Fractional-Pixel CO2 Laser Treatment in Patients With Urodynamic Stress Urinary Incontinence: 1-Year Follow-Up.

BACKGROUND AND OBJECTIVES: Vaginal pixelated low power and long pulses (LPLP) CO2 laser has been suggested as an optional treatment for stress urinary incontinence (SUI) with many studies reporting short-term improvements. The objective of this study was to assess the 1-year subjective and objective efficacy of vaginal CO2 laser in women with urodynamic SUI. STUDY DESIGN/MATERIALS AND METHODS: This was a prospective multicenter study. Patients with confirmed urodynamic SUI graded as mild or moderate were included. We used three sessions of fractional pixelated CO2 laser for vaginal application and followed up the patients at 6 and 12 months. We used the following measures at follow-up: 1-hour pad test (ICS protocol), questionnaires including Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ), Patient Global Impression of Improvement (PGI-I), and a 3-day urinary diary. The urodynamic assessment was repeated at 6 months. RESULTS: Fifty-two patients with SUI had three laser treatments, of whom 48 completed a 6-month follow-up and 42 patients completed 12-month follow-up. No serious adverse events were recorded during the study period. A significant reduction on the 1-hour pad test was found from baseline (6.3 ± 1.6 g) to the 12-month follow-up (3.7 ± 1.4 g, P < 0.05) was found. PGI-I showed 75.0%, 61.9%, and 64.3% improvements at 3, 6, and 12 months, respectively. PFDI improved significantly and consistently from baseline until 12 months (37.2 ± 3.89 to 16.1 ± 3.7, P < 0.05). Similarly, PFIQ showed significant improvements from the first treatment up to 12 months. Urodynamic assessment at 6 months showed that 41.4% of patients had no stress incontinence. CONCLUSION: The vaginal CO2 laser was found to be effective for mild-to-moderate SUI over a follow-up period of 1 year, according to a variety of objective and subjective parameters. The wide range of parameters enables optimal patient consultation and subsequent treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

The Routine Use of Intrapartum Ultrasound in Clinical Decision-Making during the Second Stage of Labor - Does It Have Any Impact on Delivery Outcomes?

BACKGROUND/AIMS: The study aimed to assess whether the use of intrapartum transperineal ultrasound (US) can reduce the rate of failed vacuum extraction (VE). METHODS: This is a retrospective cohort study including all women delivering at term with the diagnosis of protracted second stage of labor. The mode of delivery and rate of failed VE were compared between women who underwent a US examination prior to the decision on obstetrical interventions ("+US" group) and those in whom clinical decisions were based upon digital assessment only ("no-US" group). RESULTS: The study included 635 women. Among the "no-US" group (536), there were 13 failed VE attempts (3.6%) vs. none in the "+US" group (99, p = 0.1). There was a significant difference between the groups regarding mode of delivery (p = 0.001), with a lower cesarean section (CS) rate (20.2 vs. 27.8%) among the "+US" group. Maternal age, body mass index, nulliparity, gestational age at delivery, and birth weight, as well as neonatal short-term outcome did not differ significantly between the 2 groups. CONCLUSIONS: We demonstrate that among women who had the addition of intrapartum US during the second stage of labor there was a trend toward a lower rate of failed VE (although not reaching statistical significance), with a lower rate of CS but not affecting neonatal outcome.

Prolonged feeding with green tea polyphenols exacerbates cholesterol-induced fatty liver disease in mice.

SCOPE: This study investigated the potential deleterious impact of dietary supplementation with green tea extract (GTE) on the progression of fatty liver disease, in a mouse model of cholesterol-induced steatohepatitis that represents chronic liver injury. METHODS AND RESULTS: Male C57BL mice (n = 32, 8-wk-old) were fed for 6 wk with one of the following diets: normal control diet (ND, Con), Con + 1% w/w polyphenols from GTE (Con + GTE); high cholesterol diet, Con + 1% cholesterol + 0.5% cholate w/w (HCD); HCD + 1% green tea polyphenols w/w (HCD + GTE). Hepatic steatosis, oxidative, and inflammatory markers and bile acid synthesis pathways were measured. HCD supplementation resulted in hepatic steatosis and liver damage. In animals supplemented with the HCD + GTE an exacerbated hepatic steatosis, oxidative stress, and inflammatory response were observed compared to HCD supplemented animals. HCD + GTE supplementation elevated blood levels of liver enzymes and serum bile acids compared HCD-treated animals. HCD + GTE supplementation altered bile acid synthesis in the cholesterol clearance pathway, inducing a shift from the classically regulated CYP7A1 pathway to the alternative acidic pathway. CONCLUSION: Prolonged GTE supplementation dramatically increased hepatic oxidative stress, inflammation and liver injury, and altered the bile acid synthesis pathway in mice fed a HCD.

Shortness of Breath During Pregnancy: Could a Cardiac Factor Be Involved?

BACKGROUND: Shortness of breath (SOB) is common among healthy women with normal pregnancies. However, when no overt cardiac or extra cardiac etiology is found, a subtle cardiac source must be excluded. HYPOTHESIS: Pregnancy may induce or unmask myocardial dysfunction that may cause SOB. METHODS: Healthy pregnant women with significant SOB were recruited for this study. We performed a comprehensive echocardiographic assessment including tissue Doppler imaging (TDI) and 2- dimensional strain imaging (2DS). The echocardiographic data obtained were compared with that of a control group of pregnant women without SOB. RESULTS: Thirty pregnant women with SOB were enrolled in the study (age, 31.8 ± 4.9 years, and gestation, 38.2 ± 2.8 weeks) for whom no overt etiology for SOB was detected. Patients with SOB compared with controls had thicker hearts (septum: 10.1 ± 1.1 vs 8.9 ± 0.9 mm; P < 0.001; posterior wall: 9.4 ± 1.1 vs 8.9 ± 0.9 mm; P < 0.01), shorter E-wave deceleration time (158.0 ± 50.1 vs 187.1 ± 37.6 msec; P = 0.01), and higher pulmonary artery pressure (26.8 ± 6.2 vs 19.0 ± 6.5 mm Hg, P < 0.01). Women with SOB tended to have a lower S' velocity TDI (P = 0.05) and a trend toward increased torsion on 2DS (P = 0.09). CONCLUSIONS: Significant SOB during otherwise normal pregnancy is associated with significant echocardiographic findings that may suggest a subtle cardiac involvement. Further investigation is necessary to verify such an association, which may have therapeutic implications for treating SOB of pregnancy.

"Onion skin" sign in an ovarian mucinous cyst.

The sonographic "onion skin" sign was initially described as concentric echogenic layers in mucinous tumors unrelated to the female reproductive system. Typically, the sonographic appearance of ovarian mucinous cystadenoma includes numerous septa and fine, gravity-dependent echoes. We present a case of the "onion skin" sign in a mucinous ovarian tumor.

[The use of a synthetic analog of prostaglandin E1 for medical treatment of first trimester pregnancy failure].

First trimester failure is a common event accruing in 15-20% of pregnancies that has traditionally been treated by surgical curettage. An alternate therapy is medical treatment using misoprostol, a synthetic analog of prostaglandin E1. Numerous studies have been carried out comparing treatment by misoprostol with a placebo. They have found a significant advantage to misoprostol mode of treatment. Other studies comparing surgical and medical treatment found the surgical treatment to be superior to the latter. It must be noted that the medical mode of treatment was indeed found to be successful in over 80% of cases. No significant differences were noted in the complication rates of the two groups. Misoprostol therapy has been found to be effective when administered orally or vaginally, although vaginal therapy is slightly superior. No large scale studies have been carried out to date testing the safety of this treatment in patients with a scarred uterus (due to Cesarean section or hysterotomy). However, on the basis of reported facts, it seems plausibLe to suggest misoprostoL treatment for these patients.

Induction of labor with oral misoprostol for premature rupture of membranes at term in women with unfavorable cervix: a randomized, double-blind, placebo-controlled trial.

AIM: To evaluate the efficacy and safety of oral misoprostol for labor induction in women with term premature rupture of membranes (PROM) and an unfavorable cervix. METHODS: We randomized 130 women with PROM of < or =4 h to either oral misoprostol, 50 microg, or a placebo given every 4 h for up to three doses. Intravenous oxytocin was initiated if active labor did not begin within 12 h. RESULTS: Sixty-four women received oral misoprostol and 66 received placebo. The PROM-to-delivery interval was shorter with misoprostol than with placebo (13.7+/-5.8 vs. 20.3+/-6.8 h, respectively, P<0.05). Misoprostol significantly reduced the need for oxytocin (28.1 vs. 72.7%, P<0.001) and antibiotics (25 vs. 69.7%, P<0.001). No significant differences in cesarean section or hyperstimulation rate were noted. CONCLUSION: Oral misoprostol given to women with unfavorable cervix soon after term PROM significantly reduces the induction-to-delivery time and the need for oxytocin and antibiotics.

Variable echogenicity as a sonographic sign in the preoperative diagnosis of ovarian mucinous tumors.

OBJECTIVE: The purpose of this study was to evaluate the reliability of the "variable echogenicity" sign in the preoperative sonographic diagnosis of ovarian mucinous tumors. METHODS: Variable echogenicity was detected sonographically in different compartments of 8 adnexal multilocular masses. This finding was correlated with the final histologic results. RESULTS: All 8 tumors were mucinous cyst adenomas. In 3 of them, borderline malignancy was present. CONCLUSIONS: The sonographic detection of variable echogenicity in the contents of an adnexal multilocular cyst strongly suggests a mucinous tumor.

Laparoscopic hysterectomy versus total abdominal hysterectomy: a comparative study.

OBJECTIVE: The objective of this study was to compare the intraoperative and short-term postoperative complications of laparoscopic hysterectomy and total abdominal hysterectomy. STUDY DESIGN: Retrospective study of 167 women who had laparoscopic hysterectomy and 119 women who had total abdominal hysterectomy. For assessing the learning curve, the laparoscopic hysterectomies were further subdivided to the first 30 hysterectomies and the later hysterectomies. For data analysis Student's t-test, chi2-test and Fisher's exact test were used. RESULTS: There were no statistically significant differences between the two groups for age, body mass index, previous abdominal surgery, uterine weight, first postoperative day hemoglobin drop, blood transfusion and major or minor complications rate. Operation time was significantly longer for laparoscopic than abdominal hysterectomy (156+/-40 and 91.2+/-33 min, respectively; P<0.001) but the length of hospital stay was significantly shorter (3.9 and 6.55 days, respectively; P<0.001). The conversion rate of laparoscopic hysterectomy was 1.8% (three cases). CONCLUSIONS: Laparoscopic hysterectomy can be safely done even during the learning curve with a low and reasonable complication rate, and a shorter hospital stay but with longer operation time. As experience is gained the operation time, complication rate and hospital stay are decreased.

Twin pregnancy consisting of a complete hydatidiform mole and co-existent fetus: report of two cases and review of literature.

Hydatidiform mole with co-existing live fetus is a rare entity. Two cases are reported. In the first, complete mole with a co-existing live fetus was suspected on ultrasound examination at 16 weeks of gestation. A termination of pregnancy was performed due to early onset of severe preeclampsia and thyrotoxicosis. In the second case, the patient was admitted at 26 weeks of gestation due to preeclampsia. Genetic amniocentesis at 19 weeks of gestation revealed a normal 46 XX karyotype. Ultrasound examination at 21 weeks of gestation demonstrated two cystic lesions in the fetal liver, wide multicystic placenta and polyhydramnious. Following deteriorating severe preeclampsia, a live female infant (730 g) along with a huge placenta (1350 g) was delivered by a cesarean section. Unfortunately, the newborn died after 35 days. Pathological examination in both cases was consistent with a complete mole co-existing with a viable fetus. During a 1 year follow up period, there was no evidence of persistent or metastatic disease in both cases. Review of literature discussing the diagnostic tools, clinical features, management and outcome of pregnancies with complete mole with a co-existing live fetus is presented.

Head pushing versus reverse breech extraction in cases of impacted fetal head during Cesarean section.

OBJECTIVE: To compare maternal and neonatal morbidity associated with two methods to extract the impacted fetal head during Cesarean delivery. STUDY DESIGN: We retrospectively analyzed cases with difficult extraction of the impacted fetal head during Cesarean section. We compared maternal and neonatal outcomes between cases that were delivered by head extraction following pushing through the vagina ('push' method) and those that were delivered by the reverse breech technique ('pull' method). RESULTS: We reviewed 3105 Cesarean section reports. Difficult extraction necessitating the 'push' or 'pull' methods was noted in 48 (1.5%) instances. Women that were delivered by the 'pull' method had significantly lower rate of postpartum fever (5% versus 46%; odds ratios, 0.06; 95% confidence intervals, 0.007-0.51) and extensions of the uterine incision (15% versus 50%; odds ratio, 0.17; 95% CI, 0.04-0.74) compared to those that were delivered by the 'push' method. Neonatal outcomes were good in all cases. CONCLUSIONS: In cases with difficult extraction of the impacted fetal head during Cesarean section, 'pull' method may result in lower maternal morbidity compared to the traditional 'push' method.

The role of laparoscopy in ovarian tumors of low malignant potential and early-stage ovarian cancer.

UNLABELLED: Although it is feasible today to perform laparoscopic surgical staging and treatment of ovarian low malignant potential tumors and early-stage ovarian cancer safely, it is still generally agreed that a patient with ovarian cancer should have a laparotomy. Concerns related to laparoscopy in managing gynecologic malignancy include the accuracy of intraoperative diagnosis, inadequate resection, significance of tumor spillage, improper or delay in surgical staging, delay in therapy, and the possibility of port-site metastasis. On the other hand, laparoscopy has the advantages of being a minimally invasive surgery, with shorter hospitalization, decreased postoperative pain, and quicker return to normal daily activities. We review the current literature discussing the consequences of laparoscopic surgery in ovarian tumors of low malignant potential and early-stage ovarian cancer. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to list the concerns related to laparoscopic management of ovarian malignancies, to outline the accuracy of the diagnosis of low malignant potential (LMP) ovarian tumors on frozen section, and to summarize the data on the effect of capsule rupture on overall prognosis for patients with ovarian cancer.

A randomized trial comparing a 30-mL and an 80-mL Foley catheter balloon for preinduction cervical ripening.

OBJECTIVES: The purpose of this study was to compare the efficacy of cervical ripening with 2 Foley catheter balloon volumes. STUDY DESIGN: Pregnant women admitted for induction of labor with a term singleton gestation were randomly assigned for cervical ripening by a balloon inflated with 30 mL or 80 mL of sterile saline. RESULTS: Two hundred and three women were included in the analysis. Ripening of the cervix with the larger balloon volume was associated with a significantly higher rate of post-ripening dilatation of 3 cm or more (76.0% vs 52.4%, P < .001). In primiparous women, the larger balloon volume resulted in a significantly higher rate of deliveries by 24 hours (71.4% vs 49%, P < .05), and a significantly less requirement of augmentation with oxytocin (69.3% vs 90.4%, P < .05). CONCLUSION: Ripening of the unfavorable cervix in primiparous women with a Foley catheter balloon inflated with 80 mL provided effective more dilatation, faster labor, and decreased need for oxytocin than with a balloon inflated with 30 mL of sterile saline.

The malignant potential of endometrial polyps.

OBJECTIVES: To determine the pre-malignant and malignant potential of endometrial polyps and to assess whether different clinical parameters are associated with malignancy in the polyps. STUDY DESIGN: Four hundred and thirty consecutive cases of hysteroscopic diagnosis of endometrial polyp were retrieved. The medical records, preoperative vaginal sonography results and histopathology findings were reviewed. Statistical analysis was performed. RESULTS: Hysteroscopy truly identified endometrial polyps in 95.7% of the cases. In 11.4% cases, hyperplasia without atypia was found in the endometrial polyp. In 3.3 and 3.0% of women pre-malignant or malignant conditions were found in the polyp. Older age, menopause status and polyps larger than 1.5 cm were associated with significant pre-malignant or malignant changes, although the positive predictive value for malignancy was low. All the malignant polyps were diagnosed only in postmenopausal women. The presence of postmenopausal or irregular vaginal bleeding, was not a predictor of malignancy in the polyp. CONCLUSIONS: Postmenopausal women with endometrial polyps are at increased risk of malignancy in the polyp. Those patients, whether symptomatic or not should be evaluated by hysteroscopic resection of the polyps. Asymptomatic premenopausal patients with polyps smaller than 1.5 cm can be observed.

The onion skin sign: a specific sonographic marker of appendiceal mucocele.

OBJECTIVE: To evaluate the association of the onion skin sign as a sonographic marker for appendiceal mucocele. METHODS: The sonographic onion skin sign was considered specific for the preoperative diagnosis of appendiceal mucocele. Therefore, detection of this sign in a mass located in the right lower abdomen, unrelated to the female reproductive organs, indicated surgical intervention with a presumptive diagnosis of appendiceal mucocele. From 1998 through 2001, female patients who were found to have atypical cysts containing this sign underwent surgery. The cases were closely followed, and intraoperative findings and final histologic diagnoses were recorded. RESULTS: Appendiceal mucocele was the final diagnosis in all 7 patients in whom the onion skin sign was observed. One additional patient had an appendiceal mucocele with a sonographic picture of a clear tubular cystic structure. CONCLUSIONS: A sonographically layered cystic mass in the right lower quadrant of the abdomen in the presence of a normal ovary strongly suggests the diagnosis of appendiceal mucocele. Recognition of the sonographic onion skin sign in a cystic mass in the right lower quadrant may facilitate the accurate preoperative diagnosis of appendiceal mucocele.