Prognosis and treatment of desquamative inflammatory vaginitis

Objective: Desquamative inflammatory vaginitis is a clinical syndrome frequently unrecognized, characterized by vaginal rash and purulent discharge. We describe patient outcomes and treatment at follow-up in a case series of 98 women diagnosed with this syndrome. Methods: We performed a chart review of 130 patients diagnosed with desquamative inflammatory vaginitis between 1996 and 2007 in a referral university-based vaginitis clinic. Clinical findings, laboratory findings, and treatment were documented during the first 12 months and at 2 and 4 years. Results: Of the 98 patients reviewed, 97 were white; mean age was 48.6 years (plus or minus 10.2 years), and 50% were postmenopausal. All patients were symptomatic with vaginal inflammation and 72% had vestibular findings. Treatment with topical 2% clindamycin (54%) or 10% hydrocortisone (46%) dramatically relieved symptoms within 3 weeks (median) in 86% of patients. Treatment was discontinued (median 8 weeks) in 53 patients experiencing clinical remission accompanied by normal wet mount appearance; however, 17 (32%) relapsed within 6 weeks. At 1 year, cure was achieved in 25 patients (26%), 57 (58%) were asymptomatic but remained dependent on maintenance treatment, and 16 (16%) were partially controlled only. A favorable initial response to therapy was associated with positive clinical prognosis by 20 weeks of follow-up (P=.01). Conclusion: Desquamative inflammatory vaginitis is a chronic inflammatory process involving both vagina and vestibule, occurring almost exclusively in white women, that responds well to topical anti-inflammatory therapy, although long-term maintenance therapy frequently is required. © 2011 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins

Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications

Abstract Background Repeat cesarean delivery (CD) accounts for approximately 15% of all annual deliveries in the US with an estimated 656,250 operations per year. We aimed to study whether prolonged operative time (OT; skin incision to closure) is a risk marker for post-operative maternal complications among women undergoing repeat CD. Methods We conducted a cross-sectional retrospective study in a single tertiary center including all women who underwent repeat CD but excluding those with cesarean hysterectomy. Prolonged OT was defined as duration of CD longer than the 90th percentile duration on record for each specific surgeon in order to correct for technique differences between surgeons. Bi-variate analysis was used to study the association of prolonged OT with each one of the following maternal complications: post-operative blood transfusion, prolonged maternal hospitalization (defined as hospitalization duration longer than 1 week post-CD), infection necessitating antibiotics, re-laparotomy within 7 days post-CD, and re-admission within 42 days post-CD. A multivariate regression analysis was performed controlling for maternal age, ethnicity, parity, number of fetus, gestational age at delivery, trial of labor after cesarean, anesthesia, and number of previous CDs. The adjusted odd ratio was calculated for each complication independently and for a composite adverse maternal outcome defined as any one of the above. Results A total of 6507 repeat CDs were included; prolonged OT was highly associated (P value < 0.000) with: post-operative blood transfusion (4.4% vs. 1.5%), prolonged hospitalization (8.4% vs. 4.0%), infection necessitating antibiotics (2% vs. 1%), and readmission (1.8% vs. 0.8%) when compared to control. The composite adverse maternal outcome was also associated with prolonged OT (20.2% vs. 11.2%, p < 0.000). These correlations remained statistically significant in the multivariate regression analysis when controlling for confounders. Conclusions Among women undergoing repeat CD, prolonged OT (reflecting CD duration greater than 90th percentile for the specific surgeon) is a risk marker for post-operative maternal complications

Preconception Screening for Cytomegalovirus: An Effective Preventive Approach

Congenital cytomegalovirus (CMV) is the leading infectious cause of sensorineural hearing loss and delayed psychomotor development. Viral transmission to the fetus is far more likely to occur following a primary than a secondary maternal infection. Primary prevention seems to be the best means to reduce the burden of congenital CMV due to the lack of treatment options during pregnancy. We evaluated this approach on a cohort of 500 women planning pregnancy who attended our fertility clinic. Of the 444 who underwent CMV screening, 18 (4.1%) had positive IgM serology for CMV; of these, IgG avidity was high in 12 (remote infection) and low in 6 (recent infection). The latter were advised to delay pregnancy. All women who were seroimmune for CMV (366/444, 82.4%), including the 12 with remote infection, continued fertility treatment. The remaining patients (72/444, 16.2%), who were not immune to CMV at the initial screen, were advised to minimize CMV exposure by improving personal hygiene and to continue fertility treatment. None of the 69/72 (95.8%) women who were followed for one year were infected with CMV. Cytomegalovirus testing and counselling at preconception seemed effective in reducing CMV exposure in pregnancy