May Alarab

Singleton vaginal breech delivery at term: still a safe option.

OBJECTIVE: To examine the obstetric and perinatal outcome of pregnancies with singleton breech presentation at term when selection for vaginal delivery was based on clear prelabor and intrapartum criteria. METHODS: The outcomes of all pregnancies with a breech presentation after 37 weeks of gestation were retrospectively reviewed from January 1997 to June 2000. Criteria for prelabor cesarean or trial of vaginal breech delivery included type of breech, estimated fetal weight (more than 3,800 g), maternal preference, and gestation more than 41 weeks. An intrapartum protocol excluded induction and oxytocin augmentation of labor, combined with a low threshold for cesarean delivery for dystocic labor; an experienced obstetrician was in attendance during labor and delivery. RESULTS: Of 641 women, 343 (54%) underwent prelabor cesarean, and 298 (46%) had a trial of vaginal delivery, of whom 146 (49%) delivered vaginally. Significantly fewer nulliparas (58 of 158, 37%) than multiparas (88 of 140, 63%; P < .001) achieved vaginal delivery after trial of labor. Significantly more infants weighing more than 3,800 g were selected for prelabor (87 of 343, 25%) and intrapartum (31 of 152, 20%) cesarean than delivered vaginally (15 of 146, 10%). Two neonates (0.7%) had Apgar scores of less than 7 at 5 minutes; both were neurologically normal at 6 weeks. There were no nonanomalous perinatal deaths and no cases of significant trauma or neurological dysfunction; 3 infants delivered vaginally died due to lethal anomalies. CONCLUSION: Safe vaginal breech delivery at term can be achieved with strict selection criteria, adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance. Our protocol effectively selects larger infants for cesarean delivery. LEVEL OF EVIDENCE: II-2

Effect of childhood dysfunctional voiding on urinary incontinence in adult women.

OBJECTIVE: To determine whether a history of childhood dysfunctional voiding is associated with urinary incontinence in adulthood. METHODS: Using a case-control study, we surveyed patients presenting with or without urinary incontinence. Cases were patients referred to a tertiary urogynecology clinic, and controls were patients referred to a general gynecology clinic. Patients completed a validated childhood questionnaire about dysfunctional voiding. A total score of 6 or more in girls is indicative of dysfunctional voiding, a condition characterized by urgency, frequency, constipation, urinary or fecal incontinence, and/or urinary tract infections. Using an alpha of 0.05, a power of 80%, and a baseline prevalence of dysfunctional voiding of 8%, we determined that 170 patients were needed to show a 3-fold difference between groups. RESULTS: Cases (n = 84) and controls (n = 86) had similar baseline characteristics except for body mass index and incidence of previous pelvic surgery. Although the total dysfunctional voiding score was higher in cases than controls (7.3 versus 5.0, respectively; P = .001), the difference in the number (%) of patients with history of childhood dysfunctional voiding between the 2 groups was not significant (47 [56%] versus 36 [42%], respectively; odds ratio 1.76, 95% confidence interval 0.96–3.24; P = .07). When all patients from both groups were combined, there was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (P = .004), urgency (P = .03), stress incontinence (P = .01), and urge incontinence (P = .009). CONCLUSION: Women with adult lower urinary tract symptoms may have a higher prevalence of history of childhood dysfunctional voiding. LEVEL OF EVIDENCE: II-2

Pelvic organ prolapse: demographics and future growth prospects

Pelvic Organ Prolapse (POP) is the hidden epidemic. Demographic studies have shown that women over the age of eighty are the fastest growing population segment in the United States and Canada. Over the next thirty years the rate of women who will seek treatment for POP will double. Risks for the development of POP have been categorized into factors that predispose, incite, promote, and decompensate. Connective tissue disorders may play a role in the pathogenesis which may involve a reduction in total collagen content secondary to increased collagenolytic activity. Eventually clinicians may be able to identify women who may be genetically predetermined to develop POP. The role of adjuvant materials in performing reconstructive pelvic surgery may improve success rates, but evidence based medicine and randomized controlled trials are currently lacking.

LOX family enzymes expression in vaginal tissue of premenopausal women with severe pelvic organ prolapse.

Introduction and HypothesisThe extracellular matrix proteins collagen and elastin provide tissue strength and resilience, whereas lysyl oxidase enzymes play a major role in their stabilization. This study examines the expression and tissue localization of lysyl oxidase family proteins in the anterior vaginal wall of premenopausal women with advanced pelvic organ prolapse (POP, n = 15) and asymptomatic controls (n = 11). All women were in the proliferative phase of menstrual cycle.MethodsTotal mRNAs and proteins extracted from the vaginal tissue were examined by real-time polymerase chain reaction and immunoblotting, and tissue specimens were analyzed by immunohistochemistry.ResultsThe expression of LOX, LOXL1, and LOXL3 genes as well as LOX and LOXL3 proteins were significantly reduced in POP patients (P < 0.05). Immunolocalization of LOX family proteins was confirmed in all vaginal specimens.ConclusionWe proposed that reduced expression of LOX enzymes may result in defective assembly of pelvic tissues and development of POP.

Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research

Vaginal delivery is the major risk factor for the development of pelvic organ prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. This article reviews the perineal trauma mechanism during vaginal delivery and discusses implications of current and future research projects.

Genes responsible for vaginal extracellular matrix metabolism are modulated by women's reproductive cycle and menopause

OBJECTIVES To analyze the expression of genes involved in extracellular matrix (ECM) biogenesis and remodeling in vaginal tissue of women with clinically normal pelvic floor support (defined as controls) according to the phase of menstrual cycle and postmenopausal women with and without pelvic organ prolapse (POP). MATERIALS AND METHODS This study examined the expression of matrix metalloproteinases (MMPs), their tissue inhibitors (TIMPs), and the Lysyl oxidase (LOX) family genes in the anterior vaginal wall of Caucasian women by real-time RT-PCR. Initially, mRNA expression was assessed in premenopausal controls in the secretory (group 1, n = 10) vs. proliferative (group 2, n = 8) phase of menstrual cycle. In addition, we compared premenopausal controls in the proliferative phase (group 2) vs. postmenopausal controls (group 3, n = 5). Finally, we analyzed postmenopausal controls (group 3) vs. postmenopausal women with advanced POP (group 4, n = 13). RESULTS According to the phase of menstrual cycle, MMP1 was significantly reduced (p = 0.003), whereas the expression of TIMP1 and LOXL4 was significantly up-regulated during proliferative phase (both p < 0.01) when compared to the secretory phase in premenopausal control women. Regarding menopausal status/ageing, all MMPs were down-regulated, while TIMP3, TIMP4 and LOXL2 were significantly up-regulated in postmenopausal control women when compared to premenopausal controls (p = 0.005, p = 0.01 and p < 0.001, correspondingly). TIMP4 and LOXL2 mRNA levels were significantly decreased in postmenopausal POP patients compared to asymptomatic postmenopausal controls (p < 0.01 for both). CONCLUSIONS Our results indicate that ovarian cycle and age-related changes influence the expression of genes encoding proteins responsible for ECM metabolism in human vagina. Moreover, POP is associated with alteration in vaginal ECM components after menopause.

Expression of Bone Morphogenetic Protein-1 in vaginal tissue of women with severe pelvic organ prolapse

OBJECTIVES To analyze the differential gene and protein expression of Bone Morphogenetic Protein-1 in vaginal tissue of women with advanced pelvic organ prolapse and controls. STUDY DESIGN We sampled the anterior vaginal wall of 39 premenopausal (23 patients and 16 controls), and 18 postmenopausal women (13 patients and 5 controls) during hysterectomy. Total mRNAs and proteins were quantified by real-time RT-PCR and immunoblotting. RESULTS Bone Morphogenetic Protein-1 gene expression was decreased in pre- and postmenopausal pelvic organ prolapse patients compared with asymptomatic women (P = .01). The expression of 130 kDa, 92.5 kDa, and 82.5 kDa isoforms of Bone Morphogenetic Protein-1 were down-regulated in postmenopausal patients (P = .01), whereas the 130 kDa isoform expression was up-regulated in premenopausal patients (P = .009), when compared with respective controls. CONCLUSION The Bone Morphogenetic Protein-1 expression in human vagina was altered in patients with severe pelvic organ prolapse and influenced by menopausal status. Dysregulation of Bone Morphogenetic Protein-1 may contribute for a deficient vaginal connective tissue and support.

Expression of Extracellular Matrix-Remodeling Proteins Is Altered in Vaginal Tissue of Premenopausal Women With Severe Pelvic Organ Prolapse

Aim: The molecular etiology of pelvic organ prolapse (POP) is complex and not well understood. We compared the expression/activity of extracellular matrix (ECM)-processing (procollagen I N-proteinase/ a disintegrin and metalloproteinase with thrombospondin motifs [ADAMTS]-2,-3,-14) and ECM-degrading (matrix metalloproteinase [MMP]-1, -2, -7, -8, -9, -12) enzymes and their natural tissue inhibitors (tissue inhibitors of metalloproteinase [TIMP]-1,-2,-3,-4) in vaginal tissues from premenopausal women with advanced POP (POP-Q stage ≥ 3) and asymptomatic controls (POP-Q = 0). Study Design: We sampled the anterior vaginal wall of 36 premenopausal women (17 patients with POP and 19 controls) undergoing total hysterectomy. Exclusion criteria include steroid therapy, malignancy, previous pelvic surgery, and connective tissue diseases. Total RNAs and proteins were quantified by real-time polymerase chain reaction, immunoblotting, and Luminex assay; MMPs activity was analyzed by zymography and tissue localization by immunohistochemistry. Results: The MMP-2 gelatinase activity as well as expression of 58-kDa isoform of ADAMTS-2 was upregulated in patients with POP, irrespective of menstrual phase status, secretory or proliferative, when compared to controls (P < .05). The TIMP-1-4 gene and TIMP-1 protein expression were significantly (P < .05) reduced, whereas protein expression of MMP-12 (pro and active forms) was significantly increased in vaginal biopsies of patients with POP in the proliferative phase of the menstrual cycle compared to corresponding controls. Analyses of MMP-12, TIMP-1, and ADAMTS-2 tissue immunostaining indicate similar localization in the vaginal specimens from control and patients with POP. Conclusion: Expression of ECM-remodeling proteins is altered in the vagina of premenopausal patients with severe POP. We speculate that dysregulation of MMP/TIMP complexes and ADAMTS-2 proteins may cause connective tissue defects, which result in weakened vaginal wall support and POP development.

Randomized Trial of Oxybutynin Extended Versus Immediate Release for Women Aged 65 and Older with Overactive Bladder: Lessons Learned from Conducting a Trial

OBJECTIVE This trial was designed to investigate the effectiveness of extended release versus immediate release oxybutynin in reducing symptoms of overactive bladder in a community-dwelling female population over the age of 65. METHODS This was a prospective randomized 12-week, open-label study. The primary outcome was number of micturitions per 24 hours, 12 weeks after treatment. The a priori sample size estimate was 60 patients per group. RESULTS Of the 318 women approached, only 72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely because of recruitment difficulties and an interim analysis revealing the need for a much larger sample than had been estimated to show a significant difference between treatments. After 12 weeks of treatment, there was no difference between the oxybutynin extended release and immediate release groups in the number of micturitions per 24 hours or in other outcomes. CONCLUSION This study did not demonstrate differences between oxybutynin extended release and immediate release and in reducing symptoms of overactive bladder or quality of life, possibly because the study did not reach the necessary sample size. The difficulty in recruiting subjects for the trial likely resulted from the onerous study requirements (4 study visits required over 12 weeks) and the downtown location of the study centres: these factors would cause particular difficulties for women over age 65 with overactive bladder, for whom travelling may be a problem. Evidence is needed to guide prescribing for older patients, but designing research to obtain adequate sample sizes is difficult. Studies in older subjects should ensure that a much larger budget is allocated for recruitment than would be allocated for studies in younger subjects, that meticulous attention is paid to issues of transport and access, and that support is provided for subjects who agree to take part research.

Efficacy and Safety of Tension-Free Vaginal Tape Compared With Transobturator Tape Among Obese Women With Stress Urinary Incontinence: A Retrospective Cohort Study

OBJECTIVE To determine the efficacy and safety of tension-free vaginal tape (TVT) compared with transobturator tape (TOT) in obese women with stress urinary incontinence (SUI). METHODS We performed a retrospective chart review of patients who underwent insertion of TVT or TOT for stress urinary incontinence between January 2003 and October 2009. Women were excluded if they had had previous surgery for SUI or had a diagnosis of intrinsic sphincter deficiency. RESULTS One hundred eighty obese women (BMI > 30 kg/m²) with SUI and with follow-up for at least one year were identified (90 had TVT and 90 had TOT). The rates of success on the objective criteria were 91% for the TVT group and 88% for the TOT group (P = 0.46) and 87% versus 80% (P = 0.23) on subjective assessment. CONCLUSION Our retrospective cohort study demonstrated similar rates of cure for obese women with SUI who underwent insertion of TVT and TOT.