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Objective: To investigate the vaginal and gut microbes changes during the carcinogenesis of cervical and the auxiliary diagnostic value. To investigate the effect of microbiome-specific metabolites butyric on cervical cancer cells. Methods: We studied 416 vaginal 16S rRNA sequencing data and 116 gut sequencing data. Reads were processed using VSEARCH. We used Shannon index, Chao1 index, Simpson diversity index, β diversity index, Linear discriminant analysis Effect Size (LEfSe), co-abundance network and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis to explore microbiome differences between groups. We constructed random forest models based on genus and verified its discriminant effect. Finally, we used the cell counting kit-8 (CCK-8) method to detect cell proliferation capacity and flow cytometry to detect apoptosis and induction of cell cycle progression. Results: Compared to the non-cancerous population, patients with cervical cancer had unique microbial community characteristics in both vaginal and gut ecological niches. Our predictive model based on genus in two ecological regions achieved high accuracy in the diagnosis of cervical cancer (vaginal model AUC=91.58 %; gut model AUC=99.95 %). Butyric inhibited cervical cancer cell proliferation in a concentration-dependent manner and promoted apoptosis of cancer cells. Conclusion: Significant differences were found in vaginal and gut microbes in patients with cervical cancer compared to the non-cancerous population. The prediction models constructed at the genus level in both ecological sites have good diagnostic value. Microorganisms may be involved in cervical cancer progression in a metabolite-dependent way, and targeting butyric may provide therapeutic options for cervical cancer.

Objective: The safety of spontaneous vaginal delivery in pregnant patients with known unruptured intracranial aneurysms (UIAs) has been supported by increasing evidence over the past two decades. However, the extent to which this increased evidence has since influenced changes, if any, in actual clinical practice, has yet to be studied., Methods: Using the 2012 to 2020 Nationwide Inpatient Sample (NIS), trends in vaginal versus caesarian delivery among mothers with UIAs were assessed in temporal fashion and compared to overall trends in delivery modality during the same period. Demographic, hospital, and insurance characteristics were also assessed for relationship with method of delivery., Results: A total of 6,624,556 obstetrical patients presented for elective delivery in the 2012-2020 NIS. This included 419 patients with UIA included in the final analysis. Patients in later years were over twice as likely to have been given a trial of vaginal delivery (OR 2.01, 95% CI 1.29 to 3.14, p = 0.002). This was also statistically significantly different from overall rates of vaginal versus caesarian delivery in the overall cohort (p < 0.001). Hospital, regional, demographic and payer characteristics analyzed were not significantly associated with delivery method., Conclusion: There was a significant trend over the 2010s toward permitting more spontaneous vaginal deliveries for obstetrical patients with known UIAs., (Copyright © 2025 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To provide available evidence comparing surgical outcomes of different vaginal hysterectomy (VH) techniques and devices., Data Sources: PubMed, Embase, and ClinicalTrials.gov databases were searched from inception to December 1, 2023, using relevant keywords., Methods of Study Selection: Studies comparing at least 2 surgical techniques and devices for VH were included. An arm-based random effect frequentist network meta-analysis was performed. All available surgical outcomes were evaluated., Tabulation, Integration, and Results: Ten randomized controlled trials and 7 observational studies were eligible reporting on 1577 women undergoing VH with different techniques and devices (50% conventional, 22.5% Ligasure, 17.3% BiClamp, and 9.2% transvaginal natural orifice transluminal endoscopic surgery [vNOTES]). All surgical techniques/devices had a comparable risk ratio (RR) in terms of intraoperative complications, but Clavien-Dindo grade III postoperative complications were significantly reduced in the vNOTES group (RR, 0.15; 95% confidence interval [CI], 0.03-0.82; I 2 = 0%) compared with conventional VH. The pooled network analysis showed a lower standard mean deviation for blood loss when comparing energy-based vessel sealing technologies (Ligasure: standard mean deviation, -0.92; 95% CI, -1.47 to -0.37; BiClamp: standard mean deviation, -1.66; 95% CI, -2.77 to -0.55) with conventional VH. Total operative time, postoperative hemoglobin variation, and pain were significantly reduced only in the Ligasure group compared with conventional VH. Bilateral salpingectomy or bilateral salpingo-oophorectomy was most commonly performed in the vNOTES group (RR, 1.9; 95% CI, 1.17-3.10) compared with the conventional VH group., Conclusion: Modern surgical techniques/devices have the potential to improve anatomic exposure and to reduce morbidity of VH. This may drive resurgence of vaginal approach to hysterectomy., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: Evaluate the safety of Ovaprene, an investigational nonhormonal vaginal contraceptive designed for monthly use., Study Design: Open-label, multicenter study enrolling heterosexually-active women with previous permanent contraception who underwent assessments during five menstrual cycles: baseline postcoital test cycle, diaphragm postcoital test cycle, Ovaprene safety cycle, and two Ovaprene postcoital test cycles. Safety outcomes included treatment-emergent adverse events, systemic laboratory findings, pelvic examinations, colposcopies, Nugent scores, determination of community state types of vaginal microbiota, and anti-Escherichia coli activity and inflammatory markers in cervicovaginal fluids., Results: We enrolled 38 participants. Of these, 33 used Ovaprene and completed 77 Ovaprene cycles. The most common product-related urogenital treatment-emergent adverse events were bacterial vaginosis and vaginal odor. The frequency of transitioning from Lactobacillus-dominated community state type to community state type IV (not Lactobacillus-dominated) was similar before Ovaprene use and afterwards. Mean Nugent scores were <4 at each visit without a discernible upward trend. Inflammatory markers showed wide variation but no upward trend, and E. coli inhibitory activity of cervical secretions did not change. We found no Staphylococcus aureus, the causative agent in toxic shock syndrome, on used Ovaprenes or in vaginal samples. No clinically important changes in systemic laboratory findings, pelvic examinations, or colposcopies occurred during Ovaprene use., Conclusions: Ovaprene use did not result in cervicovaginal irritation or adverse effects on resident vaginal microbiota and did not impact transitions from a Lactobacillus-dominated community state type to community state type IV., Implications: The finding that the use of Ovaprene, an investigational monthly user-controlled nonhormonal vaginal contraceptive, does not appear to result in adverse changes in vaginal health during short-term use supports further evaluation of the contraceptive potential of the device., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: One of the controversies regarding the management of twin gestations relates to the mode of delivery. Currently, counseling regarding the mode of delivery and the chance of successful vaginal twin delivery is based on the average risk for intrapartum cesarean delivery in the general population of twin pregnancies. Decision support tools that provide an individualized risk for intrapartum cesarean delivery based on the unique characteristics of each patient can improve counseling and decision-making regarding the choice of mode of delivery in twin pregnancies., Objective: This study aimed to develop and validate a prediction model to determine the risk for intrapartum cesarean delivery in twin pregnancies., Study Design: In this secondary analysis of the Twin Birth Study, a multicenter randomized controlled trial, we considered the subgroup of individuals who underwent a trial of vaginal delivery. Candidate predictors included maternal age, parity, previous cesarean delivery, conception method, chorionicity, diabetes and hypertension in pregnancy, gestational age at birth, the onset of labor, presentation of the second twin, sonographic fetal weight estimation, and fetal sex. The co-primary outcomes were overall intrapartum cesarean delivery and cesarean delivery of the second twin. Multivariable logistic regression models were used to estimate the probability of the study outcomes. Model performance was evaluated using measures of discrimination (the area under the receiver operating characteristic curve), calibration, and predictive accuracy. Internal validation was performed using the bootstrap resampling technique., Results: A total of 1221 individuals met the study criteria. The rate of overall intrapartum cesarean delivery and cesarean delivery for the second twin was 25.4% and 5.7%, respectively. The most contributory predictor variables were nulliparity, term birth (≥37 weeks), a noncephalic presentation of the second twin, previous cesarean delivery, and labor induction. The models for overall intrapartum cesarean delivery and cesarean delivery of the second twin had good overall discriminatory accuracy (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.688-0.752 and 0.736; 95% confidence interval, 0.669-0.803, respectively) and calibration (as illustrated by the calibration plot and Brier scores of 0.168; 95% confidence interval, 0.156-0.180 and 0.051; 95% confidence interval, 0.040-0.061, respectively). The models achieved good specificity (66.7% and 81.6%, respectively), high negative predictive value (86.0% and 96.9%, respectively), and moderate sensitivity (68.1% and 57.1%, respectively)., Conclusion: The prediction models developed in this study may assist care providers in counseling individuals regarding the optimal timing and mode of delivery in twin pregnancies by providing individualized estimates of the risk for intrapartum cesarean delivery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Natural orifice transluminal endoscopic surgery (NOTES) may be useful in gynecologic endoscopic surgery. This study evaluated the efficacy, safety, and perioperative outcomes of combined NOTES and vaginal approach, transvaginal endoscopic surgery-assisted adnexectomy (TVEA), for the surgical treatment of presumed benign ovarian tumors. Materials and methods: Records were reviewed for 33 consecutive TVEA procedures performed between May 2011 and March 2014. Patient age, body mass index, parity, mass size, and mass bilaterality were used to select comparable patients who had undergone conventional laparoscopic adnexectomy (CLA). Results: A total of 236 patients were included in this study (203 CLAs and 33 TVEAs). No cases switched to abdominal laparotomy. Operating time and length of postoperative stay were significantly longer in the CLA group than in the TVEA group, while total hospital charges were higher in the TVEA group (p

Objective: Evaluate reduction in progressively motile sperm per high power field (HPF) in midcycle cervical mucus after intercourse with Ovaprene: an investigational monthly non-hormonal vaginal contraceptive consisting of a vaginal ring and mechanical barrier, releasing spermiostatic ferrous gluconate., Study Design: Open-label, multicenter study enrolling heterosexually-active women with previous permanent contraception. Participants underwent a baseline postcoital test cycle with no device to confirm the presence of sperm, followed by one diaphragm postcoital test cycle, one Ovaprene safety cycle, and two Ovaprene postcoital test cycles. In each postcoital test cycle, participants underwent a midcycle cervical mucus evaluation to confirm an Insler score ≥10 and absence of sperm, and then returned two to four hours after vaginal intercourse for repeat cervical mucus evaluation. We considered <5 progressively motile sperm/HPF indicative of preliminary contraceptive effectiveness., Results: We enrolled 38 participants; 23 completed the study. All participants had ≥5 progressively motile sperm/HPF in the baseline cycle and <5 progressively motile sperm/HPF in all 49 Ovaprene cycles and all 35 diaphragm cycles, meeting the definition of a successful postcoital test. This was true regardless of examiner blinding, prior vaginal delivery or vaginal ring use, body mass index, or dislodgements noted by the participant or investigator. The mean of 27.2 (±17.9) progressively motile sperm/HPF in baseline postcoital test cycles was reduced to 0.5 (±1.1) and 0.5 (±1.3) progressively motile sperm/HPF in the first and second Ovaprene cycles, respectively. Ovaprene fit all participants and all could insert, position, and remove it., Conclusion: Use of Ovaprene resulted in meeting the prespecified criterion for contraceptive effect by all participants during all postcoital test cycles., Implications: The finding that use of Ovaprene, an investigational monthly non-hormonal vaginal contraceptive, resulted in postcoital testing of cervical mucus that met the pre-specified definition of success (<5 progressively motile sperm/HPF) supports further evaluation of contraceptive efficacy of the device in users at risk for pregnancy., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to compare the effectiveness of misoprostol via sublingual and vaginal administration versus the combination route in the termination of 13 to 24 week pregnancies. Materials and Methods: One hundred and ninety-five patients, divided into three groups, were enrolled in this study. In the vaginal group, two 200-μg misoprostol tablets were inserted into the posterior fornix every 4 hours for 48 hours. In the sublingual group, patients took two 200-μg misoprostol tablets every 4 hours for up to 48 hours. In the combination group, two 200-μg misoprostol tablets were inserted within the posterior fornix followed by the administration of 400 μg misoprostol sublingually every 4 hours for a period of 48 hours. Efficacy was defined as a successful termination without the need for any interventions. Results: The success rate, after 24–48 hours, was not significantly different among the three groups. It was significantly higher within the first 12 hours of misoprostol administration within the sublingual group (p = 0.031). Nonetheless, the overall failure rate was not significantly different between three groups. The mean duration of abortion was shortest among the sublingual group (655 ± 46 minutes), p = 0.005, and the number of misoprostol tablets administered was lower when compared to the other groups (5.9 ± 0.3), p = 0.001. The duration of abortion and the number of misoprostol tablets used significantly varied in the cases in which the patient had a history of a previous normal vaginal delivery (NVD; p = 0.007). The average number of tablets administered was the lowest in the sublingual group. The prevalence of fever among the NVD cases were significantly higher in the combination group (p = 0.008). Overall, of all the methods, patients preferred the sublingual route (p = 0.001). Conclusion: Sublingual misoprostol has a higher efficacy when compared to the vaginal and combination methods.

Analysis of DNA mixtures from sexual assault evidence is an ongoing challenge for DNA casework laboratories. To assist the forensic scientist address source and activity level propositions there is a significant need for new techniques that can provide information as to the source of DNA, particularly for sexual assault samples that do not involve semen. The goal of this study was to develop a new biological signature system that provides additional probative value to samples comprised of mixtures of epidermal and vaginal cells, as may be observed in cases involving digital penetration. Signatures were based on morphological and autofluorescence properties of individual cells collected through Imaging Flow Cytometry (IFC). Comparisons to reference cell populations from vaginal tissue and epidermal cells collected from hands showed strong multivariate differences across > 80 cellular measurements. These differences were used to build a predictive framework for classifying unknown cell populations as originating from epithelial cells associated with digital penetration or epidermal tissue. As part of the classification scheme, posterior probabilities of specific tissue group membership were calculated for each cell, along with multivariate similarity to that tissue type. We tested this approach on cell populations from reference tissue as well as mock casework samples involving hand swabbings following digital vaginal penetration. Many more cells classifying as non-epidermal tissue were detected in digital penetration hand swab samples than control hand swabbings. Minimum interpretation thresholds were developed to minimize false positives; these thresholds were also effective when screening licked hands, indicating the potential utility of this method for a variety of biological mixture types and depositional events relevant to forensic casework. Results showed that samples collected subsequent to digital penetration possessed markedly higher numbers of cells classifying as vaginal tissue as well as higher posterior probabilities for vaginal tissue (≥ 0.90) compared to cell populations collected from hands without prior contact with vaginal tissue. Additionally, digital penetration cell populations may be resolved from saliva cell populations and other non-target tissue types., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Crown Copyright © 2023. Published by Elsevier B.V. All rights reserved.)

Caesarean scar pregnancy (CSP) is an increasingly common clinical conundrum. The non-curettage surgical management of CSP can be categorised into hysteroscopic, vaginal, laparoscopic, and open removal modalities and the choice of treatment is surgeon-dependent. A systematic review of original studies reporting surgical treatment outcomes of CSP until March 2023 was conducted to evaluate the non-curettage surgical management of this highly morbid condition. A total of 60 studies of mostly weak methodological quality were identified involving 6720 CSP cases. Success rates were generally high across all treatment modalities although highest in vaginal and laparoscopic excisional approaches. Morbidity was most associated with haemorrhage although unplanned hysterectomy rates remained low across all treatment groups. Subsequent pregnancies are associated with morbidity despite being underreported and the impact of CSP treatment on future pregnancy is poorly understood. Substantive study heterogeneity precludes meta-analyses of pooled data and treatment superiority has not been demonstrated., Competing Interests: Declaration of competing interest The authors have no conflicts of interest., (Copyright © 2023. Published by Elsevier Ltd.)

The Body Fluid Forum of the Association of Forensic Science Providers recognised concerns raised by forensic practitioners regarding the lack of data to inform on the incidence of significant AP (Acid Phosphatase) reactions from vaginal and oral samples, i.e. those which might be misinterpreted as indicating the presence of semen. This is particularly relevant in the light of appeal court rulings regarding the need for data to support evaluations. This paper presents collaborative data on the nature and incidence of AP reactions from vaginal and oral swabs provided by donors. The results demonstrate that caution is required with mid to strong purple AP reactions from direct testing of oral swabs and with mid purple reactions from vaginal swabs. The use of a Bayesian approach to assist with the provision of opinions regarding the presence of seminal fluid is highlighted., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier B.V. All rights reserved.)

Study Objective: To determine the difference in surgical complications for patients with a previous cesarean section (CS) undergoing abdominal, vaginal, or laparoscopic hysterectomy., Design: A population-based retrospective cohort study., Setting: Province of Ontario, Canada., Patients: 10 300 patients with at least 1 CS between July 1, 1991, and February 17, 2018., Interventions: Benign, nongravid hysterectomy between Apr 1, 2002, and March 31, 2018., Measurements and Main Results: The primary outcome was a composite of all surgical complications within 30 days of surgery. Secondary outcomes were rate of genitourinary complications, readmission to hospital, and emergency department visit occurring within 30 days of surgery. Of 10 300 patients who had at least one previous CS, who underwent subsequent hysterectomy for a benign indication, 7370 underwent an abdominal hysterectomy (71.55%), 813 (7.9%) had a vaginal hysterectomy, and 2117 (20.55%) underwent a laparoscopic hysterectomy. The adjusted odds of any surgical complication from hysterectomy was significantly lower when performed by the vaginal approach than the laparoscopic approach (odds ratio, 0.32; 95% confidence interval, 0.20-0.51; p <.0001). There was no difference in the odds of surgical complication between abdominal and laparoscopic approaches (odds ratio, 1.09; 95% confidence interval, 0.87-1.37; p = .45)., Conclusion: Our retrospective population-based study demonstrates that, after previous CS, patients selected to undergo vaginal hysterectomy experienced lower risk than either abdominal or laparoscopic approaches. This suggests that CS alone should not be a contraindication to vaginal hysterectomy., (Copyright © 2023 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the influence of sexual arousal on vaginal mucosal inflammatory cytokine and antibody production in healthy women with and without histories of childhood and/or adult sexual violence., Methods: Ninety-one premenopausal healthy women (ages 18-42) attended a single laboratory session in which they provided vaginal fluid samples before and after viewing one neutral and one erotic film. While viewing the films, participants' vaginal sexual arousal was recorded using vaginal photoplethysmography., Results: Of the 91 participants, 41 (45%) reported no history of sexual violence, 17 (19%) reported a history of childhood sexual abuse (CSA) only, 19 (21%) reported a history of adult sexual assault (ASA) only, and 10 (11%) reported a history of both CSA and ASA, with 4 participants choosing not to provide information on their sexual violence history. For women with a history of ASA but not CSA, there was a significant increase in vaginal IL-1β following arousal, while for women with a history of CSA (with or without ASA), there was a significant decrease. Women without CSA histories had a significant increase in vaginal IgA following sexual arousal, while women with CSA histories had a decrease., Conclusion: Sexual arousal possibly plays a role in modifying vaginal immune responses in young, healthy women. Moreover, these effects may vary depending upon sexual assault histories, such that relative to women without assault histories, women with a history of early life sexual trauma showed significantly altered vaginal immune responses following sexual arousal. If replicated, these findings may help explain the increased risk for sexually transmitted infections observed among women with sexual assault histories., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Early amniotomy shortens the duration of spontaneous labor, yet there is no clear evidence on the optimal timing of amniotomy following cervical ripening. There are limited high-quality studies on the use of early amniotomy intervention following labor induction., Objective: This study aimed to evaluate whether amniotomy within 1 hour of Foley catheter expulsion reduces the duration of labor among individuals undergoing combined misoprostol and Foley catheter labor induction at term., Study Design: This was a randomized clinical trial conducted from November 2020 to May 2021 comparing amniotomy within 1 hour of Foley catheter expulsion (early artificial rupture of membranes) with expectant management. Randomization was stratified by parity. Labor management was standardized among participants. Individuals undergoing induction at ≥37 weeks with a singleton gestation and needing cervical ripening were eligible. Our primary outcome was time to delivery. Wilcoxon rank sum, Pearson chi-square, and Cox survival analyses with intent-to-treat principles were performed adjusting for age, body mass index, parity, mode of delivery, Bishop score, and the interaction between randomization group and parity. A sample size of 160 was planned to detect a 4-hour reduction in delivery time., Results: A total of 160 patients (79 early artificial rupture of membranes, 81 expectant management) were randomized. Early artificial rupture of membranes achieved a faster median time to delivery than expectant management (early artificial rupture of membranes: 11.1 hours; interquartile range, 6.25-17.1 vs expectant management: 19.8 hours; interquartile range, 13.2-26.2; P<.001). A greater percentage of individuals in the early artificial rupture of membranes group delivered within 24 hours (86% vs 70%; P=.03). There was no difference in the cesarean delivery rate between the 2 groups (22% vs 31%; P=.25). Individuals delivered 2.3 times faster following early artificial rupture of membranes (hazard ratio, 2.3; 95% confidence interval, 1.5-3.4; P<.001). There were no significant differences in maternal and neonatal outcomes., Conclusion: Amniotomy within 1 hour of Foley catheter expulsion resulted in 2.3 times faster delivery than expectant management. Therefore, early artificial rupture of membranes should be considered in individuals undergoing mechanical cervical ripening at term., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The design of carriers for insulin delivery has recently attracted major research attentions in the biomedical field. In general, the release of drug from polymers is driven via a variety of polymers. Several mechanisms such as matrix release, leaching of drug, swelling, and diffusion are usually adopted for the release of drug through polymers. Insulin is one of the most predominant therapeutic drugs for the treatment of both diabetes mellitus; type-I (insulin-dependent) and type II (insulin-independent). Currently, insulin is administered subcutaneously, which makes the patient feel discomfort, pain, hyperinsulinemia, allergic responses, lipodystrophy surrounding the injection area, and occurrence of miscarried glycemic control. Therefore, significant research interest has been focused on designing and developing new insulin delivery technologies to control blood glucose levels and time, which can enhance the patient compliance simultaneously through alternative routes as non-invasive insulin delivery. The aim of this review is to emphasize various non-invasive insulin delivery mechanisms including oral, transdermal, rectal, vaginal, ocular, and nasal. In addition, this review highlights different smart stimuli-responsive insulin delivery systems including glucose, pH, enzymes, near-infrared, ultrasound, magnetic and electric fields, and the application of various polymers as insulin carriers. Finally, the advantages, limitations, and the effect of each non-invasive route on insulin delivery are discussed in detail., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: Ingestion, inhalation, and insertion of foreign bodies (FB) are commonly encountered problems in the emergency departments (ED). Radiologists pay a key role in their diagnosis and management. Selecting an appropriate imaging modality is important depending on the route of entry and reported type of FB. Diagnosing FB is time sensitive and requires radiologists to be astute and familiar with varied imaging appearances of FB. In this article, we review imaging features of most common FB seen in clinical practice and their complications., Teaching Points: SUMMARY: FB in body orifices are frequently seen in the ED. Imaging plays a pivotal role in the management in majority of the cases. In this article, we present several cases of commonly encountered FB., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Induction of labor is among the most common procedures for pregnant women. Only a few randomized clinical trials with relatively small samples have compared misoprostol with dinoprostone. Although their efficacy seems similar, their safety profiles have not been adequately evaluated, and economic data are sparse., Objective: This study aimed to test the noninferiority of vaginal misoprostol (prostaglandin E1) (25 μg) to a slow-release dinoprostone (prostaglandin E2) pessary (10 μg) for induction of labor with an unfavorable cervix at term., Study Design: This was an open-label multicenter randomized noninferiority trial at 4 university hospitals of the Research Group in Obstetrics and Gynecology between 2012 and 2015. We recruited women who underwent induction of labor for medical reasons, those with a Bishop score of ≤5 at ≥36 weeks' gestation, and those with a cephalic-presenting singleton pregnancy with no previous cesarean delivery. Women were randomly allocated to receive either vaginal misoprostol at 4-hour intervals (25 μg) or a 10-mg slow-release dinoprostone pessary. The primary outcome was the total cesarean delivery rate. Noninferiority was defined as a difference in the cesarean delivery rates between the groups of no more than 5%. Secondary outcomes included neonatal and maternal morbidity, vaginal delivery at <24 hours after starting the induction of labor process, and maternal satisfaction., Results: The study included 1674 randomized women. The per-protocol analysis included 790 women in each group. The total cesarean delivery rates were 22.1% (n=175) in the misoprostol group and 19.9% (n=157) in the dinoprostone group, a difference of 2.2% (with an upper-bound 95% confidence limit of 5.6%) (P=.092). Results in the intention-to-treat analysis were similar. Neonatal and maternal morbidity rates were similar between groups. Vaginal delivery within 24 hours was significantly higher in the misoprostol group (59.3% vs 45.7%; P<.001) as was maternal satisfaction, assessed in the postpartum period by a visual analog scale (mean score, 7.1±2.4 vs 5.8±3.1; P<.001)., Conclusion: The noninferiority of a 25-μg dose of vaginal misoprostol every 4 hours to the dinoprostone pessary for cesarean delivery rates after induction of labor at term could not be demonstrated, although the confidence limit of the difference barely exceeded the noninferiority margin. Nonetheless, given the small difference between these cesarean delivery rates and the similarity of neonatal and maternal morbidity rates in this large study, the clinical risk-to-benefit ratio justifies the use of both drugs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Combining pharmacologic agents with mechanical ripening achieves the shortest time to labor; however, there is no clear evidence on route of drug administration. Buccal administration of misoprostol has shown greater patient acceptance but remains understudied., Objective: This study aimed to evaluate the difference in time to delivery between buccal and vaginal administration of misoprostol along with a Foley catheter for induction of labor., Study Design: The BEGIN trial (buccal vs vaginal misoprostol combined with Foley catheter for cervical ripening at term) was an institutional review board-approved, randomized clinical trial conducted from June 2019 to January 2020 comparing identical doses (25 μg) of buccal misoprostol and vaginal misoprostol along with a Foley catheter for induction of labor. Randomization was stratified by parity. Labor management was standardized among participants. Individuals undergoing induction of labor at ≥37 weeks with a singleton gestation and needing cervical ripening were included. Our primary outcome was time to delivery. Kruskal-Wallis, Pearson chi-squared, and Cox survival analyses with intent-to-treat principles were performed. A sample size of 216 was planned to detect a 4-hour reduction in delivery time., Results: A total of 215 women (108 in the buccal drug administration group and 107 in the vaginal drug administration group) were randomized. The vaginal route of drug administration achieved a faster median time to delivery than the buccal route of drug administration (19.7 hours in the vaginal route vs 24.1 hours in the buccal route; P<.001). A greater percentage of women in the vaginal drug administration group delivered within 24 hours compared with the buccal drug administration group (65% vs 49%; P=.02). There was no difference in the cesarean delivery rate between the 2 groups (17% in the vaginal drug administration group vs 21% in the buccal drug administration group; P=.6). Individuals who received vaginal misoprostol with Foley catheter delivered 2 times faster than women who received buccal misoprostol with Foley catheter after censoring for cesarean delivery and adjusting for parity (hazard ratio, 2.13; 95% confidence interval, 1.44-3.17). There was no significant difference in maternal and neonatal outcomes., Conclusion: We found that vaginal administration of misoprostol was superior to buccal administration of misoprostol along with a Foley catheter for induction of labor. Furthermore, vaginal administration of misoprostol resulted in twice the chance of delivering earlier compared with buccal administration of misoprostol with no difference in cesarean delivery rates. Therefore, the vaginal route of administration of misoprostol should be preferred among individuals undergoing a combined pharmacologic and mechanical induction., (Copyright © 2021 Elsevier Inc. All rights reserved.)

A multigravida presented for a 13-week abortion. The surgeon noted a transverse vaginal septum with small central perforation at the time of bimanual exam. The surgeon performed dilation and suction curettage through the septum without resection in the outpatient setting., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cervical ripening is commonly needed for labor induction. Finding an optimal route of misoprostol dosing for efficacy, safety, and patient satisfaction is important and not well studied for the buccal route., Objective: To compare the efficacy and safety of vaginal and buccal misoprostol for women undergoing labor induction at term., Study Design: The IMPROVE trial was an institutional review board-approved, triple-masked, placebo-controlled randomized noninferiority trial for women undergoing labor induction at term with a Bishop score ≤6. Enrolled women received 25 mcg (first dose), then 50 mcg (subsequent doses) of misoprostol by assigned route (vaginal or buccal) and a matching placebo tablet by the opposite route. The primary outcomes were time to delivery and the rate of cesarean delivery performed urgently for fetal nonreassurance. A sample size of 300 was planned to test the noninferiority hypothesis., Results: The trial enrolled 319 women, with 300 available for analysis, 152 in the vaginal misoprostol group and 148 in the buccal. Groups had similar baseline characteristics. We were unable to demonstrate noninferiority. The time to vaginal delivery was lower for the vaginal misoprostol group (median [95% confidence interval] in hours: vaginal: 20.1 [18.2, 22.8] vs buccal: 28.1 [24.1, 31.4], log-rank test P = .006, P noninferiority  = .663). The rate of cesarean deliveries for nonreassuring fetal status was 3.3% for the vaginal misoprostol group and 9.5% for the buccal misoprostol group (P = .033). The rate of vaginal delivery in <24 hours was higher in the vaginal group (58.6% vs 39.2%, P = .001)., Conclusion: We were unable to demonstrate noninferiority. In leading to a higher rate of vaginal deliveries, more rapid vaginal delivery, and fewer cesareans for fetal issues, vaginal misoprostol may be superior to buccal misoprostol for cervical ripening at term., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: This guideline reviews the evidence relating to the potential benefits of the vaginal hysterectomy (VH) and supracervical hysterectomy (SCH) versus total abdominal hysterectomy (TAH) with respect to postoperative sexual function, urinary function, and peri- and postoperative complications. Laparoscopic options are not included in this guideline., Options: Women considering hysterectomy for benign disease can be given the option of retaining the cervix or proceeding with a total hysterectomy., Outcomes: The outcomes measured are postoperative sexual function and urinary function, and peri- and postoperative complications., Evidence: The Cochrane Library, Medline, and Embase were searched for articles published in English from January 1950 to March 2008 specifically comparing VH and SCH with TAH in the prevention of sexual dysfunction, urinary dysfunction, and peri- and postoperative complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Additional publications were identified from the bibliographies of these articles. Randomized controlled trials were considered evidence of the highest quality, followed by cohort studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies., Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table)., (Copyright © 2018. Published by Elsevier Inc.)

Background: The American Congress of Obstetricians and Gynecologists recommends that "the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy," resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy., Objective: The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms., Study Design: This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow-up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and χ 2 test when appropriate. Questionnaire scores were compared using paired t tests., Results: Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m 2 ; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5-5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5-22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001)., Conclusion: Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible., (Copyright © 2017. Published by Elsevier Inc.)

A primigravid immigrant woman presented for termination of a 16-week pregnancy. The cervix was obscured by a transverse vaginal septum and was only identifiable by ultrasound. We used mifepristone for cervical preparation before concurrent septoplasty and dilation and evacuation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The objective of our study was to determine survival and prognostic factors associated with isolated local recurrence of endometrial cancer., Methods: Data of 1229 patients with endometrial carcinoma treated between 2000 and 2012 were extracted from maintained databases of nine French University Hospitals as well as from the Senti-Endo trial. Patients with isolated central pelvic and vaginal recurrence were selected for further analysis., Results: Two hundreds and twenty five patients recurred during the inclusion period, 20 with isolated central pelvic recurrence and 23 with vaginal recurrence. Patients without recurrence had initially significantly less lymphovascular space invasion (p = 0.01), less advanced diseases (>stage II) (p < 0.001) and more often low or intermediate risk tumours than patients with local recurrence. Local recurrence was statistically associated with better overall survival than non-local recurrence (p = 0.028) but dramatically decreased overall survival when compared to patients without any recurrence (p < 0.001). The site of recurrence, i.e. vaginal or central pelvic, was significantly associated with overall survival (p = 0.015). Patients without brachytherapy at initial management were more likely to have local recurrence of their disease when compared to those without recurrence (p = 0.03). None of the prognostics factors for survival in patients with local recurrence was statistically significant in multivariate analysis., Conclusions: Local recurrence is a key event in endometrial cancer evolution severely impacting overall survival. Better understanding of the factors associated with prolonged survival is mandatory to improve our management of these patients., (Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Controversy exists regarding the optimal route of delivery for fetuses who are diagnosed prenatally with myelomeningocele. Current recommendations are based partly on antiquated studies with questionable methods. All studies that have been published to date suffer from nonstandardized outcome measures, selection bias, and small sample size. The larger studies are >15 years old., Objective: The purpose of this study was to provide information for evidence-based decision-making regarding the impact of route of delivery on motor outcomes for pediatric patients with prenatally were diagnosed myelomeningocele in a well-defined retrospective cohort., Study Design: Medical records were reviewed retrospectively for all neonates who had been diagnosed with a myelomeningocele at birth from 1995-2015 within the University of Pittsburgh Medical Center system, as identified through the Children's Hospital of Pittsburgh Neurosurgery Department operative database. Records were matched with maternal records with the use of the Center for Assistance in Research that used eRecord. Data from 72 maternal-neonatal pairs were analyzed for multiple variables. The primary outcome measure was the difference between the functional and anatomic motor levels in the child at the age of 2 years, stratified by mode of delivery and presence or absence of labor. The sample size necessary to detect a difference between the groups with power of 0.8 and significance of .05 was calculated to be 52 subjects total (26 per group)., Results: Functional levels were slightly better than predicted by anatomic levels for all pediatric patient groups, regardless of mode of delivery or presence of labor. Anatomic levels were slightly lower (better), and defects were smaller for those infants who underwent vaginal delivery or a trial of labor, likely attributable to selection bias. Attempts to correct for this selection bias did not change the results. No other outcomes that were analyzed were associated significantly with mode of delivery or presence of labor., Conclusion: No benefit to motor function from delivery by cesarean section or avoidance of labor was demonstrated statistically in this mother-infant cohort., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Morcellation is the fragmentation of tissue to facilitate removal of the specimen through small incision in minimally invasive surgery. This technique is not unique to gynecology and is used in general surgery with the goal of improved surgical outcomes including decreased pain, cost, hospital length of stay, and rapid return to normal activities and work. Gynecologic laparoscopic power morcellation (LPM) has come under increased scrutiny over the last 2 years due to widespread attention to a known but rare complication, an unanticipated dissemination of malignancy, namely occult uterine leiomyosarcoma. This chapter focuses on complications associated with gynecologic tissue morcellation from inoculation of benign or malignant tissue fragments within the peritoneal cavity and direct trauma from morcellation techniques. We also include a review of the various morcellation techniques from knife to electrical and the use of intraperitoneal specimen containment systems., (Copyright © 2016. Published by Elsevier Ltd.)

Laparoscopically assisted vaginal radical vaginal hysterectomy (LAVRH), a minimally invasive technique that seems to be an attractive alternative to traditional surgery, remains unexplored in the treatment of cervical cancer. We searched Medline (1966-2013) and Scopus (2004-2013) search engines, as well as reference lists from all included studies. Ten studies were retrieved; including 6 retrospective cohort studies, 2 prospective cohort studies, 1 retrospective randomized trial, and a phase II randomized control trial. LAVRH provided equal recurrence-free rates when performed in patients with tumors not exceeding 2 cm in greatest diameter. Its main advantages seem to be less intraoperative blood loss and more radical pelvic lymphadenectomy. The primary disadvantages of the technique are a higher rate of disease-positive surgical margins, resulting in the need for adjuvant therapy, and the slow learning curve required for a surgeon to gain expertise. With use in minimally invasive surgery of newer techniques such as total laparoscopic radical hysterectomy and robotic-assisted radical hysterectomy, and possible future adoption of more conservative techniques such as cervical conization with pelvic lymphadenectomy, the question remains as to whether LAVRH will be adopted by the surgical community or lost to oblivion., (Copyright © 2013 AAGL. Published by Elsevier Inc. All rights reserved.)

Vaginal pre-exposure prophylaxis has focused heavily on gel formulations. Low adherence linked with frequent dosing and short therapeutic duration has emerged as the major reason for inconsistent efficacy outcomes with gels in clinical trials. Osmotic pumps can achieve versatile drug release profiles however, have not been explored for vaginal delivery. In this report, we describe an osmotic pump tablet (OPT) that can deliver antiretrovirals for several days. We also describe configuring the OPT for pH sensitive delivery where the drug delivery system consistently delivers an antiretroviral at vaginal pH and then gives a burst release triggered by a coitally associated pH increase. We have investigated the vaginal OPT for multiple day delivery of a potent antiretroviral, IQP-0528 in a sheep model. To effectively register spatial drug distribution we also engineered a tool to precisely collect multiple vaginal fluid samples. In a 10-day duration post single application, high micromolar mucosal levels were obtained with peak concentration more than 6 logs higher than the EC50 of IQP-0528. Overall, our results show successful implementation of the osmotic pump technology for vaginal antiretroviral delivery., (Copyright © 2013 Elsevier B.V. All rights reserved.)