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

Recurrent hydatidiform moles - Uncorrected Proof

Denise Williams, Victoria Hodgetts, Janesh Gupta — 2010-02-08

Abstract: Hydatidiform moles (HMs) are abnormal conceptions of excessive trophoblast development resulting in abnormal human pregnancies with no embryo and cystic degeneration of the chorionic villi. Prompt diagnosis, treatment and follow-up of patients using assays for βhCG from centres that specialise in this condition enable early diagnosis of potential malignant change.Hydatidiform moles occur quite frequently and although recurrence is rare, women who have experienced one molar pregnancy should be aware that they are at an increased risk of a further molar pregnancy in comparison to other women in the general population. For some women multiple molar pregnancies occur. In these women the recurrent molar pregnancies may be non-familial, referred to as recurrent molar hydatidiform moles in this article, or may result from an inherited predisposition, which we refer to as familial recurrent hydatidiform moles. We use the term familial biparental hydatidiform moles (FBHMs) for cases in which the parental contribution to the moles has been investigated and found to be biparental. It is important to recognise, however, that in some apparently non-familial cases, the absence of female siblings, or the absence of female siblings who have tried to conceive, may not allow the inherited nature of the molar pregnancies to manifest in more than one woman and be obviously familial.This review considers our current understanding about the aetiology of HMs and explores the mechanisms of both types of recurrent hydatidiform moles. It highlights the role that genetics can play in determining the origin of multiple molar pregnancies, which should be considered essential in providing women with accurate advice about their risk of recurrence, so allowing them to make appropriate reproductive choices.

Sonographic lesions in fecal incontinence of obstetric origin: Obstetric sphinter rupture - Uncorrected Proof

I. Pascual, M.C. Martínez Puente, J.A. Pascual Montero, D. García Olmo — 2010-02-08

The problem of fecal incontinence in women is often related to several factors, including age, pregnancy, vaginal delivery and proctologic surgery. Comprehensive study of the anal sphincters is essential to offer each patient the most appropriate treatment such as biofeedback, sphincteroplasty, sacral nerve stimulation, sphincter replacement or muscle transposition. In recent years anal endosonography has been shown to be the most sensitive, specific and inexpensive type of imaging for studying the anal sphincters of patients with fecal incontinence . We have observed that external sphincter injury at the mid anal canal is the most frequent abnormality in fecal incontinence of obstetric origin, whilst internal anal sphincter injury has largely been reported as an endosonographic finding associated with incontinence after anal surgery . This sonographic pattern may be the result of how obstetric trauma occurs – from top to bottom and inside outwards – unlike the mechanism by which sphincter lesions occur in anal surgery, from the mucosa to the muscle.

Longitudinal follow-up of a cohort of 350 singleton infants born at less than 32 weeks of amenorrhea: neurocognitive screening, academic outcome, and perinatal factors - Corrected Proof

2010-01-20

Abstract: Objective: To analyse the incidence of neurodevelopmental disorders at the age 6–10 years, in children born at less than 32 weeks of amenorrhea, and to identify the perinatal and neonatal factors associated with adverse neurodevelopmental outcomes at this age.Study design: Longitudinal prospective trial in a French university and tertiary perinatal care centre. A total of 350 preterm singletons born in hospital at less than 32 weeks of amenorrhea between 1997 and 2001 were included. Children were invited for examination to screen for neurocognitive disorders between 4 and 8 years of age and re-contacted when they were between 6 and 10 years of age to evaluate school results. Three profiles of neurocognitive outcome were defined (normal, minor disorder, or major disorder) and correlated with maternal, antenatal, perinatal, and neonatal factors.Results: The survival rate of our cohort was 80.8% (283/350) and the proportion of survivors followed-up was 71.4% (202/283). There were 137 children (68%) with normal profiles, 29 (14%) with minor disorders, and 36 (18%) with major disorders. For those born at less than 28 weeks of amenorrhea, the survival rate was 62.7% (64/102) and the proportion of survivors followed-up was 78.1% (50/64). Among these children, 24 (48.0%) had normal outcomes, 8 (16.0%) suffered from minor disorders, and 18 (36.0%) had major disorders. The three principal independent risk factors for major or minor disorders at school age were gestational age less than 28 weeks of amenorrhea (adjusted odds ratio: 1.28 [95% confidence interval: 1.06–1.56]), chronic lung disease at birth (adjusted odds ratio: 2.92 [95% confidence interval: 1.15–7.42]), and an abnormal electroencephalogram before discharge (adjusted odds ratio: 2.61 [95% confidence interval: 1.10–6.18]). Moreover, abnormal brain ultrasonography was identified as an independent risk factor for occurrence of major disorders (adjusted odds ratio: 2.98 [95% confidence interval: 1.31–6.71]).Conclusion: Very preterm infants remain at high risk for long-term neurodevelopmental disorders. Several neonatal factors, particularly chronic lung disease, seem to be important determinants of long-term outcome.

Editor's highlights - Corrected Proof

J. Drife — 2010-01-18

With the approach of Easter, it is time for a reminder that March 30 is the deadline for the registration of authors presenting at the European Congress of Obstetrics and Gynaecology in Antwerp, Belgium, at the beginning of May. The congress website, www.ebcog2010.be, gives details of the meeting and includes some fascinating background information. We already knew that Antwerp has beautiful buildings and a rich cultural history but we were unaware that this inland city is Europe's second-largest international shipping port, or that the Flanders Concert and Congress Centre (the venue for the congress) is situated in Antwerp's world-famous zoo. As the EBCOG President, Professor Peter Hornnes, points out in his letter of invitation, conference participation includes access to the zoo but you can expect human behaviour at the sessions. For non-presenters, early registration with reduced fee also ends on March 30.

Prenatal finding of a fetus with 47,XX,t(4;5)(q26;p15),+der(4)t(4;5)mat due to familial balanced reciprocal translocation - Corrected Proof

Xiao Xi Zhao — 2010-01-11

We found that a fetus with multiple congenital malformations had a rare karyotype. A 28-year-old woman, at her 24th week of gestation, was referred to our hospital for foetal chromosome analysis. The ultrasonography findings revealed the hydrocephalus and cleft lip of the fetus. The first pregnancy of the woman had resulted in a first-trimester miscarriage. Her next pregnancy was uneventful until the 24th week of gestation when the foetal hydrocephalus and cleft lip were diagnosed through routine sonographic screening. After genetic counselling, the amniocytes were cultured and analysed according to the standard G-banding method. When the chromosomal aberration was detected in the amniotic fluid cultures, the parents decided to terminate the pregnancy. A female fetus weighing 1250g was delivered, and blood was taken from the umbilical cord to culture for chromosomal analysis. The result of the analysis was the same as that of the amniocytes. The parents consented to an autopsy, which revealed cleft lip, cleft palate, and hydrocephalus disorders.

Determinant factors of fertility outcomes after laparoscopic colorectal resection for endometriosis - Corrected Proof

2010-01-11

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

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

2010-01-11

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

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

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

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

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

2010-01-11

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

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

2010-01-08

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

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

2010-01-07

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

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

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

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

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

Atsushi Imai, Noriko Suzuki — 2010-01-07

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

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

2010-01-07

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

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

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

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

Excess of maternal mortality in foreign nationalities in Spain, 1999–2006 - Corrected Proof

Miguel Ángel Luque Fernández, Aurora Bueno Cavanillas, Salvador de Mateo — 2010-01-06

Abstract: Objective: This study aimed to compare maternal mortality by province, autonomous region and mother's country of birth in Spain during 1999–2006.Study design: A cross-sectional ecological study with all live births and maternal mortality cases occurring during 1999–2006 in Spain was done. Data were drawn from the National Statistics Institute (INE) and we used the Movement of Natural Persons (MNP) and death statistics broken down by cause of death. Maternal mortality rates by province, autonomous region and mother's country of birth were calculated. To compare maternal mortality by province, standardised mortality ratios were calculated using an indirect standardisation. The risk of maternal death by autonomous region, age and mother's country of birth was calculated by a Poisson regression.Results: Sub-Saharan nationalities present the highest maternal mortality rates. Adjusted by age and autonomous region, foreign nationalities had 67% higher risk of maternal mortality (RR=1.67; 95%CI=1.22–2.33). Adjusted by mother's country of birth and age, two autonomous regions had a significant mortality excess: Andalusia (RR=1.84; 95%CI=1.32–2.57) and Asturias (RR=2.78 95%CI=1.24–6.24).Conclusion: This study shows inequalities in maternal mortality by province, autonomous region and mother's country of birth in Spain. It would be desirable to implement a maternal mortality active surveillance system and the use of confidential qualitative surveys for analysis of socio-economic and healthcare circumstances surrounding deaths. These measures would be invaluable for in-depth understanding and characterisation of a preventable phenomenon such as maternal death.

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

2010-01-06

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

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

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

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

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

2010-01-06

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

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

2010-01-05

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

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

2010-01-05

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

The inflammation-based modified Glasgow Prognostic Score in patients with vulvar cancer - Corrected Proof

2010-01-05

Abstract: Objectives: To evaluate the prognostic potential of the modified Glasgow Prognostic Score (mGPS), known to reflect the degree of tumor-associated inflammation and cachexia, in patients with vulvar cancer.Study design: We included 93 consecutive patients with vulvar cancer into our study. As previously published, the pre-therapeutic mGPS was calculated as follows: patients with elevated C-reactive protein (CRP) serum levels (>10mg/L) and hypoalbuminaemia (<35g/L) were allocated a score of 2, patients with elevated CRP serum levels without hypoalbuminaemia were allocated a score of 1, patients with normal CRP serum levels with or without hypoalbuminaemia were allocated a score of 0. The mGPS was correlated with clinico-pathological parameters. The association between mGPS and prognosis was evaluated by univariate and multivariate survival analysis.Results: Mean (SD) pretreatment CRP and albumin serum levels were 9.5 (9.6)mg/L and 41.4 (5.3)g/L, respectively. mGPS was associated with tumor stage (p=0.01), but not with lymph node involvement (p=0.4), histological grade (p=0.8), and patients’ age (p=0.7). In univariate analyses, mGPS (p=0.006, p=0.001), tumor stage (p<0.001, p<0.001), lymph node involvement (p<0.001, p<0.001), and patients’ age (p=0.04, p=0.007), but not histological grade (p=0.1, p=0.3) and year of surgery (1995–2001 vs. 2002–2008, p=0.7, p=0.3) were associated with disease-free and overall survival, respectively. In a multivariate analysis, tumor stage (p=0.01, p=0.02) and lymph node involvement (p<0.001, p=0.001), but not mGPS (p=0.7, p=0.8), patients’ age (p=0.6, p=0.4), histological grade (p=0.2, p=0.1), and year of surgery (p=0.4, p=0.8) were associated with disease-free and overall survival, respectively.Conclusions: Despite being associated with prognosis in a univariate analysis, mGPS cannot be used as an independent inflammation-based predictor for survival in patients with vulvar cancer.

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

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

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

Retroperitoneal tuberculosis in a patient with uterine papillary serous carcinoma - Corrected Proof

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

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

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

2009-12-28

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

Use of herbal products among 199 Italian women during pregnancy - Corrected Proof

Laura Cuzzolin, Giovanni Zanconato, Daniela Ventrella, Giuseppina Benoni — 2009-12-28

Results from studies conducted in Europe, USA and Australia indicate that between 7 and 45% of pregnant women use herbal products . We investigated the use of herbal products among a sample of Italian women, enrolled and interviewed within 3 days after childbirth at the maternity ward of the University Hospital of Verona. All contacted women agreed to participate in the study and gave their written consent.

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

2009-12-28

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

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

2009-12-28

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

Vaginal laceration in a premenarcheal girl after sliding down a water chute - Corrected Proof

Martina Eder, Vesna Bjelic-Radisic, Gero Luschin-Ebengreuth, Uwe Lang — 2009-12-28

We want to describe a case of a young girl with heavy vaginal bleeding after sliding down a water chute. Vaginal injuries can occur with water sports such as water skiing , and sliding from a water chute, causally determined by high-pressure water jet .

Betamethasone before elective caesarean section at term: A survey of practice in France - Corrected Proof

Romain Guilherme, Daniel Rotten, The CEGORIF group — 2009-12-28

In 2005, a multicentre randomised trial demonstrated that a single course of antenatal betamethasone administered in the 48h before planned caesarean section (CS) at term reduced the incidence of transient respiratory distress in newborns . Knowing that the CS rate is rising in most developed countries, we thought this new role for antenatal corticosteroids at term could have appeared appealing for obstetricians .

The association of IL-1β, IL-2, and IL-6 gene polymorphisms with bone mineral density and osteoporosis in postmenopausal women - Corrected Proof

2009-12-25

Abstract: Objective: Osteoporosis is a common disorder with a strong genetic component. The genetics of osteoporosis impacts on the prediction, diagnosis, prognosis, and treatment of the disease.Study design: The aim of the present study was to examine associations between cytokine gene polymorphisms (IL-1β, IL-2, IL-6) and bone mineral density (BMD) values in postmenopausal women.The study included 226 postmenopausal women with a diagnosed BMD T-score lower than −2.5 SD (mean: −3.02±.053) and 224 postmenopausal women with a BMD T-score greater than −2.5 SD (mean: −1.33±0.51).Results: Among the women with T-scores below −2.5 SD, the BMD values were significantly lower in the carriers of the IL-6 GG genotype compared with those with the CC and GC genotypes (0.70±0.38 vs. 0.73±0.25 and 0.74±0.23 for the lumbar spine, 0.54±0.18 vs. 0.56±0.15 and 0.58±0.22 for the femoral neck). There were no statistically significant associations between the IL-1β and IL-2 genotypes and BMD values in the group of women with T-scores below −2.5 SD.Conclusion: The results of the present study suggest an association of the IL-6 −174 G/C polymorphism with osteoporosis in postmenopausal women.

Fetal programming of atherosclerosis: Possible role of the mitochondria - Corrected Proof

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

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

Expression of the imprinted IGF2 and H19 genes in the endometrium of cases with unexplained infertility - Corrected Proof

2009-12-23

Abstract: Objective: As genomic imprinting plays a critical role in the development of the placenta, the aim of this study was to detect whether the expression levels of the imprinted genes IGF2 and H19 in the endometrium differ between infertile and fertile women.Study design: : Total RNA was extracted from 30 (15 unexplained infertile and 15 fertile) women's endometrial tissue. cDNA was synthesized from total RNAs of each sample. IGF2 and H19 mRNA expression levels were measured quantitatively using the Real Time PCR method. In order to determine the allelic expression of IGF2 and H19, genomic DNA was extracted from endometrial tissues.Results: When compared with the control group, increased mRNA expression of IGF2 was detected (1.5-fold change, P=0.015) in the unexplained infertility group. In contrast, H19 expression was lower in the infertility group as compared to the control group (4-fold change, P<0.0001). Restriction analysis of cDNA-derived PCR product showed that all patients and controls indicated monoallelic expression of IGF2 and H19.Conclusion: Our results showed that altered expression of these imprinted genes might affect implantation and that their timely and appropriate activation is important for proper functioning. To understand the molecular epigenetic basis of implantation and placental development, genomic imprinted genes should be further investigated.

Inherited antithrombin deficiency and pregnancy: Maternal and fetal outcomes - Corrected Proof

2009-12-21

Abstract: Objective: To describe the outcome of pregnancy in women with inherited antithrombin (AT) deficiency.Study design: A descriptive retrospective study was performed. Medical records were reviewed in order to collect data about maternal thrombotic complications and pregnancy outcomes. All women with known inherited AT deficiency and at least one pregnancy looked after at the Vall d’Hebron University Hospital were included. Relatives with known AT deficiency but no pregnancies looked after in our institution were excluded. Eighteen pregnancies were registered among nine AT-deficient women during 1991–2005. This cohort included women without antithrombotic treatment because AT deficiency was not known at the time of their pregnancies.Results: In 12 pregnancies (66.7%) anticoagulant therapy with low-molecular weight heparin was given, while not in the other six (33.3%) because AT deficiency was not known at this time. Three episodes of venous thromboembolism were recorded (16.7%). Among all pregnancies 10 suffered an adverse outcome (55.6%), including miscarriage (11.1%), stillbirth (11.1%), intrauterine growth restriction (33.3%), placental abruption (6.7%), preeclampsia (6.7%) and intrapartum fetal distress (23.1%). No relation between AT activity and pregnancy complications was found. A lower incidence of pregnancy complications was observed among women with antithrombotic treatment.Conclusions: Inherited antithrombin deficiency is associated with a high risk of venous thromboembolism during pregnancy and the puerperium. We also observed a high incidence of poor pregnancy outcome among AT-deficient women.

Factors influencing success of pelvic organ prolapse repair using porcine dermal implant Pelvicol® - Corrected Proof

T.A. de Boer, D.A. Gietelink, J.C.M. Hendriks, M.E. Vierhout — 2009-12-21

Abstract: Objective: To evaluate factors influencing pelvic organ prolapse (POP) recurrence after repair surgery with a porcine dermal collagen implant (Pelvicol®).Study design: From December 2003 to August 2005, 78 patients with mainly stage 3 pelvic organ prolapse by the Pelvic Organ Prolapse Quantification (POP-Q) system underwent vaginal repair using porcine dermal implant. Assessments were made preoperatively and at 6 weeks and one year follow-up. These included physical examination with POP-Q, Incontinence Impact Questionnaire, Urogenital Distress Inventory and the Defaecatory Distress Inventory and questions from the Patient Global Impression of Improvement. Data were recorded on changes in functional status, mesh erosion and adverse events. Procedural success was defined as POP-Q stage 0/1.Results: 71 patients returned for one year follow-up. The overall cure rate was 74.6%. The chance of a successful operation in the younger group was significantly higher than in the older group (OR: 7.5; 95% CI 1.38, 40.69), but this effect is lower and no longer significant after adjusting for compartment (post, anterior, post+anterior) (adjusted OR: 5.5; 95% CI 0.92, 32.6).Conclusions: A low complication rate and satisfactory overall results were observed in a group of women after POP repair surgery with Pelvicol®. Whether these results are better or worse than with conventional surgery or non-resorbable mesh implantation is unclear and can only be determined in a randomized controlled trial. There was a strong tendency towards better results in the younger women than in the older women, but the reason for this phenomenon is unclear.

Guidelines for the management of ovarian cancer during pregnancy - Corrected Proof

2009-12-17

Abstract: Adnexal masses may be detected during prenatal ultrasound, and ovarian cancer may be suspected during pregnancy. Even though such masses are rarely malignant (1/10,000 to 1/50,000 pregnancies), the possibility of borderline tumour or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk.The care of a pregnant woman with cancer involves evaluation of sometimes competing maternal and fetal risks and benefits. These recommendations attempt to balance these risks and benefits; however, they should be considered advisory and should not replace specific interdisciplinary consultation with specialists in maternal–fetal medicine, gynecologic oncology and pediatrics, as well as imaging and pathology, as needed.Second level ultrasound including Doppler is needed. MRI is not often necessary, and CA 125 is of low contribution. We suggest surgery be performed after 15 weeks gestation for ovarian masses which (1) persist into the second trimester, (2) are greater than 5–10cm in diameter, or (3) have solid or mixed solid and cystic ultrasound characteristics. During the antepartum period surgical staging and debulking, unilateral salpingo-oophorectomy on the side with the tumour, peritoneal cytology and exploration are necessary. Women found to have advanced stage epithelial ovarian cancer should consider having completion of the debulking of the reproductive organs at the conclusion of the pregnancy. If chemotherapy is indicated, we recommend delaying administration, if possible, until after the delivery or at least after 20 weeks in order to minimize the potential fetal toxicity.

Macrosomia is the only reliable predictor of shoulder dystocia in babies weighing 3.5kg or more - Corrected Proof

Asmah Mansor, Kulenthran Arumugam, Siti Zawiah Omar — 2009-12-17

Abstract: Objective: To determine if shoulder dystocia can be predicted in babies born weighing 3.5kg or more.Study design: A case–control study nested in a perinatal database of 899 mothers and their babies who weighed 3.5kg or more. All were term pregnancies and delivered vaginally. A case was defined as any baby that encountered shoulder dystocia at delivery. Controls were deliveries over the same period that were not complicated by shoulder dystocia. A logistic regression model was created with macrosomia, parity, previous delivery of more than 3.5kg, diabetes in pregnancy, prolonged labor, prolonged second stage and instrumental delivery as the independent variables. The adjusted odds ratio and the receiver operator characteristics (ROC) curves were used to see if these variables, both individually and as a model, were associated with or were discriminative enough to predict shoulder dystocia; an ROC curve of more than 0.7 showing good prediction.Results: There were 36 cases of shoulder dystocia during the study period, an incidence of 4%. Previous delivery of more than 3.5kg, prolonged labor and prolonged second stage were not associated with shoulder dystocia. Although diabetes and instrumental delivery were independently and significantly associated with shoulder dystocia their importance as a predictor became relevant only in the presence of macrosomia.Conclusion: Macrosomia is the only reliable predictor of shoulder dystocia.

Migration and perinatal health surveillance: An international Delphi survey - Corrected Proof

Anita J. Gagnon, Meg Zimbeck, Jennifer Zeitlin — 2009-12-16

Abstract: Objective: While the perinatal health of migrants has been identified as a priority by many governments, there is no consensus on indicators for monitoring migration and perinatal health. The Reproductive Outcomes and Migration international research collaboration and the EURO-PERISTAT project convened an expert panel to recommend migration indicators for national and international monitoring of migration and perinatal health.Study design: A Delphi consensus process involved 38 perinatal clinicians, epidemiologists, and experts in health information systems from 22 countries who completed one or more questionnaires. Panel members ranked migration indicators from a list inventoried from the published literature.Results: Country of birth was considered ‘essential’ or ‘recommended’ for routine collection by 100% of respondents, followed by length of time in country (88%), language fluency (70%), immigration status (67%), and ethnicity as defined by maternal parents’ place of birth (55%). Feasibility with ‘minor’ or ‘no modifications’ to current data collection systems was highest for country of birth (69%), followed by length of time in country (61%). Other indicators were judged to be less feasible. In respect to migration, the perinatal health indicators considered to be ‘essential’ by 94% of respondents included fetal, neonatal, and infant mortality. A smaller proportion (73%) considered maternal mortality to be ‘essential’.Conclusions: A strong consensus was achieved for including country of birth in core perinatal health indicator sets. Length of time in country was also recommended as a second indicator for routine data collection. Specific studies should be undertaken to complement routine data collection on: immigration status, language fluency, and ethnicity as defined by maternal parents’ place of birth.

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

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

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

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

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

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

Pregnancy in immigrants: Are we doing the best we can? - Corrected Proof

2009-12-09

Recent decades have been characterized by important migratory flows from industrializing to industrialized nations , and immigrants bring new challenges to any health system. Given its strategic position, Italy is one of the first stops for immigrants arriving from Africa, Asia and Eastern Europe. The Veneto Region, located in North East Italy, has the second largest immigrant population in the country.

Evans’ syndrome in pregnancy: A systematic literature review and two new cases - Corrected Proof

Eleftheria Lefkou, Catherine Nelson-Piercy, Beverley J. Hunt — 2009-12-09

Abstract: Evans’ syndrome, the coexistence of immune thrombocytopenia (ITP) with autoimmune haemolytic anaemia (AIHA), is rare in pregnancy, with a few published cases. Concerns about the teratogenic effect of pharmacological agents used in the management of Evans’ syndrome limit the treatment options in pregnancy. In this paper we performed a systematic review of the literature of all published cases with Evans’ syndrome in pregnancy and we report two new cases. The review was performed by searching the electronic databases PubMed, EMBASE, Cochrane Library and Google scholar up to the end of December 2008. The selection criteria were Evans’ syndrome in pregnancy; autoimmune haemolytic anaemia; immune thrombocytopenia. Thirteen papers reporting 14 pregnancies in women with Evans’ syndrome have been published: 7 papers are written in English. Evans’ syndrome can be diagnosed with a full blood count, film and Coombs testing. It runs a more benign course in pregnancy than in non-pregnant state (notably neutropenia does not occur) and very often resolves post-delivery. The fetal outcome may be less favourable: a minority of fetuses are affected by transplacental passage of antibody and have a significant morbidity and mortality. With appropriate treatment, women with Evans’ syndrome can have successful pregnancies, with a good response to conventional treatment. More detailed studies of Evans’ syndrome in pregnancy, especially of fetal outcome, are required.

Evaluation of transobturator tapes (E-TOT) study: randomised prospective single-blinded study comparing inside-out vs. outside-in transobturator tapes in management of urodynamic stress incontinence: Short term outcomes - Corrected Proof

Mohamed Abdel-fattah, Iain Ramsay, Stewart Pringle, Chris Hardwick, Hassan Ali — 2009-12-09

Abstract: Objectives: To compare the “inside-out (TVT-O)” vs. “outside-in (ARIS)” transobturator tapes in the management of female urodynamic stress incontinence (USI) and to identify independent risk factors of failure of transobturator tapes.Study design: A prospective, single blinded, randomised trial. Women undergoing transobturator tapes as sole procedure in the period April 2005 and April 2007 were randomised to TVT-O™ for the inside-out approach and TOT–ARIS for the outside-in approach. The primary outcome measure at 6 months was the absence of USI on urodynamics. Secondary outcomes included; patient-reported success rates, overall patient satisfaction and peri-operative complications.Results: 341 women were recruited: 171 in the outside-in group and 170 in the inside-out. Severe post-operative thigh pain was twice as common in the inside-out group but this was not statistically significant (6.7% vs. 3.5%, p=0.19). 317 women completed the 6 months follow-up; objective cure rates and patient-reported success rates were 85.4 and 80.5%, respectively, with no significant difference between the groups (p=0.28 and p=0.138, respectively). On multivariate analysis: low maximum urethral closure pressure (MUCP) (<30cm H2O) and previous incontinence surgery were confirmed as independent risk factors for objective failure of transobturator tape with increased odds of failure of 7.06 (2.85–17.48) and 6.22 (2.34–16.52), respectively.Conclusion: This study shows no significant differences in the objective cure rates and patient-reported success rates between the “inside-out (TVT-O™)” and “outside-in (ARIS)” transobturator tape procedures in the management of female USI at 6 months follow-up. Previous incontinence surgery and low MUCP were significant risk factors for failure of transobturator tapes.

Different physical treatment modalities for lymphoedema developing after axillary lymph node dissection for breast cancer: A review - Corrected Proof

2009-12-07

Abstract: The purpose of this article is to provide a systematic review of Combined Physical Therapy, Intermittent Pneumatic Compression and arm elevation for the treatment of lymphoedema secondary to an axillary dissection for breast cancer. Combined Physical Therapy starts with an intensive phase consisting of skin care, Manual Lymphatic Drainage, exercises and bandaging and continues with a maintenance phase consisting of skin care, exercises, wearing a compression sleeve and Manual Lymphatic Drainage if needed.We have searched the following databases: PubMed/MEDLINE, CINAHL, EMBASE, PEDro and Cochrane. Only (pseudo-) randomised controlled trials and non-randomised experimental trials investigating the effectiveness of Combined Physical Therapy and its different parts, of Intermittent Pneumatic Compression and of arm elevation were included. These physical treatments had to be applied to patients with arm lymphoedema which developed after axillary dissection for breast cancer.Ten randomised controlled trials, one pseudo-randomised controlled trial and four non-randomised experimental trials were found and analysed. Combined Physical Therapy can be considered as an effective treatment modality for lymphoedema. Bandaging the arm is effective, whether its effectiveness is investigated on a heterogeneous group consisting of patients with upper and lower limb lymphoedema from different causes. There is no consensus on the effectiveness of Manual Lymphatic Drainage. The effectiveness of skin care, exercises, wearing a compression sleeve and arm elevation is not investigated by a controlled trial. Intermittent Pneumatic Compression is effective, but once the treatment is interrupted, the lymphoedema volume increases.In conclusion, Combined Physical Therapy is an effective therapy for lymphoedema. However, the effectiveness of its different components remains uncertain. Furthermore, high-quality studies are warranted. The long-term effect of Intermittent Pneumatic Compression and the effect of elevation on lymphoedema are not yet proven.

IVF outcome in women with PCOS, PCO and normal ovarian morphology - Corrected Proof

Alexander Swanton, Lisa Storey, Enda McVeigh, Tim Child — 2009-12-07

Abstract: Objective: To examine the outcome of IVF in women who have normal ovaries, ovulatory PCO or PCOS.Study design: Analysis of a prospectively collected database in an assisted conception unit in a university teaching hospital including 290 women <37 years of age undergoing their first IVF cycle. The main outcome measure was severe OHSS requiring hospitalization.Results: Severe OHSS rates were significantly higher in women with PCO (12.6%) and PCOS (15.4%) compared to those with normal ovaries (2.7%). Coasting was used significantly more often. Live birth rates per cycle started are similar among women with PCO (38%), PCOS (37%) and normal ovaries (40%).Conclusion: Women with ovaries of polycystic morphology are at increased risk of developing severe OHSS and of requiring avoidance techniques such as coasting, regardless of ovulatory status. However, live birth rates per cycle are similar to women with normal ovaries.

Increased plasma metastin levels in adolescent women with polycystic ovary syndrome - Corrected Proof

Xiaoli Chen, Yaqin Mo, Lin Li, Yaxiao Chen, Yu Li, Dongzi Yang — 2009-12-07

Abstract: Objective: This study was designed to:Study design: The study was a clinical study. Nineteen adolescent women with PCOS, twenty-three adult women with the syndrome, and twenty adolescent controls were selected. Blood samples were collected between day 1 and day 5 of a spontaneous bleeding episode in the PCOS groups and of a menstrual cycle of the controls at 9 a.m. after an overnight fast. Circulating levels of LH, FSH, prolactin, testosterone (T), free testosterone, DHEAS, sex hormone-binding globulin, insulin, glucose and metastin were measured.Result(s): Plasma metastin levels are increased in adolescent women with PCOS compared to adolescent controls. Plasma metastin levels were positively correlated with LH levels, 2-h glucose levels and T levels.Conclusion(s): These results indicate that metastin is increased in adolescent PCOS women. The increased metastin levels were positively correlated with LH and T levels, and may affect the development of PCOS in adolescents.

Maternal polycystic ovary syndrome may be associated with adverse pregnancy outcomes - Corrected Proof

2009-12-04

Abstract: Objective: To determine whether maternal polycystic ovary syndrome (PCOS) is associated with adverse pregnancy outcomes in a population of Italian parturients.Study design: Retrospective study carried out in an academic hospital in Bologna, Italy, including 516 consecutive Italian women who delivered between January and April 2006. PCOS women, women with hyperandrogenic features not configuring PCOS (Intermediate group) and non-hyperandrogenic controls were identified by a telephone survey of 229 women. Statistical analysis was performed using ANOVA or chi-square.Results: PCOS women, accounted for 6.6% of our cohort. Gestational diabetes mellitus (GDM) was significantly more frequent in the PCOS group than in the other groups (20% vs. 3.6% and 4%; P<0.01). The association of GDM and pregnancy-induced hypertension occurred in one subject in the PCOS group but in none of the other groups (P<0.001). Preterm birth was more frequent in the PCOS group than in control group (20% vs. 6.9%; P<0.05), whereas mean length of gestation was not different. The higher occurrence of adverse outcomes may be, at least partly, related to a higher weight gain during pregnancy in PCOS group with respect to the other groups (P<0.05).Conclusions: Women affected by PCOS carry an increased risk of adverse pregnancy outcomes.

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

2009-12-04

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

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

2009-12-04

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

Re-vascularisation in human ovarian tissue after conventional freezing or vitrification and xenotransplantation - Corrected Proof

2009-12-04

Abstract: Objective: In ovarian tissue grafts there is a massive loss of follicles during the ischaemic period until re-vascularisation is established. The aim of our study was to investigate the influence of different cryopreservation techniques on the ability for the re-vascularisation of ovarian tissue transplanted to SCID mice.Study design: Ovarian fragments from five patients were cut into pieces (∼0.5mm×1.0mm×1.0mm) and randomly distributed into three groups: fresh non-treated tissue (group A); tissue conventionally frozen in standard 0.5ml insemination straws with 1.5M ethylene glycol+0.1M sucrose, with thawing in a 40°C water bath and step-wise removal of cryoprotectants at room temperature in 0.5M, 0.25M and 0.15M sucrose with gentle agitation (group B); tissue vitrified in 2.62M dimethylsulphoxide+2.6M acetamide+1.31M propylene glycol+0.0075M polyethylene glycol, with warming by direct plunging of solid specimens with ovarian pieces into 20ml of 50% vitrification solution pre-warmed to 40°C and dilution of cryoprotectants in a decreasing concentration of vitrification solution (25%, 12.5%) at room temperature (group C). We used a xenograft model in which ovarian tissue pieces of all three groups were subcutaneously transplanted in SCID mice. The animals were sacrificed on the third day after ovarian tissue transplantation and then weekly during 1 month to obtain the ovarian tissue grafts. These samples were examined by immunohistochemical staining with the endothelial cell-specific marker platelet endothelial cell adhesion molecule-1 (PECAM-1) to determine angiogenesis. Histological observation of tissue after explantation was performed and quality and quantity of follicles were assessed.Results: No PECAM-1 staining was observed in all treatment groups prior to grafting. After warming and in vivo culture of ovarian tissue, the beginning of angiogenesis in pieces from all treatment groups on the third day was detected by PECAM-1 staining. After 4 weeks of in vivo culture the overall area of PECAM-1-positive blood vessels significantly increased (P<0.05), independent of the type of cryopreservation (groups B and C vs. group A). It was found that transplantation technique had negative influence on the integrity of follicles independent of the type of treatment during in vivo culture. The duration of in vivo culture has a negative, but not statistically significant, influence on follicle quality in long-cultured transplants inside each treatment group (P>0.5).Conclusion: The process of re-vascularisation of transplanted ovarian tissue is independent of the type of treatment and does not influence follicle quality.