Letter to the Editor- Familial Vulval Carcinoma We found that while vulval carcinoma is a rare condition, accounting for less than 1% of all new cancer cases in females , we recently had three cases of multi-focal differentiated vulval carcinoma in three women with one degree of familial separation with similar histological characteristics, in the absence of a known genetic mutation. Their characteristics are described in Table 1.
Prolapse mesh complication: large stone on vaginal mesh extruded in the bladder We found an unusual and severe complication of mesh prolapse surgery we will to report. Synthetic meshes augmentation for pelvic organ prolapse repair by vaginal route has been associated with better anatomical outcomes without improvements in terms of symptoms and quality of life. However their widespread use raised a growing awareness of mesh-related complications which lead in 2011 to FDA warning. These complications include infection, fibrosis, shrinkage and exposure [1,2]. In particular mesh extrusion inside the urinary tract is uncommon and has been mainly related to incorrect suburethral tape positioning (bladder/urethra perforation or submucosal placement) .
Fetal growth and maternal alcohol consumption during early pregnancy The relationship between light maternal alcohol consumption and fetal outcome remains contentious and the professional advice women receive is conflicting. The aim of this large epidemiological study was to examine the relationship between fetal growth and maternal alcohol behaviour before and during early pregnancy.
Seminal exosomes induce interleukin-6 and interleukin-8 secretion by human endometrial stromal cells Exosomes are extracellular microvesicles that participate in intercellular communication. Seminal plasma (SP) contains very large amounts of exosomes which are deposited in female genital tract after insemination. Although the response of vaginal cells to seminal exosomes (SE) is recently being elucidated, the interaction of uterine cells with SE is still unknown. Here, we aimed to evaluate the effect of SE on cytokine secretion by human endometrial stromal cells (eSC).
Twin vaginal delivery: To maintain skill - simulation is required We have designed a simulation device that improves obstetrical skills for second twin delivery and which we hope will participate in the comeback of vaginal delivery for this indication and contribute to the fight against the dangerous trend of rising rates of cesarean delivery for twins. Our model completely fits the paradigm of simulation in medical pedagogy.
Optical coherence tomography angiographic findings in preeclampsia – A novel longitudinal report Preeclampsia is a hypertensive disorder affecting between 2%–8% of pregnancies. Ocular complications described in preeclampsia include hypertensive retinopathyretinal vessels occlusion, hypertensive choroidopathy, serous retinal detachment and choroidal infarcts with the commonest finding being severe arteriolar spasm [1,2]. In the acute stage of the diseasesub retinal and intraretinal fluids may be demonstrated by optical coherence tomography (OCT), a light-based imaging modality with near-histologic, ultrahigh resolution.; En face OCT (special software reconstruction of OCT images) provides segmented visualization of the various retinal layerswhile OCT angiography, allows a noninvasive micro vascular assessment .
Sexual function specific questionnaires as a useful tool in management of urogynecological patients – Review Urinary incontinence, fecal incontinence and pelvic organ prolapse are one of the most prevalent gynaecological conditions and constitute a huge global problem affecting approximately 20% of women, increasing with age. Pelvic floor disorders can have negative influence on women’s quality of life, decreasing social, psychological, occupational, physical and sexual well-being. Pelvic organ prolapse results in anatomical changes to the urogenital tract and it is perceived to be one of the main factor influencing sexual function.
Collagen changes in pelvic support tissues in women with pelvic organ prolapse Pelvic organ prolapse is a group of diseases caused by weakened pelvic supportive tissue, but the pathophysiology is not completely understood. Collagen is one of the most important components of the extracellular matrix in connective tissue, as it maintains the supportive functions of the pelvic floor. Collagen I and III are two major subtypes in pelvic tissues. With conflicting results of different studies, changes of their content and ratio are still disputed. The structure of collagen fibrils of pelvic organ prolapse patients become loose, disorderly and discontinuous and become stiffer than control group.
Placental morphology, apoptosis, angiogenesis and epithelial mechanisms in early-onset preeclampsia Early-onset preeclampsia is a form of preeclampsia requiring delivery before 34 weeks of gestation. The etiology is unknown, but placental dysfunction appears crucial. We evaluated the immunohistochemical expression of the antiapoptotic protein Bcl-2, the angiogenetic factors VEGF and PlGF, and the epithelial factors HGF, c-Met and STAT3 in placental samples of pregnancies complicated by early-onset preeclampsia.
Managing pain after synthetic mesh implants in pelvic surgery Pelvic mesh surgery has courted controversy with around 10% of patients experiencing complications. This article concentrates on the factors around pain, its presentation and management. Immediate pain is related to insertion and immediate removal recommended. With later presentation excision of the mesh relieves pain in up to 80% of women. Infection may be contributory but in refractory cases other factors maybe involved. Idiosyncratic reaction to mesh without risk factors appears to be relatively rare.
Adverse pregnancy outcomes related to preterm cesarean delivery Cesarean delivery at a preterm gestational age has been related to maternal complications such as bleeding and infection. However, previous reports are conflicting, and there is no consensus on the matter. We aimed to clarify the adverse effect of preterm cesarean delivery with an emphasis on maternal bleeding.
Changing trends in the Turkish maternal deaths, with a focus on direct and indirect causes Objective: Our aim is to evaluate trends in the direct and indirect causes’ distribution using data from National Maternal Mortality Surveillance (2012–2015).Study design: A population-based retrospective review was performed on all pregnancy-associated maternal deaths in Turkey from 2012 to 2015. Causes of death were grouped into direct and indirect maternal deaths and compared in the context of distribution. Maternal mortality rate was reported. Statistics included chi-square test or Fisher’s exact test for categorical variables.
Cryopreservation of human spermatozoa by vitrification versus conventional rapid freezing: Effects on motility, viability, morphology and cellular defects Sperm cryopreservation has great potential for male infertility treatment as used in assisted reproduction technology (ART). There are a variety of cryopreservation methods in order to preserve sperm in a long term. Although conventional freezing and vitrification now are used widely, they have damage on sperm parameters as well as sperm DNA integrity. It is necessary to answer which method is better and appropriate for sperm cryopreservation. The aim of this study was to compare the effect of conventional freezing and vitrification regarding to motility, vitality and morphology of sperm found in washed and unwashed samples.
Enoxaparin (or plus aspirin) for the prevention of recurrent miscarriage: A meta-analysis of randomized controlled studies Enoxaparin treatment has emerged as an important approach to prevent recurrent miscarriage, but the use of enoxaparin for the prevention of recurrent miscarriage has not been well established. We conduct a systematic review and meta-analysis to evaluate the efficacy of enoxaparin to prevent recurrent miscarriage. PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials (RCTs) assessing the influence of enoxaparin (or plus aspirin) treatment versus placebo on prevention of recurrent miscarriage are included.
Advanced stage (IIIC/IV) endometrial cancer: Role of cytoreduction and determinants of survival Endometrial cancer is unique in that relatively few cases are diagnosed in the advanced stages. Surgical stage III/IV disease accounts for over 50% of uterine cancer related deaths and the treatment strategies for these patients has evolved from hormonal therapy with progestational agents, to radiation and chemotherapy [1–3].The association between residual disease following surgery and survival has been explored in the initial studies of Memarzadeh, Bristow and Chi et al [4–6].Following the meta-analyses presented by Barlin et al in 2010 , further survival data was published on the role of cytoreduction in women who have received neoadjuvant chemotherapy (NACT) and those with pure endometrioid carcinomas [8,9].
Predictors of goal achievement in patients undergoing hysterectomy Objective: The primary objective of our study was to identify predictors of goal achievement in patients undergoing simple hysterectomy for benign indications. We also sought to describe the goals of patients in this population.Study Design: This was a prospective cohort study of patients undergoing hysterectomy for benign indications performed at a single academic institution. We documented patient-reported goals of treatment prior to undergoing hysterectomy in 57 patients, and assessed goal achievement and other patient-centered outcomes three months after surgery in 47 of the patients (82.5%).
Osteogenesis imperfecta type VIII: Association with increased nuchal translucency and prenatal diagnosis by targeted exome sequencing Osteogenesis imperfecta (OI) is a genetically heterogeneous skeletal dysplasia that affects approximately 1 in 10,000–20,000 births . Although most of the time prenatal diagnosis of OI can be confirmed by molecular testing, sonography is still the primary diagnostic modality. Criteria for the prenatal diagnosis of OI using second-trimester sonography include hypomineralization of the skull, early onset of bone shortening, and bowing due to multiple fractures involving long bones. However, the sonographic detection of OI at the first trimestr of pregnancy is challenging.
Successful angioembolization treatment in a patient with a mechanical heart valve with hemorrhagic corpus luteum A 23 year-old nulliparous patient presented to our emergency department due to lower abdominal pain lasting for 3 weeks with aggravation two days prior to her admission after coitus. Her history was remarkable for prosthetic aortic valve replacement 4 years ago due to regurgitating congenital bicuspid aortic valve. She was recently switched from warfarin treatment to enoxaparin, a low molecular weight heparin, as the patient was trying to conceive. At presentation, the patient was in severe pain.
Plasmapheresis—A lifesaving treatment for life threatening HELLP syndrome Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome is a rare and serious complication of pregnancy characterized by microangiopathic hemolytic anemia, increased levels of liver enzymes, and thrombocytopenia. The optimal management approach of women with HELLP is highly controversial. We herein present a case of successful treatment of life threatening HELLP by plasmapheresis.
Health care service in paediatric and adolescent gynaecology throughout Europe: A review of the literature Paediatric and adolescent gynaecology is a special field of interest within general gynaecology and obstetrics. The care for children and young people differs from adults. In gynaecology, children should not be treated like little adults. Within Europe, there is great variability in the provision of care, availability of clinical networks and lack of national standards within paediatric and adolescent gynaecology. Therefore, this review aims to summarize the current evidence regarding best clinical practice within Europe.
The future of paediatric and adolescent gynaecology in Europe Paediatric and Adolescent Gynaecology (PAG) is a subspecialty under the umbrella of Obstetrics and Gynaecology but linked to other branches of medicine including Paediatrics, Surgery, Endocrinology and Urology. Therefore future developments in clinical care and education requires a multidisciplinary approach combining aspects of all the above medical specialties, and also with inputs from Public Health, Genetics, Radiology and Psychology. A multidisciplinary collaboration among different specialists is as important as the establishment and adoption of standards in education, training and management.
Laparoascopic sacrohysteropexy Introduction: There is an increased interest in uterine preservation for prolapse surgery, laparoascopic sacrohysteropexy is one surgical method for treating uterine prolapse using a non absorbable mesh.
Laparoscopic sacrocolpopexy with the use of a mesh for treatment of uterine prolapse Introduction: Uterine prolapse is the herniation of the uterus into or beyond the vagina as a result of failure of the ligamentous and fascial supports. It often coexists with prolapse of the vaginal walls, involving the bladder or rectum. We present an interesting case of a patient diagnosed with uterine prolapse that underwent laparoscopic sacrocolpopexy with the use of a mesh.
Uterus-preserving lateral mesh suspension with minor modification Introduction: Sacrocolpopexy is the gold standard to treat the apical prolapse. However it is known to be with potentially major complications. Laparoscopic lateral mesh suspension technique was recently described by Dubuisson that avoids dissection of the promontory.
Surgical technique: Total colpocleisis Introduction: Total colpocleisis is a surgical treatment option using native tissue for complete eversion in older women not interested in coital function, and in whom conservative measures and other compartment repair surgeries have failed. We present a video describing the technical considerations for performing a total colpocleisis in the management of symptomatic post-hysterectomy pelvic organ prolapse (POP).
Laparoscopic female sterilization Introduction: Laparoscopic female sterilization (LFS) is a surgical procedure that permanently prevents pregnancy by total occlusion of the fallopian tubes. The first case was performed in Switzerland by Bösch in 1936, and it is the most used method to provide definitive contraception to women. The main indication is patient's desire and the few contra-indications include: the patient is unable to understand its intended permanence; a medical condition requiring hysterectomy or bilateral oophorectomy; and pregnancy.
Cesarean scar pregnancies: A laparoscopic approach Introduction: Cesarean scar pregnancy is a rare iatrogenic entity and is defined as a trophoblastic implantation in a myometrial defect of a previous uterine scar. Early diagnosis and prompt institution of treatment are critical to minimize its associated risks and complications and to preserve fertility. Laparoscopic excision is a good option in hemodynamically stable women and when performed by an experienced surgeon.
Bipolar resectoscopy – Surgical technique Introduction: Resectoscopy is a minimally invasive gynecological procedure in which an endoscopic optical lens is inserted through the cervix into the endometrial cavity to direct treatment of various types of intrauterine pathology.
Office diagnostic hysteroscopy by vaginoscopy Introduction: Diagnostic hysteroscopy is considered the gold standard for the inspection of the uterine cavity. The history of hysteroscopy started in 1806 with Philipp Bozzini, but the modern technique was first described by Raoul Palmer, who performed several exams in 1957, in the outpatient setting. The authors’ department has a wide experience in the minimal invasive approach techniques, with about 10,000 office hysteroscopies performed over the past 20 years.
Laparoscopic treatment of pelvic endometriosis and intraligamentary fibroid in a nulliparous woman Introduction: Endometriosis is a benign gynecological disorder characterized by the presence and growth of endometrium-like tissue in sites outside the uterine cavity, primarily on the pelvic peritoneum and ovaries It affects 5–10% of women of reproductive age and the main clinical features are chronic pelvic pain and infertility. We present an interesting case of a nulliparous patient that underwent laparoscopic surgery for pelvic endometriosis and 2 years after a laparoscopic excision of an intraligamentous fibroid.
Endoscopic sentinel node biopsy using indocyanine green in early stage vulvar cancer Introduction: Video-endoscopic lymphadenectomy is progressively emerging as an appealing strategy in patients with vulvar cancer; at the same time, sentinel node biopsy (SNB) is currently recognized as standard of care in patients with early stage vulvar cancer (ESVC). Therefore, the integration of endoscopic approaches and SNB appears as an intriguing horizon, and we present here the first endoscopic SNB using indocyanine green (ICG) performed in a patient with ESVC.
Recurrence of vulvar carcinoma: A multidisciplinary approach Introduction: Although oncogynaecological management of bulky vulvar tumors tends to minimally-invasive approaches preceded by neoadjuvant therapies, ultra-radical surgery with curative intent still have an important role in a subset of patients. These procedures remain associated with significant short and long-term complications, imposing the need for novel reconstructive techniques, in order to improve patient outcomes and quality-of-life.
Breast wire-guided lumpectomy and axillary sentinel lymph node mapping and resection by the combined technique Introduction: Breast cancer is the top cancer and the more lethal in women worldwide. Indication for lumpectomy is breast cancer without contraindications to conservative surgery. In impalpable malignancies, wire-guided excision can be performed. Sentinel lymph node (SLN) mapping and resection is recommended for assessment of the pathologic status of the axillary lymph nodes in patients with clinical stage I and II disease. In 2016, at the authors’ department, 134 women had surgery for breast cancer and 43.5% were submitted to lumpectomy.
Is there a place for pharmaceutical oncoprevention in 2018? Introduction: Should we prescribe pharmaceutical drugs as oncopreventive medication? This presentation tries to emphasize and focus on the preclinical and clinical update on different molecules and their role in prevention of carcinogenesis.
Intracytoplasmatic sperm injection cycles with cryopreserved versus fresh testicular sperm: Is there any difference? Introduction: Intracytoplasmatic sperm injection (ICSI) offers azoospermic men an option to father biologic children. Open testicular biopsy with testicular sperm extraction (TESE) is an option for retrieval of sperm and is indicated in azoospermia and when ejaculation is not possible. The testicular sperm can be used fresh or cryopreserved. The use of cryopreserved testicular sperm eliminates the need for simultaneous oocyte and sperm retrievals, decreasing the need for repeated testicular biopsies, thus minimizing threat to testicular tissue and function.
Next-generation sequencing technology: New horizons in preimplantation genetic screening Introduction: Aneuploidy is prevalent chromosome abnormality in human oocytes and resulting embryos. Avoiding the selection of aneuploid embryos for embryo transfer in IVF cycles is highly desirable. Preimplantation genetic screening (PGS) can provide an accurate chromosome copy number of a biopsied blastomeres from the early embryos or trophoblast cells of the blastocyst. Various robust and reliable technologies have been recently introduced for this purpose, such as microarray comparative genomic hybridization (aCGH), single-nucleotide polymorphism arrays (SNP) or quantitative PCR, which have confirmed the high incidence of aneuploidy in human oocytes and embryos.
Cardiotocographic (CTG) changes observed with clinical and subclinical chorioamnionitis Introduction: Chorioamnionitis is an important cause of non-hypoxic fetal compromise, associated with a 5-fold increase in cerebral palsy. However, only 10% of the cases of chorioamnionitis present with maternal pyrexia and maternal tachycardia and 90% remain subclinical with no maternal symptoms or signs. CTG is a test for fetal hypoxia and its role in diagnosing chorioamnionitis is uncertain. An increase in the fetal heart rate without preceding decelerations reflects a ‘non-hypoxic’ cause. Other CTG features such as reduced variability, lack of accelerations, and lack of cycling may be markers of chorioamnionitis.
The value of laparoscopic removal of subendometrial fibroids Introduction: Submucous myomas and intramural myomas which protrude in the endometrial cavity affect a significant proportion of reproductive age women and may cause excessive menstrual bleeding and adverse reproductive outcomes. Hysteroscopic myomectomy by means of resectoscopic removal is considered the golden standard for their treatment. However, it may cause significant damage to endometrial line leading to the formation of endometrial synechiae and possible infertility. Moreover, the hysteroscopic approach does not permit always complete removal of the fibroid; thus, resulting in recurrences.
The impact of multi-professional obstetric emergencies training on human factors and organisational processes in a middle-income setting Introduction: Multi-professional obstetric emergencies training are one promising strategy to improve global maternity care. Effective training can improve perinatal outcomes as well as human and organisational factors. However, literature on implementation in middle-income settings is limited. PRactical Obstetric Multi-Professional Training (PROMPT) is a multi-professional obstetric emergencies training programme with evidence of effect in high and low-income settings. The Philippines PROMPT Project successfully implemented local PROMPT courses in seven hospitals in the Philippines, a middle-income setting, training 92% of all maternity staff.
Does caesarean section at night increases risk of wound infection? Introduction: Surgical site infection (SSI) after caesarean section (CS) is common and carries significant morbidity. Recent research suggests that wound healing efficacy may be influenced by time of surgery, with injuries sustained at night healing more slowly. A possible downstream effect may include an increased risk of SSI.
Prediction of stillbirth in pregnancies complicated by overweight or obesity, a registry based cohort study Introduction: Stillbirth remains a major public health problem and account for the largest part of all perinatal death in high-income countries. The incidence of stillbirth in high-income countries has become stable or decreased only marginally in many regions over the past decades. Most stillbirth are now antepartum death, frequently associated with placental dysfunction and restricted fetal growth, however many remain unexplained. The risk for stillbirth is increasing almost linear with rising body mass index (BMI).
Particularly severe congenital disorder: Parents’ antenatal journey and experience Introduction: Antenatal journey represents an experience filled with worries for parents, especially during prenatal screening and diagnosis. Mostly reported anxiety causes concern the risk of being confronted to a fetal abnormality and having to decide whether to terminate or to persue the pregnancy. The revelation of a severe fetal disease intensifies their distress and becomes a trauma for the parents.
The impact of perceived control during delivery in the context of traumatic birth-experience Introduction: Traumatic aspects occur in up to 50% of all women during delivery, whereas the prevalence of posttraumatic stress disorders (PTSD) in the postpartum period ranges from 2 to 6%. There is evidence that risk factors (intensity of pain, anxiety) and protective factors (support by medical staff) are important predictors for traumatic symptoms. Up to now it has not been investigated whether these effects are mediated by perceived control during childbirth.
Induction of labour for gestational diabetes, impact on caeserean rates Introduction: Gestational diabetes mellitus (GDM) impacts approximately 10–15% of pregnancies worldwide. Currently the recommendation is that pregnancies affected with GDM requiring medication should be delivered by their due date. There is a paucity of evidence to support that induction of labour would be beneficial. Evidence derived from other studies support that inductions do not increase the caesarean section rate. The aim of this study is to assess whether induction of labour for GDM increases the caesarean section (LSCS) rate.
Vaginal breech delivery of pregnancy before and after the estimated due date – A case–control study Introduction: At term, 3–4% of pregnant women expect a baby in breech presentation. National societies regard vaginal breech delivery as a safe option, but only for a specific and thoroughly counseled group of patients. To avoid adverse outcomes, many practitioners recommend elective cesarean section once their patients go past the estimated due date. Since encompassing evidence is missing, we need to evaluate this common clinical practice.
Denosumab and cancer cell migration Introduction: Denosumab, a human monoclonal antibody to receptor activator of nuclear factor-κB ligand, suppresses bone resorption and a potential treatment for bone destruction in metastatic cancer. Denosumab may have an additional effect on cancer than the previously demonstrated bone-protective effects.
The role of DCE-MRI in surgical treatment planning of symmetric uterine anomalies Introduction: Prognosis of the onset and course of pregnancy depends on the type of uterine anomaly and on the rate of blood circulation in myometrium. It is reasonable to study the blood flow in myometrium and in area of intrauterine septa by magnetic resonance imaging with dynamic contrast enhancement (DCE-MRI). DCE-MRI allows to move from morphological to functional assessment of pathology.
Infertility and donor conception: Pregnancy is just the beginning! Introduction: Since 2000, the Donor Sibling Registry (DSR) has connected more than 15,500 donor offspring with half-siblings and their biological parents. Accordingly, they have been able to create and explore these new familial relationships and can also understand their ancestry and learn about their medical backgrounds. 56,000 gamete donors, offspring, and recipients in 105 countries have registered on the DSR, seeking to find those with whom they share genetic ties.
Cold atmospheric plasma for potential in vivo applications: Raman microsprectrometry determined effects on cervical cancer cells Introduction: The incidence of cervical cancer (CC) in developed countries has been reduced by strict screening, active monitoring and treatment of cervical intraepithelial neoplasia (CIN); however, ablation of the CIN by laser-induced thermal destruction or surgery usually requires general anaesthesia and clinical backround. Recently, cold temperature atmospheric plasma (CAP) containing various biologically reactive factors has shown to induce anti-neoplastic effects in several tumor entities and might be a promising tool for low-invasive treatment of tumoral and pretumoral lesions of the cervix.
Factors related to overtreatment in the see and treat approach: A retrospective multicentric observational study Introduction: The “see and treat” approach is a single step method including colposcopy and treatment with cervical excision at the same time. See and treat reduces costs, creates less anxiety for patients and increases compliance but it poses a risk of overtreatment. Since cervical excisions could present a risk of several complications such as infection, haemorrhage, cervical stenosis and prematurity in future pregnancies, it is of crucial importance to careful select patients who will benefit more from a see and treat approach, in order to avoid unnecessary treatments.
Are there any factors influencing the efficacy of misoprostol in the first-trimester miscarriage induction? Introduction: First-trimester miscarriage is defined as pregnancy failure up to 13 completed weeks. In cases of missed miscarriage or anembryonic pregnancy the surgical curettage used to be the treatment of choice – as a quick, efficient intervention, with the possibility of histological examination. Nowadays, the FIGO/WHO recommend misoprostol therapy, 800mcg vaginally or 600mcg sublingually, repeated after 3h, maximum twice daily to induce pharmacological abortion.
Dietary intakes of smokers compared to non-smokers at the first prenatal visit Introduction: Maternal smoking is an important modifiable risk factor for intrauterine growth restriction. Yet, many women continue to smoke throughout pregnancy. During pregnancy, the daily requirement for many micronutrients increases due to higher physiologic demands. Outside of pregnancy, the dietary intakes of smokers compare unfavourably with non-smokers but there is limited information on the dietary intakes of women continuing to smoke in pregnancy.
Is simulation training needed? Slovenian trainees’ perception Introduction: Simulation training has become a standard in medical education. It improves technical skills, especially in non-frequent procedures. Slovenian national data show that 14% of primigravidae with breech presentation still deliver vaginally. There is a steady rate of 3.5% for vacuum delivery and no forceps use. We have currently two obstetric simulation courses (Training in obstetric emergencies, Ljubljana, Simulation of Delivery, Maribor), however they are not incorporated in the postgraduate programme.
Are they ready? Organizational readiness for change among clinical teaching teams Introduction: Curriculum change and innovation are inevitable parts of progress in postgraduate medical education (PGME). Although implementing change is known to be challenging, change management principles are rarely looked at for support. Change experts contend that organizational readiness for change (ORC) is a critical precursor for successful implementation of change initiatives.
Associations between sexually transmitted infections and cervical precancerous lesions in Latvian women Introduction: Vaginal microbiome and sexually transmitted infections play a role in the acquisition and persistence of human papilloma virus, thus leading to cervical carcinogenesis (Adebamowo, 2017; Kim, 2016). There are studies that show relations between Mycoplasma genitalium infection and cervical precancerous diseases (Adebamowo, 2017; Gomih-Alakija, 2014; Yin, 2013), but still the data remain controversial.
How do clinical teaching teams implement curriculum change: An interview study Introduction: Previous research has shown that program directors are ‘in the lead’ in regards to the implementation of curriculum changes in PGME. However, in these change processes there is little guidance from an appropriate change model. It is unclear how clinical teaching teams and program directors in particular deal with curriculum changes they are faces with.
Learner engagement: Preliminary observations from a distance learning ultrasound programme Introduction: Distance learning is booming in a world where technology brings closer Learners who are otherwise geographically far apart. There has been emergent literature on the benefit of online content as an alternative to face-to-face learning. Our accredited ultrasound diploma course utilises a virtual learning environment whereby students have access to content to aid the learning outcomes. Assessments include periodic quizzes, assignments submission and online interaction.
Pregnancy after bariatric surgery: What is the optimal interval? Introduction: Bariatric surgery has become an effective approach to lose weight in a sustainable way and reduce the morbidities associated with severe obesity. Approximately 40% of bariatric procedures are performed in reproductive aged women. Generally, women are advised to delay pregnancy for 12–24 months, because this time frame is when they are losing the most weight.
Quality of life measurement in breast cancer patients: Reliability of an ePRO tool using EORTC QLQ-C30 Introduction: The importance of patient reported outcomes (PRO) such as “health related quality of life” (HRQoL) increases. Especially in the field of breast cancer, the most common type of cancer in women, it is very important to focus on patient's quality of life, both in adjuvant and palliative setting. Due to evolving digitalization in medicine, new possibilities such as electronic measurement via tablet or computer arise. However, before changing to a new mode of administration from pen and paper to an electronic, equivalence across those two different modes of administration has to be guaranteed.
Risk of preeclampsia in twin pregnancies – A register study based on 16,000 twin pregnancies Introduction: Preeclampsia is a hypertensive disorder combined with proteinuria and occurs only during pregnancy. The condition is potentially dangerous for the mother and the foetus, and is one of the most common reasons for maternal and foetal mortality and morbidity globally. The aetiology is still unknown, but many risk factors are identified. Risk of preeclampsia is higher among nulliparous women compared with parous women. Advanced maternal age, obesity, diabetes mellitus and pre-pregnancy hypertension increase the risk of preeclampsia.
SAFER: Electronic risk management for aspirin prophylaxis in pre-eclampsia Introduction: Low-dose aspirin prophylaxis in pre-eclampsia is safe and reduces the risk of pre-eclampsia by 17% among the high risk. Prior to the introduction of the ‘SAFER’ electronic risk assessment tool at a district general hospital, only high risk pregnancies were identified for prophylactic aspirin for pre-eclampsia. No system was in place to ensure consistent identification and provision of aspirin for women with multiple moderate risk factors. SAFER was implemented in 2015 to manage venous thromboembolism, intrauterine growth restriction and gestational diabetes.
European patient's perspective on the general competencies and soft skills of the gynaecologist Introduction: The perspective of patients on delivery of care has gained importance in improving health care. Patients particularly emphasize the importance of well developed communication skills, and other soft skills. For obstetricians and gynaecologists, development of soft skills acquired importance. Despite the increasing importance in delivery of care, training in soft skills does not always seem to be in line with the requirements of patients.
Ovarian torsion: Tips & tricks via ultrasonography Introduction: Ovarian torsion represents an acute gynecological condition that should be treated immediately, especially in young nullipara women. Increase in size of the ovary, thickening of external wall and/or twisted vascularity are the specific ultrasonic features that are up to moment applied during the diagnostic approach of a possible ovarian torsion.
Birth characteristics of Syrian refugees at a tertiary medical center in Istanbul, Turkey Introduction: The Syrian crisis, which started in March 2011, caused 5,163,650 people (as of August 2017) to become refugees, majority of them from Egypt, Iraq, Lebanon, Jordan and Turkey . According to latest data, the number of Syrian refugees living in Turkey is 3,106,932.2 46.8% of these are females (0–4 years 6.6%, 5–11 years 8%, 12–17 years 6.8%, 18–59 years 23.6% and 60+ years 1.7%) . As of August 2017, 224,750 Syrian babies have been born in Turkey . Istanbul is one of four cities that have more than 300,000 Syrian refugees .
Individual approach at the treatment of vaginal aplasia in adolescents by using the physiotherapy techniques Introduction: Aplasia of the vagina and uterus is found 1 times in the 4000–5000 newborn girls. From all cases of aplasia 90% takes syndrome Rokitansky-Kuster-Hauser-Mayer. The main complaint of patients is the absence of menstruation and inability in sexual life. The first line of therapy is vaginal dilation. Aplasia of the vagina – a pathology that not endangered for life, but causes psychological, social and reproductive difficulties that's why it is necessary to modernize the classical treatment to improve the quality of medical care and its effectiveness.
Association between elastogram of uterine cervix to preterm delivery among pregnant women at risk for preterm labor Introduction: Preterm delivery (PTD) is a major cause for neonatal morbidity and mortality. Strategies to prevent PTD were developed using risk factors, ultrasonographic examinations and cervical fluid biomarkers. Tissue elastography is a technique using ultrasound color doppler to evaluate the amount of fluids in the tissue. The higher the fluid content, the more tissue elasticity is found. This technique is used for breast and prostate pathologies, and recently was described for the prediction of PTD.
Perimenopausal features in Slovenian women Introduction: At menopause a variety of changes take place in the body. Menopause transition results in a complex interplay of biological, psyhosexual and socio-relational factors. Many women experience symptoms in this period of life, most of which are self-limiting but can be disabling and affect their quality of life.
Postpartum ultrasound Introduction: Practitioners are continuously concerned with the differences between the normal puerperium and the uterine involution after complicated deliveries: operative evacuation of RPT, caesarean section or postpartum endometritis.
Experience of a childcare educational group interview to preparing return at home at the CHU Nord Marseille maternity Introduction: An educational interview in childcare is offered to all parents as part of the preparation return at home. This interview responds to Frenchs’ recommendations on child health and the organization of maternity leave. A pediatric nurse and a childcare assistant interact with a group of parents on the following topics: rhythms, sleep, sleeping, feeding (breastfeeding, preparation of baby bottles), care and follow-up (MSIN prevention, vaccinations, etc.) for children. Videos and brochures are used as teaching aids.
Inhibition of cervical cancer cell growth by non-thermal atmospheric plasma application utilizing a thermal argon plasma source Introduction: The intraepithelial neoplasia of the cervix (CIN) is a serious precursor of invasive cervical cancer (CC). Non-thermal atmospheric plasma (CAP) application might be a promising tool for low-invasive treatment of tumoral and pretumoral lesions of the cervix without requirement of local or general anaesthesia and hospitalization. CAP is a low-temperature ionized gas and leads to generation of reactive oxygen and nitrogen species (RONS), as well as other free charged particles and UV radiation.
Effects of an enhanced recovery protocol after surgery in gynecology Introduction: Enhanced recovery programs after surgery (ERAS) were first developed for colorectal surgery. They comprise a multimodal analgesia, a reduction in preoperative fasting, an earlier refeeding and mobilization. They aim at improving patients comfort, and at fastening the recovery of their autonomy. The benefit for the hospital is a potential earlier discharge, at the cost of a change in perioperative protocols, and a shift in organization within a mandatory multidisciplinary approach.
Avoiding looking through rose tinted glasses Introduction: Submucosal fibroids result in abnormal uterine bleeding and infertility leading to hysteroscopic resections. The data on whether submucous fibroids should be removed is conflicting. The Cochrane dated February 2015 suggests that there is not enough evidence to recommend routing hysteroscopic resection of submucous fibroids. The AAGL (American Association of Gynecologic Laparoscopists) recommends the removal of submucous fibroids in infertility and in selected patients with abnormal uterine bleeding and recurrent pregnancy loss.
Inversion procedure could mirror the underlying pathology of an ovarian mass Introduction: Ovarian pathology via ultrasonography is accurately diagnosed based on subjective impression of the expert via pattern recognition. Taken into account that “the expert” is not always and everywhere available, ADNEX model and Simple Rules, introduced by IOTA group, are easily applied and accurate diagnostic tools in less experienced hands. But both models require specific training regarding gynecological ultrasound examination. Newer technologies (3D/4D software), producing images of high quality, could support the sonographer via “numerical transformation of image signalling into clinical information”.
The comparison of the bacterial colonisation of the oral cavity and vaginal ecosystems Introduction: The right bacterial flora of the vagina is, first of all, lactobacilli. Lactobacilli inhibit the development of pathogens and restore the right bacterial flora of the vagina. Any disorders of the vaginal ecosystem most typically result from epithelium damage, a low concentration of estrogens and atrophy of the right vaginal microflora. In the vagina, both systemic, sexually transmitted infections as well as the infections characteristic of the vagina occur. Among the latter, the following can be distinguished: bacterial vaginosis–the most frequent, candidal vulvovaginitis, trichomoniasis, the infection with aerobic bacteria, and mixed infections (MI).
Use of the sepsis screening form in a regional Irish maternity hospital Introduction: The established approach to reducing morbidity and mortality associated with sepsis is early recognition and treatment.  In order to ensure correct diagnosis and effective management of these patients, a standardised sepsis screening form was developed and implemented in Irish maternity hospitals.
Office hysteroscopy: Identifying risk factors for technique failure and surgical complications Introduction: Office hysteroscopy is an accessible, accurate, well-tolerated and cost-effective procedure that allows evaluation of the uterine cavity with a low rate of surgical complications. However, it is essential to investigate the risk factors for technique failure and surgical complications in order to accurately select patients who will benefit from its performance in an outpatient setting.
Outpatient hysteroscopy: Scope for improvement? Introduction: Outpatient hysteroscopy is a well-established and safe diagnostic test in widespread use across Europe. It is the gold standard for the diagnosis of abnormal uterine bleeding. In NHS Lothian there are two clinical sites where outpatient hysteroscopies are performed, one a central tertiary referral centre, the other a district general hospital. There are currently perceived differences in the services provided at each site which may be affecting patient outcomes.
Hysteroscopic assessment of fallopian tubal patency by air bubble sign Introduction: Most common reason for infertility is the blockage of the Fallopian tubes. Checking tubal patency is the fist line of fertility check up. Several methods have been introduced to evaluate tubal patency. In previous studies it has been shown that during hysteroscopy air bubbles can be detected. The flow of the air bubbles is an indirect sign of tubal patency.
The role of professional society in quality of perinatal care: Experience from Estonia Introduction: Estonian Medical Birth Registry collects data about all births in Estonia since 1992. Estonian Gynecologists’ Society has analysed perinatal quality indicators in different clinics and at national level to improve quality of perinatal care. In 2016, five perinatal quality indicators were chosen by the Estonian Health Insurance Fund as national quality indicators for obstetrical care.
Histological differentiation in endometrioid endometrial adenocarcinoma Introduction: In developed countries, endometrial carcinoma represents the fourth most common malignancy in women and the most prevalent female genital tract cancer. The endometrioid type accounts for 80–90% of cases. Histological grading takes into account the proportion of solid (non-squamous and non-morular) areas, which is somewhat subjective. Current recommendations for surgical staging in early stage disease don’t take into account if the tumour is well (G1) or moderately (G2) differentiated.
Methylation status of KLF4 CpG islands in endometrial cancer Introduction: Endometrial carcinoma is one of the most frequent gynaecological malignant disease in developed countries. Despite its relatively frequent occurrence, role of epigenetic changes such as methylation status of this tumor are not well characterised. In this study we focused on a tumor suppressor KLF4 gene (Kruppel Like Factor 4, zinc finger transcription factor), which is involved in the regulation of proliferation, differentiation, apoptosis and somatic cell reprogramming as it controls G1-to-S transition of the cell cycle.
Endocervical adenocarcinoma a pattern-based clinical classification Introduction: Endocervical adenocarcinoma (EAC) staging is based on tumor depth of invasion. Because EAC spreads primarily by lymphatic dissemination, treatment except from the primary tumor site should investigate the adjacent tissues and the state of lymph nodes (LN). However, aggressive lymphatic dissections lead to increased morbidity.
Effective and safe method of labor induction in women with previous caesarian section Introduction: Numerous factors are known to increase the risk of a uterine rupture (UR) but even in high-risk subgroups, incidence is low. A previous Cesarean section (CS) has shown to be the strongest risk factors for UR, and increased at least two-fold when labor is induced. Women are allowed to deliver vaginally after one previous CS, regardless if labor starts spontaneously or is induced. An important question is whether the method of induction is of importance for UR, and if so, which method is the most effective and safe.
Emerging treatment of endometriosis: Where we are? Introduction: Approximately only half of women with endometriosis get pain relief from existing medical or surgical treatments. Over the past 2 decades a wide variety of medical options has been tested. All are aimed at a specific target that contributes the pathogenesis of the disease.
Surgical treatment of endometriosis: a five-year hospital cohort Introduction: Endometriosis is characterized by pelvic pain and subfertility. Laparoscopy is the gold-standard diagnostics. Since 2010, patients with endometriosis have increasingly been treated with radical surgical procedures at our gynecologic department.
Manual therapy approach in endometriosis Introduction: Endometriosis is a disease where endometrial tissue is seen outside of the uterus. The primary symptom of endometriosis is pelvic pain, often associated with your menstrual period.
Role of CA 125 level in management of endometriosis Introduction: There is a need of an accurate non invasive diagnostic biomarker, with which we can detect the endometriosis. To our knowledge perfect biomarker has not been identified yet. Among the potential biomarkers the CA 125 is the most investigated, but most of the previous studies have several limitations.
Diabesity and perinatal risk – A new paradigm Introduction: Maternity obesity (IMC>30kg/m2) and gestational diabetes (GD) prevalence have been growing in a global way. Diabesity is related to many pathological mechanisms associated to insulin resistance and hyperinsulinemia.
Audit of outcomes and experience of women with one previous caesarean birth Introduction: There is consensus that planned vaginal birth after caesarean (VBAC) is a clinically safe choice for the majority of women with a single previous lower segment caesarean delivery. Such choice is also supported by health economic modelling and may be a strategy used to limit further escalation of caesarean delivery rates and maternal morbidity associated with multiple caesarean deliveries.
Group B Streptococcus early-onset neonatal sepsis in term neonates Introduction: Early-onset neonatal sepsis (EOS) remains a common and serious cause of perinatal mortality and morbidity. The overall EOS incidence worldwide has decreased from 1.5 to 0.24 cases per 1000 live births in developed countries by implementing Group B Streptococcus (GBS) screening in pregnant woman and antibacterial intrapartum prophylaxis.
Maternal death in a state of the Amazon Region: Historical quantification from 1996 to 2017 Introduction: Female mortality due to complications associated, directly or indirectly, with gestation, childbirth and the puerperium still represents a great waste of lives in developing countries. The main causes of maternal death in Brazil and in the world are hemorrhage, mostly followed by infection (septicemia), eclampsia, abortion and obstructed labor, with some small proportions varying from country to country. Although statistics show a rates are still very high in third world countries.
Investigation and management of venous thromboembolism in pregnancy Introduction: Venous thromboembolic events (VTE) is a serious complication of pregnancy that is associated with mortality. VTE has two components – pulmonary embolism (PE) and deep vein thrombosis (DVT), both of which its risk is increased during pregnancy. Within the UK, the incidence of thrombosis and thromboembolic events have decreased to 0.85 (MBBRACE, 2016). However, VTE remains a leading cause of direct maternal morbidity in the western world, suggesting the need for greater recognition of risk and effective management.
Chikungunya virus infection in a tropical country and maternal–fetal repercussion: Bibliographic review Introduction: The chikungunya virus (CHIKV) is an RNA virus of the family Togaviridae, of the genus Alphavirus, had its first cases reported between 1952 and 1953. It was isolated from a patient's serum during an outbreak of dengue on the Makonde Plateau in Southern Tanzania. In tropical countries, conditions such as disorderly occupation of urban areas, lack of basic sanitation and deforestation favor the proliferation of two very competent vectors in the transmission of these viruses: Aedes aegypti and Aedes albopictus.
Pregnancy outcome and maternal characteristic of patents with low PAPP-A Introduction: PAPP-A is a glycoprotein produced by placenta which circulates in high quality within maternal blood in pregnancy. PAPPA are functionally involved in tissue growth and cell structure remodelling. Low level of circulating PAPP-A in pregnancy is associated with poor placenta function and bad pregnancy outcome. This makes PAPP-A a useful maker to predict pregnancy outcome. The associated with poor outcomes have led to increase surveillance in patient with low PAPP-A in pregnancy. The method of surveillance have not been fully verified and standardised for the risk factors.
Nemaline myopathy – Diagnostic and management dilemma Introduction: We are presenting a case on prenatal diagnosis of nemaline myopathy, in a couple whose last baby died from the same genetic condition. Nemaline myopathy is a rare genetic disorder affecting the muscles with a range of severity and can be inherited as recessive or dominant. There are 13 different genes known to be linked with this condition. In her last pregnancy, the only ultrasound finding was isolated talipes and patient declined further invasive testing at the time. The diagnosis was made clinically when baby was born and confirmed with muscle biopsies and genetic testing.
Breast cancer and Flammer syndrome: A linkage to better prediction, prevention and personalised medical approach Introduction: Breast cancer (BC) epidemic is characterized by around half a million deaths and 1.7 million new cases registered annually worldwide. An epidemic scale of BC prevalence is actually recognized with increasing trends both in the post- and premenopausal BC prevalence and metastatic disease is major cause of death in this patient cohort. Particularly alarming is that the sporadic BC (90% of all patients) creates currently unpredictable subpopulations in terms of disease predisposition, development and progression.
Molecular profile of breast cancer – About 467 cases Introduction: Breast cancer is the most common cancer it represents the second leading cause of death in the world. A molecular classification of this cancer has been recently established. The molecular classification of breast cancer based on gene expression and then on the protein profile allowed to distinguish five molecular groups: luminal A, luminal B, Her2/neu, basal-like and not classified.
Selective interaction of triple-negative breast cancer cells with netrin-4 correlates with CD146 expression Introduction: Netrins are a family of laminin-related extracellular matrix proteins which includes in humans the secreted netrin-1 and netrin-4. Both family members are not only involved in normal tissue development, but also in different types of malignancies. In primary breast cancer a direct correlation exists between the expression of netrin-1, the state of the disease and the generation of distant metastases. Netrin-4 expression in invasive breast tumors is a strong prognostic marker for overall survival.
Non monitored gestational diabetes Introduction: Gestational Diabetes is a transient glucose intolerance affecting 3–10% of pregnancies. It is associated with poor obstetric outcomes, such as fetal macrossomia, hydramnios, hypertension, and complication in the newborn such as infection, hypoglycemia, respiratory distress and higher risk of shoulder dystocia, clavicle fracture and Erb paralysis.
Maternal and neonatal expression of vascular growth factors in gestational diabetes mellitus Introduction: Vascular growth factors play an important role in intrauterine fetal growth. Serum expression of biochemical transducers, such as vascular growth factors, affects development in utero. Especially, angiogenesis among placental villi modulated by metabolic routes determines fetal growth. However, in pregnancies affected with gestational diabetes mellitus (GDM) this process may be disturbed and lead to abnormal fetal growth associated with high risk of adverse perinatal outcomes.
The influence of body mass index (BMI) on placental stiffness Introduction: Elastography is a technique which is used to measure the stiffness that represents the constituent of soft tissues. Considering that a pathological process may alter the elastic properties of the involved tissue, the stiffness determination could be useful to obtain diagnostic information about the presence or status of a disease. To date, consistent data about placental stiffness in low-risk, uneventful pregnancies and among the entire course of pregnancy, including the first trimester, are lacking.
Does an elective induction policy negatively impact on vaginal delivery rates? Introduction: The rate of induction of labour (IOL) varies across regions in Ireland averaging at 23.3 per 100 deliveries in 2005–2009. Some studies report an increased rate of Caesarean section (CS) and neonatal and maternal morbidity. Elective induction (without medical indication) is contentious for this reason.
Labor induction in moderate to late preterm birth Introduction: In many international guidelines, it is mentioned that there is no indication to perform an elective cesarean section in case of elective preterm birth but there are no specific guidelines regarding preterm labor induction because data remains sparse, especially in moderate and late preterm birth.
Caesarean scar ectopic: A case series and literature review Introduction: Caesarean scar ectopic pregnancies are a rare, but hazardous complication of early pregnancy with an incidence of 1:1800, which is increasing in the recent years due to rising Caesarean sections rates and may be up to 6% of ectopic pregnancies. They can be very difficult to diagnose and there are multiple modalities for their treatment, described in the literature.
A vaginismus study: Really need surgery? Introduction: Vaginismus is a condition that greatly impairs the quality of life of women and their partners. The 5th edition of the DSM (DSM-5) recently introduced a substantial revision of the definition, classifying vaginismus with dyspareunia under the broader label of “genito-pelvic pain/penetration disorder”. Psychosexual cognitive behavioral approaches are prevalently uses as an alternative to the surgery on vaginismus. Psychosexual cognitive behavioral approaches for focus on promoting changes in attitudes and thoughts, decreasing anxiety, and increasing orgasmic ability and sexual satisfaction.
Tobacco smoking relapse in post-partum period Introduction: Smoking tobacco during pregnancy is a preventable risk factor of adverse pregnancy outcomes. Pregnancy was identified as an appropriate moment to stop smoking and advocated developing preventive procedures. Post-partum is a key period with high level of relapse rate.
Happiness feelings at 12 weeks can predict fetal birth weight Introduction: Psychological morbidity is considerably high in women of reproductive age, and although mood and anxiety disorders are common, they are often underestimated during pregnancy. Providing adequate emotional management during pregnancy can be crucial for the health of new generations.
Why couldn’t newborns over 4500g be delivered vaginally? Introduction: In the upcoming years, fetal macrosomy may be increased since the associated risk factors such as maternal obesity and advanced maternal age are increasing. Birth management of macrosomic fetuses remains uncertain.
Impact of nulliparous women's pre-pregnancy weight and risk of laceration at birth Introduction: Pre-pregnancy overweight and obesity lead to an increment of maternal and perinatal complications. The impact of a woman body mass index (BMI) on the risk of genital tract trauma is less clear. Maternal obesity is associated with fetal macrosomia which can be associated with an increased rate of genital tract trauma. According to that, obese nulliparous women can possibly have a higher risk to have a genital tract trauma.
Vaginal birth after cesarean section (VBAC) for breech singletons at term – A prospective evaluation Introduction: Although breech presentation occurs in 3–4% of all term deliveries, the clinical management of those patients is still a controversially discussed topic among experts. Despite missing empirical evidence, a planned cesarean is often recommended to women with a prior cesarean section. Further research is inevitable to develop a guideline for breech deliveries, encourage vaginal birth after cesarean section (VBAC) in breech and prevent unnecessary elective cesarean sections.
Clinicopathological features of MSI endometrial cancer with MLH1 promoter hypermethylation Introduction: Endometrial cancer (EC) is one of the mostly widespread gynaecological tumours worldwide. Loss of DNA mismatch repair (MMR) is a frequent event in ECs, leading to an easily recognizable molecular phenotype known as microsatellite instability (MSI). Though in colorectal cancers MSI appears to be of prognostic significance, the relationship between MSI and outcome and other clinicopathologic variables in EC has not been firmly established.
Sentinel lymph node biopsy in vulvar cancer: A series of 19 cases Introduction: Vulvar cancer is a relatively rare gynaecologic malignancy that represents less than 5% of gynaecological cancers and is primarily seen in postmenopausal women. The classical approach for the surgical management of vulvar cancer was radical vulvectomy with en-bloc inguinofemoral lymphadenectomy. In current practice, radical local excision and sentinel lymph node biopsy (SLNB) is the best surgical option for selected patients, with comparable efficacy, less morbidity and disfigurement.
Testosterone, DHEA, progesterone: How to handle male aging? Introduction: Well aging medicine should consider the androgen deficiency in the ageing male which is associated with the loss of libido, erectile dysfunction, decreased cognitive ability, depression, lethargy, osteoporosis, and sarcopenia.
Laparoscopic myomectomy: Our experience Introduction: Leiomyomas are the most frequent benign gynaecological neoplasia and a common cause of morbidity in women of reproductive age. Surgical treatment is recommended when they become symptomatic, being laparoscopic myomectomy a therapeutic option for women who wish to preserve their fertility or do not accept losing their uterus.
Interval surgery in advanced stage ovarian cancer Introduction: The management of patients with diffuse peritoneal carcinomatosis of ovarian origin has evolved considerably in recent years. The introduction of neo-adjuvant chemotherapy prior to exeresis surgery has reduced postoperative morbidity in these patients with diffuse tumors and improved their quality of life.
Mucinous ovarian tumors and the importance of frozen section biopsy Introduction: Intraoperative diagnosis of ovarian tumors via frozen section is an invaluable tool for surgeons in order to decide the extent as well as the kind of operation that will follow. However, mucinous ovarian tumours are a diagnostic problem for frozen section biopsy, associated with high inaccuracy compared to the final paraffin sections diagnosis.
Prevalence of Lynch syndrome mutations in women with endometrial and colorectal cancer Introduction: Lynch syndrome or hereditary non-polyposis colon cancer (HNPCC) is inherited disorder in DNA mismatch repair genes which lead to microsatellite instability and increased risk of developing such cancers as colorectal, gastric, endometrial and others in relatively young adults under 50 years of age. Since genes who account for this syndrome have been identified and are transferred to next generations, many countries have launched a screening programme for selected patient groups to carry out prevention strategies.
Immunohistochemical study and prognostic value of CYLD protein expression in endometrial cancer Introduction: The gene of cylindromatosis (CYLD) codes a deubiquitinating enzyme playing a crucial role in several cellular processes as immune responses, inflammation, cellular death, and proliferation. This enzyme is also associated with the regulation of signaling pathways, like NF-kB, Wnt/β-catenin and MAPK pathways. Another critical characteristic of CYLD protein is its tumour suppressing activity. Loss of function and mutations of CYLD were linked to different types of tumors.
Features related to recurrence in advanced squamous cell vulvar carcinoma Introduction: Vulvar carcinoma is a rare malignancy of the female genital tract for which surgery is the main treatment option that can be followed by adjuvant radiotherapy. Clinical features such as initial tumour size, nodal status, surgical margins, lymphovascular space invasion (LVSI) and depth of penetration are considered risk factors for local recurrence.
Alteration of the PD-1/PD-L1 axis in cervical intraepithelial neoplasia-preliminary study Introduction: Programmed cell death 1 (PD-1) and its ligand PD-L1 have an important function in the maintenance of the immune homeostasis. PD-1 as the inhibitory checkpoint controls damage of the healthy tissues during infection and promotes self-tolerance. High PD-1 expression on the surface of T cells changes its ability to eliminate of cancer and infectious disease. Cervical intraepithelial neoplasia is a premalignant transformation associated with infection with oncogenic types of HPV human papillomavirus, which is a direct precursor to cervical cancer.
Reproductive outcome in women after having extrauterine pregnancy with spontaneous regression Introduction: An ectopic pregnancy occurs when a fertilised egg implants outside the uterine cavity, mostly in one of the Fallopian tubes. In the developed countries, between 1% and 2% of all reported pregnancies are extrauterine gravidities. The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding; however, only about 50% of patients present with all 3 symptoms. Ectopic pregnancy is common in women of reproductive age, therefore its treatment requires special attention and ideal management strategies.
Efficiency of surgical management of miscarriage within a central London teaching hospital Introduction: The National Institute for Health and Clinical Excellence advises women diagnosed with miscarriage should be offered, where appropriate, all three management options: expectant, medical and surgical (which includes surgical management of miscarriage under general anaesthetic [SMM]). Women who opt for surgery often expedite the miscarriage process for physical, social, and psychological reasons. Currently there is no standard for the maximum time a woman should need to wait for her preferred SMM option.
The relationship between maternal dietary and supplemental intakes and blood folate levels with Haemoglobin in pregnancy Introduction: In a survey of national guidelines throughout 20 European countries regarding the use of folic acid (FA) in pregnancy, only four advise that folic acid should be commenced at least 4 weeks preconception to prevent Neural Tube Defects (NTDs). There is no consensus on when FA should be discontinued. However, the World Health Organisation (WHO) recommends that all women should take 600 mcg dietary folate equivalent (DFE) throughout pregnancy because of fetomaternal requirements.
Impact of gestational weight gain on obstetric outcomes Introduction: Inadequate gestational weight gain (GWG) can be associated with unfavourable outcomes, namely gestational diabetes, fetal growth restriction (FGR), fetal macrossomia, premature birth and labour induction, regardless of pregestational body mass index (BMI).
Impact of hyperemesis gravidarum on the number of pregnancies and pregnancy terminations Introduction: Hyperemesis gravidarum (HG), excessive vomiting in pregnancy, affects approximately 0.3–3.0% of pregnancies. Recurrence in following pregnancies ranges from 15% to 81%. Questionnaire studies have suggested that some women have decided not to have more children or have terminated a pregnancy due to HG, but research remains scarce and it is not known if the phenomenon is substantial enough to be seen on population scale. We used our national register data to find out.
Management of some nightmare scenarios in Obstetrics Introduction: Haemorrhage, sepsis & hypertension are major causes of maternal morbidity & mortality worldwide. Improvements in education, awareness, nutrition & access to healthcare have led to improvements in the lives of women. However, rapid deterioration and/or complex presentations happen, and the outcomes are very varied depending on their management.
Disseminating laparoscopic skills for endometrial cancer Introduction: Total hysterectomy with biltaeral salpingo-oopohorectomy offers the best chance of long term survival in endometrial cancer. Laparoscopic hysterectomy is associated with a lower incidence of postoperative complication and reduced hospital admission. In this district general hospital, the impression was that the rate of laparoscopic intervention was low with all total laparoscopic hysterectomies performed by one visiting gynae-oncological subspecialist.
VBAC vs C-section, a reflection of practice Introduction: In our country, VBAC (Vaginal Birth After Caesarean Section) is not widely applied during current obstetrical practice. As a result the percentage of C-sections is considerably high and this contributes to an increase in postpartum complications.
Unusual presentation of placenta increta in mid-trimester loss: A case report Introduction: Abnormal placentation is a major cause of maternal morbidity and mortality worldwide. There are three variants: placenta accreta, when the chorionic villi attach to the myometrium; placenta increta, in which placental villi extend into the myometrium; and placenta percreta, when the villi invade through the myometrium into the uterine serosa and may invade adjacent organs, such as the bladder. Previous caesarean section (CS) is the most important risk factor. The risk increases with the number of CSs.
Uterine rupture following misoprostol improper use Introduction: Misoprostol, a synthetic prostaglandin E1 analogue, is considered safe and is being used worldwide for second trimester pregnancy terminations, with successful results. However, complications of uterine rupture and hysterectomy have been reported, and the incidence is higher among women with prior cesarean scar. Maternal morbidity and mortality following induced abortions are directly proportional to the gestational age at termination. We report a case of a 32-year-old multipara, G3P2, with two prior low transverse cesarean sections, who experienced uterine rupture after vaginal misoprostol administration, following an illegal second trimester abortion of an undesired pregnancy of about 20 weeks’ gestation.
Two cases of maternal mortality in sinus thrombosis in low risk cases Introduction: A venous sinus thrombosis is a thrombotic occlusion of the cerebral venous drainage. Patients present with unspecific symptoms such as headache, vision disturbances, or altered consciousness. Complications include intracerebral bleeding and/or increased intracranial pressure leading to poor neurological outcome. Besides clotting disorders, pregnancy and puerperium constitute risk factors for this rare condition. Roughly 0.004–0.01% of pregnancies are complicated by cerebral venous sinus thrombosis (CVST).
Congenital thrombocytopenia, intractable menorrhagia at menarche and Ischemic stroke Introduction: Menorrhagia is one of the most common presenting complaints seen in modern gynecology. Familial Congenital thrombocytopenia is known to cause menorrhagia although case reports are very sparse and confirmed cases seldom seen in gynecology practice. We present a rare case of severe intractable menorrhagia occurring with the first period in a 12-year-old girl who has a positive family history of bleeding disorder. She presented with a series of challenges in terms of diagnosis, management, and therapy.
Pelvic inflammatory disease and sepsis: the diagnostic challenge Introduction: The absence of the classic risk factors for pelvic inflammatory disease (PID) and the triad of cervical motion, uterine or adnexal tenderness does not preclude the diagnosis of PID and tubo-ovarian abscess (TOA). Despite the rarity with which PID occurs in perimenopausal women, consideration and early recognition of the diagnosis is crucial.
Adenocarcinoma of Pancreas mimicking pregnancy Introduction: 45 year old lady, Para 2+2, background history of hypercholesterolemia and pancreatitis, presented to the ED with left sided pain, shoulder tip pain and amenorrhea for four weeks, and positive pregnancy test. Gynaecology team took over her care to investigate for an ectopic pregnancy. The serum beta Hcg was 2206mU/L, however, pelvic US showed an empty uterus with large amount of free fluid consistent with hemoperitoneum. She was taken for a diagnostic laparoscopy. Intraoperative findings included normal ovaries and tubes with no bleeding or hyperemia but spleen appeared large and inflamed with capsular rupture.
Cure of urovaginal fistula by catheter drainage: Experience from 97 patients treated at a national competence centre Introduction: Genital fistula leads to urinary or faecal incontinence and is a feared delivery complication in the developing world. Surgery or radiation is a more frequent cause in industrialized countries. Surgical repair (trans-vaginal or abdominal procedure) is the main treatment. Urine deviation (catheter drainage/pyelostomy) will reduce leakage and can confer healing without surgery. From 1995, treatment-information of genital fistulas has prospectively been registered at our gynaecological department, since 2012 as the Norwegian national referral centre.
Placental transfer of elvitegravir and cobicistat in an ex vivo human cotyledon double perfusion model Introduction: Sustained suppression of plasma viral load is the key to preventing vertical transmission from HIV-infected women to their infants. Current guidelines recommend antiretroviral therapy for all HIV infected pregnant women, starting before the pregnancy. However, the choice of which antiretroviral medications to be used must take into account the tolerance for the developing fetus, in view of the placental transfer of the drugs used.
Pregnancy outcome in patients with intrahepatic cholestasis of pregnancy in a single German center Introduction: The clinical management of patients with intrahepatic cholestasis of pregnancy (ICP) is still a controversially discussed issue among clinicians. In fact, the Green-top guideline of the RCOG considers ICP as a risk factor for spontaneous preterm birth, iatrogenic preterm birth, and fetal death. Treatment with ursodesoxycholic acid and induction of labour at 37+0 weeks of gestation are currently recommended as standards for clinical practise.
The relationship between maternal plasma homocysteine in early pregnancy and birth weight Introduction: Homocysteine (HCY) is an amino acid that is known to increase in the maternal circulation if either folate or vitamin B12 are inadequate. It has previously been shown that HCY levels are lower in women who are taking folic acid (FA) supplementation and higher in women with pregnancies complicated by neural tube defects (NTDs). It has also been reported that maternal HCY correlates negatively with birth weight.
The efficacy and safety of rhTM for obstetric DIC Introduction: Obstetric disseminated intravascular coagulation (DIC) is a secondary phenomenon, and the two leading causes of obstetric DIC are placental abruption and postpartum hemorrhage. Recombinant human soluble thrombomodulin (rhTM) is widely used to treat patients with sepsis-induced DIC. However, limited clinical evidence supports the use of rhTM for obstetric DIC.
Saltatory pattern vs Zigzag pattern on the CTG, and perinatal outcomes Introduction: On the CTG, variability reflects the oxygenation of the CNS. Increased baseline variability at >25bpm is called “Saltatory Pattern” (SP) and has been considered as a pathological feature. However, not all fetuses demonstrate such an amplified “bandwidth”. If the fetus is exposed to a rapidly evolving hypoxia, simultaneous increased activity of the SNS to obtain more oxygen as well as enhanced activity of the PNS to reduce the myocardial workload can lead to autonomic instability. This exaggerated response can be seen on the CTG as a “ZigZag pattern” (ZZP) with variability >25bpm lasting more than 30s.
Operative Vaginal Delivery in labour ward, a reflection of practice Introduction: Approximately 6% of all deliveries in our labour ward in 2017 were operative deliveries. In an era of increased caesarean section rate, there is need of adopting instrumental delivery in obstetrical practice, safeguarding at the same time maternal and neonatal well being.
Mode of delivery in pregnancies with prelabour rupture of membranes Introduction: Prelabour rupture of membranes refers to the rupture of the membranes prior to the onset of labor and prior to the onset of clinically apparent labour contractions. It is classified as preterm PROM and term PROM, depending if the event occurs before or after 37 weeks of gestation. Pre-labour rupture of membranes is an important cause of maternal and fetal complications and may influence the mode of delivery leading to increased cesarean section rate.
To NIPT or not to NIPT Introduction: Fetal chromosomal abnormalities, particularly aneuploidies such as Down's syndrome and other trisomies are common and their detection has been one of the main goals of fetal medicine. Prenatal diagnosis of fetal aneuploidies requires invasive procedures but these are risk-associated and expensive. Consequently strategies have focused on the development of effective methods of screening to define the group in need for such invasive testing.
Correlation of calvicular length with femur length for estimation of gestational age in fetus in a tertiary institute Introduction: Accurate determination of gestational age has become important for deciding the appropriate time for termination of the pregnancy as well as to monitor the fetal growth during the entire period of pregnancy. The clavicle begins ossification between the fifth and sixth week of fetal life. Measurement of the clavicle is of special interest since it permits not only the estimation of gestational age, but also the detection of severe congenital anomalies. The purpose of this study is to correlate the fetal clavicular with gestational age during pregnancy [2,3].
Morphometric parameters of placentas in dichorionic diamniotic twins Introduction: The frequency of spontaneous multiple pregnancies (MP) in population is 1:80–1:100. The number of monochorionic (MC) twins is fairly stable (1:250). Over the past 25 years, the frequency of MP has doubled. An important factor for managing of MP is chorionicity. There are next factors influencing the development of the discordance of fetuses – the type of placentation, fixing the umbilical cord, presence of vascular anastomoses, peculiarities of gestational period and sex of the fetuses.
The impact of chorionicity on maternal and fetal outcomes Introduction: Twin pregnancy involves careful monitoring because it is associated with higher rates of almost every potential complication of pregnancy compared to single pregnancy. However, the provided prenatal care is identical whether it is a bichorionic or monochorionic twin pregnancy, with the exception of complications unique to the latter.
Vaginal delivery in monochorionic twins, an option to consider? Introduction: Monochorionic pregnancies have a significantly increased risk of adverse outcomes. Fetal demise, preterm delivery and complications related to placental anastomoses are the major causes of poor outcome. Delivery of such high risk pregnancies is still a delicate matter.
Acute feto-fetal transfusion simulation in monochorionic diamniotic twins Introduction: Acute feto-fetal transfusion (F-F TRF) is a serious complication affecting exclusively monochorionic multiple pregnancies. The pathophysiological background is feto-fetal exsanguination in the presence of interfetal placental vascular anastomoses. The risk of the death or neurological disability of the surviving twin in case of the co-twin demise is 15% and 30% respectively, regardless of clinical subtype.
Sildenafil use in twin IUGR pregnancy Introduction: Intrauterine growth restriction (IUGR) is defined as a fetus failing to reach its genetically defined growth potential. IUGR affects approximately 5% of singleton pregnancies and 25% of twin ones. Still, there is not yet an effective medical therapy for this disorder. IUGR is managed by monitoring of the fetal condition, with timely delivery in case of compromise. Unsurprisingly, it is often complicated by early fetal prematurity, accentuating the major risks IUGR poses to perinatal morbidity and mortality.
Experience in the surgical treatment of deep infiltrative endometriosis Introduction: The frequency of colorectal endometriosis according to a number of authors is 20% among all cases of endometriosis. Severe endometriosis plays a decisive role in reducing reproductive potential. There is sufficient data in the literature of the positive effect of the operative treatment of colorectal endometriosis on the incidence of spontaneous pregnancy and the results of IVF.
Surgical approach of adnexial masses – From clinical diagnosis to histological results Introduction: Adnexial masses can be diagnosed in a symptomatic patient or incidentally in pelvic scan. The prevalence of adnexial masses reaches 12% and if symptoms are present or malignancy is suspected, surgical approach is indicated. Although most adnexial masses are benign, the exclusion of malignancy is crucial and ultrasound characterization, risk factors and tumoral markers can be helpful in the distinction.
Prophylactic hysterectomy in Lynch syndrome: Feasibility and outcomes Introduction: Lynch syndrome (LS) is a hereditary predisposition to cancers, first of all, colo-rectal and endometrial cancers. Although recommended, gynecologic screening has never proven its benefit. Prophylactic surgery is recommended once the parental project is completed in case of identified mutation or high risk of developing a gynecologic cancer. Currently, there is few data regarding the assessment of prophylactic surgery.
Inflammation biomarkers in pelvic inflammatory disease Introduction: Pelvic inflammatory disease has a serious socio-demographic and economic importance and continues to be ranked as the most prevalent in Ukraine. Difficulties in diagnosing and choosing the optimal treatment program for patients are largely associated with the polymorphism of clinical symptomatology, late or non-profiled hospitalization of patients, the lack of a single classification and, most importantly, the lack of a systematic approach to assessing the severity of the course.
Adenocarcinoma in situ of the uterine cervix and the value of conservative management Introduction: Adenocarcinoma in situ (AIS) is considered the precursor of cervical adenocarcinoma. Its incidence is increasing and is usually found in younger women with average age 35.8 years. The management of this lesion is complicated since recommendations vary from radical hysterectomy to more conservative treatments like cone biopsy in women who want childbearing. Fertility spearing management in well-selected patients has shown comparable oncological outcomes as more radical treatments, with the status of the excision margins being the hallmark for the prediction of disease.
PROM at term should be managed at home? A before-and-after study Introduction: Preterm prelabor rupture of membrane (PROM) are currently managed expectantly and with home care. In case of term PROM, guidelines are to the benefit of expectant management with variable duration but there are no recent available data about home management during expectative.
Surgical approaches to treatment of genital prolapses with use of a cross mesh implant Introduction: The prolapse of pelvic bodies considerably worsens quality of life of women in connection with development of the accompanying dysfunction of adjacent bodies. The prevalence in female population is from 2.9 to 53% with a tendency to “rejuvenation”. There are no uniform standards of surgical treatment of prolapses of genitals now.
Controversies and challenges in use of mesh in Urogynaecology Introduction: Pelvic organ prolapse is a common problem worldwide & causes considerable physical & psychological distress to affected women adversely affecting their quality of life. Traditional repair distorts anatomy, has high failure rates & often does not address the underlying cause. Mesh repair aims to overcome these deficiencies but has varying success rates & is faced with increasing litigation due to associated morbidity.
From tissue viscoelasticity to vectorial perineology Introduction: During the abdominal efforts, the pelvic structures are in motion. Dynamic imaging by ultrasound or RMI shows slight quasi-static elastic deformations. During the effort, the abdominal pressure generates a viscous deformation of the pelvic musculo-ligamentous structures. This deformation depends on the direction of the abdominal forces.
Impact of bariatric surgery (modified sleeve gastrectomy “MSG”) on obstetric outcomes Introduction: Use of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age. The significant increase in the number of obese women who become pregnant. In this setting, in recent years, there has been an exponential rise in the number of bariatric procedures, with approximately half of them performed in women of childbearing age, and a significant increase in the number of women who become pregnant after having undergone bariatric surgery (BS).
Bariatric surgery and pregnancy – The experience of a tertiary center Introduction: The proportion of obese women in reproductive age is increasing, so the need to perform surgical treatment for obesity is growing each year. The surgical approach to this pathology may improve the reproductive potential of women in childbearing age, but when pregnancy is achieved, targeted obstetric care is required to monitor nutritional needs, control weight gain and the potential prevention of maternal and neonatal morbidity.
Folate and vitamin B12 levels in early pregnancy and maternal obesity Introduction: Maternal obesity has been associated with a two-fold increased risk of a pregnancy complicated by Neural Tube Defects (NTDs) which are preventable by periconceptual Folic Acid (FA) supplementation. Folate biomarker studies in obese women have been conflicting. We examined the relationship between maternal Body Mass Index (BMI) and maternal serum folate, red blood cell (RBC) folate and vitamin B12 in early pregnancy.
Membrane-binding hemoglobin in erythrocytes of women with pregnancy complications Introduction: Oxidative stress is considered as one of the main driver of pregnancy complication. We hypothesize that one of the mechanism of pregnancy complication progression would be connected with oxidative damage of erythrocytes. Insights into intracellular molecular transformations in red blood cells (RBCs) will need to be considered for understanding the mechanisms of its contribution to pregnancy complication progression. Membrane-bound hemoglobin (MBHb) is one of the RBCs proteins with poorly studied properties.
Quality and access to maternal care in Georgia: A qualitative study among stakeholders Introduction: Maternal mortality and morbidity are directly related to the organization of the maternal care system. During the last decade, the Georgian government has emphasized the importance of improving the maternal care system. However, the improvement of maternal health and the reduction of the maternal mortality ratio (MMR) remain an important concern for the country.
Recurrence of breast cancer: Free disease time and location according to molecular subtype Introduction: Breast cancer is the most diagnosed malignancy in women. The main purpose of follow-up is detection of local or distant recurrence. In literature the presence of symptoms is the first indicator of relapse, followed by physical examination and image exams and it seems to exist a correlation between the molecular subtype and free disease time and local of recurrence.
Expectant versus active management of HELLP syndrome Introduction: Management of HELLP syndrome occurring before 34 weeks of gestation is still controversial since its evolutive profile remains unpredictable. Hence most authors recommend active management with prompt delivery, whose benefit should be balanced with induced prematurity.
Clinical management of severe preeclampsia Introduction: In recent years, preeclampsia has been divided into two forms: early preeclampsia and late preeclampsia, which differ in the severity of the flow and in the outcomes for the mother and fetus. If, in severe late preeclampsia, tactics are defined and reduced to immediate delivery, then in the early course of preeclampsia, the issue of the possibility of prolonging pregnancy remains very debatable.
Maternal serum AMP-activated protein kinase levels in mild and severe preeclampsia Introduction: Phosphorylated Adenosine Monophosphate Activated Protein Kinase (AMPK) is present in human placenta, increases under hypoxic conditions, and enables uterine artery blood flow. Alterations in AMPK signal pathways and trophoblastic differentiation may induce pregnancy-associated disorders, including intrauterine growth retardation, placental insufficiency, PE, and impaired fetal growth and/or viability.
Differential diagnosis of hypertensive disorders in pregnancy using urine peptidome profiling Introduction: High incidence of maternal and perinatal morbidity and mortality, as well as the short and long-term consequences of preeclampsia (PE) determine the need for early diagnosis of this Great obstetrical syndrome. A clear diagnosis of hypertensive disorders during pregnancy which differently determine not only the outcomes for the mother and fetus, but also the quality of the woman's subsequent life is also needed. Proteomic/peptide analysis seems to be one of the most promising accurate methods for reliable diagnosis of PE.
Serious risks of multiple C-section deliveries Introduction: With the rise of C-Section rate, there also rises the repeated C-Section, consequently were rised also the perinatal complications as placental pathology like (Pregnancy scare, Placenta Previa, Placenta accreta, Increta and Percreta).
Comparative study of postplacental CU-T insertion in vaginal and caesarean deliveries Introduction: To address the unmet need during the post-partum period the Ministry of Health and Family Welfare, Government of India developed a national strategy to expand Post-Partum Intrauterine Device (PPIUD) services among public sector facilities. Since, not much work has been done in assessing the complications and side effects of PPIUCD in CAESAREAN AND VAGINAL DELIVERIES, we decided to undertake this study.
Granulosa cell tumor of the ovary, risk factors for recurrence Introduction: Granulosa cell tumors (GTC) are characterized for late recurrence which happens in 10-33% of patients. Prognostic factors related with recurrence are stage at presentation, patient's age, tumor size, extent of surgery, cell atypia and mitosis.
Importance of intra-operative frozen section in the laparoscopic approach to ovarian tumors Introduction: Laparoscopic management of adnexal masses remains as one of the most frequently performed laparoscopic intervention. The use of intraoperative frozen section (IFS) is an important and helpful adjuvant in the operative management of suspicious adnexal masses. It is usually performed in order to define the adequate surgical plan: either by obtaining histological confirmation of suspected malignant or borderline primary ovarian tumours, or by ruling out malignancy in a suspicious adnexal mass.
Suppression of heme oxygenase-1 protein as potential target in ovarian cancer treatment Introduction: Intraperitoneal chemotherapy and regional hyperthermia (HIPEC) are used to treat peritoneal carcinomatosis caused by ovarian cancer. Overexpression of heat shock protein heme oxygenase-1 (HO-1) in cancer cells contributes to cellular resistance against chemotherapy. There is no sufficient data about the role of HO-1 in ovarian cancer treatment.
Phagocytic function of peripheral monocytes and neutrophils in ovarian cancer Introduction: Neutrophil granulocytes and monocytes are phagocytes of the innate immune system and play an important role in the defense against tumor cells. Recently, several studies have been reported describing changes in the functions of tumor-infiltrating immune cells in various types of cancer (e.g. ovarian cancer). However, fewer studies address the role of peripheral immune cells in the pathogenesis of cancer.
Discrimination between benign and malignant pelvic masses using the risk malignancy index in the Maltese scenario Introduction: Ovarian cancer is the commonest cause of cancer death from gynaecologic tumours in the developed world, with one of the most common presentations being a pelvic mass. Increasing the ability to ascertain in advance whether an ovarian neoplasm is benign or malignant in the pre-operative assessment will aid in appropriate referral and in planning the optimal surgery. CA125, Ultrasound Score and Risk of Malignancy Index (RMI) are known methods that can be used to triage such masses. Nonetheless, no data exists as to the performance of such indices in the Maltese local scenario.
Early term gestation: Simple term? Introduction: The redefinition of the classical concept “term gestation” has led to the creation of the two subcategories: “early term gestation” and “full term gestation”. The first one represents the gestational period between the 37 weeks and the 38 weeks and 6 days whilst the second one, the period between the 39 weeks and the 40 weeks and 6 days of gestation. Early term newborns seem to have higher morbidity and mortality rates than the full term newborns.
Lamellar bodies as a predictor of fetal lung maturity Introduction: Respiratory disorders remain an important newborn complication. Currently, there have been alarming information about the impact of repeated courses (even one “resque” course) of RDS prophylaxis on the quality of health in childhood and adulthood. Therefore, the search for available tests to determine the fetal lungs maturity in women at high risk of PTB is an important practical problem. Lamellar bodies (LBCs) produced by type II pneumocytes and appearing in the amniotic fluid in 28–32 weeks may serve as a possible such potential marker.
Preterm delivery after large loop excision of the transformation zone Introduction: Many of the women undergoing local treatment for cervical dysplasia are of reproductive age. Such treatments are associated with poor obstetrical outcomes, particularly, large loop excision of the transformation zone (LLETZ) for cervical dysplasia is known to increase the risk for preterm delivery. Moreover, some studies have shown that this risk worsens with increasing cone depth.
Prolonged premature rupture of membranes in nullipara and the risk of spontaneous premature birth in the subsequent pregnancy Introduction: Preterm birth (before 37 weeks of gestation) affects 10% newborns in some populations and is a leading cause of neonatal death and long-term morbidity. Data have shown that the risk for preterm birth is influenced by chronic infection and some study have shown that prolonged premature rupture of membranes (PROM) had higher risk of infection especially in Cesarean delivery. This study sought to gain a better understanding of the relationship between duration of PROM in first pregnancy and term of delivery of the subsequent pregnancy.
Epidemiology of oral clefts in Centro Hospitalar do Porto: A prenatal perspective Introduction: Oral clefts are the most common congenital defects of the head and neck, yielding an estimated incidence of 1 in each 700 live births. Most of the times these deformities occur sporadically, but sometimes there is an association with genetic syndromes, specially among newborns with cleft palate. With the wide use of obstetrical ultrasound screening the number of oral clefts with prenatal diagnosis have been rising, which is critical for planning the long-term treatment, establishing the prognosis and properly counseling the parents.
3D power Doppler placental bed vascularization in the first trimester combined screening for preeclampsia Introduction: Accurate prediction of PE is important for identifying those women who require more intensive monitoring and timing interventions. Currently, none of the screening tests meets the criteria of the ideal screening test for PE. Improvements in ultrasonographic imaging provide a tool for estimating placental villous blood flow using 3-dimensional power Doppler (3DPD) angiography. The vascular indices (vascularisation index, VI; flow index, FI and vascularisation-FI, VFI) calculated with the aid of new technologies are an emerging screening tool for PE prediction.
Maternal plasma cell-free DNA in prediction of preeclampsia Introduction: Total cell-free DNA (cfDNA) in maternal blood is presented by maternal and fetal fractions. The fetal cfDNA originates from apoptotic villous trophoblasts. Preeclampsia (PE) is characterized by accelerated apoptosis of trophoblastic cells. Therefore, the fetal cfDNA may be used as a potential biomarker of PE.
Review of the use of Esmya in University Hospital of Wales Introduction: Esmya 5mg (ulipristal acetate) has recently been introduced for pre-operative and long term treatment of symptoms secondary to uterine fibroids. It should decrease the size of fibroids to improve the symptoms and make surgery easier. The treatment alternatives are GnRH analogues with or without add-back hormonal replacement therapy (HRT) for a limited period of time due to side effects. Another alternative is hysterectomy.
Summer birthsday is risk factor for myomas in Slovak women. Retrospective study Introduction: Uterine leiomyomas are hormonally dependent benign tumors with high prevalence and morbidity. Understanding of their ethiology is so far incomplete. Several studies have confirmed that season of birth affects the incidence of some tumors: skin cancer in Italy, non-Hodgkin lymphoma and breast cancer in Sweden.
Effect of pregnancy and childbirth on pre-existing uterine fibroids: An observational study Introduction: The relation between pregnancy and uterine fibroids is not completely known yet; recent evidences report that fibroids may undergo size modification during pregnancy, with a non-linear trend of increasing volume in early pregnancy, a slowdown by mid-pregnancy and a stabilization or initial regression in the third trimester. However, the effect of the “entire” pregnancy, including childbirth and post-partum, on pre-existing uterine fibroids and in the evolution of uterine fibromatosis as a disease must be better clarified.
Uterine ultrasound after normal labor Introduction: The physiological puerperium period is still not fully investigated. There is still a shortage of studies describing the uterine ultrasound differences found in primiparous and multiparous patients after normal labour from the earliest puerperium until 8 weeks of postpartum period. Only a few studies include doppler measurements of uterine arteries during the normal involution period, or the scope of the examination is very narrow. A longitudinal sonographic study is the best way to explore the similarities and differences that are likely to occur in primiparous and multiparous patients during puerperium.
What about phloroglucinol injectable formulation (antispasmodics drug) consumption during labour in France in 2014? Introduction: A prolonged labour may lead to maternal, foetal, neonatal and obstetrical complications. Those risks may be prevented by shortening labour duration. Active management of labour has shown to decrease the occurrence of prolonged labour. Administering antispasmodics during labour could lead to faster and more effective dilatation of the cervix. According to Cochrane collaboration and WHO recommendations, antispasmodics should not be used during labour as there is no evidence of their efficiency and safety.
Development of a risk score to predict the vacuum extraction failure Introduction: Safe operative vaginal delivery (O.V.D.) requires a careful assessment of the clinical situation. The complexity of the delivery can lead to choose between an O.V.D. and a cesarean section (C-section). An emergency C-section for failed O.V.D. is associated with a higher fetal and maternal morbidity, compared to an O.V.D. and to a C-section straightaway.
Longitudinal FHR assessment study Introduction: Acting according to pattern recognition of CTG without understanding types of hypoxia and fetal responses only increases the rate of operative deliveries (to up to 60%) without improvement of perinatal outcome.
The association of socioeconomic status and preterm births in King Abdulaziz Medical City (KAMC) Introduction: Preterm birth (PB), occurring at less 37 weeks gestation, is estimated to be 9% in Saudi Arabia. Socioeconomic status (SES) is a reflective measurement of individuals positions in community-based on different factors such as education, income, and occupation, hence, individuals classified into social hierarchy. Few studies conducted to investigate the effect of SES on PB and results were conflicting. None of these studies used a validated scoring system and no such studies published in Saudi Arabia.
Preterm birth in the Maltese cohort: Risks and outcomes Introduction: Preterm birth is a major contributor to neonatal morbidity and mortality. Sequelae can include respiratory difficulties, a prolonged hospital stay and emotional and mental developmental delays. Identifying and dealing with the risk factors can aid in decreasing the incidence of these complications.
Advanced stage cervical cancer in pregnancy – A clinical challenge Introduction: Cervical cancer in pregnancy is an rare event (incidence 0.05–1%) and most patients are diagnosed at an early stage of disease. It represents a complex situation that requires a multidisciplinary approach, especially when diagnosed in advanced stage.
Case of endometrial adenocarcinoma associated with primitive neuroectodermal tumor Introduction: Endometrial cancer is the second most common gynaecologic malignancy in developed countries. In Estonia it counted for 5% of all malignancies among women in 2015. Histologically endometrial carcinoma is the most common subtype of endometrial cancer. Uterine primitive neuroectodermal tumors (PNET) are a very rare form of tumors thought to be derived from neuroectodermal cells. They can occur in pure form or combined with another component. Prognosis is usually poor as the disease is mostly diagnosed in advanced stage.
Papillary thyroid carcinoma in struma ovarii – An enigmatic condition Introduction: Struma ovarii is a monodermal variant of a mature teratoma containing predominantly thyroid tissue. It represents 3% of all ovarian teratomas. About 5–10% of these tumors undergo malignant transformation, with papillary and follicular carcinoma being the most common.
Teratoma-associated anti-NMDA receptor encephalitis – A case report Introduction: Teratoma is a germ cell tumor that differentiates toward one or more of the three embryo layers – ectoderm, mesoderm and endoderm. The tissues can be mature or immature, the latter making up less than 1% of ovarian teratomas and frequently containing neural differentiation.
Disease of paget vulvar case report Introduction: Extramammary Paget's disease (EPD) is an uncommon neoplasic condition observed mostly in areas with numerous apocrine and or eccrine glands. In the woman it is most commonly seen on the vulva, although it can occur in other locations. Vulvar paget's disease (VPD) can be classified into primary, of cutaneous origin, and secondary, of extracutaneous origin, with significant clinical e prognostic implications. The lesion appears as a solitary patch with an eczematous, erythematous and squamous surface.
Idiophatic hemophagocytic lyphohistiocytosis during pregnancy Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe clinical syndrome characterized by a disregulated hyperinflamatory inmune response. The diagnosis of HLH during pregnancy is especially changelling due to the rarity of this condition. The highly variable clinical presentation, laboratory findings, and associated diagnoses accompaniyng this syndrome complicate the problem. A pronounced hyperferritinemia in the setting of systemic signs and symptom along with a negative infectious should raise suspicions for HLH.
Pregnant woman with valvular bioprosthesis insufficiency attended at a hospital in the Western Amazon Introduction: Mitral valve stenosis has peculiarities when it affects patients during pregnancy due to the physiological changes inherent to this period associated with the increase in blood volume and the appearance of the placental arteriovenous fistula, which causes the cardiovascular system to undergo important hemodynamic overload – increase in heart rate and cardiac output, and high rate of oxygen consumption. These women may present hemodynamic instability as the volume overload becomes poorly tolerated due to fixed valve obstruction.
Castleman's disease in a pregnant woman attended at a maternity hospital in Western Amazonia: Case report Introduction: Castleman's disease, also called lymphoid angiofollicular hyperplasia or giant cell ganglionar hyperplasia, is a rare lymphoproliferative disease of unknown cause and pathogenesis, but with characteristic histological changes. Classified as angioimmunoblastic lymphadenopathy, transplanted lymphoproliferations and polyclonal immunoblastic proliferations, it is on the border between reactive adenopathies and lymphomas, situations with which the differential diagnosis is made. No predilection for sex, race or age, with mixed forms usually at more advanced ages.
The great pretender: Diagnosing tuberculosis in the second trimester Introduction: Tuberculosis is a leading cause of indirect maternal mortality world-wide, but it is a rare diagnosis to make in the Northeast of England. In the UK, the incidence has been estimated at 1/24,000 maternities, with all cases found in women of ethnic minorities born outside the UK, most commonly recent immigrants. New presentations in pregnancy can present a diagnostic challenge; extrapulmonary TB is more common, so classical symptoms of cough, dyspnoea and haemoptysis are seen less frequently than non-specific symptoms including malaise, weight loss and night sweats.
A case of ascites complicating preeclampsia Introduction: Preeclampsia is typically presented by elevated blood pressure and proteinuria. However, It is often complicated by various clinical conditions which may increase the maternal morbidity and mortality.
Neonatal alloimmune thrombocytopenia report Introduction: Neonatal alloimmune thrombocytopenia is the commonest cause of early onset isolated thrombocytopenia in an otherwise healthy neonate. It frequently affects the first infant. The thrombocytopenia results from maternal immunization against specific platelet alloantigens paternally inherited by the fetus. During pregnancy, the maternal alloantibodies can cross the placental barrier as soon as 14 weeks of gestation. The fetal opsonized platelets are then cleared in the reticulo-endothelial system.
Folate deficiency related pancytopenia in pregnancy – A case report Introduction: Pregnancy is a state of high metabolic demand leading to anemia and thrombocytopenia most commonly resulting from dilutional effect of increased plasma volume. In most cases there is no need for treatment as long as there is no deficiency in micronutrients, which is often seen in developing countries.
Malaria falciparum severe in the gestation in a hospital of the western Amazon: Case report Introduction: Malaria is considered a serious public health problem because its etiologic agents, the plasmodia, are found in areas where it inhabits almost half of the world population. About 40% of the population in more than 90 countries is living with the risk of malaria contagion. In the Americas, 21 countries are endemic and 357 million of inhabitants are at risk of becoming ill. Brazil is the country with the largest number of cases in the Americas, with an estimated 300,000 cases per year.
Listeriois with non specific symptoms: A dilemma Introduction: Listeriosis is a rare infection, but is 20 times more common in pregnancy. Should be considered in pregnant women who present with non specific symptoms. It can present as a dilemma? To clinicians as there are no data to guide the management of an exposed, afebrile pregnant woman with mild symptoms that do not strongly suggest Listeriosis?
Discordant anomalies in monochorionic twin pregnancies Introduction: The risk of congenital anomalies in twins is higher than in singletons, as well as abnormalities occur more frequently in identical twins than in other pregnancies. Although monozygotic, most Monochorionic (MC) twins are not identical, and significant discrepancies in birth weight, genetic disease, the prevalence of congenital anomalies in is nearly twice that in dichorionic.
Spontaneous quadrigemelar gestation attended at the maternity of the Amazon region: Case report Introduction: The rate of multiple gestation has increased significantly since the beginning of assisted reproduction techniques. In the human species a multiple pregnancy occurs in every 80 pregnancies, being more frequent in the black race. Bigemelar pregnancy is the most frequent and can be classified as monozygotic (1/3) and dizygotic (2/3). In this type of gestation, maternal–fetal complications are more frequent than in unifetal gestation, emphasizing arterial hypertension, pre-eclampsia, anemia, and postpartum haemorrhage.
Sirenomelia in a twin pregnancy at the western Amazon school hospital: Case report Introduction: Sirenomelia is a rare congenital defect characterized by fused or single lower limbs and severe visceral anomalies. Due to the fusion, it is also known as Mermaid Syndrome. With an estimated prevalence of 0.98: 100,000 births, 10–15% of occurrences occur in the birth of twins, mainly monozygotic. Due to oligodramnia, these newborns are often born with Potter's face and pulmonary hypoplasia. It is associated with anomalies of the genitourinary system, including renal agenesis and absence of malformed external genitalia.
Discordant heart block in an anti-Ro Sjögren's syndrome twin pregnancy Introduction: Sjogren's syndrome is an autoimmune disease with a variable expression of antibodies. Expression of Anti-Ro antibody is associated with greater severity of the syndrome, and it is known that 2% of pregnancies expressing anti-Ro antibody will suffer from congenital fetal heart block.
DCDA twin pregnancy after endometrial ablation: Case presentation Introduction: Endometrial ablation (EA) has gained increased popularity as an alternative to hysterectomy for treatment of women with menorrhagia. Pregnancy after EA is rare and associated with high morbidities. The rate of pregnancy post EA is variable from 0.7 to 2.4%. From literature review many of these pregnancies undergo surgical or medical terminations. Ongoing pregnancies are complicated by fetal anomaly, intra-uterine growth restriction, preterm labour, placental abnormalities and caesarean–hysterectomy.
Cervicovaginal agenesis: a case report Introduction: Mullerian anomalies arise from the failure in the development of mullerian ducts and their associated structures during organogenesis that gives adverse impact in fertility and reproductive health.
Fast-growing abdomino-pelvic mass – A presentation of giant ovarian teratoma Introduction: Cystic teratomas account for about 20% of ovarian neoplasms and occur most often in reproductive-aged. The clinical features of these masses are only identified when they grow large enough to denote a palpable pelvic mass or pain by twisting of the pedicle, and the majority are diagnosed incidentally by ultrasound. More than 90% of the teratomas have dimensions smaller than 15cm at diagnosis.
Xanthograulomatous oophoritis: Case presentation Introduction: Xanthogranulomatous inflammation is an uncommon chronic inflammation characterized by infiltration of tissues predominantly by lipid-laden foamy histiocytes. It usually involves the kidneys and urinary bladder. It is very rare in female genital organs and mainly involves endometrium.
Ovarian vein thrombosis diagnosed as hydroureter – A case report Introduction: Ovarian vein thrombosis is a very uncommon but serious life-threatening condition, most commonly seen during the postpartum period. The incidence varies between 0.005% and 0.18% of the pregnancies and up to 2% following a Caesarean section. They can also present following pelvic surgery, pelvic inflammatory disease and malignancy. There is preponderance to the right ovarian vein in 80–90% of the cases and several theories have been proposed to explain this. Symptoms typically develop within 4 weeks postpartum and most frequently in the first 10 days.
Have you ever seen a “volvulus” of a fallopian tube on an epiploic bridle? Introduction: In front of an acute, violent and localized pelvic pain, the role of the clinician is to eliminate a surgical emergency. The strangulation of an intraperitoneal organ constitutes one. It is imperative to make the diagnosis of suffering ischemic ovarian or digestive and take care of it as soon as possible. It is usual to find digestive strangulations on omental flange, or to see adnexal torsions, but a fallopian tube that makes a “volvulus” on an omental bridle has not been described in the literature.
Paratubal cyst can present as an acute emergency Introduction: Paraovarian or Paratubal cysts constitute about 10% of diagnosed adnexal masses. Although they are not uncommon; they rarely cause symptoms and are usually incidentally found. The symptoms occur when they grow excessively, or in case of haemorrhage, rupture or torsion.
Ultrasound and laparoscopic aspects of a pelvic hydatid cyst Introduction: Hydatid disease is common in North African countries. It often affects the liver and lungs. The pelvic location is exceptional. Ultrasound and computed tomography helps in diagnosis. We report the case of a pelvic hydatid cyst which is an extremely rare localization of hydatidosis.
Interstitial ectopic pregnancy in high risk maternity in the Amazon region: Case report Introduction: Ectopic pregnancy represents approximately 2% of all pregnancies and is considered an important cause of morbidity and mortality related to the first trimester of gestation. The interstitial type represents 2–4% of all forms of EG and refers to the implantation of the egg in the interstitial portion of the uterine tube, a tubal segment that crosses the muscular wall of the uterus. This segment is generally 0.7mm in diameter and 1–2cm in length and has a considerable capacity for dilatation before disruption of its distal segment.
Ovarian ectopic following previous salpingectomy Introduction: Ovarian ectopics following previous salpingectomy are incredibly rare with only two being reported previously in the literature. We discuss a case of a 30 year old who had a previous left salpingectomy due to ectopic pregnancy and then had a subsequent left sided ovarian ectopic.
How often we can miss heterotropic pregnancy? Introduction: Heterotropic pregnancy is an uncommon clinical condition but remain a significant cause of morbidity and mortality. The reported incidence varies from 1:100 to 1:500 with the use of assisted reproductive technology (ART) to 1:30,000 pregnancies of natural conception. The incidence is higher with ovulation induction, history of pelvic infection and IVF pregnancy.
Heterotopic pregnancy in natural conception: About two cases Introduction: Heterotopic gestation is defined as the coexistence of an intrauterine (IUP) and extra uterine pregnancy (EUP) regardless of its location. The incidence of heterotopic pregnancy is very low but it is difficult to diagnose clinically.
Amniotic embolisation in a gestant in an hospital of the western Amazon: Case report Introduction: Amniotic fluid pulmonary embolism is a rare but often fatal complication of gestation with pathophysiology not yet completely elucidated. The incidence in the literature is variable ranging from one case to 8000–80,000 deliveries. Due to its rarity, national registries were created in the United States and England, with very restricted criteria, which probably selected a subgroup of greater severity.
Adnexal torsion and pregnancy: About 3 cases Introduction: Adnexal torsion is a rare pathology and it is due to total or partial rotation of the appendix around its vascular axis. The occurrence of an appendix twist associated with pregnancy is an even rare situation.
Adnexal masses in pregnancy – A case report Introduction: Adnexal masses in pregnancy are a rare finding. They are often benign and disappear spontaneously during the first trimester. Its persistence during the second trimester raises greater concern regarding obstetric behaviour, the possibility of torsion, rupture or haemorrhage, the possibility of dystocia and the risk of malignancy.
Successful myomectomy at 22 weeks: A case presentation Introduction: Almost 4% of all pregnant women will have uterine fibroids, the vast majority of which will cause no problems during pregnancy. Antenatal myomectomy is generally contra-indicated. However in exceptional circumstances, acute severe abdominal pain which is unresponsive to conservative management due to fibroid torsion, red degeneration or rapid increase in size, is an indication for intervention during pregnancy. Although uncommon, myomectomy in pregnancy is being used ever more frequently worldwide and has been shown to be a safe treatment option.
Hodgkin lymphoma in pregnancy Introduction: Hodgkin lymphoma is a tumour of the lymphatic system which is the fourth commonest cancer in pregnancy and has a 90–95% 5-year survival with treatment.
Breast cancer in pregnancy – Case report Introduction: Breast cancer is one of the most common malignancies in pregnancy. Although pregnancy itself doesn’t worsen the prognosis, its management is challenging and demands a multidisciplinary setting.
Brain tumor during pregnancy Introduction: 34-year-old pregnant woman gravida 2, para 2, presented at Vilnius University Hospital Santaros Klinikos, in 38 weeks of pregnancy due to headache, head dizziness, nausea and fever. During the last 6 months of pregnancy she had three episodes of headache and head dizziness. She was consulted by obstetrician gynecologist, there were no obstetric pathologies. After neurological counselling, a computerized tomography (CT) revealed a brain tumor.
Challenges of ultrasound imaging in prenatal diagnosis: A clinical case of genito-urinary tract anomaly Introduction: Congenital anomalies occur more frequently in multiple pregnancies, particularly cardiac, central nervous system and genito-urinary malformations. Ultrasound is essential because it allows not only to diagnose malformations but also to screen chromosomal defects, given the lower sensitivity of maternal biochemistry in multiple pregnancy. Genito-urinary anomalies constitute about 20% of all congenital anomalies, most of them diagnosed in the prenatal period, around 16–20 weeks.
Thanatophoric dysplasia type 2 – Rare entity report Introduction: Thanatophoric dysplasia (TD) is the most frequent lethal skeletal dysplasia (SD), with an estimated incidence of 0.7/10,000. According to the clinical presentation, it is divided into TD type 1 and type 2. Its transmission is autosomal dominant, although germline mosaicism of the parents cannot be excluded, and genetic study of them is advised.
Case report of a fetus with hemivertebrae: Diagnosis and management Introduction: The most common congenital malformation of the spine is hemivertebrae with incidence 1:1500 of live births. In hemivertebrae one of the two centers of chondrogenesis of the vertebral body, which normally merge at 7th–8th week of gestation, is not formed. Malformations from other systems, mainly heart and urinary tract, and rarely gastrointestinal and CNS, coexist in 15–18% of the cases. Hemivertebrae is not directly correlated with chromosomal abnormalities but has been associated with genetic syndromes (VATERL, Potter, Klipper–Fiel, Jarcho–Levin).
Cavernous lymphangioma of fetal leg: A case report of prenatal diagnosis and vaginal delivery Introduction: Lymphangioma is a benign neoplasm that involves the skin and subcutaneous tissues. Lymphangiomas account for 25% of fetal tumors detected by prenatal sonography. However, lymphangiomas of the lower extremities are very rare and while the clinical manifestations at birth make the postnatal diagnosis quite simple, very few cases of prenatal diagnosis of the disease are described in the literature.
Cardiac extrophy, interest of prenatal screening Introduction: Cardiac extrophy is a rare pathology of unknown etiology and a bad prognosis. She belongs to the group of upper colostomies. It could be secondary to a failure of cranio-caudal migration of the mesoderm.
Partial hydatidiform mole and coexisting fetus during second trimester pregnancy Introduction: Hydatidiform mole is an abnormal pregnancy characterized by proliferation of cytotrophoblast and synciotrophoblast and vesicular swelling of placental villi. Partial hydatidiform mole and coexisting fetus is a rare condition that presents a dilemma for physicians and the parents of the fetus, particularly when it is detected during the second trimester of pregnancy.
Arnold-Chiari syndrome in fetus of pregnant woman attended at a Hospital of the Western Amazon: case report Introduction: Arnold-Chiari syndrome is defined as a congenital malformation of the central nervous system is related to displacement of the posterior fossa of the skull through the occipital foramen. CNS malformations have a high prevalence, ranging from 1 to 10: 1000 of live births. Chiari malformations are a set of conditions originally described in 1891 and 1896 by Hans Chiari, a German pathologist. 3 degrees of herniation (type 1, 2, 3) of cerebellar structures involving or not involving the brainstem have been described.
Management of TRAP syndrome at first trimester with interstitial laser Introduction: TRAP syndrome (Twin Reversed Arterial Perfusion) is a rare complication of monochorionic twins with an incidence of 1:100 in monozygotic twins and 1:35,000 in all pregnancies. One of the twins lacks cardiac function (acardiac) but grows slowly receiving blood from the healthy twin through arterio-arterial anastomoses. The risk of death for the fetus-donor is high (50%) due to cardiac insufficiency, and in 33% demise happens <16th week of gestation. There is also increased risk of premature delivery (25%).
Uterus malformation and intrauterin growth restriction Introduction: Intrauterin growth restriction (IUGR) is defined as an estimate fetal weight less than 10th centile associated with arguments for a pathological fetal growth: stopping or flexing of fetal growth curve. Its causes are multifactorial and can be either intrinsic or extrinsic.
Diffuse systemic scleroderma in a pregnant woman at an outpatient clinic in Western Amazon Introduction: Systemic scleroderma is an autoimmune disease of unknown etiology, manifested by fibrous and vascular lesions. It is divided into its diffuse and limited forms, both affecting internal organs, although differing in the location of the cutaneous lesions. It is a rare condition. Its diagnosis is clinical, since there are no specific laboratory tests for diagnostic confirmation. In pregnancies of mothers with scleroderma there is a higher frequency of prematurity, abortions, gestational hypertension and intrauterine growth restriction as a result of uteroplacental vascular abnormalities.
Prolapsed uterine myoma: Case report Introduction: Uterine leiomyomas are the most frequent pelvic tumors of the female genital tract. Affects 20–30% of women of childbearing age and 40% over 40 years old. Symptomatic in 50% of cases. Rare before menarche, regresses after menopause. 3–9 times more incident in black women. More prevalent in the uterine body and less in the cervix. Pedicled leiomyomas may originate from the subserosa or submucosa. Submucosa with exaggerated growth of the pedicle can be expelled through the cervical canal, being called “Prolapsed Uterine Leiomyoma”.
Vaginal leiomyomas. Report of two cases Introduction: Vaginal leiomyomas are rare mesenchymal tumors that arise from the smooth muscle of the vagina with approximately 300 cases reported. They most commonly from the anterior vaginal wall causing varied clinical presentations. Vaginal leiomyomas are commonly seen in women of reproductive age.
Giant retroperitoneal primary cystic leiomyoma: A rare case Introduction: Giant retroperitoneal leiomyomas with cystic degenerations are rarely seen. Both clinical and imaging findings give the appearance of adnexal/abdominal mass. Therefore, the preoperative diagnosis is unclear. The diagnosis is only approached with pathologic examination.
Perivascular epithelioid cell tumor of vulva: A rare case Introduction: Perivascular epithelioid cell tumor (PEComa) is very rare mesenchymal tumor with an unpredictable natural history. To the best of our knowledge, there is only one reported case of PEComa of vulva in the English language medical literature.
Zoon's vulvitis and importance of histology in diagnosis of benign vulvar lesions in outpatient setting Introduction: Zoon's disease is rare benign circumscribed inflammatory disorder of the vulvar mucosa with characteristic histological features Histology is characterised by dense inflammatory band-like infiltrate parallel to the basal membrane compose of predominantly plasma cell. They appear as irregular shaped shiny macular erythematous lesions of the vulva Pts’ presentation varies from asymptomatic to unrelenting itch with burning sensation and dyspareunia It is a rare condition resulting in severe local discomfort with psychosocial distress The differential diagnoses to this rare condition are Lichen sclerosis and contact dermatitis.
Ureterovaginal fistula 35 days after laparoscopic hysterectomy: A case report Introduction: Total laparoscopic hysterectomy as become an increasingly common practice. However, the laparoscopic hysterectomy is not completely out of risks. Data from multiple studies of laparoscopic hysterectomy report a rate of urinary tract injury of 1.2–3 percent. One of the most important urinary tract injury is related to ureteral lesion. Unfortunately, 70% of these lesions are not recognised during surgery and they are lately discovered through hydronephrosis, anuria (bilateral lesion), urine vaginal leaks, paralytic ileus or even peritonitis.
Necrotizing fasciitis after alloplastic slings Introduction: Necrotizing fasciitis (NF) was first described by Fournier in 1883. It is a very rare condition with an incidence of 0.4 on 100,000 persons/year, causing potentially devastating morbidity and frequent mortality. The first description after insertion of a TVT sling was given by Johnson 2003, followed by 16 publications, 9 after TOT, 4 with TVT and another 3 after meshes.
Necrotizing fasciitis: A case report Introduction: Pelvic organ prolapse with or without stress urinary incontinence is a common gynaecological condition, which occurs predominantly in middle and old age.
Suburethral endometrioma Introduction: Extrapelvic endometriosis is infrequent and can appear in unusual places. It is often difficult to diagnose and more challenging to treat. As it may present with atypical symptoms of endometriosis, diagnosis is based on surgical excision and histopathological examination. We report a case of endometriosis presenting as a recurrent sub-urethral vaginal cyst.
Deep infiltrating vaginal endometriosis Introduction: Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations.
Cerebellar stroke in pregnancy Introduction: Gestational cerebral vascular ischaemia is a rare diagnosis affecting about 4 per 100,000 deliveries. It is commonest during the third trimester and in the puerperium. Cerebellar stroke accounts for 2% of all strokes during pregnancy.
Posterior reversible encephalopathy syndrome Introduction: Posterior reversible encephalopathy (PRES) is a rare clinicoradiological condition characterised by altered mental status, headaches, seizures and cortical vasogenic oedema.
Accidental ultrasound detection of Galen vein aneurysm at term pregnancy Introduction: Galen vein aneurysm is the most common congenital arteriovenous (AV) malformation. It consists of an arteriovenous shunt dilating vascular bed. Brain structures of the posterior cranial fossa are often compressed by this dilatation. The most often manifestations are ischemic changes of neonatal brain as a stroke, steal phenomenon, hydrocephalus or heart failure.
Chronic fetal suffering in pregnant attended in a hospital of the western Amazon: Case report Introduction: Fetal distress is the decrease or absence of oxygen that must be received by the fetus through the placenta. Chronic cases of suffering are due to some maternal pathology that causes a reduction in the oxygen concentration of the mother to the fetus: severe anemia, respiratory or cardiac pathologies, arterial hypertension, low placental irrigation or gestational diabetes. Even though these problems do not lead to obvious changes in fetal oxygenation during pregnancy, they can occur at the time of delivery, when there is a reduction in placental irrigation caused by uterine contractions.
Uterine preservation surgery in severe postpartum haemorrhage: What impact on reproductive function? Introduction: Postpartum haemorrhage (PPH) remains one of the most risky situations in obstetrics and major cause of maternal morbidity and mortality worldwide. There can be major psychological sequelae also. Treatment options for PPH include conservative management with uterotonic drugs, selective devascularization by ligation or embolization of the uterine artery, external compression with uterine sutures, intrauterine balloon and hysterectomy. This last issue adds to the maternal drama of a situation with definitive infertility.
Expectant management of placenta increta after vaginal delivery Introduction: Placenta increta can cause severe maternal morbidity. Recommended management of suspected placenta accreta/increta is planned preterm cesarean hysterectomy. There are several cases reported of placenta accreta/increta diagnosis after vaginal delivery and even less cases of conservative management. Various conservative, uterus preserving, treatment modalities have been suggested, such as methotrexate therapy, embolization of the uterine arteries and uterus preserving surgery. There is no evidence that one conservative treatment is better than others.
A case report: Undiagnosed idiopathic thrombocytopenic purpura (ITP) patient presenting with a post-partum haemorrhage Introduction: Post-partum haemorrhage (PPH) is a life threatening condition which could occur due to uterine atony, retained products, trauma or a coagulation defect. Among the coagulation defect which occur due to thrombocytopenia, ITP occurs in one or two of every 1000 pregnancies. ITP is usually diagnosed before conception and treated with steroids to minimize its detrimental effects during labour. However, if it is not controlled, the reduced platelets can result in PPH.
Inside out – A case study of uterine inversion Introduction: Uterine inversion is a rare cause of postpartum hemorrhage. It may occur after both a vaginal delivery and the cesarean section. Due to its high mortality rate, it is important to be aware of this condition and prepared to react promptly.
Diagnostic of rare form of acute stroke (venous stroke) in early postpartum period Introduction: Venous stroke (VS) is a rare form of acute ischemic stroke as a thrombosis of Trolard vein (the frequency 0.1% to 3–5%) occurs when the outflow of blood from the superficial cortical veins of the brain along the large anastomotic vein of Trolard and the small anastomotic vein of Labbe in turn, flow into the large vein of Gallen, which collects blood from the deep cerebral veins and falls into a straight sinus. Verification of VS is difficult due to the following features: the defeat of the parieto-occipital region gives meagre focal neurologic symptoms and more pronounced cerebral symptoms.
A case of rapidly deteriorating Ogilvie syndrome Introduction: Ogilvie syndrome is an acute dilation of the colon in the absence of any mechanical obstruction in severely ill patients, also known as acute megacolon. Mortality rate can be as high as 30%. Ogilvie syndrome may occur after surgery, it can be due to imbalance in the regulation of colonic motor activity by the autonomic nervous system.
A case of puerperium complicated by iliopsoas abscess Introduction: Iliopsoas abscess is a rare phenomenon with an incidence of 0.4 in 100,000 per year in the general population. It is three times commoner in males. Patients who are immunosuppressed, diabetic or have renal failure are at increased risk. Psoas abscesses can be either primary through haematogenous spread or secondary through infection or inflammation in the surrounding areas.
Sacro-iliitis: A rare complication post caesarian section Introduction: Sacro-iliac joint septic arthritis is an infrequent disease entity representing 1–2% of septic arthritis. Here, we report a case of a 29-year-old female with sacro-iliitis secondary to MRSA bacteraemia that followed an uneventful C-Section.
Necrosant fasceíte in patient in the late puerpério – Case report Introduction: Necrotizing fasciitis, more popularly known as “meat-eating bacteria”, is a bacterial infection that progresses rapid and high discharge caused by beta-hemolytic Streptococcus. How bacteria penetrate like deeper layers of skin and subcutaneous tissues, spreading rapidly through superficial fascias and subcutaneous tissue.
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