European Journal of Obstetrics & Gynecology and Reproductive Biology

Editorial Board

2010-09-01

Editor's highlights

J. Drife — 2010-09-01

As the summer fades, and with it the memory of an excellent European performance in football's World Cup, many countries are facing a winter of economic austerity. Our specialty may not be first in line for cuts to funding – governments want people to keep having babies – but we cannot escape some of the effects of budget reductions. These bring risks. Staff in many public services are already thinly spread and overworked. If this process goes too far in the maternity services, it begins to threaten the low maternal and perinatal mortality rates that much of Europe takes for granted. As always, poor people are most at risk. On the academic front, research funding becomes even harder to find in tough economic times. We must all speak up to ensure that even when governments are struggling with debt, women's health remains a priority.

Systematic review and meta-analysis of the test accuracy of ductus venosus Doppler to predict compromise of fetal/neonatal wellbeing in high risk pregnancies with placental insufficiency

2010-05-11

Abstract: Objective: To evaluate the test accuracy of ductus venosus Doppler for prediction of compromise of fetal/neonatal wellbeing.Study design: The search strategy employed searching of electronic databases (Medline, Embase, Cochrane library, Medion) from inception to May 2009, hand searching of journal and reference lists, contact with experts. Two reviewers independently selected articles in which the results of ductus venosus Doppler were associated with the occurrence of compromise of fetal/neonatal wellbeing. There were no language restrictions applied. Data were extracted on study characteristics, quality and results to construct 2×2 tables. Likelihood ratios for positive and negative test results, sensitivity, specificity and their 95% confidence intervals were generated for the different indices and thresholds.Results: Eighteen studies, testing 2267 fetuses met the selection criteria, all performed in a high risk population with placental insufficiency in second/third trimester. Meta-analysis showed moderate predictive accuracy. The best result was for the prediction of perinatal mortality, positive likelihood ratio 4.21 (95% CI 1.98–8.96) and negative likelihood ratio 0.43 (95% CI 0.30–0.61). For prediction of adverse perinatal outcome the results were positive likelihood ratio 3.15 (95% CI 2.19–4.54) and negative likelihood ratio 0.49 (95% CI 0.40–0.59).Conclusion: Abnormal ductus venosus Doppler showed moderate predictive accuracy for compromise of fetal/neonatal wellbeing overall and perinatal mortality in high risk pregnancies with placental insufficiency.

Maternal urological problems in pregnancy

Paul Fiadjoe, Kurinji Kannan, Ajay Rane — 2010-05-10

Abstract: Urological conditions in pregnancy represent a major diagnostic and therapeutic challenge. During pregnancy the urinary tract undergoes some anatomical and physiological changes that may result in many symptoms and pathological conditions affecting both the mother and fetus. With prompt evaluation and expeditious treatment, the prognosis is good. Fear of causing harm is unfounded. This article describes urological problems in pregnancy, specifically infection, calculus, renal failure, renal tumour, lower urinary tract symptoms and trauma and their management.

Turner syndrome and pregnancy: clinical practice. Recommendations for the management of patients with Turner syndrome before and during pregnancy

2010-06-07

Abstract: Following the death in France by acute aortic dissection of two women with Turner syndrome who were pregnant following oocyte donation, the Director of the French Biomedicine Agency (Agence de la biomédecine) sent a letter to the President of the French College of Obstetricians and Gynaecologists (FCOG). He requested the College's expertise in reviewing point-by-point the cases and risk factors and in determining whether there are grounds to propose additional measures complementary to the recommendations made by the Haute autorité de santé or French National Authority for Health (HAS) in 2008 in terms of indication and monitoring of patients. A joint practice committee of the FCOG, the French Cardiologic Society, the French Chest and Cardiovascular Surgery Society, the French Society of Anaesthesia and Intensive Care, the French Endocrine Society, the French study group for oocyte donation, and the Biomedicine Agency defined the exact questions to be put to the experts, chose these experts, followed them up and drafted the synthesis of recommendations resulting from their work.The questions concerned the check-up before pregnancy of Turner patients, contraindication and acceptance of pregnancy, information for the patients, and recommendations for antenatal care, delivery and postnatal follow-up.

Effectiveness of percutaneous vesico-amniotic shunting in congenital lower urinary tract obstruction: divergence in prior beliefs among specialist groups

2010-05-11

Abstract: Objective: To explore the prior beliefs regarding the effectiveness of percutaneous vesico-amniotic shunting in congenital lower urinary tract obstruction among different clinical specialist groups involved in caring for this condition.Study design: Questionnaire survey of experts in the field based on principles of Bayesian elicitation of prior beliefs. The sample was 59 consultants in three specialties. Of these, 37 (63%) were subspecialty trained fetal medicine practitioners, 16 (27%) were paediatric nephrologists and 6 (10%) were paediatric urologists. The questionnaire elicited experts’ opinions as to: control arm perinatal mortality, effect of vesico-amniotic shunting on perinatal mortality, current clinical practice and the level of evidence required to change current practice.Results: The response rates were 28% for fetal medicine specialists, 29% for paediatric nephrolgists and 10% for paediatric urologists. The median belief for fetal medicine specialists was a 10% (inter-quartile range, IQR 0–20%) reduction in perinatal mortality with shunting and a mean control arm perinatal mortality of 61%. For paediatric nephrologists the results were 5% (IQR −10 to 15%) and 18% and for paediatric urologists 10% (IQR 0–15%) and 17%. Fetal medicine specialists had the most optimistic beliefs regarding effect of shunting on perinatal mortality. Thirty-eight experts (68%) indicated that vesico-amniotic shunting would most likely reduce morbidity associated with renal dysfunction.Conclusion: The prior beliefs show a divergence of opinion among specialists. This establishes clinical equipoise, which should be resolved with a randomised trial.

Long-term amnioinfusion through a subcutaneously implanted amniotic fluid replacement port system for treatment of PPROM in humans

Michael Tchirikov, Joscha Steetskamp, Manfred Hohmann, Heinz Koelbl — 2010-05-11

Abstract: Objectives: To introduce a novel method for the treatment of PPROM (preterm premature rupture of membranes) using continuous amnioinfusion via a subcutaneously implanted port system.Study design: After development and testing since 2001 in a fetal sheep model, the port system has been successfully implanted in two humans with PPROM. In the first case, the subcutaneous port system was implanted during the 23rd week of gestation in a 39-year-old 5th-gravida with PPROM since the 18th week of gestation; in the second case, the port system was implanted during the 24th week of gestation in a 27-year-old 3rd gravida with PPROM since the 21st week of gestation. After port implantation, 100ml/h saline solution was infused intermittently into the amniotic cavity. The whole course of treatment was supported by tocolysis.Results: In the cases presented, gestation was terminated by cesarean section, in one case in the 29th week of gestation, and in the other case in the 30th week. The newborns showed no signs of lung hypoplasia and were successfully extubated on the 1st or 2nd day after delivery. Six months later the children did not exhibit any deviation from the normal development.Conclusion: Long-term amnioinfusion via a subcutaneously implanted port system could be used in humans with PPROM for prolongation of pregnancy and to avoid lung hypoplasia. Prospective randomized studies are ongoing.

Lactate concentration in amniotic fluid: a good predictor of labor outcome

2010-05-31

Abstract: Objective: Previous publications have suggested that high levels of lactate in amniotic fluid (AF) correlate with dysfunctional labor. The aim of this study was to investigate whether lactate concentration in AF together with the partogram is a better predictor of operative intervention in dysfunctional labor than the partogram alone.Study design: A prospective observational study was carried out of 825 laboring women. Samples of AF were collected and the lactate concentration was analyzed at the bedside during labor. The main outcome of the study was the method of delivery (operative/spontaneous vaginal) in relation to the concentration of lactate in AF. Logistic regression was used to estimate the association between lactate concentration in AF and labor outcome and to adjust for well-known risk factors for dysfunctional labor.Results: 385/825 women had an arrested labor according to the partogram, and 193 of them were delivered operatively. High lactate in AF (>10.1mmol/l) when labor arrested was associated with an increased risk of operative intervention due to dysfunctional labor (adjusted OR, 5.4, 95% CI, 3.2–9.1). Low levels of lactate in AF (<10.1mmol/l) were associated with an increased probability of spontaneous vaginal delivery (adjusted OR, 2.7, 95% CI, 1.7–4.8).Conclusion: The partogram together with the concentration of lactate in AF is a better predictor of operative intervention in dysfunctional labor than the partogram alone.

Morphological characteristics of placentas associated with idiopathic intrauterine growth retardation: a clinicopathologic study

Sandra Zekic Tomas, Damir Roje, Ivana Kuzmic Prusac, Ivica Tadin, Vesna Capkun — 2010-05-31

Abstract: Objectives: To investigate histopathologic findings, placental diameters and characteristics of syncytial knots in the placentas from idiopathic intrauterine growth retardation (IUGR) pregnancies, and to compare them with a normal birth weight group.Study design: Based on strict eligibility criteria, this prospective case–control study included 52 term placentas from idiopathic IUGR pregnancies and 69 term placentas from normal birth weight pregnancies. The study was carried out at the Clinical Hospital Centre, Split, where all placentas were collected and examined. For each placenta, diameters were measured and the following histopathologic findings were recorded: infarction, intervillous thrombosis, abruption, villous branching and maturation, chorioamnionitis, decidual vasculopathy and hemorrhagic endovasculitis for each placenta. In addition we assessed quantitative (number of syncytial knots and number of syncytial nuclei per syncytial knot) and qualitative (density and surface area) characteristics of syncytial knots in each placental sample. Statistical significance was tested using χ2-test, Student's t-test and Mann–Whitney U-test. Statistical significance was set at P≤0.05.Results: There was no difference in investigated histopathologic findings between idiopathic IUGR placentas and control group placentas. Placental diameters correlated significantly with neonatal birth weight (r=0.64; P<0.01); with higher birth weight there is an increase in placental diameters. Syncytial knots from idiopathic IUGR had significantly smaller surface area (Z=2.637; P=0.008) and higher density (Z=3.225; P=0.001) compared with the control group, while there is no difference in number of syncytial knots per individual villus, total number of syncytial knots in each placenta sample or number of syncytial nuclei per syncytial knot.Conclusions: The investigated histopathologic findings in idiopathic IUGR placentas are incidental, with no higher frequency than in placentas from uncomplicated pregnancies, and should not be considered as possible causative factors for idiopathic IUGR. The demonstrated qualitative changes of syncytial knots in placentas associated with IUGR could represent a compensatory mechanism.

The natural history of hereditary angioedema and the impact of treatment with human C1-inhibitor concentrate during pregnancy: a long-term survey

2010-06-02

Abstract: Objective: The course of hereditary angioedema (HAE) and the efficacy and safety of human C1-INH concentrate were appraised during pregnancy and the postpartum period, in patients with HAE.Study design: Retrospective analysis of clinical data on 118 pregnancies (82 full-term and 36 abortions) in 41 female patients, extracted from the National HAE Registry, medical charts and patient diaries.Results: HAE attack frequency increases in 48% of pregnancies, whereas 33% of pregnancies were associated with mitigation of clinical signs and 19% of the pregnancies had no influence on the course of HAE, as compared to disease severity seen during the 2-year period preceding the pregnancy. During 46 full-term pregnancies, 26 patients reported attacks; 52% of these occurred in the third trimester. Abdominal attacks are the most common presentation of HAE during pregnancy. Attack number was significantly higher in patients who had sustained their initial attack before 8 years of age. Attack number increased during the third trimester if the fetus was afflicted by HAE. During the postpartum period, attacks occurred in 6/82 pregnancies. Patients received 91 vials of C1-INH concentrate altogether for the relief of acute attacks and for short- or long-term prophylaxis during pregnancy. This therapy was effective in all instances; no adverse effects were observed.Conclusions: Pregnancy can either aggravate or mitigate edematous attacks, or alternatively, it may have no influence on the severity of the disease. According to our experience, C1-INH concentrate is an effective and safe therapeutic option during pregnancy.

The effects of ritodrine and magnesium sulfate on maternal and fetal Doppler blood flow patterns in women with preterm labor

N. Cenk Sayin, Sezer Arda, Füsun G. Varol, Necdet Süt — 2010-06-07

Abstract: Objective: To determine the effects of ritodrine and magnesium sulfate on maternal–fetal blood flows.Study design: A total of 85 pregnant women between 26th and 36th weeks with preterm labor, and 83 healthy pregnant women were included. Patients in the study group were randomly assigned to receive either ritodrine (with the addition of verapamil) (n=46) or magnesium sulfate (n=39). Blood flow examinations on the umbilical artery (UA), middle cerebral artery (MCA), bilateral uterine arteries (Ut.A) and ductus venosus (DV) were performed before and 48h after initiating therapy.Results: UA pulsatility index (PI) significantly differed in women receiving tocolysis compared to controls after 48h. DV PI increased in women receiving MgSO4, whereas it decreased in the ritodrine and control groups. Ut.A values did not significantly change after 48h in the groups.In women between the 26th and 32nd weeks, UA, MCA and DV PI did not significantly change after 48h in the three groups. However, in women between the 32nd and 36th weeks UA and MCA PI significantly differed in the treatment groups compared to controls after 48h. DV PI increased in women receiving MgSO4, whereas it decreased in the ritodrine and control groups.Conclusions: MgSO4 and ritodrine affect blood flow patterns after 48h in some maternal–fetal vessels. These effects on blood flow are particularly significant in women between 32nd and 36th weeks. The effects of both drugs on fetal and maternal Doppler flows seem similar, except the increased resistance to flow in DV in women receiving MgSO4.

Modulation of endocrine and transport functions in human trophoblasts by saquinavir and nelfinavir

2010-06-07

Abstract: Objectives: The distribution of drugs to the maternal–fetal interface is influenced by the expression of various efflux transporters. Among these transporters, P-glycoprotein (P-gp) is responsible for the efflux of a great number of drugs such as protease inhibitors of the human immunodeficiency virus, thus reducing the chemical exposure of the fetus.Study design: The effects of saquinavir and nelfinavir were evaluated on human trophoblast functions and integrity by investigating their effect on human chorionic gonadotropin (hCG) secretion and on P-gp expression and functionality.Results: Nelfinavir significantly reduced hCG secretion by 30% after a 48-h treatment but it had no effect on syncytia formation. Saquinavir had no effect on hCG secretion but significantly increased both expression (to a 2-fold extent) and functionality (by 17.9%) of P-gp, whereas nelfinavir only increased functionality (by 23.1%) with a dissociation of P-gp from caveolin-1.Conclusion: These results suggest that the effects of saquinavir and nelfinavir differ on trophoblast functions.

Ultrasound-guided transvaginal aspiration as initial treatment for adnexal torsion following ovarian hyperstimulation

Eun Mi Chang, Ari Kim, Ji Won Kim, Tae Ki Yoon — 2010-05-31

Abstract: Objective: To evaluate the safety, feasibility, and pregnancy outcomes of adnexal detorsion using simple aspiration following ovarian hyperstimulation in pregnancy.Study design: Retrospective review of eight pregnant women who underwent ultrasound (US)-guided transvaginal aspiration to induce natural reduction of ovarian torsion following ovarian hyperstimulation.Results: Six of the eight patients were successfully treated with simple aspiration only, without any complications. Symptoms recurred in two patients, necessitating further laparoscopic detorsion. The outcome of the pregnancy was normal in seven women, with the eighth experiencing loss of one fetus from a twin pregnancy 2 days after laparoscopy. Normal ovarian blood flow was confirmed within one month after the treatment.Conclusion: US-guided transvaginal aspiration for adnexal detorsion in pregnant women following ovarian stimulation might serve as a simpler, less morbid and equally effective alternative to conventional treatment.

Endothelial nitric oxide synthase gene polymorphisms (−786T>C, 4a4b, 894G>T) and haplotypes in Korean patients with recurrent spontaneous abortion

2010-06-07

Abstract: Objective: To investigate the association of three common polymorphisms (−786T>C, 4a4b, 894G>T) of the endothelial nitric oxide synthase (eNOS) gene with idiopathic recurrent spontaneous abortion (RSA).Study design: In a prospective case–control study, 340 patients with unexplained recurrent spontaneous abortion and 115 controls with at least one live birth and no history of pregnancy loss were enrolled. Polymerase chain reaction and restriction fragment length polymorphism analysis were performed to identify the genotypes.Results: The recurrent spontaneous abortion patients exhibited a significantly higher frequency of the eNOS 894GT+TT genotype (Odds ratio (OR), 2.39; 95% confidence interval (CI), 1.25–4.58; p=0.008) compared to the control group; no significant differences in the −786T>C and 4a4b genotype frequencies were observed. The eNOS 894GT genotype (OR, 1.94; 95% CI, 1.00–3.75; p=0.056) was marginally different between recurrent spontaneous abortion and control groups. The frequency of the −786T-4b-894T haplotype (p=0.001) was significantly higher in the idiopathic RSA group than in the control group.Conclusion: The eNOS 894GT+TT genotype and the −786T-4b-894T haplotype are significantly associated with idiopathic recurrent spontaneous abortion in Korean women.

Laparoscopic ovarian tissue harvesting for cryopreservation: an effective and safe procedure for fertility preservation

2010-06-16

Abstract: Objective: To critically review our experience with the method of laparoscopic ovarian tissue harvesting for ovarian cryopreservation.Study design: In a retrospective cohort study 85 patients undergoing surgery for cryopreservation of ovarian tissue were included. One random ovarian cortical slice was histologically examined in order to determine the presence of primordial follicles and to detect possible malignant cells. Selective microbiological culture techniques from swabs were taken from all slices immediately after excision. Intra- and postoperative courses, histological and microbiological findings were evaluated.Results: Eighty-five patients underwent cryopreservation of ovarian tissue, mostly for malignant diseases (78/85, 91.8%). Sixty patients (70.6%) underwent laparoscopy for ovarian tissue harvesting only, without any additional surgical procedure. The median operating time was 30min (range 10–75min). The intraoperative course was uneventful in these patients. In two patients slight postoperative increases in C-reactive protein levels were found. Microbiological examination revealed no contamination apart from one case revealing sporadic Propionibacterium acnes. Histological examination revealed intact ovarian tissue with primordial follicles in 81/85 patients (95.3%).Conclusion: Laparoscopy is a safe and effective procedure for ovarian tissue harvesting. We suggest microbiological and histological testing of ovarian tissue as mandatory tools to guarantee safety regarding ovarian tissue transplantation.

Primary dysmenorrhea among Mexican university students: prevalence, impact and treatment

Mario I. Ortiz — 2010-05-10

Abstract: Objective: To evaluate the prevalence, impact and treatment of primary dysmenorrhea among Mexican university students.Study design: A multiple-choice questionnaire was administered to 1539 students in six university programs: medicine, nursing, nutrition, dentistry, pharmacy and psychology. Data on the presence, severity, symptoms, treatment and limitations caused by dysmenorrhea were obtained and analyzed.Results: The mean±SD age of the women was 20.4±2.0 years; the mean age of menarche was 12.3±1.5 years. A total of 64% of the women experienced dysmenorrhea. Dysmenorrhea was more prevalent among nutrition and psychology students than among medicine, pharmacy and dentistry students (p<0.05). Dysmenorrhea was mild in 36.1% of women, moderate in 43.8% and severe in 20.1%. Nursing students showed an intensity of pain that was significantly higher than that of medicine and dentistry students (p<0.05). Sixty-five percent of the women with dysmenorrhea reported that it limited their daily activities, and 42.1% reported school absenteeism (SA) as a result. Of those who experienced dysmenorrhea, 25.9% consulted a physician, and 61.7% practiced self-medication (SM). The most common medications used were an over-the-counter (OTC) medication with paracetamol (an analgesic), pamabrom (a diuretic), and pyrilamine (a histamine antagonist), another OTC with metamizol (a non-steroidal anti-inflammatory drug [NSAID]) plus butylhioscine (an antispasmodic drug) and naproxen (a NSAID). Of those women using prescribed medications, 18.4% reported complete remission of their symptoms, while 78.1% reported little to moderate alleviation, and 3.6% reported no effect on their menstrual distress. Similarly, of the women who practiced SM, 23.4% reported complete relief, 75.5% reported little to moderate effectiveness, and 1.0% reported no efficacy.Conclusion: The prevalence of dysmenorrhea among Mexican university students is high, and the pain that these women suffer can be severe, disabling and result in short-term SA. The pain is often not completely relieved despite the use of medication. It is necessary to improve the therapeutic options for relief of pain caused by dysmenorrhea and to minimize the impact of dysmenorrhea on social, economic and school activities.

Absence of activating somatic mutations of PI3KCA and AKT1 genes in South Indian women with endometriosis

Priyanka Rai, Mamata Deenadayal, Sisinthy Shivaji — 2010-05-11

Abstract: Objective: To investigate whether the PI3KCA and AKT1 gene influences the risk of developing endometriosis in South Indian women.Study design: Mutations in exon 9 and 20 of PI3KCA gene and E17K mutation in exon 4 of AKT1 gene were tested for association in a case–control study between eutopic and ectopic endometrium tissue from 30 endometriosis cases and eutopic endometrium tissue from 30 controls. The genotype frequencies of these mutations were compared using polymerase chain reaction and direct sequencing analysis of tissue DNA.Results: The analysis did not reveal any activating somatic mutations in either PI3KCA or AKT1 gene in the cases.Conclusion: In the present study we could not observe any mutation in PI3KCA and AKT1 gene, indicating that these mutations are rarely associated with endometriosis in South Indian women.

Caesarean section greatly increases risk of scar endometriosis

2010-05-18

Abstract: Objective: To estimate the incidence of scar endometriosis after different surgical procedures.Study design: A retrospective study of 72 patients diagnosed with scar endometriosis between 1978 and 2003 was performed. Patient age, site of endometriosis, previous operations, time-gap between last surgery and onset of symptoms, nodule characteristics, and recurrence were evaluated.Results: Age ranged from 16 to 48 years. Location varied according to the previous surgery: 46 caesarean section, one hysterectomy, one in abdominal surgery, 19 episiotomy, one was a relapse and two pelvic floor procedures, two women with no previous surgery. The incidence of scar endometriosis after caesarean section was significantly higher than after episiotomy (0.2 and 0.06%, respectively: p<0.00001) with a relative risk of 3.3. Pain was the most frequent symptom. The mean time between surgery and onset of symptoms was 3.7 years.Conclusion: Our findings confirm that scar endometriosis is a rare condition and indicate, probably for the first time, that caesarean section greatly increases the risk of developing scar endometriosis.

Efficacy and safety of aceclofenac and drotaverine fixed-dose combination in the treatment of primary dysmenorrhoea: a double-blind, double-dummy, randomized comparative study with aceclofenac

2010-06-02

Abstract: Objective: To evaluate the efficacy and safety of aceclofenac–drotaverine combination against aceclofenac alone in patients with primary dysmenorrhoea.Study design: This double-blind, double-dummy, randomized, comparative, multicentric study enrolled 200 women (100 women in each arm) in the age range of 18–35 years with primary dysmenorrhoea at four centers. The patients were randomly allocated to either aceclofenac 100mg–drotaverine 80mg b.i.d or aceclofenac 100mg alone b.i.d for a maximum of 3 days. Primary efficacy parameters were total area under pain relief (PR) score up to 4 and 8h (TOPAR/4 and TOPAR/8). Secondary efficacy measurements were pain-intensity difference (PID), sum of PID over 4 and 8h (SPID/4 and SPID/8), peak PID over 4 and 8h and peak PR over 4 and 8h, total study drug consumption, and patient's and investigator's global evaluation of the efficacy.Results: Both treatments showed significant improvement in baseline values in all efficacy parameters. The combination was significantly superior to monotherapy in terms of TOPAR/4 (24.0 vs 18.54) (p=0.000) and TOPAR/8 (40.3 vs 35.2) (p=0.003), SPID/4 (−17.9 vs −13.88) (p=0.000) and SPID/8 (−31.06 vs −26.8) (p=0.001), peak PID/4 (−6.60 vs −5.75) (p=0.001) and peak PR/4 (8.26 vs 7.10) (p=0.000). At the end of 8h, both treatments were comparable with respect to peak PID/8 and peak PR/8 (p>0.05). The total number of doses consumed by patients treated with combination therapy was less than with monotherapy (150 vs 168 doses). The combination was significantly superior to monotherapy with respect to patient's and investigator's global evaluation of the efficacy (p=0.002 and p=0.001, respectively). Both treatments were well tolerated.Conclusion: This study establishes the efficacy of aceclofenac–drotaverine combination in patients with primary dysmenorrhoea. The fixed-dose combination of aceclofenac and drotaverine should therefore be considered as a suitable, effective and well tolerated treatment option for primary dysmenorrhoea.

Evaluation of preoperative lymphoscintigraphy and sentinel node procedure in vulvar cancer

2010-06-07

Abstract: Objective: To assess the value of preoperative lymphoscintigraphy, and to evaluate the validity and feasibility of the sentinel node (SN) procedure in vulvar carcinoma.Study design: Retrospective clinical and histopathological review of 77 patients with invasive squamous cell carcinoma in vulva who were treated at Karolinska University Hospital Stockholm, Sweden, from 2000 to 2007. The patients underwent SN mapping preoperatively with radioactive tracer and blue dye (n=60) or only blue dye (n=17). The SN was removed separately followed by complete inguinofemoral lymphadenectomy.Results: The relation between SNs detected on the scintigram and those found during surgery showed good agreement using weighted kappa. The detection rate of SN was 98% for radioisotope plus blue dye, and 94% for blue dye alone. Two cases of false negative SN (false negative rate 2.7%) were found, both with large midline tumors.Conclusion: Preoperative scintigram is a valuable help to identify and localize the SNs and gives the best estimate of the accurate number but cannot determine if unilateral or bilateral groins should be explored in cases of midline tumors. Our results are in favor of using radioisotope and blue dye to identify the SNs. This study support previous reports that the method is not recommended for tumors larger than 40mm to optimize detection of SN and minimize the false negative detection rate.

The burden of uterine fibroids in five European countries

2010-06-07

Abstract: Objective: To quantify the burden of uterine fibroids (UF) on health-related quality of life (HRQOL) and work productivity in a general population of women.Study design: Women diagnosed with or experiencing UF-related symptoms living in five Western European countries (France, Germany, Italy, Spain, and the United Kingdom) were identified through a cross-sectional Internet-based survey. The following parameters and outcomes of interest were captured and analysed: patient history and demographics, treatment and diagnosis patterns, symptom severity and HRQOL, work productivity and activity impairment, and disease or symptom-related health care resource use for the past year (e.g., provider visits, hospitalisation).Results: This analysis included 1756 women (France, 358; Germany, 345; Italy, 351; Spain, 352; United Kingdom, 350). Prevalence of a diagnosis of UF ranged from 11.7% to 23.6%, and that of undiagnosed bleeding symptoms from 14.7% to 24.6% across the five countries. Between 9.0% and 32.5% of women waited ≥5 years before seeking treatment for UF. Mean UFS-QOL symptom severity scores ranged from 24.7 (95% confidence interval [CI], 21.1–28.3) to 37.6 (95% CI, 32.2–43.0; P<0.001), suggesting mild to moderate severity. Mean UFS-QOL scores ranged from 59.2 (95% CI, 54.2–64.2) to 69.7 (95% CI, 66.5–73.0; P=0.002), suggesting moderate impairment. In pooled analyses, absenteeism was reported by 32.7% of employed women with a diagnosis of UF. Overall worker productivity was reduced by 36.1% and general activity was impaired by 37.9%.Conclusions: UF are common in women residing in Western Europe. They are associated with impairment of HRQOL and productivity. A substantial number of women delay seeking medical help. Encouraging symptomatic women to seek help and treatment earlier may benefit women by improving their HRQOL and may also benefit society through enhanced worker productivity.

Nerve-preserving sacrocolpopexy: anatomical study and surgical approach

2010-06-02

Abstract: Objective: The aim of our study is to describe the course of the autonomic nerves in the presacral space and to find the best nerve-preserving approach for sacrocolpopexy.Study design: The autonomic nerves of the presacral space were dissected on six specially preserved female cadavers.Results: The superior hypogastric plexus is located in front of the abdominal aorta and its bifurcation and deviates to the left of the midsagittal plane. At the level of the promontory, or just below, the superior hypogastric plexus branches into two hypogastric nerves that run in front of the sacrum. In the presacral space the parasympathetic pelvic splanchnic nerves from the ventral rami of the sacral spinal nerves (S2–S3) join the hypogastric nerves, forming the inferior hypogastric plexus on both sides. From the inferior hypogastric plexus, nerve fibres spread out bilaterally to the pelvic organs. In two of the six cadavers sacral splanchnic nerves could be identified leading from the sacral sympathetic ganglion S1 of the sympathetic trunk to the inferior hypogastric plexus.Conclusion: Longitudinal incision of the peritoneum along the right common iliac artery and above the promontory allows for a safe approach for sacrocolpopexy. After exposing the vascular structure (e.g. medial sacral vessels) above the promontory, the anterior longitudinal ligament becomes visible and can be prepared for the fixation of the mesh for vaginal suspension. By protecting the superior hypogastric plexus and the part of the presacral area below the promontory we can preserve the hypogastric nerves, the sacral and pelvic splanchnic nerves and thus the autonomic innervation of the pelvic organs. Awareness of the course of the autonomic nerves in the presacral space will significantly improve the functional outcome of sacrocolpopexy and reduce bowel, urinary and sexual dysfunctions.

Clinical outcome of transvaginal sacrospinous fixation with the Veronikis ligature carrier in genital prolapse

2010-06-07

Abstract: Objective: To evaluate the clinical outcome of sacrospinous fixation (SSF) using the Veronikis ligature carrier (VLC) for genital prolapse.Study design: A retrospective longitudinal study was performed. From December 2003 through June 2008, SSF was performed in 76 patients using the VLC as part of their site-specific reconstructive pelvic surgery. All patients were followed up postoperatively at 6 weeks, 3 months, 6 months, 12 months, and annually thereafter.Results: The median operative time of SSF was 34min. It took less than 5min to introduce two sutures through the ligament using the VLC. Four patients (5.3%) had recurrent vaginal vault descent at 3–8 months, and received SSF again. Three patients had recurrent stage 1 cystocele at 6–12 months, but did not require further surgery.Conclusion: The VLC allowed effective introduction of the suspending suture through the sacrospinous ligament and might be considered an important surgical component in the treatment of severe genital prolapse.

Bilateral primary breast lymphoma masquerading as lactating mastitis

2010-06-07

We recently experienced a case of bilateral lymphoma masquerading as bilateral mastitis in a 30-year-old lactating female, 1 month postpartum. The patient initially presented at a regional hospital with bilateral breast edema, which developed during the first 2 weeks postpartum. Physical examination revealed a tender, firm, solid mass in each breast; the right breast was larger and had peau d’orange appearance and minor pyorrhea (a). Following a month of intravenous antibiotic therapy without clinical improvement, the patient was referred to our hospital for further diagnostic workup. Evaluation with ultrasonography and magnetic resonance tomography suggested bilateral mastitis. A mammogram was omitted, because a localized breast cancer was not included in the differential diagnosis. Due to the unusual presentation and the lack of response to antibiotics, fine-needle aspiration cytology (FNAC) was also obtained, which was however not diagnostic. Subsequent core biopsy of the right breast revealed infiltration of the mammary tissue and skin by lymphocytes in a dense and diffuse manner; immunohistochemical staining exerted CD-20 and CD-79a positivity, as well as CD-23 and CD-5 negativity. The staging procedure did not reveal an extramammary primary site, and the condition was classified as Ann Arbor stage IVE diffuse large B-cell lymphoma with an International Prognostic Index (IPI) score of 2. The patient received eight R-CHOP chemotherapy cycles achieving undetected complete remission (b), and therefore 2-year rituximab-based maintenance immunotherapy was initiated.

Radical trachelectomy in late pregnancy: is it an option?

2010-06-07

A patient of 25 years of age at 22 weeks’ gestation with heavy vaginal bleeding was referred to the gynecologic oncology clinic. Pelvic examination revealed a bloody exophytic cervix, which was biopsied. Magnetic resonance imaging demonstrated no suspicious lesion in the vagina, uterus or parametrium or any evidence of pelvic or distant lymphadenopathy or hydronephrosis.

Management of non-gestational ovarian choriocarcinoma: laparoscopy can be essential. Report of two cases

A.S. Gremeau, N. Bourdel, W. Kondo, K. Jardon, M. Canis — 2010-06-07

We describe two cases of non-gestational choriocarcinoma mimicking ectopic pregnancy with laparoscopic management. A 26-year-old woman (gravida 2, para 1) presented with pelvic pain and metrorrhagia. Transvaginal ultrasound demonstrated an empty uterus and a homogeneous left adnexal mass. The β-HCG level was 1183IU/l. The diagnosis of an ovarian ectopic pregnancy was considered and she underwent laparoscopy with intraoperative findings of no ectopic pregnancy and the presence of a left ovarian cyst (A and B). An intraperitoneal cystectomy was performed in accordance with oncology rules to eliminate a germinal tumor. On postoperative day one, β-HCG levels fell to 493IU/l and other tumor markers were normal. Pathological examination showed a malignant germ cell tumor, so she underwent second-look surgery for peritoneal biopsies and left oophorectomy. The final diagnosis was a stage Ia mixed malignant germ cell ovarian tumor with choriocarcinoma and dysgerminoma (FIGO). She had chemotherapy with bleomycin, etoposide and cisplatin (BEP) and one year later she had presented no sign of recurrence.

More rigour needed when evaluating effects of female narghile tobacco smoking on in vitro fertilisation outcome

Kamal Chaouachi — 2010-04-30

In their recent study on the effects of female narghile smoking on in vitro fertilisation outcome, Dr Hannoun et al. (called “the authors” furtherdown) state that in an Egyptian study “men who are regular nargile smokers were at 2.5 times increased risk of male infertility as opposed to non-smokers” . However, they do not report the full picture of the corresponding study (non-specific of water pipes in that country) which contains a counterintuitive result. Indeed, the odds ratio (O.R.) for cigarette smoking does not vary (0.5, CI: 0.2–1.3) after adjustment for “water pipe smoking, tea drinking, marital duration, husband's age, husband's education” whereas the O.R. for water pipe smoking (type not specified), when adjusted for the same confounding factors (“cigarette smoking” obviously instead of “water pipe smoking”), shows the following variation: 1.8 (CI: 0.8–4.1) to 2.5 (CI: 1.0–6.3) .

Authors’ reponse: nargile smoking and its effect on in vitro fertilization: a critical eye on the available literature

Anwar H. Nassar, Antoine Abu-Musa, Antoine Hannoun, Ihab M. Usta — 2010-07-12

We are writing in reply to the comments raised by Dr. Chaouachi on our recently published paper . Although the results of the article by Inhorn and Buss showed a significant change in the effect of nargile smoking on male infertility after adjusting for confounding variables, including cigarette smoking (whereas this was not the case in cigarette smoking), the effect is statistically plausible and does not preclude citing this reference.