Myomectomy using purse-string suture during cesarean section

Background

Conventionally, myomectomy during cesarean section is reserved only for pedunculated myomas because resection of myomas at the time of cesarean section usually stimulates profuse bleeding.

Cases

Thirty-one patients underwent myomectomy using purse-string suture during cesarean section. Myoma could be excised without profuse bleeding, while an assistant maintains strong tension on the purse-string suture around the myoma. The suture was tightened and tied immediately after complete resection of the myoma and then stitches of another purse-string suture were placed alternately with each previous stitch in the inner side of the first suture. We have used this method for more than 3 years and have not observed failures and serious complications, such as late hemorrhage and uterine rupture during a subsequent pregnancy.

Conclusion

Myomectomy using purse-string suture during cesarean section is a safe, useful, and convenient technique.

     

Symptoms of uterine myomas: data of an epidemiological study in Germany

Purpose

Currently, no reliable data are available concerning the type and frequency of symptoms in premenopausal women with uterine myomas.

Methods

2296 women were examined by means of vaginal ultrasound for the presence of myomas in seven gynaecological outpatient departments in Germany. From this population, 1314 premenopausal women between the ages of 30 and 55 years were evaluated to determine the type and frequency of myoma-related symptoms and their relationship to anamnestic factors, and the number, size, and location of the myomas. Standardised questionnaires were used to record the symptoms.

Results

Prevalence: In almost every second premenopausal woman (n = 639; 48.6%), uterine myomas were diagnosed. The frequency of myomas increased continuously with age and was highest in women between 46 and 50 years (65.2%). Age itself was found to be the main risk factor for the presence of myomas (p < 0.001). Symptoms: 54.3% (n = 347) of the women suffered from myoma-related symptoms. The four main symptoms were identified as: Heavy menstrual bleeding (40.7%), dysmenorrhoea (28.2%), lower abdominal pain (14.9%), and intermenstrual bleeding (14.1%). In the majority of cases, the symptoms occurred simultaneously. Determinants for symptoms: Symptoms did not follow a clear age-related trend, whilst the number and size of the myomas did determine the presence of symptoms. The main influencing factor for the presence of intermenstrual bleeding was the location of the myomas.

Conclusions

The high prevalence of uterine myomas highlights the importance of the diagnosis uterine myomas in standard gynaecological practice: The presence of only one myoma caused symptoms in 46.5% and small myomas of up to 2 cm in diameter resulted in symptoms in 39.5%.

     

Effectiveness of the contemporary treatment of preterm labor: a comparison with a historical cohort

Aim

To evaluate the outcome of a cesarean myomectomy (CM) versus a cesarean delivery (CD) alone in women with uterine myomas and the risk factors for adverse outcomes.

Methods

A retrospective cohort study of all women undergoing CDs with uterine leiomyomatas and singleton pregnancies was performed. Patients with known risk factors for hemorrhage were excluded. Measured adverse outcome parameters included estimated blood loss, drop in hemoglobin levels (pre/postoperatively), operation time, and the use of additional uterotonics. Outcome parameters of women with CM were compared to women with CD alone. Possible risk factors for adverse outcomes were analyzed in a multivariate regression analysis. Evaluated risk factors for CM were according to localization and type of myomatas, the myoma size, BMI ≥30 kg/m², age ≥40 years, fetal weight ≥4 kg, repeat CD, and unplanned CD in the first stage of labor. The influence of localization and myoma type were further analyzed in a subgroup analysis.

Results

Of the 162 women with uterine myomatas during CD, 48 underwent CM and were analyzed. Overall, CM was not associated with adverse outcomes. Independent of a concomitant myomectomy, a large myoma size of ≥5 cm was associated with an increased blood loss of ≥500 ml (adj. OR 2.7 CI 95 % 1.2–6.2, p = 0.02), and women ≥40 years of age had a significant postoperative drop in hemoglobin (adj. OR 2.4 CI 95 % 1.0–5.4, p = 0.04). In the univariate subgroup analysis, CM of multiple myomatas was associated with an increased blood loss and an increased operation time compared to women with multiple myomatas and CD alone. Prolonged operation times were also observed in women with pedunculated and subserosal myomatas with concomitant myomectomy. There were no cases of hysterectomy or blood transfusions.

Conclusion

CM performed by an experienced obstetrician can be safe in selected patients who are without additional preexisting risk factors. Risk factors that are associated with increased blood loss in women with uterine leiomyomatas include a larger size of the leiomyoma (≥5 cm) and a maternal age of ≥40 years.

     

Kinderwunsch und Schwangerschaft bei Endometriose

Background

Endometriosis is the second most frequent benign gynecological disease in women during the fertile period after uterine myoma. Endometriosis is frequently associated with infertility.

Objective

The aim of this article is to provide insights into the causes and treatment options for patients with endometriosis and a desire for children and to discuss the influence of endometriosis on pregnancy.

Material and methods

This article gives a review and summary of the current literature on this topic.

Results and conclusion

Surgical removal of endometriosis can have a positive impact on the prognosis for spontaneous conception. Endometriosis should no longer be automatically surgically treated prior to in vitro fertilization (IVF) treatment or intracytoplasmic sperm injection (ICSI). Although there is no proven impact of ovarian endometriosis, deep infiltrating endometriosis and colorectal endometriosis on the probability of pregnancy after IVF or ICSI treatment, these lesions can potentially have a harmful effect during pregnancy.

     

Endometrial preparation with Dienogest before hysteroscopic surgery: a systematic review

Purpose

Hysteroscopic surgery is considered the gold standard for the minimal invasive treatment of many endouterine diseases such as endometrial polyps or submucous myomas. Recently, many studies have evaluated the effect of preoperative administration of a number of drugs to reduce endometrial thickness and achieve important intraoperative advantages. The purpose of this systematic review is to summarize the available evidence about the use of Dienogest, an orally administrable progestin, for endometrial preparation before hysteroscopic surgery.

Methods

All studies published on this topic and indexed on PubMed/MEDLINE, Embase or Google scholar databases were retrieved and analysed.

Results

We retrieved five studies about this topic. Considered together, the published data analyses allow us to conclude that Dienogest is effective in reducing the thickness of the endometrium, the severity of bleeding and also of operative time, with a lower number of side effects compared with other pharmacological preparations or no treatment.

Conclusion

Administration of Dienogest may be an effective and safe treatment for endometrial thinning before operative hysteroscopy. However, this conclusion is based on few reports and further studies to prove or disprove it are warranted.

     

Investigating the clinical potential for 14-3-3 zeta protein to serve as a biomarker for epithelial ovarian cancer

Objective

Recently, 14-3-3 zeta protein was identified as a potential serum biomarker of epithelial ovarian cancer (EOC). The goal of this study was to investigate the clinical potential of 14-3-3 zeta protein for monitoring EOC progression compared with CA-125 and HE4.

Design

Prospective follow-up study.

Setting

University of Pecs Medical Center Department of Obstetrics and Gynecology/Oncology (Pecs, Hungary).

Population

Thirteen EOC patients with advanced stage (FIGO IIb-IIIc) epithelial ovarian cancer that underwent radical surgery and received six consecutive cycles of first line chemotherapy (paclitaxel, carboplatin) in 21-day intervals.

Methods

Pre- and post-chemotherapy computed tomography (CT) scans were performed. Serum levels of CA-125, HE4, and 14-3-3 zeta protein were detected by enzyme-linked immunosorbent assay (ELISA) and quantitative electrochemiluminescence assay (ECLIA).

Main outcome measures

Serum levels of CA-125, HE4, and 14-3-3 zeta protein, as well as lesion size according to pre- and post-chemotherapy CT scans.

Results

Serum levels of CA-125 and HE4 were found to significantly decrease following chemotherapy, and this was consistent with the decrease in lesion size detected post-chemotherapy. In contrast, 14-3-3 zeta protein levels did not significantly differ in healthy postmenopausal patients versus EOC patients.

Conclusions

Determination of CA-125 and HE4 serum levels for the determination of the risk of ovarian malignancy algorithm (ROMA) represents a useful tool for the prediction of chemotherapy efficacy for EOC patients. However, levels of 14-3-3 zeta protein were not found to vary significantly as a consequence of treatment. Therefore we question if 14-3-3 zeta protein is a reliable biomarker, which correlates with the clinical behavior of EOC.

     

A long-standing incomprehensible matter of obstetrics: meconium-stained amniotic fluid,a new approach to reason

Objective

We sought to determine whether meconium-stained amniotic fluid is based on chronic hypoxia or not? In case of chronic hypoxia, higher red blood cell (Rbc) count and/or total hemoglobin levels (Hgb) and/or higher fetal hemoglobin (HbF) and/or lower adult hemoglobin (HbA) levels were expected when compared with controls.

Design

Case–control study.

Setting

Obstetric unit of a tertiary ministry of health hospital.

Sample

Fifty singleton pregnancies with meconium-stained amniotic fluid and 50 singleton pregnancies with clear amniotic fluid at all stages of labor.

Methods

Umbilical cord blood samples were collected for determination of total blood parameters and hemoglobin electrophoresis.

Main outcome measures

Red blood cell count, total hemoglobin, fetal and adult hemoglobin contents (HbF and HbA).

Results

Red blood cell count, total hemoglobin, fetal hemoglobin (HbF) and adult hemoglobin (HbA) contents were not different between meconium stained and clear amniotic fluid groups.

Conclusion

These results suggest that meconium passage may not be associated with chronic fetal hypoxia as demonstrated by similar red blood cell count, total hemoglobin values and fetal hemoglobin (HbF) and adult hemoglobin (HbA) contents.

     

Hemostasis Techniques in Myomectomies

Purpose of Review

Myomectomy can be associated with significant blood loss, particularly when large and numerous fibroids are removed. Surgeons have incorporated a large number of methods to reduce blood loss, including pre-operative optimization, the use of minimally invasive surgery, and intraoperative techniques. The purpose of this review is to summarize these methods and evaluate the literature supporting those with clinical value.

Recent Findings

The use of minimally invasive surgery has clear benefit in reducing blood loss in myomectomy for appropriately selected patients. Preoperative hormonal treatments reduce myoma size and reduce the complexity of myomectomy. Myometrial vasoconstriction, vessel ligation or compression, and the use of barbed suture decrease blood loss in myomectomy.

Summary

Surgeons should be aware of the large number of pre-operative and intraoperative measures to reduce blood loss in myomectomy and employ those with proven clinical benefit, particularly in operations that are likely to involve excessive bleeding and the need for transfusion.

     

Is the yolk sac a new marker for chromosomal abnormalities in early pregnancy?

Introduction

Abnormal yolk sac size is associated with fetal miscarriage. This is a case report of two pregnancies with abnormal yolk sacs.

Materials and methods

In one case, a twofold sac was found; in the other case, the yolk sac was not of spherical form.

Conclusion

Currently available publications demonstrate a correlation between abnormal yolk sac size and miscarriage. However, in both cases a trisomy was confirmed. It should therefore be discussed whether form and size of the yolk sac could be a marker for chromosomal abnormalities of the fetus.

     

Recommendations for the surgical treatment of endometriosis—part 1: ovarian endometrioma

Study question

What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?

Summary answer

This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.

What is already known

Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.

Study design, size and duration

A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.

Participants/materials, setting and methods

This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.

Main results and the role of chance

The document presents general recommendations for surgery of endometrioma and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.

Limitations and reasons for caution

Owing to the limited evidence available, recommendations are mostly based on clinical expertise.

Wider implications of the findings

These recommendations complement previous guidelines on the management of endometriosis.

Study funding/competing interests

The meetings of the working group were funded by ESGE, ESHRE and WES. CB declares to be a member of the independent data monitoring committee for a clinical study by ObsEva and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences and Volition. ES received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest.

     

Decision making processes of women who seek elective oocyte cryopreservation

Purpose

The aim of this study is to analyze women’s opinions and their decision making processes regarding elective oocyte cryopreservation (OC).

Methods

One hundred twenty-four women who had elective OC counseling at the CHA Seoul Fertility Center were asked to complete a survey after their first visit. Data collection regarding age, marital status, monthly income, occupation, religion, reproductive history, questions about the participant’s view on their own fecundity, and future parenthood were included. The modified Reproductive Concerns After Cancer scale and the Decisional Conflict Scale were used for analysis.

Results

The participants’ mean age was 37.1?±?4.8 years old. Eighty-six percent of the participants had regular periods. Ninety-two percent thought it was important to have their own biological offspring, and 86% were willing to pursue OC. Forty-nine percent appeared to have high DCS scores regarding making a decision of OC. Sixty-eight percent pursued OC, and the mean number of oocytes cryopreserved per patient was 10.5?±?8.3. Multivariate analysis revealed that age was the only factor associated with high DCS scores (P?=?0.002). Feeling less fertile than other women of same age and low DCS scores were the factors associated with pursuing OC (P?=?0.02 and 0.004, respectively) after adjusting for possible confounding factors, including age.

Conclusions

Older women had more difficulties in making decisions about OC. Adjusting for age, women who thought that they were less fertile than other women of same age and those with lower decisional conflict were more likely to pursue OC. Further studies should focus on the validation of older women’s decisional conflicts regarding OC.

     

Osteoprotegerin (OPG) activates integrin,focal adhesion kinase (FAK), and Akt signaling in ovarian cancer cells to attenuate TRAIL-induced apoptosis

Background

Resistance to apoptosis is a major problem in ovarian cancer (OC) and correlates with poor prognosis. Osteoprotegerin (OPG) is a soluble secreted factor that acts as a decoy receptor for receptor activator of NF-κB ligand (RANKL) and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). OPG has been reported to attenuate TRAIL-induced apoptosis in a variety of cancer cells, including OC cells. OPG-mediated protection against TRAIL has been attributed to its decoy receptor function. However, OPG activates integrin/focal adhesion kinase (FAK) signaling in endothelial cells. In OC cells, activation of integrin/FAK signaling inhibits TRAIL-induced apoptosis. Based on these observations, we hypothesized that OPG could attenuate TRAIL-induced apoptosis in OC cells through integrin/FAK signaling.

Methods

In vitro experiments including immunoblots, colony formation assays, and apoptosis measurements were used to assess the effect of OPG on TRAIL-induced apoptosis.

Results

Exogenous OPG protected from TRAIL-induced apoptosis in a TRAIL binding-independent manner and OPG protection was αvβ3 and αvβ5 integrin/FAK signaling-dependent. Moreover, OPG-mediated activation of integrin/FAK signaling resulted in the activation of Akt. Inhibition of both integrin/FAK and Akt signaling significantly inhibited OPG-mediated attenuation of TRAIL-induced apoptosis. Although OPG also stimulated ERK1/2 phosphorylation, inhibition of ERK1/2 signaling did not significantly altered OPG protection.

Conclusions

Our studies provide evidence, for the first time, that OPG can attenuate TRAIL-induced apoptosis in a TRAIL binding-independent manner through the activation of integrin/FAK/Akt signaling in OC cells.

     

Handling aberrant vessels located in the posterior bladder wall in surgery for abnormally invasive placenta: a non/less-touch technique

Background

At cesarean hysterectomy for abnormally invasive placenta, rupture of aberrant vessels around the uterus causes massive bleeding.

Purpose

This study aimed at describing a technique to reduce bleeding from aberrant vessels at the posterior bladder wall in this surgery.

Methods

The bladder is filled with 200–300 mL of water during handling the posterior bladder wall.

Results

This technique facilitates understanding that some aberrant vessels do not have communications with the cervix-uterus. Some aberrant vessels have communication with the cervix-uterus and this technique makes cutting and ligation of these vessels easy.

Conclusions

Filling the bladder may reduce bleeding from the posterior bladder wall at cesarean hysterectomy for abnormally invasive placenta.

     

Effects of dietary advice on insulin-like growth factors among healthy newborns

Objectives

In fetal life, insulin, insulin-like growth factor (IGF) 1, IGF 2 and IGF-binding protein (IGFBP) 3 are essential growth factors. The purpose of this study is to investigate the effects of dietary intervention on insulin-like growth factors in the cord blood of neonates.

Methods

The study involved 52 pregnant women who were followed up in Gazi University Medical School Hospital at Ankara, Turkey. They were randomly divided into two groups: The experimental group was involved in nutrition education. We measured IGF 1, IGF 2 and IGFBP 3 concentrations in cord blood from 52 neonates.

Results

In the experimental group, cord serum levels of IGF 1, IGF 2 were observed to be higher than that of control group.

Conclusion

Dietary advice had positive effects on the cord serum IGF 1 and IGF 2 concentrations. Dietary advice during pregnancy proved to be effective in fetal development.

     

Sirenomelia: a review on embryogenic enviromental theories,novel three-dimensional ultrasound imaging and first trimester diagnosis in a case of mosaic 69,XXX/46,XX fetus

Purpose

Sirenomelia is caused by atrophy of the lower extremities that is commonly associated with gastrointestinal and urogenital malformations.

Methods

Embryogenic environmental theories and systematic review of the literature are reported.

Results

Genetic basis of the condition has been demonstrated in the animal model. In humans, association with de novo balanced translocation has only recently been documented.

Conclusions

A case of triploidy mosaic fetus with sirenomelia and posterior fossa anomaly diagnosed at first trimester using novel three-dimensional ultrasound imaging techniques is presented.

     

Pulsatile Gonadotropin-Releasing-Hormon-Behandlung

Background

Pulsatile gonadotropin-releasing hormone (GnRH) therapy is an option for ovulation induction in patients with central hypothalamic functional disorders, which is often only initiated as second-line treatment due to the alleged effort involved in treatment.

Objective

The indications, course and results of a standardized pulsatile GnRH treatment are presented in order to demonstrate the value of this form of treatment.

Results

In addition to the classical indications for hypothalamic amenorrhea, pulsatile GnRH treatment can also be used for drug-resistent hyperprolactinemia and some mixed forms of polycystic ovarian syndrome (PCOS). Current data demonstrate that pulsatile GnRH stimulation is one of the most effective forms of treatment in reproductive medicine, particularly in patients with hypothalamic amenorrhea and infertility.

Discussion

In cases with clear indications, pulsatile GnRH should be the first choice treatment for ovarian stimulation.

     

Audit of Female Genital Aesthetic Surgery: Changing Trends in India

Introduction

Female genital cosmetic surgery (FGCS) is undoubtedly a fast-growing speciality in the world with increasing demand for a variety of procedures to beautify the female genitals. In India, over the last few years, there has been a steady growth in the interest for these procedures.

Materials and Methods

A variety of FGCS procedures were performed on 76 patients from January 2012 to August 2016. The procedures performed were as follows: vaginal tightening, labia minoraplasty, labia majoraplasty, clitoral hood reduction, and hymenoplasty.

Discussion

Based on FSFI scores, labia minoraplasty was more valuable as a cosmetic procedure and vaginal tightening was associated with better sexual function after surgery.

Conclusion

FGCS is no doubt in its infancy in India. However, there is a steady rise in the awareness and demand for these procedures. A combination of procedures to improve individual components leads to improved aesthetic and functional aspects of female genitalia.

     

Artificial Intelligence: The Future of Obstetrics and Gynecology

Background

Artificial intelligence or ‘big data’ comprises of algorithms which aid in decision making. It has made an impact on a number of professions including obstetrics and gynecology.

Objective

To make readers aware of where artificial intelligence has a role in obstetrics and gynecology.

Material and methods

A comprehensive review of the literature was undertaken to compile a list of instances where artificial intelligence was applied to obstetrics and gynecology.

Conclusion

Artificial intelligence should be utilized to benefit patient care and assist the physician in providing data for decision making.

     

Kinetics of human male pronuclear development in a heterologous ICSI model

Purpose

To evaluate human sperm nuclear chromatin decondensation in a heterologous ICSI system using hamster ova injected with human sperm.

Materials and methods

Frozen hamster oocytes were injected with Triton X-100 treated sperm and fixed at different time points post ICSI. Oocytes injected with non-treated sperm served as controls. Male pronuclear decondensation was evaluated after staining with DAPI.

Results

Sperm cells with partially destroyed membranes and depletion of the acrosome decondense more rapidly and to a greater extent than membrane/acrosome intact cells. Marked variability in pronuclear size was observed for any time point post ICSI, which most probably reflects the heterogeneity in the mature human sperm population.

Conclusion

Remodeling of male gamete nuclei in this heterologous ICSI mimics events that occur during natural fertilization in humans and therefore this approach may be used for studies of human sperm chromosomes transformations.