Posterior Fornix Research Articles

Anatomical distribution of endometriosis: Across-sectional analysis of transvaginal ultrasound in symptomatic patients.

The anatomical distribution of deep endometriosis (DE) is essential in treating patients with symptoms associated with the disease. There is an evidence gap in correlating clinical features and symptoms with disease patterns. The study aimed at determining DE anatomic distribution based on advanced transvaginal ultrasound and describe the relationship with symptoms obtained with the World Endometriosis Foundation Questionnaire. A cross-sectional study included 549 ultrasound results and 370 questionnaire responses between July 2018 and January 2021. Descriptive statistics are presented. Continuous variables were compared by a simple t-test and ANOVA and categorical variables by the chi-squared test. Logistic regression and R2 values summarised the relationship between positive ultrasound and possible predictor variables (software SAS version 9.4). The anatomical locations with signs of endometriosis on ultrasound were the right uterosacral ligament (USL) 23.3% (n=128), left USL 21.3% (n=117) and bowel 19.1% (n=105). Endometriomas in the right and left ovaries (14%, n=77, and 14.7%, n=81 respectively), superficial endometriosis in 15.5% (n=85), torus uterinus in 11.7% (n=64), Pouch of Douglas (POD) in 9.7% (n=53), rectovaginal septum in 4.2% (n=23), vaginal fornix in 3.5% (n=19). A negative 'sliding-sign' was noted in 25.3% (n=139), and ovarian medial immobility was noted frequently (left 20.2%, n=111 and right 16.9%, n=93). Dyspareunia, dysmenorrhoea, infertility and family history were associated with endometriosis lesions (P < 0.05). Prediction models based on symptomatology presented low discriminatory power. This large real-life cohort associating the description of the anatomical distribution of endometriosis as seen on advanced TVS in symptomatic patients confirmed that uterosacral ligaments, torus uterinus, ovaries and bowel represent the most common anatomical sites of endometriosis. Also, the dynamic abnormalities elicited via ultrasound, such as the uterus 'sliding-sign' and ovarian mobility, remain common. The knowledge of the general locations of identifiable endometriosis on ultrasound and the dynamic abnormalities is essential to sonologists and sonographers in implementing advanced TVS protocols to detect endometriosis. In addition, the different presentations of dyspareunia can be associated with USL and bowel endometriosis. Subfertility might also be associated with USL, ovarian and bowel endometriosis. Nevertheless, prediction models showed suboptimal results. Endometriosis is mainly distributed in USLs, bowel and ovaries. POD obliteration is frequent. Symptoms can be associated with anatomic locations; however, prediction models showed low clinical applicability.

Safety and Efficacy of Misoprostol for the Management of Early Pregnancy Loss: A Non-Randomized Clinical Trial

Background: Management of early pregnancy loss is very crucial for the safety of women.&#x0D; Objective: The purpose of the present study was to see the safety and efficacy of misoprostol for the management of early pregnancy loss.&#x0D; Methodology: This non-randomized clinical trial was conducted in the Department of Obstetrics and Gynaecology in Shaheed Ziaur Rahman Medical College Hospital, Bogra, Bangladesh from January 2007 to December 2007 for a period of 12 months. Women with early pregnancy loss who were fulfilling the selection criteria were selected as the study population during the study period. On admission all women were received a vaginal administration of 800 μg misoprostol by digital insertion into the posterior fornix through a speculum (4 tablets of 200 μg misoprostol). The interval between administration of misoprostol and expulsion of product of conception was recorded. After 7 days (8th day) they were instructed to come to the hospital to see the completeness of expulsion of product of conception by ultrasonography. If sonography shows incomplete expulsion then surgical evacuation was done. Every woman were advised to come for follow-up on 15th day. Results: A total of 200 women with first-trimester pregnancy loss were non-randomly assigned to give treatment with misoprostol. The mean with the SD of the study population was 24.95±4.17 years. In most cases expulsion occurred within 24 hours of application of misoprostol, 142(71.0%) cases completed expulsion within 48 hours, 168(84.0%) cases within 7 days, 170(85.0%) cases out of 200 cases completed expulsion occurred. Complete evacuation after the first dose was in 142(71.0%) cases and remained incomplete was 58(29.0%) cases. After administration of the second dose (85.0%) complete evacuation occurred and 30(15.0%) cases remained complete that needed surgical evacuation. Analysis was reveled statistically significant (P&lt;0.05). Vaginal misoprostol treatment appeared to be well tolerated. Only few percent shows mild side effects. About 190(95.0%) cases required no blood transfusion. Conclusion: In conclusion the efficacy of misoprostol for the management of early pregnancy loss gives a good results with minimum adverse events.&#x0D; Journal of National Institute of Neurosciences Bangladesh, July 2022;8(2):152-156

Abnormal white matter integrity in Papez circuit in first-episode medication-naive adults with anxious depression: A combined voxel-based analysis and region of interest study

BackgroundAnxious depression is one of the subtypes of major depressive disorder (MDD), usually defined as “patients with MDD and high levels of anxiety symptoms”. Compared to non-anxious MDD (naMDD), patients with anxious MDD (aMDD) have more severe depressive symptoms and suicidal ideation, worse treatment outcomes and remission rates, and poorer prognosis. Current research suggests that the Papez circuit is an important brain structure closely related to emotion, memory, and cognition. This study applied DTI to explore the altered white matter integrity in Papez circuit of patients with aMDD. MethodsDTI data were acquired from 30 medication-naive outpatients with naMDD and 55 with aMDD and 88 demographically similar healthy control (HC) subjects. Voxel-based analysis (VBM) and region of interest (ROI) analysis were conducted to explore the significant difference of fractional anisotropy (FA) values among 3 groups. Pearson's correlations were performed to analyze the correlation between FA values and the score of HAMA-14 and HAMD-17. ResultsWe found that aMDD patients had significantly higher FA values in left fornix (belong to Papez circuit) and left posterior thalamic radiation and right anterior corona radiata (belong to limbic-thalamo-cortical circuitry) compared with HC. And there was variability in the white matter integrity in right posterior thalamic radiation (belong to limbic-thalamo-cortical circuitry) and left fornix (belong to Papez circuit) between aMDD and naMDD patients. LimitationsThe cross-sectional study and the population vary between aMDD group and naMDD group are limitations. ConclusionsAbnormal white matter integrity in Papez circuit and Limbic-Thalamo-Cortical circuitry may play an important role in the neuropathology of aMDD and might help to identify aMDD.

Clinicoetiological study on vaginal discharge among sexually active women attending a tertiary center in North Kerala, India.

Vaginal discharge is a common complaint among women attending the sexually transmissible infections (STIs) clinic and is a cause for concern and mental distress. It can be attributed to physiological or pathological causes. This study aims to understand the prevalence of various etiologies of vaginal discharge, which would help frame health policies based on local needs. (1) To estimate the prevalence of discharge per vaginum among sexually active women attending the STI clinic at a tertiary care center during a 1-year period, (2) To identify the organisms causing vaginal discharge, (3) To have a clinicoetiological correlation of the cases, and (4) To identify the subspecies of Candida causing vaginal candidiasis. A total of 126 patients with vaginal discharge attending the STI clinic at a tertiary care center were included in the study. A detailed clinical history, physical examination of the external genitalia, and vaginal examination were done on each patient. Five swabs were taken from the posterior fornix and lateral vaginal wall for evaluation of the organisms. The mean age of the study population was 31.51 ± 7.9 years. Vulvovaginal candidiasis (VVC) was found to be the most common cause of vaginal discharge, followed by bacterial vaginosis, mucopurulent cervicitis, herpes genitalis, and trichomoniasis. The most common species of Candida was found to be Candida albicans. Even though VVC still remains the major cause, other viral infections like herpes significantly contribute. Vaginal discharge is an important indicator of women's reproductive health and its detailed evaluation helps identify the prevalence of various STIs in the community.

Detection of Creatinine in Vaginal Secretions of Women with Premature Rupture of Membranes in Third Trimester from Semiurban Population: A Cross-sectional Study

Introduction: Spontaneous rupture of the membranes any time beyond the 28th week of pregnancy but before the onset of labour is called Premature Rupture of Membranes (PROM). There are many techniques for diagnosing PROM that is based on both clinical assessments and biological studies. Each of these procedures has benefits and drawbacks. Since foetal urine is the major source of amniotic fluid, the presence of vagina and a high creatinine level may aid in the diagnosis of PROM. Aim: To determine the cut-off levels of serum creatinine in predicting the PROM. Materials and Methods: A cross-sectional study was conducted at Dr. DY Patil Medical College, Hospital and Research Centre in Pune, Maharashtra, India from June 1 2020 to June 5 2021. Two equal groups of 140 each pregnant women with gestational ages ranging from 28-42 weeks were created: one with a history of vaginal leaking (the study group, P), and the other with gestationally matched no leakage (the control group, C). Patient’s details such as age, gestational age, and obstetric history were noted. Each patient was examined and cervicovaginal secretions were collected. A 5 mL of saline was flushed in the posterior fornix of vagina. This fluid with vaginal wash was aspirated and creatinine concentration from vaginal fluid was determined by Jaffee synthetic chemical colorimetric method. The Student’s t-test and the Chi-square test were used to analyse the data. Results: The study group’s vaginal fluid creatinine level was substantially higher (p-value&lt;0.001). The cut-off value of 0.6 mg/dL had highest sensitivity 96.1% and specificity 100%. The area under the Receiver Operating Characteristics (ROC) curve was 0.917. The Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of serum creatinine at cut-off 0.6 mg/dL was 100% and 96.3% respectively. Conclusion: Vaginal fluid creatinine is simple and easily available, which makes it acceptable to the candidate for a diagnosis of PROM.

A study on the accuracy of a new fluorescent detection method for vaginal fungi

BackgroundTo investigate the positive rate and clinical applicability of liquid—based fungal method for detecting of vaginal fungi. We collect the secretions from the posterior vaginal fornix and the vaginal wall of 198 patients with clinically suspected fungi vaginitis patients for study.MethodsThe vaginal fungi of vaginal discharge were detected by fluorescence method, i.e., by liquid—based thin-layer fungi fluorescence morphology staining detection kit (liquid—based fungal method), saline smear method and fungal culture method.ResultsThe positive rate of liquid-based fungal method, saline smear method was 50%, 25.75% respectively. The positive rate of liquid-based fungal method were 50%. The true positive rate of liquid-based fungal method (87.85%) was higher than that of saline smear method (45.79%, P < 0.001), which was easy to miss diagnosis. Moreover, the Kappa (K) of liquid-based fungal method was 0.81, and P < 0.01, which was statistically significant, indicating that the consistency of the two detection methods is good. Of the eight common symptoms of fungal vaginitis, the positive symptom coincidence rate of liquid-based fungal method was consistent with that of fungal culture method. It was also easier to see fungi under a microscope than with saline smear method.ConclusionThe liquid-based fungal method has a high positive coincidence rate and accuracy in the detection of vaginal fungi, and it is convenient to operate and implement steps. Therefore, it may be applied in clinical practice. Or a combination of several detection methods can be used.

Microbiological safety of the Dr. Arabin cervical pessary in pregnant women with short cervix

BACKGROUND: The insertion of a cervical pessary is a method for treating short cervix and preventing preterm birth. The study of the vaginal microbiota composition and the need for its routine correction after the pessary insertion remain to be investigated. To date, there are no works devoted to the assessment of changes in vaginal microbiocenosis after the cervical pessary insertion.&#x0D; AIM: The aim of this study was to assess the microbiological safety of the Dr. Arabin cervical pessary in pregnant women with short cervix.&#x0D; MATERIALS AND METHODS: This prospective study included 22 pregnant women with singleton or multiple pregnancies with short cervix (25 L.J. Salomon scale) and threatened miscarriage in the second and third trimesters who received the Dr. Arabin cervical pessary. The obtained clinical materials included the secretion of the posterolateral vaginal fornix. We used the Femoflor 16 test (NPO DNA-Technology Ltd., Moscow, Russia) as a method of molecular biological analysis. In addition, the patients independently controlled the pH of the vaginal contents using the pH-balance express test. Vaginal microbiocenosis was assessed in a dynamic manner: before the cervical pessary insertion, then every two to four weeks after it, and on the day the pessary was removed. In all 22 pregnant women, clinical material was obtained twice: before the cervical pessary was inserted and when it was removed; in 15 women (68.18%) three times, and in nine pregnant women (40.91%) four times.&#x0D; RESULTS: The analysis of vaginal microbiocenosis showed no significant changes in vaginal microbiocenosis in the examined pregnant women before and after the insertion of the cervical pessary (p 0.05). The concentration of lactobacilli remained high (in the range of 107 lg DNA copies/ml) during the entire observation period. The numbers of facultative and obligate anaerobic bacteria, as well as yeast-like fungi of the Candida genus, Ureaplasma spp., and Mycoplasma hominis were within the physiological levels. No pathogenic microorganisms such as Mycoplasma genitalium were detected in any patient. After the cervical pessary insertion against the background of normocenosis, 72.73% of pregnant women noted an increase in the amount of light and odorless discharge from their genital tract. However, we found no changes in the vaginal microbiota composition.&#x0D; CONCLUSIONS: The insertion of the Dr. Arabin cervical pessary under conditions of vaginal normocenosis is a microbiologically safe way to correct short cervix and prevent preterm birth, and does not disrupt the vaginal microflora in pregnant women before delivery.

Risks of microbial colonization in newborn born to mothers with chorioamnionitis

BACKGROUND: Chorioamnionitis, or intra-amniotic infection, is an infection of the membranes and amniotic cavity caused by polymicrobial associations, including Streptococcus agalactiae (SGB), predominantly localised to the lower genital tract of women. The colonization of a infant with GBS occurs as a result of ascending infection from the mother, in the intranatal period during passage through the natural birth canal of the mother. Colonization of the skin and mucous membranes of the infant in the vast majority of cases proceeds without the clinical implementation of the infectious process, only 2-5% of infected newborns develop an infection associated with GBS.&#x0D; AIM: The aim of the study is to investigate the vaginal and uterine microflora in women with chorioamnionitis and to determine the degree of neonatal colonization.&#x0D; MATERIALS AND METHODS: A microbiological examination was undertaken in 113 motherchild pairs. Main group (group I): pregnant women with full-term pregnancy (37 weeks gestation) who were diagnosed with clinical chorioamnionitis and prescribed antibacterial agents, and their newborns (n = 77). Comparison group (group II): 36 pregnant women without clinical chorioamnionitis with a gestational age of 37 weeks gestation and their newborns with a physiological course of the early neonatal period. Clinical specimens: secretions from the posterior vaginal fornix and the inner surface of the uterine wall at surgical delivery in women in labour with clinical signs of chorioamnionitis (group I) and without clinical manifestations of chorioamnionitis (group II). Material was obtained at the height of body temperature in group I and during the 1st period of labour in group II. The clinical materials were umbilical cord blood, skin surface of the occipital fold, discharge from the cavity, and discharge from the tracheobronchial tree (in case of respiratory therapy with ventilator therapy).&#x0D; RESULTS: At bacteriological examination in women of Group I the frequency of microorganism isolation from the vaginal discharge was: Enterococcus faecalis 31.8%, S. agalactiae (SGB) 30.3% and Escherichia coli 24.2%. The proportion of SGB at 106 CFU/ml was 70%. The proportion of E. coli at 106 CFU/ml was 75% and that of Candida albicans 72%. Among microorganisms isolated from the uterine cavity, the proportion of SGB at 106 CFU/ml was 60%, E. coli 100%. Bacteriological testing of the examined children showed that S. agalactiae (SGB), E. faecalis and E. coli were isolated from almost all neonatal loci studied. Comparative studies have shown that the colonisation of newborn infants was most frequently caused by S. agalactiae (SGB), E. faecalis and E. coli. The frequency of maternal transmission of these organisms to the foetus and the newborn is 100% for S. agalactiae (SGB) and 1850% for E. faecalis and E. coli. In all examined children of the main group and with the presence of S. agalactiae (SGB) in the uterine cavity of their mothers (n = 5), these microorganisms were isolated from different loci (in all cases from the skin surface of the auricular fold and from oral discharge, and in three cases from umbilical cord blood), but clinical manifestations of the infection process did not develop in any child.&#x0D; CONCLUSIONS: Despite antibiotic therapy for chorioamnionitis in women, the incidence of micro-organism isolation from both the vagina and the uterine cavity remains high. In most cases, newborns from mothers with chorioamnionitis colonised with micro-organisms, including S. agalactiae (SGB), do not develop a clinical picture of an infective process. Further research is needed to develop preventive measures in terms of perinatal and neonatal infections.

Management of breech presentation with a large pelvic hydatid cyst in late pregnancy in Tibet: a case report

BackgroundHydatid cystic disease (HCD) is primarily a disease of sheep and cattle. Human beings are accidental hosts. It is prevalent in the Tibet Autonomous Region (TAR) of China. In pregnancy, it can cause many complications.Case presentationWe present a multigravida with breech presentation at 37 weeks of pregnancy in whom a large pelvic hydatid cyst and multiple hepatic hydatids were diagnosed by ultrasonography. The large pelvic hydatid cyst was drained through the posterior fornix under the guidance of ultrasound, and an external cephalic version was performed. A healthy baby was delivered vaginally with head presentation at term.ConclusionHCD during pregnancy presents with management difficulty. It is important to formulate individualized treatment plans according to the actual situation of the patient and the local level of treatment.

Like a rolling stone: Psychotherapy without (episodic) memory.

People with profound amnesia still retain the capacity to learn about the emotional value of experiences, which is crucial in developing and sustaining interpersonal relationships. In a 2017 paper, we demonstrated for the first time (with patient JL) that transferential feelings develop across the therapeutic process, despite profound episodic memory impairment after medial temporal lesions. This paper reports a second case (GA) of a profoundly amnesic patient in psychotherapy, this time after lesions to the anterior fornix. The work with GA opens issues such as the differences and similarities to the previous case, counter-transference phenomena, and the effects of hyperphagia. The findings make it clear that many phenomena are common to both GA and JL, such as forgetfulness, various types of repetition, the importance of the therapeutic alliance, and the ability to make therapeutic gain. However, there were differences between the cases, for example as regards confabulation, which may relate to either pre-morbid personality or lesion site. The paper also discusses the way in which patients of this type bear the very status of psychotherapeutic work with profoundly amnesic patients. Where others have seen barriers and in principle problems in working with such patients, we see many opportunities.

Laparoscopic Myomectomy of Vaginal Leiomyoma: A Video Case Report

<h3>Study Objective</h3> To demonstrate the surgical steps of a laparoscopic excision of a vaginal leiomyoma. <h3>Design</h3> We present a video of laparoscopic excision of a vaginal myoma. <h3>Setting</h3> Private hospital in Curitiba, Paraná, Brazil. <h3>Patients or Participants</h3> A 45 years-old woman, G2 P2, was referred to our outpatient clinic with a complaint of abdominal pain, frequent urination and nocturia over five months. She underwent vaginal hysterectomy one year earlier due to uterine myoma. On digital examination a round and firm mass was palpable in the left vaginal wall. Magnetic resonance imaging of abdomen and pelvis reported a solid tumor in the left side of vaginal fornix measuring 28 × 26 mm, located 2mm from ureter. The patient underwent a laparoscopic excision of the vaginal tumor. The post-operative histopathology confirmed leiomyoma. <h3>Interventions</h3> A laparoscopic myomectomy was recorded and presented in the video. <h3>Measurements and Main Results</h3> We described the main steps of laparoscopic myomectomy of vaginal leiomyoma. Step 1: Exposure of the operation field. Step 2: Incision and dissection with ultrasonic instrument of visceral peritoneum over the vaginal fornix and towards the rectovaginal space. Step 3: Vaginal opening and excision. Step 4: Dissection towards the leiomyoma to reach the cleavage plane. Step 5: Grasping and traction of the leiomyoma with a traumatic forceps to its enucleation and excision. Step 6: Extraction of leiomyoma through the vagina. Step 7: Vaginal closure with intracorporeal suturing in two layers: first with continuous suture, followed by a second layer with three X stitches of zero poliglecaprone 25. Step 8: Bipolar hemostasis. <h3>Conclusion</h3> The laparoscopic myomectomy of vaginal leiomyoma presented can be an effective and safe treatment due to the advantages of minimally invasive surgery. Our patient was previously hysterectomized, but laparoscopy is a prudent approach as well when necessary to undergo myomectomy of vaginal and uterine fibroids concomitantly.

Single Port Robotic Hysterectomy after the Previous Robotic Radical Trachelectomy

<h3>Study Objective</h3> The basic treatment for cervix cancer is hysterectomy. For nullipara women, trachelectomy may be considered. In this video, we described the technique of a single port robotic hysterectomy to a patient who underwent a multi-port robotic radical trachelectomy previously. <h3>Design</h3> Case Report. <h3>Setting</h3> Academic medical center. <h3>Patients or Participants</h3> This 32-year-old woman presented with a recurrence of cervical cancer. She had a history of robotic radical trachelectomy with pelvic lymphadenectomy for stage IA1 cervical cancer 9 years earlier. <h3>Interventions</h3> At first, we described the typical multi-port robotic radical trachelectomy which preserved the main uterine artery and round ligament. There was no recurrence in follow up MRI and colposcopy after the surgery. But in December 2021, her pap-smear revealed adenocarcinoma. MRI of the pelvis and PET CT were all normal. After careful consideration, our team used DaVinci SP system to perform the hysterectomy and BS. The operation was similar to a general hysterectomy, but there was an adhesion between the uterus and the ovary due to the previous operation. Although several branches of the uterine artery were ligated, the blood supply to the uterus was sufficient. The uterus and bladder also had moderate adhesion. After the colpotomy, the thread of cervical cerclage in the previous operation was confirmed. The subsequent procedure was similar to that of a typical hysterectomy. <h3>Measurements and Main Results</h3> The operation was performed successfully with no intraoperative complications. <h3>Conclusion</h3> Single port robotic hysterectomy after the previous robotic trachelectomy is a safe and effective approach for the recurrence of cervical cancer patients. There was some difficulty in finding the incision margin between the uterus ithmus and the upper vagina. The bladder and vagina fornix should be carefully dissected. The secondary assistant should push the colpotomizer in the same direction as the incision. Single port Robotics can help to overcome the limitations of laparoscopy, especially in complicated procedures.

Intraoperative Ultrasound Elastography Guided Rectal Shaving for Endometriosis

<h3>Study Objective</h3> Rectal surface endometriosis is more common in cases of cul-de-sac obstruction, and it is preferable in endometriosis surgery to remove as much of the deep endometriosis region as possible. The degree of rectal shaving may be confusing because the depth of the rectal superficial lesion cannot be assumed from the outside during surgery. For safe and appropriate resection, we attempted to confirm the location of the endometriosis lesion with intraoperative ultrasonography and elastography. <h3>Design</h3> Case report. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> A 23-years-old woman with dysmenorrhea diagnosed with left endometrioma and cul-de-sac obstruction by magnetic resonance imaging (MRI). <h3>Interventions</h3> Nerve-sparing endometriosis surgery including left ovarian cystectomy, cul-de-sac adhesiolysis, and deep endometriosis resection was planned. To evaluate the rectal surface endometriosis, a sterilized small ultrasound probe was inserted into the abdominal cavity through an abdominal trocar or small incision in the posterior vaginal fornix. Rectal surface fibrosis and the distance from the rectal muscularis were tried to be visualized with ultrasound elastography. <h3>Measurements and Main Results</h3> Intraoperative ultrasonography clearly indicated the safety distance from the rectal muscularis, and elastography showed hard fibrotic region on rectal surface with color visualization. There was no intra/post-operative complication. The pathological examination revealed the presence of endometriosis in the resected tissue. The visual analog scale (VAS) for dysmenorrhea was reduced from 70 to 10, and the VAS for dyspareunia was reduced from 50 to 0. <h3>Conclusion</h3> Intraoperative ultrasound elastography is considered to be a useful auxiliary means for safe rectal shaving by visualizing the fibrosis caused by endometriosis.

Upper Vaginectomy for Rectovaginal Endometriosis: Manual Guidance for Deep Rectovaginal Dissection

<h3>Study Objective</h3> The objective of this video is to demonstrate a robotic-assisted excision of a rectovaginal endometriosis nodule. <h3>Design</h3> This case involves a 31-year-old nulligravid patient with dysmenorrhea, dyschezia, and dyspareunia. <h3>Setting</h3> This surgery was performed at an academic tertiary care center. The patient was in the dorsal lithotomy position and the robot was docked from the patient's left side. <h3>Patients or Participants</h3> The patient had a palpable rectovaginal nodule, which was confirmed with magnetic resonance imaging. <h3>Interventions</h3> The patient underwent diagnostic laparoscopy which showed bilateral pelvic sidewall endometriosis and cul-de-sac obliteration. The ovaries and fallopian tubes were normal. Pelvic sidewall dissection with extensive peritoneal stripping was required to remove all of the endometriosis implants. Bilateral uterosacral ligaments were excised. Within the posterior cul-de-sac, the rectocervical nodule was not visible due to tethering of the rectum. The rectovaginal space was carefully dissected with monopolar scissors. Despite opening the left para-rectal space, the nodule was still not visible. An assistant placed a single digit into the posterior fornix to mobilize the nodule to guide the surgeon. The surgeon dissected the rectovaginal space until the fibrosis was visualized abdominally. Chocolate cyst fluid was expelled, consistent with deep infiltrating endometriosis. Full-thickness entry into the vagina was required, and the colpotomy was closed with running barbed suture. After complete excision of endometriosis, a flat-tire test was performed to confirm rectal integrity. The surgery was then completed. <h3>Measurements and Main Results</h3> The patient did well and was discharged home from the recovery room. She had significant improvement in her pain, and her recovery proceeded without complications. <h3>Conclusion</h3> This surgical video demonstrates the importance of careful pre-operative planning and intra-operative use of resources to accomplish complete excision of endometriosis. Surgeons often need to be creative when tissue planes are obscured, and the target pathology is not clearly visible.

Comparison of Conventional Treatment of Prom (Pre Labor Rupture of Membranes) with Active Treatment in Term Patients

Objectives: To compare outcome of conventional treatment of Pre labor rupture of membranes (PROM) with active treatment in term patients. Place and Duration: This study was Conducted in Family Medics Infertility and Maternity Centre Karachi from March 2022 till June 2022. Materials &amp; Methods: We conducted a randomized control trial on 74 registered patients who presented to the labor room with term pregnancy and with the ruptured membranes at thirty-seven weeks or more gestation verified from the last normal menstrual period or a dating scan. Two groups were randomized as either spontaneous labor or active management by Prostin.37 patients presented in Prelabour rupture of membranes were examined as per departmental policy and left for spontaneous labor and 37 women were actively managed by inserting Prostin in the posterior fornix. Main Outcomes Measured: The outcome of interest was intervention vs .non intervention regarding timespan between PROM and initiation of labour in respective groups. Secondary outcome included patients who did not respond to either conventional measures or active treatment and required caesarian section. Results: The time duration between rupture membrane and initiation of labour was less in intervention group as compared to conservative group (6.40hrs vs. 5.03hrs).The rates with respect to normal delivery or caesarian section were same in test and control groups (27 pts. vs. 25 pts.). There was no statistically significant difference regarding complication in both the arms in study. (P-value=0.967) Conclusion: The results of our study showed that there are no differences in outcomes of conservative management of PROM with that of active management. However, patients managed actively in intervention group delivered earlier as matched with patients with spontaneous management. Keywords: Term pregnancy, PROM, Spontaneous vaginal delivery, Emergency Cesarean section. The Registration number of the study specified by the university is JSMU/IRB/2022/-601.

A Case Report On Imperforated Hymen

At pubescence, a patient with a flawless hymen commonly gives a vaginal lump of flimsy hymeneal tissue with a dim or somewhat blue tone brought about by the hematocolpos behind it. Different discoveries that might be available incorporate stomach bulk, incontinence of urine, obstruction, and dysphasia. The objective of evaluation is to distinguish a perfect hymen from other blocking anatomical causes; such are the distal vaginal artesian, urogenital sinus, cross-over vaginal septum, and labial connections. Careful mediation is fundamental just in suggestive pre adolescent client. Following the declaration of the conclusion, Most of the time, careful intervening is permitted prior to pubertal estrogenization because the flawless hymen might open precipitously at pubescence. Finishing a stomach and a perinea examination is significant. Further imaging is not necessary if an ultrasound reveals hematocolpos and a genuine assessment shows a swollen hymen. Nonetheless, on the off chance that the results are uncertain or alternatively, A cross-over or longitudinal vaginal septum, immaculate or cervical arteriosclerosis, an obstructed uterine horn, or any of these conditions may be present, according to attractive reverberation imaging. The ideal time for careful mediation on hymnal tissue is before the beginning of agony and after the beginning of the pubertal turn of events when the vaginal tissue is nitrogenised. Careful administration of clinically critical hymnal varieties includes extraction of the hymeneal tissue and seldom is related to long-haul squeal. If the patient is concerned for whatever reason a cross-over vaginal septum or a distal vaginal artesian, the patient should have skilfully alluded to the middle in the treatment of these illnesses. A thin strip of stratified squamous epithelium called the hymen surrounds the vaginal introits. An imperforate hymen is one that does not spontaneously rupture throughout a new-born’s growth. The female genital and urinary systems may become obstructed during pregnancy, childhood, or adolescence due to an imperforate hymen, an uncommon reason for primary amenorrhea. When endogenous maternal oestrogen is stimulated in infants with the virginal membrane, a mucosal. The Müllerian duct and the urogenital sinus make up the transverse vaginal septum. Which is a remnant of the vaginal plate? The failure of the membrane among the urogenital sinuses and the vaginal cavity to perforate leads to an imperforate hymen. We describe a rare instance of these two situations coexisting. A 16-year-old woman was referred to our hospital after receiving multiple puncture therapies for hematomata and hematocolpos when she was 16 years old owing to her monthly incidence of lower abdomen discomfort without menstrual flow. The growth of the vaginal fornix, hematomata, and hematocolpos were seen on magnetic resonance imaging. The imperforate hymen was cut, and there was a little adhesion that could be detached at the lower vaginal cavity. After that, a 5 mm thick full transverse vaginal septum was found. After a puncture that was guided by ultrasonography, it was removed. Melamine persisted although there were two cycles of menstrual flow. Six months after the initial procedure, a second operation was carried out; when it was observed that there was once again adhesion in the lower vaginal cavity. She was given a silicon dilator but was unable to use it at home, so she substituted a tampon. Four months following the second operation, cyclical menstrual bleeding is seen.

The patterns of topographic and anatomical relations of the uterus and rectum in vivo

Objective. The aim is to identify patterns of lifetime topographic and anatomical relationships of the rectum and uterus based on magnetic resonance imaging data to justify transvaginal surgical access to the abdominal cavity through the posterior vaginal fornix.&#x0D; Material and methods. The study was performed on 58 results of MRI examinations of pelvis of women of average age 41.355.45 years on the EXCELART Vantage Atlas 1.5 TSL tomograph., Toshiba, using a standard combination of pulse sequences (in modes T1-VI, T2-VI, T-1 Fsat, T-2 Fsat, DWI, T-2 STIR, section thickness 3-5 mm) without I / V contrast in a moderately filled bladder using a standard combination of pulse sequences in typical (anteversio-anteflexio) and variant (retro, sinistro et dextrodeviatio uteri) positions of the uterus.&#x0D; Results. It was found that in more than half of cases, the supravaginal portion of the rectum, along with the sacral flexure, is supplemented by a flexure in the frontal plane. It causes close or distant anatomical location of the rectum to the uterus. This position of organs determines the shape of recto-uterine pouch and tactics of performing transvaginal accesses to the abdominal cavity through the posterior vaginal fornix. A narrow shape of excavation serves as a reason for refusal of interventions, a wide shape is a favorable anatomical prerequisite for the implementation. The vaginal portion of rectum is in most cases represented by a sacral flexure and only in a small number of cases it is supplemented by a flexure in the frontal plane.&#x0D; Conclusions. The degree of anatomical proximity of the rectum to the uterus (maximum anatomical proximity or distance), determines the shape of the recto-uterine pouch. It is crucial for performing transvaginal surgical access to the abdominal cavity through the posterior vaginal fornix.

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Clinical practice guidelines for endometriosis in Japan (The 3rd edition).

Brain structure and episodic learning rate in cognitively healthy ageing

Memory normally declines with ageing and these age-related cognitive changes are associated with changes in brain structure. Episodic memory retrieval has been widely studied during ageing, whereas learning has received less attention. Here we examined the neural correlates of episodic learning rate in ageing. Our study sample consisted of 982 cognitively healthy female and male older participants from the Vallecas Project cohort, without a clinical diagnosis of mild cognitive impairment or dementia. The learning rate across the three consecutive recall trials of the verbal memory task (Free and Cued Selective Reminding Test) recall trials was used as a predictor of grey matter (GM) using voxel-based morphometry, and WM microstructure using tract-based spatial statistics on fractional anisotropy (FA) and mean diffusivity (MD) measures. Immediate Recall improved by 1.4 items per trial on average, and this episodic learning rate was faster in women and negatively associated with age. Structurally, hippocampal and anterior thalamic GM volume correlated positively with learning rate. Learning also correlated with the integrity of WM microstructure (high FA and low MD) in an extensive network of tracts including bilateral anterior thalamic radiation, fornix, and long-range tracts. These results suggest that episodic learning rate is associated with key anatomical structures for memory functioning, motivating further exploration of the differential diagnostic properties between episodic learning rate and retrieval in ageing.

Striving for Egg-Cellence: Step-by-Step Guide to Oocyte Pick Up

Background: Oocyte pick up (OPU) involves the suction aspiration of ovarian follicles following controlled ovarian stimulation, via an ultrasound guided needle through the vaginal fornices 1 . There is international recognition of a lack of training tools in OPU, highlighting opportunity for technology and simulation to be further developed 1 . Aim: Here we provide a step-by-step approach to performing transvaginal ultrasound guided OPU with supporting video demonstration. Result: Interviews and procedural observation was undertaken with four fertility specialists performing OPU at a single IVF centre. Routine practice was combined with tips and tricks into a step-by-step guide to OPU. Step one covers procedural planning, patient identification and vaginal preparation. Step two discusses the gentle and steady techniques for optimal follicle aspiration, Step three highlights the important steps required for the care of the oocyte to ensure the best outcomes. Conclusion: A meticulous approach to the retrieval of oocyte is paramount to maintaining their quality; maximising training tools for technique is therefore essential 1 .