Variability in diagnosis of clue cells, lactobacillary grading and white blood cells in vaginal wet smears with conventional bright light and phase contrast microscopy.

OBJECTIVE: Study the reproducibility of wet smear interpretation of clue cells, lactobacillary grades and leukocyte dominance with conventional bright light and phase contrast microscopy. STUDY DESIGN: Sets of vaginal specimens were taken from unselected consecutive women attending an outpatient gynaecology clinic. Air-dried vaginal fluid on a microscope slide was rehydrated with isotonic saline before examination by six independent international investigators. Some investigators initially used a conventional bright light microscope, followed by phase contrast technique. RESULTS: Using phase contrast microscopy, an excellent inter-observer agreement was obtained among all investigators for clue cells detection (Kappa values from 0.69 to 0.94) and lactobacillary grades (Kappa 0.73-0.93). When conventional light microscopes were used, poor agreement was obtained for these criteria (Kappa index 0.37-0.72 and 0.80, respectively), but switching to phase contrast microscopy by the same investigators, improved Kappa to 0.83-0.85 and 0.88, respectively. The inter-observer agreement for estimation of the leukocyte/epithelial cell ratio (Kappa index 0.17-0.67) was poor, irrespective of the type of microscopy applied. Intra-observer agreement of clue cell detection and lactobacillary grading was also found to be excellent if phase contrast microscopy was used (Kappa 0.87-0.93), and poor with conventional bright light microscopy (Kappa 0.45-0.66). CONCLUSION: Clue cells and the lactobacillary grades are reliably identified by phase contrast microscopy in wet smears, with excellent intra- and inter-observer reproducibility agreement, and better than when simple bright light microscopy was used. Evaluation of leukocyte grading, on the other hand, was inconsistent among the different microscopists, irrespective of the type of microscope used. We propose to grade the leukocytes in a different way than searching for leukocyte dominance over epithelial cells, namely by counting them per high power field and per epithelial cell.

Prediction of post-operative pain after a laparoscopic tubal ligation procedure.

BACKGROUND: Pre-operative identification of reliable predictors of post-operative pain may lead to improved pain management strategies. We investigated the correlation between pre-operative pain, psychometric variables, response to heat stimuli and post-operative pain following a laparoscopic tubal ligation procedure. METHODS: Assessments of anxiety, mood, psychological vulnerability and pre-operative pain were made before surgery using the State-Trait Anxiety Inventory (STAI), the Hospital Anxiety Depression Scale (HADS), a psychological vulnerability test and the Short-Form McGill Pain Questionnaire (SF-MPQ), respectively. Pre-operative assessments of thermal thresholds and pain response to randomized series of heat stimuli (1 s, 44-48 degrees C) were made with quantitative sensory testing technique. Post-operative pain intensity was evaluated daily by a visual analogue scale during rest and during standardized dynamic conditions for 10 days following surgery. Univariate and multivariate regression analyses were used to construct prediction models. RESULTS: Fifty-nine patients completed the study. Post-operative pain was significantly correlated with pre-operative pain (SF-MPQ), heat pain perception, psychological vulnerability, STAI and HADS. In the multiple regression model pre-operative pain and heat pain perception were significant predictive factors (R=0.537-0.609). CONCLUSION: The study indicates that pre-surgical pain and heat pain sensitivity are important pre-operative indicators of post-operative pain intensity, while psychological factors like vulnerability and anxiety seem to contribute to a lesser degree after laparoscopic tubal ligation. The prediction model accounted for 29-43% of the total variance in post-operative movement-related pain.

Bacterial vaginosis. Transmission, role in genital tract infection and pregnancy outcome: an enigma.

Whether bacterial vaginosis (BV) is acquired from an endogenous or an exogenous source is subject to controversy. Despite findings of an association between sexual behaviour and BV, some data indicate that BV is not a sexually transmitted infection in the traditional sense, while other data indicate that BV is an exogenous infection. A third aspect of BV is its tendency to go unnoticed by affected women. All of this will have a strong impact on how physicians view the risks of asymptomatic BV. This review focuses on whether or not BV should be regarded as a sexually transmitted infection (STI), its role in postoperative infections and pelvic inflammatory disease (PID), and on whether or not treatment of BV during pregnancy to reduce preterm delivery should be recommended. The reviewed studies do not lend unequivocal support to an endogenous or exogenous transmission of the bacteria present in BV. For women undergoing gynaecological surgery such as therapeutic abortion, the relative risk of postoperative infection is clearly elevated (approx. 2.3-2.8). A weaker association exists between BV and pelvic inflammatory disease. Data on treatment of BV as a way of reducing preterm delivery are inconclusive and do not support recommendations for general treatment of BV during pregnancy. The discrepant associations between BV and preterm birth found in recent studies may be explained by variations in immunological response to BV. Genetic polymorphism in the cytokine response--both regarding the TNF alleles and in interleukin production--could make women more or less susceptible to BV, causing different risks of preterm birth. Thus, studies on the vaginal inflammatory response to microbial colonization should be given priority.

An ultra-short perineal pad-test for evaluation of female stress urinary incontinence treatment.

We assessed the reproducibility and feasibility of a rapid perineal pad-test designed for evaluation of stress urinary incontinence treatment. In an experimental study, we included 34 women with genuine stress incontinence, 13 with urge incontinence and 10 non-incontinent volunteers for a repeated pad-test with a standardized bladder volume (300 mL) and a standardized physical activity during one minute. The pad was weighed before and after the exercise to estimate the volume of any leaked urine. In order to find out the percentage of unselected, incontinent women who had been able to perform a preoperative pad-test, we identified all 120 women operated on for stress incontinence during a one-year period in a separate retrospective analysis. In another retrospective analysis, we compared the subjective outcome of laparoscopic colposuspension with the outcome of the test performed before and after the procedure among 93 women with genuine stress incontinence. Among stress incontinent women, the median of the differences in leakage between the first and the second test was 8.5 mL (range 0-60 mL) and the repeatability coefficient was 33.6 mL. None of the 13 women with urge incontinence leaked during the tests. One of the 10 controls leaked (during both tests). Of the unselected women, 104/120 (87%) were able to perform the test. Reduction of leaking after surgery was significantly associated with subjective report of outcome (P < 0.0001). In conclusion, the described pad-test has an acceptable reproducibility and feasibility making it suitable for follow-up studies.

Obstetric risk factors for stress urinary incontinence: a population-based study.

OBJECTIVE: To evaluate obstetric and maternal risk factors for stress urinary incontinence. METHODS: We linked three national, Swedish, population-based registries with the use of unique personal identification numbers. All women born between 1932 and 1977 and operated on for stress urinary incontinence between 1987 and 1996 were identified from the Hospital Discharge Registry. This information was linked with the Medical Birth Registry (for the years 1973-1995), containing information on antenatal care, delivery, and the newborn, and the Fertility Registry (for the years 1932-1997), containing information on the number of children delivered by each Swedish woman. For determination of odds ratios (ORs) and approximate 95% confidence intervals (CIs), we used the Mantel-Haenszel method and a test-based method after suitable stratifications and exclusions. RESULTS: Diabetes mellitus, body mass index (BMI), age at first delivery, parity, birth weight, and epidural analgesia were positively associated with incontinence surgery. In contrast, cesarean delivery, forceps/vacuum extraction, and episiotomy were negatively associated with incontinence surgery. No association was found between surgery for stress incontinence and age at last delivery, smoking during pregnancy, level of education, multiple birth, large perineal tear, or breech presentation at any vaginal delivery. The OR for incontinence surgery was similarly decreased for nulliparous women and for uniparous women delivered by elective cesarean. CONCLUSION: Vaginal delivery, notably the first, is strongly associated with later surgery for stress incontinence, but the association is modified by maternal conditions and interventions during delivery. No association was found between surgery for stress incontinence and pregnancy per se.

Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study.

BACKGROUND: Bacterial vaginosis (BV) and intermediate flora is known risk-factor for postoperative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy. AIM: To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion. DESIGN: Prospective, double-blinded, placebo-controlled, multicenter study. MATERIAL AND METHODS: Consecutive women attending for surgical termination prior to 11+4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables. RESULTS: Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal flora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group. CONCLUSION: Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora).

Laparoscopic colposuspension: a short term urodynamic follow-up and a three-year questionnaire-study.

BACKGROUND: The purpose of the study was to evaluate outcome, urodynamic correlates and adverse effects of laparoscopic colposuspension using polytetrafluoroethylene sutures. METHODS: Eighty-five consecutive women with primary stress urinary incontinence at one university hospital were included in this prospective non-controlled study. During videolaparoscopic surgery, two polytetrafluoroethylene sutures were placed on each side of the urethra and fixed to the Cooper ligaments. Pre- and postoperative clinical and urodynamic evaluations, including pad-test, were performed. A mailed questionnaire was used to evaluate cure-rate and complication-rate three years after surgery. RESULTS: At follow-up examination, we considered 62 of 76 women (82%) as being cured, ten (13%) improved, and four (5%) as being failures. The questionnaires were returned by 80 women; 41 (51%) considering themselves as cured and 31 (39%) improved, and eight women (10%) as unimproved or minimally improved. Clinical outcome was not associated with alterations in urethral functional length or in urethral closing pressure. Short preoperative urethral functional length was associated with failure (p=0.04).The incidence of new onset urge symptoms and of new onset recto/enterocele was 13% and 9% respectively. CONCLUSIONS: Laparoscopic colposuspension resulted in acceptable cure rate in short-, and medium long term evaluation. However, a decline in cure rate was observed. Cured women had significantly longer preoperative urethral functional length than women still leaking after surgery.

Laparoscopic Burch colposuspension for stress urinary incontinence: a randomized comparison of one or two sutures on each side of the urethra.

OBJECTIVE: To compare 1-year cure rates after laparoscopic Burch colposuspension using one double-bite or two single-bite sutures on each side of the urethra. METHODS: Consecutive women with primary stress urinary incontinence at one university hospital were included. Preoperative clinical and urodynamic evaluation included cystoscopy, cystouretrometry at rest and stress, and a standardized pad test. Immediately before surgery, the patients were randomized to have one or two polytetrafluoroethylene (GoreTex CV 2; W. L. Gore Inc., Flagstaff, AZ) sutures placed on each side of the urethra. During surgery, access to the space of Retzius was achieved by transperitoneal videolaparoscopic technique. Women were scheduled for postoperative interview and pad test 1 year after surgery. RESULTS: We included 161 women in the study; 78 were randomized to one suture (group A) and 83 to two sutures (group B). Median time for surgery was significantly shorter for group A than for group B (60 compared with 77 minutes; P < .001). We examined 158 women 1 year after surgery, at which time 148 performed a pad test. Objective cure rate was significantly higher in group B than in group A (83% compared with 58%; P = .001). CONCLUSION: Two single-bite sutures resulted in a significantly higher objective short-term cure rate than one double-bite suture on each side of the urethra.

Infertility following pelvic inflammatory disease.

OBJECTIVE: To assess the frequency of infertility after pelvic inflammatory disease (PID) and factors important in postinfectious tubal damage in an urban population at high risk for sexually transmitted diseases. METHODS: From a cohort of 213 women with PID documented by laparoscopy and/or endometrial biopsy, 58 women (27% of the initial cohort) were interviewed by phone 2 to 9 years after an index episode of PID. Data regarding the initial history, physical examination, microbiology, laparoscopic, and serologic findings, and data concerning interval contraception, subsequent pregnancy, subsequent infection, and chronic pelvic pain were compared among those with and without infertility at follow up. RESULTS: Nineteen (40%) of the 48 women not using contraception were involuntarily infertile after the index episode of PID. Compared with those who had an interval pregnancy, infertile women were older (P = 0.02), more likely to have a history of infertility prior to the index episode of PID (P = 0.001), and were more likely to have occluded or partially occluded fallopian tubes (P = 0.03), peritubal adhesions (P = 0.007), or perihepatic adhesions (P = 0.02) seen by laparoscopy performed during the index episode. Surprisingly, recovery of Chlamydia trachomatis was negatively related to infertility (P = 0.001), although a similar proportion of both groups had chlamydia immunoglobulin M antibody (40% vs. 31%). Chlamydia heat shock protein was weakly related to infertility (P = 0.08). The isolation of Neisseria gonorrhoeae was not significantly different between groups (53% vs. 57%). CONCLUSIONS: The high rate of postinfection infertility found was probably related to a combination of tubal damage before and during the index episode of PID. Prevention of recurrent PID and better understanding of the pathophysiology of postinfection tubal damage (which may differ between chlamydia and gonorrhea) is needed to develop more effective strategies to reduce permanent tubal damage.

Cost-effectiveness analysis of in-vitro fertilization: estimated costs per successful pregnancy after transfer of one or two embryos.

Standard protocols for in-vitro fertilization (IVF) include transfer of two or three embryos. Not surprisingly, the rate of twin pregnancy after IVF is high (about 24% of all pregnancies). Routine transfer of one, rather than two, embryos would be expected to result in a much lower rate of twin pregnancies at the cost of a lower take-home baby rate. The aim of this study was to compare hypothetical costs to society incurred by pregnancies achieved with IVF protocols based on the transfer of one or two embryos. We compared actual (for two-embryo transfers) and hypothetical (for one-embryo transfers) take-home baby rates; risks of twin pregnancies; and costs of sick leave and hospitalization during pregnancy, deliveries, neonatal intensive care, and handicap care after transfer of one or two embryos. The study showed that even when more treatments might be needed to achieve similar baby take-home rates after transfer of one compared with two embryos, the lower twin pregnancy rate of the former approach caused it to be more cost-efficient than the latter. In conclusion, IVF costs are the sum of fertilization treatment costs and the costs for health care of the pregnant women and their offspring. Considering the association of the latter costs with numbers of embryos transferred, studies of one-embryo transfer protocols are urgently needed.

Risk factors for acidemia at birth.

OBJECTIVE: To identify risk factors for acidemia at birth. METHODS: From September 1988 to December 1996, cord arterial blood pH was measured in 23,016 of 27,064 live-born infants (85.0%). Values below 7.05 were observed in 264 newborns (1.1%), of whom 14 born by cesarean delivery before labor and one triplet infant were excluded from the study. The remaining 249 newborns with acidemia and their mothers were compared with 249 unmatched controls with normal pH (the first infant with umbilical arterial pH above 7.10 born after each case). Multivariate logistic regression was used to adjust for potentially confounding variables. RESULTS: Variables significantly and independently associated with acidemia at birth were labor with breech presentation (adjusted odds ratio [OR]2.9), oxytocin administration (OR 2.1), meperidine administration (OR 2.0), cord entanglement (OR 1.7), and male gender of the infant (OR 1.4). Clinical evidence of chorioamnionitis also was associated with acidemia, although after adjustment for prematurity, the association was not statistically significant (OR 3.9, 95% confidence interval 0.8, 19). CONCLUSION: Labor with breech presentation, administration of oxytocin and meperidine, cord entanglement, and male gender are associated with an increased risk for insufficient fetomaternal gas exchange.

Prevalence and correlates of antibody to chlamydial heat shock protein in women attending sexually transmitted disease clinics and women with confirmed pelvic inflammatory disease.

A cross-sectional study of 306 women was done to correlate antibody to the chlamydial hsp60 (Chsp60) with epidemiologic, serologic, and laparoscopic findings of women with and without pelvic inflammatory disease (PID). Of the 306 women, 150 had confirmed PID by laparoscopic (n = 69) or histologic (n = 81) criteria, and 156 sexually transmitted disease clinic attendees without clinical PID did (n = 94) or did not (n = 62) have chlamydia. In multivariate analyses, Chsp60 antibody was independently associated with confirmed PID, age > 20 years, nonwhite race, > 10 lifetime sex partners, current oral contraceptive use, and IgG antibody titers; it was not associated with a positive Chlamydia trachomatis culture. Among the 69 women with laparoscopic evidence of PID, the highest level of Chsp60 antibody (optical density > 1.0) was found in 8 (80%) of 10 women with occluded tubes, compared with 11 (19%) of 58 with patent tubes (P < .001). We conclude that antibody to Chsp60 was significantly correlated with risk factors for PID, confirmed PID, and occluded fallopian tubes but not with acute C. trachomatis infection without PID.

No evidence of deteriorating semen quality among men in infertile relationships during the last decade: a study of males from Southern Sweden.

The aim of this study was to investigate whether the quality of semen has deteriorated during the last decade. Laboratory records containing semen analysis results were reviewed. The records, arranged according to date of birth, are kept in shelves. Every fifth record for analyses performed between 1985 and 1995, and only those of men in infertile relationships, were included. The data were abstracted in a data base, and time-related changes in semen characteristics were studied using linear regression analyses. During the study period, there was a slight, but significant increase in sperm concentration, percentage of motile spermatozoa, percentage of spermatozoa with normal morphology, and the base-value of the penetration test. The seminal volumes decreased slightly, but significantly. Sperm characteristics were not associated with age or date of birth of the men. In conclusion, these data show no evidence of deterioration in sperm quality during the last decade among men in infertile relationships.

Antibodies to the chlamydial 60 kd heat-shock protein are associated with laparoscopically confirmed perihepatitis.

OBJECTIVE: Our purpose was to examine clinical, microbiologic, serologic, and laparoscopic findings associated with perihepatitis. STUDY DESIGN: In a prospective study of 157 women with a clinical diagnosis of pelvic inflammatory disease, 27 women with laparoscopically confirmed perihepatitis and salpingitis were compared with 46 patients with salpingitis alone. RESULTS: Both current use or a history of ever using oral contraceptives was negatively associated with perihepatitis (p = 0.05 and p = 0.008, respectively). Moderate-to-severe pelvic adhesions were present at laparoscopy significantly more often in the perihepatitis-salpingitis group (70%) than in the salpingitis alone group (35%, p = 0.003). Antibody to the chlamydial 60 kd heat-shock protein at > or =0.5 optical density was detected in 67% of the perihepatitis-salpingitis group and in 28% of the salpingitis alone group (p = 0.005), and the median titer was significantly higher in the former group (p = 0.02). CONCLUSION: Compared with women with salpingitis alone, patients with perihepatitis-salpingitis do not have distinctive clinical or microbiologic findings but do manifest a higher prevalence of moderate-to-severe pelvic adhesions and both a higher prevalence and higher titers of antibody to the chlamydial heat-shock protein-60.

Maternal fever in term labour in relation to fetal tachycardia, cord artery acidaemia and neonatal infection.

OBJECTIVE: To determine 1. whether maternal fever during term labour is associated with acidaemia at birth and neonatal infection and 2. whether fetal tachycardia precedes maternal fever and is associated with neonatal infection. DESIGN: Retrospective matched-pair case-control study. SUBJECTS: Two hundred and forty-eight newborn infants whose mothers developed fever during term labour (cases) and 248 control infants. The women were matched for parity and duration of labour. MAIN OUTCOME MEASURES: Cord artery acid-base status, Apgar scores, neonatal infections, and fetal heart rate before maternal fever. RESULTS: Mean pH, as well as the rate of cord artery acidaemia at birth (pH < 7.10) was equal in cases and controls (in both groups 7.24% and 6%, respectively). Signs of septicaemia and/or pneumonia were identified in 17 case newborns (7%) and in one control (0.4%; OR 17.0, P < 0.001). Of 212 pairs with complete heart rate data, fetal tachycardia preceded maternal fever in 39 cases (18%) and in 16 controls (8%) (OR 2.6, P = 0.003). Tachycardia before maternal fever was not associated with increased neonatal infectious morbidity. CONCLUSIONS: Maternal fever during term labour was associated with perinatal infection, but not with acidaemia at birth. Elevated fetal heart rate preceded maternal fever in a minority of cases and was not associated with perinatal infection.

Acute pelvic inflammatory disease: associations of clinical and laboratory findings with laparoscopic findings.

OBJECTIVE: To assess the relation of clinical variables and laboratory data to pelvic laparoscopic observations of tubal occlusion, adnexal adhesions, and peritoneal exudate in women with acute salpingitis. METHODS: Clinical and laboratory evaluations were performed systematically before laparoscopy in 155 women with suspected acute pelvic inflammatory disease (PID), 82% of whom proved to have acute salpingitis confirmed with laparoscopy. Laparoscopic findings were scored in three categories (tubal patency, adhesions, and exudate.) RESULTS: Two general categories of laparoscopic findings were present: 1) tubal occlusion and moderate to severe adhesions in 30 women, and 2) pelvic-abdominal exudate in 27 women. In the remaining 16 women, these laparoscopic findings occurred alone or in other combinations. Among women with acute salpingitis, tubal occlusion was associated positively with older age, palpable adnexal mass, and moderate to severe pelvic adhesions; negative associations were found with abdominal rebound tenderness, mean abdominal-pelvic tenderness score, pelvic-abdominal exudate, and isolation of either Neisseria gonorrhoeae or Chlamydia trachomatis. Moderate or severe pelvic adhesions were associated positively with increased duration of abdominal pain (5 versus 3 days) compared with limited or no pelvic adhesions, but they were associated negatively with mean abdominal-pelvic tenderness score and with pelvic-abdominal exudate (47% versus 73%). Free exudate in the pelvis or abdomen as compared with limited or no exudate was associated positively with abdominal rebound tenderness (86% versus 65%), abdominal-pelvic tenderness score, elevated white blood cell count (83% versus 52%), and recovery of N gonorrhoeae (79% versus 57%). Free exudate was associated negatively with the median duration of pain (3 versus 6 days), oral contraceptive use (4% versus 26%), and palpable adnexal mass (7% versus 25%). Analyses limited to women without a history of PID gave similar results. CONCLUSIONS: Although clinical and laboratory criteria traditionally used to judge the clinical severity of acute PID partially predict the degree of tubal or other pelvic abnormalities among women with acute salpingitis and tend to distinguish those with tubal occlusion or moderate to severe adhesions from those with peritonitis, these criteria have low predictive value and are not reliable in the individual patient.

Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections.

This cohort study of 182 women attending a sexually transmitted disease clinic evaluated the hypothesis that women colonized by lactobacilli have decreased acquisition of vaginal infections. During a 2-year follow-up, 50 women acquired bacterial vaginosis (BV), 25 acquired symptomatic vulvovaginal candidiasis (VVC), and 7 acquired vaginal trichomoniasis. By multivariate analysis, utilizing Cox proportional hazards modeling with time-dependent covariates, acquisition of BV was independently associated with lack of vaginal H2O2-producing lactobacilli (hazard ratio [HR] = 4.0, P < .001) or presence of only non-H2O2-producing lactobacilli (HR = 2.2, P = .02). Acquisition of BV was associated with having a new sex partner (HR = 2.5, P = .004) and with douching for hygiene (HR = 2.1, P = .05). Absence of lactobacilli did not increase acquisition of VVC. Trichomoniasis was associated only with having a new sex partner (HR = 4.7, P = .05). These results support the hypothesis that H2O2-producing vaginal lactobacilli protect against acquisition of BV but do not protect against VVC or vaginal trichomoniasis.