Digital Vaginal Examination Research Articles

Mechanisms of Pelvic Floor Muscle Function and the Effect on the Urethra during a Cough

BackgroundCurrent measurement tools have difficulty identifying the automatic physiologic processes maintaining continence, and many questions still remain about pelvic floor muscle (PFM) function during automatic events. ObjectiveTo perform a feasibility study to characterise the displacement, velocity, and acceleration of the PFM and the urethra during a cough. Design, setting, and participantsA volunteer convenience sample of 23 continent women and 9 women with stress urinary incontinence (SUI) from the general community of San Francisco Bay Area was studied. MeasurementsMethods included perineal ultrasound imaging, motion tracking of the urogenital structures, and digital vaginal examination. Statistical analysis used one-tailed unpaired student t tests, and Welch’s correction was applied when variances were unequal. Results and limitationsThe cough reflex activated the PFM of continent women to compress the urogenital structures towards the pubic symphysis, which was absent in women with SUI. The maximum accelerations that acted on the PFM during a cough were generally more similar than the velocities and displacements. The urethras of women with SUI were exposed to uncontrolled transverse acceleration and were displaced more than twice as far (p=0.0002), with almost twice the velocity (p=0.0015) of the urethras of continent women. Caution regarding the generalisability of this study is warranted due to the small number of women in the SUI group and the significant difference in parity between groups. ConclusionsDuring a cough, normal PFM function produces timely compression of the pelvic floor and additional external support to the urethra, reducing displacement, velocity, and acceleration. In women with SUI, who have weaker urethral attachments, this shortening contraction does not occur; consequently, the urethras of women with SUI move further and faster for a longer duration.

Clinical and Transvaginal Sonographic Evaluation of the Prostate in Transsexual Women

To assess feasibility and diagnostic performance of prostate examination through transvaginal palpation and transvaginal ultrasound in transsexual women (TSW). Fifty TSW who were at least 6 months' posttransition were recruited in a University Hospital. Speculum examination and digital vaginal examination were performed by a gynecologist. Transvaginal ultrasound of the prostate was performed by a radiologist. The information gathered included: ease of insertion of the speculum, vaginal length, palpability of the prostate, vaginal mobility and presence of scar tissue, ease of introduction of the ultrasound probe, ability to visualize prostate and seminal vesicles, echogenicity of the peripheral zone and the central gland, presence of calcifications and delineation of prostatic capsule, attitude toward gynecologic examinations, and anticipated and experienced painfulness of the different examinations. Speculum examination was possible in all but 1 patient and was easy in 78% of the patients. Median vaginal length was 7 cm. A regular digital vaginal examination was possible in 44% of the patients, the vagina was rather mobile and with limited scar tissue on average. In 48% of the patients, the prostate was palpable. In 94% of the patients, the prostate was visible on transvaginal ultrasound. Mean prostate volume was 14 mL, calcifications were present in 33%, and none had cysts. Capsule of the prostate was well delineated in 74% and seminal vesicles were visualized in 80%. All examinations were very well tolerated and nearly painless. Gynecologic examination and prostate assessment were acceptable to TSW. Transvaginal palpation of the prostate is of poor clinical value, yet transvaginal ultrasound allows for proper evaluation of the prostate status.

Sonographic evaluation in the second stage of labor to improve the assessment of labor progress and its outcome

Sonographic evaluation in the second stage of labor to improve the assessment of labor progress and its outcome

Salmonella: the pelvic masquerader

Salmonella sp is a significant cause of morbidity and mortality. Although commonly infecting the gastrointestinal system, other presentations are not unheard of. Salmonella is an unlikely and an unusual cause of genital tract infection. We describe a woman with suspected pelvic inflammatory disease eventually confirmed as Salmonella O C2 infection.

Inter-observer reliability of digital vaginal examination using a four-grade scale in different patient positions

This study aims to compare digital vaginal examination with the patient in supine and standing position and to correlate the degree of pelvic organ prolapse (POP) with a prolapse quality of life (P-QOL) questionnaire. Two hundred and seven women with POP symptoms were digitally examined in supine and standing positions using a four-grade scale (none, minimal, moderate, and severe). P-QOL was used to assess the severity of prolapse symptoms. Cohen's kappa coefficient was used to calculate the inter-observer agreement and Spearman rank correlation test to assess the correlation between examination findings and P-QOL scores. Only vaginal examination findings in standing position had a good inter-observer reliability (kappa value 0.76-0.91). The severity of P-QOL scores only correlated with the examination findings in the standing position (P < 0.001). Digital examination of POP is unreliable if woman is supine but is reliable and correlates with symptoms and QOL impairment when the examination is performed with the patient standing.

Comparison of the learning curves of digital examination and transabdominal sonography for the determination of fetal head position during labor

To evaluate the learning curve of transabdominal sonography for the determination of fetal head position in labor and to compare it with that of digital vaginal examination. A student midwife who had never performed digital vaginal examination or ultrasound examination was recruited for this study. Instructions on how to perform digital vaginal examination and ultrasound examination were given before and after completing the first vaginal and ultrasound examinations, and repeated for each subsequent examination for as long as necessary. Digital and ultrasound diagnoses of the fetal head position were always performed first by the student midwife, and repeated by an experienced midwife or physician. The learning curve for identification of the fetal head position by either one of the two methods was analyzed using the cumulative sums (CUSUM) method for measurement errors. One hundred patients underwent digital vaginal examination and 99 had transabdominal sonography for the determination of fetal head position. An error rate of around 50% for vaginal examination was nearly constant during the first 50 examinations. It decreased subsequently, to stabilize at a low level from the 82(nd) patient. Errors of +/- 180 degrees were the most frequent. The learning curve for ultrasound imaging stabilized earlier than that of vaginal examination, after the 32(nd) patient. The most frequent errors with ultrasound examination were the inability to conclude on a diagnosis, particularly at the beginning of training, followed by errors of +/- 45 degrees. Based on our findings for the student tested, learning and accuracy of the determination of fetal head position in labor were easier and higher, respectively, with transabdominal sonography than with digital examination. This should encourage physicians to introduce clinical ultrasound examination into their practice. CUSUM charts provide a reliable representation of the learning curve, by accumulating evidence of performance.

Labor as a bacteriuric event—assessment and risk factors

Objective. Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate the incidence of bacteriuria following labor and to identify risk factors predisposing to this condition.Methods. Three hundred and fifty parturients were recruited, 301 were included in the analysis. Women receiving antibiotic drugs during delivery were excluded. Urine cultures were obtained from the study group before delivery and prior to discharge. Data regarding management of labor was collected prospectively.Results. Positive urine cultures were present on admission in 5.4% of women, whereas 12.9% had a positive urine culture at discharge (p < 0.003). Bacteriuria was acquired during labor in 12.7% of patients who had negative cultures on admission. Escalating number of digital vaginal examinations (p = 0.04), recurrent bladder catheterization (p = 0.05), duration of epidural anesthesia (p = 0.002), and vacuum delivery (p = 0.02) correlated significantly with an increased risk for acquiring bacteriuria.Conclusion. Labor is a bacteriuric event. Iatrogenic interventions can predispose parturients with sterile urine cultures to postpartum bacteriuria.

Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis

Deeply infiltrating endometriosis affecting the retrocervical region and the rectosigmoid generally requires surgical treatment. Clinical examination, transvaginal ultrasonography (TVUS) and pelvic magnetic resonance imaging (MRI) are useful in the preoperative diagnosis of the involvement of these sites. The objective of this study was to evaluate the capacity of digital vaginal examination, TVUS and MRI to diagnose rectosigmoid and retrocervical involvement. A total of 104 patients with clinically suspected endometriosis were submitted to clinical examination, pelvic MRI and TVUS until 3 months prior to videolaparoscopy and the findings of these methods were matched with histopathological confirmation of endometriosis. Endometriosis was histologically confirmed in 98 of 104 (94.2%) patients. With respect to the rectosigmoid and retrocervical sites, respectively, digital vaginal examination had a sensitivity of 72 and 68%, specificity of 54 and 46%, positive predictive value (PPV) of 63 and 45%, negative predictive value (NPV) of 64 and 69% and accuracy of 63 and 55%. For TVUS, sensitivity was 98 and 95%, specificity 100 and 98%, PPV 100 and 98%, NPV 98 and 97% and accuracy 99 and 97%. MRI had a sensitivity of 83 and 76%, specificity of 98 and 68%, PPV of 98 and 61%, NPV of 85 and 81% and accuracy of 90 and 71%. TVUS had better sensitivity, specificity, PPV, NPV and accuracy in cases of deep retrocervical and rectosigmoid endometriosis when compared with MRI and digital vaginal examination, confirming that it is an important preoperative examination for the definition of surgical strategies.

Postpartum tightening operations on two delivery wards in Sudan

This paper describes a study to explore the prevalence of postpartum tightening operations of the vulva and reinfibulation (RI) in Sudan. Participatory observations with digital vaginal examinations before and after delivery were carried out on a sample of 100 women in two hospital settings. In 61% of the women tightening vulval operations had been carried out after delivery. Of the women who had not been submitted to female genital mutilation (FGM) with suturing before delivery, 35% had such an operation after delivery. Two out of 20 women without any primary FGM had undergone a tightening operation following delivery. In the two study settings observed, the prevalence of postpartum tightening operations was 61% and included women without previous FGM. The tradition of tightening operations of the vulva after delivery is an important issue for further research concerning the implicit socio-cultural determinants and their possible relation to the tradition of primary forms of FGM.

Avaliando o conhecimento sobre pré-natal e situações de risco à gravidez entre gestantes residentes na periferia da cidade de Rio Grande, Rio Grande do Sul, Brasil

The aim of this study was to assess knowledge on prenatal care and pregnancy risk among women in poor neighborhoods in the city of Rio Grande, Rio Grande do Sul State, Brazil. Data were collected using a cross-sectional design. A standard questionnaire was applied to all pregnant women from poor neighborhoods. Trained interviewers visited these women at home, covering demographic, socioeconomic, and reproductive data and knowledge concerning prenatal care and pregnancy risk factors. A total of 367 pregnant women were interviewed using non-random sampling. Except for urine tests and HIV testing, spontaneously reported as necessary, other procedures were reported by no more than 30% of the women. Digital vaginal examination, clinical breast examination, and Pap smear were reported by a maximum of 7% of the women. Only two-thirds felt that vaginal bleeding and abdominal pain were serious signs during gestation. Other signs and symptoms were reported by a maximum of one-third of the women. In conclusion, knowledge of prenatal tests and situations indicating serious risk fell far short of the desired levels. Improving this level of information in pregnant women could help reduce maternal and child morbidity and mortality.

Conservative Management of Urinary Incontinence

ObjectiveTo outline the evidence for conservative management options for treating urinary incontinence. OptionsConservative management options for treating urinary incontinence include behavioural changes, lifestyle modification, pelvic floor retraining, and use of mechanical devices. OutcomesTo provide understanding of current available evidence concerning efficacy of conservative alternatives for managing urinary incontinence; to empower women to choose continence therapies that have benefit and that have minimal or no harm. EvidenceThe Cochrane Library and Medline (1966 to 2005) were searched to find articles related to conservative management of incontinence. Review articles were appraised. ValuesThe quality of evidence is rated, and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care. Benefits, Harms, CostsEvidence for the efficacy of conservative management options for urinary incontinence is strong. These options can be advocated as primary interventions with minimal or no harm to women. Recommendations1.Pelvic floor retraining (Kegel) exercises should be recommended for women presenting with stress incontinence. (I-A)2.Proper performance of Kegel exercises should be confirmed by digital vaginal examination or biofeedback. (I-A)3.Follow-up should be arranged for women using pelvic floor retraining, since cure rates are low and other treatments may be indicated. (III-C)4.Kegel exercises may be offered as an adjunct to other treatments for overactive bladder (OAB) syndrome, but they should not be the only treatment offered for these symptoms. (I-B)5.Although functional electrical stimulation (FES) has not been studied as an independent modality, it may be used as an adjunct to pelvic floor retraining, especially in patients who have difficulty identifying and contracting the pelvic muscles. (III-C)6.FES should be offered as an effective option for the management of OAB. (I-A)7.Vaginal cones may be recommended as a form of pelvic floor retraining for women with stress incontinence. (I-A)8.Continence pessaries should be offered to women as an effective, low-risk treatment for both stress and mixed incontinence. (II-B)9.Bladder training (bladder drill) should be recommended for symptoms of OAB, since it has no adverse effects (III-C), and it is as effective as pharmacotherapy. (I-B)10.Behavioural management protocols using lifestyle changes in combination with bladder training and pelvic muscle exercises are highly effective and should be used to treat urinary incontinence. (I-A)

Postpartum tightening operations on two delivery wards in Sudan

This paper describes a study to explore the prevalence of postpartum tightening operations of the vulva and reinfibulation (RI) in Sudan. Participatory observations with digital vaginal examinations before and after delivery were carried out on a sample of 100 women in two hospital settings. In 61% of the women tightening vulval operations had been carried out after delivery. Of the women who had not been submitted to female genital mutilation (FGM) with suturing before delivery, 35% had such an operation after delivery. Two out of 20 women without any primary FGM had undergone a tightening operation following delivery. In the two study settings observed, the prevalence of postpartum tightening operations was 61% and included women without previous FGM. The tradition of tightening operations of the vulva after delivery is an important issue for further research concerning the implicit sociocultural determinants and their possible relation to the tradition of primary forms of FGM.

Comparison of transvaginal sonography with digital examination and transabdominal sonography for the determination of fetal head position in the second stage of labor

Precise determination of fetal head position in labor is a prerequisite for safe instrumental deliveries, and essential for the assessment of labor progress. Recent studies have cast serious doubts on the accuracy of the time-honored digital vaginal examination (DVE) in comparison to transabdominal ultrasound scans (TUS). However, transabdominal imaging is technically difficult with a deeply engaged fetal head in the second stage of labor. We examined the accuracy and time requirements of transvaginal scans (TVS) in the second stage of labor for determination of fetal head position. Sixty laboring women in the second stage of labor with a deeply engaged fetal head were examined by experienced nurse midwives and senior residents. Fetal head position was recorded as "time on a 12-hour clock." Subsequently, TUS and TVS were independently performed by a skilled sonographer. Accuracy and time requirements for all 3 examinations were recorded. Fetal head position could be determined in all cases by TVS, but not in 7 cases and 9 cases by DVE and TUS, respectively (P < .03; P < .008). A discrepancy of 60 degrees or more between the DVE and TUS or TVS was found in 13/60 cases (21.7%) and 14/60 cases (23.3%), respectively. A > or = 90 degrees discrepancy was found in 9/60 cases (15%) and 12/60 cases (20%), respectively (P < .02 for comparison of TUS and TVS). In 5 cases, the digital examination erroneously perceived an occiput posterior position as occiput anterior. No significant differences in fetal head position were detected between TUS and TVS, when the examination was technically feasible. The mean time (+/-SD) required for determining fetal head position was shortest for TVS (8.7 +/- 5.8 seconds) in comparison to DVE (22.7 +/- 14.6 seconds; P < .0001) or TAS (31.7 +/- 19.1 seconds; P < .0001). Transvaginal sonography was the most successful and accurate method for determination of fetal head position in the second stage of labor, and required the least time for performance. We believe that TVS should be routinely performed in the labor room setting for the determination of fetal head position.

Fetal head position during the second stage of labor: Comparison of digital vaginal examination and transabdominal ultrasonographic examination

Objective To study the correlation between digital vaginal and transabdominal ultrasonographic examination of the fetal head position during the second stage of labor. Methods Patients ( n = 110) carrying a singleton fetus in a vertex position were included. Every patient had ruptured membranes and a fully dilated cervix. Transvaginal examination was randomly performed either by a senior resident or an attending consultant. Immediately afterwards, transabdominal ultrasonography was performed by the same sonographer (OD). Both examiners were blind to each other's results. Sample size was determined by power analysis. Confidence intervals around observed rates were compared using chi-square analysis and Cohen's Kappa test. Logistic regression analysis was performed. Results In 70% of cases, both clinical and ultrasound examinations indicated the same position of the fetal head (95% confidence interval, 66–78). Agreement between the two methods reached 80% (95% CI, 71.3–87) when allowing a difference of up to 45° in the head rotation. Logistic regression analysis revealed that gestational age, parity, birth weight, pelvic station and examiner's experience did not significantly affect the accuracy of the examination. Caput succedaneum tended to diminish ( p = 0.09) the accuracy of clinical examination. The type of fetal head position significantly affected the results. Occiput posterior and transverse head locations were associated with a significantly higher rate of clinical error ( p = 0.001). Conclusion In 20% of the cases, ultrasonographic and clinical results differed significantly (i.e., >45°). This rate reached 50% for occiput posterior and transverse locations. Transabdominal ultrasonography is a simple, quick and efficient way of increasing the accuracy of the assessment of fetal head position during the second stage of labor.

Transvaginal Sonography of the Uterine Cervix Prior to Labor Induction

The only standard means of predicting successful labor induction has been digital examination to detect a ripened cervix. Possible alternatives are screening for fetal fibronectin in vaginal secretions and transvaginal sonography of the uterine cervix. The present prospective study, enrolling 179 women who required induction of labor for medical reasons, was an attempt to evaluate ultrasonography when done before induction to learn whether cervical length can predict the mode of subsequent delivery. Only women with singleton pregnancies, a cephalic presentation, intact membranes, and more than 37 weeks of amenorrhea were included in the study. Cervical length was measured on arrival in the labor room but was not a factor in selecting the induction procedure. The Bishop score was determined by digital vaginal examination, after which the woman emptied her bladder and had a transvaginal ultrasound scan to estimate cervical length from the internal to the external os. Labor usually was induced right away by infusing oxytocin and doing an amniotomy when the Bishop score exceeded 5. Otherwise cervical ripening was carried out by placing 2 mg of dinoprostone in the posterior fornix and repeating this every 6 hours as needed until the cervix was favorable for oxytocin induction. The commonest indications for induction in these women, who were about equally divided between primiparas and multiparas, were postterm pregnancy and pregnancy-induced hypertension. The cesarean delivery rate was 30%. Threshold values of the Bishop score and cervical length for predicting cesarean delivery were comparable. The optimized cutoff values were 5 for the Bishop score and 26 mm for ultrasound cervical length. The Bishop score did not predict mode of delivery, but cesarean deliveries were significantly less frequent in women whose cervical length on arrival at the labor ward was less than 26 mm. The difference in cesarean delivery rates was significant only when surgery was done before 8 cm of cervical dilatation. Cervical length was related to mode of delivery only in women whose Bishop score was 5 or less. The interval from the start of cervical ripening and vaginal delivery was shorter, to a highly significant degree, when the cervix was short. Transvaginal sonographic estimates of cervical length are a more accurate predictor of the risk of cesarean delivery than is the Bishop score when labor is induced for medical reasons. When there is an unfavorable Bishop score, a cervical length less than 26 mm correlates with a shorter labor and a lower chance of cesarean delivery.

FEMALE PARAURETHRAL LEIOMYOMA: IMMUNOHISTOCHEMICAL APPROACH TO THE RELATIONSHIP BETWEEN LEIOMYOMA AND OVARIAN HORMONES

The majority of leiomyomas are uterine in origin, and paraurethral leiomyoma is relatively rare. Leiomyoma mainly occurs during the reproductive period. Its development has been suggested by some investigators to be related to ovarian hormones,1 while others have reported no relationship. We report a case of female paraurethral leiomyoma and the results of immunohistochemical analysis using ovarian hormone receptors. CASE REPORT A 49-year-old married woman, gravida 0, who had last menstruated 2 months previously presented with a mass on the vulva. Hormonal status was that of a woman in menopause. Serum levels of follicle-stimulating hormone and luteinizing hormone were slightly higher than the normal limit of standard menstruants, and estradiol was at the lowest limit of normal. The patient had no history of illness involving the urinary tract. Physical examination revealed a tender reddish walnutsized mass that was floating and elastic firm, had a smooth surface and was situated on the right side of the urethral meatus. The mass was palpated to about 3 cm. from the ostium vaginae on digital vaginal examination. The urethral meatus was then shifted to the left, causing a shift in the urinary stream. Axial plain computerized tomography (CT) revealed a 2.5 2.0 cm. well-defined, homogeneously low density mass on the right side of the urethra, while contrast enhanced CT showed a slightly enhanced mass. T2-weighted magnetic resonance imaging (MRI) demonstrated a heterogeneously iso or mildly hypointense lesion (fig. 1, A). The central part of the lesion was hypointense on T2-weighted MRI, and was not as enhanced as the rest of the lesion on contrast enhanced T1-weighted MRI (fig. 1, B). The preoperative diagnosis was a paraurethral tumor. A small longitudinal incision was made on the vaginal vestibule. The mass, which was sharply delimited, was easily enucleated. Histological examination revealed marked proliferation of the bundles of smooth muscle cells, especially at the center of the tumor. In the rest of the tumor the proliferation was not as marked, and there was a myxoid matrix around the smooth muscle cells. These findings coincided with the difference in the enhancing effect on contrast enhanced T1-weighted MRI. The tumor was histopathologically diagnosed as a paraurethral leiomyoma. The nuclei of the tumor cells were stained with estrogen receptor (ER), estrogen receptor (ER) and progesterone receptor (PR) by the immunohistochemical technique (fig. 2). There was no recurrence of symptoms or tumor at 6-month followup.

Does Digital Vaginal Examination Using Lubricant Have an Impact on Testing for Chlamydia trachomatis by Polymerase Chain Reaction?

IN MANY CLINICAL SITUATIONS, it is convenient and efficient for the healthcare provider to perform a bimanual pelvic examination before a vaginal speculum examination, and more comfortable for the patient. These situations include uterine sizing and cervical evaluation before outpatient dilation and curettage as well as cervical examination of pregnant patients evaluated for preterm labor for rapid assessment and triage. Some practitioners also use vaginal lubricants on the blades of a speculum to decrease patient discomfort. There is concern, however, that these lubricants may interfere with the sensitivity of vaginal and cervical microbiologic testing. Part of this concern presumably arises from the active ingredient in bacteriostatic gel: a 0.25% concentration of chlorhexidine, which is a substance used for its antimicrobial properties. The performance of any diagnostic test relies on adequate sample collection. Excess cervical mucus and blood, for example, may interfere with adequate endocervical sampling for Chlamydia trachomatis.1 Sensitivity of culture and antigen detection tests for chlamydia is greatly affected by specimen adequacy. Chlamydia testing using polymerase chain reaction (PCR) does not require viable organisms, so it was believed that specimen adequacy would be less critical in testing by PCR. However, one study demonstrated a 75% reduction in the sensitivity of chlamydia PCR testing performed on inadequate versus adequate endocervical samples.2 The use of a lubricant before specimen collection could affect the ability to obtain an adequate sample by decreasing the absorbency of the swab, diluting the number of organisms in the sample, or directly inhibiting the PCR assay. Because no data is currently available regarding the effect of lubricants on STD testing, this study was designed to investigate the impact a lubricant containing no chlorhexidine may have on C trachomatis PCR testing. From January 1997 to May 1998, women at least 18 years of age with positive test results for chlamydia on routine screening by PCR testing (Amplicor C trachomatis test; Roche Diagnostics, Branchburg, NJ) who had not yet been treated were recruited for participation in this study approved by the institution review board. Nonpregnant women attending the Magee-Womens Hospital Emergency Department and Ambulatory Care Clinics were eligible to enroll. Exclusion criteria involved use of an antibiotic or spermicide within 3 weeks of the original positive PCR test and previous hysterectomy. After informed consent was obtained, a sterile unlubricated vaginal speculum was placed in the vagina. A Dacron swab was inserted into the endocervix, rotated for 10 seconds, and placed in PCR transport media. The speculum then was removed, and the entire contents of a 3-g package of sterile water-soluble lubricating jelly containing no chlorhexidine were placed on a gloved hand for bimanual examination of the pelvic organs (Operand, Prichard, WV). The unlubricated speculum was then reinserted, and a second endocervical sample was collected for chlamydia PCR testing in the same fashion. The chlamydia PCR assay was performed according to the manufacturer’s recommendation (Amplicor C trachomatis test; Roche Diagnostics). All the patients were treated The authors thank Marijane A. Krohn, PHD for statistical assistance. Supported by the Irene McLenahan Young Investigator Research Award, Magee-Womens Hospital, Pittsburgh, Pennsylvania. Received for publication August 29, 2000, revised June 28, 2001, and accepted July 17, 2001. From the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine and Magee-Womens Research Institute, Pittsburgh, Pennsylvania

Transvaginal ultrasound and digital examination in predicting successful labor induction

Objective: To compare transvaginal ultrasound and digital cervical examination in predicting successful induction in post-term pregnancy. Methods: Transvaginal ultrasound and digital vaginal examinations were performed on 122 women at 41 or more weeks’ gestation, immediately before labor induction. Ultrasound assessments of cervical length, dilatation, and presence of funneling were compared with the components of the Bishop score. The primary outcome was the rate of vaginal delivery. Secondary outcomes assessed included the rates of active labor in 12 hours, vaginal delivery in 12 and 24 hours, mean duration of latent phase, and induction to vaginal delivery interval. Linear and multiple logistic regression models were generated to identify factors independently associated with successful induction. Results: No ultrasound characteristic predicted primary or secondary outcomes. Bishop score (odds ratio [OR] 2.98, 95% confidence interval [CI] 1.71, 5.20), cervical position (OR 4.35, 95% CI 1.41, 12.50), and maternal age (OR 1.15, 95% CI 1.01, 1.30) independently predicted vaginal delivery. Maternal weight (OR 0.96, 95% CI 0.94, 0.98), cervical dilatation (OR 6.08, 95% CI 1.70, 21.68), and effacement (OR 2.34, 95% CI 1.16, 4.73) independently predicted active labor in 12 hours. Independent predictors of vaginal delivery in 12 hours were induction method ( P < .001), cervical dilatation (OR 11.16, 95% CI 3.17, 39.29), gravidity (OR 2.06, 95% CI 1.13, 3.77), and maternal weight (OR 0.96, 95% CI 0.93, 0.99). Cervical effacement (OR 2.70, 95% CI 1.59, 4.57) and parity (OR 7.10, 95% CI 2.22, 22.72) independently predicted vaginal delivery in 24 hours. Maternal weight, cervical position, and cervical dilatation were independently associated with latent phase labor duration. Factors independently associated with length of induction to delivery interval were parity, cervical effacement, and maternal weight. Conclusion: Transvaginal ultrasound does not predict successful labor induction in post-term pregnancy as well as digital cervical examination.

Urinary Bladder Herniation through a Vaginal Tear in a Rottweiller with Dystocia

SummaryA four‐year old female Rottweiler presented with a 34‐hour history of dystocia. Physical examination revealed a purple‐black, fluid‐filled sac protruding from vulva and suspended by a similar colored stalk. Digital vaginal examination indicated that the stalk of tissue extended up into the cervix and beyond. Due to the grossly necrotic appearance, the stalk of tissue was ligated, and the sac was removed. Three puppies were delivered vaginally, but a subsequent caesarian section was required due to uterine inertia likely secondary to exhaustion. Three more live puppies were delivered via the c‐section. Further abdominal exploration revealed a tear in the left vaginal wall, one ligated ureter, and the second ureter free at its distal end and leaking urine into the abdomen. The surgical findings indicated that the bladder, ureters, and urethra had herniated through the vaginal tear and prolapsed through the vulva.

Follow Up of Women With Simple Ovarian Cysts Detected by Transvaginal Sonography in the Tokyo Metropolitan Area

From late 1990 through 1991, 10,294 asymptomatic women participated in a screening program for ovarian tumors at the Tokyo Metropolitan Cancer Detection Center. The screening examination included a Papanicolaou test, colposcopy, digital vaginal examination, and transvaginal ultrasonography using a 5.0-MHz transducer with a 100-Hz sump filter to eliminate low-frequency sounds. Women with abnormalities (ovary greater than 2 cm in diameter, ovarian cyst or mass) underwent a second scan 6 weeks later to exclude functional cysts. Apparent simple cysts in premenopausal women (no papillary component, thick septa, or solid tumor) were rescanned every 3 months and watched carefully for any changes in the nature or size of the cyst. Women with other abnormalities underwent further evaluation, including measurement of serum levels of CA-125, CA-199, and carcinoembryonic antigens (CEAs) and in some cases computed tomographic scanning. Results of the screening program are presented in Figure 1. Of the 372 women with abnormal findings, 32 were diagnosed with a uterine fibroid, and 340 were found to have an adnexal mass. Of these patients, 115 had either an ovarian mass larger than 6 cm in diameter or an elevated blood serum CA-125 level and were referred for exploratory surgery. Eight women refused to undergo surgery and were followed up elsewhere. In the remaining 107, two stage Ia mucinous cyst adenocarcinomas, one stage Ic endometrioid adenocarcinoma, and one endometrial carcinoma metastatic to the ovary were found. In addition, three borderline malignancies were diagnosed.Fig. 1: Breakdown of patients with adnexal masses screened by transvaginal ultrasonography (TV-UST).Two hundred twenty-five of the 340 women had an adnexal mass less than 6 cm in diameter with normal blood serum CA-125 levels and were followed up every 3 months for 75 months. One hundred sixty-five (73 percent) of the masses had regressed by the end of the follow-up period, 80 at the first follow-up examination and most (146) within 12 months. None of the cysts recurred. In 31 (41 percent) women, the mass persisted throughout the follow-up period, and in 29 (13 percent), progression of the adnexal mass occurred, most often (21) within 24 months. Three cysts persisted for 5 years before beginning to grow; one of these was found to have enlarged in the 75th month. Of the 29 women with progression, 9 had either rising CA-125 levels, greatly enlarged cysts (>6 cm), or a multiloculated cyst and underwent surgery. Three women were diagnosed with endometriosis, three with mature teratoma, two with cystadenoma (one serous and one mucinous), and one with an endosalpingeal cyst. In women with normal blood serum CA-125 levels and cysts less than 6 cm in diameter at the time of initial diagnosis, the outcome at 75 months was significantly correlated with ultrasound findings (cystic mass vs. solid or mixed mass, P = .01), mass diameter (<4 cm compared with >5 cm, P = .05), blood serum CEA levels (<0.7 vs. >1.0, P = .02), and blood serum CA-199 levels (<7 vs. >20, P = .001). A multivariate analysis of risk factors for tumor growth was conducted for the 140 women with complete information recorded. Blood serum CA-199 and CEA levels at the time of initial diagnosis were found to be significant predictors of tumor regression (P = .004 and P = .02, respectively). A CA-199 level of 20 IU/mL or higher had a relative probability of tumor regression of 0.34. Similarly, a CEA level of 1.0 IU/mL or higher had relative probability of regression of 0.53.