Biofilm formation by vaginal Lactobacillus in vivo.

Biofilm formation by nonpathogenic bacteria is responsible for their stable maintenance in vivo ecosystems as it promotes long-term permanence on the host's vaginal mucosa. Biofilm formation by Lactobacilli has been reported in vitro but not in vivo. We hypothesize the presence of biofilm formation in vivo could be also documented by microscope photographs (MP) of wet mounts obtained from uninfected vaginal samples satisfying rigorous scientific identification criteria. We analyzed 400 MP from our database, and we were able to determine that 12 MP from 6 different patients contained clues of the formation of biofilm by Lactobacilli. The most probable lactobacillus involved is presumed to be Lactobacillus jensenii. The documentation of biofilm formation by vaginal Lactobacilli at fresh wet mount preparation is significant and has several important clinical preventive and therapeutic implications.

Vulvodynia and fungal association: a preliminary report.

Vulvodynia (vulvar pain syndrome) is a chronic multifactorial disease affecting almost 13 million women in the USA and can lead to morbidity and a reduced quality of life. We hypothesize that an initial microbiological insult in the vagina causes modifications in the biological vaginal milieu and/or an alteration on the lactobacilli flora. The vaginal milieu responds to the insult by developing an inflammatory reaction with abnormal cytokine production. These hypotheses were tested quantifying vaginal lactobacillus and cytokines, in patients with vulvodynia compared to matched healthy controls. Our preliminary data suggest a vaginal flora alteration and an immunological response involving Candida in patients with vulvodynia. Ongoing studies will assist us to clarify these findings.

Conditions associated with placental dysfunction.

Placental dysfunction is a term to describe suboptimal placental function leading to variations in the fetal supply of all its necessary required nutrients as well as the disruption in the cleansing of fetal catabolic products. The dysfunctional placenta may interrupt the manufacturing of other essential factors involved in pregnancy conservation, can compromise the fetal appropriate, atraumatic and sterile medium to grow, the immunologic shield from maternal antibodies and the normal amniotic fluid levels. Placental dysfunction can lead to a group of disorders representing a diverse and important category of pathological processes conducting to fetal and neonatal morbidity and mortality. The mechanisms by which these inflammatory processes cause death and disability are diverse and can be separated into four distinct classes: first, placental damage with loss of function; second, induction of premature labor; third, release of inflammatory mediators; fourth, transplacental infection. Several conditions have been associated with placental dysfunction: IUGR, hypertension, hypoxic-ischemic injury, preterm labor, and fetal death.

Vulvodynia, a step-wise therapeutic prospective cohort study.

Vulvodynia is characterised by the presence of vulval allodynia (pain evoked by non-painful stimuli) and vulval dysaesthesias (burning, soreness, rawness, stinging and irritation). We assessed a protocol for the evaluation and management of vulvodynia. The protocol was based on the most recent evidence available. We began a simple evaluation and proceeded to an aggressive one. From the cohort of 74 patients, 69 patients (93.2%) were adherent to the protocol. A total of 25 patients (36.3%) improved after antibiotic therapy: 14 patients (20.4%) had a positive fungal culture and 11 patients (15.9%) had a positive bacterial culture; none with a positive viral culture. Eight patients (11.6%) improved with dietary modification. Ten patients (14.5%) benefitted from tricyclic medications; 13 patients (18.8%) improved after gabapentin therapy; 13 patients (18.8%) did not show improvement of their condition. Some 56 patients (81.2%) manifested an improvement of their symptoms, which allowed them to achieve painless sexual intercourse.

Pregnancy outcome after placement of 'rescue' Shirodkar cerclage.

OBJECTIVE: Mid-trimester painless cervical dilation is associated with high rates of perinatal morbidity and mortality. 'Rescue' cerclage is one option in managing these patients. We evaluated pregnancy outcomes of women in whom we placed Shirodkar cerclage. STUDY DESIGN: We analyzed the pregnancy outcome of a retrospective cohort of women carrying singleton pregnancies who experienced late mid-trimester cervical dilation in whom we placed Shirodkar cerclage. Exclusion criteria were uterine contractions, bleeding, premature rupture of membranes and chorioamnionitis. Primary outcomes were gestational age at delivery, maternal, fetal and neonatal outcomes and surgical complications. RESULT: Between January 2003 and December 2005, 68 patients met our inclusion criteria. The average maternal age was 26.4+/-8.3 years and the mean gestational age at the time of surgery was 19.6+/-3.2 weeks. Seven women opted for expectant management and 5 more were followed up by their referring physicians; the 12 of them were used as a comparison group. Fifty-six women underwent placement of Shirodkar cerclage. We were unable to place a cerclage in three women (5.1%) and all three delivered before 23 weeks. Of the 56 women who had cerclage, 14 (23.7%) delivered at term, 20 (33.9%) delivered between 34 and 36.9 weeks, 13 (22%) between 30 and 33.9 weeks, 6 (10.2%) between 24 and 29.9 weeks and 3 (5.1%) before 24 weeks. Median time from diagnosis to delivery was longer in the cerclage group (9.1 weeks) than in the comparison group (3.3 weeks P<0.01). CONCLUSION: When pregnancies are complicated by late mid-trimester cervical dilation, placement of Shirodkar cerclage in appropriately selected patients has the potential to be a beneficial therapeutic option.

Management of painless mid-trimester cervical dilatation: Prophylactic vs emergency placement of cervical cerclage.

Women with recurrent painless mid-trimester miscarriages are often diagnosed with cervical insufficiency. Presenting symptoms typically include vaginal pressure and minimal bleeding; when the cervix is examined, advanced dilatation is usually detected. Labour is short and the premature fetus is born alive. Women with this history were traditionally considered candidates for the placement of cervical cerclage. Recently, this practice has been called into question. Rather than routine placement of prophylactic cervical cerclage at 12 - 14 weeks, many patients are followed expectantly with serial sonographic assessments of cervical length. The goal of this update is to review the literature regarding management options of mid-trimester cervical dilatation.

Changes in the threshold of fetal lung maturity testing and neonatal outcome of infants delivered electively before 39 weeks gestation: implications and cost-effectiveness.

OBJECTIVE: To compare the neonatal outcome of infants delivered before 39 weeks' gestation following documentation of fetal lung maturity before and after the lamellar body count (LBC) threshold was increased from 30,000 to 50,000 LB/ul. We discuss the algorithm employed for testing fetal lung maturity, the cost of testing and potential savings. MATERIAL AND METHODS: We studied the outcome of infants delivered electively before 39 weeks' gestation after fetal lung maturity was documented by amniotic fluid analysis. We compared the outcome of neonates born before and after the LBC threshold was increased. RESULTS: Our cohort included 527 neonates who were divided into two groups: 264 who underwent fetal lung maturity studies before the change in LBC threshold and 263 who underwent testing after the change. In the first group, 158 neonates met the criteria of LBC >30,000 LB/ul and were delivered without further testing. The second group included 154 neonates who were mature by LBC >50,000 LB/ul and were delivered. Seven of the neonates born in the first group required admission to the neonatal intensive care unit (NICU), whereas in the second group only two neonates required admission (P = 0.02). Additionally, 16 neonates in the first group required respiratory assistance compared with six in the second group (P = 0.04). The overall neonatal complication rate was significantly higher in the first group (P = 0.001). CONCLUSION: Changing the LBC threshold resulted in a significant decrease in neonatal morbidity. Employing the algorithm, we described for testing fetal lung maturity is cost effective, and more importantly, represents sound evidence-based medical management.

Gender-related differences in fetal heart rate during first trimester.

OBJECTIVE: Many expecting parents wish to ascertain fetal gender early in pregnancy. Our goal was to determine whether fetal heart rate (FHR) of males and females during the first trimester is significantly different. MATERIALS AND METHODS: From November 1997 to February 2003 we enrolled pregnant women with singleton gestations who underwent obstetric sonography at less than 14 weeks of gestational age. Indications for the sonographic study included first-trimester bleeding, uncertain gestational dating, poor obstetrical history, and aneuploidy screening by nuchal translucency. The sonographic studies were performed by a single sonographer and reviewed by the first author. The FHR was determined by m-mode. All subjects underwent second-trimester sonography at 18.0-24.0 weeks' gestation by the same team, and fetal gender was recorded. Multiple gestations, miscarriages and pregnancies with uncertain fetal gender were excluded. Sonographically assigned fetal gender was confirmed at delivery. RESULTS: Of the 966 first-trimester studies performed, 477 met the inclusion criteria. Of these, 244 (51%) were female and 233 (49%) were males. There were no statistical differences in mean maternal age, gravidity, parity, and mean gestational age at the time of the first study (9.0 +/- 2.3 weeks for female fetuses and 9.0 +/- 2.3 weeks for males, p = 0.7). The average female FHR was 151.7 +/- 22.7 bpm and male FHR was154.9 +/- 22.8 bpm (p = 0.13). DISCUSSION: Contrary to beliefs commonly held by many pregnant women and their families, there are no significant differences between male and female FHR during the first trimester.

Hysteroscopy in the evaluation of patients with recurrent pregnancy loss: a cohort study in a primary care population.

BACKGROUND: The purpose of this study was to determine the prevalence of structural uterine defects (SUD) in patients with recurrent pregnancy loss (RPL) attending a large family medicine practice and to determine the effectiveness of the therapeutic intervention. METHODS: This prospective cohort study from October 1995 to October 1998 included 23 patients aged 23 to 35 years (mean, 28.1) with an otherwise unexplained history of three or more 1st- or 2nd-trimester miscarriages and no live births. None of the couples were tobacco or alcohol users, all of them and had normal cytogenetic examinations and testing. Their jobs were unrelated to chemical handling. All patients had a complete history taken and underwent physical examination and hysteroscopy with directed biopsy. They had normal values for complete blood count, sedimentation rate, urinalysis and culture (gonorrhea, Chlamydia, syphilis, hepatitis B, HIV), lupus anticoagulant, anticardiolipin antibodies, spermiogram, progesterone, and pelvic ultrasound. RESULTS: Fourteen patients (60.9%) had a normal hysteroscopy (with biopsies). Nine patients (39.1 %) had SUD, as follows: Five patients (21.8%) had intrauterine adhesions, two patients (8.7%) had a septated uterus, one patient (4.3%) had submucosal myoma, and one patient (4.3%) had multiple factors. After appropriate therapy of the SUD, seven patients (77.8%) achieved successful pregnancy and two patients (22.2%) had recurrent miscarriage. In the normal hysteroscopy group, eight patients (57.1%) had recurrent miscarriages, two patients (14.3%) had infertility, and four patients (28.6%) achieved successful pregnancy with no further therapy. CONCLUSIONS: The prevalence of SUD in our studied population was 39.1 %. After appropriate treatment, the rate of live-birth pregnancies in these patients was 77.8%. Because SUD are the most treatable cause of RPL, these patients should be identified early after other potential causes of RPL are eliminated.

A controlled clinical study on the efficacy of benzydamine in the topical treatment of non-specific cervicitis and vaginitis.

The authors report the results achieved in a controlled clinical study carried out for evaluating the efficacy of some topical preparations in the treatment of the so-called non-specific cervicovaginitis. The best results have been observed in 55 patients treated with a 0.1% benzydamine solution, whose efficacy was found to be significantly greater than that of povidone-iodine vaginal suppositories or a 0.2% aluminium acetate solution that were used in an additional 45 patients suffering from non-specific vulvovaginitis and exocervicitis, according to a fully randomized experimental study protocol. The results obtained in the non-selected population of the present study confirm the usefulness of benzydamine vaginal douches in the therapy of non-specific inflammations involving the lower female genital apparatus.