Successful Third Consecutive TVT in a Patient With Two Previous TVT Failures

BackgroundDuring 10 years of use, the transvaginal tape (TVT) technique has proved highly effective for the treatment of stress urinary incontinence. There is limited published information about experience with repeated TVT placementsCaseA 47-year-old multiparous woman presented with a history of two previous TVT sling procedures but persistent urinary incontinence. Persisting urinary incontinence was noted at six months after the first placement, and a second TVT placement was also unsuccessful. The preoperative urodynamic assessment showed type II and III urinary incontinence. The uterus was enlarged to the size of a 16-week pregnancy, and a hysterectomy was performed. At the same time, a third TVT sling procedure was performed using the standard free tension sling technique, leaving the arms uncut for 24 hours. The patient has remained continent during ten months of follow-up.ConclusionAccording to our experience with this patient, the placement of a third TVT after two failures is safe and effective.     

Rates of Spontaneous and Therapeutic Abortions Following Use of Antidepressants in Pregnancy: Results From a Large Prospective Database

ObjectiveThe use of antidepressants during pregnancy remains a controversial issue, and there is little information on the risk of spontaneous abortions following antidepressant exposure in early pregnancy. We sought to examine whether use of antidepressants increases the rates of spontaneous abortion (SA) and therapeutic abortion (TA) in women exposed in early pregnancy.MethodsIn a cohort of women who contacted the Motherisk program during pregnancy, we compared two groups of women, one exposed and the other not exposed to antidepressants during pregnancy, and calculated the associated rates of SA and TA.ResultsAmong 937 women exposed to antidepressants prior to and during early pregnancy, there were 122 SAs (13.0%) including three ectopic pregnancies, and in the comparison group there were 75 SAs (8.0%) and no ectopic pregnancies. The relative risk was 1.63 (95% CI 1.24–2.14). Three-fold more women reported a TA in the exposed group, 26 (2.4%) compared to 8 (0.7%) in the non-exposed group (RR 3.25; 95% CI 1.48–7.14). A sub-analysis revealed that in both groups, of 338 women with a prior SA, 58 (17.2%) reported having a SA in the current pregnancy, compared with 61/652 (9.4%) with no prior SA (χ2 = 12.09, P < 0.001). In the antidepressant group, the incidence was 20.7%, and in the non-exposed group, it was 13.3%. Logistic regression confirmed that only antidepressant exposure and prior SA were significantly associated with current SA.ConclusionExposure to antidepressants in the first trimester of pregnancy appears to be associated with a small but statistically significant increased risk of SA and decision to terminate a pregnancy. The risk for SA is further elevated with a history of previous SA. However, any underlying depression must be taken into consideration when evaluating these results.     

Successful Pregnancy in a Patient with Previous Bladder Exstrophy

EDITORIAL COMMENT: Usually we do not accept anecdotal case reports for publication. Chambers twentieth century dictionary defines an anecdote as 'a short narrative of an incident of private life'. Readers can decide if this case is anecdotal. There appears to be a lot left unsaid about this woman's private life, if not her private pans. She was admitted to hospital as a nonbooked emergency case in labour. The symphyseal separation shown in figure 2 clinched our decision to accept the case for publication. The editor did not see such a case in 38 years of obstetrics practice.
Summary: Bladder exstrophy is an unusual congenital anomaly. Patients becoming pregnant with such anomaly after surgical repair are even rarer. The present case reports a lower segment Caesarean section delivery of a living healthy baby in a woman who had been operated on for bladder exstrophy at the age of 18 years. This is the first case of this type seen in our institution in 35 years.     

重复性早期流产患者雌、孕激素及其受体研究

本文采用定量的生化法测定重复性早期流产患者子宫内膜组织中雌、孕激素受体（ＥＲ、ＰＲ）含量．并结合血清激素水平和子宫内膜病理学变化，探讨了ＥＲ、ＰＲ含量，子宫内膜发育和血清激素水平三者之间的关系。我们发现，重复性早期流产患者黄体期的雌激素水平明显低于对照组，而增生或子宫内膜ＥＲ和分泌期ＰＲ含量明显低于对照组。重复性早期流产患者蜕膜组织中的ＰＲ也明显减低，ＰＲ的分布也异常。由于子宫内膜的ＥＲ、ＰＲ减少所致的重复性流产在本组资料中占４０％。本研究进一步明确了重复性流产的病因，可用以指导临床治疗。     

肝移植术后宫腔内人工授精成功妊娠并足月分娩一例及文献复习

肝移植是终末期肝脏疾病患者的最终选择。大部分生育年龄的女性患者接受肝移植后能很快恢复正常生活,并希望养育后代。通过自然受孕并顺利分娩的患者并不少见,但仍有部分患者因为各种原因出现不孕。关于不孕的器官移植后患者接受辅助生殖技术（assisted reproductive technology,ART）实现妊娠的报道极少,因为这不仅涉及到复杂的伦理问题,而且需要多个学科间的联合协作。ART的目的必须以健康妊娠为前提,最大限度地降低母体和胎儿并发症。本文介绍了1例不孕的肝移植术后患者,经过宫腔内人工授精（intrauterine insemination,IUI）成功妊娠并足月分娩,探讨妊娠对移植肝脏的影响及免疫抑制剂和肝移植对妊娠的影响。     

Recurrent Hydatidiform Mole: A Report of a Patient with 7 Consecutive Moles

A rare case of hydatidiform mole occurring 7 consecutive times in a Chinese woman is presented. She was first seen in 1979 at the age of 23 years, with a molar pregnancy and subsequently had 6 consecutive moles, the last being in July, 1986; at this visit the patient and her husband were very depressed, and convinced that a normal pregnancy was unlikely and requested a hysterectomy. They were warned earlier several times, of the possible long-term consequences of a recurrent mole and that their chance of having a normal baby was very remote. A total hysterectomy was performed at her last presentation as the patient requested one, instead of dilatation and curettage for a persistently high HCG and bulky uterus following suction evacuation. Histology revealed an invasive mole. The beta HCG level was less than 4IU/l by the end of September, 1986 and she is still being followed-up.     

Successful Pregnancy in Patients with Diabetes Following Myocardial Infarction

EDITORIAL COMMENT: We accepted this paper for publication to remind readers that women in Australia with severe medical disease, which in the past would be considered grounds for sterilization or even termination of pregnancy (Case 2) now expect or hope to tackle pregnancy successfully. It will be a challenge for obstetricians to maintain the maternal mortality rate in Australia at 1 in 7,860 births with current expectations of low and high-risk mothers (A). In Case 2 the mother died more than 6 weeks after delivery and so would not be classified as a maternal death. Such cases explain why Henry et al have discussed the value of the maternal mortality definition being changed to include all deaths of women dying within 1 year of confinement (B). This paper informs us that women with a past history of significant myocardial infarction can cope safely with pregnancy and the puerperium.

• (A) 

  Report on Maternal Deaths in Australia, 1988–1990.
• (A) 

  Henry OA, Sheedy MT, Beischer NA. When is a maternal death a maternal death? A review of maternal deaths at the Mercy Maternity Hospital, Melbourne, M J Aust 1989; 151:629–631. Also editorial comment, same issue, 615–616.

Summary: Two cases of successful pregnancy are described in insulin-dependent diabetic patients following myocardial infarction. Both mothers survived the pregnancies but 1 died from presumed cardiovascular causes 3 months postpartum. The relevant current literature is reviewed.     

G显带和aCGH技术联合检测92例早期自然流产妊娠物核型分析

目的:探讨影响早期自然流产妊娠物染色体异常的因素以及微阵列比较基因组杂交技术(aCGH)在流产妊娠物核型检测中的应用价值.方法:收集在我院妇产科门诊确诊为“胚胎停育”的病例共92例,对清宫后获得的妊娠物进行绒毛染色体G显带核型分析,绒毛体外培养或G显带分析失败的进行aCGH检测.结果:本实验对92例自然流产妊娠物的绒毛组织进行体外培养,85例(92.4％)G显带染色体核型分析成功,失败的7例进行aCGH检测,两种方法联合分析的成功率100％.其中异常核型50例(异常率54.3％),非整倍体40例(非整倍体率43.5％).复发性流产和偶发性流产患者的异常率分别是50.0％和58.3％,差异无统计学意义(P＞0.05).年龄≥35岁患者妊娠物核型为非整倍体的概率(61.5％)大于年龄＜35岁的患者(36.4％),差异有统计学意义(P＜0.05).流产儿男女性别比约为1∶1.2,男性胚胎核型异常率(42.9％)小于女性(64.0％),差异有统计学意义(P＜0.05).超声检查示妊娠囊内无胎芽和有胎芽患者的核型异常率分别为53.3％和54.8％ (P ＞0.05);曾见胎心和从未见胎心患者的异常率分别为58.7％和50.0％,差异均无统计学意义(P＞0.05).结论:自然流产妊娠物核型异常的风险与流产次数以及有无胎芽或胎心无关,非整倍体妊娠的风险随母体年龄增大,女性胚胎在早孕期更易发生染色体异常.aCGH技术在检测流产妊娠物核型中有优越性.     

Successful Laparoscopic Surgery without Neuromuscular Blockade in a Patient with Malignant Hyperthermia Susceptibility

Malignant hyperthermia (MH) is a life-threatening clinical syndrome of hypermetabolism involving skeletal muscle. Susceptibility to MH is inherited in an autosomal dominant manner. Its common trigger is exposure to volatile anesthetic agents or depolarizing muscle relaxants. Deep neuromuscular blockade using muscle relaxants can improve the quality of surgical conditions and prevent cardiorespiratory adverse events during laparoscopic surgery. Here we report a case of successful laparoscopic surgery under anesthetic management without neuromuscular blockade in an MH-susceptible patient. A 22-year-old woman with a family history of MH underwent laparoscopic excision of ovarian endometrioma under total intravenous anesthesia and a posterior transversus abdominis plane block. The surgery was completed uneventfully. Our experience suggests that this type of anesthetic management is useful when performing laparoscopic surgery in MH-susceptible patients.     

复发性自然流产患者子宫蜕膜及绒毛组织白血病抑制因子基因表达的研究

目的 :探讨白血病抑制因子 (LIF)基因在子宫蜕膜及绒毛组织中的表达与反复自然流产 (RSA)的关系。方法 :采用逆转录 -聚合酶链反应 (RT -PCR)技术 ,对 2 0例RSA患者和 30例正常妊娠妇女子宫蜕膜和绒毛组织进行LIFmRNA检测。结果 :RSA组蜕膜组织中LIFmRNA的表达水平为 0 5 12± 0 32 6 ( x±s,下同 ) ,正常妊娠组为 1 345± 0 885 ,RSA患者蜕膜组织中LIFmRNA表达显著性降低 (P <0 0 5 ) ;RSA组绒毛组织中LIFmRNA的表达水平为 0 6 0 1± 0 10 5 ,正常妊娠组为 1 75 9± 0 318,前者较后者明显降低 (P <0 0 1)。结论 :LIF对妊娠的维持可能起一定的作用。LIF基因表达减弱可能是导致复发性自然流产的原因之一     

不育、习惯性流产妇女血清对2－细胞鼠胚体外生长的影响

本文报道２０例原发不育妇女、２５例习惯性流产妇女以及１１例正常生育妇女血清作ＢＷＷ培养基添加剂分别对昆明小白鼠的８１３个、１０８５个和３８１个２—细胞鼠胚进行体外培养的比较研究。结果显示：各组７２ｈ囊胚形成百分率分别为４８．７０±１３．５０％，３７．３２±２０．３５％和５９．０５±７．３３％。不育组、习惯性流产组囊胚形成率与正常生育组囊胚形成百分率经统计学处理分别为Ｐ＜０．０５，Ｐ＜０．０２，均有显著性差异。这些结果提示：部分不育与习惯性流产妇女血清中可能存在有抑制早期胚胎发育的因子，因此检测血清中鼠胚生长抑制因子，有助于分析免疫性妊娠失败的病因。     

不育、习惯性流产妇女血清对2－细胞鼠胚体外生长的影响

本文报道２０例原发不育妇女、２５例习惯性流产妇女以及１１例正常生育妇女血清作ＢＷＷ培养基添加剂分别对昆明小白鼠的８１３个、１０８５个和３８１个２—细胞鼠胚进行体外培养的比较研究。结果显示：各组７２ｈ囊胚形成百分率分别为４８．７０±１３．５０％，３７．３２±２０．３５％和５９．０５±７．３３％。不育组、习惯性流产组囊胚形成率与正常生育组囊胚形成百分率经统计学处理分别为Ｐ＜０．０５，Ｐ＜０．０２，均有显著性差异。这些结果提示：部分不育与习惯性流产妇女血清中可能存在有抑制早期胚胎发育的因子，因此检测血清中鼠胚生长抑制因子，有助于分析免疫性妊娠失败的病因。     

Spontaneous Perforation of Pyometra Presenting as Generalized Peritonitis in a Patient with Cervical Cancer

Pyometra is a relatively common event. However, it is extremely rare for this condition to perforate spontaneously into the peritoneum, and to date only 14 cases have been reported in English literature. We recently experienced such a case in a patient with cervical cancer. The clinical features, pathologic findings, diagnosis, therapy, and outcome of these 15 cases were reviewed. Only 5 cases were associated with malignant diseases, consisting of 2 cervical cancers, 2 colon cancers, and 1 endometrial cancer. All of the patients developed generalized peritonitis, and 4 patients died of this. Correct preoperative diagnosis was difficult. Therefore, immediate and appropriate therapy is important.     

Successful Pregnancy in a Patient with Pseudomyxoma Peritonei Arising from Ovarian Mucinous Cystadenocarcinoma Treated with Cisplatin

A 24-year-old Japanese woman clinically showing pseudomyxoma peritonei arising from ovarian mucinous cystadenocarcinoma FIGO stage Ic is reported. She received intra-abdominal administrations of cisplatin five times following left oophorectomy. After being free of disease for 6 months, she conceived and carried two pregnancies to successful deliveries at 34 and 37 weeks, respectively. At the Cesarean sections, there were no abnormal findings except for right ovarian mucinous cystadenoma. She has had no evidence of recurrence by the time of the 60-month postoperative examination.     

原因不明性反复自然流产患者免疫治疗结局的探讨

目的观察淋巴细胞免疫治疗原因不明性反复自然流产的效果,探讨封闭抗体对治疗结局的意义.方法对54例原因不明性反复自然流产患者进行淋巴细胞免疫治疗.结果11例患者已分娩正常活婴,5例处于妊娠中期,6例再次发生流产.妊娠成功率72.73%(16/22).免疫治疗后,患者血封闭抗体的阳性率明显高于治疗前(P＜0.005);封闭抗体阳性者再次妊娠的成功率高于阴性者,差异有显著性.结论淋巴细胞免疫治疗原因不明性反复自然流产有效、安全.封闭抗体对再次妊娠结局有一定预示价值.     

Robotic Colostomy Takedown in a Patient with Extensive Ventral Hernias and Adhesive Disease

Study ObjectiveTo demonstrate a surgical video wherein a robot-assisted colostomy takedown was performed with anastomosis of the descending colon to the rectum after reduction of ventral hernias and extensive lysis of adhesions.DesignCase report and a step-by-step video demonstration of a robot-assisted colostomy takedown and end-to-side anastomosis.SettingTertiary referral center in New Haven, Connecticut.A 64-year-old female was diagnosed with stage IIIA endometrioid endometrial adenocarcinoma in 2015 when she underwent an optimal cytoreductive surgery. In addition, she required resection of the sigmoid colon and a descending end colostomy with Hartmann's pouch, mainly secondary to extensive diverticulitis. After adjuvant chemoradiation, she remained disease free and desired colostomy reversal. Body mass index at the time was 32 kg/m².Computed tomography of her abdomen and pelvis did not show any evidence of recurrence but was notable for a large ventral hernia and a parastomal hernia. She then underwent a colonoscopy, which was negative for any pathologic condition, except for some narrowing of the distal rectum above the level of the levator ani.InterventionsEnterolysis was extensive and took approximately 2 hours. The splenic flexure of the colon had to be mobilized to provide an adequate proximal limb to the anastomosis site. An anvil was then introduced into the distal descending colon through the colostomy site. A robotic stapler was used to seal the colostomy site and detach it from the anterior abdominal wall. Unfortunately, the 28-mm EEA sizer (Covidien, Dublin, Ireland) perforated through the distal rectum, caudal to the stricture site. A substantial length of the distal rectum had to be sacrificed secondary to the perforation, which mandated further mobilization of the splenic flexure. The rectum was then reapproximated with a 3-0 barbed suture in 2 layers. This provided us with approximately 6- to 8-cm distal rectum. An end-to-side anastomosis of the descending colon to the distal rectum was performed. Anastomotic integrity was confirmed using the bubble test. Because of the lower colorectal anastomosis, a protective diverting loop ileostomy was performed.The patient had an uneventful postoperative course. A hypaque enema performed 3 months after the colostomy takedown showed no evidence of anastomotic leak or stricture. The ileostomy was then reversed without any complications.ConclusionRobot-assisted colostomy takedown and anastomosis of the descending colon to rectum were successfully performed. Although there is a paucity of literature examining this technique within gynecologic surgery, the literature on general surgery has supported laparoscopic Hartmann's reversal and has demonstrated improved rates of postoperative complications and incisional hernia and reduced duration of hospitalization [1]. Minimally invasive technique is a feasible alternative to laparotomy for gynecologic oncology patients who undergo colostomy, as long as the patients are recurrence free.     

Normal Term Intra-uterine Pregnancy in a Nulliparous Patient After 3 Consecutive Ectopic (Tubal) Pregnancies

Summary: A case of normal term intra-uterine pregnancy in a nulliparous patient after 3 consecutive ectopic (tubal) pregnancies is presented.