European Journal of Obstetrics & Gynecology and Reproductive Biology - Articles in Press

The efficacy and tolerability of short-term low-dose estrogen-only add-back therapy during post-operative GnRH agonist treatment for endometriosis - Uncorrected Proof

2010-08-27

Abstract: Objective: To evaluate the efficacy and tolerability of a low-dose estrogen-only regimen as a short-term add-back therapy during post-operative GnRH agonist (GnRHa) treatment of patients with endometriosis.Study design: Retrospective cohort study. One hundred seventeen women of reproductive age who were treated with post-operative GnRHa after conservative laparoscopic surgery for endometrioma were eligible for this study. The patients were divided into two groups: group A (n=56) received tibolone (2.5mg) between 2002 and 2004 and group B (n=61) received estradiol valerate (1mg) between 2005 and 2007 as an add-back therapy for five months, beginning at the time of the second injection of a GnRHa. The incidence of hypoestrogenic symptoms and the degree of pelvic pain according to a verbal rating scale (VRS) scoring system, the incidence and patterns of uterine bleeding during add-back therapy, the endometrial thickness by ultrasonography two months after the last GnRHa treatment, and the serum CA-125 level were evaluated.Results: The incidence of uterine bleeding, hypoestrogenic symptoms such as hot flashes and sweating, and pelvic pain did not differ significantly between the two treatment groups. However, the endometrium was thicker in group A than group B (p=0.022). In group B, the frequency of uterine bleeding was lower from the second month after starting add-back therapy than in group A, but without statistical significance (at the sixth month, p=0.086).Conclusion: The low-dose estrogen-only regimen was efficacious and tolerable as a short-term add-back therapy during post-operative GnRHa treatment after surgery for endometriosis.

Embryology and anatomy of the vulva: the female orgasm and women's sexual health - Uncorrected Proof

Vincenzo Puppo — 2010-08-27

Abstract: Sexual health is vital to overall well-being. Orgasm is a normal psycho-physiological function of human beings and every woman has the right to feel sexual pleasure. The anatomy of the vulva and of the female erectile organs (trigger of orgasm) is described in human anatomy textbooks. Female sexual physiology was first described in Dickinson's textbook in 1949 and subsequently by Masters and Johnson in 1966. During women's sexual response, changes occur in the congestive structures that are essential to the understanding of women's sexual response and specifically of their orgasm. Female and male external genital organs arise from the same embryologic structures, i.e. phallus, urogenital folds, urogenital sinus and labioscrotal swellings. The vulva is formed by the labia majora and vestibule, with its erectile apparatus: clitoris (glans, body, crura), labia minora, vestibular bulbs and corpus spongiosum. Grafenberg, in 1950, discovered no “G-spot” and did not report an orgasm of the intraurethral glands. The hypothetical area named “G-spot” should not be defined with Grafenberg's name. The female orgasm should be a normal phase of the sexual response cycle, which is possible to achieve by all healthy women with effective sexual stimulation. Knowledge of the embryology, anatomy and physiology of the female erectile organs are important in the field of women's sexual health.

ABH secretor genetic polymorphism: evidence of intrauterine selection - Uncorrected Proof

2010-08-23

Abstract: Objective: Fucosyltransferase locus 2 (FUT2) controls the presence or absence of blood group substances (A, B, H) in the saliva and other body secretions. Secretor/non-secretor phenotypes are associated with some metabolic and infectious diseases. ABO and FUT2 contribute to build up oligosaccharide structures of the cell surface that are important for blastocyst adhesion and resistance to microbial invasion. We investigated a possible selection on ABH secretor phenotypes during intrauterine life.Study design: Three hundred and fifty-six consecutive healthy puerperae and their newborn infants from the caucasian population of Rome were studied. Informed consent for study participation was obtained from the mothers to participate and the study was approved by the Institutional Review Board. ABH secretor Se phenotype was determined on saliva by standard laboratory procedure.Results: Symmetry analysis of mother infant Se phenotype revealed a deficit of mother Se+/newborn Se− with respect to expected values. The asymmetry is present only in infants carrying the A blood group antigen. The asymmetry was dependent on several maternal and neonatal parameters including maternal age, smoke, parity and gestational duration.Conclusions: The data suggest intrauterine selection against Se− of the embryo carried by a Se+ mother. Such selection is dependent on factors influencing the maternal environment. The study could have practical importance in assessing the risk of infertility and success of artificial insemination.

Younger maternal age (at initiation of childbearing) and recurrent perinatal mortality - Uncorrected Proof

Hamisu M. Salihu, Jingyi Duan, Sarah K. Nabukera, Alfred K. Mbah, Amina P. Alio — 2010-08-23

Abstract: Objective: To assess whether young maternal age at initiation of childbearing is associated with recurrence of perinatal mortality (PM), as well as its components: stillbirth and neonatal death.Study design: We conducted a population-based, retrospective cohort study on the Missouri maternally linked longitudinal data files comprising adolescent (10–19 years; n=73,533) or mature (20–24 years; n=78,618) mothers in their first pregnancy with follow-up in their second pregnancy to document the occurrence of PM or its components. The study covered the period 1989–2005. We used unconditional logistic regression modeling to generate odds ratios and to control for confounding.Results: A history of perinatal mortality, stillbirth, or neonatal mortality increased the risk of a recurrence by 4–5 times. Among women with a history of PM or stillbirth in the first pregnancy, maternal age at initiation of pregnancy was not a risk factor for subsequent PM or its components. However, adolescent mothers with a history of neonatal mortality in the first pregnancy were about 5 times as likely to experience stillbirth in the second pregnancy, as compared to their mature counterparts.Conclusions: Young maternal age at the initiation of childbearing is not associated with an overall increased risk of recurrent perinatal loss. However, prior history of neonatal mortality among teen mothers is strongly predictive of subsequent stillbirth.

A novel androgen receptor gene mutation in a Chinese patient with complete androgen insensitivity syndrome - Uncorrected Proof

Sun Shunchang, Luo Fuwei, Zhou Zhiming, Wu Weiqing — 2010-08-23

Abstract: Objective: To identify the underlying androgen receptor gene mutation in a Chinese patient with typical symptoms of complete androgen insensitivity syndrome.Study design: A Chinese female phenotype with 46, XY karyotype was diagnosed because of primary amenorrhea. Mutations were determined by polymerase chain reaction followed by DNA sequencing.Results: DNA sequencing of the androgen receptor gene showed a G2439T transition causing E442X mutation in exon 1 in the patient with complete androgen insensitivity syndrome. The E442X mutation was a new de novo non-sense mutation in exon 1 of the androgen receptor gene. This non-sense mutation is located in the N-terminal transactivation domain and leads to a predicted truncated protein of 441 amino acids with loss of the end part of the N-terminal transactivation domain, and the DNA-binding and ligand-binding domain.Conclusion: This E442X non-sense point mutation has not been described previously in cases of androgen insensitivity syndrome, and could lead to the synthesis of a short truncated non-functional androgen receptor probably responsible for the phenotype of complete androgen insensitivity syndrome in the affected individual. Gonadectomy should be planned to eliminate the risk of gonadal malignancy.

Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery - Uncorrected Proof

Jason Bell, Susan Bell, Anjel Vahratian, Awoniyi O. Awonuga — 2010-08-20

Abstract: Objective: To test the hypothesis that there is no difference in perioperative morbidity and the type of uterine incisions between vertical skin incisions (VSI) and low transverse skin incisions (LTSI) at the time of cesarean delivery in morbidly obese women.Study design: Retrospective cohort study of morbidly obese women (BMI>35) who underwent cesarean delivery between June 2004 and December 2006.Results: During the study, 424 morbidly obese women underwent cesarean section. Patients with VSI were older (31.0±6.2 years vs. 26.7±5.8 years), heavier (48.2±9.1kg/m2 vs. 41.7±6.7kg/m2), and more likely to have a classical than a low transverse uterine incision (65.9% vs. 7.3%), p<0.001. After controlling for confounders, women with VSI did not have an increase in perioperative morbidity, but underwent more vertical uterine incisions (adjusted odds ratio=18.49, 95% CI: 6.44, 53.07).Conclusion: VSI and LTSI are safe in morbidly obese patients undergoing cesarean section, but there is a tendency for increased vertical uterine incisions in those who underwent VSI.

Fetal myocardial morphological and functional changes associated with well-controlled gestational diabetes - Corrected Proof

2010-08-19

Abstract: Objective: To make a global evaluation of the fetal myocardial changes in a well-controlled gestational diabetic population.Study design: Twenty-four pregnant well-controlled diabetic patients were selected. Sixteen normal pregnancies were randomly collected as a control group. Measurements of morphological and functional myocardial parameters were performed. Data from the left ventricular outflow tract and peripheral Doppler data were obtained.Result: The thickness of the interventricular septum was increased in diabetic pregnancies (p<0.001). Tricuspid E/A index was the only functional parameter showing a significant variation, with lower values in diabetic pregnancies. Doppler parameters from the left ventricular outflow tract and peripheral Doppler waveforms were similar between groups.Conclusion: A tendency towards interventricular septum hypertrophy was observed even in well-controlled diabetic pregnancies. Mild hypertrophic cardiac changes were not associated with abnormal cardiac function or signs of left ventricular outflow obstruction, although minor changes in right ventricular diastolic function were recorded.

Concomitant surgical correction of occult stress urinary incontinence by TOT in patients with pelvic organ prolapse - Corrected Proof

Ates Karateke, Niyazi Tug, Cetin Cam, Mehmet Resit Asoglu, Selcuk Selcuk — 2010-08-19

Abstract: Objectives: To assess the post-operative urinary incontinence states of pelvic organ prolapse cases operated on with concomitant trans-obturator tape (TOT) procedure.Study design: Urodynamic evaluation of 79 patients with pelvic organ prolapse, before and after operation, while reducing the prolapsed organs by ring forceps placed bilaterally on the anterolateral sulcuses avoiding urethral compression. According to urodynamic tests, 25 patients were diagnosed as having occult stress urinary incontinence.Results: Post-operative overactive bladder, stress urinary incontinence and mixed incontinence were found in three (12%), two (8%) and one (4%) patients of the occult stress urinary incontinence group, respectively. The corresponding numbers were six (11%), five (9%) and three (6%) in the continent group. No significant difference was found between the groups in terms of post-operative overactive bladder symptoms, stress urinary incontinence and mixed incontinence (Kruskal–Wallis test, X2=0.52, p=0.820).Conclusions: This retrospective study suggests that a complete pre-operative urodynamic evaluation, including urodynamic tests at the time of POP reduction by placing ring forceps on the anterolateral sulcuses, is an efficient method for the diagnosis of occult symptomatic stress urinary incontinence (SUI). Prospective randomized studies are needed to establish the benefits and the risks of concomitant prophylactic surgery in patients with pelvic organ prolapse.

Correlation of thrombomodulin expression and occlusion of the uterine artery for the treatment of leiomyoma - Uncorrected Proof

Jun Gong, Yan Xie, Fangfang Dou, Le Kang, Zhongping Cheng — 2010-08-19

Abstract: Objectives: To determine the difference in thrombomodulin expression in the myometrium and in myoma; and to understand the correlation of anticoagulation/fibrinolytic function and the mechanism of uterine artery occlusion in the treatment of leiomyoma.Study design: Immunohistochemistry, western blotting and fluorescence quantitative polymerase chain reaction were used to investigate thrombomodulin protein expression and gene transcription in 15 female patients.Results: Thrombomodulin was mainly expressed in endotheliocytes in the two types of tissues. According to western blotting data, the relative expression of protein of the myometrium was 1.49 times higher than that of the myoma. This difference was significant (P<0.01). The relative transcription of thrombomodulin mRNA was 1.28 times higher in myometrial tissue than in myomal tissue (P<0.05).Conclusions: Anticoagulation/fibrinolytic functions may be higher in the myometrium than in fibroids. This may be an important explanation for the mechanism of uterine artery occlusion.

Non-syndromic malformations of the central nervous system in twin pregnancies: diagnostic and other clinical features of importance - Uncorrected Proof

2010-08-18

Abstract: Objective: The incidence of central nervous system malformations is higher among twins. Our aim was to summarize information about these malformations in twin pregnancies.Study design: Based on a sample originating from the biggest genetic centre in Hungary between January 1990 and December 2008, we examined the data of 42 twin pregnancies associated with non-syndromic malformations of the central nervous system.Results: The involvement of monozygotic fetuses and dizygotic ones of the same gender was found to be 62.5%. Usually only one of the fetuses was affected (57.1%), while the other one was healthy. The male-to-female ratio was 0.75. Identical and fraternal twins were found in 68.4% and 31.6% of the cases, respectively. In the pregnancies of our study the malformation was diagnosed before the 24th gestational week in 90% of the cases. Polyhydramnios (54.8%) was the most commonly associated non-central nervous system malformation.Conclusion: Our findings suggest that, in addition to placentation and gestational age, the position of the affected fetus with relation to the uterine orifice is of great importance in determining whether selective abortion is an option in deciding about the outcome of pregnancies affected by craniospinal malformation.

Levator defects are associated with prolapse after pelvic floor surgery - Uncorrected Proof

Angela N. Model, Ka L. Shek, Hans P. Dietz — 2010-08-18

Abstract: Objectives: Pelvic organ prolapse recurrence after pelvic floor surgery is a common problem. This study was designed to assess whether avulsion defects of the puborectalis muscle are associated with recurrent pelvic organ prolapse and its symptoms.Study design: We retrospectively evaluated 737 data sets of patients who had presented to a tertiary urogynaecology unit with symptoms of pelvic floor dysfunction. All underwent a standardised interview including a surgical history, a clinical examination and 4D pelvic floor ultrasound. Avulsion injury was diagnosed on tomographic ultrasound. The prevalence of pelvic organ prolapse and its symptoms was calculated for patients with previous hysterectomy and previous anti-incontinence and prolapse surgery, with and without confirmed avulsion injury.Results: Out of 737 patients, 248 (33.6%) reported a previous hysterectomy, 165 patients (22.4%) had undergone incontinence or prolapse procedures, 106 (14.4%) reported a previous anterior colporrhaphy, and 45 patients (6.1%) had undergone a colposuspension in the past. In all four groups avulsion injury was significantly associated with objective prolapse (relative risks between 2.3 and 3.3, odds ratios between 3.4 and 6). Symptoms of prolapse were significantly associated with avulsion injury post hysterectomy, incontinence or prolapse procedures and after anterior colporrhaphy.Conclusions: Avulsion injury of the puborectalis muscle is associated with prolapse in women with previous pelvic floor surgery.

Deep rectal and parametrial infiltrating endometriosis with monolateral pudendal nerve involvement: case report and laparoscopic nerve-sparing approach - Corrected Proof

2010-08-13

We report a case of a 32-year-old woman, referred to our unit for pelvic pain syndrome with severe constipation, dyschezia, dysmenorrhea and ano-genital pain refractory to hormonal and opioid therapy. The patient reported catamenial irradiation of pelvic pain to the right ano-genital region and to her right leg, with impaired motility and sensitivity during pain peaks. Pain was evaluated using a visual analogue scale (VAS) , which showed unbearable dyschezia (VAS score=10), severe dysmenorrhea (VAS score=8) and right pudendal neuralgia (VAS score=9).

Patients’ attitude towards residents’ participation during gynaecological surgery - Corrected Proof

Marco A.C. Versluis, Paul J.Q. van der Linden — 2010-08-13

Abstract: Objective: To evaluate patients’ attitude towards participation of residents in training in gynaecological surgery and patients understanding of resident position.Study design: An observational survey study was performed between July and February 2007–2008 in an outpatient clinic of a department of obstetrics and gynaecology of a teaching hospital. Patients planned for gynaecological surgery were concerned eligible. 247 questionnaires were handed out of which 204 were returned (response rate 82.6%). Primary outcome measure was level of confidence in a resident performing hysterectomy in various operative settings. Secondary, patients’ understanding of the medical education system was tested.Results: There was no difference between confidence in a specialist performing a hysterectomy compared to an experienced resident considered competent and under supervision of a specialist. Respondents have significantly less confidence in less experienced residents operating under supervision and in all residents operating without supervision (P<0.001). From the respondents, 85.6% believes a resident in training has received less education than a resident not in training. 38.6% believes a resident received less training than a medical student. Statistical analysis was done in SPSS 16.0 (SSPS Inc., Chicago, IL, USA) using a Wilcoxon signed-rank test.Conclusions: Respondents have confidence in a resident in training performing an operation under supervision when it concerns an experienced resident that is considered competent. A majority of respondents does not understand the position of a resident in training. Patient education on resident participation should be improved and the certainty that an operating resident is competent should be emphasized.

Persisting pregnancy of unknown location—Keep your eyes peeled for choriocarcinoma - Corrected Proof

Jens Einenkel, Romy Handzel, Lars-Christian Horn — 2010-08-13

A persisting pregnancy of unknown location (PPUL) is a very rare diagnosis defined as a plateauing in serum hCG levels without evidence of trophoblastic tissue on transvaginal sonography, uterine curettage or diagnostic laparoscopy. The serum hCG level tends to be low and the threshold was determined between 500 and 2000IU/L . A detailed management to exclude additional differential diagnoses and for treatment has not yet been published. In most studies evaluating early pregnancy disorders PPULs have been excluded from analysis or incorporated into the ectopic pregnancy group . Further characterization of these patients could not be found. We report on a young woman who was initially treated for PPUL but whose clinical course showed a grievous outcome.

Surgical repair of blunt force penetrating anogenital trauma in an 18-month-old sexually abused girl: a case report - Uncorrected Proof

Roland Csorba, Rudolf Lampé, Robert Póka — 2010-08-13

We describe an 18-month-old female who was sexually abused by her father and required surgical repair of her perineum and vagina. Postoperatively she was followed up for 18 months. Her genital/perineal injuries healed completely with minimal residual signs of trauma. This case report is unusual because it reflects serious genital and perineal injuries requiring surgical repair. Published case series of children who require surgical repair following sexual assault are limited .

Does levator avulsion increase urethral mobility? - Corrected Proof

Ka Lai Shek, Athina Pirpiris, Hans Peter Dietz — 2010-08-13

Abstract: Objective: It is often assumed that stress urinary incontinence may be due to abnormal pelvic floor muscle function or anatomy. This may be mediated through urethral hypermobility. The aim of the study was to determine the association between major levator ani defects (‘avulsion’) and urethral mobility.Study design: Three hundred and five women were referred to a tertiary referral service for lower urinary tract and prolapse symptoms between December 2006 and July 2008. All patients had undergone an interview, clinical examination, multichannel urodynamic testing and 4D transperineal ultrasound. Ultrasound volume datasets of 198 women were analysed retrospectively. Tomographic ultrasound imaging was used to diagnose levator avulsion at the time of the original assessment. To determine urethral mobility, data analysis was performed on a desktop PC using proprietary software several months later. The urethra was divided into 5 equal segments with 6 points marked evenly along the urethra from the bladder neck (Point 1) to the external meatus (Point 6) as identified in the mid-sagittal view. Measurements of vertical and horizontal distances from the dorsocaudal margin of the pubic symphysis of these 6 points were taken in the mid-sagittal plane, using volume datatsets obtained at rest and on maximal Valsalva. Mobility vectors of these 6 points were calculated using the formula SQRT ((xvalsalva−xrest)2+(yvalsalva−yrest)2) and were correlated with levator status using two sample T tests.Results: Levator avulsion was found in 18% of patients (n=35). Except at the bladder neck which almost reached significance (32.5mm in those with defects vs. 28.9mm in those without, P=0.07), there was no significant association between urethral mobility and avulsion (all P≥0.17).Conclusion: Major levator trauma does not seem to substantially affect urethral mobility, with the possible exception of the bladder neck.

Cyclic sciatica associated with contralateral endometrioma: a case report and discussion - Corrected Proof

Shih-Chieh Yu, Wan-Yu Huang, Den-Chin Lin, Tzu-Sheng Chen, Hung-Ming Wu — 2010-08-13

We report a 31-year old woman with cyclic sciatica topographically associated with a contralateral hemorrhagic cyst of ovarian endometriosis. This false localization sign may be proposed as a new mechanism of cyclic sciatica caused by endometriosis.

Clinical significance of pmTOR expression in endometrioid endometrial carcinoma - Corrected Proof

2010-08-13

Abstract: Objective: Endometrial adenocarcinoma has been proposed, due to frequent activation of the PI3K/AKT pathway, as a candidate neoplasm for treatment with mTOR inhibitors. However, data on the expression of mTOR in endometrial cancer are lacking.Study design: We used immunohistochemistry to evaluate the expression of pmTOR in 62 endometrial cancer surgical specimens.Results: The pmTOR protein was diffusely expressed in the cytoplasm of neoplastic epithelial cells, showing variable intensity. According to the chosen cutoff value, 34 (54.8%) out of 62 patients were scored as pmTOR-positive. pmTOR expression was significantly decreased in carcinomas with deep infiltration into the myometrium (P=.009), though it was not correlated with disease stage or lymph node metastasis. Univariate analysis showed that increased expression of pmTOR was significantly associated with better disease-free survival (P=.021).Conclusions: We show for the first time an association between pmTOR and better survival in patients with endometrial cancer. Future studies to stratify endometrial tumors by pmTOR status are needed.

Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage - Corrected Proof

2010-08-13

Abstract: Objectives: The aims of this study are to determine the incidence and aetiology of major obstetric haemorrhage (MOH) in our population, to examine the success rates of medical and surgical interventions and to identify risk factors for peripartum hysterectomy and end organ dysfunction (EOD).Study design: This prospective study from 2004 to 2007 was carried out in three Dublin maternity hospitals. Women were identified as having MOH if they received ≥5units of red cell concentrate (RCC) acutely. Risk factors for hysterectomy or end organ dysfunction were calculated using logistic regression.Results: One hundred and seventeen cases of MOH in 93,291 deliveries were identified (1.25/1000). The predominant cause was uterine atony. Haemostasis was achieved with medical therapy alone in 15% of cases. The hydrostatic balloon and the B-Lynch suture arrested bleeding in 75% and 40% of cases utilised respectively. Hysterectomy was required to arrest bleeding in 24% of women and 16% of women developed end organ dysfunction (11 had both). There was one maternal death. Independent risk factors for hysterectomy included the number of previous caesarean sections (OR 3.28, 95% CI 1.95–5.5), placenta praevia (OR 13.5, 95% CI 7.7–184), placenta accreta (OR 37.7, 95% CI 7.7–184), uterine rupture (OR 7.25, 95% CI 1.25–42) and the number of units of RCC transfused (OR 1.31, 95% CI 1.13–1.5). Independent risk factors for end organ dysfunction (EOD) were placenta accreta (OR 5, 95% CI 1.5–16.5), uterine rupture (OR 13.86, 95% CI 2.32–82), the number of RCC transfused (OR 1.31, 95% CI 1.13–1.5) and the minimum haematocrit recorded (OR 5.53, 95% CI 1.7–18).Conclusions: MOH is complicated by hysterectomy in 24% and end organ dysfunction in 16% of cases. The risk of peripartum hysterectomy is increased with the number of previous caesarean sections, the aetiology of the bleed, namely placenta praevia/accreta or uterine rupture and the volume of blood transfused. Critically, failure to maintain optimal haematocrit during the acute event was associated with end organ dysfunction.

Acceptability of the levonorgestrel intrauterine system in the long-term treatment of heavy menstrual bleeding: how many women choose to use a second device? - Corrected Proof

2010-08-13

Abstract: Objective: To assess the acceptability of the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) in the long-term treatment of heavy menstrual bleeding.Study design: Retrospective study of all consecutive women who had a LNG-IUS inserted for control of idiopathic heavy menstrual bleeding between January 2000 and December 2003. Duration of use, reasons for early removal, number of devices removed after 5 years of use, and number of women who decided to use a second LNG-IUS were assessed.Results: Of a total of 216 devices inserted, 129 (59.7%) were removed after 5 years of use, 68 (31.5%) were removed anytime before the completion of 5 years, and the remaining 19 (8.8%) patients were lost to follow-up. In 32 of the 68 cases (47.1%) with early removal of the LNG-IUS, the main reason for discontinuation was the appearance of the menopause. After the 5-year effective lifetime of the LNG-IUS, 51 of the 129 women (39.5%) chose to have a second device inserted. Of the 78 women who completed the 5-year treatment period and did not decide to use the LNG-IUS again, 71 (91%) had reached the menopause.Conclusion: The LNG-IUS was well accepted by women with idiopathic heavy menstrual bleeding as shown by 39.5% of users (or 87.9% if menopausal women are excluded) deciding to use a second device when the first LNG-IUS expired after 5 years of use.

Benign metastasizing leiomyoma of external iliac vessels: an unusual case report - Corrected Proof

Gennaro Scutiero, Luigi Nappi, Alessandra Spada, Pantaleo Bufo, Pantaleo Greco — 2010-08-13

Uterine smooth-muscle tumours with unusual growth patterns are rare and include a variety of neoplastic lesions histologically characterized by their similarity to adult smooth-muscle tissue. They include three primary neoplasms: intravenous leiomyomatosis, benign metastasizing leiomyoma (BML), and leiomyomatosis peritonealis disseminata. BML of the uterus is a rare but well recognized entity, which has been described primarily in women of reproductive age . We illustrate a case of retroperitoneal leiomyoma encasing the right iliac vessels.

Laparoscopic evaluation of pelvic pain with Surgicel vaginoplasty in a woman with Mayer Rokitansky Kuster Hauser syndrome - Corrected Proof

Deepika Deka, Nupur Gupta, Vatsla Dadhwal, Suneeta Mittal — 2010-08-13

Mullerian agenesis, or Mayer Rokitansky Kuster Hauser syndrome (MRKH), affects 1 in 4000–10,000 women and is the second most common cause of primary amenorrhoea . We report a case of abdominopelvic pain and its evaluation by laparoscopy in a young woman with MRKH.

When nausea becomes a tricky question - Corrected Proof

2010-08-13

In November 2008 we saw a 40-year-old primiparous woman, 27 weeks pregnant, in our emergency department, because of weakness and weight loss of 20kg. She had had progressive nausea, vomiting and epigastric pain, with polyuria and polydipsia, since early pregnancy. Following several earlier medical consultations for these complaints she was treated for anemia. One day before admission the patient perceived reduced fetal movements. At presentation she was lethargic with low skin turgor. The fundus height corresponded to 27 weeks of pregnancy. Laboratory studies showed severe hypercalcemia (calcium 4.05mmol/l and albumin 27g/l) and increased parathyroid hormone-related protein (PTH-rp) concentration (PTH-rp 5.9 pmol/l, reference values 0–0.6pmol/l).

Serous and mucinous borderline ovarian tumors: are there real differences between these two entities? - Corrected Proof

2010-08-11

Abstract: Objective: To evaluate the clinical outcome and pathological features of patients with borderline ovarian tumors (BOT) with special emphasis on serous and mucinous histology.Study design: Medical and anatomopathological records were reviewed in the Gynecological Oncology Department of the Canarian University Hospital between 1990 and 2005. Survival rates were analyzed by using the Kaplan–Meier technique.Results: The study included 163 patients. Serous tumors corresponded to 68 cases and mucinous tumors to 91 cases. Eighty-nine percent of patients were at FIGO stage I, 1.2% at stage II and 9.8% at stage III. Serous histology was significantly related to the presence of peritoneal implants (22.4% vs 3.6%; p=0.001), positive peritoneal cytology (35.7% vs 8.5%; p=0.001) and bilaterality (27.9% vs 1.1%, p<0.0001). Event-free survival (EFS) rates at 2, 5 and 10 years were 96.7%, 92.7% and 90.5%, respectively, with a mean survival time of 183 months (CI 95% 172–193). Thirteen recurrence cases were found (7.9%) with a mean time to recurrence of 39.6 months (range 4–140). Overall survival (OS) rates at 2, 5 and 10 years were 100%, 96.4% and 93.6%, respectively, with a mean time of 189 months (CI 95% 179–198). Mucinous BOT were associated with significantly lower OS rates than serous BOT (10 years OS: 88.5% vs 98.2%; p=0.01).Conclusions: Serous tumors present more unfavorable anatomopathological characteristics but are associated with better prognosis than mucinous tumors. If mucinous BOT diagnosis is retained physicians should be aware that their aggressive potential is not negligible.

Press coverage of hormone replacement therapy and menopause - Corrected Proof

2010-08-02

Abstract: Objective: To evaluate the information reported by Italian press articles about hormone replacement therapy (HRT) and menopause, in terms of completeness, clarity of language and transparency.Study design: In the framework of the Consensus Conference Informing women about hormone replacement therapy, 225 articles published from 2000 to 2007 in Italian lay press were evaluated. Health magazines, weekly news magazines, newspapers, women's magazines and medical practitioners’ journals were selected. A form covering graphic layout, completeness of information, clarity of language and transparency was applied to each article by a reviewer. The form was tested in a pilot phase.Results: HRT was recommended to treat menopausal symptoms in more than half of articles (56%) and was described as a preventive measure in almost half (48%). Risks related to HRT were under-reported (58% of the articles). Information on conflicts of interest was lacking (88%). Opinions of experts were the main source of information cited in the articles (66%).Conclusions: The information reported by the articles is lacking in several aspects. Many women are likely to receive unbalanced information from the press. Qualified sources of information delivered on the scientific knowledge available are needed, reporting advantages and disadvantages of HRT, pharmacological and non-pharmacological alternative treatments and their effectiveness. Scientific journalism needs to grow through training. The role of researchers and clinicians is discussed.

Oligomenorrhoea in adolescents with type 1 diabetes mellitus: relationship to glycaemic control - Corrected Proof

2010-08-02

Abstract: Objective: To investigate oligomenorrhoea in adolescents with type 1 diabetes and the possible relationship with glycaemic control.Study design: The study group consisted of 81 female adolescents with type 1 diabetes whose mean age was 15.0 years (range 12–18). The control group consisted of 205 healthy adolescents with a mean age of 15.5 years (range 12–18). Data on menstruation were collected by two parallel self-administered questionnaires. Oligomenorrhoea was defined as having a menstrual cycle longer than 36 days throughout the past year (5–6/year). The metabolic control of diabetes was evaluated by calculating the mean value of HbA1c during the past year.Results: Age of menarche was greater for adolescents with type 1 diabetes (12.2±1.4 vs. 11.7±1.2, p<0.000) compared to healthy age-matched controls. Logistic regression analysis with oligomenorrhoea as the dependent binary variable revealed an odds ratio equal to 7.8 (95% CI 3.411–17.853) for adolescents with type 1 diabetes (p<0.000). Finally, a second logistic regression analysis, concerning only adolescents with type 1 diabetes and with the same binary variable, estimated an odds ratio of 4.8 (95% CI 1.784–13.057, p<0.002) for HbA1c, and an odds ratio of 5.3 (95% CI 1.821–15.130, p<0.002) for the frequency of hypoglycaemia.Conclusion: In adolescents with type 1 diabetes, menarche occurs later and oligomenorrhoea is more frequent. The relative risk of having oligomenorrhoea is greater when there is an increased value of HbA1c or when hypoglycaemia is more frequent.

Microsatellite instability in endometrial polyps - Corrected Proof

2010-08-02

Abstract: Objective(s): To investigate the prevalence of microsatellite instability (MSI) in endometrial polyps and to evaluate whether there are clinical and histopathological parameters associated with this kind of instability.Study design: Between September 2008 and April 2009, endometrial polyps were collected from 109 patients. MSI was evaluated using the NCI recommended markers BAT25, BAT26, D2S123, D5S346 and D17S250. Histopathological analysis was performed, and clinical information was obtained from patients’ records.Result(s): MSI low was detected in 6.4% of the validated samples (7/109). Of the seven MSI that were detected, six were positive for instability at D17S250 and one at D5S346. There were no significant differences between polyps with or without MSI with regard to age, BMI, menarche, parity, miscarriage or menopause; however, MSI was more frequent in polyps with simple hyperplasia without atypia (3/20; 15%). Furthermore, patients with multiple polyps had a marginally but statistically insignificant increase in the frequency of MSI (p<0.07).Conclusion(s): This is the first prospective study of MSI in endometrial polyps using hysteroscopically obtained samples. In a population of 109 patients, MSI was infrequent in endometrial polyps. Although MSI appears to be more frequent in multiple polyps and polyps with simple hyperplasia without atypia, this was not statistically significant.

Comparison between transumbilical and transabdominal ports for the laparoscopic retrieval of benign adnexal masses: a randomized trial - Corrected Proof

2010-08-02

Abstract: Objective: To compare the feasibility, operative time, specimen retrieval time, and effect on postoperative pain of laparoscopic retrieval of benign adnexal masses between a 10-mm transumbilical and a 10-mm transabdominal port.Study design: Fifty women with adnexal masses who were scheduled for a laparoscopic procedure between July 2008 and April 2009 were enrolled. The patients were randomized into two groups; these were patients where a transumbilical port was used for specimen retrieval (transumbilical group, n=25) and patients where a transabdominal port was used for specimen retrieval (transabdominal group, n=25). Preoperative suspicion of malignancy and indications suggesting a need for hysterectomy or myomectomy were considered to be exclusion criteria. Randomization was centralized and computer-based. Patients recorded the severity of incisional pain on a visual analog scale (VAS) with 0 meaning no pain and 10 meaning unbearable pain.Results: There were no significant differences in age, body mass index, umbilical thickness, abdominal thickness, cyst size, cyst amount, cyst weight, histology, complications and duration of hospital stay when the two groups were compared. Patients in the transumbilical group had a significantly shorter specimen retrieval time (0.7±1.8min vs. 4.9±12.6min, p=0.006) and a significantly lower postoperative day (POD) 0 VAS pain score (5.2±2.1 vs. 6.6±2.2, p=0.015). Significantly fewer patients in the transumbilical group had a specimen retrieval time of ≥10min (0% vs. 20%, p=0.025) and a POD 0 VAS pain score of >5 (36% vs. 84%, p<0.001). However, the average POD 1 VAS pain score (3.2±1.8, vs. 3.6±1.6) and the proportion with a POD 1 VAS pain score >5 (12% vs. 12%) were similar for the two groups.Conclusion: When laparoscopic surgery on benign adnexal masses is carried out using a 10-mm incision wound, removal of the specimen via the umbilical port has a shorter retrieval time and produces less postoperative pain than retrieval via a lateral abdominal port.

Anorexia nervosa: a psychiatric illness with gynecological manifestations. A survey of knowledge and practice among Greek gynecologists - Corrected Proof

Lina Michala, Aris Antsaklis — 2010-08-02

Abstract: Objective: Anorexia nervosa (AN) affects a large number of women, usually in their adolescence. One of the primary manifestations of the disease is menstrual irregularity, and the presence of a menstrual cycle is often used as a sign of recovery among patients. Women with AN are likely to seek medical advice from a gynecologist with regards to their period problems. The role of the gynecologist is therefore crucial in identifying and referring these patients promptly to specialised centers.Study design: A brief anonymous questionnaire was completed by 94 gynecologists practising in Athens.Results: Approximately half of the responders felt that the conditions were rarer than it really is, and 25% thought that the disease primarily affects women in their early twenties. Although 56% of gynecologists would not prescribe the combined oral contraceptive in women with AN in order to restore their periods, the remainder of gynecologists were in favour of prescribing hormone replacement with a view to reducing the risk of osteopenia. This is despite the fact that emerging evidence shows there is no benefit. Ten percent of gynecologists never weigh their patients during evaluation of amenorrhoea and 72% felt that their level of knowledge as far as anorexia nervosa is concerned is inadequate.Conclusion: More education is required among gynecologists on the subject of anorexia nervosa, in order to identify and refer patients in the early stages of the disease process.

Thrombophilic risk factors for placental stillbirth - Corrected Proof

Michal J. Simchen, Keren Ofir, Orit Moran, Alon Kedem, Eyal Sivan, Eyal Schiff — 2010-08-02

Abstract: Objectives: To define the characteristics of placental stillbirth and the possible contribution of thrombophilic risk factors.Study design: A prospective cohort study was performed. Women diagnosed with antenatal stillbirth (>20 weeks) of singleton pregnancies between 2006 and 2008 were referred postpartum for evaluation. Maternal risk factors, fetal, placental and cord abnormalities, and a detailed thrombophilia screening, including inherited and acquired thrombophilia, were evaluated. Fetal autopsy and placental pathology were encouraged.Placental stillbirth was defined as death of a normally-formed fetus with evidence of intrauterine fetal growth restriction, oligohydramnios, placental abruption and/or histological evidence of placental contribution to fetal death. Pregnancy characteristics and thrombophilia profiles were compared between placental and non-placental stillbirth cases.Results: Sixty-seven women with stillbirth comprised the study group. Placental stillbirth was evident in 33/67 (49.3%). Significantly more women with placental stillbirth were nulliparous, when compared with non-placental stillbirth women (21/33 vs. 9/34, p=0.002). Mean gestational age was lower for placental, compared with non-placental stillbirth (31.1±6.1 weeks vs. 33.9±4.8 weeks, p=0.04), as was birth weight. Thirty-six of the 67 women (53.7%) tested positive for at least one thrombophilia. The prevalence of maternal thrombophilia was higher for placental stillbirth women (63.6%), and even higher (69.6%) for women after preterm (<37 weeks) placental stillbirth. Factor V Leiden and/or prothrombin G20210A mutation were much more prevalent in placental versus non-placental stillbirth women (OR 3.06, 95% CI 1.07–8.7).Conclusions: Placental stillbirth comprises a unique subgroup with specific maternal characteristics. Maternal thrombophilia is highly prevalent, especially in preterm placental stillbirth. This may have implications for the management strategy in future pregnancies in this subgroup.

Different injection sites of radionuclide for sentinel lymph node detection in breast cancer: single institution experience - Corrected Proof

Manuel Garcia-Manero, Begoña Olartecoechea, Pedro Royo — 2010-07-27

Abstract: Objective: The sentinel node is defined as the first lymph node in a regional basin that receives lymph flow from the primary tumor. There is still a controversy over deep versus superficial injection administration in the breast.Study design: From June 2006 to June 2008, 133 patients with biopsy proven breast carcinoma and clinically negative axilla have been treated with conservative surgery and a study of their axillary sentinel lymph nodes (SLN) has been conducted.Results: The median number of SLN detected was significantly higher in the periareolarly injected (PA) group (2.43) than in the intratumorally injected (IT) group (1.92) (p=0.008). The incidence of positive SLN in the PA group was not significantly different from the incidence observed in the IT group (p=0.22).Conclusion: Both techniques seem to reliably identify the true SLN in the axilla. Although intradermal as compared with intratumoral injection has numerous advantages, including ease of injection, shorter time between injection and sentinel node identification, and increased radiotracer nodal uptake, nevertheless, intradermal injection allows almost exclusive identification of axillary nodes, and only on rare occasions, of non-axillary nodes. We therefore think that intratumoral injection must be preferred to intradermal when possible to identify the node that is the first draining step of the tumoral tissue.

The pressure profile test is more sensitive and specific than Palmer's test in predicting correct placement of the Veress needle - Corrected Proof

2010-07-26

Abstract: Objectives: Although the majority of laparoscopic complications result from improper Veress needle placement, the safety tests commonly used to determine correct placement are not always reliable. A prospective observational study (Canadian Task Force Classification II-2) was set up to determine the reliability of Palmer's and pressure profile tests in predicting the correct intraperitoneal placement of the Veress needle prior to insufflation.Study design: One hundred consecutive women undergoing gynaecological laparoscopic surgery between September 2006 and June 2007 were recruited. The operating surgeons conducted Palmer's and pressure profile tests in all 100 cases and recorded the ease with which these tests were performed and whether or not they felt that the needle placement was correct. They were also asked to comment on the saline drop test and double click acoustic test if appropriate.Results: The overall sensitivity of Palmer's test was 0.92 while its specificity was 0.5. The overall sensitivity and specificity of the pressure profile test were 0.99 and 0.75, respectively, making this a more reliable test for predicting intraperitoneal placement of the Veress needle.Conclusions: The pressure profile test was a more reliable guide to confirming the correct placement of the Veress needle as a negative test is more likely to indicate failure to achieve intraperitoneal placement.

Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis? A randomised controlled cross-over trial - Corrected Proof

2010-07-26

Abstract: Objective: The aim of the study was to examine whether acupuncture is an effective additional pain treatment for endometriosis.Study design: One hundred and one women aged 20–40 years participated and were randomised into two groups, each receiving two units of 10 acupuncture treatments, twice a week over a period of five weeks. Group 1 (n=47) received verum-acupuncture during the first series, and group 2 (n=54) received non-specific acupuncture. After the first unit of 10 treatments, an observation period of at least two menstruation cycles was set, followed by a second unit, according to a cross-over design. Prior to the study (during a two-week run-in period) the patients’ actual pain intensity was surveyed. Throughout the study period, participants were asked to keep a ‘pain protocol’, in which they defined and recorded their pain according to the 10-point visual analogue scale (VAS).Results: Eighty-three out of a total of 101 patients finished the study. Group 1 showed a significant reduction of pain intensity after the first 10 treatments. In comparison, group 2 showed significant pain relief only after the cross-over.Conclusion: Acupuncture treatment on specific acupuncture points appears to be an effective pain treatment for endometriosis, but this has to be confirmed in further study.

Human seminal plasma hypersensitivity: an unusual indication for in vitro fertilization - Corrected Proof

Banu Bajardeen, Joan Melendez, Wai Yoong — 2010-07-23

We would like to report a case of severe allergy to seminal fluid, a rare but interesting indication for assisted conception treatment. A 29-year-old teacher, known to be allergic to latex and penicillin, was seen in the gynaecology clinic with eighteen months’ history of localised urticaria lasting under 12h whenever her partner's semen came into contact with her skin. Vaginal intercourse with ejaculation had led to local vaginal irritation for 24 or more hours while oral sex would lead to local irritation of the mouth and mild shortness of breath accompanied by a wheeze and tightness of the chest. Cutaneous or vaginal contact with semen did not produce systemic anaphylaxis but the symptoms would repeat again without improvement every time she came in contact with her partner's semen. The use of a non-latex condom appeared to avert all reaction and she had not suffered from any of these symptoms with her previous partner.

Antepartum and postpartum maternal plasma levels of E-selectin in pre-eclampsia, gestational proteinuria and gestational hypertension - Corrected Proof

2010-07-22

Pathophysiologic features of pre-eclampsia (PE) suggest that generalized endothelial cell damage and dysfunction are the major features of the disease. E-selectin is a cell adhesion molecule and its increased expression indicates endothelial cell activation . In this pilot study, we have investigated alterations of maternal antepartum and postpartum plasma levels of soluble(s) E-selectin in normotensive pregnant women and women with PE, gestational hypertension (GH) and gestational proteinuria (GP). We further sought to determine whether changes in plasma levels of sE-selectin from antepartum to postpartum would correlate with the postpartum regression of PE.

Genetic variations in vascular endothelial growth factor but not in angiotensin I-converting enzyme genes are associated with endometriosis in Estonian women - Corrected Proof

2010-07-22

Abstract: Objective: To determine plausible associations between endometriosis and vascular endothelial growth factor gene (VEGF −2578 A/C, −1154 G/A, −634 G/C and 936 C/T), also angiotensin I-converting enzyme gene (ACE −240 A/T and 2350 A/G) single nucleotide polymorphisms (SNPs), as well as their respective haplotypes.Study design: PCR-based restriction fragment length polymorphism analysis was used to detect SNPs in VEGF and ACE genes in 150 Estonian women with endometriosis and 199 control subjects.Results: The CC genotype of the VEGF −2578 A/C SNP was correlated with a decreased risk of endometriosis (OR=0.40, 95% CI 0.20–0.78). Other VEGF and ACE SNPs and haplotypes were not associated with endometriosis.Conclusion: This case-control study demonstrated that the VEGF −2578 A/C SNP may influence susceptibility to endometriosis in the Estonian population, while associations between endometriosis and other VEGF and ACE SNPs, as well as the respective haplotypes are unlikely.

Symptomatic pelvic hematoma following transvaginal reconstructive pelvic surgery: incidence, clinical presentation, risk factors, and outcome - Corrected Proof

Yakir Segev, Ron Auslender, Arie Lissak, Ofer Lavie, Yoram Abramov — 2010-07-21

Abstract: Objective: To assess the incidence, clinical presentation, risk factors and outcome of symptomatic pelvic hematomas following transvaginal pelvic reconstructive surgery.Materials and methods: We reviewed the medical records of all women undergoing transvaginal reconstructive pelvic surgery in our institution between January 2006 and July 2009.Results: 462 patients underwent pelvic reconstructive surgery, of whom 28 (6%) presented with symptomatic pelvic hematomas. All cases occurred after transvaginal hysterectomy, 25 (90%) presented with fever, 20 (71%) with pelvic pain and 5 (20%) with urinary retention. All hematomas were diagnosed by ultrasound. They were located at the vaginal cuff in 18 (64%), anterior vaginal wall in six (21%) and posterior vaginal wall in four patients (14%), and had a mean volume of 590±140cm3. Laboratory data included leukocytosis (71%), thrombocytosis (57%) and elevated liver enzymes (18%). Nine patients (33%) required ultrasound-guided drainage of the hematoma, which resulted in marked clinical improvement. Surgical outcome was not affected by the presence of pelvic hematoma.Conclusions: A postoperative symptomatic pelvic hematoma is not rare and is closely related to transvaginal hysterectomy. Its clinical presentation includes fever, pelvic pain, leukocytosis, thrombocytosis and occasionally liver dysfunction. Surgical outcome is generally unaffected.

Maternal gastric carcinoma metastatic to the placenta - Corrected Proof

Arthur M. Baker, Sina Haeri, Aaron Shafer, Julie S. Moldenhauer — 2010-07-21

Malignancy diagnosed in pregnancy occurs in approximately one per 1000 births . Metastasis to the placenta or fetus is uncommon and typically occurs when there is widespread disease present. We report a case of maternal gastric carcinoma with extensive metastatic disease, which included the placenta.

Aneuploidies detection in miscarriages and fetal deaths using multiplex ligation-dependent probe amplification: an alternative for speeding up results? - Corrected Proof

2010-07-21

Abstract: Objective: The aim of this prospective study was to apply the MLPA technique to products of miscarriages and fetal deaths in order to detect the more frequent chromosome aneuploidies and compare the results to conventional karyotyping.Study design: Multiplex ligation-dependent probe amplification (MLPA) is a relatively new molecular technique for targeted detection of common chromosomal aneuploidies, namely trisomy 13, 18, 21 and sex chromosomal abnormalities. The reliability and high accuracy of this technique constitute an alternative for rapid results in large scale testing. In this study, a total of 489 DNA samples from fetal tissue were used for aneuploidy detection of chromosomes 13, 18, 21, X and Y using a commercial MLPA kit (SALSA P095) and were simultaneously subjected to conventional karyotyping.Results: MLPA was the only result available in 33% of the cases. A cytogenetic result was obtained in only 328/489 samples. MLPA detected 7.8% of chromosome aneuploidies. Among the total samples karyotyped, MLPA failed to detect some aneuploidies and the false-negative rate was 0.82%. As expected, ploidy changes and reciprocal translocations were not detected by this technique, but MLPA gave a conclusive result even in cases of mosaicism.Conclusion: The present data confirm that MLPA is a rapid, simple and reliable method for detection of chromosome 13, 18, 21, X and Y abnormalities in fetal tissue.

Notes on a stick: use and acceptability of woman-held maternity notes - Corrected Proof

2010-07-21

Abstract: Objective: To provide expectant mothers with a USB stick containing their maternity notes, including ultrasound images, and to assess its use and acceptability versus conventional care with exclusively hospital-held notes.Study design: USB group: 200 women attending Zurich University Hospital Obstetrics Department for antenatal-to-postnatal care in 2006–2007. Controls: 200 women attending the Obstetrics Department for delivery only, after receiving conventional antenatal care elsewhere. Women were interviewed using an essentially identical postpartum questionnaire for each group, with minor wording differences. Main outcome measures: Overall satisfaction with pregnancy and delivery, feeling of safety, interest in the pregnancy, partner involvement, usefulness of USB stick in emergencies, impact on smoking behaviour, data confidentiality concerns, pregnancy and infant outcome. Stepwise multiple regression was used to identify determinants of overall impressions of pregnancy and delivery.Results: Of the USB group, 98.5% wished to repeat the USB experience in a subsequent pregnancy; of the controls, 86.5% would have appreciated the experience, and 18.0% could think of situations in their pregnancy (vacation, emergencies) where the stick would have helped; 7.5% of the USB group shared their stick data with a doctor outside the Department, and 80.5% felt safer having the stick available. Along with preterm delivery and mode of delivery, the USB stick was a significant determinant of the overall positive impression of pregnancy. Primary caesarean section was (inexplicably) more frequent in the USB group.Conclusion: The questionnaire confirmed that issuing women with their maternity notes on a USB stick is a major advance in patient empowerment, satisfaction and safety.

Single-port laparoscopic myomectomy using transumbilical GelPort access - Corrected Proof

2010-07-21

Abstract: Objective: To describe our initial experience with single-port laparoscopic myomectomy (SP-LM) using transumbilical GelPort access and the surgical technique used, and to evaluate the safety and feasibility of this procedure.Study design: A prospective observational study was performed at a university teaching hospital from January 2009 to December 2009. Fifteen patients with symptomatic subserosal or superficial intramural myomas (≤8cm) underwent SP-LM.Results: The mean age and body mass index were 35.0±8.6 years and 22.6±2.6kg/m2. Two patients had a history of previous abdominal surgery, consisting of one and two cesarean deliveries. The mean operating time, hemoglobin change, return of bowel activity, and length of hospital stay were 81±21.5min, 1.1±0.5g/dL, 34.3±5.9h, and 3.1±0.5 days, respectively. In one patient (6.7%), SP-LM was converted to two-port LM. There were no surgical or wound complications in any patient, and the histopathological result was leiomyoma in all the cases.Conclusion: SP-LM is feasible in selected patients with symptomatic myoma.

Interventions to improve rates of post-mortem examination after stillbirth - Corrected Proof

Sarah J. Stock, Lesley Goldsmith, Margaret J. Evans, Ian A. Laing — 2010-07-21

Abstract: Objective: Despite recognition of the value of post-mortem examination following stillbirth, worldwide rates have declined since the early 1990s. There is a paucity of published evidence relating to factors that can improve post-mortem uptake. The aim of this study was to assess post-mortem rates following stillbirth and identify trends in the past 18 years that may have affected acceptance of the investigation.Study design: Retrospective cohort study.Results: Sharp declines in post-mortems coincided with publicity surrounding unlawful organ retention. Although nationally post-mortem rates have continued to fall, in our unit there was recovery in post-mortem rates. This increase was associated with implementation of policies to promote the uptake of perinatal post-mortem, including availability of specialist perinatal pathologists, education in the value of post-mortem, and senior staff involvement in counselling regarding the procedure.Conclusion: The need to improve uptake of post-mortem examination following stillbirth is internationally recognized. The results of this study suggest that increased local availability of specialist perinatal pathologists, who can support education in the value of post-mortem, along with senior staff obtaining consent, may help achieve this goal.

Short- and long-term outcome of infants born after maternal (pre)-eclampsia, HELLP syndrome and thrombophilia: a retrospective, cohort study - Corrected Proof

2010-07-20

Abstract: Objectives: To investigate the short- and long-term outcome of children born from mothers with pre-eclampsia, eclampsia and/or HELLP syndrome, and to determine the differences between children born from mothers with and without underlying thrombophilic disorder.Study design: Four hundred and nine infants (from 370 women) born between February 1991 and January 2006 were eligible for evaluation and were classified into group A (n=162) and group B (n=247). Thirty-four infants were not admitted to the hospital. Between-group differences were tested with regard to neonatal mortality, morbidity and follow-up measurements for neuromotor and mental development at 9 months and 2 years of age, using two-tailed Student's t-tests, Fisher's exact tests and logistic regression models.Results: Of the 409 infants, 44 infants (10.8%; n=20 group A/n=24 group B) died. The mean gestational age in both groups was 31.9 (SD: 3.5) weeks. Of the 375 admitted infants 152 (40.5%) were related to a thrombophilic mother and 223 (59.5%) were not. Six children were lost to follow-up. At 9 months and 2 years of age development was assessed in 326 surviving children. At 9 months of age, 193 (59.2%; n=66 group A/n=127 group B) children showed a normal (52% group A versus 63.8% group B, P=0.046), 24 (7.4%; n=9 group A/n=15 group B) a suspect and 14 (4.3%; n=6 group A, n=8 group B) an abnormal development during follow-up assessment. Ninety-five children (29.1%; n=46 group A/n=49 group B) did not have a follow-up assessment. At 2 years of age, 112 children (34.4%; n=43 group A/n=69 group B) had a normal, 21 (6.4%; n=11 group A/n=10 group B) a suspect and 17 (5.2%; n=5 group A/n=12 group B) an abnormal development. 176 children (54%; n=70 group A/n=106 group B) did not have a follow-up assessment.Conclusion: Short-term outcome was not different between infants from mothers with or without thrombophilic disorders. At 9 months of age, the probability of having a normal development was significantly lower in children born from a mother with an underlying thrombophilic disorder than in those without. At 2 years of age, no differences in development were observed.

Evaluation of pelvic floor muscle cross-sectional area using a 3D computer model based on MRI in women with and without prolapse - Corrected Proof

2010-07-20

Continence and pelvic organ support depend on the interaction between muscles and endopelvic fascia . Alterations in pelvic floor muscle morphology and function have been associated with parity, age and the presence of pelvic organ prolapse (POP) . Recent advances in imaging technology and computer models have improved the assessment of pelvic floor structures . This study was designed to evaluate (not to predict) the pelvic floor muscle cross-sectional area (CSA) in women with and without prolapse using a new technique based on a 3D computer model, contributing to a better understanding of the mechanism of prolapse. The advantage of using the present 3D model is the fact that any CSA can be calculated.

The effect of hormonal status on the expression of estrogen and progesterone receptor in vaginal wall and periurethral tissue in urogynecological patients - Corrected Proof

2010-07-20

Abstract: Objective: Our objective was to study the expression of estrogen receptor (ER) isoforms ER alpha (α) and ER beta (β) and of progesterone receptor (PR) in the vaginal wall and in periurethral tissue of women who underwent urogynecological surgical treatment with reference to estrogen status.Study design: The study included 89 patients undergoing vaginal surgery for urogynecological conditions. Patients’ history and clinical data including estrogen status and body mass index (BMI) were evaluated. Biopsies from the vaginal wall and from periurethral tissue were obtained during surgery. The expression of ER α and β and of PR in vaginal wall and periurethral tissue was measured by RT-PCR.Results: Nine patients were premenopausal. Eighty women were menopausal, of whom 21 were taking estrogen/progestin replacement therapy (HRT), 20 used local estrogen, and 39 had no endocrine treatment. Neither BMI nor age had any influence on the expression of ER and PR. Menopausal women showed a higher amount of PR expression in vaginal tissue than premenopausal women. Women with no endocrine treatment showed a lower amount of ER β expression in vaginal tissue.Conclusion: Steroid receptors are expressed in periurethral and vaginal tissue. The receptor expression varies with hormonal changes only in vaginal tissue. Vaginal tissue seems to be more sensitive to estrogen than periurethral tissue.

Accuracy of sonographic fetal weight estimation of fetuses with a birth weight of 1500g or less - Corrected Proof

2010-07-20

Abstract: Objective: To compare 35 commonly used formulae for small and average sized fetuses on their accuracy in estimating the birth weight in fetuses of 1500g or less.Study design: For this retrospective study a database search was performed for all singleton pregnancies without structural or chromosomal defects and with a birth weight of 1500g or less where the last ultrasound examination was performed within seven days before delivery. Percentage error and absolute percentage error were calculated based on 35 different weight estimation formulae. Multiple regression analysis was used to determine the significant contributors to the absolute percentage error.Results: One hundred and ninety-three cases fulfilled the inclusion criteria. The median birth weight was 990g. The percentage error ranged between −15.2% (underestimation with the Merz I formula) and 37.4% (overestimation with the Jordaan formula) and the respective standard deviations between 10.5% (Mielke I) and 54.0% (Schillinger), respectively. The absolute percentage error was between 8.5% and 37.6%. The most accurate weight estimation was achieved with the formula from Mielke (percentage error 1.8% and absolute percentage error 8.5%). Multiple regression analysis showed that significant contributors to the percentage error of the Mielke formula were biparietal diameter (OR=−0.206, p=0.045), occipitofrontal diameter (OR=0.765, p<0.0001), abdominal circumference (OR=−2.953, p<0.0001), femur length (OR=−0.903, p<0.0001), head to abdomen ratio (OR=−1.080, p<0.0001) and fetal weight (OR=2.847, p<0.0001).Conclusion: When estimating fetal weight in fetuses weighing 1500g or less, one has to be aware of the great differences in accuracy among the formulae.

The effects of acrylamide on sperm parameters and membrane integrity of epididymal spermatozoa in mice - Corrected Proof

2010-07-20

Abstract: Objective: Acrylamide is a chemically reactive substance used in various industries. Recently, the discovery of acrylamide in a variety of human foods including heat-processed starchy foods such as potato chips and bread has been reported. Acrylamide is also known as a carcinogen and cytotoxic material. The aim of this study was to evaluate the detrimental effects of acrylamide on membrane integrity and sperm parameters in mice.Study design: This experimental study was conducted on thirty male NMRI mice, aged 8–10 weeks and weighing 25–30g. They were randomly allotted into three equal groups. Group I (low dose) and group II (high dose) were fed on water solutions containing acrylamide 5 and 10mg/kg/day, respectively, for 2 months, while the third group received fresh water as the control group. Sperm analysis was done for parameters as well as evaluation of membrane integrity by Hypoosmotic Swelling Test (HOS-test) for sperm tails and Eosin-Y staining for sperm heads.Results: Total sperm motility and progressive motility (fast and slow) in both groups, I and II, decreased significantly (P=0.00), but no significant change was observed in non-progressive motility (P>0.05). The total motile sperm percentage decreased significantly only in group II (P=0.01). Sperm morphology did not significantly change in the experimental groups compared to the controls (P>0.05). In sperm membrane integrity evaluation, functional intact membrane of sperm tail in both groups I and II had a significant decrease (P=0.00), but membrane integrity of the sperm head decreased significantly only in group II (P=0.00).Conclusion: These results indicate that acrylamide, through effects on membrane integrity, decreased sperm vitality as well as causing abnormal sperm parameters in progressive motility and total motility.

Necrotic adnexal tumor after detorsion in pregnancy: excise or leave? - Corrected Proof

Nuria Abril, Cristina Ruiz, Miguel Angel García-Pérez, Antonio Cano — 2010-07-20

Reports suggest that, despite a necrotic appearance at the time of diagnosis, adnexal torsion may be managed conservatively . We describe the case of a pregnant woman who was diagnosed with a devitalized, non-symptomatic adnexum several weeks after an apparently successful detorsion at laparotomy.

Perinatal morbidity and mortality in twin pregnancies with dichorionic placentas following assisted reproductive techniques or ovarian induction alone: a comparative study - Corrected Proof

2010-07-20

Abstract: Objective: To compare maternal and perinatal outcome in non-spontaneously and spontaneously conceived dichorionic twin pregnancies.Study design: We report a retrospective study of all 350 twin pregnancies delivered ≥22 weeks of gestation between January 1, 2001 and December 31, 2005 in a tertiary maternity unit. We compared maternal outcome, perinatal morbidity and neonatal mortality between spontaneous and non-spontaneous dichorionic twin pregnancies, with a subgroup analysis separating pregnancies following assisted reproduction technology (ART group) from those following ovarian induction alone (OI group). Generalized linear model and multivariate analysis were performed.Results: The proportion of primiparous women and the mean maternal age were higher in the non-spontaneously conceived dichorionic twin pregnancy group as expected (70.2% vs. 38.2%, p<0.001 and 32.1±3.8 vs. 30.7±4.6 years, p<0.01). Multivariate analysis, adjusted for maternal age and parity, revealed that non-spontaneously conceived dichorionic twin pregnancies were associated with a higher risk of very preterm birth (OR 2.20, 95% confidence interval 1.02–4.77, p<0.05), low birth weight (1.77, 1.21–2.61, p<0.01), very low birth weight (1.99, 1.13–3.49, p<0.05), NICU admission (1.66, 1.14–2.43, p<0.01), and fetal or neonatal death (3.21, 1.30–7.95, p<0.05). Multivariate analysis confirmed that the mean gestational age (p<0.01) and mean birth weight of the first (p<0.05) and second twins (p<0.01) were lower in the non-spontaneously conceived dichorionic twin pregnancy group. These associations were confirmed in the OI group analysis (n=39) but not in the ART group (n=65). Ovarian induction was associated with an increase in the risk of preterm and very preterm births (2.25, 1.06–4.75, p<0.05 and 3.47, 1.42–8.49, p<0.01, respectively), low and very low birth weights (2.87, 1.63–5.05, p<0.001 and 2.59, 1.33–5.07, p<0.01, respectively), NICU admission (2.92, 1.67–5.11, p<0.001) and fetal or neonatal death (4.20, 1.40–12.56, p<0.05). The mean gestational age (p<0.001) and mean birth weight of the first (p<0.01) and second twins (p<0.001) were also lower in the OI group.Conclusions: Twin pregnancies with dichorionic placentation following non-spontaneously conceived pregnancy are associated with a higher risk of adverse perinatal outcome compared with dichorionic spontaneously conceived twin pregnancies especially in case of ovarian induction alone.

Transvaginal repair of genital prolapse with polypropylene mesh using a tension-free technique - Corrected Proof

Rajka B. Argirovic, Aleksandra M. Gudovic, Ivana R. Babovic, Milica V. Berisavac — 2010-07-20

Abstract: Objectives: To assess the perioperative complications and short-term outcomes of prolapse repair using transvaginal polypropylene mesh.Study design: Retrospective study. In the period from April 2007 to September 2009, 67 women underwent vaginal repair with implantation of a soft mesh manufactured by Gynecare.Results: All the patients had a stage 3 or stage 4 prolapse. Total mesh was used in eight patients (11.9%), isolated anterior mesh in 36 patients (53.7%) and isolated posterior mesh in 23 patients (34.4%). We reported one intraoperative bladder injury and no other serious complications. At 3 months, all the 67 patients were available for follow-up. Vaginal erosion occurred in eight patients (11.9%), shrinkage of mesh in six patients (8.7%), granuloma without exposure in four patients (5.9%), de novo urinary incontinence in three patients (4.5%) and flatus incontinence in one patient (1.5%). Failure rate was 7.5% (recurrent prolapse stage 3 or 4, even asymptomatic).Conclusion: Our study suggests that transvaginal polypropylene mesh applied with a tension-free technique is a safe and effective method with low intraoperative complications but with considerable potential postoperative morbidity.