European Journal of Obstetrics & Gynecology and Reproductive Biology

Metabolomic biomarkers of impaired glucose tolerance and type 2 diabetes mellitus with a potential for risk stratification in women with polycystic ovary syndrome

Nicolas Galazis, Christos Iacovou, Zeina Haoula, William Atiomo — 2011-11-21

Abstract: There is a need to identify biomarkers of impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) risk in women with PCOS to facilitate screening and the development of novel strategies to prevent disease progression. Metabolomic technologies may address this need. All published studies on metabolomic biomarkers of IGT and/or T2DM identified through MEDLINE (1966-December 2010), EMBASE (1980-December 2010) and Cochrane (1993-December 2010) were retrieved. Eligible studies were screened and specific study characteristics recorded including study design, number of participants, selection criteria, type of metabolomic technique used, site of sample collection, and a list of metabolites identified to have been altered in IGT and/or T2DM versus healthy controls was created.Nine metabolomic biomarkers that could potentially be used to identify women with PCOS at risk of developing IGT and/or T2DM were identified including leucine, isoleucine, citrate, glucose, creatinine, valine, glutamine, alanine and HDL. Of these biomarkers, a panel of four biomarkers were consistently either elevated or reduced including glucose (elevated), valine (reduced), HDL (reduced) and alanine (reduced) in IGT/T2DM compared with controls. These biomarkers may predict the development of IGT/T2DM in young women with PCOS. More studies are required to test this hypothesis and translate the findings into patient benefit by reducing the morbidity/mortality associated with IGT/T2DM in PCOS.

Use of and attitudes toward complementary and alternative medicine among midwives in Turkey

Zeliha Koc, Serap Topatan, Zeynep Saglam — 2011-11-07

Abstract: Objective: The objective of the study was to evaluate the use of and attitudes toward complementary and alternative medicine (CAM) among midwives in Turkey.Study design: Information was requested from 129 midwives at family health centers in Samsun concerning their suggestions for the use of complementary and alternative medicine for pregnant women.Results: 58.9% of the midwives in this study had suggested CAM methods to pregnant women. It was found that, among CAM methods, the midwives studied made use of herbal treatment, diets and exercises the most (32.6%, 27.9% and 28.7%, respectively) and acupuncture, relaxation techniques and fast walking the least (1.6%, 6.2%, and 7.0%, respectively). It was found that the CAM method most suggested by the midwives studied was herbal therapy, and this therapy was suggested for nausea-vomiting, anemia, gastralgic complaints, constipation, sore throat, insomnia, hypertension, sinusitis, cough, the common cold, stress, hemorrhoids and asthenia-fatigue.Conclusion: Complementary and alternative medicine, especially herbal therapy, is commonly suggested to pregnant women by those midwives studied in Samsun.

Increased CXCL12 expression in the placentae of women with pre-eclampsia

Han Sung Hwang, Han Sung Kwon, In Sook Sohn, Yong Won Park, Young Han Kim — 2011-10-31

Abstract: Objective: To investigate the expression pattern of CXC chemokine ligand-12 (CXCL12) in the placentae of normal and pre-eclamptic women.Study design: Twenty-five women with severe pre-eclampsia and 30 normotensive women, matched for gestational age, were enrolled in the study. Placental tissue from each woman was collected following delivery by caesarean section. Quantitative reverse transcription polymerase chain reaction, Western blot analysis and immunohistochemical staining were performed for mRNA expression, quantification and tissue localization of CXCL12 in each placenta.Results: CXCL12 expression was greater in pre-eclamptic placentae compared with normal placentae. CXCL12 was detected in most placental tissue cells by immunohistochemical staining. CXCL12 immunoreactivity was significantly greater in syncytiotrophoblasts of pre-eclamptic placentae compared with normal placentae. However, there was no significant difference in CXCL12 immunoreactivity in other tissues between the two groups.Conclusion: CXCL12 expression is significantly greater in the placentae of pre-eclamptic women compared with normal women. This may represent part of a compensatory mechanism for pre-eclampsia.

Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction

2011-11-03

Abstract: Objectives: The clinical relevance of protein S deficiency in pregnant women remains controversial. Major debate exists regarding which parameter (total protein S antigen, free protein S antigen or functional protein S) should be evaluated in order to define protein S deficiency. The present study aimed to identify which of these parameters correlate with intrauterine growth restriction (IUGR).Study design: A retrospective case–control study of women with IUGR (n=27) and healthy controls (n=123) in the third trimester of pregnancy.Results: The maternal serum of women in the IUGR group had significantly lower levels of functional and free protein S compared with the control group: 54.07±24.72% vs 65.20±17.95% (p<0.005) and 42.88±11.01% vs 56.64±13.30% (p<0.0001), respectively. No significant correlation was found between total protein S and IUGR.Conclusions: Levels of functional and free protein S are correlated with IUGR.

Introduction of metformin for gestational diabetes mellitus in clinical practice: has it had an impact?

Preeti Gandhi, Rebecca Bustani, Priya Madhuvrata, Tom Farrell — 2011-11-24

Abstract: Objective: The aim of the study was to compare maternal and neonatal outcomes in women with gestational diabetes mellitus (GDM) treated with metformin in addition to the dietary and lifestyle advice versus those treated traditionally with dietary and lifestyle advice only.Study design: A retrospective study of singleton pregnancies in women with GDM delivered between January 2008 to June 2010 (n=592) at the Jessop Wing, Royal Hallamshre Hospital, UK. Introduction of metformin in August 2008 led to two comparable groups, those women receiving metformin, lifestyle advice (including dietary advice)±supplementary insulin and those women receiving lifestyle advice (including dietary advice)±supplementary insulin. Two hundred and ninety three women were treated with metformin and lifestyle advice and remaining 299 with lifestyle advice only. Supplementary insulin was used in both the groups if needed. Outcomes were analyzed using the chi-squared and t-tests.Results: There were no significant differences in baseline maternal characteristics between the two groups. Metformin was tolerated throughout the pregnancy by 90% of the women in the metformin+lifestyle advice group. Supplementary insulin was required by 21% in the metformin+lifestyle advice group compared to 37% in the lifestyle advice group (OR 0.46; 95% CI 0.32–0.66). Women in the metformin group had a significantly lower incidence of macrosomia (birth weight>4kg) (8.2% vs. 14.3% (OR 0.56; 95% CI 0.33–0.99)), as well as birth weight >90th centile (14.8% vs. 23.7% (OR 0.56; 95% CI 0.37–0.85)). There were no significant differences in maternal outcome measures between the groups. No serious maternal or neonatal adverse events were observed with the use of metformin.Conclusion: Metformin is safe and effective in the treatment of GDM in our experience. It is well tolerated and reduces the requirement for supplementary insulin. Women treated with metformin had a significantly lower incidence of macrosomic and large for gestational age neonates as well as a reduced caesarean section rate.

First trimester ultrasound estimation of gestational age in pregnancies conceived after in vitro fertilization

2011-11-28

Abstract: Objective: To evaluate BPD as an alternative to CRL for the estimation of gestation age in late first trimester pregnancies (between 9th and 13th gestational weeks), and to construct a first trimester reference chart of fetal BPD growth.Study design: A prospective study that compared the gestational age estimated by BPD and CRL with the IVF gestational age in 167 first trimester pregnancies (127 singletons, 40 twins).Results: Both BPD and CRL correlated well with the IVF gestational age (GA) from 9th to 13th gestation weeks. When comparing the difference of the GA (in days) estimated from the two respective ultrasound parameters versus the GA based on IVF (oocyte retrieval day +14 days), BPD estimations had a significantly lower mean difference than CRL (0.013 vs. 0.746; p<0.01), as well as a lower standard deviation (2.414 vs. 3.008; p<0.05). In addition, the 95% limits of agreement between the BPD estimated GA and IVF GA were also smaller than CRL estimated GA versus IVF GA (−4.719 to 4.745 vs. −5.149 to 6.641).Conclusion: Biparietal diameter shares similar accuracy with crown rump length in late first trimester ultrasound estimation, with additional advantages of lower random measurement errors.

Maternal caffeine intake and its effect on pregnancy outcomes

Mirosław Jarosz, Regina Wierzejska, Magdalena Siuba — 2011-11-28

Abstract: Objective: Estimation of the maternal caffeine intake during pregnancy and its influence on pregnancy duration, birthweight and Apgar score of the newborn.Study design: The research was conducted on pregnant women who gave birth at the Clinic of Obstetrics, Gynaecology and Oncology, 2nd Faculty of Medicine, Medical University of Warsaw. It covered unifetal pregnancies without diseases (N=509). Research data were collected by direct questionnaire supplemented with data from patients’ records. Statistical analysis employed a multivariate logistic regression model and a non-parametric Spearman's rank correlation coefficient.Results: 98.4% of pregnant women consume no more than 300mg of caffeine per day. Pregnant women who smoke and older women consume more caffeine than non-smokers and younger women [β 1.95 (95% CI: 1.02–2.88)] and [β 0.68 (95% CI: 0.05–1.3)] respectively. There is no association between maternal caffeine intake during pregnancy and the risk of premature birth, the birthweight or the Apgar score of newborns.Conclusion: Caffeine intake of no more than 300mg per day during pregnancy does not affect pregnancy duration and the condition of the newborn.

Mitochondrial D-loop variations in infertile women undergoing a long stimulation protocol

Yue Lin, Jing Du, Lu Li, Jing Fu, Min Wang, Zhaofeng Zhang, Xiaoxi Sun — 2011-11-21

Abstract: Objective: To study a high frequency of mtDNA D-loop variations in infertile women undergoing a long stimulation protocol and their potential relevance with endpoints of IVF.Study design: Peripheral blood was taken from 156 patient ≤42 years of age. The entire D-loop region of mtDNA was amplified in three overlapping polymerase chain reaction fragments, and variations were evaluated by direct DNA sequencing methods in 156 infertile women undergoing a long stimulation protocol.Results: A total of 48 variations were found at 47 positions in the D-loop of all patients. Median age of the patients was 34.09 years (26–42 years). The incidence of variations was significantly higher in the group of patients aged >34.09 years (P=0.001), especially 16191 C→T (P=0.017) and 199 T→C (P=0.045). In contrast, the incidence of variations was significantly lower on the day of hCG administration in the group of patients with E2>8037.97pmol/L (P=0.001). However, variations were not significantly associated with early follicular phase FSH (P=0.262), the number of oocytes retrieved (P=0.191) or the pregnancy rate (P=0.487).Conclusion: Our data suggest that the increase in mtDNA variations in peripheral blood from infertile women could have a predictive value for the response of infertile women undergoing a long stimulation protocol.

Trans-abdominal ultrasound guided transvaginal hydrolaparoscopy is associated with reduced complication rate

Caihong Ma, Yang Wang, T.C. Li, Jie Qiao, Yan Yang, Xueling Song, Shuo Yang — 2011-11-21

Abstract: Objective: To evaluate the feasibility and value of abdominal ultrasound guided access for transvaginal hydrolaparoscopy (THL).Study design: One hundred and ninety-three infertile women were retrospectively included. A total of 31 subjects were included in the study group, and 162 cases performed prior to the introduction of transabdominal ultrasound guidance constituted a comparison group. The indications for THL were: inconclusive hysterosalpingogram findings and ovarian drilling for clomiphene-resistant polycystic ovarian disease. The total of complications arising from trocar needle insertions are compared between the study (ultrasound guidance) and comparison (without ultrasound guidance) groups.Results: In the study group, two cases were transferred to standard laparoscopy without vaginal needle insertion because of no obvious fluid in the cul-de-sac. One of these cases was confirmed to have severe adhesions and the other had no pathology in the pelvic cavity. One further case was transferred due to severe adhesions found by THL. Twenty-nine patients had successful vaginal access including seven cases with a retroverted uterus (24.1%), as against only one case with retroverted uterus in the comparison group (0.6%). The difference was statistically significant (P<0.05). There were three cases of intestinal perforation and one case of uterine injury in the comparison group, but no case of complication in the study group. Fifteen cases were fully conducted by two novel medical doctors monitored by a senior doctor.Conclusions: Trans-abdominal ultrasound guided vaginal access increases the safety of THL, especially in patients with a retroverted uterus, by seeking out a better puncture spot, and making training more intuitive and safe.

Timing of fertility preservation procedures in a cohort of female patients with cancer

2011-11-24

Abstract: Objective: Comparison of time intervals from diagnosis to chemotherapy between patients opting for embryo cryopreservation or ovarian tissue cryopreservation.Study design: Retrospective analysis.Setting: University hospital in the Netherlands.Patients and methods: Thirty-five female patients undergoing fertility preservation procedures before treatment with chemotherapy for cancer. Embryo cryopreservation was performed in 12 patients and ovarian tissue cryopreservation in 23 patients. We investigated differences in time intervals (from diagnosis to start of chemotherapy) between patients opting for embryo cryopreservation and patients opting for ovarian tissue cryopreservation. We calculated time intervals between the moment of diagnosis, the moment of referral, the moment of consultation, the moment of finishing of the fertility preservation procedure and the start of chemotherapy.Results: The median time between diagnosis and referral (median=18 days) and between referral and consultation (median=5 days) was comparable in both groups. A significant difference was found between ovarian tissue cryopreservation and embryo cryopreservation for the time interval between consultation and cryopreservation (p=0.001). Ovarian tissue cryopreservation was completed for half of the patients within 6 days after consultation with the gynecologist, and the hormonal stimulation for embryo cryopreservation was completed for all patients within four weeks (median=18 days), with a median of 11 days of hormonal stimulation. A significant difference was found between ovarian tissue cryopreservation and embryo cryopreservation in the time interval between fertility preservation and start of chemotherapy (median=7 vs 19 days, p=0.019). In sum, the total duration between diagnosis and chemotherapy was significantly shorter for ovarian tissue cryopreservation patients than for embryo cryopreservation patients (median=47 vs 69 days, p=0.042).Conclusion: Embryo cryopreservation can be performed within the standard timeframe of cancer care in patients with breast cancer receiving adjuvant chemotherapy, but if delay of the start of chemotherapy is harmful, ovarian tissue cryopreservation can be done within one week.

Polymorphisms of vascular cell adhesion molecule1 (VCAM1) in polycystic ovary syndrome determined by quantitative real-time polymerase chain reaction and melting curve analysis

2011-11-28

Abstract: Objective: Polycystic ovary syndrome (PCOS) is a common endocrinopathy associated with increased risk of obesity, insulin resistance (IR) and type 2 diabetes mellitus. Low-grade chronic inflammation and imbalance between pro- and anti-inflammatory cytokines has been proposed to play a role in the pathogenesis. Vascular cell adhesion molecule1 (VCAM1) is among the parameters reflecting low-grade chronic inflammation whose expression is increased by pro-inflammatory cytokines. This study examined the possible association of T-1591C and T-833C single nucleotide polymorphisms (SNPs) of VCAM1 gene with the occurrence and the clinical/biochemical characteristics of PCOS.Study design: We analyzed genotype and allele distributions of the above-mentioned SNPs in DNA from peripheral blood leukocytes of 169 patients with PCOS and 179 healthy women, by a real-time polymerase chain reaction (PCR) method combined with melting curve analysis using fluorescence-labeled hybridization probes.Results: No significant associations between PCOS and the variant alleles of VCAM1-1591 (OR: 1.09, 95% CI=0.74–1.58) and -833 (OR: 1.42, 95% CI=0.59–3.43) were observed. None of the studied polymorphisms was found to affect IR indices and sVCAM levels significantly. However, PCOS women heterozygous for VCAM1-1591 polymorphism (CT) had significant increased triglyceride and decreased HDL-C in comparison with wild homozygous (TT) ones.Conclusions: Although there is no association between -1591 and -833 polymorphisms of VCAM1 gene and susceptibility to PCOS, higher triglyceride and lower HDL-C in VCAM1-1591 CT genotype suspect that heterozygous patients are prone to increased risk for atherosclerosis and cardiovascular disease. In addition, bearing in mind that PCOS is a consequence of interaction between various genetic and environmental factors, the association between heterozygocity of VCAM1-1591 polymorphism and some lipid parameters may depend on the impact of other known or unknown polymorphisms, being in linkage disequilibrium with this locus of VCAM1 gene.

Vaginal reconstruction with two lower abdominal skin flaps in rabbits: histological and macroscopic evaluation

2011-11-07

Abstract: Objective: To evaluate the use of two skin flaps of the lower abdominal wall in the creation of a cylindrical conduit in vaginal reconstruction surgery in rabbits, through macroscopic and histological analysis.Study design: An experimental study was performed in 16 female New Zealand rabbits, consisting of the use of two rectangular-shaped skin flaps of the lower abdominal wall measuring 1cm longitudinally and 3cm transversely anastomosed to each other through continuous suture of the edges of the two flaps to create a tube. Hysterectomy and excision of the vaginal vault were performed, and the skin tube was anastomosed to the remaining vaginal stump with separate points of polyglycolic acid 4.0. Animals were divided into 4 groups according to the euthanasia at 2, 4, 8 and 12 weeks, when after excision of the neovagina, macroscopic and histological evaluation with hematoxylin–eosin and Masson trichrome were performed.Results: Of 16 operated rabbits, only 1 presented partial abdominal wall dehiscence, not compromising the flap viability. The macroscopic analysis of the vaginal conduit showed that it was kept open throughout the experimental steps, with a good patency and gauge, showing a slight retraction in the skin conduit length of no statistical significance. In the histopathological analysis, a local inflammatory process in the anastomosis was observed, which was larger in the early evaluation but decreased in late evaluations, as well as the local fibrosis process. Integration of the vaginal and skin epithelia was made with no alterations in their primary characteristics.Conclusion: The use of two skin flaps of the lower abdominal wall as a vaginal conduit presented good integration between skin and vaginal tissue with minimal length retraction, kept the patency during evaluations and did not show strictures, presenting good local healing and a low rate of complications.

A study in vitro on differentiation of bone marrow mesenchymal stem cells into endometrial epithelial cells in mice

2011-11-14

Abstract: Objective: To investigate the differentiation conditions of bone marrow mesenchymal stem cells (BMSCs) into endometrial epithelial cells and to confirm the effect of 17β-estradiol in this process.Study design: BMSCs were cultured alone or co-cultured with endometrial stromal cells (EStCs) in control/differentiation medium (17β-estradiol, growth factors) and were co-cultured with EStCs in different concentrations of 17β-estradiol. Flow cytometry and immunocytochemistry were used to identify the isolated cells. Real-time RT-PCR and immunofluorescence were used to test the expression of epithelial cell markers.Results: The epithelial markers cytokeratin-7, cytokeratin-18, cytokeratin-19, and epithelial membrane antigen were elevated in real-time RT-PCR (P<0.05), and cytokeratin was strongly positive in immunofluorescence analysis in the differentiated BMSCs. Cytokeratin-7 and cytokeratin-19 expression levels were highest in the 1×10−8mol/L 17β-estradiol group, as shown in real-time RT-PCR (P<0.05).Conclusion: BMSCs could be differentiated in the direction of endometrial epithelial cells in appropriate conditions in vitro: 17β-estradiol may play a key role in stimulating BMSCs’ epithelial differentiation in the process of endometriosis.Condensation: Bone marrow mesenchymal stem cells can differentiate in the direction of endometrial epithelial cells in a certain microenvironment and appropriate concentration of 17β-E2 can facilitate this differentiation.

Toluidine blue staining in the diagnosis of endometrial pathologies: a preliminary study before chromohysteroscopy

2011-11-14

Abstract: Objective: To assess the efficacy of toluidine blue (TBlue) staining in the detection of endometrial premalignant or malignant lesions in uterine specimens obtained from hysterectomies. We hoped that the results of this preliminary study would help us in our future studies which may be on chromohysteroscopy.Study design: We developed an endometrium staining technique in which TBlue solution was used as a vital dye. The study enrolled 50 patients. Of these, 20 patients known to have a premalign or malign lesion of the uterus constituted the study group and 30 patients were recruited as the control group who were operated for leiomyoma of the uterus. Immediately after hysterectomy, all specimens were dyed with TBlue solution and a frozen section procedure was performed on the positively stained areas. The pre- and post-operative histopathological diagnoses of the participants were compared and the reliability of the new method was calculated.Results: The sensitivity of TBlue staining in the determination of endometrial pathologies was 100% (95%, CI 0.83–1) with a specificity of 90% (95%, CI 0.74–0.96). As a diagnostic test, the positive predictive value (PPV) was 87% with a negative predictive value (NPV) of 100%. The positive likelihood ratio (+LR) was 10 (95%, CI 3.41–29.2).Conclusions: Our preliminary results demonstrated that TBlue staining of endometrium is a reliable and highly sensitive technique that may be used in the frozen section examination of uterine specimens if a malignancy is suspected. Moreover, TBlue staining of endometrium may prove useful in hysteroscopy, although the technique, interpretation, and indications require further studies.

The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique

2011-11-14

Abstract: Objective: To describe the surgical rectus sheath block for post-operative pain relief following major gynaecological surgery.Technique: Local anaesthetic (20ml 0.25% bupivacaine bilaterally) is administered under direct vision to the rectus sheath space at the time of closure of the anterior abdominal wall.Study design: We conducted a retrospective case note review of 98 consecutive patients undergoing major gynaecological surgery for benign or malignant disease who received either standard subcutaneous infiltration of the wound with local anaesthetic (LA, n=51) or the surgical rectus sheath block (n=47) for post-operative pain relief.Main outcome measures: (1) Pain scores on waking, (2) duration of morphine-based patient controlled analgesia (PCA), (3) quantity of morphine used during the first 48 post-operative hours and (4) length of post-operative stay.Results: The groups were similar in age, the range of procedures performed and the type of pathology observed. Patients who received the surgical rectus sheath block had lower pain scores on waking [0 (0–1) vs. 2 (1–3), p<0.001], required less morphine post-operatively [12mg (9–26) vs. 36mg (30–48), p<0.001], had their PCAs discontinued earlier [24h (18–34) vs. 37h (28–48), p<0.001] and went home earlier [4 days (3–4) vs. 5 days post-op (4–8), p<0.001] [median (interquartile range)] than patients receiving standard subcutaneous local anaesthetic into the wound.Conclusions: The surgical rectus sheath block appears to provide effective post-operative analgesia for patients undergoing major gynaecological surgery. A randomised controlled clinical trial is required to assess its efficacy further.

Comparison of the dermatoglyphic characteristics of women with and without breast cancer

Elaheh Sariri, Maryam Kashanian, Mansoureh Vahdat, Saeedeh Yari — 2011-11-17

Abstract: Objective: To compare the dermatoglyphic characteristics of women with and without breast cancer.Study design: Case–control study. One hundred and thirty women=130 women with histopathologically confirmed breast cancer (case group) were compared with 127 women in the same age group but without breast cancer (control group). Fingerprints of the two groups were compared in terms of whorl, loop and arch patterns.Results: The loop pattern was most common in both groups [68 women (52.3%) in the case group and 58 women (45.7%) in the control group], followed by the whorl pattern [60 women (46.2%) in the case group and 64 women (50.4%) in the control group]; the difference was not significant (p=0.337). The number of whorl patterns and the breakdown by classification group did not differ significantly between the two groups. In addition, no significant difference was found in the dermatologlyphic patterns of the women with breast cancer with and without a family history of breast cancer.Conclusion: No difference was found in the dermatoglyphic characteristics of women with and without breast cancer. As such, this does not appear to be an effective screening method for women at risk for breast cancer.

Traction on the cervix in theatre before anterior repair: does it tell us when to perform a concomitant hysterectomy?

Richard Foon, Wael Agur, Alianu Kingsly, Paul White, Phillip Smith — 2011-11-21

Abstract: Objective: To evaluate the surgical outcome of uterine preservation during anterior colporrhaphy, in women with apparent uterine descent, after the application of validated cervical traction under anaesthesia.Study design: This study was conducted at a tertiary referral hospital in the United Kingdom. Thirty five patients with symptomatic anterior compartment prolapse (stage 2 or more) with the cervix, pelvic organ prolapse quantification (POPQ) point C, at or higher than −3cm (stage 1), who had requested surgical repair, were recruited. In all patients there was no evidence of apical descent, with point D at −8cm or above. All patients had a validated ‘cervical traction’ force applied intra-operatively to the cervix, and if the cervix, point C, did not come down further than ‘stage 2’ (+1cm) the uterus was conserved. These patients had an anterior repair, without a vaginal hysterectomy or apical support procedure, and were reviewed 3 months postoperatively. International Consultation on Incontinence Questionnaire-vaginal symptoms (ICIQ-VS) and POP-Q scores were completed pre- and post-operatively, with another POPQ performed intraoperatively during validated cervical traction. The Wilcoxon test was used to look at differences in vaginal descent and also to compare specific items of the ICIQ.Results: In all 35 women, there was cervical descent below −1cm (stage 2) when a validated amount of cervical traction was applied. When examined at follow up, however, the cervix (point C) had returned to its preoperative, asymptomatic level (stage 1) in all except one patient. There was no significant change in the position of point C pre- and 3 months post- operatively. Only one of the 35 women required a subsequent vaginal hysterectomy for prolapse (2.86%, 95% CI 0.07–14.91%). Significant improvements in ICIQ-VS scores were observed following anterior repair with uterine conservation.Conclusion: The degree of uterine descent with cervical traction under anaesthesia has not been shown to be helpful in assessing the need for vaginal hysterectomy at the time of vaginal repair. The ‘cervical traction’ test is therefore unnecessary, and the decision as to whether to perform a concomitant vaginal hysterectomy should be based on the clinical findings on examination in the clinic.

Laparoscopically guided minilaparotomy: a minimally invasive approach for the treatment of gynaecologic diseases in morbidly obese patients

2011-11-23

Abstract: Objective: Obese patients are at greater risk of gynaecologic surgery. Laparotomy is generally performed, even though this approach is regarded as highly invasive, whereas laparoscopy, though minimally invasive, is relatively contraindicated because of the high conversion rates to laparotomy. In light of this, we propose laparoscopically guided transverse minilaparotomy (LGTM) as a minimally invasive alternative technique. The rationale of diagnostic laparoscopy is to evaluate the feasibility of a minimally invasive approach. We have evaluated the feasibility and compared the outcomes with a historical group treated with laparotomy (LPTM), in morbidly obese patients (MOP) subjected to gynaecologic surgery.Study design: From November 2004, MOPs with body mass index (BMI) ≥40kg/m2 and admitted for gynaecologic surgery (early stage endometrial cancer and benign disease) were enrolled in this observational study and submitted to LGTM. Patients with a uterine size greater than the umbilical transverse line and with indication for vaginal surgery were excluded operative data and outcome were prospectively recorded.Results: LGTM was feasible in 34 cases (87%) out of 39. In two women, the procedure was aborted due to intraperitoneal and ovarian malignant disease spread diagnosed at laparoscopy. In three cases, conversion was necessary due to severe adhesions in one case; laparoscopically unrecognized disease spread in the parametria in the second, and in the remaining case a right common iliac vein injury during lymphadenectomy. When compared to LPTM, haemoglobin drop and postoperative stay were significantly reduced with LGTM. Complications were higher in the control group: due to a significantly higher incidence of wound dehiscence (OR 0.27, 95% CI 0.05–1.32, p<0.05).Conclusions: LGTM is feasible in the vast majority of MOPs and achieves significantly better results when compared to the standard approach.

Targeted detection of 65kDa heat shock protein gene in endometrial biopsies for reliable diagnosis of genital tuberculosis

2011-11-24

Abstract: Objective: To evaluate the clinical utility of PCR compared with other available diagnostic modalities in prompt diagnosis of female genital tuberculosis causing infertility.Study design: Prospective case-controlled trial. Premenstrual endometrial biopsy specimens were collected from 150 infertile women of reproductive age group suspected of having genital tuberculosis. All patients underwent diagnostic endoscopy (laparoscopy and hysteroscopy) and the samples obtained were subjected to microscopy, culture by the BACTEC 460 TB System, histopathology and polymerase chain reaction (PCR) for detection of 165bp region of 65kDa gene of Mycobacterium tuberculosis. The results were correlated with the laparoscopic findings.Results: While the laparoscopy/hysteroscopy findings were indicative of tuberculosis in 12.6% of cases, 14.6% of the specimens showed evidence of 65kDa gene of M. tuberculosis and only 3.33%, 1.33% and 0.66% were positive by culture, smear and histopathology, respectively.Conclusion: Since laparoscopy, hysteroscopy other endoscopic procedures are associated with operative risks and may cause flaring of infection, and other conventional laboratory tests including histopathology have poor sensitivity, PCR-based detection of 65kDa gene of M. tuberculosis in endometrial biopsy specimens could be a promising molecular diagnostic technique compared to conventional methods of diagnosis.

Profiles of women presenting for abortions in Singapore: focus on teenage abortions and late abortions

Limin Lim, Hungchew Wong, Euleong Yong, Kuldip Singh — 2011-11-28

Abstract: Objective: Teenage abortions predispose women to adverse pregnancy outcomes in subsequent pregnancies such as anemia, stillbirths, preterm deliveries and low birth weight babies. We aim to profile the women presenting for abortions in our institution and determine risk factors for late presentation for abortions.Study design: In this retrospective cohort study, all women who underwent an abortion at the National University Hospital, Singapore, from 2005 to 2009 were recruited. Data was obtained from a prepared questionnaire during the mandatory pre-abortion counseling sessions. Profiles of women aged <20 years were compared with those ≥20 years old using Chi-square test if the assumptions for Chi-square test were met; otherwise, Fisher's exact test was carried out. Logistic regression was used to investigate the risk factors for second trimester termination of pregnancy.Results: 2109 women presented for induced abortions, of which 1998 had single abortion throughout the course of the study. The mean age of women with single abortion was 29.1 years (sd 7). In the group of women with single abortion, 182 (9.1%) were teenage abortions. In contrast to women ≥20 years of age, pregnant teenagers were more likely not to have used any contraception (51.1% vs. 25.2%) and more likely to present late for abortions (39.6% vs. 15.9%). Other risk factors for late presentation for abortions include Malay ethnicity, singlehood, nulliparity and lack of prior usage of contraception.Conclusion: Teenagers are more likely to have no prior contraceptive usage and to present late for abortions. Lack of proper sexual education and awareness of contraceptive measures may have a major contributory factor to such a trend in teenage abortions. Recommendations have been made in order to curb this societal problem.

Morphological characteristics and co-stimulatory molecule (CD80, CD86, CD40) expression in tumor infiltrating dendritic cells in human endometrioid adenocarcinoma

Jianjun Jia, Zineng Wang, Xiaomao Li, Zhixin Wang, Xiaoyu Wang — 2011-11-28

Abstract: Objective: The purpose of this study was to investigate changes of the antigen-presenting function of tumor infiltrating dendritic cells (TIDCs) in human endometrioid adenocarcinoma.Study design: The TIDCs from 45 cases of endometrioid adenocarcinoma were compared with 20 cases of normal human endometrial tissue, using transmission electron microscopic examination, and the expression of CD80, CD86, and CD40 was analyzed by flow cytometry.Results: In comparison with the control group, the ultrastructure of TIDCs in human endometrioid adenocarcinoma showed the following differences: numerous TIDCs were small in volume and round in shape but some were oval and multi-angular. The cytoplasmic processes were obviously decreased in number and stubbed. Round primary lysosomes with high electron-dense granules, and secondary lysosomes with high or low electron-dense granules were seen frequently in the cytoplasm. TIDCs contained much rough endoplasmic reticulum (RER). Vacuoles with flocculent electron-dense granules were rare. High electron-dense contents in the granules were near one side and the other side was bright. The nucleus became markedly small in volume, nephroid or hoofed in shape. The nucleus had little euchromatin and lots of heterochromatin under the nuclear membrane. The levels of expression of CD80, CD86 and CD40 on TIDCs were low or even nonexistent. The expression levels of CD80, CD86 and CD40 on DCs in human normal endometrium were significantly higher than those on TIDCs in endometrioid adenocarcinoma.Conclusion: It is suggested that morphological differences and low expression of co-stimulatory molecules on TIDCs in endometrioid adenocarcinoma reflected the functional changes of the TIDCs in uptake, processing and presenting antigen, which may lead to the occurrence of tumor immune escape.

Prevalence of and quality of life related to anal incontinence in women with urinary incontinence and pelvic organ prolapse

2011-12-12

Abstract: Objective: To investigate the prevalence of anal incontinence (AI) in woman with urinary incontinence (UI) and pelvic organ prolapse (POP). We also evaluated the impact on quality of life (QoL).Study design: One hundred and ninety patients with UI or POP and 73 controls were recruited. AI was investigated by the Wexner index and the prevalence rates were obtained in all groups. Patients with AI completed the Fecal Incontinence Quality of Life questionnaire (FIQL). QoL was assessed using the Medical Outcome Study 36-item Short Form Health Survey (SF-36).Results: AI prevalence was 40.54% in the UI group and 27.91% in the POP group (p<0.0001). In the UI and POP groups correlations were found between the Wexner score and the domains of the FIQL and SF36.Conclusion: The UI group had higher prevalence of AI than the other groups. The AI adversely affected the QoL of patients.

A prospective cohort study of pelvic support changes among nulliparous, multiparous, and pre- and post-menopausal women

Eddie H.M. Sze, Gerry Hobbs — 2011-11-24

Abstract: Objective(s): To evaluate whether vaginal delivery affects maternal pelvic support beyond the puerperium by comparing pelvic support changes between nulliparas and multiparas, and whether menopause predisposes women to develop prolapse that protrudes beyond the hymen by comparing its occurrence between pre- and post-menopausal subjects.Study design: Women who presented to our gynecology clinic for routine care and returned for follow-up after 36±3 months were evaluated for pelvic support changes using the Pelvic Organ Prolapse Quantification, which measured changes in 1-cm increments. Exclusion criteria were women who were seen in the urogynecology clinic or had hysterectomy, vaginal repair, continence procedure, childbirth during the study period, or radiation therapy.Results: The proportion that experienced a 1-cm (21/101 vs. 27/164, p=0.374) and at least a 2-cm (5/101 vs. 9/164, p=0.849) descent of the leading edge of prolapse was similar between our 101 nulliparous and 164 multiparous subjects. At the initial examination, nine multiparas and one nullipara had prolapse outside the hymen (9/164 vs. 1/101, p=0.056). The proportion that developed pelvic support defect, which protruded beyond the hymen, was similar between the two groups (1/100 vs. 5/155, p=0.243). Eighty-five of our 265 subjects were post-menopausal while 180 were pre-menopausal. The proportions that developed a 1-cm (18/85 vs. 30/180, p=0.374) and at least a 2-cm (7/85 vs. 7/180, p=0.140) descent of the leading edge of prolapse were similar between the two groups. Eight post-menopausal and two pre-menopausal women had prolapse outside the hymen at the initial examination (8/85 vs. 2/180, p=0.002). More post-menopausal subjects developed support defect, which protruded beyond the hymen, than their pre-menopausal counterparts (5/77 vs. 1/178, p=0.010). Logistic regression showed that menopause (p=0.019) is an independent risk factor for developing prolapse which protruded outside the hymen, while parity (p=0.168) and interaction between menopause and parity (p=0.606) are not significantly associated with its occurrence.Conclusion(s): Vaginal birth has little effect on the pelvic support changes beyond the puerperium while menopause predisposes women to prolapse their pelvic organ outside the hymen.

Successful resection of an intra-cardiac lipoma during the first trimester of pregnancy, coming to term normally

Sophie Frank, Gilbert Pochmalicki, Annabel Achor, Mathieu Debauchez, Duc E. Ha — 2011-10-17

We would like to describe the first case of excision of an intra-cardiac lipoma during the first trimester of pregnancy, coming to term normally. We report the case of a 36-year-old patient, pregnant after in vitro fertilization, with no personal or family medical history of cardiac disease. At 9 weeks’ amenorrhoea (WA), she came to the fertility ward with mild ovarian hyperstimulation syndrome, and to a lesser degree with palpitations subsisting for approximately one week. Medical examination revealed a diastolic murmur; EKG detected microvoltage and diffuse flat T-waves. A transthoracic cardiac ultrasound (US) was therefore performed, and showed a dense, round and regular mass of 3.5 by 5cm in the right atrium, along the lateral wall (), suggesting a myxoma, and threatening to block the tricuspid valve. Thus it indicated emergency surgery (because of this potentially lethal complication, no cardiac MRI was performed, despite its great value in precisely defining the tumor's limits and the diagnosis).

Catastrophic antiphospholipid syndrome in the obstetric period

Noortje Thielen, Antoinette C. Bolte, Sonja Zweegman, Martine E.D. Chamuleau — 2011-10-17

Catastrophic antiphospholipid syndrome (CAPS) is defined as a rare accelerated form of antiphospholipid syndrome that is attended with three or more (micro)vascular occlusions developing within one week, often resulting in multiorgan failure. Preliminary criteria for CAPS require histologic confirmation of vessel occlusion and laboratory confirmation of the presence of antiphospholipid antibodies . We report a case to highlight the importance of considering CAPS in pregnant patients with thrombotic microangiopathy in the obstetric period.

An adnexal mass with raised serum beta-HCG: an unusual presentation of ovarian dermoid cyst

Candice Wang, Edwin Thia, Timothy Lim — 2011-11-03

We believe that this is the first case of a dermoid cyst presenting with raised serum beta HCG, as extensive literature reviews did not reveal any precedent cases. A 37 year old lady presented at 6 weeks of amenorrhoea with abdominal discomfort and vaginal bleeding. Urine pregnancy test was positive. Examination was unremarkable. Serum beta HCG on presentation was 28,578.8IU/L. Transvaginal ultrasound revealed no intrauterine gestational sac (IUGS) and endometrial thickness of 9mm. A complex solid cystic lesion measuring 13.1×9.9×8.1cm was noted in the right adnexal region. History, examination and investigations strongly suggested the initial diagnosis of ectopic pregnancy and the patient was counselled for diagnostic laparoscopy, keeping in view salpingectomy, cystectomy and salpingo-oophorectomy.

Deep infiltrating endometriosis with obstructive uropathy secondary to ureteral endometriosis

Chia-Jen Wu, Kuan-Hui Huang, Fu-Tsai Kung — 2011-11-21

The most serious urologic complication of endometriosis is hydrouretero-nephrosis secondary to ureteral involvement, which can be responsible for silent loss of renal function. There are two types of ureteral endometriosis: (1) intrinsic, characterized by the presence of endometriotic tissue within the ureteral wall resulting in a thickened wall with fibrosis and proliferation of ureteric muscularis and (2) extrinsic, which is more frequent, resulting in extrinsic compression of the ureter by extraureteral endometriosis.