A retrospective cohort study was set up to evaluate the effectiveness of conservative and radical surgery for tubal pregnancy towards subsequent fertility. Consecutive patients undergoing conservative or radical surgery for tubal pregnancy between January 1990 and August 1993 in two university hospitals were included in the study. Outcome measures were spontaneous intrauterine pregnancy (IUP) and repeat ectopic pregnancy (EP). Of the 135 patients analysed, 56 underwent conservative surgery and 79 underwent radical surgery. Patients treated with conservative surgery achieved a higher 3-year cumulative pregnancy rate than those treated radically (P < 0.001, log-rank test). In patients treated conservatively, there was only one spontaneous IUP in the period between 18 months and 3 years after the tubal pregnancy. In contrast, patients treated radically continued to conceive in this period. Multivariate analysis showed a fecundity rate ratio (FRR) of 1.9 [95% confidence interval (CI): 0.91 to 3.8] for IUP after conservative surgery in the first 18 months of follow-up. In patients with a history of bilateral tubal disease the FRR was 3.1 (95% CI: 0.76 to 12), whereas in patients without a history of bilateral tubal disease the FRR was 1.4 (95% CI: 0.13 to 16). The FRR for repeat EP was 2.4 (95% CI: 0.57 to 11). Our data indicate a beneficial effect of conservative surgery towards subsequent fertility that was not, however, statistically significant in the multivariate analysis. In view of these inconclusive data and the importance of this major health problem, randomized studies are required to assess whether conservative surgery really improves the fertility prospects of patients with tubal pregnancy.
Objective To assess the prevalence and the development of urinary incontinence in nulliparous pregnant women, both subjectively and objectively, and to investigate the relation of incontinence with the mobility of the urethro-vesical junction measured by perineal ultrasound. Design A prospective longitudinal study.Setting University Hospital and Martini Hospital Groningen, the Netherlands. Population A cohort of 117 nulliparous pregnant women and 27 nulliparous non-pregnant controls.Methods Urinary incontinence was measured by a questionnaire and by a 24-hour pad test. The position of the urethro-vesical junction and its mobility were measured by perineal ultrasound.Main outcome measure Prevalence of urinary incontinence; mobility of the urethro-vesical junction, indicated by the displacement/pressure coef®cient.Results Up to 35% of the women reported urinary incontinence in pregnancy, and 20% of the women had a positive pad test. The angle of the urethro-vesical junction angle at rest and the displacement/pressure coef®cient during coughing showed a signi®cant increasing trend during pregnancy, but no changes were seen during the Valsalva manoeuvre. No relationship was found between subjective and objective incontinence data and the position and mobility of the urethro-vesical junction.Conclusion The prevalence of incontinence in nulliparous women as found by the pad test was signi®cantly higher in pregnancy (20%) than in the non-pregnant control group (4%). Perineal ultrasound of the urethrovesical junction showed lowering of the pelvic¯oor occurring as early as 12-16 weeks of pregnancy. Serial measurements of the displacement/pressure coef®cient suggest that the dynamic characteristics of the connective tissues of the pelvic¯oor remain unaltered,whereas a signi®cant decrease in pelvic¯oor muscle contraction occurs. Since no relation was found between measurements of the urethro-vesical junction and incontinence, urinary incontinence in pregnancy is most likely explained by other factors.
Objective To assess the prevalence and the development of urinary incontinence in nulliparous pregnant women, both subjectively and objectively, and to investigate the relation of incontinence with the mobility of the urethro-vesical junction measured by perineal ultrasound. Design A prospective longitudinal study.Setting University Hospital and Martini Hospital Groningen, the Netherlands. Population A cohort of 117 nulliparous pregnant women and 27 nulliparous non-pregnant controls.Methods Urinary incontinence was measured by a questionnaire and by a 24-hour pad test. The position of the urethro-vesical junction and its mobility were measured by perineal ultrasound.Main outcome measure Prevalence of urinary incontinence; mobility of the urethro-vesical junction, indicated by the displacement/pressure coef®cient.Results Up to 35% of the women reported urinary incontinence in pregnancy, and 20% of the women had a positive pad test. The angle of the urethro-vesical junction angle at rest and the displacement/pressure coef®cient during coughing showed a signi®cant increasing trend during pregnancy, but no changes were seen during the Valsalva manoeuvre. No relationship was found between subjective and objective incontinence data and the position and mobility of the urethro-vesical junction. ConclusionThe prevalence of incontinence in nulliparous women as found by the pad test was signi®cantly higher in pregnancy (20%) than in the non-pregnant control group (4%). Perineal ultrasound of the urethrovesical junction showed lowering of the pelvic¯oor occurring as early as 12-16 weeks of pregnancy. Serial measurements of the displacement/pressure coef®cient suggest that the dynamic characteristics of the connective tissues of the pelvic¯oor remain unaltered,whereas a signi®cant decrease in pelvic¯oor muscle contraction occurs. Since no relation was found between measurements of the urethro-vesical junction and incontinence, urinary incontinence in pregnancy is most likely explained by other factors.
With a curved array real-time ultrasound scanning machine and the probe placed sagitally onto the vulva, symphysis, bladder, urethra and the pelvic floor can be visualized in one frame. With this technique we studied 10 women with stress incontinence and 10 control women. In both groups active contraction of the pelvic floor resulted in a similar elevation of the urethrovesical junction (UVJ). During Valsalva maneuver an equal descent of the UVJ was found in patients and controls. During coughing a significant descent of the UVJ only occurred in the patient group. This suggests that women with stress incontinence are capable of operating the pelvic floor muscles but do not use them adequately during a cough.
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