- Combination of noninvasive methods in diagnosis of infertile women with minimal or mild endometriosis, a retrospective study in China. [Journal Article]Medicine (Baltimore) 2019; 98(31):e16695M
- This study means to investigate a combination of noninvasive methods in diagnosis of minimal or mild endometriosis expecting to narrow down the range of laparoscopic exploration for female infertility.It is a retrospective case control study of totally 447 patients suspected unexplained infertility before surgery were eligible from May 2012 to February 2017. Of these, 299 patients were laparoscop…
This study means to investigate a combination of noninvasive methods in diagnosis of minimal or mild endometriosis expecting to narrow down the range of laparoscopic exploration for female infertility.It is a retrospective case control study of totally 447 patients suspected unexplained infertility before surgery were eligible from May 2012 to February 2017. Of these, 299 patients were laparoscopy-proved minimal or mild endometriosis group, the remaining 148 patients served as control group (normal pelvis). Preoperative age, duration of infertility, type of infertility, body mass index, baseline follicle-stimulating hormone, anti-Müllerian hormone, serum CA125, clinical symptoms, findings on vagino-recto-abdominal examinations and pregnancy prognosis had been recorded. Every variable and their combinations were evaluated.Any single factor had limited diagnostic value. The cut-off value for CA125 was 19.25 IU/L. Parallel testing had a higher sensitivity at 81.3%. Serial tests of vagino-recto-abdominal examination combined with dysmenorrhea or positive CA125 got reasonable sensitivity (51.4% and 49%), remarkable high specificities (95.7% and100%) and Positive Predictive Value (96.4% and 100%). Multivariate logistic regression identified the following factors in decreasing order of importance: (1) vagino-recto-abdominal examinations, (2) CA125, (3) dysmenorrhea, their ORs being 16.148, 3.796, and 2.809, respectively. The spontaneous pregnancy rate (50.8%) in minimal or mild endometriosis was higher than control (35.6%, P = .043).A combination of noninvasive diagnostic methods had certain preoperative diagnostic value of minimal or mild endometriosis, which might benefit some patients from avoiding laparoscopic surgery.
- StatPearls: Stages of Labor [BOOK]StatPearls Publishing: Treasure Island (FL)BOOK
- Stages of Labor Labor is the process through which a fetus and placenta are delivered from the uterus through the vagina. Human labor divides into three stages. The first stage is further divided into two phases. Successful labor involves three factors, which include maternal efforts and uterine contractions, fetal characteristics, and pelvic anatomy. This triad is classically referred to a…
Stages of Labor Labor is the process through which a fetus and placenta are delivered from the uterus through the vagina. Human labor divides into three stages. The first stage is further divided into two phases. Successful labor involves three factors, which include maternal efforts and uterine contractions, fetal characteristics, and pelvic anatomy. This triad is classically referred to as the passenger, power, and passage. Labor is typically monitored by multiple modalities. Serial cervical examinations are used to determine cervical dilation, effacement, and fetal position, also known as the station. Fetal heart monitoring is employed nearly continuously to asses fetal well-being throughout labor. Cardiotocography is used to monitor the frequency and adequacy of contractions. Medical professionals use the information they obtain from monitoring and cervical exams to determine the stage of labor of the patient and to monitor labor progression. Initial Evaluation and Presentation of Labor Women will often self-present to obstetrical triage with concern for the onset of labor. Common chief complaints include painful contractions, vaginal bleeding/bloody show, and leakage of fluid from the vagina. It is up to the clinician to determine if the patient is in labor, defined as regular, clinically significant contractions with an objective change in cervical dilation and/or effacement. When women first present to the labor and delivery unit, vital signs, including temperature, heart rate, oxygen saturation, respiratory rate, and blood pressure, should be obtained and reviewed for any abnormalities. The patient should be placed on continuous cardiotocographic monitoring to ensure fetal wellbeing. The patient's prenatal record, including obstetric history, surgical history, medical history, laboratory, and imaging data, should undergo review. Finally, a history of present illness, review of systems, and physical exam, including a sterile speculum exam, will need to take place. During the sterile speculum exam, clinicians will look for signs of rupture of membranes such as amniotic fluid pooling in the posterior vaginal canal. If the clinician is unsure about whether or not a rupture of membranes has occurred additional testing such as pH testing, microscopic exam looking for ferning of the fluid, or laboratory testing of the fluid can be the next step. Amniotic fluid has a pH of 7.0 to 7.5, which is more basic than that of normal vaginal pH. A sterile gloved exam should be done to determine the degree of cervical dilation and effacement. The measurement of cervical dilation is made by locating the external cervical os and spreading one's fingers in a ‘V’ shape and estimating the distance in centimeters between the two fingers. Effacement is measured by estimating the percentage remaining of the length of the thinned cervix compared to the uneffaced cervix. During the cervical exam, confirmation of the presenting fetal part is also necessary. Bedside ultrasound can be employed to confirm the presentation and position of the fetal presenting part. Particular mention should be noted in the case of breech presentation due to its increased risks regarding fetal morbidity and mortality compared with the cephalic presenting fetus. Management of Normal Labor Labor is a natural process, but it can suffer interruption by complicating factors, which at times necessitate clinical intervention. The management of low-risk labor is a delicate balance between allowing the natural process to proceed while limiting any potential complications. During labor, cardiotocographic monitoring is often employed to monitor uterine contractions and fetal heart rate over time. Clinicians monitor fetal heart tracings to evaluate for any signs of fetal distress that would warrant intervention as well as the adequacy or inadequacy of contractions. Vital signs of the mother are taken at regular intervals and whenever there is a concern for change in clinical status. Laboratory testing often includes the hemoglobin, hematocrit, and platelet count and are sometimes repeated following delivery if significant blood loss occurs. Cervical exams are usually performed every 2 to 3 hours unless concerns arise and warrant more frequent exams. Frequent cervical exams are associated with a higher risk of infection, especially if a rupture of membranes has occurred. Women should be allowed to ambulated freely and change positions if desired.  An intravenous catheter is typically inserted in case it is necessary to administer medications or fluids. Oral intake should not be withheld. If the patient remains without food or drink for a prolonged period of time intravenous fluids should be considered to help replace losses, but do not need to be used continuously on all laboring patients. Analgesia is offered in the form of intravenous opioids, inhaled nitrous oxide, and neuraxial analgesia in those who are appropriate candidates. Amniotomy is considered as needed for fetal scalp monitoring or labor augmentation, but its routine use should be discouraged.  Oxytocin may be initiated to augment contractions found to be inadequate. First Stage of Labor The first stage of labor begins when labor starts and ends with full cervical dilation to 10 centimeters. Labor often begins spontaneously or may be induced medically for a variety of maternal or fetal indications. Methods of inducing labor include cervical ripening with prostaglandins, membrane stripping, amniotomy, and intravenous oxytocin. Although precisely determining when labor starts may be inexact, labor is generally defined as beginning when contractions become strong and regularly spaced at approximately 3 to 5 minutes apart. Throughout pregnancy, women may experience painful contractions which do not lead to cervical dilation or effacement, referred to as false labor. Thus, defining the onset of labor often relies on retrospective or subjective data. Friedman et al were some of the first to study labor progress and defined the beginning of labor as starting when women felt significant and regular contractions. He graphed cervical dilation over time and determined that normal labor has a sigmoidal shape. Based on the analysis from his labor graphs, he proposed that labor has three divisions. First, a preparatory stage marked by slow cervical dilation, with large biochemical and structural changes. This is also known as the latent phase of the first stage of labor. Second, a much shorter and rapid dilational phase, which is also known as the active phase of the first stage of labor. Third, a pelvic division phase, which takes place during the second stage of labor. The first stage of labor is further subdivides into two phases, which are defined by the degree of cervical dilation. The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. Cervical effacement refers to the cervical length in the anterior-posterior plane. When the cervix is completely thinned out and no length is left, this is referred to as 100 percent effacement. Station of the fetus is defined relative to its position in the maternal pelvis. When the bony fetal presenting part is aligned with the maternal ischial spine, the fetus is 0 station. Proximal to the ischial spines are stations -1 centimeter to -5 centimeters, and distal to the ischial spines is +1 to +5 station. The first stage of labor contains a latent phase and an active phase. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women respectively, without being considered prolonged. Sedation can increase the duration of the latent phase of labor. In the active phase, the cervix changes more rapidly and predictably until it reaches 10 centimeters and cervical dilation and effacement are complete. Active labor with more rapid cervical dilation generally starts around 6 centimeters of dilation. During the active phase, the cervix typically dilates at a rate of 1.2 to 1.5 centimeters per hour. Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation. The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions is considered the arrest of labor and may warrant clinical intervention. Second Stage of Labor The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. The fetus passes through the birth canal via 7 movements known as the cardinal movements. These include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. In women who have delivered vaginally previously, whose bodies have acclimated to delivering a fetus, the second stage may only require a brief trial, whereas a longer duration may be required for a nulliparous female. In parturients without neuraxial anesthesia, the second stage of labor typically lasts less than three hours in nulliparous women and less than two hours in multiparous women. In women who receive neuraxial anesthesia, the second stage of labor typically lasts less than four hours in nulliparous women and less than three hours in multiparous women. If the second stage of labor lasts longer than these parameters, then the second stage is considered prolonged. Several elements may influence the duration of the second stage of labor including fetal factors such as fetal size and position, or maternal factors such as pelvis shape, the magnitude of expulsive efforts, comorbidities such as hypertension or diabetes, age, and history of previous deliveries. Third Stage of Labor The third stage of labor commences when the fetus is delivered and concludes with the delivery of the placenta. Separation of the placenta from the uterine interface is hallmarked by three cardinal signs including a gush of blood at the vagina, lengthening of the umbilical cord, and a globular shaped uterine fundus on palpation. Spontaneous expulsion of the placenta typically takes between 5 to 30 minutes. A delivery time of greater than 30 minutes is associated with a higher risk of postpartum hemorrhage and may be an indication for manual removal or other intervention. Management of the third stage of labor involves placing traction on the umbilical cord with simultaneous fundal pressure to effect faster placental delivery.
- Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker. [Journal Article]Eur Radiol 2019ER
- CONCLUSIONS: JZmax was not correlated with adenomyosis in the present premenopausal study population, but direct signs of adenomyosis such as irregularities of the JZ provided a good diagnostic accuracy.• Measuring the junctional zone thickness is of limited value for diagnosing adenomyosis with MRI and should not be used for diagnosing adenomyosis in premenopausal women with moderate disease severity. • An irregular appearance of the junctional zone, the presence of myometrial cysts, and adenomyoma appear to provide the highest specificity for diagnosing adenomyosis. • A consensus for the definition and reading of the junctional zone is needed.
- [Pelvic inflammatory diseases: Microbiologic diagnosis - CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]. [Journal Article]Gynecol Obstet Fertil Senol 2019; 47(5):409-417GO
- To determine the microorganisms potentially involved in pelvic inflammatory diseases (PIDs) and the different diagnostic methods of PID.
To determine the microorganisms potentially involved in pelvic inflammatory diseases (PIDs) and the different diagnostic methods of PID.
- Mini-invasive transvaginal repair of isthmocele: a video case report. [Case Reports]Fertil Steril 2019; 111(4):828-830FS
- CONCLUSIONS: Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.
- Severe forms of complete androgen insensitivity syndrome caused by a p.Q65X novel mutation in androgen receptor: Clinical manifestations, imaging findings and molecular genetics. [Journal Article]Steroids 2019; 144:47-51S
- Androgen insensitivity syndrome (AIS), a rare X-linked recessive genetic disorder with a normal 46, XY karyotype, is caused by defect of androgen receptor gene (AR) leading to resistance of the target tissues to androgenic hormones. There is a wide spectrum of clinical presentations of AIS, ranging from male infertility, hypospadias to completely normal female external genitalia. Here, we describ…
Androgen insensitivity syndrome (AIS), a rare X-linked recessive genetic disorder with a normal 46, XY karyotype, is caused by defect of androgen receptor gene (AR) leading to resistance of the target tissues to androgenic hormones. There is a wide spectrum of clinical presentations of AIS, ranging from male infertility, hypospadias to completely normal female external genitalia. Here, we describe a 15-year old, phenotypically female individual, who visited our clinic for primary amenorrhea. The physical examination revealed normal female external genitalia, normal breast development, as well as sparse pubic hair and absence of axillary hair. A short blind vagina pouch was noticed in gynecological examination apart from the absence of cervix and uterus. Serum testosterone measured a considerable high level, and the karyotype was indicative of a normal male (46, XY). Transabdominal ultrasound (US) and magnetic resonance imaging (MRI) confirmed the absence of uterus, ovaries and fallopian tubes, only with a small blind-ending vagina observed. The clinical, laboratory, imaging, and genetic findings strongly suggest the diagnosis of complete androgen insensitivity syndrome (CAIS). Mutational analysis of the AR gene revealed a novel small insertion mutation c.192_193insTAGCAG(Q65X) in exon 1, which gives rise to a truncated nonfunctional protein, resulting in the loss of the remaining 856 C-terminus amino acid residues. This study indicates that US and MRI are two useful and noninvasive imaging methods for the diagnosis and evaluation of CAIS, and identification of this novel mutation expands the database of AR gene mutations. Furthermore, with the availability of the identification technology for this mutation, prenatal diagnosis could be offered for future pregnancies.
- A sonographic classification of adenomyosis: interobserver reproducibility in the evaluation of type and degree of the myometrial involvement. [Journal Article]Fertil Steril 2018; 110(6):1154-1161.e3FS
- CONCLUSIONS: Our new scoring system for uterine adenomyosis is reproducible and could be useful in clinical practice. The standardization of the transvaginal approach and of the sonographer training represent a crucial point for a correct diagnosis of myometrial disease.
- Extrapelvic endometriosis in abdominal wall scar and PPAR gamma expression: A case report. [Journal Article]Int J Surg Case Rep 2018; 53:66-69IJ
- CONCLUSIONS: The endometriosis findings on the abdominal wall are rare cases. Symptoms usually are cyclic pain which is also accompanied by a palpable lump. A meta-analysis of 16 studies concluded that sensory excitatory threshold and pain tolerance approached the lowest value shortly before and during menstruation. In humans, administration of PPARy agonists reduced pain symptoms. Counseling to patients is given about the possibility of recurrence.PPAR expressivity assessment has not been used as a target for endometriosis therapy. Further studies separating epithelial tissue and stroma can be performed to prove the role of PPARγ in the pathogenesis of endometriosis.
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- Evaluation of Efficacy of Transvaginal Sonography with Hysteroscopy for Assessment of Tubal Patency in Infertile Women Regarding Diagnostic Laparoscopy. [Journal Article]Adv Biomed Res 2018; 7:101AB
- CONCLUSIONS: TVS after HSC is an accurate diagnostic tool for examination of fallopian tubal patency in infertile women.