Pelvic inflammatory disease Brunham, Robert C; Gottlieb, Sami L; Paavonen, Jorma
The New England journal of medicine,
2015-May-21, Volume:
372, Issue:
21
Journal Article
Summary Background The human papillomaviruses (HPV) are simple, nonenveloped, double-stranded DNA viruses, which are responsible for an enormous global burden of genital disease. HPV is associated ...with 500,000 new cases of cervical cancer and 250,000 cervical cancer deaths worldwide each year. Oncogenic HPV types 16 and 18 are responsible for a majority of cervical cancers and can also cause low- and high-grade cervical lesions (CIN 1, 2, 3) as well as high-grade vulvar or vaginal intraepithelial neoplasia (VIN or VaIN 2/3). Nononcogenic types HPV 6 and 11 also contribute to the overall burden of HPV disease, giving rise to CIN 1, anogenital warts, cutaneous lesions, and respiratory papillomatosis. Perspectives A substantial body of clinical evidence demonstrates the effectiveness of cytological screening in preventing cervical cancer, but these techniques have not eradicated the disease and are not widely available in most developing countries. Furthermore, evaluation and management of HPV-associated cytologic abnormalities is costly, drains health care resources, and increases the risk for adverse pregnancy outcome. Conclusions Targeting cervical cancer through universal immunization with a quadrivalent HPV 6, 11, 16, 18 vaccine may herald the beginning of the end of this deadly disease and substantially reduce the overall global burden of HPV-related genital diseases.
Objective. Placenta accreta is one of the most devastating pregnancy complications. We sought to compare outcomes between women with placenta accreta when diagnosed antenatally or intrapartum, and to ...define predictors of the antenatal diagnosis. Design. Retrospective case–control study. Setting. University teaching hospital. Population. Twenty‐four women with placenta accreta diagnosed antenatally and 20 women discovered intrapartum. Methods. Chart review of historical and delivery‐associated variables. Rates were compared between the groups. Main Outcome Measures. Placenta accreta diagnosed antenatally or intrapartum. Results. Women with antenatal diagnosis had a lower estimated blood loss of a median of 4500ml (range 100–15000ml) compared with 7800ml (range 2500–17000ml, p=0.012) and required fewer units of packed red blood cells transfused (median 7; range 0–27 compared with 13.5; range 4–31, p=0.026). Nineteen (79%) women diagnosed antenatally had balloon catheter occlusion carried out during the cesarean section. Five (21%) had the entire placenta left in situ. There was no difference in the rate of surgical complications or duration of hospitalization. The clinical diagnosis among women with antenatal diagnosis was more often placenta percreta (p=0.013). The risk factor profile of women with antenatal diagnosis of placenta accreta included higher gravidity (p=0.014) and parity (p<0.0001), history of cesarean section (p=0.004), and placenta previa in the current pregnancy (p<0.001). Conclusions. Antenatal diagnosis of placenta accreta may reduce peripartum blood loss and the need for blood transfusion. Women with antenatal diagnosis more often have placenta previa and history of previous cesarean section, and the clinical diagnosis is more often placenta percreta.
Objective Localized provoked vulvodynia (LPV) may have inflammatory etiology. We wanted to find out whether the cell-mediated immune system becomes activated in the vestibular mucosa in LPV. Study ...Design This was a controlled cross-sectional study. Vestibular mucosal specimens were obtained from 27 patients with severe LPV and 15 controls. Detailed clinical history of the patients was obtained. For immunohistochemistry, antibodies against CD3 (T cells), CD20 (B cells), IgA (mucosal plasma cells), CD163 (dendritic cells DCs), CD68 (macrophages), and CD117 (mast cells) were employed. Mann-Whitney U test and χ2 test were used for statistical analyses. Results More B lymphocytes and mature mucosal IgA-plasma cells were found in patients than in controls ( P < .001 and P < .001, respectively). In LPV samples, B and T cells were arranged into germinal centers representing local immune activation. Germinal centers were not seen in controls. Antigen-presenting DCs and macrophages were found both in patients and controls with similar densities. DCs were found to extend their dendrites into the luminal space through an intact epithelium. Similar amounts of mast cells were found evenly scattered throughout the stroma of vestibular mucosa of both patients and controls. Conclusion We demonstrate here local organized vestibule-associated lymphoid tissue analogous to mucosa-associated lymphoid tissue. Vestibule-associated lymphoid tissue may emerge as a response to local infection or inflammation in LPV.
Objective. Massive postpartum hemorrhage (PPH) is one of the most serious complications during delivery. Hysterectomy is commonly performed when other conventional treatment attempts fail. Bakri ...balloon tamponade (BBT) is a novel conservative management option for PPH. Little is known of the effectiveness of this procedure. We report a large case series from a tertiary teaching hospital. Design. Retrospective case series (October 2008–June 2011). Setting. University teaching hospital. Population. Forty‐four women with massive PPH (blood loss >1000 mL) and six other women with expected high risk of PPH (blood loss <1000 mL) managed by BBT. Methods. Chart review. Main outcome measures. Achievement of definitive hemostasis by BBT among the study population. Results. Among the women treated with BBT, the cause of PPH was uterine atony (16%), cervical rupture (14%), vaginal rupture and/or paravaginal hematoma (22%), placenta previa (18%) and placental retention (30%). The overall success rate was 86%. Seven of the 50 patients needed additional procedures. Of the seven failures, supravaginal uterine amputation or hysterectomy was required in four cases and embolization of the uterine arteries in three cases. Conclusions. BBT is a simple, readily available, effective and safe procedure for the management of PPH in selective cases. BBT does not exclude the use of other procedures if necessary. Even if BBT failed, it may provide temporary tamponade and time to prepare for other interventions or transportation from local hospital to tertiary centre. We suggest that BBT should be included in the PPH protocol.
Infections with oncogenic human papillomaviruses (HPV) globally cause about 9% of cancers in females and 1% of cancers in males. HPV disease burden can be effectively controlled by prophylactic ...HPV-vaccination provided it has high impact.
A unique series of biobank-based and health registry-based studies that exploit randomized intervention cohorts has provided data on population-level safety of HPV vaccination, duration of vaccine-induced protection and impact of gender-neutral HPV vaccination, providing a scientific basis for policies to eradicate oncogenic HPV types and associated diseases worldwide.
The ultimate goal of HPV vaccination is the eradication of high-risk (hr) HPVs. Seventy-five percent coverage gender-neutral vaccination of early adolescents will rapidly eradicate also HPV16 from the general population.
Localized provoked vulvodynia (LPV) causes dyspareunia among reproductive aged women. We review the pathogenesis of LPV and suggest that LPV is an inflammatory pain syndrome of the vestibular mucosa ...triggered by microbial antigens in a susceptible host. Tissue inflammation and hyperinnervation are characteristic findings which explain symptoms and clinical signs. Education of health care providers of LPV is important since this condition is common, often unrecognized, and patients often become frustrated users of health care. Research is needed on the antigen triggers of the syndrome. Randomized clinical trials are needed to evaluate treatment modalities.
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