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Objective: To determine whether laparoscopic sacrocolpopexy (LSC) or vaginal sacrospinous fixation (VSF) is the most optimal surgical treatment in patients with POP-Q stage =2 vaginal vault prolapse (VVP).Design: Multicentre randomised controlled trial (RCT) and prospective cohort study alongside.Setting: Seven non-university teaching hospitals and two university hospitals in the Netherlands.Population : Patients with symptomatic post-hysterectomy vaginal vault prolapse, requiring surgical treatment.Methods: Randomisation in a 1:1 ratio to LSC or VSF. Evaluation of prolapse was done using the pelvic organ prolapse quantification (POP-Q). All participants were asked to fill in various Dutch validated questionnaires 12 months postoperatively.Main outcome measures: Primary outcome was disease-specific quality of life. Secondary outcomes included composite outcome of success and anatomical failure. Furthermore, we examined peri-operative data, complications and sexual function.Results: A total of 179 women, 64 women randomised and 115 women, participated in a prospective cohort. Disease-specific quality of life did not differ after 12 months between the LSC and VSF group in the RCT and the cohort (RCT: P = 0.887; cohort: P = 0.704). The composite outcomes of success for the apical compartment, in the RCT and cohort, were 89.3% and 90.3% in the LSC group and 86.2% and 87.8% in the VSF group, respectively (RCT: P = 0.810; cohort: P = 0.905). There were no differences in number of reinterventions and complications between both groups (reinterventions RCT: P = 0.934; cohort: P = 0.120; complications RCT: P = 0.395; cohort: P = 0.129).Conclusions: LSC and VSF are both effective treatments for vaginal vault prolapse, after a follow-up period of 12 months.

Objective To investigate whether laparoscopic sacrohysteropexy (LSH) is non-inferior to vaginal sacrospinous hysteropexy (SSHP) in the surgical treatment of uterine prolapse. Design Multicentre randomised controlled, non-blinded non-inferiority trial. Setting Five non-university teaching hospitals in the Netherlands, one university hospital in Belgium. Population 126 women with uterine prolapse stage 2 or higher undergoing surgery without previous pelvic floor surgery. Methods Randomisation in a 1:1 ratio to LSH or SSHP, stratified per centre and severity of the uterine prolapse. The predefined inferiority margin was an increase in surgical failure rate of 10%. Main outcome measures Primary outcome was surgical failure, defined as recurrence of uterine prolapse (POP-Q ≥ 2) with bothersome bulging/protrusion symptoms and/or repeat surgery or pessary at 12 months postoperatively. Secondary outcomes were anatomical recurrence (any compartment), functional outcome and quality of life. Results Laparoscopic sacrohysteropexy was non-inferior for surgical failure (n = 1, 1.6%) compared with SSHP (n = 2, 3.3%, difference -1.7%, 95% CI: -7.1 to 3.7) 12 months postoperatively. Overall, anatomical recurrences and quality of life did not differ. More bothersome symptoms of overactive bladder (OAB) and faecal incontinence were reported after LSH. Dyspareunia was more frequently reported after SSHP. Conclusion Laparoscopic sacrohysteropexy was non-inferior to SSHP for surgical failure of the apical compartment at 12 months' follow up. Following LSH, bothersome OAB and faecal incontinence were more frequent, but dyspareunia was less frequent. Tweetable abstract Laparoscopic sacrohysteropexy and vaginal sacrospinous hysteropexy have equally good short-term outcomes.

Objective To compare recurrence of a cyst or abscess of the Bartholin gland after surgical treatment using a Word catheter or marsupialisation. Design Multicentre, open-label, randomised controlled trial. Setting Eighteen hospitals in the Netherlands and one hospital in England. Population Women with a symptomatic cyst or abscess of the Bartholin gland. Methods Women were randomised to treatment with Word catheter or marsupialisation. Main outcome measures The primary outcome was recurrence of the cyst or abscess within 1 year of treatment. The secondary outcomes included pain during and after treatment (measured on a 10-point scale), use of analgesics, and time from diagnosis to treatment. Analysis was by intention-to-treat. To assess whether marsupialisation would reduce the recurrence rate by 5% (from 20 to 15%) we needed to include 160 women (alpha error 0.05, beta error 0.2). Results One hundred and sixty-one women were randomly allocated to treatment by Word catheter (n = 82) or marsupialisation (n = 79) between August 2010 and May 2014. Baseline characteristics were comparable. Recurrence occurred in 10 women (12%) allocated to Word catheter versus eight women (10%) allocated to marsupialisation: relative risk (RR) 1.1, 95% confidence interval (CI) 0.64–1.91; P = 0.70. Pain scores after treatment were also comparable. In the first 24 hours after treatment, 33% used analgesics in the Word catheter group versus 74% in the marsupialisation group (P

Item does not contain fulltext STUDY QUESTION: Is curettage more effective than expectant management in case of an incomplete evacuation after misoprostol treatment for first trimester miscarriage? SUMMARY ANSWER: Curettage leads to a higher chance of complete evacuation but expectant management is successful in at least 76% of women with an incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage. WHAT IS KNOWN ALREADY: In 5-50% of the women treated with misoprostol, there is a suspicion of incomplete evacuation of the uterus on sonography. Although these women generally have minor symptoms, such a finding often leads to additional curettage. STUDY DESIGN, SIZE, DURATION: From June 2012 until July 2014, we conducted a nationwide multicenter randomized controlled trial (RCT). Women who had had primary misoprostol treatment for miscarriage with sonographic evidence of incomplete evacuation of the uterus were randomly allocated to either curettage or expectant management (1:1), using a web-based application. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included 59 women in 27 hospitals; 30 were allocated to curettage and 29 were allocated to expectant management. A successful outcome was defined as sonographic finding of an empty uterus 6 weeks after randomization. MAIN RESULTS AND THE ROLE OF CHANCE: Baseline characteristics of both groups were comparable. Empty uterus on sonography or uneventful clinical follow-up was seen in 29/30 women (97%) allocated to curettage compared with 22/29 women (76%) allocated to expectant management (RR 1.3, 95% CI 1.03-1.6) with complication rates of 10% versus 10%, respectively (RR 0.97, 95% CI 0.21-4.4). In the group allocated to curettage, no woman required re-curettage, while two women (6.7%) underwent hysteroscopy (for other or unknown reasons). In the women allocated to expectant management, curettage was performed in four women (13.8%) and three women (10.3%) underwent hysteroscopy. LIMITATIONS, REASONS FOR CAUTION: Due to a strong patient preference, mainly for expectant management, the targeted sample size could not be included and the trial was stopped prematurely. WIDER IMPLICATIONS OF THE FINDINGS: In women suspected of incomplete evacuation of the uterus after misoprostol, curettage is more effective than expectant management. However, expectant management is equally safe and prevents curettage for most of the women. This finding could further restrain the use of curettage in the treatment of first trimester miscarriage. STUDY FUNDING/COMPETING INTERESTS: This study was funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066. There were no conflicts of interests. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR3310, http://www.trialregister.nl TRIAL REGISTRATION DATE: 27 February 2012. DATE OF FIRST PATIENT'S ENROLMENT: 12 June 2012.

SUMMARY Maternal anti-HPA-1a antibodies can cause severe fetal and neonatal alloimmune thrombocytopenia (FNAIT), complicated by intracranial haemorrhage (ICH). Antenatal treatment with maternal intravenous immunoglobulin (IVIG) seems to protect against ICH even when thrombocytopenia persists. The aim of this study was to investigate if anti-HPA-1a antibodies and IVIG potentially affect vascular endothelial cells (ECs) in order to identify susceptibility for ICH. Human umbilical cord endothelial cells (HUVEC) were incubated with anti-HPA-1a antibodies with or without polyclonal IVIG and evaluated for EC activation. Maternal sera with anti-HPA-1a antibodies affected neither the EC expression of intracellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1) and tissue factor (TF) nor the release of van Willebrand factor (vWF) or interleukin (IL)-8 nor the integrity of ECs. Maternal sera obtained after IVIG treatment and polyclonal IVIG decrease constitutive and cytokine-induced ICAM-1 and VCAM-1 expression on ECs. The results show that maternal anti-HPA-1a antibodies cause no activation or damage of ECs in this model. The clinical relevance of the de-activating properties of IVIG on EC activation with respect to ICH deserves further investigation.

Background and Objectives Intracranial haemorrhage (ICH) of the fetus or newborn is a severe complication of fetal or neonatal alloimmune thrombocytopenia (FNAIT). In order to attain management decisions to prevent ICH, the risk of ICH in successive pregnancies with thrombocytopenia, with or without a history of ICH, must be established. Materials and Methods We performed a search of medline for ICH cases in untreated FNAIT pregnancies. After exclusion of cases with confounding factors, 24 reports, describing 62 pregnancies of 27 mothers, were eligible. In addition, two mothers with five pregnancies were included from our own case records. Observational studies were examined to estimate the risk of ICH in subsequent FNAIT pregnancies without a history of ICH. Finally, medline was searched for complication rates in the treatment of FNAIT pregnancies. Results In 52% of the ICH cases, a previous sibling suffered from ICH. The recurrence rate of ICH in the subsequent offspring of women with a history of FNAIT with ICH was 72%[confidence interval (CI): 46–98%] without inclusion of fetal deaths and 79% (CI: 61–97%) with inclusion of fetal deaths. In 48% of the ICH cases, the previous sibling had thrombocytopenia but not ICH. Population studies revealed an overall ICH risk in thrombocytopenic infants of 11% (CI: 0·8–23%) without inclusion of fetal deaths and 15% (CI: 1·5–19%) with inclusion of fetal deaths. Assuming occurrence in 48%, the risk of ICH in a subsequent pregnancy following a history of FNAIT without ICH, was estimated to be 7% (CI: 0·5–13%). Invasive treatment strategies carry a risk of 2·8% (CI: 1·2–4·4%) on complications. Conclusions The number of eligible publications on ICH in untreated FNAIT pregnancies is strikingly limited. The recurrence rate is high. As sufficient data on successive FNAIT cases without ICH are lacking, the occurrence of ICH in pregnancies with thrombocytopenia, but without ICH in a previous sibling, cannot be predicted. We estimate this risk to be 7%. This risk must be balanced against the risk of interventions in treatment strategies.

BACKGROUND: A caesarean section (CS) can cause a defect or disruption of the myometrium at the site of the uterine scar, called a niche. In recent years, an association between a niche and postmenstrual spotting after a CS has been demonstrated. Hysteroscopic resection of these niches is thought to reduce spotting and menstrual pain. However, there are no randomised trials assessing the effectiveness of a hysteroscopic niche resection. METHODS/DESIGN: We planned a multicentre randomised trial comparing hysteroscopic niche resection to no intervention. We study women with postmenstrual spotting after a CS and a niche with a residual myometrium of at least 3 mm during sonohysterography. After informed consent is obtained, eligible women will be randomly allocated to hysteroscopic resection of the niche or expectant management for 6 months. The primary outcome is the number of days with postmenstrual spotting during one menstrual cycle 6 months after randomisation. Secondary outcomes are menstrual characteristics, menstruation related pain and experienced discomfort due to spotting or menstrual pain, quality of life, patient satisfaction, sexual function, urological symptoms, medical consultations, medication use, complications, lost productivity and medical costs. Measurements will be performed at baseline and at 3 and 6 months after randomisation. A cost-effectiveness analysis will be performed from a societal perspective at 6 months after randomisation. DISCUSSION: This trial will provide insight in the (cost)effectiveness of hysteroscopic resection of a niche versus expectant management in women who have postmenstrual spotting and a niche with sufficient residual myometrium to perform a hysteroscopic niche resection. TRIAL REGISTRATION: Dutch Trial Register NTR3269 . Registered 1 February 2012. ZonMw Grant number 80-82305-97-12030.

Introduction The aim of this study was to compare patient satisfaction between remifentanil patient-controlled analgesia (RPCA) and epidural analgesia (EA) for labor pain. Material and methods This prospective cohort study was carried out on primiparous women requesting analgesia for labor at a Teaching Hospital, Amsterdam, the Netherlands. Women self-selected the analgesia of choice (RPCA n = 166 and EA n = 124) and were asked to complete the Woman's Views of Birth Labour Satisfaction Questionnaire (WOMBSLQ), within 24 h (T0), 3 months (T3) and 6 months (T6) after birth. The WOMBSLQ comprises 11 subscales, including pain during labor and general satisfaction. The main outcome measure was general satisfaction. Results There was no significant difference in the subscale of general satisfaction with labor and delivery (maximum of 14 points) between both groups at all three time points [median score at T0 for RPCA was 12 vs. 13 for the EA group (p = 0.95); at T3: 12 vs. 12, respectively (p = 0.41); and at T6: 12 vs. 12, respectively (p = 0.69)]. Women in the EA group had significantly better pain relief (maximum of 21 points) at all three time points [median score at T0 for RPCA was 14 vs. 18 for the EA group (p

Plaque-like lesions and amyloid angiopathy were investigated in the frontal cerebral cortex of four patients with hereditary cerebral hemorrhage with amyloidosis (Dutch) (HCHWA-D), using immunohistochemical [antibodies to beta amyloid protein (A beta), beta protein precursor (beta PP), synaptophysin, ubiquitin (UBQ), cathepsin D, paired helical filaments (PHF) and glial fibrillary acidic protein (GFAP)], enzymehistochemical (acid phosphatase) and silver [methenamine silver (MS) and Palmgren] staining methods. Whereas A beta- and MS-positive diffuse plaques were found in all patients, only the three older patients showed neuritic or congophilic plaques, which were acid phosphatase and cathepsin D positive and contained beta PP-, synaptophysin- and UBQ-positive, but PHF-negative neurites. These plaques were surrounded by reactive astrocytes. Similar immuno- and enzymereactivity was found around congophilic blood vessels. Thus, apart from neuronal degeneration in a subset of plaque-like lesions and around blood vessels, this study shows an age-related morphology of the plaques in HCHWA-D, corresponding to that in Down's syndrome (DS), with the difference that neurofibrillary (NF) pathology is absent in HCHWA-D in contrast to DS. HCHWA-D may be considered as a model for congophilic plaque formation not associated with NF pathology.

The female genital tract is rarely involved by metastatic tumors. The most common anatomic locations are the ovaries and the vagina. A case is presented of metastatic breast carcinoma to the vulva and endometrial polyp, both exceptional.We report the case of an 83-year-old female who presented with vaginal bleeding. Lobular breast carcinoma was diagnosed earlier and during follow-up vulvar metastasis was detected. Hysteroscopic examination because of postmenopausal bleeding revealed an endometrial polyp which was resected. The morphology and immunohistochemistry of the polyp were consistent with lobular breast cancer: metastatic breast cancer to an endometrial polyp. After reviewing the literature 15 cases of metastatic breast carcinoma to endometrial polyps have been reported. The clinical presentation and course, risk factors, treatment and follow-up are discussed.Metastasis of a breast carcinoma to the vulva and an endometrial polyp are extremely rare, but clinicians should be aware of both phenomena.

A 31-year-old pregnant Creole woman with sickle-cell anaemia went through a crisis of acute cholecystitis at 29 weeks' amenorrhoea. The crisis subsided after cholecystectomy, at which relative reduction of the number of sickle-cells by blood transfusions, adequate oxygenation, fluid, and antibiotic prophylaxis were provided. After 35 weeks' amenorrhoea, a healthy son was delivered by caesarean section. After the delivery, she developed fever and abdominal aches with a wound infection, and 10 days later a generalized epileptic attack. She recovered without sequelae. Pregnancy in a woman with sickle-cell anaemia may induce a sickle-cell crisis. The maternal morbidity and mortality and perinatal mortality are high, in spite of a pronounced decrease due to improved care.