Transvaginal Research Articles

Cervicoisthmic cerclage: transabdominal vs transvaginal approach

We sought to compare the outcomes of cervicoisthmic (CI) cerclage using traditional transabdominal (TA) approach vs the lesser used transvaginal (TV) approach. We conducted a retrospective cohort study of women who underwent placement of a CI cerclage. Before CI placement, the abdominal group had a total of 100 pregnancies that continued beyond the first trimester and had 27 (27%) surviving infants. After cerclage placement, there were 34 pregnancies and 24 (71%) surviving infants. Before cerclage placement, the vaginal group had a total of 90 pregnancies that continued beyond the first trimester and had 11 (12%) surviving infants. After cerclage placement, there were 29 pregnancies and 20 (69%) surviving infants. The vaginal cerclage group had a significantly shorter mean operative time of 33 vs 69 minutes, and shorter hospital stay of 0.5 vs 3.2 days. Both TV and TA CI cerclage offers select patients with cervical insufficiency improved neonatal survival. The TV placement of a CI has less morbidity than the TA approach with a comparable neonatal survival.

Experimental Endoscopic Method for Treatment of Bleeding Out of Liver and Spleen During NOTES® Procedures. A Randomized Controlled Animal Study

Introduction: Treatment of bleeding is an important issue in endoscopy. In addition, significant haemorrhage out of vessels but also out of inadvertently damaged organs is a likely complication during NOTES procedures. We tested 3 different prototype devices applied through two different access locations to the peritoneal cavity for treatment of acute bleeding of lacerations of liver and spleen in a survival animal model. Method: 12 animals were used for transgastric (TGA, n=6) and transvaginal (TVA) access. After having cut through the gastric or vaginal wall the endoscope was introduced into the peritoneal cavity to treat haemorrhage from liver and spleen, laparoscopically induced by an independent team of surgeons who observed the procedures. 3 different haemostatic techniques were applied after randomization. New methods included a)endoscopic suturing with t-bars, b)Prototype monopolar forceps, c)Experimental Forced Argon Plasma Coagulation (FAPC). Autopsy and histology were carried out after 6 weeks survival time. Results: For both, liver and splenic haemorrhage, suturing failed to be quick enough to be placed in time before the vision was inhibited. Monopolar forceps was able to control the bleeding out of the laceration in 15-48 min (mean 28 ± 12min) in 4/6 cases from TGA, but could not entirely stop it. For TVA 25 and 41 min were needed to control bleeding in 2/6 cases but in 4 no control was possible. It was not possible to stop any liver haemorrhage entirely and in no case a splenic haemorrhage could be controlled or stopped using monopolar forceps. Using FAPC it took 1.5-38 min (mean 26.5 min) to stop the bleeding of the liver entirely through TGA and 7-41 min (mean 24 ± 9.4 min) through TVA (p = 0.64). Haemorrhage of the spleen could be stopped in: TGA: 17-46min (mean: 34 ± 7 min), TVA: 12-50 min (mean 39 ± 11 min). No statistical significance was seen, when TGA was compared to TVA. Endosopic suturing was used to close the access uneventfully in all cases. No re-bleeding occurred. Autopsy showed well healed lacerations. FAPC was significantly better and quicker to control and stop bleeding out of the liver as well as the spleen from both access points than the other methods. Conclusion: Of the 3 methods tested, new experimental FAPC allowed significant bleeding out of liver and spleen to be stopped when the other methods failed. Further studies need to explore this potentially very valuable tool further.

Early ultrasound for fetal anatomy in the obese pregnant woman

ALYSSA MILLS, BRITA BOYD, BARBARA HERTZBERG, HAYWOOD BROWN, GEETA K. SWAMY, Duke University, Obstetrics & Gynecology, Durham, North Carolina, Duke University, Radiology, Durham, North Carolina OBJECTIVE: To determine whether early transabdominal (TA) plus transvaginal (TV) ultrasound (US) can optimize standard fetal anatomic survey and can be performed in a shorter amount of time. STUDY DESIGN: In this prospective, observational pilot study, 20 obese (BMI R30 kg/m2) pregnant women underwent US for fetal anatomy at 14-16 wks (US1) and again at 18-20 wks (US2). TV & TA imaging were performed to complete US1. Images were independently reviewed by 3 physicians and individual structures were described as not visualized (0 points), suboptimally visualized (1 point), or optimally visualized (2 points). Points were added for a perfect score of 6/structure, 126/US overall. Kappa statistics were used to assess inter-reviewer agreement. Paired t-test was used to compare scores, p!.05 significant. RESULTS: Mean BMI at US1 was 40.5 kg/m2. Both US took similar time to complete (mean 35 minutes for US1, 37 for US2, p=0.6). Inter-reviewer agreement ranged .12-.78. Cardiac anatomy and kidneys were equally wellvisualized at both US; however other structures were more often optimally visualized at US2. Overall, US2 performed better than US1. CONCLUSION: Early US in obese women was useful for some structures, but should not replace US at 18-20 wks.

Transvaginal cervical length measurement; Its current application in a regional Australian level II maternity hospital

To evaluate the impact of cervical length (CL) measurements in pregnant women at risk for preterm delivery on intervention and pregnancy outcome. Retrospective study. Regional high-level II maternity unit. Hospital databases were reviewed for all women delivering between March 2001 and March 2003. Women at an increased risk for preterm birth with transvaginal (TV) cervical length measurements during pregnancy were included in this audit. Patients (n = 204) were analysed together and in subgroups with different risk profiles. For women with a significant obstetrical history, most of the cervical lengths <or= 2.5 cm were found between 24 and 28 weeks gestational age. None of the patients with twin pregnancy as single indication for cervical length measurements developed a cervical length <or= 2.5 cm. In women with twin pregnancy plus additional risk factor as indication for cervical length measurement, 60.87% showed shortening of cervical length to <or= 2.5 cm. Patients with previous gynaecological operations as the only risk factor had optimal perinatal outcomes. Notwithstanding the potential beneficial effects of therapeutic measures, patients with singleton pregnancies and a significant obstetrical history, and a short cervical length had a relative risk of 3 for preterm delivery. In the group of women presenting with signs and symptoms suggestive of threatening preterm delivery and a short cervical length, significantly more patients were treated with nifedipine compared to similar patients with 'normal' cervical length. For patients with a high-risk obstetrical history, a first cervical length measurement at the time of foetal morphology scan followed by one measurement at about 24 weeks would result in a timely diagnosis of almost all cases of clinically relevant cervical shortening. Just having a twin pregnancy, in the absence of other risk factors for preterm birth, does not require cervical length monitoring. Having a twin pregnancy plus additional risk factors clearly identifies a group requiring cervical length measurement and intervention. Previous LLETZ procedures or >or= 3 preceding curettages were not found to be a major risk factor for preterm birth.

The use of transvaginal ultrasonography, sonohysterography, and endometrial biopsy as a diagnostic tool in the evaluation of abnormal uterine bleeding.

Objective: To determine the sensitivity, specificity, predictive value of a positive and a negative test, of transvaginal (TV) ultrasonography (U/S), sonohysterography (SHG), and endometrial biopsy in the evaluation of abnormal uterine bleeding (AUB). Design: Volunteers with AUB were recruited in a prospective fashion. Patients underwent pelvic exam, TV U/S, SHG, and endometrial biopsy. Within two months of these studies they underwent hysteroscopy. Volunteers were also recruited from those patients undergoing routine hysteroscopy. These results of all preoperative studies were compared directly to hysteroscopic findings. Materials/Methods: Volunteers underwent U/S exam with an ULTRAMARK 4 ©(ATL) US machine with a 5.0/7.5 MHz transducer. Measurements of the uterine and ovarian size, bilayer endometrial stripe thickness, and the presence of abnormalities were recorded. An SHG was then performed with a 5.0F H/S catheter© (Ackrad Lab Inc., Cranford, N.J.) and 10–20 cc’s of sterile saline. The uterus was systematically visualized in saggital and coronal planes. If present any polyps, submucosal myomas, or other abnormalities were measured, and their locations within the uterus and cavity noted. Endometrial biopsies were obtained in the standard fashion with a 5 mm pipelle instrument in the month prior to the U/S studies. TV U/S, SHG, and endometrial biopsy results were compared to hysteroscopic findings. All hysteroscopies were performed in the operating room with standard distension media within 2 months of the U/S studies. Results: 259 women underwent SHG. 109 patients had no intracavitary lesions identified on SHG; 104 elected a change in medical management, 3 had in office D + C’s for focal endometrial thickening and were found to have simple focal hyperplasia, two conceived with ART. The remaining 150 patients underwent office (132) or OR (18) SHG’s. Eleven patients with known abnormal office SHG’s went directly to hysterectomy; 6 myomas, 3 adenomyosis, and 2 persistent menorrhagia and anemia. Three patients with suspected endometrial pathology on SHG did not go to hysteroscopy;1 delayed surgical treatment for complex medical illness, 1 declined surgical intervention, and 1 moved out of the area and was lost to follow up. Of the 136 patients who underwent SHG, and hysteroscopy, 74 had endometrial biopsies. Results of individual tests in the evaluation of DUB. Tabled 1TV U/S (%)SHG (%)Endo Bx (%)Sensitivity559821Specificity51938PV (+)939787PV (−)49953 Open table in a new tab Conclusions: These results indicate that SHG is superior to routine TV U/S and endometrial biopsy in the diagnosis of intrauterine pathology. Endometrial biopsy was most likely to make the diagnosis correctly for hyperplasia, carcinoma, and occasionally for endometrial polyps. The SHG improved the accuracy in differentiating between intracavitary myomas and polyps, and in the location of the lesion. Supported by: ACOG/Tambrands Grant for Menstrual Health.

Sonohysterography (SHG) is more sensitive than hysterosalpingography (HSG) in the detection of intracavitary abnormalities.

Objective: To determine the sensitivity, specificity, predictive value of a positive and a negative test, of transvaginal (TV) ultrasonongraphy (U/S), sonohysterography (SHG), and HSG in the detection of uterine cavity abnormalities. Design: Volunteers were recruited from patients undergoing routine hysteroscopy as part of their evaluation for infertility. An SHG was performed in the OR just prior to the hysteroscopy. These data were retrospectively compared to findings on outpatient HSG. The clinician performing the SHG was blinded to findings on preoperative HSG. The hysteroscopies were performed within two months of HSG. The results of both the HSG and SHG were compared to hysteroscopic findings. Materials/Methods: Intraoperative SHG was performed with an ULTRAMARK 4 [copy](ATL) US machine affixed with a 5.0/7.5 MHz transducer. Measurements of the uterine and ovarian size, bilayer endometrial stripe thickness, and the presence of abnormalities were recorded. An SHG was then performed with a 5.0F H/S catheter© (Ackrad Lab Inc., Cranford, N.J.) and 10-20 cc’s of sterile saline. The uterus was systematically visualized in saggital and coronal planes. If present any polyps, submucosal myomas, or other abnormalities were measured, and their locations within the uterus and cavity noted. Preoperative HSG’s were performed under fluoroscopic guidance with a standard cone insufflation device and 10-20 cc of sinograffin. All hysteroscopies were performed in the operating room with standard distension media. Results: Although these data are limited by small sample size, sonohysterography appears to be the most specific test for the detection of uterine cavity abnormalities. See table. Results comparing TV U/S, HSG, and SHG to findings at the time of hysteroscopy. Tabled 1TV U/S (%)HSG (%)SHG (%)Sensitivity57100100Specificity8667100PV (+)10078100PV (−)67100100 Open table in a new tab Conclusions: Sonohysterography is likely to be more sensitive and specific than routine transvaginal ultrasound and HSG in the detection of uterine cavity abnormalities. These data suggest sonohysterography should be considered the procedure of choice prior to ovulation induction and ART. Supported By: ACOG/Tambrands Grant for Menstrual Health.

Thermal urethroplasty: short and intermediate results of a new treatment for stress urinary incontinence

Objective: We report on a new method of thermal treatment of the endopelvic fascia (EPF) to lift the bladder neck and urethra without the use of implantable materials, such as sutures or mesh, to treat stress urinary incontinence using either a laparoscopic (LP) or transvaginal (TV) approach.Methods: The method of using heat to contract tissue is well documented. Two parallel, independent prospective, comparative, IDE studies were conducted. In both, precisely controlled radiofrequency energy was applied to the EPF causing it to heat and shrink. Patients were followed at 3- and 6-month intervals. Ninety-three patients (76 LP, 17 TV) have been enrolled to date.Results: Systematic measurements determined the shrinkage of the EPF was approximately 25%–50%. Success rates for LP: 78%, 80% at 3 and 6 months, TV: 90%, 90% at 3 and 6 months. Overall operative complication rates were 3% and 0% for the LP and TV, respectively. Postoperative complications were 2% and 0% for LP and TV. All complications resolved within 1 week of diagnosis with conservative management.Conclusions: Preliminary results indicate thermal treatment of the EPF for stress urinary incontinence has a high success rate and low complication rate. Further study is required, including long-term follow-up.

Screening for fetal anomalies in the 12th week of pregnancy by transvaginal sonography in an unselected population.

The advantages and limitations of transvaginal (TV) sonography in detecting fetal anomalies in the 12th week of pregnancy were examined in a prospective screening study of an unselected population. During a 3-year period, 3991 examinations were performed and 35 fetuses were identified as having 43 anomalies (0.9 per cent). Most of these malformations were either severe structural disorders or isolated nuchal changes when karyotyping revealed chromosomal aberration in six cases. Twenty-one pregnancies were terminated and three fetuses died. Routine transabdominal (TA) ultrasonographic examinations were performed at 18 and 30 weeks in all those pregnancies where the TV scan had not found fetal anomalies. TA sonography identified 19 abnormal fetuses and ten cases remained undetected. TV sonography detected 51 per cent of malformed fetuses which were diagnosed prenatally (not including cases with nuchal oedema) and 41 per cent of the total were found in this study. Besides offering the possibility of early termination, first trimester screening has the advantage of identifying a transient sonographic sign, nuchal oedema, which can be used as a marker in screening for fetal chromosomal abnormalities. However, standard mid-second-trimester TA scanning is still recommended, since a significant number of malformations cannot be detected so early in pregnancy.

Pelvic inflammatory disease in the adolescent: comparison of transabdominal and transvaginal sonographic evaluation.

Transabdominal (TA) and transvaginal (TV) sonograms (n = 116) were obtained in 84 patients aged 12-21 years (mean, 16.2 years) with the clinical diagnosis of acute pelvic inflammatory disease (PID). The studies were compared for image quality and unique diagnostic information. TV sonography demonstrated superior resolution of 25 dilated fallopian tubes. Heterogeneous pelvic masses, described as tubo-ovarian abscesses on TA sonograms, could be separated on TV sonograms into various stages of PID including pyosalpinx, hydrosalpinx, tubo-ovarian complex, and tubo-ovarian abscess. Thirty-one TA and TV studies were normal despite patients fulfilling strict clinical criteria for PID. The level of severity of PID, as determined at TA sonography, was altered in 28 cases, with medical therapy changed in 23 cases because of additional TV sonographic findings. TV sonography provided superior anatomic detail in the evaluation of patients with PID, demonstrating abnormalities that were not seen at TA sonography in 71% of patients.

Adnexal and cul-de-sac abnormalities: transvaginal sonography.

Sixty-seven patients selectively chosen from 354 undergoing conventional transabdominal (TA) sonography for evaluation of a clinically suspected adnexal mass subsequently underwent transvaginal (TV) sonography either because the TA sonograms were technically suboptimal or because it was not possible to characterize with certainty an abnormality identified with TA sonography. TV sonography added diagnostically useful information in 25 of 28 patients with cystic pathologic changes in the adnexa uteri. Eight of 12 patients with tuboovarian abscess and nonspecific adnexal masses visualized with TA sonography had tube-shaped fluid collections characteristic of pyosalpinx identified with TV sonography. TV sonography added diagnostically useful information in all seven patients with diseases of the cul-de-sac (rectouterine fossa) and allowed differentiation of adnexal from primary uterine disease in three patients with TA sonograms on which findings were equivocal. It also expedited the diagnosis of a tubal pregnancy in ten of 14 patients and was useful in the detection of adhesions and perforated intrauterine devices. These results indicate that adjunctive TV sonography can provide important diagnostic information.

Oocyte pickup by laparoscopy replaced by transvaginal aspiration in an in vitro fertilization program.

The results of laparoscopic (lap) and transvaginal (TV) oocyte pickups (OPUs) performed concurrently for in vitro fertilization in 232 consecutive treatment cycles have been reviewed. The patients were compared for age, preoperative estradiol concentration, luteal-phase support, and number of follicles aspirated and were found to be similar but were not matched for cause of infertility. The lap OPU group had more oocytes recovered per follicle aspirated (P less than 0.001), but because of a lower fertilization rate (P less than 0.01), the number of embryos transferred was similar. Nevertheless, more (P less than 0.05) pregnancies occurred in the TV OPU group. Patients were subgrouped so that comparisons of patients with the same cause of infertility, tubal disease alone, were considered. This showed that the pregnancy rate was still higher in the TV OPU group (P less than 0.05). TV OPU was less painful and not associated with increased morbidity, and since the data suggest that TV OPU was at least as successful as lap OPU, it is recommended that all oocyte pickups in the future be performed transvaginally.

Antifertility effects of immunoglobulins from uterine fluids of semen-immunized rabbits.

The effects on fertility of the immunoglobulins, IgG (similar to serum IgG) and secretoy IgA (the predominant IgA in uterine fluid, different from serum IgA) and the fluids from the uteri of semen-immunized rabbits were studied. Female rabbits were immunized either by transvaginal (TV) injections (every 4 or 5 days for 3 weeks) with adjusted semen added to buffered saline containing .5 mg each polyadenylic acid )Poly-A) and polyuridylic acid or a combination of transvaginal injections and systemic injections with rabbit semen mixed with adjuvant (each once weekly for 3 weeks). 2 weeks following the last injection of semen each rabbit received a TV injection followed in 1 week by an instillation of semen and Poly A and U into uterine horns ligated at both ends. 2 weeks following intrauterine (IU) instillation uterine contents were withdrawn. Uteri were reinstilled. Passive hemagglutinating (PHA) and sperm-immobilizing antibody titers were determined on both serum and adjusted uterine fluid (UF) samples. Sperm immobilizin tests and PHA were positive in all serum samples from the contained immunization group, and PHA were positive in 4 out of 7 UF samples of this group. 2 out of 10 and 3 out of 10 samples from the TV group were positive for SI and PHA, respectively, and 4 out of 10 UF samples were PHA positive. Treatment of rabbit semen with UF samples prior to insemination of estrous rabbits resulted in an implantation rate of 2.8% for the combined immunization group and 24.2% for the TV group compared to 79.2% for controls. Some IUF samples without detectable antibodies appeared to inhibit fertility. The implantation rate of sperm treated with immune UF from the TV group absorbed with goat normal serum, anti-rabbit gamma-globulin serum, anti-rabbit-secretory IgA serum, anti-rabbit IgG serum, or sperm, were 3.4%, 88.9%, 42.9%, 64%, and 73. 3% respectively. SIgA and IgG antibodies were seperated by gel filtration. 2 of 4 pooled IgA samples and 3 of 4 pooled IgG samples depressed fertility, with 24.3% and 22.6% implantation and 25.8% 5, and 0% implantation, respectively. To assure that the antifertility effects observed were due to sperm antibodies of each immunoglobin class, SIgA fractions of 2 IUF pools were subjected to anion-exchange chromatography, and both SIgA and IgG fraction were absorbed with goat NS, anti-SIgA, and anti-IgG. IgG fractions absorbed with anti-SIgA or anti-IgG resulted in implantation rates of 0% and 56.8%, respectively, compared to a control of 89.5%. SIgA fractions absorbed with anti-SIgA or anti-IgG resulted in implantation rates of 81.8% and 19.4%. Thus IgG and secretory IgA of the uterine fluids are active in inhibition of fertility.