Vaginal tvätt vid hysterektomi
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Vaginal tvätt vid Vaginal tvätt vid hysterektomihysterektomi
Normal vaginalflora kontra bakteriell vaginos
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Bakteriell vaginos (BV), Bakteriell vaginos (BV), ett ofarligt luktproblem eller ett ofarligt luktproblem eller ett hot mot kvinnans hälsa ett hot mot kvinnans hälsa
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Är BV ett problem?Är BV ett problem?• Man dör inte av det
• Man får inte cancer av det
• Man kan inte operera bort det
• De får det ändå tillbaka
• Bättre att lindra än bota– Tjänar mer pengar på det viset
• Symtomatisk kontra asymtomatisk
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Vad är lukt?Vad är lukt?• 2004 års Nobelpris
– Richard Axel och Linda Bucks
• Luktsignal kopplad till limbiska systemet
• Lukten viktig för omedveten kommunikation – Förälskelse
– Prägling
– Menscykel?
• Hur undviker man obehaglig lukt
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Meta-analysis of antibiotic prophylaxis Meta-analysis of antibiotic prophylaxis before abdominal hysterectomybefore abdominal hysterectomy
Mittendorf Am J Obstet Gynecol 1993Mittendorf Am J Obstet Gynecol 1993
%
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Postoperative infections after Postoperative infections after Hysterectomy in women with BVHysterectomy in women with BV
Soper et al. 1990Soper et al. 1990 n=134, p<0.01n=134, p<0.01
Larsson et al 1991Larsson et al 1991 n=70, p<0.01n=70, p<0.01
Persson et al 1996Persson et al 1996 n=159, p<0.01n=159, p<0.01
exclusions: malignancy, exclusions: malignancy, postmenopausal, supravaginal, postmenopausal, supravaginal, antibioticsantibiotics
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Relative risk of infection after Relative risk of infection after hysterectomy among women with BVhysterectomy among women with BV
RR 3.2 (1.5-6.7) n = 134Soper et al 1990
RR 4.4 (1.4-13.3) n = 70Larsson et al 1991
RR 3.0 (1.3-7.0) n = 159
Persson et al 1996
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Open Randomization Open Randomization according to Selenaccording to Selen
• total abdominal hysterectomy
• benign indication
• premenopausal women
• 1 gram metronidazole rectally
• blinded diagnosis
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Postoperative vaginal cuff and wound Postoperative vaginal cuff and wound infections after abdominal infections after abdominal
hysterectomyhysterectomy
Women with abnormal Women with abnormal vaginal flora vaginal flora RR= 2.6 (0.8-8.6) NNT = 6RR= 2.6 (0.8-8.6) NNT = 6
Normal lactobacilli Normal lactobacilli florafloraRR=1.8 (0.6-5.7) NNT = 15RR=1.8 (0.6-5.7) NNT = 15
N.SN.S. Fisher’s exact test. Fisher’s exact test exclusions: malignancy, postmenopausal, exclusions: malignancy, postmenopausal, supravaginal, antibioticssupravaginal, antibiotics
n=142, n.s.n=142, n.s.
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Relative risk of postoperative vaginal cuff Relative risk of postoperative vaginal cuff and wound infection after abdominal and wound infection after abdominal
hysterectomy among all women hysterectomy among all women
n = 142
MMetronidazole rectalyetronidazole rectalyAll 142 womenAll 142 womenRR 2.7 (0.96-4.9)RR 2.7 (0.96-4.9)Infection rate 23% vs 12%Infection rate 23% vs 12%
MMetronidazole rectalyetronidazole rectalyAll 142 womenAll 142 womenRR 2.7 (0.96-4.9)RR 2.7 (0.96-4.9)Infection rate 23% vs 12%Infection rate 23% vs 12%
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Intention to treat analysis of the relative Intention to treat analysis of the relative risk of postoperative vaginal cuff risk of postoperative vaginal cuff
infection after abdominal hysterectomy infection after abdominal hysterectomy
metronidazole rectalymetronidazole rectalyn= 163n= 163
metronidazole rectalymetronidazole rectalyn= 163n= 163
All patients with/without smearAll patients with/without smearRR 0.1 (0.01-0,6)RR 0.1 (0.01-0,6)Infection rate 16% vs 1%Infection rate 16% vs 1%
All patients with/without smearAll patients with/without smearRR 0.1 (0.01-0,6)RR 0.1 (0.01-0,6)Infection rate 16% vs 1%Infection rate 16% vs 1%
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SymtomSymtom
Antalet bakterierAntalet bakterier
En sjukdom en organismEn sjukdom en organism
00
101033
101066
bakteriell vaginosbakteriell vaginosnormalnormal
101099
salpingit??salpingit??
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Endogen kontra exogen Endogen kontra exogen sjukdomsjukdom
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Normala laktobacillerNormala laktobaciller
Clueceller /Bakteriell vaginos
MikroskopMikroskop
mobiluncus
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Lactobacillus Lactobacillus sppspp
L. crispatus
L. jensinii
L. gasseri
L. iners
L. casei rhamnosus
L. acidofilusL. johnsoniiL. fermentumL. plantarum
TarmTarm
VaginaVagina
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Lactobacillus Lactobacillus sppspp
L. crispatus
L. jensinii
L. gasseri
L. iners
L. casei rhamnosus
L. acidofilusL. johnsoniiL. fermentumL. plantarum
tarmtarm
VaginaVagina
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KonklusionKonklusion• Vaginal tvätt spelar troligen ingen
roll
• Vid laktobaciller är det troligen bättre att inte tvätta
• Vid BV kan tvättning av vagina vara av värde
• Om pre-operativ BV diagnostik kan antibiotika ersätta vaginaltvätt?