Downstream changes in river avulsion style are related to channel morphology.

One of the most dramatic events in river environments is the natural diversion, or avulsion, of a channel across its floodplain. Though rarely witnessed, avulsions can cause massive floods, and over geologic time they create most of the fluvial stratigraphic record. Avulsions exhibit behavior ranging from reoccupying abandoned channels to constructing new channels and splay complexes. To quantify avulsion behavior, or style, we measure avulsion-related floodplain disturbance in modern environments. We show that for 63 avulsions from Andean, Himalayan, and New Guinean basins, avulsion style correlates with channel morphology and changes systematically downstream. Avulsions in braided rivers reoccupy abandoned channels, whereas avulsions in meandering rivers often produce flooding and sediment deposition during channel construction. These downstream changes in avulsion style can explain the abrupt transition from channel-dominated to floodplain-dominated facies commonly observed in foreland basin stratigraphy. These dynamics also explain why some avulsions are more hazardous than others.

Global-scale human impact on delta morphology has led to net land area gain.

River deltas rank among the most economically and ecologically valuable environments on Earth. Even in the absence of sea-level rise, deltas are increasingly vulnerable to coastal hazards as declining sediment supply and climate change alter their sediment budget, affecting delta morphology and possibly leading to erosion1-3. However, the relationship between deltaic sediment budgets, oceanographic forces of waves and tides, and delta morphology has remained poorly quantified. Here we show how the morphology of about 11,000 coastal deltas worldwide, ranging from small bayhead deltas to mega-deltas, has been affected by river damming and deforestation. We introduce a model that shows that present-day delta morphology varies across a continuum between wave (about 80 per cent), tide (around 10 per cent) and river (about 10 per cent) dominance, but that most large deltas are tide- and river-dominated. Over the past 30 years, despite sea-level rise, deltas globally have experienced a net land gain of 54 ± 12 square kilometres per year (2 standard deviations), with the largest 1 per cent of deltas being responsible for 30 per cent of all net land area gains. Humans are a considerable driver of these net land gains-25 per cent of delta growth can be attributed to deforestation-induced increases in fluvial sediment supply. Yet for nearly 1,000 deltas, river damming4 has resulted in a severe (more than 50 per cent) reduction in anthropogenic sediment flux, forcing a collective loss of 12 ± 3.5 square kilometres per year (2 standard deviations) of deltaic land. Not all deltas lose land in response to river damming: deltas transitioning towards tide dominance are currently gaining land, probably through channel infilling. With expected accelerated sea-level rise5, however, recent land gains are unlikely to be sustained throughout the twenty-first century. Understanding the redistribution of sediments by waves and tides will be critical for successfully predicting human-driven change to deltas, both locally and globally.

Management of vaginal agenesis.

PURPOSE OF REVIEW: Mayer-Rokitansky-Küster-Hauser syndrome is undergoing new research outcomes involving genetics and management. RECENT FINDINGS: Recent literature supports a polygenic multifactorial genetic basis for the syndrome. Management is now predominantly by vaginal dilators and nonsurgical, but holistic. The future of uterine transplantation is discussed. SUMMARY: New developments open new possibilities for understanding the genetic basis of the disease, and research in this area will continue. Management in terms of fertility may have an added dimension if uterine transplantation and successful pregnancy outcome can be proven.

Mayer-Rokitansky-Küster-Hauser syndrome: a review of 245 consecutive cases managed by a multidisciplinary approach with vaginal dilators.

OBJECTIVE: To understand the efficacy of vaginal dilators in the management of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. DESIGN: Retrospective sequential study. SETTING: Hospital. PATIENT(S): 245 women. INTERVENTION(S): Vaginal dilators. MAIN OUTCOME MEASURE(S): Functional vaginal length and sexual satisfaction. RESULT(S): Of the patients who completed the program, 232 (94.9%) achieved a successful vaginal length (defined as greater than 6 cm in length and maximum width throughout the vagina and especially at the apex) and sexual function. When the program was completed by all patients, 100% of patients were successful. CONCLUSION(S): Vaginal dilator therapy is the treatment of first choice for creation of the vagina in MRKH syndrome, and the success rates suggest that surgery is rarely, if ever, required.

Prostaglandin E2 vaginal gel or tablets for the induction of labour at term: a randomised controlled trial.

OBJECTIVE: To compare the effectiveness of prostaglandin E2 (dinopristone) vaginal gel versus vaginal tablets for the induction of labour at term. DESIGN: Randomised controlled clinical trial. SETTING: University maternity hospital in London. POPULATION: Pregnant women with cephalic presentation undergoing induction of labour after 37 weeks of gestation. METHODS: Prostaglandin E2 vaginal tablets (3 mg) or vaginal gel (1 mg/ 2 mg) was administered at 6-hourly intervals until the cervix was suitable for amniotomy. MAIN OUTCOME MEASURES: Induction to delivery interval, in minutes; rate of failed induction of labour requiring caesarean delivery. RESULTS: Eighty-two women received prostaglandin gel; 83 women received vaginal tablets. There were significant differences between the two treatment groups in the primary outcomes. The mean induction to delivery interval was significantly shorter in women who received the gel (1400 minutes, 690-2280 minutes, versus 1780 minutes, 960-2640 minutes; P = 0.03). The rate of failed induction of labour was significantly higher in women who received tablets (10.84 versus 1.22%; P = 0.01). Subanalysis showed that these differences were only representative of differences in the groups of primigravid women. There were no significant differences in any of the secondary outcomes, including the number of women who required syntocinon augmentation, the rate of uterine hyperstimulation, the need for epidural analgesia, meconium staining of liquor, the need for fetal blood sampling, or delivery by caesarean section. There were no differences in adverse maternal and neonatal outcomes. CONCLUSION: Prostaglandin E2 vaginal gel is superior to vaginal tablets for the induction of labour.

Absence of uterine arteries discovered at fibroid embolisation.

Uterine artery embolisation is an increasingly used modality for the treatment of uterine leiomyomata. A 45-year-old woman with menorrhagia due to fibroids was discovered at uterine artery embolisation to have absent uterine arteries. Knowledge of the potential anatomical variants is important for those carrying out uterine artery embolisation, and further investigation of alternative treatment methods is required.

Psychological distress in women with uterovaginal agenesis (Mayer-Rokitansky-Kuster-Hauser Syndrome, MRKH).

BACKGROUND: Uterovaginal agenesis (Mayer-Rokitansky-Küster-Hauser Syndrome; MRKH) is a congenital nonformation of the vagina and the uterus, but with normal ovaries. OBJECTIVE: The authors investigated the psychological impact of this disorder, about which very little is known. METHOD: A group of 66 women with MRKH were compared with 31 control-group women on a range of self-rating scales assessing psychological distress and self-esteem. RESULTS: Women with MRKH had significantly more pathological scores on some of the scales and subscales, such as phobic anxiety and psychoticism (interpersonal alienation), with a similar trend for subscales measuring depression and anxiety. CONCLUSION: MRKH has a lasting negative impact on affected women's level of psychological distress and self-esteem.

A cognitive behavioural model and therapy for utero-vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome: MRKH).

BACKGROUND: Utero-vaginal agenesis, also called the Mayer-Rokitansky-Küster-Hauser Syndrome (MRKH), is a congenital abnormality of the female genital tract, characterized by the non-formation of the vagina and the uterus. It is a common cause of primary amenorrhoea. Little is known about the psychological impact and management of this condition. METHOD: We describe a specific model of the core negative psychological impact of diagnosis and medical treatment of MRKH and a cognitive-behavioural therapy of MRKH based on the model (CBT-MRKH). The Medical Research Council's (2002) framework for the development and evaluation of complex health interventions was used for intervention development and evaluation. RESULTS: Evidence from a recent cross-sectional study and a small randomized controlled trial (RCT) provides preliminary support for the model and treatment (Heller-Boersma, Schmidt and Edmonds, in press; Heller-Boersma, Schmidt and Edmonds, 2007), and this is further validated by extensive qualitative material gathered over the course of the RCT from participants. CONCLUSIONS: The model and treatment described may also be applicable to a number of other congenital or acquired gynaecological conditions such as premature ovarian failure, breast cancer, early onset endometrial cancer, female genital mutilation, Turner's Syndrome, ovarian dys/agenesis or, Complete Androgen Insensitivity Syndrome, all of which have a psychological impact not dissimilar to MRKH in terms of these women's sense of self and femininity.

Fatal pulmonary embolus after uterine artery fibroid embolisation.

We report a 44-year-old woman who developed a fatal pulmonary embolus after uterine artery fibroid embolisation (UAE). Bilateral UAE was carried out through a single right-femoral artery puncture. The largest fibroid in the anterior fundal wall measured 4.5 cm, and the largest fibroid in the posterior fundal wall measured 6 cm. The appearances after UAE were satisfactory, and the procedure was apparently uneventful. No immediate complications were noted. The patient developed sudden-onset shortness of breath and went into cardiac arrest 19 h after the procedure. Postmortem autopsy confirmed that the cause of a death was a pulmonary embolism. To our knowledge this is the first reported case in the United Kingdom in which death occurred from a pulmonary embolus after UAE.

A randomized controlled trial of a cognitive-behavioural group intervention versus waiting-list control for women with uterovaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome: MRKH).

BACKGROUND: Uterovaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome: MRKH) is a congenital abnormality of the female genital tract, characterized by the non-formation of the vagina and uterus. There is a widespread agreement that MRKH has a lasting negative psychological impact on women with this condition, but as yet little is known about how to conceptualize and manage this. We developed a cognitive-behavioural group treatment (CBT) of MRKH. The aim of the present study was to determine whether this intervention, compared to waiting-list control, improves psychosocial outcomes in women with MRKH. METHODS: After stratifying for age and type of MRKH (simple or complex), 39 women with MRKH were randomized to group CBT (n = 19) or waiting list (n = 20). Outcomes were assessed at pre-treatment, post-treatment (7 weeks) and at 3 months follow-up. The main outcome measure was the Symptom Check-List (SCL-90-R). Other outcomes included impact of event, self-esteem and interpersonal functioning. RESULTS: Participants allocated to group CBT showed significantly reduced psychological symptoms on the SCL-90-R and non-significant improvements on all secondary outcomes at the end of treatment and follow-up, whereas those on the waiting list remained unchanged. CONCLUSIONS: A group CBT intervention improves psychological outcomes in MRKH. This treatment may also be applicable to other gynaecological conditions.

Congenital abnormalities of the genital tract: management or mismanagement?

Congenital malformations of the genital tract are uncommon and their management requires skill that is only available in a very few centres worldwide. The management requires sensitivity both in terms of the psychological welfare of the patient and the physical welfare and these must be combined together to provide such support. Management of patients outside of these environments is less than optimal and this article seeks to exemplify a principle of management excellence.

Retroperitoneal solitary fibrous tumour arising from the pelvis in women--a case report and review of literature.

A solitary fibrous tumour is an unusual spindle cell neoplasm that most frequently occurs in the pleura based intrathoracic region. In recent years attention has been drawn towards solitary fibrous tumours arising in extrathoracic sites. They are usually benign but malignant solitary fibrous tumours have also been reported (Nielson et al. 1997). There is far less information about the clinical behaviour of an extra thoracic solitary fibrous tumour unlike intrathoracic tumours which is well reported in many case series (England et al. 1989). Although solitary fibrous tumours are well described lesions, the occurrence of similar tumours in the pelvic retroperitoneum of women and presenting as pelvic mass have been reported only sporadically. Because of the rarity, unpredictable behaviour; lack of information available about the clinical behaviour (recurrence and metastasis) and lack of follow up protocol, we are reporting this case which we encountered along with the review of previously reported cases.

Sexual function in women treated with dilators for vaginal agenesis.

OBJECTIVE: To discover the sexual satisfaction of young women treated with vaginal dilators for vaginal agenesis. DESIGN: Anonymous questionnaire study. MAIN OUTCOME MEASURES: Comparison of sexual desire arousal lubrication, orgasm satisfaction and pain with a normal population. RESULTS: There was no significant difference between the study population and controls for the domains of sexual desire, sexual arousal, and satisfaction with a sexual relationship. There was, however, a significant difference for vaginal lubrication and orgasm where the Rokitansky patients scored lower. 22.3% of patients reported some degree of dyspareunia following vaginal penetration. However, this did not affect their enjoyment of the sexual act. CONCLUSION: The use of graduated vaginal dilators for patients with Mullerian agenesis is highly successful in creating a neovagina. Although the lack of adequate lubrication, pain and difficulty in reaching orgasm is significantly higher in this group, the patients subsequently enjoy sexual satisfaction that is comparable to a normal population.

Preconception transabdominal cervicoisthmic cerclage.

OBJECTIVE: The purpose of this study was to report pregnancy outcome and complication rates for women with recurrent late pregnancy loss who were treated with preconception transabdominal cervicoisthmic cerclage. STUDY DESIGN: This was a case note review of 19 women at high risk for second trimester loss and early preterm delivery who were treated with preconception transabdominal cervicoisthmic cerclage at Queen Charlotte's and Chelsea Hospital from 1994 to 2003. RESULTS: Preconception transabdominal cervicoisthmic cerclage was associated with a postoperative fetal survival rate of 100% for pregnancies that reached >12 weeks of gestation, compared with a preoperative fetal survival rate of 12%. There were no significant intraoperative, antenatal, intrapartum or neonatal complications. CONCLUSION: Within this case series, preconception transabdominal cervicoisthmic cerclage was a safe alternative to transabdominal cervicoisthmic cerclage that was performed in pregnancy with no risk to a fetus. It should be considered in appropriate cases in women seen for prepregnancy counseling.

Parental perceptions of the therapeutic effect from osteopathic manipulation or acupuncture in children with spastic cerebral palsy.

Fifty children were involved in a randomized, controlled trial to evaluate the effectiveness of either osteopathic manipulation or acupuncture as a 6-month therapeutic adjunct for children with spastic cerebral palsy. Exit interviews were used to obtain parental perceptions and form the basis of this report. Only 2 of 17 parents reported positive gains while their child was in a wait-list control period but all 17 reported gains while in the treatment phase of the study. Ninety-six percent (48 of 50) of the parents reported some improvement while their child was receiving treatments but the gains varied from child to child. The most frequent gains were seen in improvement in the use of arms or legs (61% and 68%) and more restful sleep (39% and 68%) in the osteopathic and the acupuncture groups, respectively. Improvement in mood and improved bowel function were also very common benefits noted by the parents in both groups.

Congenital malformations of the genital tract and their management.

While congenital malformations of the genital tract are not common, the sequelae of their presence can be serious. The practising gynaecologist must be aware of the range of congenital abnormalities that may occur and the symptoms that may result from them. Failure to manage these patients correctly may have long-term sequelae for their psychological, sexual and reproductive health. The involvement of a multi-disciplinary team in dealing with these patients is imperative, and preparation for surgery-particularly in congenital malformations of the vulva and the vagina-is imperative if the long-term sexual function in these patients is to be fulfilled. Surgical correction of vulval abnormalities in adolescence is related solely to sexual function as most of the reconstructive surgery is done in childhood. For the management of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, the recommendation is now that passive dilatation by Franks' technique is the treatment of first choice and only if that fails should surgical approaches be embarked upon. The results of the surgery are similar in all techniques and the particular surgical centre will have its own preference of which technique it adopts. Congenital absence of the cervix is a complex surgical problem and should be dealt with solely in centres with expertise.