as predictors. Conclusion : Predictors for a successful trial of vaginal delivery following cesarean section were fetal weight less than or equal to 3,500 grams and station of fixed or engaged fetal cephalic presentation.

Laparoscopic urinary undiversion due to recurrent neobladder vaginal fistula: from orthotopic neobladder to ileal conduit / Desderivación urinaria laparoscópica por fístula neo-vesico vaginal recurrente: de neovejiga ortotópica a conducto ileal

Objective: Describe our experience in laparoscopic urinary undiversion due to recurrent neobladder vaginal fistula (NBVF). Methods: Retrospective review of patients who underwent laparoscopic urinary undiversion. Complications were characterized according to the Clavien classification. The Patient Global Impression of Improvement (PGII) questionnaire was used at one year of follow-up to assess the quality of life (QOL). Results: Three laparoscopic urinary undiversions, from orthotopic neobladder to ileal conduit. Two patients underwent laparoscopic cystectomy due to bladder cancer, and one open pelvic exenteration due to cervical cancer. All patients had received previous pelvic radiotherapy. Complications during the first 2 months were Clavien II (two patients). According to the PGII score, two patients felt "much better" and one felt "very much better." Conclusion: Urinary undiversion is a last resort, complex procedure. Even though, it may be the only chance to improve QOL in patients with recurrent or unrepairable NBVF. A laparoscopic approach with neobladder resection, fistulectomy, and intracorporeal ileal conduit is feasible. Further studies are required to assess the best approach in the management of NBVF.

Objetivo: Describir nuestra experiencia en desderivación urinaria laparoscópica por fístula neo-vesico vaginal recurrente (NBVF). Métodos: Revisión retrospectiva de pacientes a los que se les realizó desderivación urinaria laparoscópica. Las complicaciones se caracterizaron según la clasificación de Clavien. El cuestionario de Impresión Global de Mejora del Paciente (PGII) se utilizó al año de seguimiento para evaluar la calidad de vida (QoL). Resultados: 3 desderivaciones urinarias laparoscópicas, de neovejiga ortotópica a conducto ileal. Dos pacientes se sometieron a cistectomía laparoscópica por cáncer de vejiga y una exenteración pélvica abierta por cáncer de cuello uterino. Todos los pacientes habían recibido radioterapia pélvica previa. Las complicaciones durante los primeros 2 meses fueron Clavien II (2 pacientes). Según la puntuación PGII, dos pacientes se sintieron «Mucho mejor¼ y uno se sintió «Muchísimo mejor.¼ Conclusión: La desderivación urinaria laparoscopica es un procedimiento complejo y de último recurso. Sin embargo, puede ser la única oportunidad para mejorar la calidad de vida en pacientes con NBVF recurrentes o irreparables. El abordaje laparoscópico con resección de neovejiga, fistulectomía y conducto ileal intracorpóreo es factible. Se requieren más estudios para evaluar el mejor enfoque en el manejo de NBVF.

Characteristics of women who underwent one or more previous cesarean sections according to Nascer no Brasil / Características de mulheres com uma ou mais cesáreas anteriores no nascer no Brasil

ABSTRACT OBJECTIVE To descriptively analyze Brazilian parturient women who underwent previous cesarean section and point out the factors associated with Vaginal Birth After Cesarean (VBAC) in Brazil. METHODS The study used data from women with one, two, or three or more cesarean sections from the survey Nascer no Brasil (Birth in Brazil). Differences between categories were assessed through the chi-square test (χ2). Variables with significant differences (p < 0.05) were incorporated into logistic regression. FINDINGS Out of the total of 23,894 women, 20.9% had undergone a previous cesarean section. The majority (85.1%) underwent another cesarean section, with 75.5% occurring before the onset of labor. The rate of Vaginal Birth After Cesarean (VBAC) was 14.9%, with a success rate of 60.8%. Women who underwent three or more cesarean sections displayed greater social vulnerability. The chances of VBAC were higher among those who opted for a vaginal birth towards the end of gestation, had a prior vaginal birth, underwent labor induction, were admitted with over 4 centimeters of dilation, and without partner. Receiving care from the private health care system, having two or more prior cesarean sections, obstetric complications, and deciding on cesarean delivery late in gestation reduced the chances of VBAC. Age group, educational background, prenatal care adequacy, and the reason for the previous cesarean section did not result in significant differences. CONCLUSION The majority of women who underwent a previous cesarean section in Brazil are directed towards another surgery, and a higher number of cesarean sections is linked to greater social inequality. Factors associated with VBAC included choosing vaginal birth towards the end of gestation, having had a previous vaginal birth, higher cervical dilation upon admission, induction, assistance from the public health care system, absence of obstetric complications, and without a partner. Efforts to promote VBAC are necessary to reduce overall cesarean rates and their repercussions on maternal and child health.

RESUMO OBJETIVO Analisar descritivamente as parturientes brasileiras com cesariana anterior e apontar os fatores associados ao parto vaginal após cesárea (Vaginal Birht After Cesarean- VBAC) no Brasil. MÉTODOS Foram utilizados dados de mulheres com uma, duas ou três e mais cesáreas da pesquisa Nascer no Brasil. As diferenças entre categorias foram avaliadas pelo teste de qui-quadrado (χ2). As variáveis que apresentaram diferença significativa (< 0,05) foram incluídas em regressão logística. RESULTADOS Do total de 23.894 mulheres, 20,9% tinham cesárea anterior. A maior parte (85,1%) foi submetida a outra cesárea, 75,5% antes do início do trabalho de parto. A porcentagem de VBAC foi de 14,9%, uma taxa de sucesso de 60,8%. Mulheres com três cesáreas ou mais apresentaram maior vulnerabilidade social. As chances de VBAC foram maiores entre aquelas decididas pelo parto vaginal no fim da gestação, com parto vaginal anterior, indução de parto, admitidas com mais de 4 centímetros de dilatação e sem companheiro. Assistência no sistema privado, ter duas cesáreas ou mais, complicações obstétricas e decisão por cesariana no final da gestação diminuíram as chances de VBAC. Faixa etária, escolaridade, adequação do pré-natal e razão da cesárea anterior não apresentaram diferença significativa. CONCLUSÃO A maior parte das mulheres com cesárea anterior no Brasil é encaminhada para uma nova cirurgia, e o maior número de cesáreas está associado à maior iniquidade social. Os fatores associados ao VBAC foram decisão pelo parto vaginal no fim da gestação, parto vaginal anterior, maior dilatação cervical na internação, indução, atendimento no sistema público de saúde, ausência de complicações obstétricas e ausência de companheiro. São necessárias ações de estímulo ao VBAC, visando reduzir taxas globais de cesarianas e suas consequências para a saúde materno-infantil.

The characteristics and correlations of vaginal flora in women with cervical lesions / 中华肿瘤杂志

Objective: To explore the characteristics and correlations of vaginal flora in women with cervical lesions. Methods: A total of 132 women, including 41 women diagnosed with normal cervical (NC), 39 patients with low-grade cervical intraepithelial neoplasia (CIN 1), 37 patients with high-grade cervical intraepithelial neoplasia (CIN 2/3) and 15 patients with cervical squamous cell carcinoma (SCC), who came from the gynecological clinic of Second Hospital of Shanxi Medical University during January 2018 to June 2018, were enrolled in this study according to the inclusive and exclusive criteria strictly. The vaginal flora was detected by 16S rDNA sequencing technology. Co-occurrence network analysis was used to investigate the Spearman correlations between different genera of bacteria. Results: The dominant bacteria in NC, CIN 1 and CIN 2/3 groups were Lactobacillus [constituent ratios 79.4% (1 869 598/2 354 098), 63.6% (1 536 466/2 415 100) and 58.3% (1 342 896/2 301 536), respectively], while Peptophilus [20.4% (246 072/1 205 154) ] was the dominant bacteria in SCC group. With the aggravation of cervical lesions, the diversity of vaginal flora gradually increased (Shannon index: F=6.39, P=0.001; Simpson index: F=3.95, P=0.012). During the cervical lesion progress, the ratio of Lactobacillus gradually decreased, the ratio of other anaerobes such as Peptophilus, Sneathia, Prevotella and etc. gradually increased, and the differential bacteria (LDA score >3.5) gradually evolved from Lactobacillus to other anaerobes. The top 10 relative abundance bacteria, spearman correlation coefficient>0.4 and P<0.05 were selected. Co-occurrence network analysis showed that Prevotella, Peptophilus, Porphyrinomonas, Anaerococcus, Sneathia, Atopobium, Gardnerella and Streptococcus were positively correlated in different stages of cervical lesions, while Lactobacillus was negatively correlated with the above anaerobes. It was found that the relationship between vaginal floras in CIN 1 group was the most complex and only Peptophilus was significantly negatively correlated with Lactobacillus in SCC group. Conclusions: The increased diversity and changed correlations between vaginal floras are closely related to cervical lesions. Peptophilus is of great significance in the diagnosis, prediction and early warning of cervical carcinogenesis.

Correlation between persistent high-risk human papillomavirus infection and vaginal microecology and cervical lesions / 中国热带医学

@#Abstract: Objective To investigate the correlation between persistent and non-persistent HPV infection and vaginal microecology and cervical lesions, and to provide the basis for HPV prevention and treatment. Methods In this prospective study, 229 female patients with high-risk type (HR-HPV) were selected for cervical cytology and vaginal microecological examination in the gynecological outpatient department of Baise Maternal and Child Health Hospital from January 2018 to June 2021. The patients were followed up for 1 year to detect persistent HR-HPV infection. The relationship between HR-HPV persistent infection and vaginal microecology and cervical lesions was analyzed using the HPV-negative group as a control. Results Among 229 patients with HR-HPV, there were 109 patients with persistent HR-HPV infection and 120 patients with non-persistent HR-HPV infection in 1-year follow-up, and the incidence of persistent HR-HPV infection was 47.6%. In the HR-HPV persistent and non-persistent infection and HPV-negative groups, the bacterial vaginal incidence was 20.2%, 15.0% and 8.6%, respectively; vulvovaginal candidiasis was 19.3%, 13.3% and 7.9%, respectively; trichomoniasis vaginitis was 12.8%, 9.2% and 4.5%, respectively; mixed infection was 10.1%, 6.7% and 2.7%; H2O2 detection rate was 24.8%, 18.3% and 12.0%,the positive rate of pH value was 52.3%, 40.8% and 36.4%, and microecological normal detection rate was 22.9%, 32.7% and 40.2%, respectively. There were significant differences among the three groups (χ2=10.634, 10.522, 9.010, 9.374, 10.054, 8.268, P<0.01). In the HR-HPV persistent and non-persistent infection groups, the rates of atypical squamous cell detection were 12.8% and 10.0%, and 8.3% and 4.2% for low-grade squamous cell lesions, and 4.6% and 1.7% for high-grade squamous cell carcinoma, 2.8% and 0 for squamous cell carcinoma, respectively. There was no significant difference in the composition of atypical squamous cells between the two groups (χ2=4.358, P>0.05), there were significant differences in the composition of low-grade, high-grade and squamous cell carcinoma (χ2=11.472, 12.685, 11.378, P<0.01). Spearman rank correlation analysis showed that the presence or extent of HPV infection was positively correlated with bacterial vaginosis, vulvovaginal candidiasis, trichomonal vaginitis and mixed infection (P<0.05), positively correlated with H2O2, sialdase, leucocyte esterase,pH positive and positive for all four items (P<0.05), negatively correlated with microecology (P<0.01), positively correlated with low grade, high grade and squamous cell carcinoma (P<0.01), and not significantly correlated with atypical squamous cell carcinoma (P>0.05). Conclusion Persistent cervical HPV infection is an important factor of dysregulation in vaginal microecology and aggravates the degree of dysregulation in vaginal microecology, which is related to the development of cervical lesions.

Structural Characterization of Vaginal Microbiota in Threatened Abortion Patients with Syndrome of Kidney Deficiency by 16S rRNA Sequencing / 中国实验方剂学杂志

ObjectiveTo investigate the structural features of vaginal microbiota in the early threatened abortion patients with the syndrome of kidney deficiency. MethodThirty-one patients with early threatened abortion of kidney deficiency syndrome （DK-TA group） and 116 women with normal early pregnancy （NP group） attending the First Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2018 to December 2020 were selected. The vaginal secretions were collected for 16S rRNA sequencing， which can reveal the vaginal microbiota composition and differential bacteria between the two groups. ResultThe DK-TA group had higher abundance and diversity of vaginal microbiota than the NP group. The Binary jaccard and unweighted_unifrac distance matrix analysis showed that the similarity， dispersion， abundance， and phylogenetic relationship of vaginal microbiota were significantly different between the two groups. At the phylum level， the DK-TA group had lower relative abundance of Bacteroidetes and Fusobacteria and higher relative abundance of Proteobacteria and Gemmatimonadetes than the NP group. At the genus level， the DK-TA group had lower relative abundance of Sneathia and Bifidobacterium and higher relative abundance of Escherichia-Shigella and Shuttleworthia than the NP group. Linear discriminant analysis Effect Size（LEfSe）revealed that Bacteroidetes， Fusobacteria， and Bifidobacteria were dominant in the NP group and Proteobacteria and Firmicutes in the DK-TA group. The function prediction found that DK-TA was closely associated with 38 functional pathways， including cyclic adenosine monophosphate signaling pathway and regulation of tryptophan channels by inflammatory mediators. In addition， the vaginal differential bacteria between the two groups had significant positive or negative association with the differential metabolic pathways. ConclusionProteobacteria， Gemmatimonadetes， and Bacteroidetes in the vaginal microbiota may be biomarkers for threatened abortion of kidney deficiency syndrome.

Characteristics of vaginal microbiota in pregnant women with premature rupture of membranes and establishment of prediction model / 中华微生物学和免疫学杂志

Objective:To study the characteristics of vaginal microbiota in pregnant women with premature rupture of membranes (PROM) and to establish prediction models for PROM.Methods:This study involved 35 women with preterm premature rupture of membranes (PPROM), 180 with term premature rupture of membranes (TPROM) and 255 term birth cases without premature rupture of membranes (TBWPROM, control group). The V3-V4 hypervariable region sequences in the vaginal samples collected at 16-28 weeks of gestation were detected by 16S rRNA gene next-generation sequencing. The differences in Alpha and Beta diversity, and the attributes and metabolic function prediction of each recognized species among the three groups were analyzed. Subsequently, a random forest model was used to establish the prediction models for PROM using vaginal microbiota species and environmental risk factors.Results:Compared with the control group, the Alpha diversity of the PPROM group was higher (Observed features, P=0.022; Faith_pd index, P=0.024) and Beta diversity was also significantly different (Unweighted UniFrac, P=0.010; Jaccard index, P=0.008). In PPROM cases, Megasphaera genomosp. typeⅠ was significantly increased ( P=0.017) and Lactobacillus mulieris was significantly decreased ( P=0.003). In the patients with TPROM, Megasphaera was significantly increased ( P=0.009) and Lactobacillus mulieris was significantly decreased ( P=0.002). In terms of functional pathways, sulfur oxidation ( P=0.021), methanogenesis from acetate ( P=0.036), L-histidine biosynthesis ( P=0.009), adenosylcobalamin biosynthesis ( P=0.041) and fucose degradation ( P=0.001) were significantly increased in patients with PPROM; L-histidine biosynthesis ( P<0.001) and fucose degradation ( P=0.030) were significantly increased in patients with TPROM. The prediction models were established using the random forest model with vaginal microbiota species and environmental risk factors and the prediction model for PPROM performed well [AUC: 0.739 (95%CI: 0.609-0.869), sensitivity: 0.928, specificity: 0.659, positive predictive value: 0.750, negative predictive value: 0.906], which had a certain reference value. Conclusions:Vaginal microbiota might be related to the development and progression of PROM. Studying the differences in vaginal microbiota might provide a new idea for the prevention and treatment of PROM. Functional prediction provided a direction for further research on the mechanism of PROM. The established prediction model could prevent the occurrence of PPROM and promote maternal and infant health.

Comparison of teaching effect of hands-on instruction versus video demonstration in forceps delivery for training residents / 中华全科医师杂志

Objective:To evaluate the effectiveness of hands-on training and video demonstration in training of forceps delivery for residents.Methods:Forty nine residents who were rotating in the obstetrics department of Peking Union Medical College Hospital from 2019 to 2021 were enrolled. The residents were randomly divided into two groups: the instructor group ( n=24) was taught by hands-on training of forceps delivery and the video group ( n=25) was instructed by watching video demonstration. All the trainees completed the self-confidence questionnaire survey, and were evaluated by written tests and objective structured assessment of technical skills scoring system. Results:The scores of self-confidence in each item after the simulation training were higher than those before training in both groups; and there were no significant differences between two groups in the increment of scores(mastering knowledge: 1.54±0.98 vs. 1.40±0.71, U=266.68, P=0.480;mastering operation skills: 1.42±0.93 vs.1.80±0.87, U=233.47, P=0.161; mastering forceps structure: 1.63±1.10 vs. 1.88±0.93, U=261.63, P=0.416; confidence in independent operation: 1.13±0.90 vs. 1.00±1.08, U=287.74, P=0.799; evaluation of simulation training: 0.21±0.51 vs. 0.16±0.55, U=288.27, P=0.776). In the written tests, the scores of the instructor group were significantly higher than those of the video group (83.00±7.18 vs.70.56±10.37; t=4.86, P<0.001). In the practical operation, the instructor group significantly outperformed the video group in items of “right blade placement” (0.71±0.46 vs. 0.20±0.41, U=147.54, P<0.001), “objective total score” (6.17±1.46 vs. 4.72±1.65, U=155.49, P=0.003) and “correct traction” (0.85±0.31 vs. 0.56±0.51, U=213.86, P=0.036). Conclusion:Training delivered via hands-on instruction and demonstration was generally more effective than that delivered via video, although both groups show a increased self-confidence in learning and performing forceps delivery.

Analysis of vaginal microecology in 23 181 cases of the gynecological female outpatients / 中华妇产科杂志

Objective:To analyze the vaginal microecological status of vaginitis population and non-vaginitis population of gynecological female outpatients.Methods:A total of 30 265 women who visited the gynecological outpatient clinic of Beijing Obstetrics and Gynecology Hospital from December 2018 to December 2020 completed vaginal microecological examination. After removing the follow-up patients, 23 181 women were divided into group with symptoms and signs of vaginitis (6 697 cases) and group without symptoms and signs of vaginitis (16 484 cases), according to whether the women with symptoms and signs of vaginitis or not. And the vaginal microecological status of the two groups was compared and analyzed.Results:(1) The total detection rate of vaginitis in the initial women was 34.87% (8 083/23 181), of which 46.10% (3 087/6 697) in group with symptoms and signs of vaginitis and 30.31% (4 996/16 484) in group without symptoms and signs of vaginitis, nearly 1/3 of the gynecological outpatients without signs and symptoms of vaginitis had vaginitis. (2) Among the types of simple vaginitis, vulvovaginal candidiasis (VVC) was the most frequent in group with symptoms and signs of vaginitis (16.01%, 1 072/6 697), followed by aerobic vaginitis (AV; 12.83%, 859/6 697), with significant differences compared with group without symptoms and signs of vaginitis (all P<0.001). There were no statistical differences between the two groups of bacterial vaginosis (BV) and trichomonal vaginitis (TV), indicating that BV and TV were more likely to be neglected (all P>0.05). (3) The proportion of various combinations of vaginitis among 2 632 cases of mixed vaginitis were, in descending order: BV+AV, VVC+AV, BV+AV+VVC, AV+TV, AV+TV+BV, BV+VVC. (4) Microecological analysis of 15 098 cases diagnosed with non-vaginitis had normal flora (including those with normal flora and those with normal flora but decreased function) in 14 013 cases (92.81%, 14 013/15 098), abnormal flora in 429 cases (2.84%, 429/15 098) and the BV intermediate in 656 cases (4.34%, 656/15 098); this indicated that the vast majority of the microecological tests were normal in the vaginal microbiota of those without vaginitis. Conclusions:Microecological examination could diagnose multiple pathogenic infections at once, and is especially important as a guide for the definitive diagnosis of mixed vaginitis and vaginitis with atypical clinical symptoms. Vaginal infections such as BV and TV that are easily overlooked should be concerned.