Severe pelvic organ prolapse treated by vaginal native tissue repair: long-term analysis of outcomes in 146 patients

Aims

The aim of this study was to assess the effectiveness and safety of vaginal native tissue repair (VNTR) as a surgical treatment for severe pelvic organ prolapse (POP) and, second, to evaluate the impact on the quality-of-life (QoL) and sexual function.

Methods

Women with symptomatic POP (≥III stage according to POP Quantification System) with or without stress urinary incontinence (SUI) underwent VNTR. The clinical stage, 3-day voiding diary, and urodynamic testing were evaluated in the preoperative and postoperative times, respectively. The International Consultation on Incontinence Questionnaire–Urinary Incontinence Questionnaire Short Form (ICIQ–UI SF), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12), and the prolapse quality-of-life questionnaire (P-QoL) were administered.

Results

One hundred forty-six patients were recruited. The median follow-up was 48 months (36–63). Fifty-two women (36%) had a previous hysterectomy, and 16 (11%) had a previous prolapse/continence surgery. Preoperatively, 135 (92.5%), 109 (74.7%), and 98 (67.1%) patients had anterior, central, and posterior descent ≥III stage, respectively. Thirty-two patients (22%) had concomitant diagnosis of SUI. Median operative time was 85 min (37–154), and median postoperative hospital stay was 2 days (2–4). No intraoperative severe complications occurred. At the long-term follow-up, the subjective cure rate for prolapse was 97.3% and the objective cure rate was 91.1%. A significant improvement of ICIQ-UI SF, the P-QoL, and the PISQ-12 was recorded at the follow-up (p?<?0.001).

Conclusion

VNTR is effective, safe, and durable and improves POP-related symptoms and sexual function.

     

Hysterectomy technique and risk of pelvic organ prolapse repair: a Danish nationwide cohort study

Purpose

The purpose was to investigate, in a large cohort, how hysterectomy technique influences the incidence of subsequent pelvic organ prolapse (POP) repair among women hysterectomized for benign conditions.

Methods

From the Danish National Patient Registry, we collected data on all hysterectomies on benign indications, and all POP operations performed in Denmark from January 1, 1977 to June 10, 2016. We excluded patients with prior POP repair. We analyzed the incidence of POP surgery by cumulative incidence curves and hazard ratio (HR) for women with and without POP diagnoses or concomitant POP repair at hysterectomy.

Results

In all, 178,282 women underwent hysterectomy in the study period and were included in the cohort. When examining the crude HR for the risk of POP repair after hysterectomy, vaginal hysterectomy (VH) had a threefold rise in HR compared to total abdominal hysterectomy (TAH). When restricting the analyses to women without POP at time of hysterectomy, the HR for VH decreased to 1.25. The same tendency was noticed when stratifying by compartment. In the subgroup of women without POP at hysterectomy, we found that supravaginal abdominal hysterectomy had a small increase in risk compared to TAH. Laparoscopic hysterectomy had the same risk of POP as TAH.

Conclusions

Overall, we found only small differences in risk of POP repair between the different hysterectomy techniques after restricting the analyses to women without POP at hysterectomy.

     

Dienogest Versus Leuprolide Acetate for Recurrent Pelvic Pain Following Laparoscopic Treatment of Endometriosis

Objective

To compare the efficacy and safety of dienogest (DNG) with depot leuprolide acetate (LA) in patients with recurrent pelvic pain following laparoscopic surgery for endometriosis.

Design

Prospective randomized trial.

Setting

Zagazig University hospitals, Egypt.

Patients

Two hundred and forty-two patients with recurrent pelvic pain following laparoscopic surgery for endometriosis.

Intervention

Dienogest (2 mg/day, orally) or depot LA (3.75 mg/4 weeks, intramuscularly) for 12 weeks.

Main Outcome Measures

A visual analogue scale was used to test the intensity of pain before and after the end of treatment.

Results

There was highly significant reduction in pelvic pain, back pain and dyspareunia in both groups with mean of difference in dienogest group (28.7?±?5.3, 19.0?±?4.3 and 20.0?±?3.08 mm, respectively) and in LA group (26.2?±?3.01, 19.5?±?3.01 and 17.9?±?2.9 mm, respectively). The most frequent drug-related adverse effects in dienogest group were vaginal bleeding and weight gain (64.5 and 10.8%, respectively) which were significantly higher than LA group (21.5 and 3.3%, respectively). While the most frequent drug-related adverse effects in LA group were hot flushes and vaginal dryness (46.3 and 15.7%, respectively) which were significantly higher than dienogest group (15.7 and 3.3%, respectively).

Conclusion

Daily dienogest is as effective as depot LA for relieving endometriosis-associated pelvic pain, low back pain and dyspareunia. In addition, dienogest has acceptable safety, tolerability and lower incidence of hot flushes. Thus, it may offer an effective and well-tolerated treatment in endometriosis.

     

Laparoscopic sacral colpopexy and a new approach to mesh fixation: a randomized clinical trial

Purpose

Laparoscopic sacral colpopexy (LSC) plus supracervical hysterectomy (LSH) for pelvic organ prolapse (POP) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to vaginal-mesh fixation during LSC with continuous locked suture.

Methods

This is a prospective randomized double-blinded clinical trial enrolling 90 patients with severe POP from January 2016 to April 2017. Patients underwent LSH plus a “two-meshes” LSC and were randomized, regarding mesh fixation, in Group 1 (extracorporeal interrupted 3-0 delayed absorbable sutures) and Group 2 (running locked 3-0 delayed absorbable suture). Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications.

Results

A total of 42 patients for group completed the study. Baseline characteristics were similar between the groups. Overall mesh fixation time (24 vs. 39 min; p?<?0.01), and operative time (121 vs. 138 min; p?<?0.05) resulted significantly lower in Group 2. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications.

Conclusions

Laparoscopic continuous locked 3-0 absorbable suture for anterior and posterior mesh fixation during LSC guaranteed a faster and effective alternative to multiple interrupted sutures. The significant operative time reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LSC.

     

A long-term cohort study of surgery for recurrent prolapse comparing mesh augmented anterior repairs to anterior colporrhaphy

Background

There are safety concerns regarding the use of mesh in vaginal surgery with a call for long-term follow-up data. This study was designed to evaluate the long-term safety and efficacy of vaginal repairs performed for recurrent cystocele using Perigee (non-absorbable trans-obturator) mesh.

Methods

A retrospective consecutive cohort of 48 women who underwent surgery for recurrent prolapse between March 2007 and December 2011 in a single centre was reviewed. Satisfaction was assessed using the patient global impression of improvement (PGI-I). Symptoms were assessed with the pelvic floor distress inventory (PFDI). Women were questioned regarding pain, sexual activity and pelvic floor surgery performed since the original procedure and examined for erosion. Women were compared to 25 controls from a consecutive cohort of repeat anterior colporrhapies.

Results

The mean length of follow-up was 6.5 years (78 months; range 48–106). Significantly more women in the mesh group reported that they were “much better” or “very much better” (69 vs 40% p?=?0.02). The rate of mesh erosion at follow-up was 11.6%. Two women in the mesh group required surgical excision of eroded mesh in the operating room (4%). The reoperation rate for a combination of de novo stress incontinence, recurrent prolapse and mesh exposure was similar in each group (33% mesh vs 32% native tissue).

Conclusions

A vaginal mesh repair using a non-absorbable trans-obturator mesh has improved satisfaction compared to an anterior colporrhaphy.

     

LAVH superior to TVH when concomitant salpingo-oophorectomy is intended in prolapse hysterectomy: a comparative cohort study

Purpose

This comparative cohort study evaluated the influence of surgical route for prolapse hysterectomy (vaginal or laparoscopically assisted) on the achievement of intended elective salpingo-oophorectomy, which was a procedural goal planned with the patient before primary vaginal native-tissue prolapse surgery.

Methods

Consecutive patients who underwent total vaginal hysterectomy (TVH; n?=?163) or laparoscopically assisted vaginal hysterectomy (LAVH; n?=?144) and vaginal native-tissue repair for pelvic organ prolapse at Jena University Hospital were enrolled.

Results

Peri- and postoperative parameters, including Clavien–Dindo (CD) classification of surgical complications, were compared between groups using Student’s t test, Fisher’s exact test, and multivariable regression. Patient characteristics were similar, except that grade IV prolapse was more common in the LAVH group (p?<?0.001). The following parameters differed between the TVH and LAVH groups: concomitant salpingectomy (1.2% vs. 34%) and salpingo-oophorectomy (45% vs. 66%), non-performance of intended salpingo-oophorectomy (36% vs. 0% OR 0.006, 95% CI < 0.001–0.083), adhesiolysis (0% vs. 44%), CD II–III complications (51% vs. 14.6% p < 0.001), operating time (153?±?61 vs. 142?±?27 min), and postoperative in-patient days (9.02?±?4.9 vs. 4.99?±?0.96; all p?<?0.001).

Conclusions

LAVH enabled the safe performance of planned concomitant salpingo-oophorectomy in all cases. To achieve the procedural goal in such cases, laparoscopic assistance in prolapse hysterectomy should be considered.

     

Fractionated Palliative Pelvic Radiotherapy as an Effective Modality in the Management of Recurrent/Refractory Epithelial Ovarian Cancers: An Institutional Experience

Background

The advent of effective chemotherapeutic agents for ovarian carcinoma has made radical abdomino-pelvic radiation redundant. Nevertheless, palliative pelvic radiotherapy still has a role in palliating local symptoms. However, its effect on progression-free survival (PFS) may be debated.

Aims

To study the outcome of fractionated palliative pelvic radiotherapy in relapsed ovarian cancers in terms of symptom control and PFS.

Methods

Twenty-three patients of ovarian cancers, heavily pretreated with chemotherapy and with recurrent or residual pelvic masses, were planned for palliative pelvic radiotherapy to the dose of 46–50 Gy in 23–25 fractions in 4.5–5 weeks. Symptom control and outcomes have been analyzed.

Results

Post-radiotherapy, abdominal pain was controlled in 15 out of 17 patients (88.2 %), bleeding per vaginum in all 5 patients and vaginal discharge stopped in 4 out of 5 patients (80 %). On follow-up, of 23 patients, 17 (74 %) had progressive disease post-radiation, and median time to disease progression was 10 months (range 1–49). On univariate analysis, increased PFS was observed in patients who received radiation late in their course of disease, those with serous histology, and with lesser disease bulk in pelvis (≤2 cm) prior to radiation initiation.

Conclusion

Fractionated palliative pelvic radiotherapy is an efficient method for symptom palliation in relapsed ovarian cancers. Patients who are heavily pretreated with chemotherapy and have a small-volume pelvic disease may show a prolonged PFS with addition of pelvic radiotherapy. Indications of radiotherapy, however, need to be defined.

     

The effect of tension-free vaginal tape placement on distal anterior vaginal wall support at the time of laparoscopic sacral colpoperineopexy

Purpose

The occurrence of stress urinary incontinence and pelvic organ prolapse can often coexist resulting in the need for concomitant surgical procedures to treat both conditions. The purpose of this study was to determine if tension-free vaginal tape (TVT^®) at the time of laparoscopic sacral colpoperineopexy (LSCP) had an effect on distal anterior vaginal wall support.

Methods

This was a retrospective cohort study of patients that had LSCP between January 2005 and December 2007 (n = 121). These patients were divided according to those with (n = 63) and without TVT (n = 58) at the time of LSCP. Pre- and postoperative information was compared between groups using Student’s t tests, ANCOVA, and Fisher’s exact tests (P ≤ 0.05).

Results

Preoperatively, there were no significant differences between groups for all demographic and anatomic variables (P > 0.05). Patients were followed-up until 12 months after surgery. Patients with and without TVT had similar postoperative anterior vaginal wall measurements (points Aa and Ba) and stage of prolapse (P > 0.05). There were also no differences between groups with regard to recurrent prolapse symptoms or surgical satisfaction (P > 0.05).

Conclusions

Tension-free vaginal tape at the time of LSCP did not improve postoperative distal anterior vaginal support.

     

Comparative mid-term anatomical and functional outcomes following laparoscopic sacrocolpopexy in women under and over 65: results from a prospective study

Purpose

To compare mid-term anatomical and functional outcomes following laparoscopic sacrocolpopexy (LS) between women under and over 65.

Methods

Prospective and observational study involving patients with symptomatic pelvic organ prolapse (POP) undergoing LS. Study population was stratified according to patients’ age at the time of surgery. POP symptoms and impact on quality of life were assessed by PFIQ-7 and PFDI-20 questionnaires at baseline and during follow-up.

Results

Among our study population (n?=?72), 26 women were over 65 and 46 under 65. Mean follow-up duration was 17.6 months, and complete follow-up was available in 90% of patients. No differences between study groups were observed regarding surgery duration, length of stay, and peri-operative complications. Recurrence rate was 1.4% at 18 months of follow-up. Questionnaires analysis revealed a significant improvement in PFIQ-7 and PFDI-20 scores. We found no differences in post-operative scores between control and elderly groups. Sixteen patients experienced de novo stress urinary incontinence (22.2%), with no difference between groups (p?=?0.7). Among them, seven required surgical management.

Conclusions

LS was associated with high anatomical success rate and good functional outcomes, regardless of age at the time of surgery. LS should thus be considered in women over 65. Beyond age, the route of surgery should be driven by patient’s choice and medical condition.

     

Pelvic organ prolapse surgery in elderly patients

Purpose

Pelvic organ prolapse (POP) can cause incomplete bladder emptying or hydronephrosis and renal failure. These are serious conditions, especially in elderly women, requiring resolution of POP. Pessary use is an alternative, but there are specific problems or patients may not want it. We therefore conducted a retrospective study on surgical treatment of elderly women with respect to the type of surgery and intra- and postoperative complications.

Methods

From two urogynecologic centers, we reviewed treatment data between 2003 and 2013, including patients ≥80 years of age. From the hospital records, intra- and postoperative data were extracted.

Results

91 cases met the inclusion criteria. Mean age was 84.38 years (±3.05, max 92 years). Two patients (2.2%) were diagnosed with hydronephrosis and two with urosepsis/renal failure. The mean length of surgery was 81 min (±45 min, range 10–270), 94.5% of patients were under general anesthesia. Two bowel lesions occurred. The mean length of hospital stay was 8 days (range 1–22, n = 90). There were no perioperative mortalities. Six patients (6.6%) were admitted to intensive care unit.

Conclusions

In the future, we will be facing a growing number of elderly women seeking care for POP. In our retrospective analysis, we were able to show that POP surgery could be performed safely. We therefore consider surgical treatment as a valuable alternative if pessary use is not an option.

     

Effects of bariatric surgery on pelvic floor disorders in obese women: a meta-analysis

Purpose

Obesity is an established risk factor for pelvic floor disorders (PFD) but the effects of bariatric surgery on PFD are uncertain. This meta-analysis was conducted to evaluate the effects of bariatric surgery on PFD in obese women.

Methods

A systematic search of PubMed, Cochrane Library, CNKI and CBM databases up to October 2016 was performed, and studies reporting pre-operative and post-operative outcomes in obese women undergoing bariatric surgery were included. The Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Incontinence Questionnaire (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Female Sexual Function Index and the International Consultation on Incontinence Questionnaire-Urinary Incontinence short form score were used for evaluating pelvic floor dysfunction after bariatric surgery.

Results

Eleven cohort studies were finally included. Pooled results revealed that bariatric surgery was associated with a significant improvement in PFD for obese women on the whole [PFDI-20: SMD = 0.89, 95% CI (0.44, 1.34), P < 0.001; PFIQ-7: SMD = 1.23, 95% CI (0.17, 2.29), P = 0.023]. In the subscale analysis, there was significant improvement in urinary incontinence and pelvic organ prolapse. However, no significant improvement was found in fecal incontinence and sexual function.

Conclusions

Bariatric surgery is associated with significant improvement in urinary incontinence, and has a benefit on pelvic organ prolapse for obese women. However, there is no significant improvement in fecal incontinence and sexual function. Further multi-center, large-scale and longer-term randomized controlled trials are needed to confirm these results.

     

The use of barbed sutures for vaginal cuff closure during laparoscopic hysterectomy

Purpose

To compare surgical outcomes and complications of 334 women who underwent total laparoscopic hysterectomy with or without the use of barbed sutures for vaginal cuff closure.

Methods

A retrospective study was conducted on a cohort of women who underwent total laparoscopic hysterectomy for benign gynecologic diseases at Dae-Jeon St. Mary’s Hospital, between May 2009 and May 2016. Surgical outcomes and complications were compared between the two groups.

Results

A total of 334 women were included: 212 cases of vaginal cuff suture performed with traditional suture material and 122 cases of vaginal cuff suture performed with the barbed suture. No difference in major complications including vaginal bleeding and vaginal cuff dehiscence was found between the two groups, with a significant reduction in operative times for the barbed suture group (P = 0.002). Underlying clinical variables including diabetes, pelvic adhesion, and obesity showed no significant differences in complication rate.

Conclusion

Vaginal cuff suture performed with barbed suture material is a safe and well-tolerated procedure and reduces operative times. We did not find any meaningful decrease in postoperative vaginal complications including vaginal cuff dehiscence based on the suture material.

     

Oral Misoprostol Solution for Induction of Labour

Objective

To determine the effects of oral misoprostol solution for induction of labour.

Study Design

This is a prospective observational study.

Setting

This study was conducted in Government Medical College, Aurangabad.

Method

Patients undergoing induction of labour after 36 weeks of pregnancy were allocated by randomization to induction of labour with oral misoprostol solution administered 2 h apart. Delivery within 24 h after induction with oral misoprostol solution was the primary outcome on which the sample size was based. The data were analysed by Statistical Software for Social Sciences software.

Result

Two hundred patients were randomly selected for induction with oral misoprostol solution. There were no significant differences in substantive outcomes. Vaginal delivery within 24 h was achieved in 80.5 % of patients. The caesarean section rate was 19.5 %. Uterine hyperactivity occurred in 4 % of patients. The response to induction of labour in women with unfavourable cervices (modified Bishop’s score <2) was somewhat slower with misoprostol, induction to delivery interval was more, oxytocin requirement was more, and vaginal delivery rate was less.

Conclusion

This new approach to oral misoprostol solution administration was successful in achieving vaginal delivery rate in 24 h in 80.5 % of patients; rate of LSCS was less 19.5 %.

     

Association between pelvic floor dysfunction,and clinical and ultrasonographic evaluation in primiparous women: a cross-sectional study

Purpose

Disorders related to pelvic floor include urinary incontinence (UI), anal incontinence, pelvic organ prolapse, sexual dysfunction and pelvic pain. Because pelvic floor dysfunctions (PFD) can be diagnosed clinically, imaging techniques serve as auxiliary tools for establishing an accurate diagnosis. The objective is to evaluate the PFD in primiparous women after vaginal delivery and the association between clinical examination and three-dimensional ultrasonography (3DUS).

Methods

A cross-sectional study was conducted in a in tertiary maternity. All primiparous women with vaginal deliveries that occurred between January 2013 and December 2015 were invited. Women who attended the invitation underwent detailed anamnesis, questionnaire application, physical examination and endovaginal and endoanal 3DUS. Crude and adjusted predictor factors for PFD were analyzed.

Results

Fifty women were evaluated. Sexual dysfunction was the most prevalent PFD (64.6%). When associated with clinical features and PFD, oxytocin use increased by approximately four times the odds of UI (crude OR 4.182, 95% CI 1.149–15.219). During the multivariate analysis, the odds of UI were increased in forceps use by approximately 11 times (adjusted OR 11.552, 95% CI 11.155–115.577). When the clinical and obstetrical predictors for PFD were associated with 3DUS, forceps increased the odds of lesion of the pubovisceral muscle and anal sphincter diagnosed by 3DUS by sixfold (crude OR 6.000, 95% CI 1.172–30.725), and in multivariate analysis forceps again increased the odds of injury by approximately 7 times (adjusted OR 7.778, 95% CI 1.380–43.846).

Conclusion

Sexual dysfunction was the most frequent PFD. The use of forceps in primiparous women was associated with a greater chance of UI and pelvic floor muscle damage diagnosed by 3DUS.

     

Prevalence,Clinical and Laparoscopic Features of Endometriosis Among Infertile Women

Objective

To study the prevalence, clinical and laparoscopic characteristics of endometriosis in infertile women.

Study Design

This is a hospital-based prospective study.

Patients

Five hundred and two (502) patients underwent diagnostic laparoscopy for evaluation of cause for infertility. Staging of endometriosis was done according to the rAFS scoring system.

Results

Out of 502 women, 276 (54.98 %) showed the presence of endometriosis, while 226 (45.01 %) did not have endometriosis. One hundred and eighty-three (66.3 %) women had stage I endometriosis, 49 (17.77 %) had stage II, 23 (8.33 %) had stage III and 21 (7.6 %) had stage IV endometriosis.

Conclusion

More than 50 % of patients in our study were asymptomatic; however, the presence of menorrhagia, dysmenorrhoea, dyspareunia and chronic pelvic pain are also clinically statistically significant. So, we would like to recommend the evaluation and treatment of a patient reporting in gynaecological OPD with the above-mentioned complaints with high suspicion of endometriosis.

     

How common is ballooning? Hiatal area on 3D transperineal ultrasound in urogynecological patients and its association with lower urinary tract symptoms

Introduction

Pelvic floor ultrasound plays a major role in urogynecologic diagnostics. Using 3D ultrasound we can identify integrity of levator ani and measure hiatal area in the axial plane. The main goal of our study was to measure hiatal area on Valsalva in a cohort of urogynecological patients. Furthermore, we aimed to correlate hiatal area with urogynecological symptoms, levator integrity and evaluate cut-off values for pelvic organ prolapse.

Materials and methods

In a retrospective analysis, we included 246 patients seen for urogynecological problems in our tertiary urogynecological unit. After a standardized interview and physical examination, a 3D pelvic floor ultrasound was performed. According to the cardinal urogynecological symptoms and signs, patients were categorized into three groups: pelvic organ prolapse, stress urinary incontinence and overactive bladder symptoms.

Results

Median age of our study population was 66 (range 29–94) years, median parity was 2.1 (range 0–9) with 17 (6.9 %) nulliparous women. Symptoms of overactive bladder in 71.1 % were most common, followed by 54.5 % symptoms of stress incontinence and 32.1 % symptoms of prolapse. On examination 49.2 % showed signs of prolapse. Levator avulsions on 3D ultrasound were detected in 20.7 %. Hiatal area was normally distributed with a median of 28.7 cm² (range 10.4–50.0 cm²). Patients with levator avulsion had a significantly larger hiatal area (p < 0.001). Also patients with signs of prolapse had a significantly larger hiatal area (p < 0.001). There was no correlation between hiatal area and symptoms of overactive bladder (p = 0.374). Although not reaching statistical significance there was evidence of a smaller hiatal area for patients with stress incontinence (p = 0.016). In our cohort there were 33.7 % (83) women without ballooning, 27.2 % (67) showed mild, 18.3 % (45) moderate, 12.3 % (30) marked and 8.5 % (21) severe ballooning. The ROC curve analysis for hiatal area on patients with prolapse yielded an AUC of 0.755 [95 % CI (0.696–0.814)]. Using the Youden-Index we obtained 27.53 cm² as a cut-off with a sensitivity of 0.70 and a specificity of 0.69.

Discussion

Hiatal area is a new repeatable diagnostic parameter. Its clinical application could improve our understanding of the pathophysiology of pelvic organ prolapse as a form of hiatal hernia.

     

Predicting Successful Trial of Labor After Cesarean Delivery: Evaluation of Two Scoring Systems

Background

Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient’s preexisting demographic and clinical factors.

Objective

To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.

Methods

Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.

Results

A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.

Conclusion

Both prediction models, the FLAMM and the “close to delivery” nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

     

Comparison Between Sublingual and Vaginal Administration of Misoprostol in Management of Missed Abortion

Aim

The aim of the present study is to compare between sublingual administration of misoprostol and vaginal administration in the management of missed abortion.

Materials and Methods

The study was conducted in El-Shatby Maternity Hospital on 160 patients diagnosed as missed abortion by ultrasonographic examination. Cases were divided into two groups according to the methods of misoprostol administration, whether sublingual or vaginal. Patients of the two groups were observed for the times of uterine colic starting, cervical dilation, and conceptus expulsion, along with recording of any side effects.

Result

During the follow-up of our cases we found that sublingual route is more effective than vaginal route in the management of missed abortion. The difference between the two groups in percentage of conceptus expulsion was statistically significant. The most common side effects were nausea which was present in 55 % of cases in group I (sublingual) and in 40 % of cases in group II (vaginal) then severe pain in 25 % of cases in group I (sublingual) and in 20 % of cases in group II (vaginal) and hyperpyrexia in 15 % of cases in group I (sublingual) and in 5 % of cases in group II (vaginal).

Conclusion

Sublingual administration of misoprostol is more effective than its vaginal administration in missed abortion management. Side effect of misoprostol as nausea, vomiting, fever is more common with sublingual administration in comparison with its vaginal administration.

     

Sequential Versus Concurrent Use of Vaginal Misoprostol Plus Foley Catheter for Induction of Labor: A Randomized Clinical Trial

Background

To compare between the sequential and concurrent use of vaginal misoprostol plus Foley catheter for labor induction.

Methods

This single-center, non-blinded randomized study was conducted at the department of Obstetrics and Gynecology, Faculty of medicine, Zagazig University. A total of 160 women with full term singleton pregnancy, cephalic presentation and bishop score ≤ 6 were randomized for labor induction with either concurrent or sequential use of vaginal misoprostol plus Foley catheter (80 cases in each group). The primary outcome measured was induction-to-delivery interval and secondary outcomes mesaured were vaginal delivery within 24 h, number of doses needed to induce labor, need of oxytocin for augmentation of labor, cesarean section rate, maternal or neonatal complications.

Results

The mean induction-to-delivery interval was 22.33 ± 13.28 h versus 18.45 ± 14.34 h (p = 0.041) in sequential and concurrent group, respectively. The percentage of women who completed vaginal delivery within 24 h was 51% versus 61% (p = 0.046) in sequential and concurrent group, respectively. Other maternal and neonatal outcomes were similar in both groups

Conclusion

Concurrent use of vaginal misoprostol plus Foley catheter for labor induction was associated with shorter induction-to delivery interval compared to sequential use, and it increases the rate of vaginal delivery in the first 24 h.