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Introduction and hypothesis: Er:YAG laser is frequently used in dermatology and gynecology. Clinical studies document high satisfaction rates; however, hard data on the effects at the structural and molecular levels are limited. The aim of this systematic review was to summarize current knowledge about the objective effects of non-ablative Er:YAG laser on the skin and vaginal wall. Methods: We searched MEDLINE, Embase, Cochrane, and the Web of Science. Studies investigating objectively measured effects of non-ablative Er:YAG laser on the skin or vaginal wall were included. Studies of any design were included. Owing to the lack of methodological uniformity, no meta-analysis could be performed and therefore results are presented as a narrative review. Results: We identified in vitro or ex vivo studies on human cells or tissues, studies in rats, and clinical studies. Most studies were on the skin (n = 11); the rest were on the vagina (n = 4). The quality of studies is limited and the settings of the laser were very diverse. Although the methods used were not comparable, there were demonstrable effects in all studies. Immediately after application the increase in superficial temperature, partial preservation of epithelium and subepithelial extracellular matrix coagulation were documented. Later, an increase in epithelial thickness, inflammatory response, fibroblast proliferation, an increase in the amount of collagen, and vascularization were described. Conclusions: Er:YAG laser energy may induce changes in the deeper skin or vaginal wall, without causing unwanted epithelial ablation. Laser energy initiates a process of cell activation, production of extracellular matrix, and tissue remodeling.

Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES. ispartof: ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA vol:101 issue:6 pages:649-656 ispartof: location:United States status: published

BACKGROUND: Pregnancy and childbirth increase the risk for pelvic floor dysfunction, including sexual dysfunction. So far, the mechanisms and the extent to which certain risk factors play a role remain unclear. OBJECTIVES: In this systematic review of the literature we aimed to determine risk factors for sexual dysfunction in the first year after childbirth. SEARCH STRATEGY: We searched MEDLINE, Embase and CENTRAL using the search strategy: sexual dysfunction AND obstetric events. SELECTION CRITERIA: We included original, comparative studies, reported in English, that used validated questionnaires and the ICS/IUGA terminology for sexual dysfunction, dyspareunia and vaginal dryness. DATA COLLECTION AND ANALYSIS: We assessed the quality and the risk of bias of the included studies with the Newcastle-Ottawa scale. We extracted the reported data and we performed random-effects meta-analysis to obtain the summary odds ratios (ORs) with 95% confidence intervals (95% CIs). Heterogeneity across studies was assessed using the I2 statistic. MAIN RESULTS: Anal sphincter injury was associated with increased odds for both sexual dysfunction (OR 3.00, 95%CI 1.28-7.03) and dyspareunia (OR 1.92, 95% CI 1.47-2.52). Episiotomy was associated with dyspareunia (OR 1.64, 95% CI 1.25-2.14), but not with sexual dysfunction (OR 1.90, 95% CI 0.94-3.84). Compared with spontaneous birth, caesarean section reduced the odds for dyspareunia (OR 0.68, 95% CI 0.54-0.86) but not for sexual dysfunction (OR 1.14, 95% CI 0.89-1.46). Instrumental vaginal birth increased the odds for sexual dysfunction (OR 1.70, 95% CI 1.05-2.76), yet no difference was found for dyspareunia (OR 1.82, 95% CI 0.88-3.75). One study of low quality reported on vaginal dryness and found no association with obstetric events. CONCLUSIONS: Perineal trauma, rather than mode of birth, increases the odds for sexual dysfunction in the first year after childbirth. TWEETABLE ABSTRACT: Perineal trauma, rather than mode of birth, correlates with sexual dysfunction and dyspareunia postpartum. #dyspareunia #OASI #episiotomy. ispartof: BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY vol:129 issue:7 pages:1017-1028 ispartof: location:England status: published

INTRODUCTION AND HYPOTHESIS: Pregnancy and childbirth are considered risk factors for pelvic floor dysfunction, including anorectal dysfunction. We aimed to assess the effect of obstetric events on anal incontinence and constipation after delivery. METHODS: We systematically reviewed the literature by searching MEDLINE, Embase and CENTRAL. We included studies in women after childbirth examining the association between obstetric events and anorectal dysfunction assessed through validated questionnaires. We selected eligible studies and clustered the data according to the type of dysfunction, obstetric event and interval from delivery. We assessed risk of bias using the Newcastle Ottawa Scale and we performed a random-effects meta-analysis and reported the results as odds ratios (ORs) with their 95% confidence intervals. Heterogeneity across studies was assessed using I2 statistics. RESULTS: Anal sphincter injury (OR: 2.44 [1.92-3.09]) and operative delivery were risk factors for anal incontinence (forceps-OR :1.35 [1.12-1.63]; vacuum-OR: 1.17 [1.04-1.31]). Spontaneous vaginal delivery increased the risk of anal incontinence compared with caesarean section (OR: 1.27 [1.07-1.50]). Maternal obesity (OR:1.48 [1.28-1.72]) and advanced maternal age (OR: 1.56 [1.30-1.88]) were risk factors for anal incontinence. The evidence on incontinence is of low certainty owing to the observational nature of the studies. No evidence was retrieved regarding constipation after delivery because of a lack of standardised validated assessment tools. CONCLUSIONS: Besides anal sphincter injury, forceps delivery, maternal obesity and advanced age were associated with higher odds of anal incontinence, whereas caesarean section is protective. We could not identify obstetric risk factors for postpartum constipation, as few prospective studies addressed this question and none used a standardised validated questionnaire. ispartof: INTERNATIONAL UROGYNECOLOGY JOURNAL vol:32 issue:9 pages:2325-2336 ispartof: location:England status: published

Background Congenital diaphragmatic hernia (CDH) is, depending of the severity, a birth defect associated with significant mortality and morbidity. Prenatal screening by ultrasound may detect this condition and comprehensive assessment of severity is possible, allowing for in utero referral to an experienced centre for planned delivery. In an effort to improve outcomes, prenatal interventions to stimulate lung development were proposed. Along the same lines, new postnatal management strategies are being developed. In order to enable proper comparison of novel perinatal interventions as well as outcomes, a set of uniform and relevant outcome measures is required. Core outcome sets (COS) are agreed, clearly defined sets of outcomes to be measured in a standardised manner and reported consistently. Herein we aim to describe the methodology we will use to define a COS for perinatal and neonatal outcomes of foetuses and newborns with congenital diaphragmatic hernia and to draft a dissemination and implementation plan. Methods We will use the methodology described in the Core Outcome Measures in Effectiveness Trials (COMET) Initiative Handbook. An international steering group will be created to guide the development of the COS. We are systematically reviewing the literature to identify all potential relevant pre- and neonatal outcomes previously used in studies on perinatal interventions for CDH. We will build a consensus on these core outcomes in a stakeholder group using the Delphi method. After completion, a stakeholder meeting will decide on a final COS, using a modified Nominal Group Technique. Thereafter, we will review potential definitions and measurements of these outcomes, and again a consensus meeting will be organised, to finalise the COS before dissemination. Discussion We have started a procedure to develop a COS for studies on perinatal interventions for congenital diaphragmatic hernia, with the purpose of improving the quality of research, guide clinical practice and improve patient care and eventual use in future clinical trials, systematic reviews and clinical practice guidelines. Trial registration We prospectively registered this study in the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42019124399) and The Core Outcome Measures in Effectiveness Trials (COMET) Initiative (registration number:1296).

ispartof: FUTURE SCIENCE OA vol:6 issue:7 ispartof: location:England status: published

Background Treatment of retained products of conception (RPOC) can be expectant, medical or operative. Surgical removal of RPOC may lead to intrauterine adhesions (IUA) and Asherman’s syndrome. Objective To evaluate how treatment options for RPOC affect future fertility by means of a systematic review. Search strategy MEDLINE, EMBASE, The Cochrane Library, and clinical trial registers were searched, and reference lists were scanned. Selection criteria Randomised controlled trials (RCT) comparing different treatment options for RPOC (conservative, medical or surgical treatment, including curettage and/or hysteroscopic techniques, with or without application of anti-adhesion therapy), in women of reproductive age, were eligible for inclusion. Data collection and analysis Reviewers independently performed data extraction and quality of evidence assessment. For dichotomous variables, results were presented as risk ratio (RR) with 95% CI. Main results Two studies were included. Nonsignificant differences were observed between the use of an anti-adhesion barrier gel versus no treatment after operative hysteroscopy in IUAs (RR 0.32, 95% CI 0.04 to 2.80, P value = 0.30) and clinical pregnancy (RR 2.22, 95% CI 0.67 to 7.42, P value = 0.19), and between hysteroscopic morcellation versus loop resection in IUAs (RR 0.86, 95% CI 0.06 to 13.12, P value = 0.91). Conclusion There is insufficient evidence on how different treatment options for RPOC affect future reproductive outcomes. Results from ongoing RCTs are needed to guide clinicians towards choosing the best treatment.

The aim of the study was to assess the postpartum risk for glucose intolerance since the introduction of the 'International Association of Diabetes and Pregnancy Study Groups' (IADPSG) criteria for gestational diabetes mellitus (GDM). Studies published since 2010 were included, which evaluated the risk for type 2 diabetes mellitus (T2DM), impaired glucose tolerance (IGT), and cardiovascular (CV) events in women with previous GDM compared to normal glucose tolerant women. We included forty-three studies, evaluating 4,923,571 pregnant women of which 5.8% (284,312) had a history of GDM. Five studies used IADPSG criteria (n = 6174 women, 1314 with GDM). The overall pooled relative risk (RR) for postpartum T2DM was 7.42 (95% CI: 5.99-9.19) and the RR for postpartum T2DM with IADPSG criteria was 6.45 (95% CI: 4.74-8.77) compared to the RR of 9.08 (95% CI: 6.96-11.85; p = 0.17) for postpartum T2DM based on other diagnostic criteria. The RR for postpartum IGT was 2.45 (95% CI: 1.92-3.13), independent of the criteria used. None of the available studies with IADPSG criteria evaluated the risk for CV events. Women with a history of GDM based on the IADPSG criteria have a similarly increased risk for postpartum glucose intolerance compared to GDM based on other diagnostic criteria. More studies with GDM based on the IADPSG criteria are needed to increase the quality of evidence concerning the long-term metabolic risk. ispartof: JOURNAL OF CLINICAL MEDICINE vol:8 issue:9 ispartof: location:Switzerland status: published

The results of reconstructive tubal surgery performed without any preselection of patients were evaluated. 31% of the 52 consecutive women who underwent microsurgical reconstruction of the tubes conceived and 19% delivered live infants. 4 women (8%) had spontaneous abortions -- 3 in the 1st trimester and 1 in the 2nd trimester. 2 (4%) women had ruptured tubal pregnancies and underwent salpingectomy. 20 patients (38%) had an unknown cause of tubal and peritoneal lesion. 10 (50%) conceived with 9 live birth infants and 1 spontaneous abortion. Reconstructive tubal surgery in patients with a known pelvic inflammatory disease and postpartum endometritis resulted in 3 (20%) pregnancies -- 2 spontaneous abortions and 1 tubal pregnancy. 44 (85%) women with peritubal and/or periovarian adhesions were analyzed according to the severity of their disease. 8 patients had tubal occlusion without peritoneal adhesions. 32 (62%) had grade III and IV adhesions. 3 patients with grade III adhesions conceived and none in grade IV. 2 tubal pregnancies occurred after lysis of adhesions and fimbrioplasty. Neosalpingostomy yielded 5 (22%) pregnancies and 3 (13%) live born infants. Repeated hysterosalpingograms were performed in 31 (60%) patients. In 15 (50%) the tubes were found to be reoccluded. 21 repeated diagnostic laparoscopies were performed. Of those women 10 had patent tubes and 3 of them conceived in 1 year. 11 patients had occluded tubes with grade III and IV adhesions. Repeated microsurgical reconstruction of the tubes was attempted in 2 patients without any pregnancies in the follow up period of time. Severity of adnexal disease should be evaluated prior to attempted tubal reconstructive surgery. Women with severe adnexal damage should be referred to in vitro fertilization.

The aim of this study was to assess the effects of any anti-adhesion barrier gel used after operative hysteroscopy for treating infertility associated with uterine cavity abnormalities. Gynecologists might use any barrier gel following operative hysteroscopy in infertile women for decreasing de novo adhesion formation; the use of any barrier gel is associated with less severe de novo adhesions and lower mean adhesion scores. Nevertheless, infertile women should be counseled that there is at the present no evidence for higher live birth or pregnancy rates. There is a lack of data for the outcome miscarriage. Preclinical studies suggest that the use of biodegradable surgical barriers may decrease postsurgical adhesion formation. Observational studies in the human report conflicting results. We searched the Cochrane Menstrual Disorders and Subfertility Specialized Register (10 April 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 1), MEDLINE (1950 to 4 April 2013), EMBASE (1974 to 4 April 2013), and other electronic databases of trials including trial registers, sources of unpublished literature, and reference lists. We handsearched the Journal of Minimally Invasive Gynecology (from 1 January 1992 to 13 April 2013); we also contacted experts in the field. We included the randomized comparisons between any anti-adhesion barrier gel versus another barrier gel, placebo, or no adjunctive therapy following operative hysteroscopy. Primary outcomes were live birth rates and de novo adhesion formation at second-look hysteroscopy. Secondary outcomes were pregnancy and miscarriage rates, mean adhesion scores, and severity of adhesions at second-look hysteroscopy. Two authors independently assessed eligible studies for inclusion and risk of bias, and extracted data. We contacted primary study authors for additional information or other clarification. Five trials met the inclusion criteria. There is no evidence for an effect favoring the use of any barrier gel following operative hysteroscopy for the key outcomes of live birth or clinical pregnancy (risk ratio (RR) 3.0, 95 % confidence interval (CI) 0.35 to 26, P = 0.32, one study, 30 women, very low quality evidence); there were no data on the outcome miscarriage. The use of any gel following operative hysteroscopy decreases the incidence of de novo adhesions at second-look hysteroscopy at 1 to 3 months (RR 0.65, 95 % CI 0.45 to 0.93, P = 0.02, five studies, 372 women, very low quality evidence). The number needed to treat to benefit is 9 (95 % CI 5 to 33). The use of auto-cross-linked hyaluronic acid gel in women undergoing operative hysteroscopy for fibroids, endometrial polyps, or uterine septa is associated with a lower mean adhesion score at second-look hysteroscopy at 3 months (mean difference (MD) −1.44, 95 % CI −1.83 to −1.05, P P P = 0.03, four studies, 79 women). The number needed to treat to benefit is 2 (95 % CI 1 to 4). Similarly there are less’ moderate or severe adhesions’ at second-look hysteroscopy (RR 0.25, 95 % CI 0.10 to 0.67, P = 0.006, four studies, 79 women). The number needed to treat to benefit is 2 (95 % CI 1 to 4) (all very low quality evidence). There are some concerns for the non-methodological quality. Only two trials included infertile women; in the remaining three studies, it is not clear whether and how many participants suffered from infertility. Therefore, the applicability of the findings of the included studies to the target population under study should be questioned. Moreover, only one small trial studied the effects of anti-adhesion barrier gels for the key outcome of pregnancy; the length of follow-up was, however, not specified. More well-designed and adequately powered randomized studies are needed to assess whether the use of any anti-adhesion gel affects the key reproductive outcomes in a target population of infertile women.

A 31-year-old primigravida consulted her gynaecologist in the casualty department of a private hospital in Belgium (Imeldaziekenhuis Bonheiden) with intermittent contractions presenting as lower back pain, vague hypogastric cramps and vaginal discharge of blood and mucus. She was 19 weeks and 3 days pregnant according to dates of conception and an ultrasound at 7 weeks. Her medical history was unremarkable. Serology for CMV IgG, Hepatitis A IgG, Hepatitis B surface antigen and Hepatitis C IgG was negative and there was no immunity for Toxoplasmosis. Routine ultrasound at 18 weeks was unremarkable. A few days prior to her admission in the hospital she recalled vague flu-like symptoms and diarrhoea. Before these symptoms started she had eaten cheese, made with non-pasteurised milk. On admission she had no fever, her abdomen and uterus were soft, non-tender and adequately sized for 19 weeks gestation. A sterile speculum examination revealed bulging membranes and a bloody discharge. Fetal membranes were intact. An ultrasound showed an anatomically normal, very active fetus, with biometry compatible with 19 weeks gestation, normal amount of amniotic fluid, and normal placenta. On abdominal ultrasound the cervix appeared to be 3 cm dilated and fully effaced. The C-reactive protein (CRP) was normal (0.92 mg/dl) and the leucocytosis was up to 19300/ mm with 85% neutrofils. Urinary culture was negative. Based on the patient’s history, chorioamnionitis, possibly due to Listeria monocytogenes from the cheese, was assumed. Because of the infectious risk, the decision was made not to administer tocolysis, nor to perform a cervical cerclage. Amoxycillineclavulanic acid was administered IV 1 g every 6 hours. Despite this treatment the patient developed 38.48C fever and uterine contractions within 12 hours. The CRP had risen to 2.78 mg/dl with a leucocytosis of 20500/mm (80% neutrofil count). Vaginal GBS swab cultured on a GBS selective medium was negative and aerobe and anaerobe blood cultures remained negative as well. A male fetus with Apgar 0 was promptly delivered. Anatomopathological examination showed an immature placenta with intervillous microabcesses containing necrotic debris. The membranes showed severe signs of chorioamnionitis. The fetus showed no congenital abnormalities and no signs of pneumonitis. Cultures taken from the placenta and the fetus both showed infection with B. fragilis. The patient recovered quickly and was discharged from the hospital on day 4 on oral antibiotic treatment, without a fever.

Endometrial polyps, submucous fibroids, uterine septa, and intrauterine adhesions can be found by ultrasound (US), HSG, hysteroscopy, or any combined in 10-15 % of infertile women. Observational studies suggest a better reproductive outcome when these anomalies are removed by operative hysteroscopy. The current Cochrane review assesses the effectiveness of hysteroscopy for treating these suspected anomalies in women with otherwise unexplained infertility or prior to intrauterine insemination, in vitro fertilization, or intracytoplasmic sperm injection. ispartof: Gynecological Surgery vol:10 issue:3 pages:165-167 ispartof: location:Germany status: published

Background Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility. Objectives To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). Search methods We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (6 August 2012), the Cochrane Central Register of Controlled Trials (T he Cochrane Library 2012, Issue 7), MEDLINE (1950 to October 2012), EMBASE (1974 to October 2012), CINAHL (from inception to October 2012) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2008 to October 2012) and we contacted experts in the field. Selection criteria Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage. Data collection and analysis Two authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information. Main results Two studies met the inclusion criteria and neither reported the primary outcomes of live birth and complications from the procedure. In women with otherwise unexplained subfertility and submucous fibroids, there is no evidence of benefit with hysteroscopic myomectomy compared to regular fertility-oriented intercourse during 12 months for clinical pregnancy (odds ratio (OR) 2.4, 95% confidence interval (CI) 0.97 to 6.2, P = 0.06, 94 women) and miscarriage (OR 1.5, 95% CI 0.47 to 5.0, P = 0.47, 94 women) (very low-quality evidence). The hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy (experimental event rate (EER) 63%) compared to diagnostic hysteroscopy and polyp biopsy only (control event rate (CER) 28%) (OR 4.4, 95% CI 2.5 to 8.0, P

Didelphic uterus with blind hemivagina and ipsilateral renal anomaly is a rare congenital malformation. The pathogenesis of this syndrome and its embryologic origin are still the subject of discussion. Due to the variable clinical picture and low index of suspicion, diagnosis is often delayed or inaccurate. Conservative surgical treatment- excision of the obstructing vaginal septum and marsupialization of the blind hemivagina-is considered the most appropriate treatment. This report describes the case of a 16-year-old girl with didelphic uterus and double vagina, with obstruction of the left hemivagina. The patient was also diagnosed with left renal dysplasia and ipsilateral ureter communication with the obstructed vagina. Following various examinations and left uretero-nephrectomy, the patient was effectively treated with resection of the vaginal septum. © Springer-Verlag 2010. ispartof: Gynecological Surgery vol:7 issue:3 pages:279-283 status: published

The use of robot-assisted surgery (RAS) has gained popularity in the field of gynaecology, including pelvic floor surgery. To assess the benefits of RAS, we conducted a systematic review of randomized controlled trials comparing laparoscopic and robotic-assisted sacrocolpopexy. The Cochrane Library (1970–January 2015), MEDLINE (1966 to January 2015), and EMBASE (1974 to January 2015) were searched, as well as ClinicalTrials.gov and the International Clinical Trials Registry Platform. We identified two randomized trials (n = 78) comparing laparoscopic with robotic sacrocolpopexy. The Paraiso 2011 study showed that laparoscopic was faster than robotic sacrocolpopexy (199 ± 46 vs. 265 ± 50 min; p p = .110). Costs for using the robot were significantly higher in both studies, however, in the ACCESS trial, only when purchase and maintenance of the robot was included (LSC US$11,573 ± 3191 vs. RASC US$19,616 ± 3135; p p = 0.008). Pain was reportedly higher after RASC, although at different time points after the operation. There were no differences in anatomical outcomes, pelvic floor function, and quality of life. The experience with RASC was tenfold lower than that with LSC in both studies. The heterogeneity between the two studies precluded a meta-analysis. Based on small randomized studies, with surgeons less experienced in RAS than in laparoscopic surgery, robotic surgery significantly increases the cost of a laparoscopic sacrocolpopexy. RASC would be more sustainable if its costs would be lower. Though RASC may have other benefits, such as reduction of the learning curve and increased ergonomics or dexterity, these remain to be demonstrated.