European Journal of Obstetrics & Gynecology and Reproductive Biology

Editor's highlights

J. Drife — 2010-02-12

Next month there will be two important European meetings within 100km of each other. On 5–8 May the EBCOG Congress will be held in Antwerp, Belgium, and we hope that many readers, encouraged by our comments in last month's issue, are planning to attend. Shortly after that, on 19–22 May, the European Society of Contraception and Reproductive Health will hold its eleventh Congress in The Hague, The Netherlands. The Congress's theme, Culture, Communication, Contraception, reflects its focus on diversity, and its co-presidents point out that preventive strategies must increasingly “take into account the specific cultural, sub-cultural, economic, ethnic and religious characteristics of subpopulations within the European community.” This is an important message. Our colleagues in sexual and reproductive health are the first to be aware of the cultural undercurrents that lie beneath the surface of life in Europe but these issues are of course highly relevant to obstetricians and gynaecologists. The ESC Congress programme is available at www.contraception-esc.com. Contraceptive provision is a particular challenge in Eastern Europe and we were pleased to see Cyrillic script on the programme cover, announcing that simultaneous translation into Russian will be available.What's new?

Fetal programming of atherosclerosis: Possible role of the mitochondria

Line Leduc, Emile Levy, Maurice Bouity-Voubou, Edgard Delvin — 2009-12-23

Abstract: Growing evidence indicates that being small size at birth from malnutrition is associated with an increased risk of developing type 2 diabetes (T2D), metabolic syndrome and cardiovascular disease in adulthood. Atherosclerosis is common to these aforementioned disorders, and oxidative stress and chronic inflammation are now considered as initiating events in its development, with endothelial cell dysfunction being an early, fundamental step. According to the fetal programming hypothesis, growth-restricted neonates exposed to placental insufficiency exhibit endothelial cell dysfunction very early in life that later on predisposes them to atherosclerosis. Although many investigations have reported early alterations in vascular function in children and adolescents with low birth weight, the mechanisms of such fetal programming of atherosclerosis remain largely unknown. Experimental studies have demonstrated that low birth weight infants are prenatally subjected to conditions of oxidative stress and inflammation that might be involved in the later occurrence of atherosclerosis. Arterial endothelial dysfunction has been encountered in term infants, children and young adults with low birth weight. The loss of appropriate endothelium function with decreased nitric oxide production or activity, manifested as impaired vasodilatation, is considered a basic step in atherosclerosis development and progression. Several lines of evidence indicate that mitochondrial damage is central to this process and that reactive oxygen species (ROS) may act as a double-edged sword. On the one hand, it is well-accepted that the mitochondria are a major source of chronic ROS production under physiological conditions. On the other hand, it is known that ROS generation damages lipids, proteins and mitochondrial DNA, leading to dysregulated mitochondrial function. Elevated mitochondrial ROS production is associated with endothelial cell dysfunction as well as vascular smooth muscle cell proliferation and apoptosis. Smoking, obesity, insulin-resistant T2D, hypercholesterolemia, hyperglycaemia and hypertriglyceridaemia, major, traditional precursors of atherosclerosis, are all linked to mitochondrial dysfunction.This review focuses on proof of in utero programming resulting from chronic exposure to oxidative stress and inflammation as a cause of atherosclerosis. Endothelial cell dysfunction may be the initial injury arising from adverse antenatal conditions and responsible for the early changes in vascular function seen in children. After considering the critical role of the mitochondria in atherogenesis through endothelial function abnormalities, we propose that placental mitochondrial dysfunction is present in cases of placental insufficiency and may be critical in fetal programming of atherosclerosis.

Topical non-barrier agents for postoperative adhesion prevention in animal models

Atsushi Imai, Noriko Suzuki — 2010-01-07

Abstract: Pelvic adhesion can form as a result of inflammation, endometriosis or surgical trauma. Most surgical procedures performed by obstetrician–gynecologists are associated with pelvic adhesions that may cause subsequent serious sequelae, including small bowel obstruction, infertility, chronic pelvic pain, and difficulty in postoperative treatment, including complexity during subsequent surgical procedures. An increasing number of adhesion reduction agents, in the form of site-specific and broad-coverage barriers and solutions, are becoming available to surgical teams. The most widely studied strategies include placing synthetic barrier agents between the pelvic structures. Most of the adhesions in the barrier-treated patients develop in uncovered areas in the abdomen. This fact suggests that the application of liquid or gel anti-adhesive agents to cover all potential peritoneal lesions, together with the use of barrier agents, may reduce the formation of postoperative adhesions. This article introduces the topical choices available for adhesion prevention mentioned in preliminary clinical applications and animal models. To date there is no substantial evidence that their use reduces the incidence of postoperative adhesions. In combination with good surgical techniques, these non-barrier agents may play an important role in adhesion reduction.

Clinical relationship and psychological experience of hospitalization in “high-risk” pregnancy

Melissa L. Pozzo, Valentina Brusati, Irene Cetin — 2009-12-28

Abstract: Objective: To explore, in a systemic view, the reciprocal perceived relationship between hospitalized “high-risk” pregnant women with uncertain fetal prognosis and the multidisciplinary prenatal care team, by the use of specifically developed questionnaires.Study design: A pilot study in a high-risk pregnancy department. We enrolled 52 pregnant hospitalized women and 17 clinical operators and we interviewed them by the use of open-ended and close-ended question questionnaires.Results: We described patients’ perception of doctors and staff communication, patients’ feelings and emotions relating to “high-risk” pregnancy and hospitalization, operators’ emotions, perceived facilitating factors, difficulties and resources. In a “high-risk” pregnancy condition, some difficulties in the relationship between hospitalized women and health operators occur. For inpatients the emotional difficulties were mostly connected to the pathologic situation and the contingent loneliness. Although the majority of women said that they understood staff communication and that they established a basic trust towards the entire clinical staff, there was a request for greater outspokenness. For clinical operators the relational and communication difficulties specifically concerned the overall management of the relationship with the patients studied. In particular, they perceived themselves to be called to a greater clearness and clinical reliability.Conclusions: Overcoming the dyadic model of the doctor–patient relationship (in a systemic view) by incorporating clinical operators’ and inpatients’ points of view, seems a useful tool to highlight critical and facilitating factors about the relationship and communication in “high-risk” conditions.Condensation Overcoming the dyadic vision of the doctor–patient relationship, by crossing clinical operator's and inpatient's points of view, seems a useful tool to highlight critical and facilitating factors about the relationship and communication in “high-risk” pregnancy conditions.

First-trimester prenatal diagnosis performed on pregnant women with fetal ultrasound abnormalities: The reliability of interphase fluorescence in situ hybridization (FISH) on mesenchymal core for the main aneuploidies

2009-12-28

Abstract: Objectives: To examine the reliability of interphase FISH analysis of the main aneuploidies performed on mesenchymal core when prenatal diagnosis was performed on pregnant women with first-trimester fetal abnormalities on ultrasound.Study design: 386 first-trimester prenatal examinations were investigated from chorionic villus samplings for increased nuchal translucencies or other fetal ultrasound abnormalities. Interphase fluorescence in situ hybridization (FISH) for the main aneuploidies (trisomies 13, 18, 21 and gonosomal aneuploidies) was performed on the mesenchymal core of villi. Molecular cytogenetic results were always complemented by conventional cytogenetic results on long-term cultured villi (LTC-villi). Short-term cultured villi (STC-villi) preparations were retrospectively performed only when a chromosomal abnormality was observed with interphase FISH and/or LTC-villi.Results: 88 chromosomal abnormalities (88/386=22.8% of first-trimester diagnoses) which could discuss subsequent abortions were observed after LTC-villi preparations. All cases possibly detectable by interphase FISH were detected. Thus, 85 aneuploidies (85/386=22.0% of first-trimester diagnoses; 85/88=96.6% of chromosomal abnormalities) were detected by interphase FISH, allowing early abortion by curettage before week 14 amenorrhea. No discrepancy occurred between interphase FISH and LTC-villi results for the aneuploidies studied. Three false-negative results (3/386=0.77% of first-trimester diagnoses; 3/88=3.41% of chromosomal abnormalities) were observed with STC-villi.Conclusion: We observed a high rate of false-negative results on cytotrophoblast cells. Conversely, interphase FISH of the main aneuploidies on the mesenchymal core provided rapid and reliable results, and therefore should be preferred to STC-villi in first-trimester prenatal diagnosis performed on pregnant women with fetal abnormalities on ultrasound.

Variability in caesarean section rates for very preterm births at 28–31 weeks of gestation in 10 European regions: Results of the MOSAIC project

2010-01-08

Abstract: Objective: Given the continuing debate about the benefits of caesarean section for very preterm infants, we sought to describe caesarean section rates for infants between 28 and 31 weeks of gestation in European regions and their association with regional mortality and short-term morbidity.Study design: Singletons and twins without lethal congenital anomalies alive at onset of labour from 28 to 31 weeks of gestation from the 2003 MOSAIC cohort of very preterm births in 10 European regions were analysed (N=3310). Determinants included maternal and fetal characteristics as well as regional caesarean section rates for all births. We explored correlations between caesarean section rates and mortality and morbidity on the regional level.Results: 95% of infants from pregnancies complicated by hypertension or severe growth restriction detected antenatally were delivered by caesarean section (regional range: 90–100%) versus 55.4% (range: 29–84%) for other pregnancies. Regional caesarean section rates for births at all gestations ranged from 14% to 38% and were correlated with very preterm caesarean rates (p=0.011). Determinants of caesarean section differed between regions with high versus low rates: multiples were more likely to be born by caesarean section in regions with high rates. There were no regional level correlations between caesarean section rates and mortality and morbidity.Conclusions: With the exception of pregnancies with hypertension and growth restriction, there was broad variation in very preterm caesarean section rates between regions after adjustment for clinical factors. Given maternal risks associated with caesarean section, more research on its optimal use for very preterm deliveries is necessary.

Anxiety and depression in hyperemesis gravidarum: prevalence, risk factors and correlation with clinical severity

Peng Chiong Tan, Subramaniam Vani, Boon Kiong Lim, Siti Zawiah Omar — 2010-01-07

Abstract: Objective: To evaluate prevalence, risk factors and clinical severity correlates of anxiety and depression caseness in hyperemesis gravidarum (HG).Study design: A prospective study of self-assessment using the Hospital Anxiety and Depression Scale (HADS) was performed. Women at their first hospitalization for HG were recruited as soon as possible after hospital admission. Cut-off at the score of 7/8 was used for both the anxiety and depression subscales of HADS to denote anxiety and depression caseness respectively. Risk factors for anxiety and depression caseness were identified using Chi-square test, Fisher's exact test, Mann–Whitney's U-test or the Student's t-test. Multivariable logistic regression analysis incorporating all co-variables with crude P<0.1 was performed to identify independent risk factors. Bivariate analyses were performed to identify associations between clinical markers of severity and anxiety and depression caseness. Prolonged hospitalization and a number of biochemical and hematological abnormalities were used as clinical markers of HG severity.Results: Criteria for anxiety and depression caseness were fulfilled in 98/209 (46.9%) and 100/209 (47.8%) women respectively. 78 (37.3%) participants fulfilled the criteria for both anxiety and depression caseness, 89 (42.6%) neither, 20 (9.6%) anxiety caseness only and 22 (10.5%) depression caseness only. Gestational age at commencement of vomiting, duration of vomiting leading up to hospitalization and paid employment status had crude P<0.1 in association with anxiety caseness. After adjustment, only paid employment was independently associated with anxiety caseness (AOR 2.9 95% CI 1.3–6.5; P=0.009). Previous miscarriage, gestational age at commencement of vomiting and duration of vomiting leading up to hospitalization all had P<0.1 in association with depression caseness. After adjustment, only previous miscarriage was negatively associated with depression caseness (AOR 0.4 95% CI 0.2–0.9; P=0.022). There was no marker of HG severity associated with anxiety caseness on bivariate analysis. High hematocrit was associated with depression caseness (OR 2.1 95% CI 1.1–3.9; P=0.027).Conclusion: Anxiety and depression caseness is common in HG and risk factors can be identified. There is no convincing association between anxiety and depression and more severe illness. Psychological symptoms may be a response to physical illness but further studies are needed.

Decision-to-delivery interval for emergency caesareans in the Aurore perinatal network

2010-01-11

Abstract: Objectives: To determine the interval between decision and delivery (DDI) for urgent and very urgent caesarean deliveries within a perinatal network, to compare the results according to maternity ward level and organisation, and to assess the impact of DDI on neonatal outcome.Study design: Prospective observational study in the 31 maternity units of the Aurore perinatal network (17 Level I, 12 Level II, and two Level III). The obstetric team defined the degree of urgency for the caesareans, measured the DDI, and reported neonatal outcome.Results: The study includes 666 unplanned caesarean sections. The median DDI for emergency caesareans (n=365) was 48min for Level I units, 40min for Level II, and 22min for Level III (P<0.05). For the very urgent caesareans (n=82), the median DDI was respectively 35, 24, and 13min (P<0.05) and the percentage with a DDI≤30min were 45%, 62%, and 100% (P<0.05). The proportion of DDI≤30min was 0% in maternity units where obstetricians and anaesthetists were not always onsite, 67% when only the anaesthetist was always present (P<0.05) and 88% for units where both were always present. The neonate's condition did not differ significantly according to DDI.Conclusions: DDI varies very substantially according to the level and organisation of the maternity units in the Aurore network. It was not significantly correlated with neonatal outcome in our population.

Pre-eclampsia in the first pregnancy and subsequent risk of stillbirth in black and white gravidas

2010-01-11

Abstract: Objective: To examine the association between prior pre-eclampsia and subsequent stillbirth in black women and white women.Study design: This is a population-based retrospective study of Missouri maternally linked birth cohort files from 1989 to 2005. We analyzed singleton first and second births to mothers in the state of Missouri. The study population comprised women who experienced pre-eclampsia in their first pregnancy and a comparison group consisting of women who did not. The two groups were followed to their second pregnancy to document stillbirth occurrence. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between prior pre-eclampsia and subsequent stillbirth were obtained from logistic regression models.Results: Women who experienced prior pre-eclampsia had a 43% increased risk of subsequent stillbirth [OR=1.43; 95% CI=1.08–1.89]. Whereas women with a history of late-onset pre-eclampsia had no elevated risk for subsequent stillbirth, those whose first pregnancy resulted in early-onset pre-eclampsia had a more than 4-fold increased risk of stillbirth in their second pregnancy [OR=4.07; 95% CI=2.32–7.14]. When sub-analysis was performed on the two main racial groups in the State, we found that elevated risk for subsequent stillbirth in a second pregnancy was observed among black women with prior early-onset pre-eclampsia (OR=8.21; 95% CI=4.03–16.70) but not in whites (OR=1.95; 95% CI=0.72–5.26).Conclusion: Initiation of pregnancy with pre-eclampsia elevates the risk for subsequent stillbirth. The risk elevation is most pronounced in black women with early-onset pre-eclampsia in their first pregnancy. This information is valuable for inter-pregnancy counseling of affected women.

Decreased active, total and altered active to total ghrelin ratio in normal weight women with the more severe form of polycystic ovary syndrome

2010-01-05

Abstract: Objective: To assess total, active and active to total serum ghrelin ratio in normal weight women with polycystic ovary syndrome (PCOS) and in healthy ovulatory control women.Study design: The study included 50 normal weight women with PCOS with a mean age of 23.70±4.99 years and 10 control women with a mean age of 30±5.80 years. The diagnosis of PCOS was based on the presence of biochemical hyperandrogenemia, chronic anovulation and polycystic ovarian morphology according to the Rotterdam ESHRE/ASRM-sponsored PCOS Consensus Workshop Group. Serum total and active ghrelin were measured by RIA, using commercially available kits.Results: A significantly lower serum active/total ghrelin ratio was noted in the more severe form of PCOS with hyperandrogenemia, chronic anovulation and polycystic ovarian morphology. Both total and active serum ghrelin levels were negatively correlated to hirsutism score, to plasma glucose levels and to QUICKI and HOMA-IR indices of Insulin Resistance. A statistically significant difference was detected between the more severe and the milder forms of PCOS, concerning serum levels of total ghrelin (p=0.017), active ghrelin (p=0.007) and the active/total ghrelin ratio (p=0.026).Conclusions: The results of the present study demonstrate an altered active to total ghrelin ratio, as well as a tendency towards lower both total and active fasting serum ghrelin levels in normal weight PCOS, more pronounced in the more severe forms of the syndrome.

Ovarian stimulation and emergency in vitro fertilization for fertility preservation in cancer patients

2010-01-07

Abstract: Objective: To evaluate the outcome of ovarian stimulation and in vitro fertilization (IVF) in women undergoing fertility preservation prior to chemotherapy compared with healthy patients with infertility due to tubal factor.Study design: Case control, retrospective study in an academic IVF unit. The study participants were 21 cancer patients and 1 patient with focal proliferative glomerulosclerosis, undergoing emergency IVF or intracytoplasmic sperm injection (ICSI; Group A) and 22 patients undergoing IVF for tubal factor (Group B). All patients underwent controlled ovarian stimulation, ovum pick-up, and embryo freezing or transfer. The outcome measures included: dose of gonadotropins, mean estradiol and progesterone levels, length of stimulation, number of retrieved oocytes, number of 2 pronuclei zygotes, fertilization rate, and clinical pregnancy rate. Student's t-test was used for assessment of group comparisons.Results: Patients in Group A (mean age 32.8±5.7 years) underwent 22 emergency IVF cycles for fertility preservation prior to chemotherapy. The mean number of days until human chorionic gonadotropin administration was 10.4±4.8. Eleven cycles involved normal insemination while nine involved ICSI. In one cycle three arrested immature oocytes were retrieved, and in one cycle no oocytes were retrieved. Donor sperm was used in 9 cycles. Tamoxifen was part of the treatment protocol in 6 IVF cycles of breast cancer patients. The mean age of the women in Group B was 34±4.2 years. There were no significant differences in any of the main outcome measures between the two groups. Thawed embryos were transferred in four cancer patients: two patients had colon cancer, one had breast cancer and one had pseudomyxoma peritonei. Two of these four women conceived and gave birth to healthy newborns.Conclusions: Emergency IVF is a promising approach for preserving fertility in cancer patients. Current treatment protocols offer a minimal time delay until chemotherapy is commenced, and the ovarian stimulation outcomes are comparable to those of women with tubal factor.

The degree of cycle irregularity correlates with the grade of endocrine and metabolic disorders in PCOS patients

Thomas Strowitzki, Edison Capp, Helena von Eye Corleta — 2010-01-07

Abstract: Objective: PCOS (polycystic ovarian syndrome) is a clinically heterogeneous endocrine disorder which affects up to 4–10% of women of reproductive age. A standardized definition is still difficult because of a huge variety of different phenotypes. The aim of this study was to evaluate possible correlations between the degree of cycle irregularity and the grade of endocrine and metabolic abnormalities.Study design: A cross-sectional study was carried out. Hyperandrogenic and/or hirsute women with regular menstrual cycles and polycystic ovaries on ultrasound (PCOS eumenorr, n=45), PCOS patients with oligomenorrhea (PCOS oligo, n=42) and PCOS patients with amenorrhea (PCOS amenorr, n=31) were recruited from the Department of Gynecological Endocrinology and Reproductive Medicine of the Women's University Hospital Heidelberg (Heidelberg, Germany).Results: Normocyclic patients demonstrated significantly better metabolic parameters (BMI, fasting insulin, HOMA-IR) than patients with oligo/amenorrhea. Hormonal parameters (LH, FSH, FAI and testosterone) were significantly different between patients with different menstrual patterns and patients with regular cycles.Conclusion: Determining the degree of cycle irregularity as a simple clinical parameter might be a valuable instrument to estimate the degree of metabolic and endocrine disorders. Emphasis should be given to those parameters as a first step to characterize PCOS patients with a risk of endocrine and metabolic disorders leading to consequent detailed examination.

Protective effect of a gonadotropin-releasing hormone analogue on chemotherapeutic agent-induced ovarian gonadotoxicity: A mouse model

2010-01-07

Abstract: Objective: To demonstrate the protective effect of triptorelin, a GnRH analogue, on chemotherapy-induced ovarian gonadotoxicity.Study design: Twenty-four sexually mature, virgin, female FVB/NJNarl mice were divided into four groups: busulfan (B); low-dose triptorelin plus busulfan (TL+B); high-dose triptorelin plus busulfan (TH+B); and control. Mice in the TL+B and TH+B groups were injected with 3.8 and 38mg/kg of triptorelin subcutaneously, respectively. Four weeks later, mice in the B, TL+B, and TH+B groups were injected with busulfan intraperitoneally at a dose of 36mg/kg. Histologic examinations were performed 4 weeks later.Results: Obvious destruction of ovarian structure and significant depletion of primordial, primary, and secondary follicles were demonstrated in the B group compared with the control group, affirming the gonadotoxicity of busulfan. In the TL+B group, a greater number of larger primordial and primary follicles were enumerated compared with the B group; however, statistical significance was not achieved. In the TH+B group, the number of primordial and primary follicles was significantly greater than in the B group, and the ovarian tissue in the TH+B group was spared, demonstrating the effect of triptorelin pre-treatment on ovarian protection.Conclusion: Our results have demonstrated a dose-dependent protective effect against gonadotoxic chemotherapy of a GnRH analogue on ovarian reserve, thus suggesting a novel application of GnRH analogues in fertility preservation.

Computer-Assisted Sperm Analysis (CASA) parameters and their evolution during preparation as predictors of pregnancy in intrauterine insemination with frozen-thawed donor semen cycles

Thomas Fréour, Miguel Jean, Sophie Mirallié, Sophie Dubourdieu, Paul Barrière — 2010-01-06

Abstract: Objective: To study the potential of CASA parameters in frozen-thawed donor semen before and after preparation on silica gradient as predictors of pregnancy in IUI with donor semen cycles.Study design: CASA parameters were measured in thawed donor semen before and after preparation on a silica gradient in 132 couples undergoing 168 IUI cycles with donor semen. The evolution of these parameters throughout this process was calculated. The relationship with cycle outcome was then studied.Results: Clinical pregnancy rate was 18.4% per cycle. CASA parameters on donor semen before or after preparation were not significantly different between pregnancy and failure groups. However, amplitude of lateral head displacement (ALH) of spermatozoa improved in all cycles where pregnancy occurred, thus predicting pregnancy with a sensitivity of 100% and a specificity of 20%.Conclusions: Even if CASA parameters do not seem to predict pregnancy in IUI with donor semen cycles, their evolution during the preparation process should be evaluated, especially for ALH. However, the link between ALH improvement during preparation process and pregnancy remains to be explored.

Cumulative live birth rates after GnRH-agonist triggering of final oocyte maturation in patients at risk of OHSS: A prospective, clinical cohort study

2010-01-06

Abstract: Objectives: To prospectively study the incidence of OHSS, live birth likelihood and neonatal outcome after GnRH-agonist triggering of final oocyte maturation and vitrification of all pronucleate (2PN) oocytes for later frozen–thawed embryo transfer (FRET) in an OHSS-risk population.Study design: Prospective, clinical cohort study (12/2004–5/2009). Forty patients undergoing ovarian stimulation in a GnRH-antagonist protocol and at risk of developing severe OHSS underwent triggering with 0.2mg triptorelin and elective vitrification of all 2PN-oocytes for later frozen–thawed embryo transfer.Results: The incidence of OHSS was 0% (0/40; 95% confidence interval: 0.0–6.4%). Thirty-nine patients underwent 87 FRETs (mean number of FRETs per patient: 2.2±1.6; range: 1–7). The cumulative live birth rate per patient was 35.0% (14/40; 95% confidence interval: 23.9–48.0%). Mean time-to-conception resulting in live birth after agonist triggering was 24.2 (±17.1; range: 9–67) weeks. Nine healthy singletons and five twins were born.Conclusions: A treatment algorithm combining agonist trigger with vitrification of all 2PN-oocytes is feasible and safe, and provides patients with a good cumulative chance of live birth.

A new approach to postoperative peritoneal adhesions: Prevention of peritoneal trauma by aloe vera gel

Erhan Aysan, Hasan Bektas, Feyzullah Ersoz — 2009-12-09

Abstract: Objective: Covering peritoneal surfaces with aloe vera gel may prevent peritoneal trauma and hence postoperative peritoneal adhesions.Study design: Forty Wistar albino out-bred female rats (mean weight, 180±25g; mean age, 6 months) were divided into four groups. In Group 1, 0.1mL aloe vera gel was injected into the peritoneal cavities. In Group 2, peritoneal adhesions were induced. In Group 3, adhesions were induced and the modeled area was covered by 0.1mL aloe vera gel. In Group 4, the area was covered with aloe vera gel prior to adhesion induction. The rats were sacrificed on postoperative day 10 and the adhesions were scored both microscopically and macroscopically.Results: The mean macroscopic adhesion score in the four groups was 0, 5.8±0.42, 5.2±0.79, and 1.1±1.2 respectively, with the difference between Group 4 and Groups 2 (p<0.001) and 3 (p<0.05) statistically significant. The mean histopathological fibrosis values were significantly higher in Group 3 than in Group 4 (2.6±0.51 vs 1.2±0.91, p=0.002).Conclusion: Aloe vera gel can effectively decrease adhesion formation if applied before, but not after, after peritoneal trauma. This effect is likely due not to its chemical properties but to its viscosity, providing a covering to prevent peritoneal trauma.

Systematic pelvic and aortic lymphadenectomy in intermediate and high-risk endometrial cancer: Lymph-node mapping and identification of predictive factors for lymph-node status

2010-01-06

Abstract: Objective: To systematically assess the metastatic pattern of intermediate- and high-risk endometrial cancer in pelvic and para-aortic lymph-nodes and to evaluate risk factors for lymph-node metastases.Study Design: Between 01/2005 and 01/2009 62 consecutive patients with intermediate- and high-risk endometrial cancer who underwent a systematic surgical staging including pelvic and para-aortic lymphadenectomy were enrolled into this study. Patients’ characteristics, histological findings, lymph-node localization and involvement, surgical morbidity and relapse data were analyzed. Univariate analysis was performed to define risk factors for lymph-node metastasis.Results: Of the 13 patients (21%) with positive lymph-nodes (N1), 8 (61.5%) had both pelvic and para-aortic lymph-nodes affected, 2 (15.4%) only para-aortic and 3 (23%) only pelvic lymph-node metastases. Overall, 54% of the N1-patients had positive lymph-nodes above the inferior mesenteric artery (IMA) to the level of the renal veins. Univariate analysis revealed lymph vascular space invasion (p-value: <0.001), vascular-space-invasion (p-value: <0.001) and incomplete tumor resection (p-value: 0.008) as significant risk factors for N1-status. Overall and progression-free survival was not significantly different between N1- and N0-patients.Conclusions: Since the proportion of N1-endometrial cancer patients with positive para-aortic lymph-nodes is, at 76%, considerably high, and more than half of them have affected lymph-nodes above the IMA-level, lymphadenectomy for endometrial cancer should be extended up to the renal veins, when indicated. The therapeutic impact of systematic lymphadenectomy on overall and progression-free survival has still to be evaluated in future prospective randomized studies.

Effect of human seminal fluid on the growth of endometrial cells of women with endometriosis

2010-01-05

Abstract: Objectives: We investigated the effect of human seminal fluid on the growth of endometrial cells derived from women with and without endometriosis.Study design: Seminal plasma (SP) was collected from 18 healthy fertile men. Serum, peritoneal fluid (PF) and tissue specimens of eutopic and ectopic endometrium were collected from 45 women with endometriosis and 20 women without endometriosis during laparoscopic surgery. Prostaglandin (PG) E2, hepatocyte growth factor (HGF), and estradiol (E2) levels in each sample of SP, serum and PF were measured by enzyme-linked immunosorbent assay. The growth pattern of cells derived from eutopic and ectopic endometria in response to SP was examined by 5-bromo-2-deoxyuridine (BrdU) incorporation assay.Results: Seminal plasma was able to significantly stimulate the growth of epithelial cells and stromal cells derived from the eutopic and ectopic endometria of women with endometriosis (2–3-fold) when compared with control media. The SP-promoted proliferation of both gland cells and stromal cells derived from eutopic endometria was also remarkably higher in women with endometriosis than that of women without endometriosis. Although levels of PGE2, HGF and E2 in SP were variable when compared with other body fluids, the levels of PGE2 and HGF in SP were significantly higher than those in either peritoneal fluid or serum of women with or without endometriosis. Pretreatment of cells with individual anti-PGE2 antibody, anti-HGF antibody and two selective estrogen receptor modulators, tamoxifen and raloxifene was unable to suppress SP-mediated growth of endometrial cells. However, pretreatment of cells with combined anti-PGE2 antibody plus anti-HGF antibody or combined anti-PGE2 antibody plus anti-HGF antibody plus tamoxifen or raloxifene was able to significantly suppress SP-promoted growth of eutopic and ectopic endometrial cells.Conclusion: Human seminal fluid enriched with different macromolecules may promote the growth of endometrial cells derived from women with endometriosis. Our findings may suggest some detrimental effect of unprotected sexual intercourse in women with endometriosis.

Determinant factors of fertility outcomes after laparoscopic colorectal resection for endometriosis

2010-01-11

Abstract: Objective: The aims of this prospective study were to evaluate fertility, pregnancy outcomes and their determinant factors after laparoscopic segmental colorectal resection for endometriosis.Study design: We studied 83 women who underwent colorectal resection for endometriosis. Thirty-nine women (47%) had an associated infertility and 51 (61.4%) wished to conceive after surgery. Surgical route was exclusive laparoscopy in 77 cases (92.7%) and laparoconversion in 6 (7.3%).Results: Twenty-nine pregnancies were obtained in 24 patients (43.6%) including 20 spontaneous (69%) and 9 by IVF (31%). The median time to conceive spontaneously was 6 months and 20 months by IVF. Among the 39 infertile women, 18 (46%) conceived during the study period. A relation was found between pregnancy rate and patient age (p=0.02). Reduction in pregnancy rate was correlated to the presence of adenomyosis (p=0.04) and high ASRM total score (p<0.001) as well as exclusive laparoscopy compared to conversion to laparotomy for colorectal resection (p=0.01).Conclusion: Adenomyosis and conversion to laparotomy as well as patient age, ASRM score appeared determinant factors of fertility outcome.

The risk of CIN II or greater in a one-year follow-up period in patients with ASC-H interpreted with cytology

Ke You, Yanli Guo, Li Gen, Jie Qiao — 2010-01-11

Abstract: Objective: To explore the risk of CIN II or greater in patients with cytologically interpreted atypical squamous cells, cannot exclude high grade squamous intraepithelial lesion (ASC-H) in a one-year follow-up period.Study design: Patients with ASC-H accepted high-risk human papillomavirus (HPV) testing (Hybrid Capture II), colposcopy-directed biopsy, and endocervical curettage at baseline. Patients with CIN 1 or less were re-examined with cytology at 4–6-month intervals for up to 12 months only if the cytologic result was ASC-US or worse. Correlation between HPV infection at baseline and the follow-up results was analyzed using Chi-square statistical method and Fisher's exact test.Results: 34.0% (50/147) patients were diagnosed CIN II or greater at baseline. Four patients were diagnosed CIN II or greater at repeat colposcopy among the 65.0% (63/97) of patients who were diagnosed CIN I or less at baseline and had completed follow-up. The HPV positive rate was 61.9% (91/144) at baseline. The correlation coefficient of HPV negativity with CIN I or less was 100% (32/32).Conclusions: The risk of CIN II or greater among patients with ASC-H was 40% and all patients (100%) with baseline negative HPV showed CIN I or less by cytology during the one-year follow-up period.

Laparoscopic sacrocolpopexy for female genital organ prolapse: establishment of a learning curve

2009-12-28

Abstract: Objective: The widespread diffusion of laparoscopic sacrocolpopexy in the management of female genital organ prolapse is hampered by its presumed length and technical difficulties. The aim of our study was to analyse the learning curve of a senior urogynecologic surgeon who was initiated into this technique.Study design: The first 48 laparoscopic sacrocolpopexies performed by the same surgeon were analysed retrospectively for pre-operative, operative and post-operative data. At the time of the study, patients were asked about their degree of satisfaction by an anonymous questionnaire.To discover a turning point, the duration of each procedure was reported and the study population was divided into 8 equal groups of 6 interventions each, classed chronologically. Statistical analysis was carried out by Mauchly's sphericity test and then by Student–Newman–Keul's test. Other descriptive statistics were computed with the use of standard methods for means, medians and proportions.Results: The mean operative time was of 236.9min. The learning curve showed a linear decrease in the duration of surgery with a turning point after 18–24 procedures (p<0.001). It was marked by 2 (4.1%) minor operative complications (2 cystostomies) and 2 immediate post-operative ones: one port-site hernia and one case of urinary retention. At 1 month, 1 patient (2.2%) presented an erosion of the posterior mesh. The mean follow-up was of 15.8 months. During this period, 2 patients (4.1%) presented with a recurrence of prolapse and 6 (12.5%) with de novo stress urinary incontinence. Forty-five patients (93.7%) answered an anonymous questionnaire regarding satisfaction: 40/45 (88.8%) were totally satisfied, 4 (8.8%) moderately and 1 (2.2%) not satisfied.Conclusions: The learning curve of laparoscopic sacrocolpopexy shows a steady decrease in the duration of surgery. A turning point is observed after 18–24 procedures. During the learning curve there is no increased morbidity. Anatomical and functional results at short and medium terms are similar to those reported in the literature.

Matrix metalloproteinase-9 polymorphism and risk of pelvic organ prolapse in Taiwanese women

2009-12-28

Abstract: Objective: Matrix metalloproteinase-9 is known to play an important role in the pathophysiology of pelvic organ prolapse. We investigated whether the matrix metalloproteinase-9 gene polymorphisms were associated with pelvic organ prolapse by conducting a case–control association study in 92 women with pelvic organ prolapse and 152 women without pelvic organ prolapse.Study design: Genotypes of the matrix metalloproteinase-9 gene polymorphisms (rs3918242, rs17576, and rs2250889) were determined by polymerase chain reaction, followed by restriction fragment length polymorphism analysis.Results: There was significant difference between women with and without pelvic organ prolapse in the distribution of the matrix metalloproteinase-9 rs17576 genotypes evaluated. Using multivariable logistic regression, menopausal status, matrix metalloproteinase-9 rs17576 genotype AG, and matrix metalloproteinase-9 rs17576 genotype GG were significantly associated with pelvic organ prolapse.Conclusion: The present study shows that the polymorphism of matrix metalloproteinase-9 rs17576 may be associated with pelvic organ prolapse.

Neuromuscular blockade after therapy with magnesium sulfate and amlodipine

Qiao-ai Wu, Yi-Qing Ye — 2009-12-03

We report a case of a 40-year-old pre-eclamptic patient at 32 weeks’ gestation, who developed neuromuscular blockade after taking magnesium sulfate and amlodipine. She was admitted with a diagnosis of pre-eclampsia. Her blood pressure (BP) was 200/130mmHg; proteinuria was mild (500mg/24h); no oedema was present and the other kidney function tests were normal (serum creatinine 56μmmol/L).

A cutaneous-vaginal fistula and myositis of the obturator muscle following placement of a trans-obturator tape for stress incontinence

Marco Maffiolini, Corrado R. Asteria — 2009-12-03

We found that the treatment of this case report has truly challenged our clinical practice, because of its related issues rather than its extreme infrequency. A 64-year-old woman, B.F. (BMI 26.6, Para 2, menopausal), was referred in 2004 with a long-standing history of stress urinary incontinence (SUI), grade 2, occurred immediately after hysterectomy for fibroma, by abdominal route. Investigations showed urethral hypermobility without any associated prolapse, normal profilometry, cysto-capacity of 297ml and maximal closure urethra pressure of over 20cm H2O. At the time, the patient was admitted in a different department, then a gynecologist placed a polypropylene trans-obturator tape (TVT-O) (Gynecare®-Ethicon, Somerville, NJ) from inside to outside, but, since early post-operative course, leukoxanthorrhoea with positive Candida albicans culture has occurred. Symptoms have persisted for 3 years, despite systemic and topical therapy. Both examinations and endovaginal US have scheduled during this period, averagely once every 2 months, without any trace of erosion. In early 2007, a suburethral small erosion with tape exposure was found on the left side of the vaginal wall. The exposed prosthesis was removed and vaginal erosion was sutured. Two months later, a pre-obturatory abscess surfaced at the prepubic space of tape entry, requiring an incision to drain abscess, but discharge persisted over 3 months, thereby showing that the left arm of the prosthesis was infected and needed to be removed. However, discharge did not cease for the next 12 months. In 2008, symptoms worsened with reported ambulatory difficulties (lameness), due to both crura and upper thigh pain. The patient was referred to our department and a cutaneous-vaginal fistula was diagnosed. The orifice was located in the inner part of the left thigh and connected to an internal opening of the left vaginal wall. Bacteriological samples developed mixed flora. A probe, inserted into the prepubic orifice along the track, easily and promptly identified the vaginal orifice (). Subsequently, a MRI showed that the track was passing through both the obturator membrane and the anterior corner of ischio-rectal cavity, as far as the anterior fornix. Moreover, a part of the track diverted at right angle before joining the vagina and an extended myositis involving both the external obturator and short adductor muscles was detected. Procedure comprised, first, injection inside the external orifice with a methylene blue dye (methylthioninium chloride, 100mg, SALF Laboratories, Cenate S. Bg, Italy) and then the track was cored out inwards. Finally, a vaginal approach was included to complete excision, given the sharp band of the track next to vagina. Full cessation of drainage was observed 3 months later, due to little cellulitis around the cutaneous orifice which required medications (dressing with Povidone-iodine solution 10%, weekly and Metronidazole tab. 200mg ×3, daily, for 3 weeks). At 16 months follow-up the patient is well managed, free of SUI symptoms and remission is locally stable.

Total hip replacement at thirty years. Case report of crippling complications of a transient osteoporosis of the hip during pregnancy

2009-12-04

We found this case of transient osteoporosis of the hip (TOH) during pregnancy to be of special clinical, educational and scientific interest. It is a bilateral TOH associated with a spontaneous pathological fracture subsequently complicated by coxarthrosis.

First manifestation of citrullinemia type I as differential diagnosis to postpartum psychosis in the puerperal period

2009-12-04

We found a severe hyperammonemic coma during the postpartum period in three women who were all shown to suffer from a yet undiagnosed inborn error of amino acid metabolism, citrullinemia type I (MIM# 215700). One case had a fatal outcome. This disorder is caused by a deficiency of the cytosolic urea cycle enzyme argininosuccinate synthetase (ASS1; MIM# 603470) and is inherited in an autosomal-recessive pattern . We report on the patients in order to increase the awareness in the care of women during the postpartum period and we suggest the inclusion of metabolic studies for all acute neurological symptoms in the puerperal period.

Horner's syndrome following epidural analgesia during labor: Report of six cases

Alex Rabinovich, Rania Abedelhady, Moshe Mazor, Benjamin Piura, Efraim Margolin — 2009-12-09

Contrary to some previous studies, we have observed that body mass index, position during epidural injection, catheter length and epidural solution concentration are not risk factors for Horner's syndrome (HS) following epidural analgesia (EA) during labor. However, epidural infusion technique may have had an influence on the incidence of HS.

Retroperitoneal tuberculosis in a patient with uterine papillary serous carcinoma

Allison Wagreich, Ghadir Salame, Yi-Chun Lee, David M. Sherer, Ovadia Abulafia — 2009-12-28

Endometrial carcinoma is the most common gynecologic malignancy. Among patients with tuberculosis, only 20% manifest extrapulmonary disease. Concurrent endometrial carcinoma and tuberculosis are extremely rare with only four previously reported cases .