Fetus-in-fetu: parasite or neoplasm? A study of two cases

INTRODUCTION: Fetus-in-fetu is a rare congenital fetiform mass whose etiology is still controversial. We report two cases of fetus-in-fetu. CASE 1: A fetal retroperitoneal cystic tumor including two masses was detected by ultrasonography at 26 gestational weeks. The masses showed distinctive structures resembling a vertebral axis and were prenatally diagnosed as fetus-in-fetu. A resected specimen revealed two fetiform masses. CASE 2: An intracranial tumor with hydrocephalus was detected by ultrasonography at 19 gestational weeks. The pregnancy was terminated, and a postmortem examination revealed six fetiform masses with immature teratoma. DISCUSSION: The tumors may possibly consist of parasitic monozygotic diamniotic twins or highly differentiated teratomas.     

Could chronic pelvic pain be a functional somatic syndrome?

The cause of noncyclical chronic pelvic pain (CPP) in many women is unknown: 30% have no identifiable pelvic pathology, and in those who do the relationship of CPP and the pathology is often unclear. Moreover, epidemiologic studies demonstrate that the common findings of endometriosis and adhesions do not greatly increase the odds of having CPP. CPP and the functional somatic syndromes (fibromyalgia, irritable bowel syndrome, and others) share many characteristics including pain as a prominent symptom and comorbidity. For the functional somatic syndromes, the initial focus of etiologic investigations has been on local mechanisms and then on systemic pathogeneses. We believe that the research trajectories of the functional somatic syndromes and CPP are converging. Their juncture might reveal an important pathologic mechanism for CPP in some women that is primarily outside the pelvis. This observation would open up new areas of exploration and treatment of CPP.     

Is preeclampsia an independent predictor of diastolic dysfunction? A retrospective cohort study

ObjectiveTo determine if preeclampsia is an independent predictor of diastolic dysfunction and what factors among patients with preeclampsia are associated with diastolic dysfunction.MethodsThis is a retrospective cohort study of patients who delivered between 2008 and 2013 at a single institution who had a maternal echocardiogram during their pregnancy or within 5 months of delivery. Patients with structural heart disease, ejection fraction less than 45%, pulmonary embolus, or age over 45 years were excluded. Medical records were reviewed for medical and obstetric complications and echocardiogram findings. Demographic characteristics and rate of diastolic dysfunction were compared between patients with preeclampsia and without preeclampsia. Multivariate logistic regression was performed controlling for age, ethnicity, gestational age at delivery, diabetes, preeclampsia, intrauterine growth restriction (IUGR), antihypertensive use and magnesium sulfate administration.ResultsSixty-six patients were identified, of which 39 (59%) had preeclampsia. Past history of preeclampsia, IUGR in the current pregnancy, antihypertensive use and magnesium sulfate use were higher in the preeclampsia group. Fifteen patients (39%) in the preeclampsia group were African-American compared to 2 (3%) in the control group (p < 0.01). Seventeen (44%) of the patients with preeclampsia were found to have diastolic dysfunction compared to 3 (11%) controls (OR = 6.18, 95% CI 1.59, 24.02; p = 0.006). Logistic regression analysis did not reveal other independent predictors of diastolic dysfunction. In the patients with preeclampsia, history of preeclampsia with severe features and IUGR were not associated with diastolic dysfunction.ConclusionsOur study supports previous findings that preeclampsia is associated with diastolic dysfunction.     

Is tubal endometriosis an asymmetric disease? A 17-year retrospective study

To investigate whether there are left–right asymmetries in tubal endometriosis and the factors affecting this predisposition. Women who underwent salpingectomy for gynecological diseases and were diagnosed with tubal endometriosis between January 2002 and July 2019 were included in the study. The frequencies of left and right tubal endometriosis were compared with the expected 50% using a binominal test. The demographic characteristics and presence of ovarian endometrioid cysts, adenomyosis, and hydrosalpinx were also analyzed. During the study period of more than 17 years, 305 women were diagnosed with tubal endometriosis. The distribution of tubal endometriosis in the left or right fallopian tubes was analyzed. Tubal endometriosis was found in the left fallopian tube in 168 (55.08%) women, in the right fallopian tube in 93 (30.49%), and bilaterally in 44 (14.43%). Left unilateral tubal endometriosis was found most frequently (64.37%, 168/261), and its incidence was significantly higher than 50% (P < 0.001, binominal test). Furthermore, the frequency of left ovarian endometrioid cysts (58.82%) was higher than that of right ovarian endometrioid cysts (41.18%) (P < 0.001, binominal test). Our study confirms that tubal endometriosis is a left-side asymmetric disease, and this predisposition is highly consistent with ovarian endometrioid cysts, which supports the transplantation theory of the origin of endometriosis.     

Endometriosis in patients with chronic pelvic pain: is staging predictive of the efficacy of laparoscopic surgery in pain relief?

BACKGROUND/AIMS: Endometriosis is considered an important cause of chronic pelvic pain. Despite its high prevalence, controversy still exists regarding the true association between the extent of endometriosis and the severity of symptoms. We conducted this prospective study to investigate the association between the stage of endometriosis and type and severity of pain, and to evaluate the efficacy of laparoscopic surgery in pain relief. METHODS: Ninety-five patients complaining of chronic pain were diagnosed with endometriosis and were treated with laparoscopic surgery. The severity of pain was assessed in patients with an endometriosis AFS (American Fertility Society) score less than 16 (group 1) and those with an AFS score greater than or equal to 16 (group 2), preoperatively and 6 months after surgery, using a visual pain scale. Any reduction in pain scores by 2 points or more was considered to be an improvement. RESULTS: Dysmenorrhea and deep dyspareunia, were significantly more frequent in patients of group 2. Preoperative pain scores were significantly higher for dysmenorrhea (p = 0.0022) and deep dyspareunia (p < 0.0001) but not for non-menstrual pain in group 2. Deep dyspareunia was correlated with the presence of dense pelvic adhesions. After surgery, dysmenorrhea improved in 43% of cases in group 1, vs. 66% of cases in group 2 (p = 0.0037). For deep dyspareunia, improvement was reported by 33% in group 1, vs. 67% in group 2 (p = 0.074). Improvement in non-menstrual pain was not significantly different between the two groups (67% vs. 56%). CONCLUSIONS: Advanced endometriosis is more frequently related to dysmenorrhea and deep dypareunia in comparison to early disease. Laparoscopic surgery may offer relief or improvement in the majority of patients with endometriosis and chronic pelvic pain. Cases with advanced disease seem to benefit the most.     

Twenty-year history of endometriosis-associated pelvic pain: too much surgery or not enough?

A 36-year-old woman with a 20-year history of endometriosis-associated pelvic pain was a unique case from a total of 700 patients with endometriosis recently evaluated at Yale University. Her previous treatments included 11 surgical procedures related to pelvic pain or endometriosis. Multiple recurrences of endometriosis were documented. Although clearly an unusual case, our patient highlights the importance of using even the most advanced surgical techniques judiciously.     

Adhesions in patients with chronic pelvic pain: a role for adhesiolysis?

OBJECTIVE: To review the relation between adhesions and pelvic pain and the effectiveness of adhesiolysis in pain control. DESIGN: Selective review of the literature. PATIENT(S): Patients with pelvic pain and/or undergoing adhesiolysis for pain control. RESULT(S): Intraabdominal adhesions are accepted as etiologic factors for infertility and small bowel obstruction; however, the contribution of adhesions to pelvic pain is less clear. The most common laparoscopic findings in patients with and without pelvic pain were endometriosis and adhesions. Immunohistologic studies also have shown evidence of nerve fibers in adhesions that had been removed from patients with and without pelvic pain. Multiple adhesiolysis techniques have been employed, with outcome of surgical procedures ranging from no pain relief to pain relief in 90% of patients. However, randomized trials have shown that adhesiolysis is ineffective in improving the outcome of the treatment of pelvic pain, possibly because of adhesion reformation. Interestingly, adhesions are usually not described as an etiologic factor for pelvic pain in men; this might be related to a gender difference in pain perception or the possibility that adhesions per se do not cause pain. CONCLUSION(S): The correlation between pelvic pain and adhesions is uncertain. Adhesiolysis has not been shown to be effective in achieving pain control in randomized clinical studies.     

Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review

Objective. A systematic review was undertaken to update the understanding of the available evidence for antenatal physical therapy interventions for low back or pelvic pain in pregnant women to improve functional outcomes when compared with other treatments or no treatment. Data Sources. Seven electronic databases were systematically searched and supplemented by hand searching through reference lists. Methods of study selection. Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials using the Clinical Appraisal Skills Program tool. Results. Four trials with 566 participants were identified that met the inclusion criteria. The validity of the trials was moderate. Exercise, pelvic support garments and acupuncture were found to improve functional outcomes in pregnant women with low back or pelvic pain. No meta-analysis was performed because of the heterogeneity of functional outcome measures. Conclusions. While there is some evidence that physical therapy using exercise, acupuncture and pelvic supports may be useful, further research needs to consider other treatment modalities used by physical therapists and establish an appropriate, reliable and valid functional outcome measure to assess low back and pelvic pain in pregnancy.     

Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations

Objective

Endometriosis is a chronic oestrogen-dependent gynaecological disorder, the most common symptom of which is pain. Inflammation can be considered one of the major causes of pain in endometriosis. In particular, degranulating mast cells have been found in significantly greater quantities in endometriotic lesions than in unaffected tissues. The increase in activated and degranulating mast cells is closely associated with nerve structures in painful endometriotic lesions. These observations indicate that inflammation due to mast cells may contribute to the development of pain and hyperalgesia in endometriosis. Controlling mast-cell activation may therefore relieve the pain associated with endometriotic lesions.

Study design

Four patients presenting an endometriosis-related pain intensity ≥5 (visual analogue scale for pain, or VAS) were enrolled and monitored during 3 months of the following treatment: oral palmitoylethanolamide 400 mg and polydatin 40 mg, twice daily for 90 days. Deep dyspareunia, dyschezia, dysuria, dysmenorrhoea and analgesic drug use during the 3-month follow-up period were also monitored, with the aim of demonstrating a reliable reduction in chronic pelvic pain.

Results

The preliminary results indicate that all patients enrolled experienced pain relief as early as 1 month after starting treatment. Furthermore, a reduction in the analgesic drugs usually employed for pain control was observed in all subjects treated. Additionally, some improvements in endometriotic lesions seemed to be demonstrated by imaging.

Conclusions

The palmitoylethanolamide–polydatin combination seems to be very useful in controlling chronic pelvic pain associated with endometriosis. As a result of these findings we have initiated a multi-centre pilot study to verify the effectiveness of this treatment in controlling the chronic pelvic pain associated with endometriosis.     

The tangled web of reasons for the delay in diagnosis of endometriosis in women with chronic pelvic pain: will the suffering end?

Understanding the woman's experience with chronic pelvic pain and endometriosis is critical to decreasing her suffering. Further investigation must continue to determine the relation between endometriosis and pain, despite empirical treatment with GnRH agonists becoming routine in the United States.     

Is intrapartum fever associated with ST-waveform changes of the fetal electrocardiogram? A retrospective cohort study

Please cite this paper as: Becker J, van Rijswijk J, Versteijnen B, Evers A, van den Akker E, van Beek E, Bolte A, Rijnders R, Mol B, Moons K, Porath M, Drogtrop A, Schuitemaker N, Willekes C, Westerhuis M, Visser G, Kwee A. Is intrapartum fever associated with ST-waveform changes of the fetal electrocardiogram? A retrospective cohort study. BJOG 2012;119:1410-1416. Objective To investigate the association between maternal intrapartum fever and ST-waveform changes of the fetal electrocardiogram. Design Retrospective cohort study. Setting Three academic and six non-academic teaching hospitals in the Netherlands. Population Labouring women with a high-risk singleton pregnancy in cephalic position beyond 36?weeks of gestation. Methods We studied 142 women with fever (≥38.0°C) during labour and 141 women with normal temperature who had been included in two previous studies. In both groups, we counted the number and type of ST-events and classified them as significant (intervention needed) or not significant, based on STAN(?) clinical guidelines. Main outcome measures Number and type of ST-events. Results Both univariable and multivariable regression analysis showed no association between the presence of maternal intrapartum fever and the number or type of ST-events. Conclusions Maternal intrapartum fever is not associated with ST-segment changes of the fetal electrocardiogram. Interpretation of ST-changes in labouring women with fever should therefore not differ from other situations.