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Basic Sciences, Miscellaneus in Gynecology

Breast carcinoma during pregnancy.
Loibl S, von Minckwitz G, Gwyn K, Ellis P, Blohmer JU, Schlegelberger B, Keller M, Harder S, Theriault RL, Crivellari D, Klingebiel T, Louwen F, Kaufmann M
Cancer. 2005 Dec 9;106(2):237-246.

Breast carcinoma during pregnancy (BCP) is a difficult clinical situation, as it appears to put the health of the mother in conflict with that of the fetus. An international expert meeting was conducted to form guidelines on how to diagnose and treat women with BCP. The goal for treatment of the pregnant woman with breast carcinoma is the same as that of the nonpregnant breast carcinoma patient: local control of disease and prevention of systemic metastases. However, certain treatment modalities need to be modified because of the potential for adverse effects on the fetus.

Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma.
Engelen MJ, Kos HE, Willemse PH, Aalders JG, de Vries EG, Schaapveld M, Otter R, van der Zee AG
Cancer. 2005 Dec 20;.

Consultant gynecologic oncologists from the regional Comprehensive Cancer Center assisted community gynecologists in the surgical treatment of patients with ovarian carcinoma when they were invited. For this report, the authors evaluated the effects of primary surgery by a gynecologic oncologist on treatment outcome... The surgical treatment of patients with ovarian carcinoma by gynecologic oncologists occurred more often according to surgical guidelines, tumor removal more often was complete, and survival was improved. Cancer 2006. (c) 2005 American Cancer Society.

Vaginal douching and associated factors among married women attending a family planning clinic or a gynecology clinic.
Caliskan D, Subasi N, Sarisen O
Eur J Obstet Gynecol Reprod Biol. 2005 Dec 22;.

OBJECTIVE: The aim of this study was to determine the vaginal douching habits and associated factors of women attending two different healthcare clinics. STUDY DESIGN: This cross-sectional study was conducted between 1 and 31 May 2004. All participants were women (n=635) who attended either a university hospital gynecology clinic or a primary health care center family planning unit. One-way ANOVA, chi-squared test, and binary and multiple logistic regression analyses were used for the statistical evaluation of data. RESULTS: The mean age of the participants was 36.90+/-10.72 years (range: 18-75). Half of the participants believed vaginal douching had a positive effect on health. They believed vaginal douching demonstrates cleanliness, prevents infections and pregnancy, removes sperm following intercourse, a necessity of Islamic doctrine, and reduces symptoms like discharge, unpleasant odor, etc. Of the women, 50.2% performed vaginal douching. Vaginal douching was associated with age, education level, type of dwelling, working outside of the home, age at marriage, age at birth of first child, parity, spontaneous abortion, history of pelvic inflammatory disease, use of contraceptives, and attending a healthcare clinic. CONCLUSION: Douching is a common habit among Turkish women. Many women are not aware of the harmful effects of douching. Public health and health professionals should monitor more closely this traditional habit in Turkey.

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome by modified Vecchietti's procedure.
Folgueira G, Perez-Medina T, Martinez-Cortes L, Martinez-Lara A, Gomez B, Izquierdo J, Bajo-Arenas J
Eur J Obstet Gynecol Reprod Biol. 2005 Dec 30;.

OBJECTIVE: The objective was to apply Vecchietti's principles to laparoscopy for the creation of a neovagina in patients diagnosed with Rokitansky syndrome. STUDY DESIGN: The setting was a university tertiary hospital. The design was a descriptive study to describe the outcome in 18 patients diagnosed with Rokitansky syndrome after laparoscopic creation of a neovagina applying Vecchietti's principles and implementing some useful modifications. RESULTS: In 17 patients the result was considered successful when a new neovagina measuring at least 10cm long was obtained. Less satisfactory in the 18th patient was when a shortened neovagina was found at the 2-year follow-up as the patient did not follow the postoperative recommendations. CONCLUSION: Laparoscopic creation of a neovagina is a safe, minimally invasive treatment with good functional and sexual results.

Hormonal contraceptive methodology: an historical review.
Linn ES
Int J Fertil Womens Med. 2005 Mar-Apr;50(2):88-96.

The introduction of the first hormonal contraceptive was one of the most important events of the twentieth century for women. The availability of oral contraceptives (OCs) provided women with greater control over their reproductive lives. As OC usage steadily increased, so did concern over health risks associated with their use. Concluding that adverse events were dose-related, scientists sought to develop lower-dose formulations. In the four decades since the first OC, women seeking contraception have benefited from the development of non-oral hormonal delivery systems, including injectables, intrauterine devices, implants, a vaginal ring, and a contraceptive patch. It is hoped that this expanding menu of choices affords women opportunities to find methods better suited to their individual needs. Clinicians should continually evaluate their patients' hormonal contraceptive needs, and provide adequate counseling so that every woman is afforded the opportunity to achieve contraceptive success.

The choice of elective cesarean delivery in obstetrics: a voluntary survey of Canadian health care professionals.
Farrell SA, Baskett TF, Farrell KD
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):378-83. Epub 2005 Jun 24.

To survey Canadian health care professionals about their willingness to offer elective cesarean delivery and to evaluate how their knowledge of obstetric-related pelvic-floor injury influences their practice. A voluntary questionnaire was distributed to health care professionals attending the 58th Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada in 2002. Appropriate statistical analysis was used. One hundred and sixty-two questionnaires were completed. One hundred respondents were female (62%). Twenty-three percent (37/162) of respondents approved elective cesarean delivery after informed request in nulliparous women without an obstetrical indication. Males were more likely than females to perform cesarean delivery in these circumstances (34% versus 16%; OR 2.7, CI 1.2, 6.0). When questioned about the impact of mode of delivery on bladder and bowel continence, the number of respondents who answered "usually" or "always has a detrimental effect" were: vaginal birth, 16%; forceps, 20%; and cesarean delivery "reduces bladder and bowel problems", 44%. Males were more likely to emphasize a protective effect of cesarean delivery (55% versus 38%; OR 1.9, CI 1.0, 4.0). Health care professionals would opt for cesarean delivery for themselves when forceps delivery was the alternative more often than they would offer cesarean delivery to their patients (OR 1.98, CI 1.1, 3.5). While a significant number of women's health care professionals are prepared to offer cesarean delivery to nulliparous women, informed choice seems to motivate the offer rather than a conviction that cesarean delivery will protect the pelvic floor.

Future Perspectives in the Medical Treatment of Endometriosis.
Ferrero S, Abbamonte LH, Anserini P, Remorgida V, Ragni N
Obstet Gynecol Surv. 2005 Dec;60(12):817-826.

In the last few years, our understanding of the pathogenesis of endometriosis at the cellular and molecular levels has improved significantly. This may give us the opportunity to use new, specific agents for the treatment of this disorder. Despite the effectiveness of the available treatments, novel therapeutic strategies may improve our ability to eliminate endometriotic lesions when present and to prevent the recurrence of endometriosis after surgical treatment. This review focuses on the new, experimental approaches to the medical treatment of endometriosis and its symptoms. The blockage of aromatase activity in endometriotic lesions with an aromatase inhibitor may represent a new step in the medical treatment of endometriosis. Preliminary clinical studies have demonstrated the efficacy of third-generation nonsteroidal aromatase inhibitors (ie, anastrozole and letrozole) in reducing the intensity of pain symptoms associated with the presence of endometriosis. The new selective progesterone receptor modulators may represent a valid hormonal treatment option. Therapeutic manipulation of the immune system through TNFalpha inhibitors may be beneficial in women with endometriosis. New pharmaceutical agents affecting inflammation, angiogenesis, and matrix metalloproteinase activity may prevent or inhibit the development of endometriosis. Further clinical trials may determine if these new therapies are superior to current medical treatment strategies for endometriosis. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe the new experimental medical treatments of endometriosis, state that the clinical use of nonsteroidal aromatase inhibitors for endometriosis appears to be efficacious but is based on preliminary clinical data, and recall that the drugs used for endometriosis in the future may include manipulation of the immune system.

Using anovaginal distance at the beginning of labor to predict the likelihood of instrumental delivery.
Lurie S, Boaz M, Sadan O
J Reprod Med 2005 Oct;50(10):759-63.

OBJECTIVE: To investigate whether anovaginal distance in parturients has an impact on the instrumental delivery rate. STUDY DESIGN: In this study with prospective data collection and a convenience sample, 400 parturients planning for vaginal delivery at term with a singleton fetus in vertex presentation were enrolled. Anovaginal distance was measured in the lithotomy position during the latent phase of labor or early first stage. This distance is thought to reflect the angle of inclination of the birth canal axis. RESULTS: At the cutoff point of 25 mm for anovaginal distance, the odds ratio for instrumental delivery was 2.5 (95% CI 1.48-6.6, p<0.05). A final model of instrumental delivery, controlling for various confounding variables, correctly predicted 91.38% of the instrumental deliveries (p<0.0001). The variables anovaginal distance >25 mm (OR 2.9, 95% CI 1.2-6.7, p=0.01), parity (OR 0.54, 95% CI 0.29-0.99, p=0.046) and duration of second stage of labor (OR 1.01, 95% CI 1.004-1.01, p=0.001) significantly contributed to the prediction of instrumental delivery after controlling for the other parameters. CONCLUSION: Women with an anovaginal distance of >25 mm at the beginning of labor was 2.5 more likely to undergo instrumental delivery than were women with an anovaginal distance of <25 mm.

The "rectus hitch stitch": a technique to provide length and prevent prolapse of the neovagina in gender reassignment.
Dasgupta R, Whitaker IS, Menon A, Morgan BD, Boulos PB
Plast Reconstr Surg 2005 Dec;116(7):2054-6.
Prostate 2005 Nov 21;.
Radiology 2005 Dec;237(3):1097-102.

Alternative therapies for postmenopausal women.
Speroff L
Int J Fertil Womens Med 2005 May-Jun;50(3):101-14.

Alternative therapies are being used by postmenopausal women in attempts to treat all of the complaints and medical conditions of the menopause. One-fifth of those who take prescription drugs for these indications also take herbal remedies and/or high-dose vitamins, most often without disclosing the fact to the physician. Although studies of alternative therapies are short-term and rarely focused on safety--let alone efficacy--in the long-term, there are many studies spread over the large number of substances involved. More than 130 studies, including meta-analyses, are reviewed in this article under the headings of phytoestrogens, especially from soy; therapies for hot flushes; and preventives for cardiovascular disease, osteoporosis, and breast cancer. Special attention is given to the recently recognized daidzein metabolite equol, and for the sake of completeness there are reviews of the unconventional, but not botanical, treatments estriol, transdermal progesterone, and dehydroepiandrosterone. The total picture produced by conscientious review of the studies is bleak overall, but there seems to be good reason to pursue the possibilities inherent in soy protein with phytoestrogens in populations of women who endogenously produce equol.

Training, assessment and competency in gynaecologic surgery.
Hammond I, Karthigasu K
Best Pract Res Clin Obstet Gynaecol 2005 Nov 4;.

The trainee gynaecologist requires specific teaching to achieve competency in gynaecological surgery. Basic skills such as knot tying and suturing should be acquired outside the operating theatre. They can be learned on simulations, including bench models, using synthetic materials, life-like models and animal tissue. Video training equipment is useful for the development of basic laparoscopic hand-eye coordination. Intermediate and advanced skills require simulations using more sophisticated bench models, live animals and virtual reality computerised systems. Structured teaching and assessment methods are essential. Surgical skills training models should be reliable and valid, and can be incorporated into an objective structured clinical examination, which could be used to assess individual development and allow progression through a training programme. Simulation training does translate into improved operative performance. Supervised operating experience on patients is crucial to training and should be assessed regularly using a global rating form with constructive feedback to facilitate improvement.

Clayton RD
Best Pract Res Clin Obstet Gynaecol 2005 Nov 4;.

Hysterectomy is one of the most commonly performed major surgical procedures; approximately 100 000 are performed in the UK each year. Hysterectomy can be total or subtotal. The postulated benefits of subtotal hysterectomy-better pelvic floor and sexual function-have not been confirmed in randomised trials. Traditionally, hysterectomy was performed using either an abdominal or vaginal approach. More recently, laparoscopic techniques have been used. The decision about the technique used is often related to the surgeon's training and expertise, as the indications for each technique overlap. Vaginal hysterectomy is probably the preferred route because it is quicker and cheaper than laparoscopic hysterectomy, with no other clear differences in outcome measures. Laparoscopic hysterectomy has a number of advantages over abdominal hysterectomy: specifically, shorter hospital stay and quicker return to normal activities; complication rates, however, appear to be greater. This also seems to be the case with radical hysterectomy performed for cervical cancer.

Involvement of the female genital tract in pemphigus vulgaris.
Malik M, Ahmed AR
Obstet Gynecol 2005 Nov;106(5):1005-12.

BACKGROUND: Involvement of the genital tract in women with pemphigus vulgaris has rarely been reported. We report 34 patients with pemphigus vulgaris who have involvement of the vulva, vagina, or both. METHODS: We reviewed the clinical data on 34 women treated at a tertiary dermatology referral center from July 1988 to June 2005. RESULTS: Of 34 patients, 21 had labial involvement, 3 had vaginal involvement, and 10 had both labial and vaginal involvement. The mean age of onset of pemphigus vulgaris was 49 years. All patients had pemphigus vulgaris involvement at multiple other sites, and all had other mucous membrane involvement, most commonly oral (97%). Recurrent episodes of genital pemphigus vulgaris were noted in 35%, with a mean of 6 recurrences (range 1-11). In all the patients the pemphigus vulgaris was controlled with systemic and local therapy. Long-term follow-up for a mean of 76 months (range 9-204) indicated that no long-term sequela occurred due to genital involvement. CONCLUSION: Involvement of the female genital tract in pemphigus vulgaris is rare. Vulvar lesions occur more commonly than vaginal lesions. With appropriate topical and systemic therapy, patients can have full recovery with no sequelae. LEVEL OF EVIDENCE: II-3.

Molecular identification of bacteria associated with bacterial vaginosis.
Fredricks DN, Fiedler TL, Marrazzo JM
N Engl J Med 2005 Nov 3;353(18):1899-911.

BACKGROUND: Bacterial vaginosis affects millions of women and is associated with several serious health conditions. The cause of bacterial vaginosis remains poorly understood despite numerous studies based on cultures. Bacteria in microbial communities can be identified without cultivation by characterizing their ribosomal DNA (rDNA) sequences. METHODS: We identified bacteria in samples of vaginal fluid with a combination of broad-range polymerase-chain-reaction (PCR) amplification of 16S rDNA with clone analysis, bacterium-specific PCR assay of 16S rDNA, and fluorescence in situ hybridization (FISH) performed directly on vaginal fluid from 27 subjects with bacterial vaginosis and 46 without the condition. Twenty-one subjects were studied with the use of broad-range PCR of 16S rDNA, and 73 subjects were studied with the use of bacterium-specific PCR. RESULTS: Women without bacterial vaginosis had 1 to 6 vaginal bacterial species (phylotypes) in each sample (mean, 3.3), as detected by broad-range PCR of 16S rDNA, and lactobacillus species were the predominant bacteria noted (83 to 100 percent of clones). Women with bacterial vaginosis had greater bacterial diversity (P<0.001), with 9 to 17 phylotypes (mean, 12.6) detected per sample and newly recognized species present in 32 to 89 percent of clones per sample library (mean, 58 percent). Thirty-five unique bacterial species were detected in the women with bacterial vaginosis, including several species with no close cultivated relatives. Bacterium-specific PCR assays showed that several bacteria that had not been previously described were highly prevalent in subjects with bacterial vaginosis but rare in healthy controls. FISH confirmed that newly recognized bacteria detected by PCR corresponded to specific bacterial morphotypes visible in vaginal fluid. CONCLUSIONS: Women with bacterial vaginosis have complex vaginal infections with many newly recognized species, including three bacteria in the Clostridiales order that were highly specific for bacterial vaginosis.

Varicose veins arising from the pelvis due to ovarian vein incompetence.
Hobbs JT
Int J Clin Pract 2005 Oct;59(10):1195-203.

Vulval varices and perivulval veins are common though often unrecognised, and pelvic pain is a common complaint, sometimes without an obvious cause, hence treatment is not always successful. An association between these two problems has long been established, and some cases of pelvic pain are clearly associated with venous pathology. Often, these patients present to the vein clinic with recurrent varicose veins, because the standard procedures have failed and the pelvic origin was not recognised. The understanding of the pathology has evolved and will be reviewed. To establish diagnosis, the communication from the atypical varicose veins in the legs to the ovarian veins must be shown and incompetence of one or both ovarian veins must be demonstrated. Treatment requires elimination of the retrograde flow in the ovarian veins. This can be by either surgical ligation and removal or obliteration with coils and sclerosant. Having removed the cause and relieved the pelvic symptoms, the leg veins can then be successfully treated.

Ambulatory gynaecology: What can we do?
Mikos T, Downes E
Best Pract Res Clin Obstet Gynaecol 2005 Sep 17;.

The aim of ambulatory gynaecology is to admit, treat and discharge the patient on the same day in an outpatient setting. Traditional inpatient operations are being rapidly replaced by office, outpatient or day surgery procedures. In this review, a brief assessment of current ambulatory gynaecological practice is attempted, followed by a discussion of audit and quality assessment methods. Epidemiological studies, clinical trials, socio-economic studies and meta-analyses offer research opportunities in the ambulatory setting. There is a need to review the training of junior gynaecologists and nurses in this field. At present, only a few gynaecology residency programmes offer experience in outpatient procedures and ambulatory care. Specific issues that need to be addressed include training, patient selection, consenting issues, decisions to cancel/transfer as inpatients, and the management of common gynaecological problems.

Standard setting for outpatient gynaecology procedures: A multidisciplinary framework for implementation.
Black JE, Hudson HJ, Duffy SR
Best Pract Res Clin Obstet Gynaecol 2005 Sep 9;.

This chapter describes the changing cultural background of health care from which any service is delivered. In particular, the authors hope to outline cultural, educational, technical and environmental changes that have been used as opportunities to develop a quality-assessed outpatient hysteroscopic service. Examined within the chapter will be the roles and limitations of evaluation and audit, research and the multidisciplinary team. The importance of process, relationships and collaborative working within organizations will be explored, and outpatient hysteroscopy will be used as a working example of how these inform a model of practice development.

The Impact of Age and Intrauterine Contraception on the Clinical Course of Pelvic Inflammatory Disease.
Viberga I, Odlind V, Berglund L
Gynecol Obstet Invest 2005 Oct 4;61(2):65-71.

Background: The aim of the study was to investigate the clinical course of pelvic inflammatory disease (PID) and factors that could predict failed conservative treatment of PID. Additionally, the study aimed to examine the role of age and intrauterine device (IUD) use on the severity of PID. Method: Fifty-one women admitted to hospital with the diagnosis of acute PID were recruited. Of those, 17 patients were subsequently operated because of failed conservative treatment. All women underwent careful examination and completed a questionnaire at admission. Their clinical course was followed and the clinician responsible for the patient completed forms at admission and at discharge. Two groups were established retrospectively, those who were treated conservatively and those who underwent surgery. The outcome results were analyzed with regard to IUD use, duration of IUD use (>/=5 or <5 years), and with regard to age below or above 35 years. All data were analyzed using the statistical package SAS. A p value <0.05 was considered significant. Results: Women who subsequently underwent surgical treatment were significantly older and significantly more frequently, current IUD users. There was no significant difference with regard to other socio-demographic characteristics. Women who subsequently underwent surgery had significantly more frequent complaints of severe abdominal pain, elevated body temperature, symptoms of peritoneal irritation, and appearance of adnexal mass. No differences were found between groups with regard to anaerobic microbiological findings, nor with regard to the finding of Actinomyces. IUD use and age >/=35 were found to be highly significant risk factors for surgery in patients with PID. Conclusion: Age over 35 years and IUD use, independently of each other, were factors strongly associated with an increased risk of surgery for PID as a result of failed conservative treatment.

Effect of Body Mass Index and Excessive Weight Gain on Success of Vaginal Birth After Cesarean Delivery.
Juhasz G, Gyamfi C, Gyamfi P, Tocce K, Stone JL
Obstet Gynecol 2005 Oct;106(4):741-746.

OBJECTIVE: To estimate whether excessive weight gain or obesity are risk factors affecting success for vaginal birth after cesarean (VBAC). METHODS: Patients attempting VBAC were identified by the International Classification of Diseases, 9th Revision, codes "VBAC" and "non-primary C-section" and by reviewing logbooks on labor and delivery. A chart review identified patients attempting VBAC who were eligible for inclusion. Exclusion criteria included multiple gestation, more than one previous cesarean delivery, previous classical uterine scar, delivery at less than 36 weeks of gestation, and incomplete information. Patients were divided into the following categories: underweight (body mass index [BMI] < 19.8), normal weight (BMI 19.8-26), overweight (BMI 26.1-29), and obese (BMI > 29). Excessive weight gain was defined as a weight gain of more than 40 lb. Variables of interest included diabetes, previous successful vaginal delivery or VBAC, and presence of recurrent indication for cesarean delivery. RESULTS: We identified 1,213 patients who met inclusion criteria. Overall, the VBAC success rate was 77.2%. The success rates for BMI less than 19.8, 19.8-26, 26.1-29, and greater than 29 were 83.1%, 79.9%, 69.3%, and 68.2%, respectively, P < .001. Obese patients were almost 50% less likely to have a successful VBAC when compared to underweight patients, odds ratio 0.53, 95% confidence interval 0.29-0.98, P = .043. Similarly, patients who gained more than 40 lb were almost 40% less likely to be successful at VBAC than those who gained less than that amount, odds ratio 0.63, 95% confidence interval 0.42-0.97, P = .034. They had a VBAC success rate of 66.8%, whereas patients who gained less than 40 lb were successful 79.1% of the time, P < .001. CONCLUSION: Excessive weight gain during pregnancy and obesity both decrease VBAC success. Proper patient selection will help increase the likelihood of successful VBAC. LEVEL OF EVIDENCE: II-2.

Endometrial Cancer and Hormone-Replacement Therapy in the Million Women Study.
Obstet Gynecol Surv 2005 Sep;60(9):595-597.

Women taking estrogen alone as hormone replacement therapy (HRT) are at increased risk of developing endometrial cancer. At
present, postmenopausal women who have not had a hysterectomy may be given combined estrogen-progestogen or tibolone, a synthetic steroid having estrogenic, progestogenic, and androgenic properties. The effect of such treatment on the risk of endometrial cancer was examined in 716,738 postmenopausal women in the United Kingdom without a history of hysterectomy or cancer who were followed up for 3.4 years on average, during which time 1320 endometrial cancers were diagnosed. Among 320,953 women (45%) reporting the use of HRT, 22% had last used continuous combined progestogen/estrogen treatment for 10 to 14 days each month. Another 9% had most recently taken tibolone, and 4% had last used estrogen-only HRT.Compared with women never using HRT, those who had last used continuous combined HRT had a lower risk of endometrial cancer (relative risk [RR], 071; 95% confidence interval [CI], 0.56-0.90). Risk was unchanged in women who last used cyclical combined HRT, and it was increased in those who had last used tibolone (RR, 1.79; 95% CI, 1.43-2.25) and also in those who last used estrogen-only HRT (RR, 1.45; 95% CI, 1.02-2.06). The relative risk of endometrial cancer decreased with increasing obesity. Standardized incidence rates of endometrial cancer per 1000 women over a 5-year period are shown in . Unlike endometrial cancer, the risk of breast cancer was greater with combined HRT-continuous or cyclical-than with tibolone or estrogen-only HRT. Compared with never-users, women who currently used combined preparations had a significantly greater incidence of endometrial and breast cancers combined than did women who never had used HRT ().(Figure is included in full-text article.)(Figure is included in full-text article.)These findings indicate that combining endometrial and breast cancers, the risk is greater in women using combined HRT, either continuously or cyclically, than in those using other measures because of the much greater frequency of breast cancer than endometrial cancer.

Vaginal Hysterectomy for the Enlarged Uterus.
Harmanli OH, Byun S, Dandolu V, Gaughan JP, Grody MH
Gynecol Obstet Invest 2005 Aug 17;61(1):4-8.

Objective: To evaluate the effect of uterine weight on the perioperative outcomesof vaginal hysterectomy for benign gynecological conditions. Materials and Methods: The medical records of 312 consecutive women who underwent vaginal hysterectomies for benign gynecological conditions without major pelvic reconstruction at Temple University Hospital between March 1994 and August 1999were reviewed. 88 women with uterine weights >/=250 g were compared with 224 women with uterine weights <250 g. The risk of perioperative complications, operative time, perioperative hemoglobin change, length of postoperative hospital stay, and readmission were evaluated between the groups. Results: Groups were similar with respect to age, parity, history of previous pelvic surgery and concurrent adnexal removal. Operative time was significantly increased for women with uteri weighing >/=250 g. Women with uterine weight >/=250 g had a higher risk for postoperative febrile morbidity. The risks of all other major complications, perioperative change in hemoglobin concentration, length of stay, and readmission risk were not statistically different between the groups (p < 0.05). Conclusions: Despite the increased postoperative febrile morbidity and prolonged operative time, women with uteri weighing >/=250 g who underwent vaginal hysterectomy were discharged from the hospital without any increase in other complications when compared to women with a smaller uterus.

Prevalence of vulvar lichen sclerosus in a general gynecology practice.
Goldstein AT, Marinoff SC, Christopher K, Srodon M
J Reprod Med 2005 Jul;50(7):477-80.

OBJECTIVE: To describe the rate of vulvar lichen sclerosus in 1 general gynecology practice. STUDY DESIGN: A database of 1,675 consecutive patients presenting in a 3-year period to a general gynecology practice was utilized to identify women with lichen sclerosus. Data included age, menopausal status, symptoms and physical examination findings. Pathology specimens were reexamined by a gynecologic pathologist to confirm the diagnosis of lichen sclerosus. RESULTS: Of the 1,675 patients, 28 (1.7%) had biopsy-proven vulvar lichen sclerosus. Nine patients been diagnosed previously, and 19 were new cases. The mean age at diagnosis was 52.6 years (SD +/- 15.9) versus 37.1 years (SD +/- 16.4) for those without lichen sclerosus (p < 0.001). Fifteen of the 28 patients (54%) were post-menopausal at the time of diagnosis. Of the 19 women with newly diagnosed lichen sclerosus, 8 (42%) were symptomatic. Of the 11 asymptomatic women, 7 (64%) had scarring of the clitoral prepuce or resorption of the labia minora. CONCLUSION: The rate of vulvar lichen sclerosus in 1 general gynecology private practice is approximately 1.7%. Clinicians must maintain a high index of suspicion to make the diagnosis, as at least one third of patients may be asymptomatic.

Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals.
Liguori G, Trombetta C, Bucci S, Salame L, Bortul M, Siracusano S, Belgrano E
Urology 2005 Aug;66(2):293-8; discussion 298.

OBJECTIVES: To describe 3 cases of successful laparoscopically assisted vaginal reconstruction using an ileal segment in patients with complete neovaginal stenosis. METHODS: We evaluated 5 male-to-female transsexual patients who required laparoscopic-assisted vaginal replacement for complete neovaginal stenosis after sex reassignment surgery. We performed complete laparoscopic vaginal isolation and mobilization, external configuration of the vagina, and laparoscopic-assisted vaginal anastomosis. RESULTS: No intraoperative complications occurred, and laparotomy conversion was not necessary. The mean length of the neovagina at the first postoperative visit was 13 cm. At a mean follow-up of 14 months, all patients were sexually active and completely satisfied with the operation. CONCLUSIONS: Our results have confirmed the feasibility of laparoscopic perineal neovagina construction by ileal colpoplasty. The cosmetic, functional, and anatomic results were encouraging. Isolated ileal segments provided excellent tissue for vaginal replacement, resulting in excellent patient satisfaction and relatively low morbidity. Furthermore, we report a modified surgical approach to conventional ileal vaginoplasty according to the Monti channel principle.

Vaginal delivery after ileal pouch-anal anastomosis: a word of caution.
Remzi FH, Gorgun E, Bast J, Schroeder T, Hammel J, Philipson E, Hull TL, Church JM, Fazio VW
Dis Colon Rectum 2005 Sep;48(9):1691-9.

PURPOSE: This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis. METHODS: The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique. RESULTS: Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001). CONCLUSIONS: The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.

Masculinizing genitoplasty in intersex patients.
Chertin B, Koulikov D, Hadas-Halpern I, Farkas A
J Urol 2005 Oct;174(4 Pt 2):1683-6.

PURPOSE: We reviewed cosmetic and functional outcome of masculinizing genitoplasty (MPG) in intersex patients assigned as a male performed in our service for more than 12 years. MATERIALS AND METHODS: A total of 57 patients underwent MPG in our department during a 20-year period. Of these cases MPG was performed using modern 1-stage surgical techniques from 1991 to 2003 in 39 (68%). Of the 39 children 8 (21%) had 17beta-hydroxysteroid dehydrogenase deficiency, 2 (5%) had 3beta-hydroxysteroid dehydrogenase deficiency, 8 (21%) had 5alpha-reductase deficiency, 2 (5%) had mixed gonadal dysgenesis, 1 (2.6%) was a true hermaphrodite, 1 (2.6%) had Klinefelter's syndrome, 1 (2.6%) had partially androgen insensitivity syndrome and 16 (41%) had idiopathic male pseudohermaphroditism. The presenting disease was severe proximal penoscrotal hypospadias in 30 cases (77%), perineal hypospadias in 9 (23%) and mullerian duct opening in the perineum along with the urethral meatus in 16 (28%). Median patient age at surgery was 1.8 years. MPG was performed with a transverse pedicled preputial island flap as an onlay in 29 cases (74%). The remaining 10 patients (26%) underwent tubularization of the mucosa in the perineal area and end-to-end anastomosis to a tube made from the pedicled prepuce. Scrotal transposition as well as orchiopexy was performed in some patients as an independent operation so as not to jeopardize the perineal and preputial flaps. RESULTS: In 23 (59%) of the 39 children 1 operation achieved satisfactory cosmetic and functional results in terms of good urinary stream and straight phallus during erection. Three (7%) children presented with various degrees of breakdown of the urethroplasty and required a repeat operation. In 5 patients (12.8%) a small urethral fistula developed and closure was performed. CONCLUSIONS: A 1-stage male genitoplasty for male pseudohermaphroditism is accompanied by a reasonable incidence of major complications. It should be performed in early childhood to avoid psychological and social anxiety by the child and parents.

Benign breast disease and the risk of breast cancer.
Hartmann LC, Sellers TA, Frost MH, Lingle WL, Degnim AC, Ghosh K, Vierkant RA, Maloney SD, Pankratz VS, Hillman DW, Suman VJ, Johnson J, Blake C, Tlsty T, Vachon CM, Melton LJ 3rd, Visscher DW
N Engl J Med 2005 Jul 21;353(3):229-37.

BACKGROUND: Benign breast disease is an important risk factor for breast cancer. We studied a large group of women with benign breast disease to obtain reliable estimates of this risk. METHODS: We identified all women who received a diagnosis of benign breast disease at the Mayo Clinic between 1967 and 1991. Breast-cancer events were obtained from medical records and questionnaires. To estimate relative risks, we compared the number of observed breast cancers with the number expected on the basis of the rates of breast cancer in the Iowa Surveillance, Epidemiology, and End Results registry. RESULTS: We followed 9087 women for a median of 15 years. The histologic findings were nonproliferative lesions in 67 percent of women, proliferative lesions without atypia in 30 percent, and atypical hyperplasia in 4 percent. To date, 707 breast cancers have developed. The relative risk of breast cancer for the cohort was 1.56 (95 percent confidence interval, 1.45 to 1.68), and this increased risk persisted for at least 25 years after biopsy. The relative risk associated with atypia was 4.24 (95 percent confidence interval, 3.26 to 5.41), as compared with a relative risk of 1.88 (95 percent confidence interval, 1.66 to 2.12) for proliferative changes without atypia and of 1.27 (95 percent confidence interval, 1.15 to 1.41) for nonproliferative lesions. The strength of the family history of breast cancer, available for 4808 women, was a risk factor that was independent of histologic findings. No increased risk was found among women with no family history and nonproliferative findings. In the first 10 years after the initial biopsy, an excess of cancers occurred in the same breast, especially in women with atypia. CONCLUSIONS: Risk factors for breast cancer after the diagnosis of benign breast disease include the histologic classification of a benign breast lesion and a family history of breast cancer.

Endometrial cancer and hormone-replacement therapy.
Wiegratz I, Kuhl H
Lancet 2005 Jul 16-22;366(9481):201-2.

Endometrial cancer and hormone-replacement therapy.
Bjarnason NH
Lancet 2005 Jul 16-22;366(9481):200-1.

Ovarian Conservation at the Time of Hysterectomy for Benign Disease.
Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS
Obstet Gynecol 2005 Aug;106(2):219-226.

Objective: Prophylactic oophorectomy is often recommended concurrent with hysterectomy for benign disease. The optimal age for this recommendation in women at average risk for ovarian cancer has not been determined. Methods: Using published age-specific data for absolute and relative risk, both with and without oophorectomy, for ovarian cancer, coronary heart disease, hip fracture, breast cancer, and stroke, a Markov decision analysis model was used to estimate the optimal strategy for maximizing survival for women at average risk of ovarian cancer. For each 5-year age group from 40 to 80 years, 4 strategies were compared: ovarian conservation or oophorectomy, and use of estrogen therapy or nonuse. Outcomes, as proportion of women alive at age 80 years, were measured. Sensitivity analyses were performed, varying both relative and absolute risk estimates across the range of reported values. Results: Ovarian conservation until age 65 benefits long-term survival for women undergoing hysterectomy for benign disease. Women with oophorectomy before age 55 have 8.58% excess mortality by age 80, and those with oophorectomy before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease. Conclusion: Ovarian conservation until at least age 65 benefits long-term survival for women at average risk of ovarian cancer when undergoing hysterectomy for benign disease.

Transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy for nonprolapsed uteri.
Chang WC, Huang SC, Sheu BC, Chen CL, Torng PL, Hsu WC, Chang DY
Obstet Gynecol 2005 Aug;106(2):321-6.

Background: To define a rational guideline for the use of either laparoscopically assisted vaginal hysterectomy (LAVH) or transvaginal hysterectomy in dealing with a nonprolapsed uterus. Methods: A total of 452 patients receiving LAVH or transvaginal hysterectomy were retrospectively studied between October 2002 and October 2004. The operative time, estimated blood loss, uterine weight, and complications were all recorded for analysis. Results: Significant linear correlations of uterine weight with operative time and estimated blood loss could be seen only in the transvaginal hysterectomy group. Transvaginal hysterectomy required significantly shorter operative time, but longer duration when the uterine weight exceeded 350 g. These 452 patients were stratified into 4 subgroups according to the uterine weight and hysterectomy procedure. Data are expressed as the mean +/- standard deviation. For uterine weight less than 350 g, transvaginal hysterectomy had significantly shorter operative time than LAVH (80 +/- 27 minutes compared with 118 +/- 21 minutes, P < .05) but similar blood loss (70 mL compared with 74 mL). For uterine weight 350 g or less, transvaginal hysterectomy had not only significantly longer operative time (139 +/- 30 minutes compared with 118 +/- 17 minutes, P < .05) but also more blood loss (242 +/- 162 mL compared with 66 +/- 51 mL, P < .05) than LAVH. Conclusion: In view of the shorter operative time and less blood loss, LAVH is preferable for uterine weight 350 g or more, whereas transvaginal hysterectomy is better in dealing with uteri weighing less than 350 g. Level of Evidence: II-2.

MRI of vaginal conditions.
Lopez C, Balogun M, Ganesan R, Olliff JF
Clin Radiol 2005 Jun;60(6):648-62.

Magnetic resonance imaging (MRI) has become an important part of the assessment of suspected vaginal pathology. This pictorial review demonstrates the MRI features and some of the histopathological findings of a variety of vaginal conditions. These may be congenital (total vaginal agenesis, partial vaginal agenesis, longitudinal vaginal septum, transverse vaginal septum), benign (Bartholin's cyst, diffuse vaginal inflammation, invasive endometriosis, ureterovaginal fistula, post-surgical appearances with the formation of a neovagina and adhesions) or malignant, usually due to extension or recurrence from another pelvic malignancy. In this paper, examples of the above are described and illustrated together with examples of the much rarer primary vaginal malignancies.

Voiding function in pregnancy and puerperium.
Dietz HP, Benness CJ
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):151-4; discussion 154. Epub 2004 Sep 25.

Bladder function changes significantly in pregnancy. This study prospectively examined voiding function in a nulliparous cohort. A total of 200 nulliparous women were seen twice during pregnancy and 2-5 months postpartum. Flowmetry, ultrasound estimation of residual urine and translabial ultrasound of bladder neck mobility were evaluated. The Liverpool nomograms were used to calculate maximum and average flow rate (MFR and AFR) centiles. Flowmetry was available on 186 women at 6-18 weeks, 165 women at 32-39 weeks and 162 women 2-5 months postpartum. Voided volumes decreased from 253 to 180 ml during pregnancy (p<0.001), increasing again to 198 ml postpartum. MFR centiles increased during pregnancy [from 49 (SD 28) to 58 (SD 29), p=0.003], and this trend continued postpartum [to 61.8 (SD 26.8), p<0.001]. Changes correlated weakly but significantly with changes in several parameters of bladder neck mobility (e.g. urethral rotation and MFR centiles, r=0.182, p=0.027). MFR and AFR centiles increase in pregnancy and with childbirth, and increases correlate weakly with changes in bladder neck mobility.

Defecatory symptoms during and after the first pregnancy: prevalences and associated factors.
van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 3;.

A prospective cohort study was undertaken to evaluate the impact of pregnancy and the first delivery on the defecatory symptoms and to identify associated factors. Included were 487 nulliparous pregnant women who completed four questionnaires. Flatus and fecal incontinence, constipation, and painful defecation are already present in early pregnancy and are significantly predictive for reporting symptoms after delivery, except for fecal incontinence. A third or fourth degree sphincter tear was significantly associated with fecal incontinence 12 months postpartum and with de novo fecal incontinence, while other factors associated with de novo onset of symptoms were of borderline significance. Defecation symptoms already present in early pregnancy are highly predictive for reported symptoms at 12 months postpartum except for fecal incontinence that is mainly related to anal sphincter lesion. Therefore, investigating the effects of childbirth in general on the anorectal function is not justified without knowledge of this function during pregnancy.

Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.
Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R
BMJ 2005 Jun 25;330(7506):1478.

OBJECTIVE: To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts. SELECTION OF STUDIES: Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay). RESULTS: 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials. CONCLUSIONS: Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.

Closing discussion by Dr Chauhan.
Am J Obstet Gynecol 2005 Jun;192(6):1828.

Am J Obstet Gynecol 2005 Jun;192(6):1826-1828.

Professional liability claims and Central Association of Obstetricians and Gynecologists members: myth versus reality.
Chauhan SP, Chauhan VB, Cowan BD, Hendrix NW, Magann EF, Morrison JC
Am J Obstet Gynecol 2005 Jun;192(6):1820-6; discussion 1826-8.
OBJECTIVE: The purpose of this study was to survey members of the Central Association of Obstetricians and Gynecologists about professional liability claims. STUDY DESIGN: A survey was mailed to Central Association of Obstetricians and Gynecologists members regarding medical liability experience. RESULTS: Of the 897 surveys mailed, 73% were completed. The responding 658 clinicians had been in practice for 17,136 years and had 1507 closed claims. The respondents had a claim every 11 years of practice and a trial every 69 years. Matched for years of practice, a case control comparison indicated that the litigation is significantly lower for female physicians (1.5 +/- 1.8) than for male physicians (2.2 +/- 2.0; P = .019) although the mean cases that were dropped or dismissed were higher for men (1.3 +/- 1.7 vs 0.8 +/- 1.4; P = .022). However, the mean number of trials, defense trial verdicts, and the settlement amounts were similar for both genders. CONCLUSION: We found that professional liability claims are uncommon and that the gender of the obstetrician-gynecologist influences the litigation profile.

Why are women deterred from general surgery training?
Park J, Minor S, Taylor RA, Vikis E, Poenaru D
Am J Surg 2005 Jul;190(1):141-6.

BACKGROUND: This study explored the factors contributing to the low application rates to general surgery (GS) residency by female students and compared perceptions of GS between students and female surgeons. METHODS: We distributed surveys to final-year students at 4 medical schools and nationwide to every female general surgeon in Canada. RESULTS: Of students who were deterred from GS, women were less likely than men to meet a same-sex GS role model and more likely to experience gender-based discrimination during their GS rotation (P < .05). Female students had the perception that GS was incompatible with a rewarding family life, happy marriage, or having children, whereas female surgeons were far more positive about their career choice. CONCLUSIONS: Both real and perceived barriers may deter women from a career in GS. Real barriers include sex-based discrimination and a lack of female role models in GS. There are also clear differences in perception between students and surgeons regarding family and lifestyle in GS that must be addressed.

Accuracy of estimated fetal weight in shoulder dystocia and neonatal birth injury.
Mehta SH, Blackwell SC, Hendler I, Bujold E, Sorokin Y, Ager J, Kraemer T, Sokol RJ
Am J Obstet Gynecol 2005 Jun;192(6):1877-80; discussion 1880-1.

OBJECTIVE: This study was undertaken to determine whether there is any difference in the rate of error of estimated fetal weight (EFW) in cases of shoulder dystocia compared with controls. STUDY DESIGN: Women whose delivery was complicated by shoulder dystocia were studied and compared with a control group matched for parity, race, labor type (spontaneous or induced), and birth weight (BW). Accuracy (%) was defined as [(EFW-BW)/BW] x 100. The primary outcome of the study was rate of EFW underestimation error 20% or greater. RESULTS: During the 5-year study period, there were 206 cases of shoulder dystocia that met all study criteria. There was no difference in the number of patients that had EFW underestimation error 20% or greater (shoulder dystocia 9.8% vs control 12.8%; P = .38). There was also no difference in the number of patients that had EFW underestimation error 20% or greater between shoulder dystocia with and without injury (injury 8.3% vs no injury 7.1%; P = .79). CONCLUSION: EFW underestimation error in cases of shoulder dystocia is an infrequent event and does not occur more often than in deliveries without shoulder dystocia.

Repeat cesarean section and primary elective cesarean section: recently trained obstetrician-gynecologist practice patterns and opinions.
Kenton K, Brincat C, Mutone M, Brubaker L
Am J Obstet Gynecol 2005 Jun;192(6):1872-5; discussion 1875-6.

OBJECTIVE: This study was undertaken to determine opinions of obstetrician-gynecologists regarding vaginal birth after cesarean (VBAC) section and elective cesarean section. STUDY DESIGN: A questionnaire was administered to obstetrician-gynecologists attending 2 review courses. RESULTS: Of 500 obstetrician-gynecologists, 304 completed the survey for a response rate of 61%. Most (92%) counseled VBAC candidates differently, and 84% quoted differential VBAC completion rates on the basis of the indication for prior cesarean section. Uterine rupture was virtually always discussed (99%). Pelvic floor risks were infrequently discussed with urinary incontinence, pelvic organ prolapse, and fecal incontinence discussed by less than one third of obstetricians (30%, 28%, and 25%, respectively). Fifty-nine percent of physicians would perform a primary elective cesarean section, and 67% would perform a primary elective cesarean section specifically to prevent pelvic floor disorders. CONCLUSION: Two thirds of recent graduates are willing to perform an elective cesarean section to prevent pelvic floor injury. Most offer VBAC; however, less than a third include risk of pelvic floor injury in their informed consent discussions.

Birth rate and its correlation with the lunar cycle and specific atmospheric conditions.
Morton-Pradhan S, Bay RC, Coonrod DV
Am J Obstet Gynecol 2005 Jun;192(6):1970-3.

OBJECTIVE: This study was undertaken to use the Arizona State birth certificate database for Phoenix metropolitan hospitals, in conjunction with National Weather Service records to determine whether there is a relationship between birth rate and meteorologic or lunar conditions. This study attempts to dispel or lend significance to beliefs among hospital staff that the phase of the moon and/or meteorologic conditions are related to birth rate. STUDY DESIGN: Birth records were limited to spontaneous vaginal deliveries, 37 to 40 weeks' gestation, in Phoenix, between 1995 and 2000 (n = 167,956). Daily birth counts were merged with daily surface weather statistics from the National Weather Service for Sky Harbor Airport, and records of lunar phase for the same period. RESULTS: The analyses revealed no significant correlates of birth rate. CONCLUSION: Although there exists a popular belief that the phase of the lunar cycle and weather conditions affect birth rate, no such evidence was found in this study.

Treatment of non-albicans Candida vaginitis with amphotericin B vaginal suppositories.
Phillips AJ
Am J Obstet Gynecol 2005 Jun;192(6):2009-12; discussion 2012-3.

OBJECTIVE: This study was undertaken to investigate whether amphotericin B vaginal suppositories would be effective in the treatment of non- albicans Candida vaginitis in women who failed conventional therapy. STUDY DESIGN: Thirty-two patients were identified with non- albicans Candida vaginitis. These patients were treated with conventional antifungal agents. Ten patients had persistence of the non- albicans Candida infection after treatment. Amphotericin B 50-mg vaginal suppositories were given nightly for 14 days to this subgroup of treatment failures. RESULTS: Of 10 women, 8 (80%) who were treated with amphotericin B vaginally initially showed no further infection. One of the treatment successes had 2 recurrences and responded to a second course of amphotericin B but failed a third course. If this patient is considered a treatment failure, then amphotericin B vaginal suppositories were successful in 70% of patients. The medication was well tolerated and local side effects were minimal. CONCLUSION: Amphotericin B vaginal suppositories are a viable treatment option for refractory vaginitis caused by non- albicans Candida .

Stage I squamous cell carcinoma of vagina complicating pregnancy: Successful conservative treatment.
Fujita K, Aoki Y, Tanaka K
Gynecol Oncol 2005 Jun 27;.

BACKGROUND.: Vaginal squamous cell carcinoma in pregnancy is very rare situation. CASE.: The patient was a 33-year-old woman, presenting with a complaint of vaginal brownish discharge at a 23 weeks of gestation. On pelvic examination at that time, a 2 by 2 cm mass on posterior vaginal fornix was seen. Biopsy of the lesion demonstrated a nonkeratinizing type invasive squamous cell carcinoma. She desired to continue the pregnancy and postpone the treatment until after delivery. On 23 weeks of gestation, we performed wide local excision, confirming T1 stage. On 33 weeks of gestation, a pelvic lymphadenectomy was carried out at the time of cesarean section to secure lymph node status pathologically. Further, she began intracavitary brachytherapy via vaginal cylinder in an adjuvant setting. She is 36 months from her initial surgery and remains disease free. CONCLUSION.: Treatment could be individualized for primary stage I vaginal squamous cell carcinoma complicating pregnancy.

Shoulder dystocia: are historic risk factors reliable predictors?
Ouzounian JG, Gherman RB
Am J Obstet Gynecol 2005 Jun;192(6):1933-5; discussion 1935-8.

OBJECTIVE: Our purpose was to determine the rate of associated risk factors for shoulder dystocia from a large cohort of patients delivered within our Southern California perinatal program. STUDY DESIGN: A retrospective analysis was performed of patients delivered from January 1991 to June 2001. Patients with and without shoulder dystocia were identified from our computer-stored perinatal database and compared. Statistical methods used included: chi 2 test, t test, calculation of odds ratios, and Fisher exact test, as indicated. RESULTS: Among the 267,228 vaginal births during the study period, there were 1,686 cases of shoulder dystocia (rate 0.6%). Rates for operative vaginal delivery, diabetes, epidural use, multiparity, and postdatism were similar among cases with and without shoulder dystocia. The clinical triad of oxytocin use, labor induction, and birth weight greater than 4,500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0) for shoulder dystocia, but its sensitivity and positive predictive value were only 12.4% and 3.4%, respectively. CONCLUSION: Historic obstetric risk factors for shoulder dystocia are not useful predictors for the event. Furthermore, although shoulder dystocia was observed more frequently with increasing birth weight, current limitations in estimating birth weight antenatally with accuracy preclude its practical use as a reliable predictor.

Management of Wound Complications From Cesarean Delivery.
Sarsam SE, Elliott JP, Lam GK
Obstet Gynecol Surv 2005 Jul;60(7):462-473.

Multiple factors account for the increasing number of cesarean delivery wound complications in the United States; among them are an increase in cesarean delivery and an increase in the number of overweight and obese patients. This article reviews the pathophysiology of acute wound healing. Risk factors for cesarean delivery wound complications are identified and described. Clinical practices that can reduce the risk of developing wound complications, including Centers for Disease Control and Prevention guidelines, are considered. Treatment guidelines to accelerate wound healing such as secondary closure and negative pressure wound therapy in disrupted wounds are proposed. Older guidelines for management of wounds using secondary intention are critiqued. Historical methods of wound care such as the practice of using certain cleansers and the practice of wet to dry dressings are outdated. Modern wound healing products are described. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the effects of obesity on cesarean delivery wound healing, to improve methods of wound healing in the obese patient, and to explain why wet to dry dressing changes are not effective wound management.

Lactobacilli for prevention of urogenital infections: a review.
Berger RE
J Urol 2005 Jul;174(1):165-6.

National survey for intrapartum and postpartum bladder care: assessing the need for guidelines.
Albertsen PC
J Urol 2005 Jul;174(1):273.

Vaginal construction using sigmoid colon in children and young adults.
Canning DA
J Urol 2005 Jul;174(1):310-1.

Self-assessment of genital anatomy, sexual sensitivity and function in women: implications for genitoplasty.
Canning DA
J Urol 2005 Jul;174(1):308-9.

Intestinal vaginoplasty: is it optimal treatment of vaginal agenesis? A pilot study Surgical method of sigmoid colon vaginoplasty in vaginal agenesis.
Karateke A, Gurbuz A, Haliloglu B, Kabaca C, Koksal N
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 5;.

The outcome of 11 cases with vaginal agenesis who underwent intestinal vaginoplasties are presented. Patients were between 18 and 37 years old. Ileum vaginoplasty and sigmoid colon vaginoplasty were carried out in two and nine cases, respectively. Ileum necrosis at donor site requiring ileum resection and bilateral ileostomy encountered in one of the cases was the major complication. Mild stenosis responsive to finger dilatation had been detected in two women with sigmoid vaginoplasty. Excess mucous production, long operation time, and shortness of mesentery of ileum led us to abandon ileum vaginoplasty, and sigmoid colon vaginoplasty was performed in the following cases with vaginal agenesis. All of the neovaginas were patent and functional. We suggest sigmoid colon vaginoplasty as the treatment of choice because of its large lumen, thick walls resistant to trauma, adequate secretion allowing lubrication, not necessitating prolonged dilatation, short recovery time compared with ileum vaginoplasties; and in patients reluctance to prolonged use of dilatators or in those who experienced previous failure of the other treatment modalities.

Endometrial cancer: magnetic resonance imaging.
Manfredi R, Gui B, Maresca G, Fanfani F, Bonomo L
Abdom Imaging 2005 May 6;.

Carcinoma of the endometrium is the most common invasive gynecologic malignancy of the female genital tract. Clinically, patients with endometrial carcinoma present with abnormal uterine bleeding. The role of magnetic resonance imaging (MRI) in endometrial carcinoma is disease staging and treatment planning. MRI has been shown to be the most valuable imaging mod-ality in this task, compared with endovaginal ultrasound and computed tomography, because of its intrinsic contrast resolution and multiplanar capability. MRI protocol includes axial T1-weighted images; axial, sagittal, and coronal T2-weighted images; and dynamic gadolinium-enhanced T1-weighted imaging. MR examination is usually performed in the supine position with a phased array multicoil using a four-coil configuration. Endometrial carcinoma is isointense with the normal endometrium and myometrium on noncontrast T1-weighted images and has a variable appearance on T2-weighted images demonstrating heterogeneous signal intensity. The appearance of noninvasive endometrial carcinoma on MRI is characterized by a normal or thickened endometrium, with an intact junctional zone and a sharp tumor-myometrium interface. Invasive endometrial carcinoma is characterized disruption or irregularity of the junctional zone by intermediate signal intensity mass on T2-weighted images. Invasion of the cervical stroma is diagnosed when the low signal intensity cervical stroma is disrupted by the higher signal intensity endometrial carcinoma. MRI in endometrial carcinoma performs better than other imaging modalities in disease staging and treatment planning. Further, the accuracy and the cost of MRI are equivalent to those of surgical staging.

Persistent and recurrent cervical dysplasia after loop electrosurgical excision procedure.
Brockmeyer AD, Wright JD, Gao F, Powell MA
Am J Obstet Gynecol 2005 May;192(5):1379-81.

OBJECTIVE: Our objective was to determine whether demographic, colposcopic, and pathologic variables are predictive of recurrent cervical dysplasia. STUDY DESIGN: A retrospective review of patients who underwent loop electrosurgical excision procedure (LEEP) was performed. The medical records of the subjects were reviewed to identify demographic, pathologic, and procedural characteristics that predict recurrent dysplasia. RESULTS: A total of 514 subjects were identified who underwent LEEP between 1996 and 2003. Multivariate analysis revealed that advanced age, immunosuppression, and a positive endocervical margin were associated with recurrent dysplasia. CONCLUSION: Demographic and pathologic data can be used to predict the risk of recurrence of cervical dysplasia after LEEP.

Neonatal impact of elective repeat cesarean delivery at term: a comment on patient choice cesarean delivery.
Fogelson NS, Menard MK, Hulsey T, Ebeling M
Am J Obstet Gynecol 2005 May;192(5):1433-6.

OBJECTIVE: The object of this study was to compare neonatal outcomes of term uncomplicated pregnancies delivered by scheduled repeat cesarean with outcomes of babies born to mothers intending to deliver vaginally. STUDY DESIGN: This retrospective cohort study describes neonatal outcomes of term uncomplicated pregnancies. Neonates of mothers intending to deliver vaginally (n = 3134) are compared with neonates born by elective repeat cesarean delivery prior to labor (n = 117). RESULTS: Neonates born by elective repeat cesarean are more frequently admitted to advanced care nurseries than infants born to mothers intending to deliver vaginally (risk ratio 3.58, 95% confidence interval 3.35-3.58). CONCLUSION: The decision to undergo scheduled cesarean delivery appears to negatively impact immediate neonatal outcomes.

Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery.
Goodall PT, Ahn JT, Chapa JB, Hibbard JU
Am J Obstet Gynecol 2005 May;192(5):1423-6.

OBJECTIVE: This study was undertaken to determine whether obesity is a risk factor for failed trial of labor (TOL) in women with previous cesarean delivery (CD). STUDY DESIGN: We performed a review of singleton gestations 36 weeks or greater with previous CD who underwent TOL from January 1998 to June 2002, stratifying by body mass index (BMI, kg/m2): normal (BMI <25), overweight (BMI 25-29.9), obese (BMI 30-39.9), and morbidly obese (BMI >40). Rates for failed TOL were determined, and groups compared. RESULTS: For 725 patients, failed TOL rates were as follows: 14.1%, 20.4%, 27.7%, and 30.3% for normal, overweight, obese, and morbidly obese groups, respectively (P < .0001). Significant risk factors included: no previous vaginal delivery, labor induction, recurrent CD indication, and fetal macrosomia. However, obesity remained an independent risk factor for failed TOL in the obese and morbidly obese groups with odds ratio of 1.99 (95% CI 1.20-3.30) and 2.22 (1.11-4.44) for these groups (P = .03), respectively. CONCLUSION: Obesity is an independent risk factor for failed TOL in patients with previous CD.

Effect of delivery route on natural history of cervical dysplasia.
Kaneshiro BE, Acoba JD, Holzman J, Wachi K, Carney ME
Am J Obstet Gynecol 2005 May;192(5):1452-4.

OBJECTIVE: This study was undertaken to determine the (1) impact of delivery route on the natural history of cervical dysplasia and (2) overall regression rates of cervical dysplasia in pregnant women. STUDY DESIGN: A retrospective analysis was performed on 705 pregnant women with abnormal Papanicolaou tests who presented for prenatal care at the Kapiolani Medical Center Women's Clinic in Honolulu, Hawaii, between 1991 and 2001. Data collection included demographics, delivery route, and cervical pathology. RESULTS: Two hundred one patients met the inclusion criteria. Regression rates for vaginal and cesarean section groups were as follows: atypical squamous cells (64% vs 70%, P = .32), low-grade squamous intraepithelial lesion (58% vs 42%, P = .073), and high-grade squamous intraepithelial lesion (53% vs 25%, P = .44). Of the total population, 30% of lesions persisted postpartum, 58% regressed, and 12% progressed. CONCLUSION: Mode of delivery does not influence the natural history of dysplastic lesions. Gravid and nongravid women have similar regression rates.

Management of cervical adenocarcinoma in situ during pregnancy.
Lacour RA, Garner EI, Molpus KL, Ashfaq R, Schorge JO
Am J Obstet Gynecol 2005 May;192(5):1449-51.

OBJECTIVE: Adenocarcinoma in situ (AIS) is a precursor of invasive disease that is being more frequently diagnosed during the reproductive years. Few reports have described the treatment of this condition in gravid women. The purpose of this study was to review our collective experience managing cervical AIS during pregnancy. STUDY DESIGN: Retrospective medical record review of all women diagnosed with AIS during pregnancy from 1995 to 2004 at 3 academic institutions. RESULTS: Eleven women with a median age of 32 years were identified. Five who received a diagnosis in the early second trimester underwent uncomplicated cold knife conization (CKC) at 14 to 19 weeks' gestation. Six patients underwent postpartum CKC. All 11 women delivered at term. One patient undergoing postpartum CKC required radical hysterectomy for stage IB1 cervical adenocarcinoma. Four subsequent pregnancies occurred among patients having fertility-sparing surgery. CONCLUSION: Management of cervical AIS during pregnancy by early second trimester CKC is safe for mother and fetus.

The effect of the lunar cycle on frequency of births and birth complications.
Arliss JM, Kaplan EN, Galvin SL
Am J Obstet Gynecol 2005 May;192(5):1462-4.

OBJECTIVE: The purpose of this study was to examine the influence of the lunar cycle on the frequency of deliveries and/or delivery complications. STUDY DESIGN: This was a retrospective cohort, secondary analysis of 564,039 births across 62 lunar cycles that were identified from North Carolina birth certificate data from 1997 to 2001. RESULTS: Using analysis of variance and t-tests, we found no significant differences in the frequency of births, route of delivery, births to multigravid women, or birth complications across the 8 phases of the moon or between documented high- and low-volume intervals of the lunar cycle. CONCLUSION: An analysis of 5 years of data demonstrated no predictable influence of the lunar cycle on deliveries or complications. As expected, this pervasive myth is not evidence based.

Vaginal wall stretching.
Goodlin RC
Am J Obstet Gynecol 2005 May;192(5):1759; author reply 1759-60.

Episiotomy: Beliefs, practice and the impact of educational intervention.
Lowenstein L, Drugan A, Gonen R, Itskovitz-Eldor J, Bardicef M, Jakobi P
Eur J Obstet Gynecol Reprod Biol 2005 May 20;.

OBJECTIVE: To assess the potential effect of educational intervention on episiotomy practice. STUDY DESIGN: A survey of the attitude of obstetrical caregivers toward episiotomy was conducted among obstetricians and midwives in the three public hospitals in Haifa. Data regarding episiotomy rates was collected for the years 2001-2003. At the beginning of 2002, lectures on the risks and benefits of episiotomy were given in two hospitals. Episiotomy rates before and after the lecture were compared. RESULTS: A significant and lasting reduction in episiotomy rates was observed in the two hospitals where lectures were given. There were no clinically significant and consistent changes in the episiotomy practices in the third hospital. CONCLUSION: Education may play an important role in changing common medical practices, as in episiotomy. It was clearly shown that our beliefs are not always up to date. We call for periodic reassessment of all medical procedures, as common and accepted as they are.

Experience with shared decision making in gynaecological practice: treatment decisions in patients with dysfunctional uterine blood loss.
van der Wilt GJ, Meulendijks CF, Thijssen RF
Eur J Obstet Gynecol Reprod Biol 2005 Jun 1;120(2):210-6.

OBJECTIVE: To study the impact of introducing a blood loss chart as a means to support treatment selection in women with dysfunctional uterine blood loss. STUDY DESIGN: Retrospective chart review, prospective observational study, and decision modelling. RESULTS: Introduction of a blood loss chart resulted in a 50% reduction of re-treatments within 1 year (from 25% to 12.5%). The use of the blood loss chart resulted in a slightly higher expected value and lower costs, which is reflected in a more favourable cost/quality adjusted life year (QALY) ratio. CONCLUSION: The use of a blood loss chart as an aid in treatment selection in women with dysfunctional uterine blood loss is feasible. Although its use requires an extra outpatient visit, the associated extra costs are off-set by its impact on initial treatment selection, and, in particular, on the probability of re-treatment within 1 year of follow-up.

The impact of medical legal risk on obstetrician-gynecologist supply.
Robinson P, Xu X, Keeton K, Fenner D, Johnson TR, Ransom S.
Obstet Gynecol 2005;105(6):1296-302.

OBJECTIVE: To evaluate the effects of medical legal risk on practice location of obstetrician-gynecologists. METHODS: We used the American College of Obstetricians and Gynecologists (ACOG) Membership Record to determine the number of Fellows and Junior Fellows by state. We obtained state malpractice premiums from the Medical Liability Monitor and state birth rates from the National Center for Health Statistics. The American Medical Association (AMA) "Crisis" and ACOG "Red Alert" designations, as well as state malpractice premium levels, were used to approximate malpractice risk. We examined the changes in state births to obstetrician-gynecologist rates from 1995 to 2003 by using the Student t test and Mann-Whitney tests. Comparisons were made between states of different risk levels. RESULTS: We found no significant difference in the percentage changes in births per Fellow or births per Junior Fellow between AMA "Crisis" and remaining states, nor between ACOG "Red Alert" and Safe states. The percentage changes in births per Fellow were similar in the 10 highest-premium states and the 10 lowest-premium states. The percentage increase in births per Junior Fellow in the 10 highest-premium states was significantly greater than the 10 lowest-premium states (median 28.5% versus 5.0%, P = .03). CONCLUSION: Malpractice premiums appear to influence practice location of new obstetrician-gynecologists. Neither the AMA designation of "Crisis" nor the ACOG designation of "Red Alert" had supply implications in the analysis. More research on the interaction of malpractice rates and obstetrician-gynecologist supply is needed for informed decisions regarding malpractice premium management. LEVEL OF EVIDENCE: II-3.

Vaginal yeast colonization in nonpregnant women: a longitudinal study.
Beigi RH
Obstet Gynecol 2005 Jun;105(6):1494.

Body mass index, weight, and oral contraceptive failure risk.
Creinin MD, Roberts E
Obstet Gynecol 2005 Jun;105(6):1492.

Training the gynecologic surgeon.
Fenner D
Obstet Gynecol 2005 Jun;105(6):1490.

Is peripartum hysterectomy more common in multiple gestations?
Francois K, Ortiz J, Harris C, Foley MR, Elliott JP
Obstet Gynecol 2005 Jun;105(6):1369-72.

OBJECTIVE: To compare the occurrence of peripartum hysterectomy between singleton and multiple gestations. METHODS: This was a historical cohort study comparing the occurrence of peripartum hysterectomy between singleton and multiple gestations at Banner Good Samaritan Regional Medical Center, Phoenix, Arizona, from January 1, 1996, to December 31, 2001. RESULTS: During the study years, 42,595 singleton, 1,131 twin, 164 triplet, 35 quadruplet, and 2 quintuplet deliveries occurred. A total of 100 peripartum hysterectomies were performed. Of these hysterectomies, 88 occurred in singletons, 5 in twins, 6 in triplets, and 1 in quadruplets. The overall occurrence of peripartum hysterectomy was 2.28 per 1,000, and the occurrence of emergent peripartum hysterectomy was 1.73 per 1,000. Multiple gestations had a significantly greater risk of emergent peripartum hysterectomy than singletons (odds ratio [OR] 6.04, 95% confidence interval [CI] 3.28-11.11; P < .001). This difference was more pronounced among higher-order multiple gestations: twins (OR 2.95, 95% CI 1.22-7.13, P = .03), triplets (OR 25.22, 95% CI 11.02-57.77, P < .001), and quadruplets (OR 19.53, 95% CI 3.34-114.69, P = .04). When compared with singletons, higher-order multiple gestations had nearly a 24-fold increased risk of emergent peripartum hysterectomy (OR 23.97, 95% CI 11.05-51.99, P < .001). CONCLUSION: Multiple gestations have a significantly higher occurrence of emergent peripartum hysterectomy than singletons. This information should be used in counseling and managing patients with these pregnancies. LEVEL OF EVIDENCE: II-3.

Urethral and paraurethral leiomyomas in the female patient.
Ozel B, Ballard C
Int Urogynecol J Pelvic Floor Dysfunct 2005 May 19;.

Urethral leiomyomas in women arise from the smooth muscle of the urethra and are rare, benign urethral tumors seen primarily in women. We present three cases of urethral leiomyomas identified over a 30-year period at our institution. A 45-year old woman presented with a 1 year history of frequency, nocturia, and hesitancy and was found to have both a 2-cm proximal urethral and a 3-cm posterior bladder leiomyoma. She developed stress urinary incontinence postoperatively and was treated with a Burch colposuspension. A 33-year old woman with hematuria was found to have both a 3-cm urethral and a 3-cm paraurethral leiomyoma at the bladder neck. A 21-year old without urinary complaints was found to have a 3-cm leiomyoma at the urethral meatus. Urethral leiomyomas must be differentiated from paraurethral leiomyomas, which are often asymptomatic and may be removed without disrupting the urethral mucosa or smooth muscle. The removal of urethral myomas may be complicated by the development stress urinary incontinence or urethral stricture.

Episiotomy and vaginal trauma.
Scott JR
Obstet Gynecol Clin North Am 2005 Jun;32(2):307-21.

The era of routine episiotomy is gradually ending. Previously perceived benefits gradually have been disproved as evidence-based scientific clinical studies have shown the detrimental effects of episiotomy; however, circumstances always will exist in which prudent clinical judgment may dictate the necessity for an episiotomy. In most of these situations, however, an episiotomy often can be avoided. Perhaps more hospital perinatal review committees should evaluate episiotomy rates and strive to convince their staff to reduce their rates. We can learn to be more patient and allow the natural forces of labor to gradually stretch the perineum. In reviewing the extensive volume of published literature on episiotomy and perineal-vaginal trauma, the best advice lies in the dictum "Don't just do something, sit there!"

Vaginal birth after classical Caesarean section.
de Costa C
Aust N Z J Obstet Gynaecol 2005 Jun;45(3):182-6.

Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists.
Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP
J Reprod Med 2005 Apr;50(4):261-6.

OBJECTIVE: To assess obstetrician-gynecologists' current practice patterns and opinions regarding vaginal birth after cesarean delivery (VBAC). STUDY DESIGN: Questionnaires were mailed to a random sample of 1,200 American College of Obstetricians and Gynecologists (ACOG) fellows in July 2003. Information was gathered on percentage of cesarean and VBAC deliveries performed, factors influencing changes in these rates in the past 5 years, hospital protocol regarding VBAC and factors influencing the recommendation of VBAC. RESULTS: Fifty-three percent of questionnaires were returned to ACOG after 3 mailings. Approximately 49% of respondents reported that they were performing more cesarean deliveries than they were 5 years earlier. The primary reasons for this increase were the risk of liability and patient preference for delivery method. More than 25% of physicians reported that they practiced in hospitals that do not follow the ACOG guidelines with respect to resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC. However, only 61% reported feeling competent in determining which patients will have a successful VBAC. CONCLUSION: Obstetrician-gynecologists seem to be aware of the risks and benefits of VBAC; however, there is some doubt as to who should be offered a trial of labor and what predicts a successful VBAC.

Catamenial pneumothorax.
Peikert T, Gillespie DJ, Cassivi SD
Mayo Clin Proc 2005 May;80(5):677-80.

Catamenial pneumothorax is defined as spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. Although catamenial pneumothorax is the most common clinical manifestation of intrathoracic endometriosis, this latter condition is not universally identified in women with catamenial pneumothorax and cannot fully explain the recurrent and cyclical episodes of pneumothorax. Therefore, the etiology of this syndrome is unknown, although many theories have been proposed to explain it. We describe a 37-year-old woman with recurrent episodes of spontaneous right-sided pneumothorax and chest pain that occurred close to her menstrual periods. The patient's condition did not abate after initial surgical exploration with abrasive mechanical pleurodesis or after hormonal suppressive therapy at an institution elsewhere. The patient was referred to our institution for further evaluation. A second surgical inspection of the pleural cavity and diaphragm disclosed the presence of multiple diaphragmatic fenestrations that were closed surgically at that time. Postoperatively, the patient discontinued hormonal suppressive therapy, and menstrual cycles became regular. Six months after surgery, the patient remains asymptomatic with no evidence of recurrence of pneumothorax. This case supports recent reports that diaphragmatic defects are often present in patients with catamenial pneumothorax. Surgical exploration to inspect the diaphragm and to close all Identified defects should be performed in patients who continue to experience pneumothorax despite effective hormonal suppression.

Transdermal drug delivery: clinical considerations for the obstetrician-gynecologist.
Potts RO, Lobo RA
Obstet Gynecol 2005 May;105(5):953-61.

INTRODUCTION: The first transdermal drug delivery system was introduced in the United States over 20 years ago. Created as an alternative route of administration to improve patient compliance as well as to reduce side effects, the transdermal delivery of drugs now represents a $1.5 to $2 billion market and is growing rapidly. DATA SOURCES: The medical literature from 1980 to 2005 was searched using the PubMed search engine. The search term was "transdermal," limited to human clinical trials. Abstracts were used to identify clinical trials that compared transdermal preparations and their oral counterparts in the same study. TABULATION, INTEGRATION, AND RESULTS: In this article, we review the rationale for the transdermal administration of drugs; discuss aspects of the anatomy and physiology of the skin relevant to drug transport; examine the qualities required for a drug to be a good candidate for transdermal delivery; and consider key principles for the evaluation of the relative benefits of transdermal delivery, using studies of hormone replacement therapy and oral contraceptive as examples. CONCLUSION: The data reviewed here suggest that certain clinical situations support the use of the transdermal administration of drugs over their oral counterparts.

Obstetrics and gynecology: more than just a job.
Scott JR
Obstet Gynecol 2005 May;105(5):936.

What obstetrics and gynecology means to me.
van Dis J
Obstet Gynecol 2005 May;105(5):1123.

Do no harm: avoidance of herbal medicines during pregnancy.
Marcus DM, Snodgrass WR
Obstet Gynecol 2005 May;105(5):1119-22.

Herbal medicines are regarded by the public and some health care providers as gentle and safe, but there is no scientific basis for that belief. The active ingredients of plant extracts are chemicals that are similar to those in purified medications, and they have the same potential to cause serious adverse effects. This commentary summarizes recent data on the poor quality control and toxicity of herbal remedies and on the pharmacologic activities of ginger, which is used for treatment of morning sickness. There are no rigorous scientific studies of the safety of dietary supplements during pregnancy, and the Teratology Society has stated that it should not be assumed that they are safe for the embryo or fetus. Obstetricians should advise women not to expose their fetuses to the risks of herbal medicines.

Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis.
Starr RV, Zurawski J, Ismail M
Obstet Gynecol 2005 May;105(5):1024-9.

OBJECTIVE: Postcesarean endometritis and wound infection remain significant morbidities, despite use of strategies to prevent these complications. We investigated the effect of preoperative vaginal preparation with povidone-iodine as a preventive intervention against postcesarean endometritis and wound infection. METHODS: A randomized controlled study was performed in 308 women undergoing nonemergent cesarean delivery. Subjects received either standard abdominal scrub alone or abdominal scrub with an additional vaginal preparation with povidone-iodine solution. All subjects received prophylactic antibiotic at the time of umbilical cord clamping. Each subject's postoperative course was reviewed for development of febrile morbidity (temperature > 38.0 degrees C), endometritis (temperature > 38.4 degrees C accompanied by fundal tenderness occurring beyond the first postoperative day, in the absence of evidence of other infection), and wound infection. RESULTS: Postcesarean endometritis occurred in 7.0% of subjects who received a preoperative vaginal preparation and 14.5% of controls (P < .05). There was no measurable effect of a vaginal scrub on the development of postoperative fever or wound infection. The adjusted odds ratio for developing endometritis after a vaginal preparation was 0.44 (95% confidence interval [CI] 0.193-0.997). Multivariate analysis showed an increased risk of developing endometritis in association with severe anemia (adjusted OR 4.26, 95% CI 1.568-11.582), use of intrapartum internal monitors (adjusted OR 2.84, 95% CI 1.311-6.136), or history of antenatal genitourinary infection (adjusted OR 2.9, 95% CI 1.265-6.596). CONCLUSION: Preoperative vaginal scrub with povidone-iodine decreases the incidence of postcesarean endometritis. This intervention does not seem to decrease the overall risk of postoperative fever or wound infection. LEVEL OF EVIDENCE: II-1.

Vulvar granuloma fissuratum: a description of fissuring of the posterior fourchette and the repair.
Kennedy CM, Dewdney S, Galask RP
Obstet Gynecol 2005 May;105(5):1018-23.

OBJECTIVE: To describe the characteristics of women who experience chronic fissuring of the posterior fourchette and the outcome of treatment administered. METHODS: We conducted a retrospective review of 42 women with granuloma fissuratum presenting for care between January 1, 1995, and December 31, 2003. Women underwent medical management first, and if improvement was minimal, perineoplasty was recommended. Dyspareunia and vulvar symptom scores, including itching, burning, and pain, before and after treatment were compared. RESULTS: Twenty women were managed nonoperatively, while 22 women underwent perineoplasty. The median age at diagnosis of granuloma fissuratum was 42.5 years (range 26-78). The fissure resolved in 13 of 20 women (65%) who were managed nonoperatively and in 21 of 22 women (95%) who underwent perineoplasty. Of the 11 women sexually active after perineoplasty, all had preoperative dyspareunia; it resolved in 7 (64%) women. Among the 13 women managed nonsurgically who had resolution of the fissure, 7 women were sexually active after treatment and dyspareunia resolved in 2 (29%) women. Other vulvar symptoms, such as burning, itching, pain, and discharge, showed no significant improvement after either surgical or nonsurgical treatment. CONCLUSION: Although fissuring is common with some vulvar dermatoses, such as lichen sclerosus and contact vulvitis, and often resolves with the appropriate medical management, fissuring may also occur as a primary finding and may benefit from perineoplasty. LEVEL OF EVIDENCE: II-3.

Exercise during pregnancy: a critical appraisal of the literature.
Morris SN, Johnson NR
J Reprod Med 2005 Mar;50(3):181-8.

To review the effects of exercise during pregnancy on fetal and maternal outcomes, a selective literature search was performed using MEDLINE, the Cochrane Database and bibliographies from relevant articles to identify additional references. The data on exercise during pregnancy are limited but suggest that moderate exercise during a low-risk pregnancy does not lead to adverse outcomes for the fetus or mother and improves overall maternal fitness and well-being. The data examining the impact of exercise on labor outcomes, maternal weight gain and fetal weight are conflicting. Moderate exercise in the low-risk pregnancy improves maternal well-being and does not seem to have adverse effects on the fetal or maternal outcome. However, further studies are needed.

Menopausal vasomotor symptoms: a review of causes, effects and evidence-based treatment options.
Bachmann GA
J Reprod Med 2005 Mar;50(3):155-65.

Vasomotor symptoms are the most common medical complaint of perimenopausal and postmenopausal women. Frequent vasomotor symptoms can be disabling, affecting a woman's social life, psychological health, sense of well-being and ability to work. Women with hot flushes are more likely to experience disturbed sleep, depressive symptoms and significant reductions in quality of life as compared to asymptomatic women. Despite the prevalence and impact of these symptoms, the pathophysiology of hot flushes is unclear; however, estrogen withdrawal clearly plays an important role. It is postulated that declining estrogen concentrations may lead to changes in brain neurotransmitters and instability in the hypothalamic thermoregulatory center. The most effective therapy for relieving vasomotor symptoms and reducing their impact on quality of life is hormone therapy. Other options for women who decline hormone therapy include selective serotonin reuptake inhibitors and related agents. Most herbal therapies that have been evaluated in placebo-controlled trials have shown no clinically significant benefit.

Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly.
Susini T, Massi G, Amuni G, Carriero C, Marchionni M, Taddei G, Scarselli G
Obstet Gynecol Surv 2005 May;60(5):302-3.

This study presents the results of a retrospective review of all women (n = 171) older than 70 years of age who underwent surgery for treatment of endocervical cancer between 1980 and 1999 at the University of Florence. Women who were obese, or who were otherwise considered poor surgical risks, had a vaginal hysterectomy, always with bilateral salpingo-oophorectomy and removal of a short vaginal cuff (1-2 cm). Healthy women, or those with a large uterus or coexistent adnexal mass, underwent abdominal hysterectomy and bilateral salpingo-oophorectomy. Pelvic lymphadenectomy was done at the surgeon's discretion. Patients with poorly differentiated disease or deep myometrial invasion received postoperative adjuvant whole-pelvis irradiation. Follow up was at 3- month intervals for 2 years, every 6 months until 5 years, and once a year thereafter. The median follow-up period was 67 months. Patients who died of other causes were considered to have survived until the time of their death.The mean age of patients was 74 years. Vaginal hysterectomy with bilateral salpingo-oophorectomy was performed in 128 women (75%), 11 of whom also had extraperitoneal pelvic lymphadenectomy. Most of these patients (85%) had spinal anesthesia. Forty-three patients (25%) had abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy in 27 patients.There was no significant difference in the 2 groups in rates of disease recurrence or death from disease. Seventeen of 128 patients (13.3%) in the vaginal hysterectomy group and 8 of 43 patients (18.6%) in the abdominal group died of disease. Only 1 patient, who had undergone a vaginal procedure, of 26 with disease recurrence did not die of disease. There was no significant difference between the groups in the pattern of disease recurrence. Recurrence was local in 44.4% and 50% of the vaginal and abdominal hysterectomy groups, respectively. Distant metastases were seen in 33.3% and 25%, and distant and local in 22.2% and 25%, respectively.No significant differences in survival were seen. Overall 5-year and 10-year survival rates were 84% and 80%, respectively, in the vaginal group and 78% each in the hysterectomy group.The 38 patients who underwent pelvic lymphadenectomy, only 3 of whom (7.9%) had positive nodes, had 5- and 10-year survival rates (82% each) that were similar to overall survival rates.Five percent of the women in the vaginal hysterectomy group and 7% of those in the abdominal group had serious complications associated with surgery (cerebral vascular accident, wound dehiscence, ureteral stricture, bowel obstruction, or myocardial failure). One patient in the abdominal group died from myocardial infarction.Fewer patients who had a vaginal procedure had general anesthesia (15% vs. 100% in the abdominal group; P <.001), median operative time was shorter (46 minutes vs. 115 minutes; P = .01), median blood loss was less (210 mL vs. 400 mL; P = .01), and hospital stays were shorter (median 6 days vs. 10 days; P = .05) compared with the abdominal hysterectomy group. Requirements for blood transfusion were not significantly different.

Rectus abdominis myocutaneous and myoperitoneal flaps for neovaginal reconstruction after radical pelvic surgery: Comparison of flap-related morbidity.
Soper JT, Secord AA, Havrilesky LJ, Berchuck A, Clarke-Pearson DL
Gynecol Oncol 2005 May;97(2):596-601.

PURPOSE: To compare flap-specific complications of rectus abdominis myocutaneous (RAM) and myoperitoneal (RAMP) flap neovagina reconstructions performed concurrently with radical pelvic procedures. MATERIALS AND METHODS: Retrospective single institution chart review of all patients with RAM or RAMP flap neovaginal reconstructions performed on a Gynecologic Oncology service, 1988-2003. Analysis for associations with flap-specific morbidity was performed. RESULTS: Neovaginal reconstructions comprised 32 RAM and 7 RAMP flaps. Twenty-two (69%) RAM patients underwent total pelvic exenteration compared to 1 (14%) RAMP patient (P < 0.013). Overall, 33 (85%) of the patient population had previously been treated with radiation. Flap-specific complications developed in 12 (32%) RAM versus 4 (57%) of the RAMP patients (P > 0.1). Donor site complications and incisional hernias were increased in RAMP patients (both P < 0.03), with trends for increasing risk of vaginal stricture/stenosis and superficial wound separations (both P < 0.1). Complete vaginal stenosis developed in only 1 (3%) RAM versus 3 (43%) RAMP patients. Furthermore, 3 RAMP patients developed complete stenosis when the vaginal defect was circumferential and involved >65% of the vagina while this did not occur in 22 similar RAM patients (P < 0.0005). Only patients with partial longitudinal defects maintained vaginal patency after RAMP flap. Fifteen (58%) of 26 patients surviving >12 months reported coitus, with no significant difference between the groups. CONCLUSIONS: When there is circumferential loss of the upper 2/3 of the vagina. RAMP flaps are not suitable for neovaginal reconstruction after radical pelvic surgery because of an increased risk of vaginal stenosis compared to RAM flaps. Patients with partial longitudinal vaginal defects, however, may have successful neovaginal reconstruction with RAMP flaps.

Evaluation of postmyomectomy uterine scar.
Darwish AM, Nasr AM, El-Nashar DA
J Clin Ultrasound 2005 May;33(4):181-6.

PURPOSE: To determine preoperative and intraoperative factors that affect the healing pattern of a myomectomy uterine incision and to estimate the incidence and outcome of postmyomectomy hematoma demonstrated with sonography. METHODS: This observational longitudinal prospective study followed the course of patients diagnosed with at least 1 leiomyomata. Each patent was scheduled for abdominal myomectomy. Preoperative assessments included sonographic measurement of the uterine volume as well as identification of the numbers and sites of the leiomyomata. Detailed operative notes were reported for every patient. Transvaginal sonography was performed for all cases on day 2, day 7, and at 1 month and 3 months postoperatively. The main outcome measure was the occurrence of postoperative hematoma versus preoperative and postoperative factors that possibly affect uterine healing. RESULTS: We found a statistically significant reduction of the uterine volume on follow-up (P < 0.001) of the 169 women enrolled. Hematoma in the myomectomy bed was observed postoperatively in 40 (24%) 28 (17%) and 12 (7%) patients on day 2, day 7, and 1 month, respectively. A preoperative myoma size greater than 110 cm(3), the use of a tourniquet, and the experience of the surgeon were significantly correlated with formation of uterine scar hematomas. CONCLUSIONS: The postoperative sonographic diagnosis of wound hematoma may be used as an indicator of wound healing that is usually complete within 3 months. Use of a tourniquet is frequently associated with hematoma formation. Myomectomy should usually be performed by an experienced surgeon without a tourniquet, using microsurgical principles, especially when the sizes of the leiomyomata exceed 110 cm(3). (c) 2005 Wiley Periodicals, Inc. J Clin Ultrasound 33:181-186, 2005.

Vulvoperineal reconstruction with a sulcus gluteus flap.
Bistoletti P, Cravino T, Belardi MG
J Reprod Med 2005 Feb;50(2):123-9.

OBJECTIVE: To describe vulvoperineal reconstruction with a flap of the sulcus gluteus. STUDY DESIGN: Nonrandomized, prospective study in patients with vulvar cancer and vulvar intraepithelial neoplasia. After oncologic surgery, reconstruction with a sulcus gluteus flap was performed. The flap is supplied by the internal pudendal artery, and innervation is provided by the pudendal nerve. The tuber ischiale is the anatomic landmark for locating the pedicle. Follow-up was from 2 months to 2 years. Immediate and long-term complications were assessed. Aesthetic and functional results were analyzed and related to the quality of life and length of hospitalization. RESULTS: Vulvoperineal reconstruction was carried out in 6 patients who had undergone radical surgery. For reconstruction we used the sulcus gluteus flap in 4 unilateral cases and in 2 bilateral cases, for a total of 8 flaps. Cutaneous flaps of the sulcus gluteus provided good functional and aesthetic results. All flaps survived. There was no flap necrosis. The average length of hospitalization was 4 days. Complications were 2 breakdowns of the wound and 1 lymphocele. Postoperative discomfort was minimum. Patients were allowed to walk on day 6 and to sit on day 15. CONCLUSION: The advantages of this reconstruction are that it: is useful in cases of lymphadenectomy, is sensitive and maintains innervation, is distant enough from the receptor area to be used for large vulvar lesions, is able to hide the scar from the donor area in the sulcus gluteus, has a low complication rate, has a short hospitalization time and provides very good compliance with follow-up.

A rare cause of severe dyspareunia: post-osteomalacic contracted pelvic outlet.
Dane C, Dane B, Kural C
Acta Obstet Gynecol Scand 2005 Apr;84(4):407-8.

Sjogren's syndrome diagnosed in pregnancy: a case report.
Aslan E, Tarim E, Kilicdag E, Simsek E
J Reprod Med 2005 Jan;50(1):67-70.

BACKGROUND: As in most other autoimmune diseases, Sjogren's syndrome is seen predominantly in women. Since the peak age is around the late reproductive and early postmenopausal period, the obstetric aspect has not been well studied. CASE: A 28-years-old woman, pregnant for 22 weeks and 5 days, was admitted with worsening general status, skin lesions, arthralgias, and oral and ocular symptoms typical of Sjogren's syndrome. She underwent hemodialysis for renal insufficiency. To prevent autoantibody formation, progression of the disease, therapy with methyl prednisolone, 100 mg/d intravenously; cyclophosphamide, 500 mg/month in a single intravenous application; hemodialysis 3 times a week; and plasmapheresis 7 times was instituted. An 1,100-g, male infant at 27 weeks and 5 days was delivered by cesarean section because of premature preterm rupture of membranes and severe late decelerations on cardiotocography. The infant was discharged from the neonatal intensive care unit after 30 days, weighing 1,800 g. Postnatal echocardiographic examination of the infant revealed neither cardiac malformations nor arrythmias. CONCLUSION: Since the presence of autoantibodies against SS-A and SS-B are reported to accompany congenital heart block, the primary goal of therapy should be preventing this untoward effect of the disease. Close monitoring during pregnancy is mandatory to detect preeclampsia, intrauterine growth retardation and preterm labor.

Novel modification of the vertical rectus abdominis myocutaneous flap for neovagina creation.
Sood AK, Cooper BC, Sorosky JI, Ramirez PT, Levenback C
Obstet Gynecol 2005 Mar;105(3):514-8.

OBJECTIVE: We describe a modification of the traditional vertical rectus abdominis myocutaneous flap for neovagina creation and our experience to date. METHODS: Our modified vertical rectus abdominis myocutaneous flap uses a smaller flap size with a full-thickness skin graft posteriorly to decrease the size of the abdominal wall defect. We have used the modified vertical rectus abdominis myocutaneous flap in 18 patients between March 1998 and March 2004 to create a neovagina after exenterative surgery. RESULTS: The mean age of the patients was 54 years, and the mean body mass index was 27 (range 18-44). Twelve patients underwent a total pelvic, 5 anterior, and 1 posterior exenteration. Among the 13 patients requiring a colostomy, the vertical rectus abdominis myocutaneous flap was taken from the contralateral side. In these patients, the urostomy was brought out on the vertical rectus abdominis myocutaneous flap donor side. There has been only 1 partial flap loss, which eventually resulted in a fully epithelialized neovagina. Eight patients at last follow-up were sexually active. Two other patients have died from recurrent disease, and 2 are alive with recurrence. The other 6 patients have no evidence of recurrent disease and, although not sexually active at the time of this report, have a viable and adequate neovagina. All patients had a successful primary closure of the abdominal wound in a vertical fashion. Three patients had superficial abdominal wound breakdown, which healed by secondary intention. CONCLUSION: The modified vertical rectus abdominis myocutaneous flap allows for creation of an adequate neovagina with a smaller abdominal wall defect. LEVEL OF EVIDENCE: II-3.

Birth simulator: Reliability of transvaginal assessment of fetal head station as defined by the American College of Obstetricians and Gynecologists classification.
Dupuis O, Silveira R, Zentner A, Dittmar A, Gaucherand P, Cucherat M, Redarce T, Rudigoz RC
Am J Obstet Gynecol 2005 Mar;192(3):868-74.

Objective This study was undertaken to investigate the reliability of transvaginal assessment of fetal head station by using a newly designed birth simulator. Study design This prospective study involved 32 residents and 25 attending physicians. Each operator was given all 11 possible fetal stations in random order. A fetal head mannequin was placed in 1 of the 11 American College of Obstetricians and Gynecologists (ACOG) stations (-5 to +5) in a birth simulator equipped with real-time miniaturized sensor. The operator then determined head position clinically using the ACOG classification. Head position was described as: (1) "engaged" or "nonengaged" (engagement code); (2) "high," "mid," "low," or "outlet" (group code); and (3) according to the 11 ACOG ischial spine stations (numerical code). Errors were defined as differences between the stations given by the sensor and by the operator. We determined the error rates for the 3 codes. Results "Numerical" errors occurred in 50% to 88% of cases for residents and in 36% to 80% of cases for attending physicians, depending on the position. The mean "group" error was 30% (95% CI 25%-35%) for residents and 34% (95% CI 27%-41%) for attending physicians. In most cases (87.5% for residents and 66.8% for attending physicians) of misdiagnosis of "high" station, the "mid" station was retained. Residents and attending physicians made an average of 12% of "engagement" errors, equally distributed between false diagnosis of engagement and nonengagement. Conclusion Our results show that transvaginal assessment of fetal head station is poorly reliable, meaning clinical training should be promoted. The choice not to perform vaginal delivery when the fetus is in the "mid" position strongly decreases the risk of applying instruments on an undiagnosed "high" station. Conversely, obstetricians who perform only "low" operative vaginal deliveries also deliver unrecognized "mid" station fetuses. Therefore, residency programs should offer training in "mid" pelvic operative vaginal deliveries. Birth simulators could be used in training programs.

The vacuum expandable condom mold for reconstruction of the vagina.
Bhathena HM
Plast Reconstr Surg 2005 Mar;115(3):973; author reply 973.

Prophylactic antibiotic administration prior to hysterectomy: a quality improvement initiative.
DiLuigi AJ, Peipert JF, Weitzen S, Jamshidi RM
J Reprod Med 2004 Dec;49(12):949-54.

OBJECTIVE: To determine whether institution of a preoperative antibiotic policy could increase the use of prophylactic antibiotics prior to hysterectomy. STUDY DESIGN: A retrospective cohort study of 400 women who underwent abdominal, vaginal or laparoscopic hysterectomy for benign indications at Women and Infants Hospital was performed. Rates and timing of prophylactic preoperative antibiotic administration were determined, as were the rates of postoperative febrile morbidity. These data were compared to data collected in a medical record review of 686 hysterectomies performed prior to institution of the antibiotic policy. RESULTS: Prior to the institution of the antibiotic policy, 50% of patients (342/686, 95% CI 46.0, 53.7) received prophylactic preoperative antibiotics. After introduction of the antibiotic policy, 91.2% (95% CI 88.0, 93.8) of patients received prophylactic preoperative antibiotics. Approximately 66% of the antibiotics were administered within the 60 minutes preceding the surgical incision. Postoperative febrile morbidity was noted in 14% of patients prior to the antibiotic policy as compared to 11% of patients after the policy was instituted. Abdominal surgical approach was found to be a clinically and statistically significant risk factor for febrile morbidity (OR = 7.0; 95% CI 2.3, 20.9). CONCLUSION: Rates of prophylactic preoperative antibiotic administration significantly increased after institution of a hospital policy advocating routine antibiotic prophylaxis prior to hysterectomy. Additional steps must be taken to ensure more routine and appropriately timed administration of antibiotics prior to hysterectomy and to continuously monitor the use of prophylactic antibiotics.

Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists.
Wu JM, Hundley AF, Visco AG
Obstet Gynecol 2005 Feb;105(2):301-6.

OBJECTIVE: To compare the attitudes of urogynecology and maternal-fetal medicine specialists in the United States regarding elective primary cesarean delivery. METHODS: A Web-based questionnaire was sent by e-mail to members of the American Urogynecologic Society (AUGS) and the Society for Maternal-Fetal Medicine (SMFM) who reside in the United States. The first e-mail was sent in October 2003, and 2 additional e-mails were sent to nonresponders over the next month. The survey included questions about demographics, practice patterns, and opinions about different clinical scenarios regarding elective primary cesarean delivery. RESULTS: Of 1,479 surveys sent to functioning e-mail addresses, 782 were completed (52.9% response rate). American Urogynecologic Society and Society for Maternal-Fetal Medicine members were similar in response rate (53.0% versus 52.8%, respectively). Overall, 65.4% of physicians would perform an elective cesarean delivery, but AUGS members were significantly more likely to agree to perform an elective cesarean than SMFM members (80.4% versus 55.4%, respectively, P < .001). In a logistic regression model that included age, sex, having no children, years in practice, and subspecialty (urogynecology or maternal-fetal medicine), AUGS members were 3.4 times (95% confidence interval 2.3-4.9, P < .001) more likely to agree to perform an elective cesarean. CONCLUSION: Among respondents, a majority of urogynecology and maternal-fetal medicine specialists surveyed would perform an elective primary cesarean delivery. Urogynecologists were significantly more likely to support elective cesareans. LEVEL OF EVIDENCE: II-3.

Chronic ectopic pregnancy diagnosed incidentally in an infertile woman: a case report.
Di Sardo AS, Mastrogamvrakis G, Taylor A, Sharma M, Buck L, Magos A
J Reprod Med 2004 Dec;49(12):992-6.

BACKGROUND: Chronic ectopic pregnancy is an enigma. The clinical presentation can be mild, with absent or subtle symptoms. The high incidence of negative pregnancy tests and the poor specificity of sonographic patterns can be misleading, and the correct diagnosis is sometimes established only at surgery or even histopathologically after the operation. We report the first case of a woman who was accidentally diagnosed with chronic ectopic pregnancy during diagnostic laparoscopy performed as part of a routine investigation for primary infertility. CASE: A 28-year-old woman underwent laparoscopyfor infertility. She had a regular menstrual cycle and was asymptomatic. She gave a history of a possible but unconfirmed miscarriage earlier. Her hormone profile was normal apart from a slightly raised prolactin level. An earlier ultrasound showed a polycystic appearance of the ovaries. Laparoscopy was done on the 25th day of the menstrual cycle, and beta-human chorionic gonadotropin was negative. At laparoscopy, a 2-cm mass wasfound in the right fallopian tube. There was no free blood in the pelvis, and no adhesions. Both tubes were patent at hydrotubation. The mass was excised laparoscopically, and histology confirmed a diagnosis of chronic ectopic pregnancy. CONCLUSION: A review of articles on chronic ectopic pregnancy confirmed the difficulty in diagnosing this condition preoperatively.

The rectus abdominis musculoperitoneal flap for the immediate reconstruction of partial vaginal defects.
Wu LC, Song DH
Plast Reconstr Surg 2005 Feb;115(2):559-62.

French L
Am Fam Physician 2005 Jan 15;71(2):285-91.

Dysmenorrhea is the leading cause of recurrent short-term school absence in adolescent girls and a common problem in women of reproductive age. Risk factors for dysmenorrhea include nulliparity, heavy menstrual flow, smoking, and depression. Empiric therapy can be initiated based on a typical history of painful menses and a negative physical examination. Nonsteroidal anti-inflammatory drugs are the initial therapy of choice in patients with presumptive primary dysmenorrhea. Oral contraceptives and depo-medroxyprogesterone acetate also may be considered. If pain relief is insufficient, prolonged-cycle oral contraceptives or intravaginal use of oral contraceptive pills can be considered. In women who do not desire hormonal contraception, there is some evidence of benefit with the use of topical heat; the Japanese herbal remedy toki-shakuyaku-san; thiamine, vitamin E, and fish oil supplements; a low-fat vegetarian diet; and acupressure. If dysmenorrhea remains uncontrolled with any of these approaches, pelvic ultrasonography should be performed and referral for laparoscopy should be considered to rule out secondary causes of dysmenorrhea. In patients with severe refractory primary dysmenorrhea, additional safe alternatives for women who want to conceive include transcutaneous electric nerve stimulation, acupuncture, nifedipine, and terbutaline. Otherwise, the use of danazol or leuprolide may be considered and, rarely, hysterectomy. The effectiveness of surgical interruption of the pelvic nerve pathways has not been established.

Bacterial Vaginosis and Risk of Pelvic Inflammatory Disease.
Ness RB, Hillier SL, Kip KE, Soper DE, Stamm CA, McGregor JA, Bass DC, Sweet RL, Rice P, Richter HE
Obstet Gynecol Surv 2005 Feb;60(2):99-100.

This multicenter study was conducted to investigate the association of pelvic inflammatory disease (PID) and bacterial vaginosis. Participants were recruited from women who were attending family planning, health, gynecology, and sexually transmitted disease (STD clinics in 5 medical centers. Eligible patients were women not seeking care for STD, but who were considered at high risk for acquiring STDs according to an algorithm that weighed age, race parity, number of sexual partners, habit of douching, and a history.The vaginal swabs were self-collected. Participating patients were instructed in the use of a cotton swab to collect their vaginal specimens. At intervals of 6 to 12 months, the self-obtained specimens were examined for the characteristics of bacterial vaginosis. A vaginal microflora gram stain score of 7 to 10 was considered bacterial vaginosis. Women who developed pelvic pain or who were positive for Neisseria gonorrhoeae or Chlamydia trachomatis underwent a clinical examination and endometrial biopsy for detection of PID. A diagnosis of PID required the presence of histologic endometritis and/or pelvic pain and tenderness accompanied by either a fever of 101 degrees F or higher, sedimentary rate greater than 15 mm/hr, elevated white blood count, or leukorrhea, mucopus, N. gonorrhea, or C. trachomatis in the lower genital tract.There were 1179 patients included in the analysis. The average follow up was 4 years. At the initial examination, 428 women had normal vaginal flora (36%), 280 had intermediate flora (29%), and 471 had bacterial vaginosis (40%). The baseline diagnosis was not associated with the rate of detection of PID over the 4 years of follow up. Nor was the development of PID significantly associated with age, race, education, income, smoking, sex during menses, condom use, or a history of STD or PID. Analyses according to various subgroups of patients (younger/older women, black/white women, women with/without a history of PID, with/without baseline gonococcal or chlamydia genital infection) found that only women who had a baseline report of 2 or more sexual partners in the previous 2 months and who had a baseline diagnosis of bacterial vaginosis were significantly more likely to have PID.An absence of hydrogen peroxide-producing lactobacillus was not associated with PID, even among the various subgroups. A baseline diagnosis of G. vaginalis or Gram-negative rod growth above 4 had no association with PID except in the subgroup of women who reported 2 or more sexual partners in the previous 2 months.Women with baseline diagnoses of N. gonorrhea or C. trachomatis were more likely to have PID.