Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study

BACKGROUND

In rural Nepal, where women face financial and geographic barriers in accessing ultrasound scans, the government initiated a Rural Obstetric Ultrasound Program (ROUSG) to train skilled birth attendants (SBAs) in rural birthing centers and expand access to routine ultrasound scans for local pregnant women. This study explores the perceived benefits and limitations of the training and implementation of this program.

METHODS

A qualitative study was conducted in 15 primary care facilities in Bhojpur and Dhading, two rural districts of Nepal. The research team conducted in-depth interviews with 15 trained SBAs and focus group discussions with 48 service recipients and 30 FCHVs to gain insight into their perceptions. All interviews and focus group discussions were recorded, reviewed, and manually coded into MS Excel.

RESULTS

Overall, our findings indicated that the ROUSG program was very well received among all our study participants, though critical gaps were identified, mostly during the training of the SBAs. These included insufficient guidance or practice opportunities during training and the challenges of implementing the mobile obstetric ultrasound service. Most importantly, though, our results suggest that the implementation of the ROUSG program increased access to prenatal care, earlier identification and referrals for abnormal scans, as well as reduced pregnancy-related stress. There was also a notable anecdotal increase in antenatal care utilization and institutional deliveries, as well as high satisfaction in both service providers and recipients.

CONCLUSION

Our findings highlighted that while the training component could use some strengthening with increased opportunities for supervised practice sessions and periodic refresher training after the initial 21-days, the program itself had the potential to fill crucial gaps in maternal and newborn care in rural Nepal, by expanding access not only to ROUSG services but also to other MNH services such as ANC and institutional deliveries. Our findings also support the use of ultrasound in areas with limited resources as a solution to identify potential complications at earlier stages of pregnancy and improve timely referrals, indicating the potential for reducing maternal and neonatal morbidities. This initial study supports further research into the role ROUSG can play in expanding critical MNH services in underserved areas and improving broader health outcomes through earlier identification of potential obstetric complications.

Effect of Timing by Endometrial Receptivity Testing vs Standard Timing of Frozen Embryo Transfer on Live Birth in Patients Undergoing In Vitro Fertilization: A Randomized Clinical Trial

Importance

Endometrial receptivity testing is purported to improve live birth following frozen embryo transfer by identifying the optimal embryo transfer time for an individual patient; however, data are conflicting.

Objective

To compare live birth from single euploid frozen embryo transfer according to endometrial receptivity testing vs standardized timing.

Design, Setting, and Participants

Double-blind, randomized clinical trial at 30 sites within a multicenter private fertility practice in the Eastern US. Enrollment was from May 2018 to September 2020; follow-up concluded in August 2021. Participants underwent in vitro fertilization, preimplantation genetic testing for aneuploidy, endometrial receptivity testing, and frozen embryo transfer. Those with euploid blastocyst(s) and an informative receptivity result were randomized. Exclusion criteria included recurrent pregnancy loss, recurrent implantation failure, surgically aspirated sperm, donor egg(s), and unmitigated anatomic uterine cavity defects.

Interventions

The intervention group (n = 381) underwent receptivity-timed frozen embryo transfer, with adjusted duration of progesterone exposure prior to transfer, if indicated by receptivity testing. The control group (n = 386) underwent transfer at standard timing, regardless of receptivity test results.

Main Outcomes and Measures

The primary outcome was live birth. There were 3 secondary outcomes, including biochemical pregnancy and clinical pregnancy.

Results

Among 767 participants who were randomized (mean age, 35 years), 755 (98%) completed the trial. All randomized participants were analyzed. The primary outcome of live birth occurred in 58.5% of transfers (223 of 381) in the intervention group vs 61.9% of transfers (239 of 386) in the control group (difference, -3.4% [95% CI, -10.3% to 3.5%]; rate ratio [RR], 0.95 [95% CI, 0.79 to 1.13]; P = .38). There were no significant differences in the intervention vs the control group for the prespecified secondary outcomes, including biochemical pregnancy rate (77.2% vs 79.5%, respectively; difference, -2.3% [95% CI, -8.2% to 3.5%]; RR, 0.97 [95% CI, 0.83 to 1.14]; P = .48) and clinical pregnancy rate (68.8% vs 72.8%, respectively; difference, -4.0% [95% CI, -10.4% to 2.4%]; RR, 0.94 [95% CI, 0.80 to 1.12]; P = .25). There were no reported adverse events.

Conclusions and Relevance

Among patients for whom in vitro fertilization yielded a euploid blastocyst, the use of receptivity testing to guide the timing of frozen embryo transfer, compared with standard timing for transfer, did not significantly improve the rate of live birth. The findings do not support routine use of receptivity testing to guide the timing of embryo transfer during in vitro fertilization.

Trial Registration

ClinicalTrials.gov Identifier: NCT03558399.

The Value of Anti-Müllerian Hormone in the Prediction of Spontaneous Pregnancy: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether serum anti-Müllerian hormone (AMH) level is a predictor of clinical pregnancy in women trying to achieve a natural conception.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for articles published until August 2020. Studies that met the inclusion and exclusion criteria were included in the meta-analysis; no language limitations were imposed. Quality was appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 checklist. Heterogeneity due to the threshold effect was identified; thus, we plotted a summary receiver operating characteristic curve and calculated its area under the summary receiver operating characteristic curve (AUC) and Cochran's Q index to assess whether AMH level is a predictor of spontaneous pregnancy. Publication bias and sensitivity were also assessed.

RESULTS

Eleven studies (4,388 women) were ultimately included in this meta-analysis. The AUC and Cochran's Q indices were 0.5932 and 0.5702, respectively. For women younger than 35 years, the AUC was 0.6355 and the Q index was 0.6025. For those older than 35 years, the AUC was 0.5536 and the Q index was 0.5403. Subgroup analyses by study type and population characteristics showed results similar to the overall outcome. No publication bias was identified, and the sensitivity analysis confirmed the robustness of the final result.

CONCLUSIONS

Serum AMH levels have poor predictive value for natural pregnancy. The predictive value of AMH was poor in the younger and older subgroups. Our findings suggest that low serum AMH levels are not associated with reduced fertility.

INTRODUCTION

This study investigated the predictive value of anti-Müllerian hormone (AMH) level for natural pregnancy. Other than age, few factors can predict the chances of natural fertility. AMH is an established biomarker of ovarian reserve that is widely used to predict oocyte yield in cases of in vitro fertilization (IVF) and menopause. In clinical practice, the applications of AMH are increasing. However, its predictive value for natural conception remains controversial. In this study, since AMH is closely related with ovarian reserve, we evaluated whether it has predictive value for natural pregnancy. Our findings will fine-tune the clinical application of AMH in pre-pregnancy counseling. The topic should be of wide interest to investigators in the reproductive endocrinology and gynecology fields.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2020 CRD42020216265, Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020216265.

Pathogenesis Based Diagnosis and Treatment of Endometriosis

Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.

Polycystic ovary Syndrome in Adolescents: Pitfalls in Diagnosis and Management

PURPOSE OF REVIEW

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder during a woman's reproductive lifespan, with well-documented diagnostic criteria and therapeutic strategies in adults; the same is not necessarily true for adolescents. The purpose of this review was to identify frequent pitfalls in PCOS diagnosis and management during adolescence.

RECENT FINDINGS

Although there is no global consensus on the definition, most experts converge to the presence of both oligo/amenorrhea and (clinical and/or biochemical) hyperandrogenism, as a prerequisite for diagnosis in adolescents. The former criterion includes: (a) consecutive menstrual intervals > 90 days even in the first year after menarche; (b) menstrual intervals persistently < 21 or > 45 days for ≥ 2 years after menarche; or (c) lack of menses by the age of 15 or 2-3 years after pubarche. However, these menstrual irregularity patterns may overlap with other common entities in adolescents, such as frequent or infrequent uterine bleeding or anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis. Clinical signs of hyperandrogenism are obscure, without well-validated criteria. Finally, the criterion of polycystic morphology cannot be safely used in adolescents, mostly due to technical limitations of the transabdominal ultrasound. Except for the efficacy of lifestyle intervention in overweight and obese adolescents with PCOS, limited and low-quality data exist regarding the available medications, such as oral contraceptives, metformin, and anti-androgens. Individualized management, guided by clinical experience and research data and close monitoring appear the most effective approach in this PCOS population for optimal control of its reproductive and metabolic outcomes. Research focusing on PCOS genetic and molecular mechanisms may elucidate what diagnostic and therapeutic strategies will be most appropriate in adolescents with PCOS in the future.

Hysteroscopic Photodynamic Diagnosis Using 5-Aminolevulinic Acid: A High-Sensitivity Diagnostic Method for Uterine Endometrial Malignant Diseases

STUDY OBJECTIVE

To examine the diagnostic accuracy of hysteroscopic photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5ALA) in patients with endometrial cancer and premalignant atypical endometrial hyperplasia.

DESIGN

A single-center, open-label, exploratory intervention study.

SETTING

University Hospital in Japan.

PATIENTS

Thirty-four patients who underwent hysteroscopic resection in the Department of Obstetrics and Gynecology at Keio University Hospital.

INTERVENTIONS

Patients were given 5ALA orally approximately 3 hours before surgery and underwent observation of the uterine cavity and endometrial biopsy using 5ALA-PDD during hysteroscopic resection. Specimens were diagnosed histopathologically and the diagnostic sensitivity and specificity of hysteroscopic 5ALA-PDD for malignancy in the uterine cavity was determined. Red (R), blue (B), and green (G) intensity values were determined from PDD images, and the relationships of histopathological diagnosis with these values were used to develop a model for objective diagnosis of uterine malignancy.

MEASUREMENTS AND MAIN RESULTS

Three patients were excluded from the study because of failure of the endoscope system. A total of 113 specimens were collected endoscopically. The sensitivity and specificity of 5ALA-PDD for diagnosis of malignancy in the uterine cavity were 93.8% and 51.9%, respectively. The R/B ratio in imaging analysis was highest in malignant lesions, followed by benign lesions and normal uterine tissue, with significant differences among these groups (p <.05). The R/B and G/B ratios were used in a formula for prediction of malignancy based on logistic regression and the area under the receiver operating characteristic curve for this formula was 0.838. At a formula cutoff value of 0.220, the sensitivity and specificity for diagnosis of malignant disease were 90.6% and 65.4%, respectively.

CONCLUSION

To our knowledge, this is the first study of the diagnostic accuracy of 5ALA-PDD for malignancies in the uterine cavity. Hysteroscopic 5ALA-PDD had higher sensitivity and identifiability of lesions. These findings suggest that hysteroscopic 5ALA-PDD may be useful for diagnosis of minute lesions.

Prediction of gestational age with symphysis-fundal height and estimated uterine volume in a pregnancy cohort in Sylhet, Bangladesh

OBJECTIVE

To improve the accuracy of the prediction of gestational age (GA) before birth with the standardised measurement of symphysis-fundal height (SFH), estimation of uterine volume, and statistical modelling including maternal anthropometrics and other factors.

DESIGN

Prospective pregnancy cohort study.

SETTING

Rural communities in Sylhet, Bangladesh.

PARTICIPANTS

1516 women with singleton pregnancies with early pregnancy ultrasound dating (<20 weeks); 1486 completed follow-up.

METHODS

SFH and abdominal girth were measured at subsequent antenatal care (ANC) visits by community health workers at 24 to 28, 32 to 36, and/or >37 weeks gestation. An estimated uterine volume (EUV) was calculated from these measures. Data on pregnancy characteristics and other maternal anthropometrics were also collected.

PRIMARY OUTCOME MEASURE

GA at subsequent ANC visits, as defined by early ultrasound dating.

RESULTS

1486 (98%) women had at least one subsequent ANC visit, 1102 (74%) women had two subsequent ANC visits, and 748 (50%) had three visits. Using the common clinical practice of approximating the GA (in weeks) with the SFH measurement (cm), SFH systematically underestimated GA in late pregnancy (mean difference -4.4 weeks, 95% limits of agreement -12.5 to 3.7). For the classification of GA <28 weeks, SFH <26 cm had 85% sensitivity and 81% specificity; and for GA <34 weeks, SFH <29 cm had 83% sensitivity and 71% specificity. EUV had similar diagnostic accuracy. Despite rigorous statistical modelling of SFH, accounting for repeated longitudinal measurements and additional predictors, the best model without including a known last menstrual period predicted 95% of pregnancy dates within ±7.4 weeks of early ultrasound dating.

CONCLUSIONS

We were unable to predict GA with a high degree of accuracy before birth using maternal anthropometric measures and other available maternal characteristics. Efforts to improve GA dating in low- and middle-income countries before birth should focus on increasing coverage and training of ultrasonography.

TRIAL REGISTRATION NUMBER

NCT01572532.

Follicular Output Rate and Follicle-to-Oocyte Index of Low Prognosis Patients According to POSEIDON Criteria: A Retrospective Cohort Study of 32,128 Treatment Cycles

OBJECTIVE

To investigate ovarian sensitivity in subgroups of patients with a low prognosis, as defined by the POSEIDON criteria, undergoing in vitro fertilization treatment and measures to improve ovarian sensitivity in these patients.

DESIGN

We conducted a retrospective cohort analysis.

SETTING

The study was conducted at an IVF clinic in a public hospital.

PATIENTS

A total of 32,128 fresh IVF cycles from January 2014 to October 2018 at a single IVF clinic were included in the analysis. Patients with a low prognosis were categorized into four groups based on the POSEIDON criteria.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome measures were the follicular output rate (FORT) and the follicle-to-oocyte index (FOI).

RESULTS

The FORTs in the order from the highest to the lowest were 1.18 in group 3, 0.98 in group 4, 0.76 in group 1, and 0.68 in group 2. The trend in the FOI values was consistent with that in the FORTs. Among patients with poor ovarian sensitivity, 58.41% of patients with FORTs ≥ 0.30 in the second cycle underwent an adjustment to the ovarian stimulation (OS) protocol and 41.59% underwent an adjustment to the gonadotropin (Gn) starting dose. Among patients with normal ovarian sensitivity, 43.56% of those with FORTs ≥ 0.80 in the second cycle underwent an adjustment to the OS protocol and 56.44% underwent an adjustment to the Gn starting dose.

CONCLUSION

Ovarian sensitivity was the highest in group 3 (young women with poor ovarian reserve), followed by groups 4 (women at advanced age with poor ovarian reserve) and 1 (young women with good ovarian reserve), and it was the lowest in group 2 (women at advanced age with good ovarian reserve). For patients with poor ovarian sensitivity, it is preferred to recommend an adjustment to the OS protocol, while for those with normal ovarian sensitivity, adjusting the Gn starting dose is preferred.

A Novel Ultrasound Technique Called Saline Infusion SonoPODography to Visualize and Understand the Pouch of Douglas and Posterior Compartment Contents: A Feasibility Study

Women with infertility are often investigated with saline-infusion sonohysterography and hysterosalpingo-contrast-sonography. The high prevalence of endometriosis in this population also warrants an evaluation with transvaginal ultrasound for deep endometriosis. To minimize investigations, we prospectively evaluated the feasibility of a novel combined ultrasound technique called saline-infusion sonoPODography. In most patients, the fluid infused to assess the cavity and tubal patency spilled through patent tubes and filled the pouch of Douglas, yielding a "standoff" view of posterior compartment structures, including uterosacral ligaments, rectovaginal septum, and the pouch of Douglas. We believe this improved our ability to evaluate this space.

Prediction of duration of labor based on biomechanical measurements of the cervix: A preliminary study

OBJECTIVE

Induction of labor is a common procedure in obstetrics. Predictability of duration of labor could facilitate planning as well as patient's satisfaction. The primary purpose of this study was to evaluate the usefulness of a new biomechanical measurement of the cervix based on the aspiration technique for predicting the duration of labor after induction.

STUDY DESIGN

This was a prospective single centre study. Inclusion criteria were term nulliparous pregnant women with an unfavourable cervix who needed an induction of labor. Digital (Bishop score), sonographic (cervical length and cervical consistency index (CCI)) as well as aspiration measurements (closure pressure) of the cervix were performed and compared to duration of labor. The technical feasibility and the acceptability of the measurements were explored.

RESULTS

There were no technical complications of the sonographic or aspiration measurements. Measuring the Bishop score was reported as most painful examination. Both the time to active phase of labor and the time to delivery is significantly correlated with the Bishop score, but not with the cervical length, CCI or closure pressure.

CONCLUSION

The new biomechanical measurement of the cervix, based on the aspiration technique, is technically feasible and acceptable. In our small cohort no correlation was found between the closure pressure and the duration of labor.

Comparison of the pregnancy and obstetric outcomes between single cleavage-stage embryo transfer and single blastocyst transfer by time-lapse selection of embryos

To compare the pregnancy and obstetric outcomes following single cleavage-stage embryo transfer (SCT) and single blastocyst transfer (SBT) using time-lapse imaging (TLI), a total of 2066 normally fertilized and cleaved embryos from 233 patients were divided into Day 3 SCT group (n = 171) and Day 5 SBT group (n = 62) according to patient's willingness. Embryo selection criteria were based on embryo cleavage patterns, timing parameters, and blastocyst quality. The pregnancy and obstetric outcomes of each group were evaluated. There were no statistically significant differences with regard to pregnancy outcomes including the implantation rate, early abortion rate, ongoing pregnancy rate and live birth rate, and obstetric outcomes including preterm birth rate, gestational week, birth height, birth weight and fetal malformation rate between SCT group and SBT group. SBT group had significantly higher monozygotic twinning (MZT) rates than SCT group (6.98% vs. 0, p < .05). Although not statistically significant, there was a trend of higher proportion of male-to-female sex ratio at birth in SBT group than SCT group (1.38 vs. 1.05). Based on the combination of cleavage patterns and timing parameters, SCT may be an alternative to SBT because it can provide similar pregnancy and obstetric outcomes and meanwhile lower monozygotic twinning rates.

Squamous cell carcinoma arising from mature cystic teratoma of the ovary: A challenging question for gynecologic oncologists

Mature cystic teratomas of the ovary have an incidence of 1.2-14.2 cases per 100.000 people per year. Malignant transformation occurs in approximately 2% of the cases, and usually consists of squamous cell carcinoma. The preoperative detection is difficult and the diagnostic accuracy of ultrasound, magnetic resonance imaging, and computed tomography is debated. The diagnosis is frequently made in the operating room or on final histological examination. Standard treatment consists of bilateral salpingo-oophorectomy, total hysterectomy and comprehensive surgical staging in early disease and optimal cytoreductive surgery in advanced disease. Paclitaxel/carboplatin- based chemotherapy is the most used adjuvant treatment, whereas more aggressive regimens can be adopted in patients with high tumor burden or recurrent disease. The efficacy of radiotherapy is still unproven. The prognosis is poor when the tumor has spread beyond the ovary. There are few information to provide commonly accepted guidelines for this malignancy.

Dexmedetomidine sedation combined with epidural anesthesia for laparoscopy in a patient with suspected tuberculosis: A case report

RATIONALE

We herein present a case in which satisfactory analgesia and sedation were provided by the combination of epidural anesthesia with dexmedetomidine for exploratory laparoscopy in a patient who was highly suspected to have tuberculosis. This is an optimal anesthesia method to minimize the risk of nosocomial infection, especially in developing countries that lack sterilizers for anesthesia machines.

PATIENT CONCERNS

A 45-year-old woman suspected to have active tuberculosis was scheduled to undergo laparoscopy for definitive diagnosis of a pelvic mass.

DIAGNOSES

Tuberculosis was diagnosed by exploratory laparoscopy.

INTERVENTIONS

The surgery was performed under general anesthesia to prevent pain and discomfort during the procedure. However, ventilation machine used by patients with tuberculosis may have a potential risk of nosocomial infection and need disinfection by a special sterilizer machine even when using a bacterial/viral filter-heat and moisture exchanger. Therefore, the surgery was performed under continuous epidural anesthesia combined with dexmedetomidine.

OUTCOMES

The surgery was successfully completed, and pelvic tubercles were confirmed to be caseous necrotic tissue by pathologic examination. The patient began regular antituberculosis treatment after discharging from the gynecology department.

LESSONS

We conclude that administration of dexmedetomidine combined with epidural anesthesia can provide comfortable sedation for short laparoscopic procedures in patients with suspected tuberculosis. This technique can minimize the risk of nosocomial infection.

Vaginitis: Diagnosis and Treatment

Vaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Bacterial vaginosis is implicated in 40% to 50% of cases when a cause is identified, with vulvovaginal candidiasis accounting for 20% to 25% and trichomoniasis for 15% to 20% of cases. Noninfectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis, are less common and account for 5% to 10% of vaginitis cases. Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing. Bacterial vaginosis is traditionally diagnosed with Amsel criteria, although Gram stain is the diagnostic standard. Newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity have similar sensitivity and specificity to Gram stain. Bacterial vaginosis is treated with oral metronidazole, intravaginal metronidazole, or intravaginal clindamycin. The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available. Culture can be helpful for the diagnosis of complicated vulvovaginal candidiasis by identifying nonalbicans strains of Candida. Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy. The Centers for Disease Control and Prevention recommends nucleic acid amplification testing for the diagnosis of trichomoniasis in symptomatic or high-risk women. Trichomoniasis is treated with oral metronidazole or tinidazole, and patients' sex partners should be treated as well. Treatment of noninfectious vaginitis should be directed at the underlying cause. Atrophic vaginitis is treated with hormonal and nonhormonal therapies. Inflammatory vaginitis may improve with topical clindamycin as well as steroid application.

Reproductive ovarian testing and the alphabet soup of diagnoses: DOR, POI, POF, POR, and FOR

There are large variations in the number of oocytes within each woman, and biologically, the total quantity is at its maximum before the woman is born. Scientific knowledge is limited about factors controlling the oocyte pool and how to measure it. Within fertility clinics, there is no uniform agreement on the diagnostic criteria for each common measure of ovarian reserve in women, and thus, studies often conflict. While declining oocyte quantity/quality is a normal physiologic occurrence as women age, some women experience diminished ovarian reserve (DOR) much earlier than usual and become prematurely infertile. Key clinical features of DOR are the presence of regular menstrual periods and abnormal-but-not-postmenopausal ovarian reserve test results. A common clinical challenge is counseling patients with conflicting ovarian reserve test results. The clinical diagnosis of DOR and the interpretation of ovarian reserve testing are complicated by changing lab testing options and processing for anti-mullerian hormone since 2010. Further, complicating the diagnostic and research scenario is the existence of other distinct yet related clinical terms, specifically premature ovarian failure, primary ovarian insufficiency, poor ovarian response, and functional ovarian reserve. The similarities and differences between the definitions of DOR with each of these four terms are reviewed. We recommend greater medical community involvement in terminology decisions, and the addition of DOR-specific medical subject-heading search terms.

Obstetric and Gynecologic Resident Ultrasound Education Project: Is the Current Level of Gynecologic Ultrasound Training in Canada Meeting the Needs of Residents and Faculty?

OBJECTIVES

Ultrasound is a critical diagnostic imaging tool in obstetrics and gynecology (Ob/Gyn). Obstetric ultrasound is taught during residency, but we suspected a gap in Gyn ultrasound education. Proficiency in Gyn ultrasound allows real-time interpretation and management of pelvic disease and facilitates technical skill development for trainees learning blinded procedures. This study sought to evaluate ultrasound education in Canada's Ob/Gyn residency programs and assess whether residents and physicians perceived a need for a formalized Gyn ultrasound curriculum.

METHODS

We distributed a needs assessment survey to residents enrolled in Canadian Ob/Gyn residency programs and to all obstetrician/gynecologists registered as members of the Society of Obstetricians and Gynaecologists of Canada. Residents were asked to specify their current training in ultrasound and to rate the adequacy of their curriculum. All respondents rated the importance of proficiency in pelvic ultrasound for practicing obstetrician/gynecologists as well as the perceived need for formalized ultrasound training in Ob/Gyn residency programs.

RESULTS

Eighty-two residents and 233 physicians completed the survey. Extents and types of ultrasound training varied across residency programs. Most residents reported inadequate exposure to Gyn ultrasound, and most residents and physicians agreed that it is important for obstetrician/gynecologists to be proficient in Gyn ultrasound and that the development of a standardized Gyn ultrasound curriculum for residency programs is important.

CONCLUSIONS

Current ultrasound education in Ob/Gyn varies across Canadian residency programs. Training in Gyn ultrasound is lacking, and both trainees and physicians confirmed the need for a standardized Gyn ultrasound curriculum for residency programs in Canada.

Evaluation of an Obstetric Ultrasound Curriculum for Midwives in Liberia

OBJECTIVES

Point-of-care ultrasound is an effective tool for clinical decision making in low- and middle-income countries, but lack of trained providers is a barrier to its utility in these settings. In Liberia, given that midwives provide most prenatal care, it is hypothesized that training them in prenatal ultrasound through an intensive condensed training course is both feasible and practical.

METHODS

This quantitative prospective study of preobservational and postobservational assessment evaluated a 1-week ultrasound curriculum consisting of 4 modules, each comprising a didactic component, a practical session, and supervised patient encounters. A knowledge-based pretest and presurvey addressing prior use and comfort were administered. At the intervention conclusion, identical posttests and postsurveys were administered with an objective structured clinical examination (OSCE). The test, survey, and OSCE were repeated after 1 year. All scores and responses were tabulated, and qualitative analysis with paired t tests was performed.

RESULTS

Thirty-one midwives underwent intervention and written evaluation, with 14 followed up at 1 year. Seventeen underwent the OSCE, with 8 retained at 1 year. There was a significant increase between pretest and immediate and 1-year posttest scores (36.6% versus 90% and 66%; P < .001) but no difference between immediate and 1-year posttest scores (90% versus 66%; P > .05). Average overall comfort using ultrasound increased from presurvey to immediate postsurvey scores (from 1.8 to 3.8; P< .001) and remained higher at the 1-year postsurvey (1.8 to 3.4; P< .05). Overall OSCE scores remained high from immediately after the OSCE to 1 year after the OSCE (78% to 55%; P > .05).

CONCLUSIONS

Midwives in Liberia had very low baseline knowledge and comfort using ultrasound. A 1-week curriculum increased both short- and long-term knowledge and comfort and led to adequate overall OSCE scores that were retained at 1 year.

Gestational Age-specific Cut-off Values Are Needed for Diagnosis of Subclinical Hypothyroidism in Early Pregnancy

During the first trimester of pregnancy, thyroid-stimulating hormone (TSH) >2.5 mIU/L has been suggested as the universal criterion for subclinical hypothyroidism. However, TSH levels change continuously during pregnancy, even in the first trimester. Therefore the use of a fixed cut-off value for TSH may result in a different diagnosis rate of subclinical hypothyroidism according to gestational age. The objective of this study was to obtain the normal reference range of TSH during the first trimester in Korean gravida and to determine the diagnosis rate of subclinical hypothyroidism using the fixed cut-off value (TSH >2.5 mIU/L). The study population consisted of pregnant women who were measured for TSH during the first trimester of pregnancy (n=492) and nonpregnant women (n=984). Median concentration of TSH in pregnant women was lower than in non-pregnant women. There was a continuous decrease of median TSH concentration during the first trimester of pregnancy (median TSH concentration: 1.82 mIU/L for 3+0 to 6+6 weeks; 1.53 mIU/L for 7+0 to 7+6 weeks; and 1.05 mIU/L for 8+0 to 13+6 weeks). Using the fixed cut-off value of TSH >2.5 mIU/L, the diagnosis rate of subclinical hypothyroidism decreased significantly according to the gestational age (GA) at TSH (25% in 3+0 to 6+6 weeks, 13% in 7+0 to 7+6 weeks, and 9% for 8+0 to 13+6 weeks, P<0.001), whereas the diagnosis rate was 5% in all GA with the use of a GA-specific cut-off value (P=0.995). Therefore, GA-specific criteria might be more appropriate for the diagnosis of subclinical hypothyroidism.

Systematic evaluation of women with suspected endometriosis using a 5-domain sonographically based approach

In recent years, knowledge has evolved regarding the role of transvaginal sonography in the assessment of the pouch of Douglas status and the preoperative prediction of extraovarian endometriosis in specific locations. Despite these advances in transvaginal sonography, the challenge of developing a comprehensive, cost-effective, and reproducible preoperative classification system for endometriosis remains. Critical to this classification system should be a sonographically based evaluation protocol that is systematic, evidence based, and reproducible with clearly defined end points. To date, no structured evaluation protocol exists for the assessment of the pelvis in women with suspected endometriosis. In this article, we propose a domain-based evaluation protocol for the assessment of women with suspected endometriosis using transvaginal sonography.

[Role of prebioptic and bioptic methodsin the screening and diagnosis of cervical cancer]

OBJECTIVE

To describe the available prebioptical and bioptical methods used in screening and diagnosis of cervical cancer.

DESIGN

Review article.

SETTING

Center of outpatient gynecology and primary care, Brno; Department of Obstetrics and Gynecology, University Hospital, Olomouc.Subjects and methods of the study: In a review article there are outlines of the prebioptical investigative techniques and related diagnostics aim to detect, verificate and treat cervical lesions. It describes and compares various methods, including their mutual correlation.

CONCLUSION

The oncological cytology, colposcopy and HPV testing have an irreplaceable role in diagnosis of cervical cancer. Appropriate combination gives us a chance to achieve high sensitivity in detection of severe lesions of the cervix.

[What is the current stage of vulvovaginal discomfort diagnostics in the Czech Republic? Pilot analysis]

OBJECTIVE

To find out the level of the diagnostic effort of gynaecologists which is focused on the issue of vulvovaginal discomfort.

DESIGN

Pilot questionnaire study.

SETTINGS

Department of Obstetrics and Gynecology, Department of Clinical Microbiology, University Hospital and Medical Faculty Hradec Králové, Charles University, Prague, Department of Biological and Medici Sciences, FaF UK in Hradec Králové.

METHODS AND RESULTS

The evaluation of selected parametres of entrance questionnaire in patients with chronic vulvovaginal discomfort (itching, burning, discharge, vulvodynia more than 4 times a year). It has been confirmed, with the questionnaires, that almost no gynaecologists are interested in the issue of this matter.

CONCLUSION

After evaluating the questionnaires a diversion of patient-tailored attitude has been found out, which can lead to negative consequences, particularly, in the future. Overuse of antibacterial and antimycotic medication and blind treatment have been prevailing.

Simplified approach to the treatment of endometriosis--ECO system

AIM

The aim of the present study was to develop a system to facilitate the approach for patients with endometriosis, mainly for non-specialized gynecologists.

METHODS

This was a multicenter study (Canadian Task Force classification II-3). The study aimed to correlate three known parameters for endometriosis, qualifying and quantifying their importance in terms of disease severity and treatment complexity. Patients were divided into three groups.

RESULTS

Each parameter was scored from 0 to 2 in order to determine medical or surgical management for endometriosis based on the clinical and imaging results, where the total score of 0 to 2 was for medical treatment, score 3 was possible medical treatment or surgical and score of 4 to 6 was for surgical intervention. A total score from the three parameters was obtained. Anatomical extent of infiltration and complaints and objective of the patient was helpful in deciding on management of patients with endometriosis.

CONCLUSION

The ECO system can be a qualified and helpful tool in the approach to patients with suspected endometriosis, mainly for non-specialized gynecologists.

[Adding parity to the Bishop score for term labor induction: a retrospective study]

OBJECTIVE

To evaluate the interest to add parity to the Bishop score before induction of labor by intravenous oxytocin.

PATIENTS AND METHODS

This retrospective cohort study compared cesarean section rate for induction failure by intravenous oxytocin in nulliparous and multiparous with modified Bishop score from 7 to 9. The modified Bishop score is calculated by adding 2 points to the Bishop score if the patient had a previous vaginal delivery and 0 point in nulliparous.

RESULTS

Over 2 years, 468 patients were included (201 nulliparous and 267 multiparous). Cesarean section rate for induction failure was higher for nulliparous with a modified Bishop score equal to 7 or varying between 7 and 9. These results confirm that parity is an important predicting factor of successful labor induction. In multiparous, cesarean section rates for induction failure were not significantly different with Bishop score or modified Bishop score equal to 7.

CONCLUSION

Adding 2 points for multiparity at the Bishop score did not increase cesarean for failure of labor induction with intravenous oxytocin with a modified Bishop score from 7 to 9.

Does neuromuscular blockade affect the assessment of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to determine if anesthesia with neuromuscular blockade alters the Pelvic Organ Prolapse Quantification (POP-Q) examination.

METHODS

A prospective, multi-center trial was conducted of women undergoing pelvic surgery. A POP-Q examination performed pre-operatively was compared with an examination performed intra-operatively under neuromuscular blockade. For the latter examination, an Allis clamp was used to apply gentle traction until the point being examined did not undergo further descent. International Continence Society (ICS) stages and individual POP-Q points were compared using a paired sample t test. A sample size of 32 provided 80% power to detect a clinically significant difference between office and operating room measurements (Sample Power, SPSS, 1997).

RESULTS

Of 153 women, 76% received general endotracheal anesthesia and 21% laryngeal mask airway. With an increase of 3 cm, the apical compartment was significantly more prolapsed in the operating room (OR; p < 0.05); however, a comparison of the mean values demonstrated a larger change in means for all points except total vaginal length. When separated into anterior, apical, and posterior compartments, the ICS stages were systematically different in the OR than in the office for all stages (p < 0.0005).

CONCLUSIONS

Neuromuscular blockade leads to significantly greater increases in POP-Q examination measurements compared with the office measurements, and this increase is most pronounced apically.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh

INTRODUCTION AND HYPOTHESIS

We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery.

METHODS

In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test.

RESULTS

Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months.

CONCLUSIONS

Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

Ovarian aging and implications for fertility female health

Ovarian aging is a major detrimental factor of pregnancy achievement and it is related to other issues of women's health. The purpose of this review is to present an update on ovarian aging risk factors followed by contemporary methods of its assessment and an overview of its current management strategies in assisted reproductive technologies (ART). Ovarian aging is a multifactorial trait governed by several factors including medical, lifestyle, genetic, autoimmune and idiopathic. There are several established risk factors and many others that are still being revealed. Heritability has a major influence on ovarian aging. Different genetic strategies and approaches for ovarian aging evaluation have been rapidly expanding; however the mission is far from complete. Genome-wide association studies seems to be the most applicable to advance this research. Although anti-Müllerian hormone and antral follicle count (AFC) biomarkers seems to be the most reliable predictors of ovarian aging, none has demonstrated conclusive evidence to predict pregnancy achievement in an ART setting. The debate continues which of the two predictors is the most suitable in ART as well as non-ART settings. Although multivariate models have been shown to be equally predictive to AFC, latest data support the notion that chronological age and genetic markers inclusion may increase their reliability. Several strategies have been suggested to manage ovarian aging in ART settings. None of the stimulation protocols or ART interventions has been shown to be convincingly beneficial to ovarian aging women and individualization of treatment is still recommended. Ovarian priming by different androgen preparations has been shown to be promising but more randomized controlled studies are required to substantiate these findings. Except for oocyte donation other ART strategies have not shown a persuasive evidence for advanced ovarian aging infertility patients. The new development of oocyte vitrification may well introduce opportunities for fertility preservation to woman at risk. It is concluded that proper assessment and detection of ovarian aging, employing current or developing biomarkers of ovarian reserve, may enable health providers to recommend, at appropriate biological time, early pregnancy achievement or fertility preservation in women at risk.

Menstrual disorders

Menstrual disorders are very common in adolescence, and can be the cause of a significant amount of stress to both the patients and their parents. Variations of the menstrual cycle in this age are very broad and are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis. Amenorrhea (either primary or secondary), abnormal uterine bleeding and dysmenorrhea are conditions that require careful evaluation through a stepwise and logical manner. The term primary amenorrhea refers to the condition when menarche fails to occur, while secondary amenorrhea refers to the cessation of menses once they have begun. The occurrence of irregular, prolonged or heavy abnormal uterine bleeding is one of the most urgent gynecological problems in adolescence and the diagnosis of dysfunctional uterine bleeding should be used only when all other organic and structural causes of abnormal vaginal bleeding have been ruled out. Dysmenorrhea refers to painful menstruation and is the most common reason for which a young girl may refer to a gynecologist. It is characterized as primary in the absence of an underlying organic disease, and as secondary when there is evidence of pelvic pathology. Appropriate and early management of the patient is necessary in order to minimize the possibility of future complications regarding woman's reproductive ability.

Diagnostic methods in pediatric and adolescent gynecology

The evolving role of imaging techniques and endoscopic tools used in gynecologic practice has become essential over the last several years. Pelvic organs of the young girl are deeply hidden in the abdomen and the vagina is narrow and atrophic. The presence of an intact hymen provides an additional obstacle to vaginal examination. Therefore, bimanual pelvic (vaginal/rectal) examination has a limited advantage in this population. It could cause unnecessary discomfort and hamper further 'patient-doctor' dialog. Imaging techniques are constantly improving in sensitivity, thus providing more accurate diagnoses. Ultrasonography which is a safe and available modality provides real-time images of multiple planes and therefore is ideal for pelvic evaluation. It should be an integral part of child and young adolescent examination. Additional modalities such as CT and MRI should be reserved for cases which are ultrasonography doubtful and be applied as a subsequent evaluation. Vaginoscopy and laparoscopy, although invasive, are used for final diagnosis and provision of treatment as 'see and treat' procedures. These main modalities used in the diagnosis of gynecologic disorders in the young are described in this chapter.

Chronic pelvic pain in the adolescent

Chronic pelvic pain occurs commonly in the adolescent and can be a diagnostic and therapeutic challenge for the clinician, the adolescent, and her family. Defined as lower quadrant or lower abdominal pain lasting 3-6 months or longer, chronic pelvic pain can lead to missed school and activities, decreased functioning, and decreased quality of life in the adolescent. Both the primary care clinician and the pediatric gynecologist need to be aware of the most common causes of chronic pelvic pain in the adolescent, including surgical and nonsurgical, gynecologic versus other pathology including the psychosomatic, and the role of the mind in control of somatic pain in the adolescent. Adding to this complexity is the standard adolescent sense of invulnerability; a knowledge of adolescent development remains essential to the delivery of appropriate gynecologic care for this age group. Education and communication with both the adolescent and her family requires sensitivity, especially in cultures where adolescent sexuality is taboo or discouraged. This chapter will discuss the developmental stages of adolescence and how that impacts care of the patient with chronic pelvic pain at the varying ages, the issue of confidentiality when obtaining a sexual history on the adolescent, and etiologies of chronic pelvic pain specific to the adolescent, including gynecologic and nongynecologic causes. Diagnostic and treatment considerations for chronic pelvic pain in the adolescent will also be addressed.

Sexual abuse in prepubertal children and adolescents

Medical involvement in the diagnosis and treatment of child sexual abuse (CSA) has a well-defined role within a multidisciplinary concept. Due to the increasingly high rate of normal anogenital findings in victims of CSA, forensic aspects are of limited value in establishing the diagnosis. In selected cases however, medical findings may play an important role in corroborating a child's history. Correct evaluation of normal and abnormal findings, normal variations and several differential diagnoses requires sound knowledge in pediatric gynecology. In some cases, physical consequences of CSA (injuries, infections, and pregnancy) need to be diagnosed and treated (prevented) accordingly. The majority of abused children have an altered and distorted body image. It is of paramount importance to reassure the child that its body is normal, physically undamaged, intact or that it will heal ('primary therapeutic aspect of the medical examination'). Thus, the medical examination has an enormous potential to incorporate a therapeutic message into the diagnostic procedure if performed in a qualified and sensitive manner. By communicating with the psychosocial und jurisdictional systems, physicians may initiate proper child protection and therapy. Therefore, medical evaluation of sexually abused children must always be integrated into a multiprofessional concept of child protection.

Ovarian cysts in prepubertal girls

Visualization of follicles is perfectly physiological during childhood, their diameter generally does not exceed 10 mm. Ovarian cyst in childhood is well defined for a fluid image >20 mm. Generally mild and asymptomatic, ovarian cysts are fluid formations usually discovered incidentally by ultrasound. Some are hormonally active and cause the development of sexual characteristics. The natural history of functional cysts is eventual regression, and persistence is suggestive of organic tumor. The onset of pain is a sign of complication, and an abrupt sharp pain with vomiting is suggestive of ovarian torsion, in which case surgical intervention is urgent. In all cases, the diagnosis is based on pelvic ultrasound. MRI and tumor marker assays are required to determine the nature of an organic cyst before proceeding to surgery. These cysts may appear functional from the fetal period onward and will require management from the first days of life. Certain endocrine disorders such as precocious puberty, hypothyroidism, and aromatase deficiency cause functional cysts in girls. Recurrent bleeding is due to hormonally active cysts and suggests McCune-Albright syndrome. Although the persistence of a cyst suggests a neoplasm, a fluid character indicates benignity. Imagery is a useful aid in the diagnosis of epithelial tumors (cystadenomas) or teratoma (dermoid cyst).

Vulvovaginitis and other common vulvar disorders in children

Vulvovaginitis, labial adhesions, and other vulvar disorders occur commonly in children and can provoke high anxiety in both the parent and child. Performed correctly, the pediatric gynecologic examination can diagnose and treat, educate and reassure both parent and child. This examination requires patience, sensitivity, direct communication with the child as well as with the parent, and an open manner that inspires trust in both parties to manage a potentially anxiety-provoking situation. This chapter will review common vulvar disorders, including vulvovaginitis, lichen sclerosis et atrophicus, bubble bath vaginitis, labial adhesions, urethral prolapse, and other common problems. A discussion of childhood sexual abuse is beyond the scope of this chapter, with appropriate references available elsewhere. Practical pearls will be offered to make this exam easy for the primary care clinician and/or subspecialist.

Delayed puberty

Since puberty is a long ongoing developmental process with significant individual and population differences in timing, the definition of delayed puberty for a given individual needs to rest on simple, though arbitrary criteria based on epidemiological data. Although several genes involved in the hypothalamic-pituitary-gonadal maturation cascade have been characterized recently from familial or sporadic cases of primitive isolated hypogonadotropic hypogonadism, many genes regulating puberty onset remain undetermined. In case of delayed puberty and/or primary amenorrhea, a complete clinical examination including a detailed past history will evaluate the development of secondary sex characteristics, verify the association with a growth delay and look for specific indicative features pertaining to the etiological diagnosis. This clinical check-up completed if necessary with biological, ultrasonographic, radiological and genetic investigations will try to determine which girls will have a permanent sexual infantilism of gonadal, hypophyseal or hypothalamic origin, which girls will undergo spontaneous but delayed puberty and which girls have primary amenorrhea with developed secondary sex characteristics. Therapeutic attitude will have to integrate etiological factors, statural prognosis, bone mass preservation and psychological factors.

Increased endometrial placenta growth factor (PLGF) gene expression in women with successful implantation

OBJECTIVE

To analyze the vascularization of the endometrium via hysteroscopy and to assess its correlation with angiogenic factor gene expression and embryo implantation rate.

DESIGN

Cross-sectional study.

SETTING

Public university hospital.

PATIENT(S)

Patients undergoing hysteroscopy for supposed infertility.

INTERVENTION(S)

Endometrial quality assessment according to Sakumoto-Masamoto, performed in the early secretory phase of the cycle. Collection of an endometrial tissue biopsy.

MAIN OUTCOME MEASURE(S)

RNA extraction, reverse transcription, and determination of gene expression of angiogenesis- and implantation-relevant factors using quantitative polymerase chain reaction. Retrieval of pregnancy information from the medical records.

RESULT(S)

Good quantity/quality RNA with infertility history was obtained from 63 participating women. Those with a "good" endometrium and subsequent pregnancy showed increased gene expression for placenta growth factor when compared with patients with a "bad" endometrium and who did not succeed with pregnancy to date. Nonpregnant women with a "good" endometrium presented an intermediate result. No significant differences were observed for several other genes tested, but trends in the same direction were observed.

CONCLUSION(S)

This study demonstrates for the first time that endometrial PLGF expression corresponds to the hysteroscopic appearance of the endometrium, and therefore has potential as a clinically relevant prognosticator for infertility treatment success.

Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging

The prolapse of one or several pelvic organs is a condition that has been known by medicine since its early days, and different therapeutic approaches have been proposed and accepted. But one of the main problems concerning the prolapse of pelvic organs is the need for a universal, clear and reliable staging method.Because the prolapse has been known and recognized as a disease for more than one hundred years, so are different systems proposed for its staging. But none has proved itself to respond to all the requirements of the medical community, so the vast majority were seen coming and going, failing to become the single most useful system for staging in pelvic organ prolapse (POP).The latest addition to the group of staging systems is the POP-Q system, which is becoming increasingly popular with specialists all over the world, because, although is not very simple as a concept, it helps defining the features of a prolapse at a level of completeness not reached by any other system to date. In this vision, the POP-Q system may reach the importance and recognition of the TNM system use in oncology.This paper briefly describes the POP-Q system, by comparison with other staging systems, analyzing its main features and the concept behind it.

Risk of malignancy index in preoperative evaluation of pelvic masses

OBJECTIVE

The aim of this study was to evaluate the use of risk of malignancy index (RMI) based on a serum CA125 level, ultrasound findings and menopausal status in primary evaluation of patients with adnexal masses in daily clinical practice.

METHODS

One hundred and fifty one women with adnexal masses were enrolled. Ultrasound characteristics, menopausal status and serum CA125 level were documented preoperatively, and combined into the RMI afterwards. The sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of the RMI in prediction of ovarian cancer were calculated.

RESULTS

The RMI identified malignant cases more accurately than any individual criterion in diagnosing ovarian cancer. Using a cut-off level of 238 to indicate malignancy, the RMI showed a sensitivity of 89.5%, a specificity of 96.2%, a PPV of 77.3%, a NPV of 98.4% and an accuracy of 95.4%.

CONCLUSION

RMI is a simple, easily applicable method in the primary evaluation of patients with adnexal masses of high risk of malignancy, resulting in timely referal to gynecological oncology centers for suitable surgical operations.

Cervical Cancer Screening in Low Resource Settings Using Visual Inspection With Acetic Acid

Cervical cancer is one of the leading causes of death for middle-aged women in the developing world, yet it is almost completely preventable, if precancerous lesions are identified and treated in a timely manner. Cervical cancer screening based on cytologic examination is largely unavailable in developing countries or made available to a small, select group of women in private facilities, maternal child health sites, or family-planning clinics, missing the age groups at highest risk for precancerous lesions. Visual inspection with acetic acid (VIA) can be used to screen women. It can be done by nurses or midwives with appropriate training. Although still under investigation, research results show that VIA is simple, accurate, cost-effective, and acceptable to most women. This article reviews the natural history of cervical cancer and important aspects to consider related to cervical cancer screening in low resource settings. The VIA technique is described in detail.

American Academy of Pediatrics. Clinical report--gynecologic examination for adolescents in the pediatric office setting

The American Academy of Pediatrics promotes the inclusion of the gynecologic examination in the primary care setting within the medical home. Gynecologic issues are commonly seen by clinicians who provide primary care to adolescents. Some of the most common concerns include questions related to pubertal development; menstrual disorders such as dysmenorrhea, amenorrhea, oligomenorrhea, and abnormal uterine bleeding; contraception; and sexually transmitted and non-sexually transmitted infections. The gynecologic examination is a key element in assessing pubertal status and documenting physical findings. Most adolescents do not need an internal examination involving a speculum or bimanual examination. However, for cases in which more extensive examination is needed, the primary care office with the primary care clinician who has established rapport and trust with the patient is often the best setting for pelvic examination. This report reviews the gynecologic examination, including indications for the pelvic examination in adolescents and the approach to this examination in the office setting. Indications for referral to a gynecologist are included. The pelvic examination may be successfully completed when conducted without pressure and approached as a normal part of routine young women's health care.

Measurement of electrical resistance of dermal-visceral zones as a diagnostic tool for gynecologic disorders

BACKGROUND

Non-invasive screening tests may allow early diagnosis and prompt treatment, thereby potentially reducing morbidity and mortality and reducing costs for the community. This may be especially important for gynecologic pathologies that are difficult to promptly diagnose, such as endometriosis or ovarian cancer.

OBJECTIVES

To evaluate the reliability of measuring skin resistance using the Medex Test for screening and diagnosis of gynecologic pathologies in a blinded single-center study.

METHODS

We enrolled 150 patients: 59 with a functional disorder and 91 with an organic disease. Measurements were carried out in all patients and the results were analyzed separately by a second physician who was blinded to the patients' diagnosis.

RESULTS

A high correlation was found between the clinical diagnosis and the results of the measurement of electrical skin resistance, with a specificity of 76.3% (45/59) for functional disorders and a sensitivity of 85.7% (78/91) for organic disorders, positive predictive value of 84.8% (78/92) and negative predictive value 77.6% (45/58). The kappa value for the results was 0.622, representing a value much better than expected randomly.

CONCLUSIONS

The Medex Test has a good specificity and a high sensitivity for the diagnosis of gynecologic disorders. Further prospective studies are needed to validate these preliminary findings.

Near-infrared micro-Raman spectroscopy for in vitro detection of cervical cancer

Near-infrared Raman spectroscopy is a powerful analytical tool for detecting critical differences in biological samples with minimum interference in the Raman spectra from the native fluorescence of the samples. The technique is often suggested as a potential screening tool for cancer. In this article we report in vitro Raman spectra of squamous cells in normal and cancerous cervical human tissue from seven patients, which have good signal-to-noise ratio and which were found to be reproducible. These preliminary results show that several Raman features in these spectra could be used to distinguish cancerous cervical squamous cells from normal cervical squamous cells. In general, the Raman spectra of cervical cancer cells show intensity differences compared to those of normal squamous cell spectra. For example, several well-defined Raman peaks of collagen in the 775 to 975 cm(-1) region are observed in the case of normal squamous cells, but these are below the detection limit of normal Raman spectroscopy in the spectra of invasive cervical cancer cells. In the high frequency 2800 to 3100 cm(-1) region, it is found that the peak area under the CH stretching band is lower by a factor of approximately six in the spectra of cervical cancer cells as compared with that of the normal cells. The Raman chemical maps of regions of cancer and normal cells in the cervical epithelium made from the spectral features in the 775 to 975 cm(-1) and 2800 to 3100 cm(-1) regions are also found to show good correlation with each other.

Accuracy of vaginal symptom self-diagnosis algorithms for deployed military women

BACKGROUND

Deployed military women have an increased risk for development of vaginitis due to extreme temperatures, primitive sanitation, hygiene and laundry facilities, and unavailable or unacceptable healthcare resources. The Women in the Military Self-Diagnosis (WMSD) and treatment kit was developed as a field-expedient solution to this problem.

OBJECTIVES

The primary study aims were to evaluate the accuracy of women's self-diagnosis of vaginal symptoms and eight diagnostic algorithms and to predict potential self-medication omission and commission error rates.

METHOD

Participants included 546 active duty, deployable Army (43.3%) and Navy (53.6%) women with vaginal symptoms who sought healthcare at troop medical clinics on base.In the clinic lavatory, women conducted a self-diagnosis using a sterile cotton swab to obtain vaginal fluid, a FemExam card to measure positive or negative pH and amines, and the investigator-developed WMSD Decision-Making Guide. Potential self-diagnoses were "bacterial infection" (bacterial vaginosis [BV] and/or trichomonas vaginitis [TV]), "yeast infection" (candida vaginitis [CV]), "no infection/normal," or "unclear." The Affirm VPIII laboratory reference standard was used to detect clinically significant amounts of vaginal fluid DNA for organisms associated with BV, TV, and CV.

RESULTS

Women's self-diagnostic accuracy was 56% for BV/TV and 69.2% for CV. False-positives would have led to a self-medication commission error rate of 20.3% for BV/TV and 8% for CV. Potential self-medication omission error rates due to false-negatives were 23.7% for BV/TV and 24.8% for CV. The positive predictive value of diagnostic algorithms ranged from 0% to 78.1% for BV/TV and 41.7% for CV.

DISCUSSION

The algorithms were based on clinical diagnostic standards. The nonspecific nature of vaginal symptoms, mixed infections, and a faulty device intended to measure vaginal pH and amines explain why none of the algorithms reached the goal of 95% accuracy. The next prototype of the WMSD kit will not include nonspecific vaginal signs and symptoms in favor of recently available point-of-care devices that identify antigens or enzymes of the causative BV, TV, and CV organisms.

Evaluation of high-sensitivity C-reactive protein in comparison with C-reactive protein as biochemical serum markers in women with endometriosis

OBJECTIVE

To compare high-sensitivity C-reactive protein (hs-CRP) with CRP as a soluble serum marker for the diagnosis of women with endometriosis.

DESIGN

Prospective nonrandomized controlled trial (Canadian Task Force classification II-1).

SETTING

University hospital.

PATIENT(S)

Eighty-two women were laparoscopically evaluated. No endometriosis was diagnosed in 34 women (the non-E group). Endometriosis was confirmed by histology in 48 women (the E group). Eighty-two women did not undergo laparoscopic evaluation (the unknown-E group). Afterward, the women were staged according to the revised American Society for Reproductive Medicine criteria (r-ASRM).

INTERVENTION(S)

CRP and hs-CRP were measured initially before laparoscopy.

MAIN OUTCOME MEASURE(S)

The hs-CRP and CRP levels and the correlation of those parameters with the stage of the disease.

RESULT(S)

There was a trend toward higher CRP levels and higher hs-CRP levels in the E group, while the lowest levels of both markers were found in the non-E group. There was a significantly lower hs-CRP level in the non-E group in comparison with the CRP level in this group. No differences between the different stages of the disease were found with either marker.

CONCLUSION(S)

Measurement of the two markers did not appear to be advantageous for the diagnosis of endometriosis independent of the stage of the disease. Nevertheless, a very low hs-CRP level might serve as a marker for an absence of endometriosis.

[Gynecological clinical study in girls and adolescent victims of sexual abuse]

In spite of a very important under-registration, sexual abuse represents a social and public health problem worldwide. In Mexico, estimated prevalence of sexual abuse in women is 17.3%, half of them in youngsters under 15 years old. Most of cases have a late gynecological evaluation, due to a delay in a formal complaint. Gynecologist or pediatrician are the specialists who most frequently perform the genital examination of girls suspected of sexual abuse, due to this a complete knowledge of the topic is necessary in order to make an accurate diagnosis, register the physical findings and give prompt medical and psychological treatment as well as follow up to the patient. Despite the low risk of acquiring a sexually transmitted infection, it is important to evaluate the use of prophylactic treatment and the prevention of unwanted pregnancy with emergency contraception. Big efforts are being made by preventive programs on sexual abuse, sexually transmitted infections and unwanted pregnancy, all of which are serious problems in Mexican children and youths, and should constitute a fundamental part of the public politics on sexual health.

Nuclear pore complex proteins mark the implantation window in human endometrium

Nucleolar channel systems (NCSs) are membranous organelles appearing transiently in the epithelial cell nuclei of postovulatory human endometrium. Their characterization and use as markers for a healthy receptive endometrium have been limited because they are only identifiable by electron microscopy. Here we describe the light microscopic detection of NCSs using immunofluorescence. Specifically, the monoclonal nuclear pore complex antibody 414 shows that NCSs are present in about half of all human endometrial epithelial cells but not in any other cell type, tissue or species. Most nuclei contain only a single NCS of uniform 1 microm diameter indicating a tightly controlled organelle. The composition of NCSs is as unique as their structure; they contain only a subset each of the proteins of nuclear pore complexes, inner nuclear membrane, nuclear lamina and endoplasmic reticulum. Validation of our robust NCS detection method on 95 endometrial biopsies defines a 6-day window, days 19-24 (+/-1) of an idealized 28 day cycle, wherein NCSs occur. Therefore, NCSs precede and overlap with the implantation window and serve as potential markers of uterine receptivity. The immunodetection assay, combined with the hitherto underappreciated prevalence of NCSs, now enables simple screening and further molecular and functional dissection.