Extremely low ventricular rate in a fetus with an isolated non-autoimmune complete congenital heart block. Case report

Congenital complete heart block (CCHB) is an uncommon disorder with an incidence of about 1/20,000 in liveborn infants. It can occur in the setting of structurally normal heart or with structural disease; it is associated with high mortality and morbidity and requires a high index of suspicion for early diagnosis and therapy. Isolated CCHB in a fetus is usually associated with the presence of autoantibodies to SSA (Ro) and SSB (La) antigens in the maternal circulation. Such antibodies cross into the fetal circulation and cause inflammation of the conduction tissues; the causal mechanism is not known. Although the prognosis for the majority of fetuses is good, it is less favourable in fetuses with a ventricular rate <55 bpm in early pregnancy or with a decrease in the ventricular rate by >5 bpm during pregnancy. It is not known if the same prognostic criteria apply for fetuses with isolated non-autoimmune CCHB. This article reports authors' experience in managing a pregnancy with an extremely low fetal heart rate (47 bpm) in a single fetus with an isolated non-autoimmune CCHB in which the outcome was favorable.     

Identification of a human sperm antigen to infertile women's serum and follicular fluid with high sperm immobilizing activity

In our previous paper, we reported a sperm coating antigen with a molecular weight of approximately 12,000 daltons from sperm membrane fraction by using rabbit anti-seminal plasma antiserum. In this paper, we isolated a human sperm antigen with the same sperm preparation by using sera of infertile women with sperm immobilizing antibody. The isolated antigen showed the following characteristics: (1) It is a glycoprotein with an affinity with lentil lectin and its molecular weight is approximately 15,000 daltons. (2) Little activity of the antigen was seen in seminal plasma. The antigen is localized on the equatorial segment of the acrosome. These facts indicate that the antigen is a genuine sperm antigen and is not a sperm coating antigen. (3) The antigen is bound with the sperm immobilizing antibody in follicular fluid of an infertile woman who has a sperm immobilizing antibody in her serum. This indicates that sperm immobilizing antibody in follicular fluid recognizes the same antigen as in the serum.     

Rupture of an unscarred uterus with misoprostol induction: case report and review of the literature

Uterine rupture is a serious and often tragic complication that is life threatening to both mother and child. It occurs at a frequency of around 1% in patients with a previously scarred uterus. Rupture of an unscarred uterus is an unexpected and devastating complication of pregnancy. With the increased use of misoprostol as a labor-inducing agent, cases of rupture of an unscarred uterus following its use have been published in the literature. We report a case of uterine rupture in a multigravid woman with an intrauterine fetal death at 29 weeks' gestation whose labor was induced with misoprostol. A review of all cases of uterine rupture with misoprostol induction is also included. Excessive doses of misoprostol should be used with extreme caution in multiparous women and in patients with a previously scarred uterus even in the context of intrauterine fetal death or termination of pregnancy.     

Anti-Müller-Hormon (AMH)

Anti-Mullerian hormone (AMH) is produced by Sertoli cells in men and granulosa cells in women. It is interesting from a clinical point of view in evaluating the ovarian reserve in women of reproductive age. AMH is mainly produced by primary, secondary and early antral follicles and is therefore a marker of the growing follicle pool in the ovary. AMH correlates with age, with the number of oocytes retrieved in an in vitro fertilization (IVF) cycle and with the pregnancy and birth rate. AMH is stable over the cycle, with only a small drop after ovulation. AMH is stable and can be measured to evaluate the ovarian reserve during treatment with oral contraceptive pills and during pregnancy. AMH is also a useful tumor marker for granulosa cell tumors. In newborns or children with intersex disorders, AMH can be measured to evaluate whether or not testicular tissue is present.     

Hysteroscopic endometrial resection and high-dose-rate brachytherapy: treatment of endometrial cancer in a medically compromised patient.

OBJECTIVE: The use of a combined treatment option for endometrial cancer in a medically compromised patient is outlined. METHODS/RESULTS: A case of a 49-year-old severely medically compromised patient with endometrial cancer is described. A complete hysteroscopic endometrial resection with insertion and suturing in place of an endocervical cannula allowed weekly outpatient delivery of high-dose-rate intracavitary radiation without anesthetic or repeat dilatation of the endocervical canal. CONCLUSION: The use of hysteroscopic endometrial resection with adjuvant high-dose-rate radiation therapy is a feasible treatment option for patients with endometrial cancer in whom surgery is contraindicated.     

Vaginal birth after cesarean delivery.

VBAC is considered safe and is often successful in carefully selected populations of women. Women with prior CDs are given the option of elective repeat CD or a trial of labor; neither option is risk free. Less morbidity is encountered in women with successful VBACs versus those with elective repeat CD. Patients who undergo successful trials of labor experience fewer blood transfusions, fewer postpartum infections, and shorter hospital stays and generally have no increased perinatal mortality. The high CD rate begins with the high frequency of the first CD. Therefore, a concerted effort should be made to decrease primary CDs. Paul and Miller remind us of the importance of the decision to proceed with the initial CD in their statement, "once a cesarean, always a scar (p 1907)." Many patients present for prenatal care with one or more prior uterine scars. Careful and thoughtful counseling of patients with a previous CD regarding the risks and benefits of a labor trial based on the current available literature is prudent. Pitkin's editorial in Obstetrics and Gynecology in 1991 stated, "Without question, the most remarkable change in obstetric practice over the last decade involves management of the woman with a prior cesarean delivery (p 939)." Controversies regarding the management of women with scarred uteri remain. In his review of the CD controversy, Flamm leaves us with an important thought: "A woman with a prior cesarean is at increased risk regardless of her mode of birth, and eliminating VBAC will not eliminate the risks. Vigilance with respect to primary cesarean delivery is the only way to avoid this dilemma (p 315)."     

The limited role of splenectomy in patients with leukemia

Splenectomy is a valuable method of management of approximately 80 per cent of patients with hairy cell leukemia who have hypersplenic complications develop; operation can be performed with minimal morality and morbidity. Removal of the spleen also provides useful palliation in patients with chronic lymphocytic leukemia who have symptomatic splenomegaly or autoimmune hemolytic anemia; success is less predictable when operation is performed for thrombocytopenia. Splenectomy is linked with a high mortality and is of little benefit in patients with chronic granulocytic leukemia except when operation is performed as a prerequisite to bone marrow transplantation. Several patients with acute leukemia who have signs of splenic infarction and intra-abdominal bleeding develop had a short survival period after splenectomy.     

The surgical treatment of coarctation of the aorta.

Patients with coarctation of the aorta have a significantly decreased life expectancy. Surgical correction is curative and involves a low mortality rate which increases with coexisting cardiovascular abnormalities. In our series, there were no operative deaths in patients with pure coarctation of the aorta. Age is an important factor and postoperative complications were more frequent in older patients. Re section of the narrowed area with end-to-end anastomosis is the technique of choice. If theis is not possible, a Dacron tube is a good alternative. Early diagnosis and early intervention are of utmost importance, even in asymptomatic patients.     

Epidemiology of gestational trophoblastic diseases

The epidemiology of gestational trophoblastic diseases is unclear. Problems with collection and interpretation of differing data abound. Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. This is further influenced by age, ethnicity and a prior history of an HM suggesting a genetic basis for its aetiology. Whilst a prior HM is significant in the development of trophoblastic neoplasia there is no clear explanation for the development of gestational trophoblastic neoplasia in association with a normal gestation. The development and improvements in suction curettage, termination of pregnancy, contraceptive techniques, diagnostic imaging and biochemical testing have been associated not only with a fall in the birth rate, but also with a reduction in the incidence of trophoblastic diseases. Future study should examine the mechanism of malignant change in normal and abnormal trophoblast.     

Epidemiology of complete hydatidiform mole in Paraguay

The incidence of complete hydatidiform mole in Paraguay is 0.23-0.25 cases per 1,000 pregnancies. The incidence is as high at the extremes of reproductive age as at other ages. That finding is at variance with long-accepted concepts. The incidence in the 15- to 19-year age group is lower than earlier, with a greater use of contraceptives in the older group. Complete mole is a rare condition with a high incidence in certain geographical areas.     

The burden of premature ejaculation: the patient's perspective

Premature ejaculation (PE) remains an underdetected and under-treated condition, despite the advances in available treatment options. Men with PE often feel stigmatized by the condition and embarrassment is a key barrier to discussing the problem with healthcare professionals. Men with PE perceive themselves as having little control over ejaculation and this lack of control is mirrored in diminished satisfaction with sexual intercourse. The burden of PE is both emotional and physical. Premature ejaculation is associated with low self-esteem, anxiety, and feelings of shame and inferiority. In some studies there is an association with depression. Premature ejaculation places a significant burden on the patient-partner relationship and there is evidence to suggest that there is a higher prevalence of female sexual dysfunction associated with PE. Patients with PE often view the condition as purely psychological or as a problem that will resolve with time and many are unaware that medical treatment could be of benefit. This endorses the particularly important role of healthcare professionals in recognizing the barriers to patient diagnosis and promoting the view that PE is not only a common but also a treatable medical condition.     

A new hyrogen ion telemetry technique for evaluating gastroesophageal reflux.

A new pH capsule telemetry technique was used to measure the pH fluxes in the upper part of the gastrointestinal tract in normal volunteers, symptomatic patients and in those with hiatal herniorrhaphy during the preoperative and postoperative period. The Darvon-sized pH capsule is swallowed with ease and with minimal discomfort by a fasting patient. The pH of the surrounding media activates an FM radio transmitter within the capsule to emit a continuous radio signal which is converted by a receiver to a linear graph on a strip chart recorder. This pH capsule telemetry test is easy to perform on an ambulatory basis and allows an accurate and reproducible determination of the presence or absence of esophageal reflux in patients with and without a hiatal hernia. Its correlation with symptomatic reflux is higher than that found with a conventional gastrointestinal series examination. The technique allows a much clearer distinction to be made between those patients with real symptomatic esophagitis secondary to actual reflux and those with other esophageal, cardiac or pulmonary symptoms existing withour reflux. This study also reveals a consistently lower fasting gastric pH in patients with signs and symptoms of reflux than in normal individuals without reflux. The technique enabled a more accurate assessment of the efficacy of hiatal hernia repair and revealed a reduced degree of esophageal reflux in those patients who had undergone successful repair with fundic plication.     

La anticoncepción en la mujer obesa

The increasing prevalence of obese women of childbearing age is a public and social health crisis. Contraception is a key issue in women with obesity. Obese women have a sexual activity no different from women of normal weight, and the use of contraception is considered less effective, as there is a higher risk of having an unwanted pregnancy. Due to a variety of metabolic disorders, obesity is a cardiovascular risk factor that can increase when combined with hormonal contraception. All these factors should be considered when choosing a contraceptive method in an obese woman. The objective of this review is to evaluate the risk-benefit of each type of available contraception, and the problem of contraception after bariatric surgery, in order to provide doctors with a practical guide on the use of oral contraceptive pills in obese women.     

Pregnancy and functional paraganglioma

The association of pregnancy with a catecholamine-secreting tumor is rare. The high maternal and fetal mortality rate is significantly reduced when the diagnosis is made antepartum and adequate management is started. In 1979 Burgess reviewed 42 cases with antepartum diagnosis, demonstrating the benefits of alpha-blockade (Obstet Gynecol 1979; 53:266-270). When diagnosis was made in the third trimester of pregnancy, a combined procedure of cesarean section and tumor resection was best. The best surgical approach in first- and second-trimester diagnosis, however, remains controversial. A case with second-trimester diagnosis is described. Following a period of alpha- and beta-blockade, a combined surgical procedure in the third trimester resulted in a healthy mother and infant. Follow-up procedures included a meta-iodobenzylguanidine scan of the mother. Postpartum, ultrasonography of the child's brain revealed periventricular leucomalacia. The prognosis associated with this finding is poor. Some more recent information about certain aspects of these tumors is also discussed.     

Preventing endometrial cancer risk in polycystic ovarian syndrome (PCOS) women: Could metformin help?

Current data indicate that there is a significant risk of endometrial cancer (EC) in women with polycystic ovarian syndrome (PCOS), although further research needed to clarify the exact molecular mechanisms. Endometrial hyperplasia is a premalignant condition that usually heralds EC and it shares identical risk factors with EC. Metabolic syndrome with a triad of obesity, hyperinsulinaemia and diabetes, which is commonly observed in PCOS appears to be a key mechanism in EC pathogenesis. Measures to improve insulin resistance could therefore play a role in reducing the risk of EC in women with PCOS. Metformin is an insulin sensitising agent which is safe, widely available and currently licensed for type-2 diabetes. It has been clearly shown in both animal and human studies that metformin is of value in reversing endometrial hyperplasia. Metformin may therefore prevent EC in PCOS. This article reviews the use of metformin in reducing EC risk in PCOS and makes a case for future research on this topic.     

Invasive squamous cell carcinoma of the vagina in the setting of true hermaphroditism

BACKGROUND: Primary vaginal cancer constitutes less than 2% of all malignancies of the female genital tract and is even rarer in true hermaphrodites. A unique case report of the occurrence of both of these developments in the same patient is presented. CASE: A 31-year-old 46,XX hermaphrodite presented with a history of vague abdominal symptoms and weight loss. Surgery was performed, and pathology revealed invasive squamous cell cancer arising in an epithelial-lined tissue consistent with vagina. The patient subsequently completed whole pelvic external-beam radiation therapy with cisplatin chemosensitization. CONCLUSION: This is a case of primary vaginal cancer in a patient with true hermaphroditism, which is exceedingly rare. It is a reminder that malignant changes in residual mullerian tissue should be considered in these patients.     

血小板膜糖蛋白Ⅱb/Ⅲa受体与子痫前期

糖蛋白Ⅱb/Ⅲa（glycoproteinⅡb/Ⅲa,GPⅡb/Ⅲa）受体是血小板膜上最丰富的一种蛋白,在血小板聚集、血栓形成过程中起关键性调节作用。子痫前期是一种病因不明伴有多系统功能障碍的病理妊娠,表现为高血压、蛋白尿、高凝血、高纤溶倾向,是围产期孕产妇死亡的主要原因,又是产妇远期并发心脑血管疾病的高危因素。GPⅡb/Ⅲa受体在子痫前期发病过程中起“承前启后”的调节作用,有可能为子痫前期的病因探索、临床治疗提供新的突破。     

A clinical opinion on how to manage the risk of preterm birth in twins based on literature review

Twin pregnancies are prone to preterm birth and consequent morbidity. There is an increasing evidence base concerning the prediction and prevention of preterm birth in singletons, including the reduction of morbidity with therapies such as magnesium sulphate and antenatal corticosteroids. However, the research in twins is less clear, partly due to fewer numbers being investigated, but also evidence is largely based on twins without a previous history. Prophylactic interventions such as cerclage, progesterone and vaginal pessaries are increasingly showing benefit in singleton pregnancies with a prior history and when the cervix is short. Cerclage in twins has not been adequately researched in women with previous preterm birth, and as with singletons should not be used on the basis of a short cervix alone. Vaginal progesterone does not work in twins, but its value in high-risk twins, with a prior history and short cervix is uncertain. The vaginal pessary may be valuable in the twin with a short cervix. Currently, it is reasonable to extrapolate some of the evidence from singletons to twins, e.g. with antenatal corticosteroids and magnesium sulphate. Cerclage, vaginal pessaries and progesterone should not be routinely used in twin pregnancies without an additional high-risk factor such as prior history of preterm birth or short cervix, until further evidence is obtained.     

Obesity and menstrual disorders

Obesity is a growing public health concern and is associated with a range of menstrual disorders, including heavy menstrual bleeding, oligomenorrhea, dysmenorrhea, and endometrial pathology. Investigations may be more logistically challenging in those in the population with obesity, and because of the heightened risk of endometrial malignancy, there should be a low threshold for biopsy to exclude endometrial hyperplasia. Although treatment modalities for women with obesity are broadly similar to those with a normal BMI, additional consideration must be given to the risks associated with estrogen in obesity. Outpatient management of heavy menstrual bleeding is a developing field and outpatient treatment modalities are preferable in the population with obesity to avoid the morbidity associated with anesthetics.     

Clinical management of the short cervix

Cervical cerclage is associated with prolongation of gestation in singleton pregnancies with prior spontaneous preterm delivery and a short cervix on vaginal ultrasonography in the mid-trimester. Ultrasound screening of cervical length is not indicated in low-risk singleton pregnancies and in women with multiple gestations. 17α-Hydroxyprogesterone does not prevent preterm delivery in twin gestations with a short cervix. Cervical cerclage may cause detrimental effects in twin gestations. Vaginal pessary for the prevention of preterm birth in women with a short cervix is currently under active investigation.