Unusual presentation of late-stage ectopic tubal pregnancy (19 weeks' gestation): Case report and literature review

Ectopic pregnancy is a medical condition in which a fertilized egg takes an unexpected detour away from the uterine cavity and the fallopian tube becomes a popular host, with the ampulla being the prime location. However, it can occur in other areas such as cervix, ovaries, or abdomen. The most common risk factors are pelvic inflammatory disease, previous pelvic or abdominal surgery, abnormal anatomy of genital organs, endometriosis, previous ectopic pregnancies, assisted reproductive technologies, endocrine disorders, and even the subtle influence of low-dose progestins from contraceptives. We will present a rare case of unrecognized late-stage tubal ectopic pregnancy. The following case report is of a 25-year-old Caucasian female patient (G2, P0) who presented to the emergency department with a 24-hour abdominal pain syndrome. The patient did not have a gynecological examination for this reason. During the examination, taking into account the clinical and ultrasound findings, a suspicion of pregnancy in a bicornuate uterus was raised, and an MRI of the pelvis was performed. MRI showed ectopic pregnancy in the left fallopian tube with a properly developed fetus that corresponded to a gestation of 19 weeks. An emergency laparotomy was performed and the left fallopian tube with the fetus was removed. The early and late course of recovery went smoothly. The patient was discharged after adequate clinical development.

Relationship between COMT Gene Polymorphism, Anxiety, and Pain Perception during Labour

BACKGROUND

The COMT gene polymorphism is associated with neurological and psychiatric disorders and pain perception. The present study investigates the existence of anxiety and pain perception in relation to the COMT (catechol-O-methyltransferase) gene polymorphism in labouring women (during "natural" childbirth) with or without inhaled analgesia.

METHODS

A total of 181 women who chose vaginal birth were enrolled in this study. To present the difference in pain perception, the parturients were divided into one group (n = 90) that chose labour analgesia with inhaled nitrous oxide (50% nitrous oxide and 50% oxygen) and one group (n = 91) without analgesia. The blood samples were taken during the pregnancy as a part of routine pregnancy controls in the hospital. The COMT gene polymorphism was detected with the PCR technique. The pain perception of parturients was self-evaluated two times according to the VAS (Visual Analogue Scale), and anxiety as a personality trait was determined with the STAI-T (State Trait Anxiety Inventory). Pain perception as well as anxiety were compared according to COMT genotypes.

RESULTS

In the 181 pregnant women, there were 40 women (22%) of wild homozygotes (GG) of COMT, 95 women (53%) of mutant heterozygotes (GA), and 46 women (25%) of mutant homozygotes (AA). A negative association of pain perception with the GA (mutant heterozygote) polymorphism of the COMT gene versus the wild-type (GG polymorphism) was observed. The GA polymorphism of the COMT gene was associated with 0.46 units lower pain perception compared to the wild type (GG). The anxiety trait score in group AA was lower than in groups GA and GG. The difference reached statistical significance only when comparing AA versus GA (p > 0.042). Analgesic efficacy of nitrous oxide was noticed in 22% of labouring women who reported moderate pain (VAS score 4-7).

CONCLUSIONS

The COMT gene polymorphism was associated with pain perception and anxiety among parturients. The COMT gene polymorphism GA was associated with negative pain perception among labouring women. Nitrous oxide showed statistical significance in anxiolytic efficacy during labour in women with mild anxiety as a personality trait. Anxiolytic efficacy of nitrous oxide has shown better efficacy in parturients with the COMT gene polymorphism AA.

WNT5A, β‑catenin and SUFU expression patterns, and the significance of microRNA deregulation in placentas with intrauterine growth restriction

Placental insufficiency is a common cause of intrauterine growth restriction (IUGR). It affects ~10% of pregnancies and increases fetal and neonatal morbidity and mortality. Although Wnt and Hh pathways are crucial for embryonic development and placentation, their role in the pathology of IUGR is still not sufficiently explored. The present study analyzed the expression of positive regulators of the Wnt pathway, WNT5A and β‑catenin, and the expression of the Hh pathway negative regulator suppressor of fused (SUFU). Immunohistochemical and reverse transcription‑quantitative PCR (RT‑qPCR) assays were performed on 34 IUGR and 18 placental tissue samples from physiologic singleton‑term pregnancies. Epigenetic mechanisms of SUFU gene regulation were also investigated by methylation‑specific PCR analysis of its promoter and RT‑qPCR analysis of miR‑214‑3p and miR‑378a‑5p expression. WNT5A protein expression was higher in endothelial cells of placental villi from IUGR compared with control tissues. That was also the case for β‑catenin protein expression in trophoblasts and endothelial cells and SUFU protein expression in trophoblasts from IUGR placentas. The SUFU gene promoter remained unmethylated in all tissue samples, while miR‑214‑3p and miR‑378a‑5p were downregulated in IUGR. The present results suggested altered Wnt and Hh signaling in IUGR. DNA methylation did not appear to be a mechanism of SUFU regulation in the pathogenesis of IUGR, but its expression could be regulated by miRNA targeting.

IS THERE A RELATIONSHIP BETWEEN COMPLICATIONS OF EARLY PREGNANCY AND BIOMETEOROLOGICAL FORECAST?

The aim of our study was to connect the possible complications of early pregnancy (miscarriage and symptomatic ectopic pregnancy) up to the 12th week of gestation with biometeorological conditions while assuming a greater number of incidents with an unfavorable biometeorological forecast. We performed a retrospective observational study using medical data of a single medical center of Department of Gynecology and Obstetrics, Sveti Duh University Hospital and meteorological data from the Croatian Meteorological and Hydrometeorological Service in Zagreb. We tracked the number of visits to the gynecology and obstetrics emergency unit on a daily basis during 2017. Days with five or more visits were selected and underwent further analysis, during which the number of miscarriages and symptomatic ectopic pregnancies was noted. The information from the biometeorological forecast was then extracted and added to the database. Our results did not show a statistically significant difference between the groups determined by biometeorological forecast in the number of spontaneous abortions or ectopic pregnancy. Also, statistically significant results did not follow the expected trend of the increasing number of complications related to worse biometeorological forecast, or vice versa, a decreased number of complications with better forecast. Our single-center retrospective analysis of emergency unit visits related to weather conditions did not show a connection between the complications of early pregnancy and biometeorological conditions. However, different results could emerge in future studies. Considering the large and high-quality database collected for this study, efforts in researching the connection between other gynecologic pathologies and weather conditions will be feasible.

Diagnostic Accuracy of Salivary aMMP-8 Test in Infertile Women and Blood Finding Analysis

Introduction

The literature reviewed in this paper suggests that infertile patients present worse periodontal status, which may be causative to conception complications. This study aimed to validate an aMMP-8 point-of-care mouth rinse test in the population of women with unexplained infertility and compare it to age-matched fertile women with and without periodontitis. Furthermore, blood sampled inflammatory parameters were analyzed and compared between the two groups. It was hypothesized that the infertile women would present worse periodontal status and a greater number of positive aMMP-8 tests than fertile women, and they would have increased inflammatory blood parameters.

Material and methods

The study included 50 healthy norm-ovulatory females aged 25-45 years with strictly defined unexplained (idiopathic) infertility, and 50 healthy norm-ovulatory women of the same age who had conceived and delivered naturally.

Results

The sensitivity and specificity of the test for detecting periodontitis was 84% and 72% in the group of infertile patients, 88% and 68% in the group of fertile patients and 86% and 70% in the overall patient population. Infertile patients with periodontitis had less advanced periodontitis than the control group although this difference was not statistically significant. Blood inflammatory markers were significantly higher in infertile than in fertile women.

Conclusion

This study has shown that infertile patients had better periodontal status and less advanced periodontitis than fertile women of the same age. Therefore, when interpreting the results of aMMP-8 tests for diagnosis of periodontitis, one should keep in mind the periodontal status of the examined population.

Infertility-related stress and sexual satisfaction: a dyadic approach

PURPOSE OF THE STUDY

to examine whether women's and men's infertility-related stress, and specifically its sexual concerns aspect, is related to their and their partner's sexual satisfaction.

MATERIALS AND METHODS

In a cross-sectional study, 94 couples experiencing infertility filled out the New Sexual Satisfaction Scale and Fertility Problem Inventory, which measures infertility-related stress with dimensions of social, sexual and relationship concerns, rejection of childfree lifestyle, and need for parenthood. Dyadic analyses were performed following the Actor-Partner Interdependence Model (APIM).

RESULTS

The dyadic analysis revealed that women's and men's greater infertility-related stress contributed to their lower levels of sexual satisfaction (actor effect). Moreover, women's and men's greater sexual concerns (as the aspect of infertility-related stress) contributed to their own and their partner's lower levels of sexual satisfaction (actor and partner effect).

CONCLUSIONS

The findings suggest that both individual and relational processes are important in the association between the specific dimension of infertility-related stress and sexual satisfaction. These findings could guide the psychosocial support for couples experiencing infertility.

THE ROLE OF SALIVARY AND SERUM CA125 AND ROUTINE BLOOD TESTS IN PATIENTS WITH OVARIAN MALIGNANCIES

The use of routine blood tests has recently been shown to be promising in determining disease-free and overall survival in patients with various malignancies, and also in gynecologic malignancies. The aim of this study was to evaluate whether salivary and serum CA125 levels correlate and whether salivary and serum CA125, C-reactive protein and routine blood tests might serve as a prognostic factor in malignant ovarian tumors, and whether they might differentiate between benign and malignant ovarian tumors. A total of 98 women were included (48 with benign ovarian tumors and 50 with malignant ovarian tumors), in whom routine blood tests were made and salivary and serum CA125 levels were determined by use of ELISA. Increase in serum CA125 and amylase decreased overall survival, whereas increase in salivary CA125, potassium levels and hemoglobin increased overall survival. Significant correlation of serum CA125 and C-reactive protein was found in the group with malignant tumors. In conclusion, significant increase in the levels of serum CA125 and amylase correlated with decreased survival, whereas increased salivary CA125, hemoglobin and potassium levels significantly correlated with increased survival.

Redefining Pregnancy-Induced Rhinitis

BACKGROUND

Pregnancy-induced rhinitis (PIR) is a form of chronic non-allergic rhinitis not present before pregnancy that manifests itself during pregnancy with complete resolution of symptoms after delivery.

OBJECTIVE

The objective of this ambidirectional longitudinal cohort study is to evaluate the prevalence of PIR and to investigate the appearance and character of its symptoms, and its impact on the quality of life.Methodology: Six hundred eighty-one (681) women were recruited in the study. They completed questionnaires about nasal symptoms a day after delivery and each woman with nasal symptoms was interviewed 30 days later and data on symptom duration and quality were recorded.

RESULTS

The prevalence of PIR was 31.86% (N = 217), 47.14% (N = 321) women had no nasal symptoms and 21% (N = 143) of participants had prior sinonasal disease. The clinical presentation of pregnancy rhinitis included nasal obstruction as the most common symptom, followed by rhinorrhea, postnasal secretion, nose itching, sneezing, and hyposmia. The median duration of PIR was 4 months with their complete resolution of symptoms between 2th and 16th day after delivery in the majority of respondents. PIR was diagnosed significantly more often if the women carried a female child. PIR affected their quality of life during pregnancy in 53,9% women (N = 117), with an average VAS score of 8. It seems that pregnancy may affect the course of previously present sinonasal disease (allergic rhinitis, chronic rhinosinusitis, nonallergic rhinitis, or non-infectious rhinitis prior to the pregnancy).

CONCLUSIONS

PIR is a common clinical entity with a wide range of symptoms with a direct impact on the quality of life in pregnancy. We propose a new definition of pregnancy-induced rhinitis.

Urinary troponin concentration as a marker of cardiac damage in pregnancies complicated with preeclampsia

Pregnant women with preeclampsia experience significant hemodynamic changes which lead to an increased myocardial workload. In response to increased demands in pregnancy, the heart muscle responds with ventricular remodeling process which involves cardiac muscle hypertrophy. Opposed to occurrence of eccentric ventricular hypertrophy in normal pregnancy, myocardial remodeling in a form of concentric hypertrophy will occur in pregnant patients with preeclampsia. Increased myocardial workload is manifested by an increased troponin release. As process of troponin degradation continue, filtration of degradation fragment through glomerular membrane occur, raising the possibility of it's detection in urine. Degradation fragments of troponin molecules are estimated to be 20 kDa with preserved immunoreactivity to high-sensitivity assays. Some of the authors suggest that serum levels of cardiac troponin I might be elevated in patients with hypertension, as well as in preeclamptic pregnant women. It is to be expected that evaluation of severity of the myocardial damage in pregnant woman with preeclampsia may be performed by measuring levels of troponin in the urine using high-sensitivity assays. Designing of urine dipstick will help to detect an early phase of myocardial involvement in preeclamptic pregnancies.

HISTOPATHOLOGIC FINDINGS IN WOMEN UNDERGOING HYSTEROSCOPIC RESECTION OF ENDOMETRIAL POLYPS AND UTERINE MYOMAS

The aim of our study was to determine the prevalence of endometrial premalignant and malignant lesions in women undergoing hysteroscopy and to identify anthropologic factors related to the presence of malignancy. Data on 3470 women with submucosal myomas or endometrial polyps suspected on ultrasound were retrospectively analyzed. Hysteroscopy was performed in all these women in order to make a more precise diagnosis. Histologic analysis of endometrial samples obtained during hysteroscopy was used to confirm the diagnosis. Statistical analysis was performed using the SPSS 20.0.0 software. The mean age of study women was 49.1±13.3 years. The number of procedures performed due to the referral diagnosis of endometrial or submucosal myoma significantly increased over the 16-year study period. A significantly higher number of women had a benign histopathologic diagnosis. Histologic analysis revealed malignancy in 67 women. The youngest woman and oldest woman with malignant findings was aged 32 and 75, respectively. A significantly higher number of women with atypical hyperplasia and malignancy were in menopause. A comparable number of women with different histologic findings lived in urban and rural areas. There were a significantly larger proportion of widows among women with the histologic diagnosis of atypical hyperplasia or malignancy. The prevalence rate of malignancy in women having undergone hysteroscopy for polyps and myoma found by ultrasound was 1.93%. Postmenopausal status and older age were associated with an increased risk of malignancies, but premalignant changes and malignancies were also found in young and premenopausal women. Therefore, diagnostic hysteroscopy can be recommended in women of all age groups.

TWENTY-YEAR EXPERIENCE WITH LARGE LOOP EXCISION OF THE TRANSFORMATION ZONE AT SESTRE MILOSRDNICE UNIVERSITY HOSPITAL CENTRE

The 20-year experience with large loop excision of the transformation zone (LLETZ) at Gynecologic Oncology Unit, Department of Gynecology and Obstetrics, Sestre milosrdnice University Hospital Centre from Zagreb is presented. This retrospective observational study included 1407 women with cervical dysplasia treated by LLETZ technique during the 1995-2016 period. LLETZ was most commonly performed in the 25-35 age group (51%), followed by the 36-45 age group (22%), and least frequently in the >65 age group (2%). Histopathologic results lower than high-grade squamous intraepithelial lesion were found in 23% and high grade squamous intraepithelial lesion or worse findings in 77% of patients. Positive margin as a sign of possible residual dysplasia was found in 25% of cones, 80% of which included endocervical positive margin. Cervical canal biopsy result was positive in 18% of cases. Accurate colposcopy and its findings can help avoid overtreatment, the rate of which was higher than expected in our retrospective study. Long-term follow up is an imperative for proper assessment of the procedure success. This method is the best choice for complete disease removal without unnecessary overtreatment, but it requires continuous education and training of the whole team.

CLINICAL VALUE OF TRANSVAGINAL ULTRASONOGRAPHY IN COMPARISON TO HYSTEROSCOPY WITH HISTOPATHOLOGIC EXAMINATION IN DIAGNOSING ENDOMETRIAL ABNORMALITIES

The aim of our retrospective study was to compare the performance of transvaginal sonography in relation to histologic diagnosis of samples obtained by hysteroscopy through analysis of data collected over 16 years. Data on suspected formation of endometrial polyp or submucosal fibroid found on ultrasound examination were extracted. The study included a total of 3679 women examined during the 2000-2015 period. All women underwent ultrasound examination preoperatively for better planning the type and scope of operation to be performed. The study included only women with samples for histopathologic analysis collected during the operation. Ultrasound diagnosis of polyps compared with histology showed 89.6% sensitivity and 39.1% specificity. For submucosal myomas, sensitivity was 69.2% and specificity 91.3%. In conclusion, ultrasound is not reliable method for definitive diagnosis but it is an excellent orientation method.

Weight Gain in Pregnancy and Weight Retention after Birth

AIM:

Our study aims to determine the weight gain of pregnant women and their body weight one year after delivery. We compared these changes in body weight with education and place of residence (urban/rural).

METHODS:

Secundigravidae women (N = 113) filled out the structured checklist regarding anthropological characteristics, such as body weight (the current and before and after the first pregnancy). Some sociodemographic characteristics were also obtained.

RESULTS:

Average weight gain in pregnancy was 16.9 kg (Sd 6.1, median 16 kg; range 6-40 kg). Women with high school education only gained 2 kg more than women with college/university degree (F (1, 108) 4.11, p ≤ 0.05). There was no significant difference in weight gain when the place of residence was compared (F (1, 111) 2.86, p ≥ 0.05). The average weight difference one year after delivery was 3.3 kg (Sd 4.3, median 2 kg; spread -5 to 20 kg). There was no significant difference in weight difference one year after delivery in different educational groups. Women from rural area retained 2.5 kg more than women in an urban area (F (1, 109) 7.50, p ≤ 0.01).

CONCLUSION:

Our research has shown that women with higher education level gain less weight than women with lower degrees. They had more possibility to get access to information about health risks. The overall impression is that women do care about weight gain in pregnancy and actively work on getting back to desirable weight after delivery. This is even more important if we know that body weight before pregnancy, weight gain in pregnancy, pregnancy overweight and pregnancy obesity impact later life of mother and child. Therefore, the need for weight control in pregnancy and between pregnancies should be properly addressed.

Subcutaneous Dirofilariasis in Female Pubic Region - Case Report

BACKGROUND:

Number of reported cases of human dirofilariasis in the last couple of decades has been increasing. Dogs are the main reservoir hosts, while various mosquito species represent/serve as vectors. Human infections are caused by two different parasites: Dirofilaria immitis and Dirofilaria repens. Dirofilaria repens is currently considered to be one of the most rapidly-spreading human and animal parasite species in Europe. Clinical features are characterised by subcutaneous or ocular lesions which can persist for months without any symptoms. The disease is considered to be endemic in Mediterranean countries, central Asia, Israel, and Sri Lanka with increased incidence in Central and East Europe. Apart from the local population, tourists are also susceptible to this disease. Export of domestic animals can transfer parasites between different countries. This disease is rare in Croatia.

CASE PRESENTATION:

We are presenting a case of a 58-year-old female patient with dirofilariasis of the genital region caused by Dirofilaria repens, confirmed with PCR and sequencing.

CONCLUSION:

From the clinician point of view, subcutaneous dirofilariasis should be considered as a differential diagnosis in cases of long-lasting subcutaneous swellings.

Spontaneous Rupture of Internal Iliac Artery in Pregnancy: Case Report

SUMMARY – Rupture of the internal iliac artery is a rare complication in pregnancy that is associated with maternal and fetal morbidity and mortality. We present a case of a 30-year-old primipara admitted to our department in 39^th week of gestation after sudden onset of intense abdominal pain. On admission, the patient was pale, tachycardiac, but with normal blood pressure and afebrile. Symptoms of acute abdomen were clear and surgery was indicated. Diagnosis was confirmed during cesarean section. Enlarged gravid uterus compressed the ruptured artery and prevented heavier bleeding. Acute bleeding due to arterial rupture causes severe symptoms, predominantly abdominal pain. Changes in blood count become significant some time after the onset of rupture. As the gravid uterus compressed the arterial rupture, preoperative bleeding was by far less abundant than the bleeding after the baby had been delivered and the size of the uterus decreased. Any cause of acute abdomen during pregnancy (abruption of the placenta, spleen rupture, visceral artery thrombosis) requires urgent surgical treatment, as well as intraoperative and postoperative intensive treatment. Rupture of the internal iliac artery is a rare complication in pregnancy, but has to be considered as a differential diagnosis of abdominal pain.

Undetectable Serum Levels of Anti-Müllerian Hormone in Women with Ovarian Hyperstimulation Syndrome During In Vitro Fertilization and Successful Pregnancy Outcome: Case Report

SUMMARY – We report a unique case of undetectable serum levels of anti-müllerian hormone (AMH) in women with polycystic ovary syndrome (PCOS) who developed ovarian hyperstimulation syndrome (OHSS) during in vitro fertilization (IVF). A case is described of a 28-year-old woman with clinical symptoms of PCOS and AMH serum level below analytical sensitivity (<1.0 pmol/L). After undergoing controlled ovarian stimulation, the patient developed OHSS. After follicle aspiration, seven oocytes were recovered. Three of them were used for intracytoplasmic sperm injection (ICSI) and fertilized, but with unsuccessful pregnancy outcome. A successful pregnancy was achieved in the second IVF/ICSI cycle with six oocytes retrieved and three embryos transferred. At 39 weeks of gestation, the patient delivered a healthy baby weighing 3930 g and 50 cm long. In conclusion, although AMH is considered a useful tool in ovarian reserve assessment and in predicting response to controlled ovarian hyperstimulation, the case presented shows that AMH should not be used as an independent ovarian marker.

Abdominal Wall Endometriosis Eleven Years After Cesarean Section: Case Report

Endometriosis is a common chronic disease characterized by growth of the endometrial gland and stroma outside the uterus. Symptoms affect physical, mental and social well-being. Extrapelvic location of endometriosis is very rare. Abdominal wall endometriosis occurs in 0.03%-2% of women with a previous cesarean section or other abdominopelvic operation. The leading symptoms are abdominal nodular mass, pain and cyclic symptomatology. The number of cesarean sections is increasing and so is the incidence of abdominal wall endometriosis as a potential complication of the procedure. There are cases of malignant transformation of abdominal wall endometriosis. Therefore, it is important to recognize this condition and treat it surgically. We report a case of a 37-year-old woman with abdominal wall endometriosis 11 years after cesarean section. She had low abdominal pain related to menstrual cycle, which intensified at the end of menstrual bleeding. A nodule painful to palpation was found in the medial part of previous Pfannenstiel incision. Ultrasound guided biopsy was performed and the diagnosis of endometriosis confirmed. Surgery is the treatment of choice for abdominal wall endometriosis. Excision with histologically proven free surgical margins of 1 cm is mandatory to prevent recurrence. A wide spectrum of mimicking conditions is the main reason for late diagnosis and treatment of abdominal wall endometriosis. In our case, the symptoms lasted for eight years and had intensified in the last six months prior to surgery.

Synergetic Effects of K, Ca, Cu and Zn in Human Semen in Relation to Parameters Indicative of Spontaneous Hyperactivation of Spermatozoa

We have observed that sperm quality parameters indicative of spermatozoa hyperactivation such are lower “linearity” and “straightness”, and as showed by this research “elongation”, were more pronounced in patients with normal spermiogram compared to the group of men with reduced sperm motility who were undergoing routine in vitro fertilisation. The research encompassed 97 men diagnosed with normozoospermia (n = 20), asthenozoospermia (n = 54) and oligoasthenozoospermia (n = 23). The findings indicate that sperm quality of patients with normal spermiogram diagnosed according to WHO criteria, may be compromised by showing premature spontaneous hyperactivation which can decrease the chances of natural conception. We assessed synergistic effects of multiple chemical elements in ejaculated semen to find if premature spontaneous hyperactivation of spermatozoa can be a sign of imbalanced semen composition especially of elements K, Ca, Cu and Zn. Human semen samples showing low or high baseline status of chemical elements concentrations were found in samples from all three diagnostic groups. However, correlation of K/Ca and Cu/Zn ratios, taking into account samples from all three groups of men, were negative at statistical significance level p = 0.01. We tested if the negative correlation between K/Ca and Cu/Zn ratio works for greater number of semen samples. We found the negative correlation to be valid for 175 semen samples at statistical significance of p = 0.00002. The ratio of K/Ca and Cu/Zn, i.e. increased concentrations of K and Zn in comparison to concentrations of Ca and Cu, were associated with a decrease of “straightness” in the group of men with normal spermiogram and pronounced spontaneous hyperactivation of spermatozoa, implying that these elements act in synergy and that the balance of elements and not their absolute concentrations plays the major role in premature spermatozoa hyperactivation in ejaculated semen.

Synthetic vs natural scaffolds for human limbal stem cells

Aim

To investigate the impact of synthetic electrospun polyurethane (PU) and polycaprolactone (PCL) nanoscaffolds, before and after hydrolytic surface modification, on viability and differentiation of cultured human eye epithelial cells, in comparison with natural scaffolds: fibrin and human amniotic membrane.

Methods

Human placenta was taken at elective cesarean delivery. Fibrin scaffolds were prepared from commercial fibrin glue kits. Nanoscaffolds were fabricated by electrospinning. Limbal cells were isolated from surpluses of human cadaveric cornea and seeded on feeder 3T3 cells. The scaffolds used for viability testing and immunofluorescence analysis were amniotic membrane, fibrin, PU, and PCL nanoscaffolds, with or without prior NaOH treatment.

Results

Scanning electron microscope photographs of all tested scaffolds showed good colony spreading of seeded limbal cells. There was a significant difference in viability performance between cells with highest viability cultured on tissue culture plastic and cells cultured on all other scaffolds. On the other hand, electrospun PU, PCL, and electrospun PCL treated with NaOH had more than 80% of limbal cells positive for stem cell marker p63 compared to only 27%of p63 positive cells on fibrin.

Conclusion

Natural scaffolds, fibrin and amniotic membrane, showed better cell viability than electrospun scaffolds. On the contrary, high percentages of p63 positive cells obtained on these scaffolds still makes them good candidates for efficient delivery systems for therapeutic purposes.

Repeated cesarean scar pregnancy - Case report

Cesarehn scar pregnancy (CSP) is a rare location of an ectopic pregnancy implanted within a scar from previous cesarean section, separated from the endometrial cavity. The prevalence ranges from 1:1,800 to 1:2,226 pregnancies. It is a potential life-threatening condition, and if misdiagnosed, can cause serious maternal morbidity from uterine rupture with massive hemorrhage and even death. Until now, no universal treatment guidelines have been established, with treatment options ranging from systemic or local injection of methotrexate (MTX), suction curettage under ultrasound control to surgical treatment, including hysteroscopy and wedge resection of the ectopic pregnancy, via laparotomy or laparoscopy. The authors present a case of a 42-year old woman with two consecutive CSPs. First CSP was un- successfully treated conservatively, followed by ultrasound guided vacuum aspiration of the uterine cavity. Second CSP was treated by laparotomy and a wedge excision of a CSP and repair of a scar with interrupted sutures. The authors also discuss diagnostic pitfalls and treatment modalities.

Coexistence of ruptured ectopic tubal pregnancy, dermoid and endometriotic cyst with tubo-ovarian abscess in the same adnexa: case report

A 32-year-old pregnant woman presented to the hospital with abdominal pain and minimal vaginal bleeding. Transvaginal ultrasound revealed visible fluid in pelvic region with suspected tubal rupture, and subsequently laparoscopy was performed. During laparoscopy, additional gynecologic pathologies were noticed. Histopathologic finding showed dermoid and endometriotic cyst, as well as tubo-ovarian abscess in the same adnexa. This case report highlights the necessity of considering multiple diagnoses in the same organic system, which may be encountered by surgeon and histopathologist.

Sudden Bilateral Choroidal Detachment in a Patient with Posterior Reversible Encephalopathy Syndrome

BACKGROUND: Pre-eclampsia is one of the most important causes of a rare cliniconeuroradiological entity called posterior reversible encephalopathy syndrome. The syndrome is characterized by headacke, visual disturbances, seizures, altered mental status and radiological findings of edema in the white matter of the brain areas perfused by the posterior brain circulation.CASE REPORT: Here we present a patient with sudden bilateral visual loss and deafness in early postnatal period without any other neurological deficits, but with affiliated ophthalmological pathology. The correct diagnosis was made 3 days after the Cesarean section.The patient was diagnosed with posterior reversible encephalopathy syndrome and bilateral choroidal detachment.CONCLUSION: Vascular changes in posterior reversible encephalopathy syndrome can cause visual disturbances not only by brain edema, but combined brain and ocular pathology.

Paraoxonase 1 activity and phenotype distribution in premenopausal and postmenopausal women

Introduction

Postmenopausal women have higher risk of cardiovascular disease. One of the contributing factors could be reduced activity of anti-atherogenic enzyme paraoxonase 1 (PON1). The aim of this study was to examine differences in the lipid status, paraoxonase and arylesterase PON1 activities and PON1 phenotype in women with regular menstrual cycle and in postmenopausal women.

Materials and methods:

The study included 51 women in reproductive age (25 in follicular and 26 in luteal phase of the menstrual cycle) and 23 women in postmenopause. Lipid parameters in sera were determined using original reagents and according to manufacturer protocol. PON1 activity in serum was assessed by spectrophotometric method with substrates: paraoxon and phenylacetate. PON1 phenotype was determined by double substrate method.

Results:

Compared to the women in follicular and luteal phase, postmenopausal women have significantly higher concentration of triglyceride [0.9 (0.7–1.3), 0.7 (0.6–1.0) vs. 1.5 (0.9–1.7) mmol/L; P = 0.002], cholesterol [5.10 (4.78–6.10), 5.05 (4.70–5.40) vs. 6.30 (5.73–7.23) mmol/L; P < 0.001], LDL [3.00 (2.56–3.63), 3.00 (2.70–3.70) vs. 3.90 (3.23–4.50) mmol/L; P < 0.001], and apolipoprotein B [0.88 (0.75–1.00), 0.79 (0.68–1.00) vs. 1.07 (0.90–1.24) mmol/L; P = 0.002]. PON1 basal [104 (66–260), 106 (63–250) vs. 93 (71–165) U/L; P = 0.847] and salt-stimulated paraoxonase activity [210 (131–462), 211 (120–442) vs. 180 (139–296) U/L; P = 0.857] as well as arylesterase activity [74 (63–82), 70 (54–91) vs. 70 (60–81) kU/L; P = 0.906] and PON1 phenotype (P = 0.810) were not different in the study groups.

Conclusion:

There are no differences in PON1 activity and PON1 phenotype between women with regular menstrual cycle and postmenopausal women.

Are we estimating the adverse effects of shock-wave lithotripsy on a faulty scale?

The adverse effect of shock-wave lithotripsy (SWL) for renal stones on blood pressure is currently defined as its post-treatment increase. On the contrary, we hypothesize that even mild, unilateral renal obstruction initiates an increase in blood pressure. Then, in absence of treatment-induced injury, the stone removal should decrease the blood pressure. We derived the formula to assess the expected change in the mean arterial pressure following relief of renal obstruction without affecting the kidney functions. The predictions were well replicated in the cohort of patients with renal stone treated with parenchyma-saving open surgery, with 6.4 mmHg decrease at 3 months. On the contrary, in SWL cohort, instead of the expected 4.7 mmHg decrease, the blood pressure was unchanged. In conclusion, the absence of decrease in blood pressure is a very common adverse effect of SWL, leading to an epidemiologically significant increase in the risk of arterial vascular events.

Two cases of successful pregnancies after hysteroscopic removal of endometrioid adenocarcinoma grade I, stage IA, in young women with Lynch syndrome

We present two cases of endometrioid adenocarcinoma grade I, FIGO IA (staging according to the International Federation of Gynecology and Obstetrics) in young women, diagnosed within endometrial polyps. Both patients underwent repeated hysteroscopies and multiple biopsies after initial treatment to medroxyprogesterone one 400 mg daily or the insertion of IUD-LND (intrauterine device-levonorgestrel) for three months. In both of them, all histological samples were negative. Both of them decided that they would try to conceive. The first patient conceived spontaneously and the second patient after IVF (in vitro fertilisation) treatment. They both gave birth to full-term infants. Hysterectomy was recommended to both of our patients, and was carried out. Both of the patients fulfilled both Amsterdam II and revised Bethesda criteria for hereditary non-polyposis colorectal cancer (HNPCC).

Pregnant women's knowledge and attitudes to prenatal screening for fetal chromosomal abnormalities: Croatian multicentric survey

We aimed to assess opinion and preferences of Croatian pregnant women regarding the prenatal screening tests for trisomies. The study was conducted in Zagreb, Split, Cakovec, Nova Gradiska, Gospić and Zlatar. It was organized in the public primary healthcare centers, among the pregnant volunteers during their first visit to an antenatal clinic (7-12 weeks pregnant). The respondents filled anonymous questionnaire reflecting their knowledge and attitudes to the screening options. In total, 437 completed questionnaires were selected. The average maternal age and the level of education differed significantly between the respondents in the respective cities (P < 0.001). Of the respondents with positive attitude towards screening, the majority would prefer the first-trimester combined test (160/219; 73.1%), while 37/219 (16.9%) opted for the second-trimester biochemical screening. The remaining 22/219 (10.0%) would accept only the ultrasound screening. Among the 224 respondents, who would accept the combined first-trimester test, 95 (42.4%) held a college and university degree, whereas among 59 women, who would choose the second-trimester biochemical screening, 14 were highly educated (23.7%). The difference was statistically significant (P = 0.016). The univariate regression analysis showed that age, level of education and previous information were significant variables predictive for the choice of the test; the level of education and previous knowledge remained significant in the multivariate model. The survey has revealed some of the points that should be improved in the future concept of screening program in Croatia. Health professionals should persist to mend women's knowledge about prenatal screening, taking into consideration women's preferences as well.

Primary uterine cervical cancer: correlation of preoperative magnetic resonance imaging and clinical staging (FIGO) with histopathology findings

The most commonly used staging system for cervical cancer is based on the International Federation of Gynaecology and Obstetrics (FIGO) staging system. Magnetic resonance imaging (MRI) has been accepted as the optimal tool for evaluation of the main prognostic factors and selection of therapeutic strategy. The purpose of this study was to compare the preoperative clinical examination FIGO staging findings with MRI and postoperative pathology report in females with primary cancer of the cervix. The study prospectively included 46 females consecutively hospitalized at the Department of Gynaecology and Obstetrics at the "Sestre milosrdnice" University Hospital Center in Zagreb. Interviews, clinical examination, transvaginal ultrasound and MRI were performed in all patients. In selected patients the surgical procedure was done and the correlation of clinical findings according to FIGO classifications, MRI and histopathological findings was completed. According to FIGO classification, positive clinical findings for stage IIA were found in 26/46 (55.5%) and stage IIB in 20/46 (44.5%)patients. FIGO MR modified classification confirmed stage IIA in 30/46 (66.6%) and stage IIB in 16/46 (33.4%) patients. Surgery (Wertheim radical hysterectomy with bilateral pelvic and selective para-aortic lymphadenectomy) was performed in 33/46 (71%) patients with clinically, MR, cytologically and pathohistologically confirmed findings of cervical cancer: 26 patients with IIA clinically FIGO stage and 7 with IIB stage. MRI examination proved better than clinical examination in staging of cervical carcinoma with 90.9% versus 79.0% accuracy rate. We suggest the application of the following MR protocol in all clinically staged FIGO IIA and IIB patients: T1W, T2WI and postcontrast dynamic T1WI after 3 and 60 seconds and after 5 minutes, performed on 1.5T MR machine.

Abdominal wall endometriosis: case report

Abdominal wall endometriosis, also known as scar endometrioma, is a rare condition, in most cases occurring after previous cesarean section or pelvic surgery. The incidence of scar endometrioma is estimated to 0.03%-1.5% of all women with previous cesarean delivery. The predominant clinical picture is cyclic pain. Due to a wide range of mimicking conditions and a relative rarity, a significant delay is often observed from the onset of symptoms to proper treatment. We report on a case of a 36-year-old patient with scar endometrioma after two previous cesarean deliveries. The possible diagnostic pitfalls and treatment options are discussed.

Detection of ovarian cancer by determination of CA 125 in different patohistologycal types of tumor according to age

During the eighteen-year period in "Sestre milosrdnice" University Hospital Center, Zagreb, 271 women with ovarian tumor was studied. 229 women with ovarian cancer and 42 with borderline tumor. The pathohistological types of tumors were different. The age of the patients ranged from 20-83 years. In all patients the value of biochemical marker CA125 was determined. The aim of this study was to determine the usefulness of CA125 measurement in different age groups and in different patohistologycal forms of tumor. CA125 has proven to be positive in 89.1% of women with ovarian cancer and in 62% with neoplasm of low malignant potential. The higher values of CA125 were detected in younger women with low malignant tumor potential. Serous and metastatic tumor types were also associated with higher values of CA125.

Heterotopic triplet pregnancy complicated with ovarian hyperstimulation syndrome following in vitro fertilization

Heterotopic pregnancy is a rare event that occurs in less than 1% of pregnancies following in vitro fertilization and embryo transfer, especially when complicated with ovarian hyperstimulation syndrome. We report a case of a 31-year-old woman in the 6th gestational week of pregnancy achieved after in vitro fertilization, who was complaining of acute lower abdominal pain and distension, breathing difficulties and vaginal spotting. Transvaginal ultrasound examination and laboratory tests confirmed the ovarian hyperstimulation syndrome in the presence of two viable gestational sacs. The patient's condition worsened five days later with sudden onset of sharp abdominal pain, nausea and vomiting, along with impaired laboratory test values. Laparoscopy was attempted, but enlarged ovaries and adhesions prevented further procedure, which was then converted to mini-laparotomy. Operative removal of the right tubal pregnancy resulted in uncomplicated course of the intrauterine twin pregnancy and delivery of two healthy neonates by cesarean section at 37 weeks of gestation. Clinicians need to be aware of this rare complication where ovarian hyperstimulation syndrome coexists with heterotopic pregnancy after in vitro fertilization and embryo transfer procedure. Enlarged ovaries may mask accurate ultrasound diagnosis, but timely surgical intervention can prevent fatal consequences and result in normal course and outcome of intrauterine pregnancy.

The possibility of respiratory distress syndrome prevention of premature born children

Pregnant women and premature born children were classified into four groups. In each group there were thirty of them. The first group included the pregnant women with premature rupture of membranes and amniotic fluid effluxed for 72 hours before the delivery. The second group included the pregnant women with amniotic fluid effluxing less then 72 hours before the delivery. The third group included the pregnant women who were given corticosteroids. The forth group was a control group formed by those pregnant women (and their premature born children) whose amniotic fluid did not efflux long and those who weren't given corticosteroids during pregnancy. In all groups of pregnant women we observed: median age of pregnant women, the duration of pregnancy and mode of delivery (vaginal or cesarean section). In groups of premature born children we also observed: newborn birth weight, Apgar score in the first minute after delivery, Apgar score in the fifth minute after delivery, pH of the blood of umbilical cord, L/S ratio of amniotic fluid (lecithin-sphingomyelin ratio), RDS (neonatologist valuation in any degree of RDS developed et newborn child). Symptoms of RDS include tachypnoea, chest wall retraction and cyanosis and a zground glass' appearance of the chest on X-ray. Histopatological examinations of placentas compared the frequency of inflammatory or noninflammatory changes, also in all groups. No significant difference was found among groups of pregnant women for the following factors: the age of pregnant women, the duration of pregnancy and mode of delivery. No significant difference was found among the groups of children for the following factors: newborn birth weight, Apgar score in the fifth minute after delivery, blood pH of umbilical cord, L/S ratio of amniotic fluid. Significant difference was found among groups for the following factors: Apgar score in the first minute after delivery, the frequency of RDS and hystology of placentas. The prevention of premature delivery is the most important. All the pregnant women with symptoms of the premature delivery must be transported to the centers with the well developed unites of intensive neonatal care ("transport in utero").

Biochemical screening of fetal aneuploidies and neural tube defects by "double-test" in Croatia: a 10 years' experience

The aim of the study is to investigate the efficiency of the second-trimester biochemical screening, with maternal serum alpha-fetoprotein (MS-AFP) and free beta-subunit of human chorionic gonadotropin (free beta-hCG), during the ten-year period. The study included 11,292 of pregnant women between the 15th and 18th gestational week, who underwent screening from November 1996 to December 2006. The risk for trisomy 21 and trisomy 18 were calculated by computer software, based on a model which generated the final risk for fetal aneuploidies from the pregnant woman's a priori age risk and the likelihood ratio of the distribution of the biochemical markers, according to the second-trimester gestation. With the cut-off value of the final risk > or = 1:250, the detection rate for trisomy 21 was 75% (21/28). In women less than or equal to 35, the detection was 57.1% (8/14) and 92.9% (13/14) in those over 35 years, respectively. The detection rate of trisomy 18 was 50% (2/4). The results confirmed that the implementation of double-test, as non-invasive screening for fetal aneuploidies, should be accepted as a complementary method of antenatal care.

Chloasma--the mask of pregnancy

Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50-70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.

Ultrasonographic differentiation of benign from malignant neck lymphadenopathy in thyroid cancer

OBJECTIVE

The aim of this study was to determine whether ultrasonography itself was able to distinguish benign from malignant lymphadenopathy in patients with thyroid cancer.

METHODS

We evaluated lymph nodes in a group of patients with thyroid cancer. Nodes were detected and measured by ultrasonography, and their shape, echogenicity, size, and location were noted. Ultrasonographically guided fine-needle aspiration biopsy (FNAB) was performed, and smears were analyzed cytologically.

RESULTS

Ultrasonographically guided FNAB was performed in 578 neck nodes in a group of 631 patients with thyroid cancer. In most cases, metastases had a round shape and various echo structures, with a predomination of hypoechoic nodes without a hilum. There were statistical differences in size between metastatic and benign nodes in terms of maximum diameter, minimum diameter, and volume. Among these, minimum diameter and the shape of the nodes seemed to be the most reliable in suggesting malignancy. A round shape with a longitudinal/transverse ratio of less than 2 of hypoechoic nodes indicated the presence of metastases, and we then performed FNAB. The absence of an echogenic hilum and the presence of cystic portions and calcifications were significantly greater in malignancies than in benign lesions (P<.001). In most cases, metastatic nodules were situated in the lower third of the neck. Reactively enlarged nodes occurred more frequently in the upper part of the neck.

CONCLUSIONS

Ultrasonography itself cannot distinguish benign from malignant lesions, but an echographic appearance suggests malignancy and helps in the selection of the node to aspirate with ultrasonographically guided FNAB, which is crucial for a final diagnosis.

Ultrasonographic estimation of fetal weight--residents accuracy

The aim of this retrospective study was to evaluate the accuracy of gynecology and obstetrics residents when performing ultrasonographic estimation of fetal weight. The total of 400 ultrasonographic estimations of fetal weight and corresponding neonatal weight were collected and divided into 3 groups according to physicians' experience (junior and senior residents, staff physicians). The accuracy of fetal weight estimation correlated positively with the level of physicians'experience. The proportional difference between ultrasound estimation and actual birth weight varied from 8.45% to 6.88% (junior residents 8.45%, senior residents 6.95%, staff physicians 6.88%). The proportion of ultrasonograhic estimates that fell within 10% of birth weight varied from 59.09% to 79.21% (junior residents 59.09%, senior residents 78.44%, staff physicians 79.21%). Senior residents reach a highly acceptable accuracy in ultrasonographic estimation of fetal weight which is comparable to staff physicians.

Carotid artery intima thickness and flow velocity after discontinuation of hormone replacement therapy in postmenopausal women: follow-up study

AIM

To investigate the effect of discontinuation of hormone replacement therapy on the intima thickness and blood flow velocity of the common carotid artery.

METHODS

The thickness of the left common carotid artery intima and maximal systolic blood velocity were measured by real-time and Doppler ultrasonography in 75 healthy postmenopausal women starting sequential combined hormone replacement therapy. The measurements were performed at the start and after 6 and 12 months of the therapy. Thirty two women decided to discontinue the therapy after 6 months, whereas 43 continued.

RESULTS

In the group that continued with the hormone replacement therapy, a significant decrease was recorded in the mean baseline values for carotid artery intima thickness and flow velocity at 6 months (0.35+0.11 vs 0.54+0.19 mm and 0.73+0.16 vs 0.87+0.19 m/s, respectively, p?0.001) and 12 months of follow-up (0.36+0.1 mm and 0.72+0.15 m/s vs baseline, respectively, p?0.001). In women who discontinued the therapy, there were significant deviations from the baseline values in the intima thickness (0.36+0.11 vs. 0.59+0.09 mm, p=0.010) and flow velocity (0.75+0.14 vs. 0.85+0.16 m/s, p?0.001) at 6 but not at 12 months of the follow-up (0.55+0.12 mm, and 0.85+0.17 m/s vs baseline; p=0.148 and p=0.965, respectively).

CONCLUSION

Decreased flow velocity and reduced intima thickness were directly related to blood vessel wall dilatation after estrogen component of hormone replacement therapy. Discontinuation of the hormone replacement therapy returned the flow velocity and intima thickness to their baseline values.

[DNA intercalators. 1. Development of 2-hydroxy-benzo(b)carbazole derivatives as cytostatics]

Reaction of p-benzoquinone 3 and aminomethylene indanones 2 via easily oxidized benzocarbazoles 4/5 affords the heterocyclic quinones 6. The structure of 4/5 and 6 is proven by derivatization to 7b and 8b. The product 9 obtained by methylation of 6 is hydrogenated to 10 or debenzylated to 11. Ether cleavage yields 12. Reaction of 9 with lithium-methyl or NaBH4 affords 13 and the intermediates 14 and 15. Phenol 6a was alkylated to 16 or aminomethylated to 17 or 18. The indole quinones 17 and 18 show strong cytotoxic activity against colon cells and pulmonary carcinoma cells.