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ABSTRACT: Induction of labor is common in obstetric practice. According to the most current studies, the rate varies from 9.5 to 33.7 percent of all pregnancies annually. In the absence of a ripe or favorable cervix, a successful vaginal birth is less likely. Therefore, cervical ripening or preparedness for induction should be assessed before a regimen is selected. Assessment is accomplished by calculating a Bishop score. When the Bishop score is less than 6, it is recommended that a cervical ripening agent be used before labor induction. Nonpharmacologic approaches to cervical ripening and labor induction have included herbal compounds, castor oil, hot baths, enemas, sexual intercourse, breast stimulation, acupuncture, acupressure, transcutaneous nerve stimulation, and mechanical and surgical modalities. Of these nonpharmacologic methods, only the mechanical and surgical methods have proven efficacy for cervical ripening or induction of labor. Pharmacologic agents available for cervical ripening and labor induction include prostaglandins, misoprostol, mifepristone, and relaxin. When the Bishop score is favorable, the preferred pharmacologic agent is oxytocin.
Diaphragm Fitting - Article
ABSTRACT: When used with a spermicide, the diaphragm can be a more effective barrier contraceptive than the male condom. The diaphragm allows female-controlled contraception. It also provides moderate protection against sexually transmitted diseases and is less expensive than some contraceptive methods (e.g., oral contraceptive pills). However, diaphragm use is associated with more frequent urinary tract infections. Contraindications to use of a diaphragm include known hypersensitivity to latex (unless the wide seal rim diaphragm is used) or a history of toxic shock syndrome. A diaphragm is fitted properly if the posterior rim rests comfortably in the posterior fornix, the anterior rim rests snugly behind the pubic bone, and the cervix can be felt through the dome of the device. The diaphragm should not be left in the vagina for longer than 24 hours. When the diaphragm is the chosen method of contraception, patient education is key to compliance and effectiveness. An extended visit with the physician or a nurse may be required for a woman to learn proper insertion, removal, and care of the diaphragm.
ABSTRACT: The American Society for Colposcopy and Cervical Pathology sponsored a consensus conference in 2001 to develop evidence-based guidelines for women with histologic abnormalities of the cervix. The options for management of cervical intraepithelial neoplasia 1, 2, and 3 are ranked according to the strength of the recommendation and the quality of the evidence. Follow-up with repeat cytology at six and 12 months or DNA testing for high-risk types of human papillomavirus at 12 months is the preferred management approach for women with cervical intraepithelial neoplasia 1 and satisfactory initial colposcopy. If results from repeat cytology are reported as atypical squamous cells of undetermined significance or greater, or if DNA human papillomavirus testing is positive for oncogenic types of the virus, repeat colposcopy is preferred. When the initial colposcopy is unsatisfactory, a diagnostic excisional procedure is preferred. Follow-up without treatment is acceptable only in women who are pregnant and adolescents with cervical intraepithelial neoplasia 1 who had unsatisfactory colposcopy. Biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 requires treatment except during pregnancy and in compliant adolescents with cervical intraepithelial neoplasia 2 and negative endocervical curettage. When colposcopy is satisfactory, treatment includes ablative or excisional procedures. A diagnostic excisional procedure is recommended in women with biopsy-confirmed cervical intraepithelial neoplasia 2 or 3 and unsatisfactory colposcopy.
Transcervical Amnioinfusion - Article
ABSTRACT: Amnioinfusion is being used to treat intrapartum problems known to be associated with fetal compromise, including prophylactic treatment of oligohydramnios during labor and after premature rupture of the membranes, treatment of severe variable decelerations during labor and reducing the risk of meconium aspiration during labor in patients with thick meconium fluid. The procedure is considered effective and easy to perform, with the benefits outweighing the risks.
ABSTRACT: Minor cytologic abnormalities of the cervix, such as atypical squamous cells of undetermined significance (ASCUS), are vastly more common than high-grade squamous intraepithelial lesions or invasive cancer. Current guidelines for the management of ASCUS include repeating the Papanicolaou (Pap) smear at specific intervals, referring all patients for colposcopy or using an adjunctive test such as hybrid capture human papillomavirus (HPV) testing or cervicography. The usefulness of the Pap smear is limited by its considerable false-negative rate and its dependence on clinician and laboratory performance. Colposcopy is a highly sensitive procedure, but many patients with ASCUS have normal colposcopic findings. The hybrid capture test not only measures quantitative HPV load but also detects both oncogenic and nononcogenic HPV types, thereby increasing the probability that serious cervical disease is not missed. Hybrid capture sampling is simple to perform, and positive results are strongly associated with cervical dysplasia. HPV testing in women with ASCUS can be used as an adjunctive test to identify those with HPV-associated disease; it can also serve as a quality assurance measure. Together, repeat Pap smears and HPV testing should identify most patients with underlying cervical dysplasia. Combined testing may also minimize the number of unnecessary colposcopic examinations in women who have no disease.
ABSTRACT: New data have emerged since publication of the American Society for Colposcopy and Cervical Pathology's 2001 consensus guidelines for management of abnormal cervical cytology and histology. The 2006 guidelines include recommendations for special populations (i.e., adolescents and pregnant women). Human papillomavirus testing is now included for management of atypical glandular cytology, for follow-up after treatment for cervical intraepithelial neoplasia, and in combination with cytologic screening in women 30 years and older. The preferred management of atypical squamous cells of undetermined significance in adult women is reflex human papillomavirus DNA testing. Colposcopy is recommended for adult women with low-grade squamous intraepithelial lesion, atypical glandular cells, high-grade intraepithelial neoplasia, and atypical squamous cells-cannot exclude high-grade intraepithelial neoplasia. Cervical intraepithelial neoplasia, grade 1 can be managed conservatively in adult women, but treatment for cervical intraepithelial neoplasia, grades 2 and 3 is recommended. Immediate treatment is an option for adult women but not for adolescents with high-grade squamous intraepithelial lesion. Conservative management of adolescents with any cytologic or histologic diagnosis except specified cervical intraepithelial neoplasia, grade 3 and adenocarcinoma in situ is recommended. Colposcopy is preferred for pregnant women with low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion, but evaluation of the former may be deferred until no earlier than six weeks postpartum. Treatment during pregnancy is unacceptable unless invasive carcinoma is identified.
Labor Induction: A Decade of Change - Editorials
ACOG Releases Guidelines on Cervical Cytology Screening - Practice Guidelines
ABSTRACT: Women who have abnormal Papanicolaou test results may undergo colposcopy to determine the biopsy site for histologic evaluation. Traditional grading systems do not accurately assess lesion severity because colposcopic impression alone is unreliable for diagnosis. The likelihood of finding cervical intraepithelial neoplasia grade 2 or higher increases when two or more cervical biopsies are performed. Excisional and ablative methods have similar treatment outcomes for the eradication of cervical intraepithelial neoplasia. However, diagnostic excisional methods, including loop electrosurgical excision procedure and cold knife conization, are associated with an increased risk of adverse obstetric outcomes, such as preterm labor and low birth weight. Methods of endometrial assessment have a high sensitivity for detecting endometrial carcinoma and benign causes of uterine bleeding without unnecessary procedures. Endometrial biopsy can reliably detect carcinoma involving a large portion of the endometrium, but is suboptimal for diagnosing focal lesions. A 3- to 4-mm cutoff for endometrial thickness on transvaginal ultrasonography yields the highest sensitivity to exclude endometrial carcinoma in postmenopausal women. Saline infusion sonohysteroscopy can differentiate globally thickened endometrium amenable to endometrial biopsy from focal abnormalities best assessed by hysteroscopy. Hysteroscopy with directed biopsy is the most sensitive and specific method of diagnosing endometrial carcinoma, other than hysterectomy.