Relationship Between Maternal Bone Biomarkers and Fetal Adiposity Through Normal Pregnancy

PURPOSE

To examine the association of maternal bone markers [sclerostin, soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteocalcin, 25-hydroxyvitamin D3] with fetal intra-abdominal and subcutaneous adipose tissue deposition and birthweight during normal pregnancy.

METHODS

One hundred pregnant women (aged 30.4 ± 5.6 years, mean ± SD) with prepregnancy body mass index = 24.1 ± 4.6 kg/m2 were seen prospectively during each trimester. At each visit they were submitted to anthropometric measurements, a fasting blood sampling, a 75-g oral glucose tolerance test, and a fetal ultrasonogram. At birth, neonates had birth weight measurement.

RESULTS

In the second trimester, maternal sclerostin concentrations correlated positively with fetal abdominal circumference and birth weight; maternal sRANKL concentrations correlated positively with fetal abdominal subcutaneous fat thickness, sagittal abdominal diameter, and abdominal circumference. Fetuses born to mothers with greater (>254 ng/mL), compared to fetuses born to mothers with lower (≤254ng/mL), sRANKL concentrations had greater abdominal circumference, sagittal diameter, and abdominal subcutaneous fat thickness. Maternal serum sclerostin concentrations were the best positive predictors of birth weight. In the third trimester maternal sclerostin concentrations correlated positively with fetal sagittal abdominal diameter; maternal sRANKL concentrations positively correlated with fetal abdominal circumference and fetal abdominal sagittal diameter.

CONCLUSIONS

Maternal bone markers sclerostin and sRANKL may relate to fetal intra-abdominal adipose tissue deposition through as yet unknown direct or indirect mechanisms, thus contributing to birthweight.

Female genital tract microbiota affecting the risk of preterm birth: What do we know so far? A review

Spontaneous Preterm birth (SPTB) is a common obstetric complication affecting 12.9 million births worldwide and is the leading cause of neonatal morbidity and mortality. Disruption in the vaginal microbiota has an impact on the maternal immunological profile leading to SPTBs. Scientists have struggled to link maternal infectious agents with the dysregulation of the maternal immune response in cases of SPTBs. Throughout the last decade, important findings regarding the role of microbiota and its genome, the so-called microbiome, have linked alterations within the population of the microorganisms in our bodies with changes in nutrition, immunity, behaviour and diseases. In this review, evidence regarding the female genital tract microbiota and microbiome has been examined to help further our understanding of its role in disrupting the maternal immune system resulting in spontaneous preterm birth.

Dysregulation of 11beta-hydroxysteroid dehydrogenases: implications during pregnancy and beyond

Glucococorticoids play a critical role in the developmental programing and fetal growth. Key molecules mediating and regulating tissue-specific glucocorticoid actions are 11beta-hydroxysteroid dehydrogenase (11beta-HSD) type 1 and 2 isozymes, both of which are expressed in the placenta and the fetal membranes. 11beta-HSD1 is implicated in the pathogenesis of metabolic syndrome and its dysregulation has been observed in pregnancy-related complications (pre-eclampsia, intrauterine growth restriction). Interestingly, preliminary clinical data have associated certain 11beta-HSD1 gene polymorphisms with hypertensive disorders in pregnancy, suggesting, if confirmed by further targeted studies, it's potential as a putative prognostic marker. Animal studies and observations in humans have confirmed that 11beta-HSD2 insufficiency is related with pregnancy adversity (pre-eclampsia, intrauterine growth restriction, preterm birth). Importantly, down-regulation or deficiency of placental 11beta-HSD2 is associated with significant restriction in fetal growth and low-birth weight, and unfavorable cardio-metabolic profile in adulthood. The potential association of 11beta-HSD1 tissue-specific dysregulation with gestational diabetes, as well as the plausible utility of 11beta-HSD2, as a biomarker of pregnancy adversity and later life morbidity, are emerging areas of intense scientific interest and future investigation.

Increased nuchal translucency and diaphragmatic hernia. A case report

Increased nuchal translucency (NT) thickness is present in 40% of fetuses with diaphragmatic hernia, including 80% of those that result in neonatal death and in 20% of the survivors. A 33-year-old nulliparous woman had first trimester scan at 12 weeks. The fetus had a NT of 2.3 mm, normal ductus venosus (DV), and tricuspid doppler and present nasal bone. Pregnancy-associated plasma protein A (PAPP-A) was 0.59 MoM and beta-human chorionic gonadotropin (b-hCG) 2.56 MoM. The couple did not opt for chorionic villous sampling (CVS) and repeat ultrasound examination was advised. At 18 weeks, ultrasound revealed left sided diaphragmatic hernia. The couple consented for termination of the pregnancy. The molecular test showed normal karyotype and male gender. In such cases with intrathoracic herniation of abdominal viscera, the increased NT may be the consequence of venous congestion due to mediastinal compression. The prolonged compression of the lungs causes pulmonary hypoplasia. Increased NT with normal fetal karyotype is associated with structural fetal anomalies like diaphragmatic hernia and screening at 16-18 weeks is imperative.

Fertility sparing management and pregnancy in patients with granulosa cell tumour of the ovaries

Granulosa cell tumours (GCTs) of the ovary are a rare entity among the neoplasms of gynaecological oncology. Deriving from the stroma of the ovary, GCTs are generally characterised by insidious growth, low malignancy potential and late recurrence. The standard treatment for these tumours is principally surgical, consisting of bilateral adnexectomy and hysterectomy. This is a narrative review of the current literature regarding the role of fertility sparing surgery in ovarian granulosa tumour. In the included studies, fertility sparing surgery was performed in 171 out of 350 patients. Recurrence rates ranged between 9.8-27.4%. Out of 131 patients, 15 achieved pregnancy. The data were limited regarding completion post-pregnancy surgery. Due to the fact that GCTs often affect younger ages, of crucial importance is the preservation of fertility by conserving the uterus and the contralateral ovary, while close monitoring is essential in order to achieve early identification and treatment of a possible recurrence. After completion of family planning, hysterectomy and salpingo-oophorectomy are recommended.

A unique case of ruptured ectopic pregnancy in a patient with negative preg-nancy test - a case report and brief review of the literature

INTRODUCTION

Despite the major advances made in the diagnosis and management of ectopic pregnancies in the last two decades, an accurate diagnosis can sometimes still be quite challenging, since it relies on the combination of ultrasound findings and serial serum beta-human chorionic gonadotrophin (β-hCG) measurements.

CASE PRESENTATION

This paper describes the case of a 36-year-old woman of Caucasian origin who was admitted to the emergency department of our clinic with clinical symptoms of hemorrhagic shock in combination with two negative pregnancy tests done by her at home and a negative urine test which was performed on her admission to the hospital. Quantitative measurement of β-hCG in the serum of the patient was 13 mIU/mL. On admission, right tubal pregnancy was diagnosed on ultrasound and she underwent an emergency laparotomy due to signs of hemodynamic shock.

CONCLUSION

It is sometimes a considerable challenge to identify a patient with an ectopic pregnancy at risk of rupture. This case of ectopic pregnancy which was followed by a negative pregnancy test illustrates the magnitude of the difficulties involved in the diagnosis of ectopic pregnancy. It also demonstrates the need to maintain a high clinical index of suspicion and to undertake careful clinical examination of the patient on the basis of the clinician's diagnostic research. Hippokratia 2014; 18 (3): 282-284.

Transvaginal ovarian trauma, poor responders and improvement of success rates in IVF: anecdotal data and a hypothesis

In this report, we propose an intervention capable of improving IVF outcomes in subfertile women with poor ovarian response. This intervention derives from anecdotal data and observations in our daily practice, but most importantly from trials on experimental models and subfertile women with Polycystic Ovarian Syndrome (PCOS). Our hypothesis suggests that transvaginal induction of trauma to the ovary in the cycle preceding IVF should benefit poor ovarian responders and their lowered pregnancy rates by increasing - at least - the number of retrieved oocytes during oocyte retrieval. Up-to-the minute data show that, via this means, there is a unique response of the ovarian surface epithelium and stroma to the induced trauma. The potential pathways of this beneficial response involve an improvement of the raised gonadotrophins to act either through the mechanical reduction of the size of the ovary or through alterations of the hormonal profile by lowering LH, inhibin and local androgen concentrations through hypothalamic-pituitary axis feedbacks, the induction of increased blood flow to the ovaries, a differentiated local immune reaction and a non-elucidated as yet role of reactive oxygen species. In this report, we also describe the technique and the associated possible negative points while we try to point out the needed research steps to ensure its efficiency before it enters daily clinical practice.

Potential Pathophysiological Mechanisms of the Beneficial Role of Endometrial Injury in In Vitro Fertilization Outcome

Successful embryo implantation is a complex process that involves multiple biological mechanisms and reciprocal interactions between the embryo and the proliferated endometrium. In this review, we provide an informative contribution on the pathways underlying the beneficial nature of endometrial injury toward improving implantation rates of embryos conceived and through in vitro fertilization. The evidence published to date are in favor of inducing local endometrial injury in the preceding cycle of ovarian stimulation to improve pregnancy outcomes in women with unexplained and recurrent implantation failure. Endometrial injury triggers a series of biological responses but the findings suggest that no particular pathway is solely adequate to explain the association between trauma and improved pregnancy rates rather than a cluster of events in response to trauma which benefits embryo implantation in ways both known and unknown to the scientific community.

Abdominal wall endometriosis after a caesarian section--an interesting case report

BACKGROUND

Endometriotic foci can be rarely found on the surgical incision following caesarean delivery and on perineotomy site following vaginal delivery.

CASE

A 33-year-old woman with a history of caesarian section five years prior was admitted to the present clinic due to right groin pain with increasing intensity during menstruation. Ultrasound revealed an endometrioma-like subcutaneous mass directly under the right edge of the Pfannenstiel scar. The mass (3.5 x 2.4 x 2 cm) was removed en bloc with ultrascissor.

CONCLUSION

The prevailing argument supports that it is a complication caused by the iatrogenic dispersal of endometrial material. Symptoms onset vary from one to five years postoperatively and mainly include pain and enlargement of the mass during menstruation. Diagnosis may be demanding due to the atypical presentation of the disease. Symptoms exacerbate during menstruation in only 20% of all cases. Abdominal ultrasound is extremely useful for diagnosis. The treatment of choice is surgical excision.

Uterine inversion after controlled cord traction during caesarean section: a case report

INTRODUCTION

Inversion of the uterus during caesarean section is a rare but life-threatening complication of the procedure that requires immediate treatment, which is reversion and awareness due to the very serious adverse effects that it may have.

MATERIALS AND METHODS

The authors present a case of a 34-year-old para 1 woman of Greek ethnicity who underwent a scheduled caesarean section at 39 weeks of gestation. During the procedure, a uterine inversion occurred as a controlled cord traction was applied in order to achieve placental detachment, after the delivery of the baby. It was managed by immediate manual uterine reversion, which was performed after exteriorization of the uterus. There were no adverse effects.

CONCLUSION

Uterine inversion during caesarean section is a serious complication, but fortunately very rare. However, the obstetrician should be aware that the complication should be quickly identified and act without hesitation because it is critical for the well being of the patient.

Reactive oxygen species in the follicular fluid of subfertile women undergoing In Vitro Fertilization: a short narrative review

Reactive Oxygen Species (ROS) are produced as a normal product of aerobic metabolism. Naturally, there is an array of protective mechanisms that neutralize ROS, while any potential imbalance between ROS and antioxidants results in oxidative stress. In an In Vitro Fertilization (IVF) setting, existing literature suggests a favorable outcome in terms of oocyte quality/maturation and fertilization rate with increased ROS levels, while other study groups have presented significant data on the detrimental effect of increased ROS concentration in the quality of embryos exposed and their potential to advance. In this study, we examine the conflicting views of the role of ROS in fertilization and embryo quality, especially through their concentration in the follicular fluid of subfertile women undergoing IVF. The current debate could possibly be attributed to the different assay methods and end-point outcomes employed by each research group, along with the noted limited number of the relevant studies published on the subject. Properly conducted studies can further validate and elicit the exact role of ROS as well as their association to female reproduction, and especially to women undergoing IVF.

Hemizona assay and sperm penetration assay in the prediction of IVF outcome: a systematic review

The limited predictive value of semen analysis in achieving natural conception or in IVF outcome confirms the need for sperm function tests to determine optimal management. We reviewed HZA and SPA predictive power in IVF outcome, with statistical significance of diagnostic power of the assays. HZA was readily efficient in predicting IVF outcome, while evident inconsistency among the studies analysed framed the SPA's role in male fertility evaluation. Considerable variation was noted in the diagnostic accuracy values of SPA with wide sensitivity (52-100%), specificity (0-100%), and PPV (18-100%) and NPV (0-100%) together with fluctuation and notable differentiation in methodology and cutoff values employed by each group. HZA methodology was overall consistent with minor variation in cutoff values and oocyte source, while data analysis reported strong correlation between HZA results with IVF outcome, high sensitivity (75-100%), good specificity (57-100%), and high PPV (79-100%) and NPV (68-100%). HZA correlated well with IVF outcome and demonstrated better sensitivity/specificity and positive/negative predictive power. Males with normal or slightly abnormal semen profiles could benefit by this intervention and could be evaluated prior to referral to assisted reproduction. HZA should be used in a sequential fashion with semen analysis and potentially other bioassays in an IVF setting.

In vitro maturation in subfertile women with polycystic ovarian syndrome undergoing assisted reproduction

BACKGROUND

Polycystic ovarian syndrome (PCOS) occurs in 4% to 7% of all women of reproductive age and 50% of women presenting with subfertility. Subfertility affects 15% to 20% of couples trying to conceive. A significant proportion of these women ultimately need assisted reproductive technology (ART). In vitro fertilisation (IVF) is one of the assisted reproduction techniques employed to raise the chances of achieving a pregnancy. For the standard IVF technique, stimulating follicle development and growth before oocyte retrieval is essential, for which a large number of different methods combining gonadotrophins with a gonadotrophin-releasing hormone (GnRH) agonist or antagonist are used. In women with PCOS, the supra-physiological doses of gonadotrophins used for controlled ovarian hyperstimulation (COH) often result in an exaggerated ovarian response, characterised by the development of a large cohort of follicles of uneven quality, retrieval of immature oocytes, and increased risk of ovarian hyperstimulation syndrome. A potentially effective intervention for women with PCOS-related subfertility involves earlier retrieval of immature oocytes at the germinal-vesicle stage followed by in vitro maturation (IVM). So far, the only data available have derived from observational studies and non-randomised clinical trials.

OBJECTIVES

To compare outcomes associated with in vitro maturation (IVM) followed by vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) versus conventional IVF or ICSI, among women with polycystic ovarian syndrome (PCOS) undergoing assisted reproductive technologies (ART).

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of controlled trials to May 2013 for any relevant trials identified from the title, abstract, or keyword sections. This was followed by a search of the electronic database MEDLINE, EMBASE, LILACS and CINAHL, without language restriction. We also performed a manual search of the references of all retrieved articles; sought unpublished papers and abstracts submitted to international conferences, searched the clinicaltrials.gov and WHO portal registries for submitted protocols of clinical trials, and contacted experts. In addition, we examined the National Institute of Clinical Excellence (NICE) fertility assessment and treatment guidelines and handsearched reference lists of relevant articles (from 1970 to May 2013).

SELECTION CRITERIA

All randomised trials (RCTs) on the intention to perform IVM before IVF or ICSI compared with conventional IVF or ICSI for subfertile women with PCOS.

DATA COLLECTION AND ANALYSIS

Three review authors (CS, MK and NV) independently assessed eligibility and quality of trials. Primary outcome measure was live birth rate per randomised woman.

MAIN RESULTS

There were no RCTs suitable for inclusion in the review, although there are currently three ongoing trials that have not yet reported results.

AUTHORS' CONCLUSIONS

Though promising data on the IVM technique have been published, unfortunately there is still no evidence from RCTs upon which to base any practice recommendations regarding IVM before IVF or ICSI for women with PCOS. Meanwhile, the results of the above-mentioned ongoing trials are awaited and, of course, further evidence from good quality trials in the field is eagerly anticipated.

Resistin in mid-trimester amniotic fluid in trisomy 21

OBJECTIVE

The aim of this study was to examine whether resistin is present in second trimester amniotic fluid from trisomy 21 (also known as Down's syndrome) pregnancies and whether its concentration differs compared with euploid pregnancies.

METHODS

The study cohort consisted of 58 women in the mid-trimester of pregnancy who underwent amniocentesis for prenatal diagnosis, 31 of whom carried a single fetus with diagnosed trisomy 21 (study group) and the rest with normal karyotype (control group, n = 27). Groups were matched for maternal and gestational age. Levels of resistin in amniotic fluid were measured by a commercially available enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

Resistin was detected in all amniotic fluid samples. Its median concentration in the second trimester amniotic fluid of trisomy 21 pregnancies (2.1 ng/ml) was statistically significantly lower (p value <0.001) in comparison with that in euploid pregnancies (3.3 ng/ml).

CONCLUSIONS

Resistin is a physiologic constituent of second trimester amniotic fluid. Lower levels of amniotic fluid resistin in pregnancies with trisomy 21 may reflect altered metabolic pathways in utero that could possibly be related with phenotypic features of the syndrome.

Granulocyte macrophage colony stimulating factor supplementation in culture media for subfertile women undergoing assisted reproduction technologies: a systematic review

Granulocyte macrophage colony stimulating factor (GM-CSF) is a cytokine/growth factor produced by epithelial cells that exerts embryotrophic effects during the early stages of embryo development. We performed a systematic review, and six studies that were performed in humans undergoing assisted reproduction technologies (ART) were located. We wanted to evaluate if embryo culture media supplementation with GM-CSF could improve success rates. As the type of studies and the outcome parameters investigated were heterogeneous, we decided not to perform a meta-analysis. Most of them had a trend favoring the supplementation with GM-CSF, when outcomes were measured in terms of increased percentage of good-quality embryos reaching the blastocyst stage, improved hatching initiation and number of cells in the blastocyst, and reduction of cell death. However, no statistically significant differences were found in implantation and pregnancy rates in all apart from one large multicenter trial, which reported favorable outcomes, in terms of implantation and live birth rates. We propose properly conducted and adequately powered randomized controlled trials (RCTs) to further validate and extrapolate the current findings with the live birth rate to be the primary outcome measure.

The practical role of anti-Müllerian hormone in assisted reproduction

The objective of this study was to offer a brief critical summary of the literature on the role of AMH in the subfertility work up and during ART, while exploring its role in predicting ART success.

Expression of E-cadherin in primary endometrial carcinomas: clinicopathological and immunohistochemical analysis of 30 cases

INTRODUCTION

Decreased expression of E-cadherin has been associated with poorly differentiated endometrial carcinomas and poorer outcomes.

AIM

The purpose of this study was to examine the distribution of E-cadherin immunohistochemical expression in specimens from primary endometrial carcinomas and its relation to classical clinicopathological prognostic factors.

MATERIALS AND METHODS

Surgically-resected tissues of 30 patients with primary endometrial carcinomas were studied. Histological type and grade, depth of myometrial invasion, lymph-vascular space invasion, fallopian tube or ovarian invasion, and the presence of tumoral necrosis were evaluated. Immunohistochemical examination was performed on deparaffinized four-microm-thick sections.

RESULTS

The mean age of patients was 65 years (+/- 11.41). The 63.54% of carcinomas were moderately/poorly differentiated. No statistical correlation was found between the score or intensity of E-cadherin immunohistochemical staining (strong or moderate positive expression) and the clinicopathological factors tested.

CONCLUSIONS

The association of E-cadherin immunoreactivity with the standard clinicopathological factors seemed to be contradictory. The classical clinicopathological factors remain the most important prognostic parameters.

Corticotropin-releasing hormone and progesterone plasma levels association with the onset and progression of labor

PURPOSE OF LNVESTIGATION: To examine the relationship between maternal plasma progesterone along with corticotropin- releasing hormone (CRH) plasma levels and the progression of labor.

MATERIALS AND METHODS

Maternal serum CRH and progesterone were measured during the latent phase of labor, active labor, and 24 hours postpartum in women who went into spontaneous labor and delivered vaginally at term. Progesterone (P) levels in women delivered by an elective cesarean section at term were also measured as baseline.

RESULTS

Mean maternal plasma P was 18% higher in the active phase than in the latent phase of labor (p < 0.01), and declined significantly by 24 hours postpartum (p < 0.001). Mean level of serum CRH was 24% higher in the active phase than in the latent phase of labor (p < 0.01), and subsequently declined significantly by 24 hours postpartum (p < 0.001).

CONCLUSIONS

As labor progresses, P and CRH increase and subsequently decrease precipitously in the immediate postpartal period. P levels tend to drop in women who are in early labor compared with non-laboring full-term women.

Mediators of chronic inflammation in polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is an endocrine disorder affecting 5-10% of reproductive-age women. Hyperandrogenemia, which characterizes the syndrome, stimulates the maturation of adipocytes and favors central obesity. The linking hub between obesity and other metabolic manifestations of the syndrome seems to be chronic low-grade inflammation. We discuss the most reliable current data regarding the role of inflammatory mediators in PCOS, with particular focus on the genetic mechanisms implicated. C-reactive protein levels are 96% higher in PCOS patients than in healthy controls. Patients with the -308A polymorphism of the tumor necrosis factor-α gene have elevated androgens in comparison with carriers of the -308G. Interleukin 18 (IL-18) is elevated in lean patients, with a further rise in the presence of obesity and insulin resistance. Polymorphisms of the IL-1a, IL-1b and IL-6 genes have also been associated with PCOS. Plasminogen activator inhibitor-1 levels are positively associated with the syndrome, and carriers of the 4G allele of the 4G/5G polymorphism are at risk of developing PCOS. Other mediators discussed include adhesion molecules, osteoprotegerin, asymmetric dimethylarginine, homocysteine and advanced glycation end-products. The elucidation of the pathogenetic mechanisms implicated in PCOS and their connection with low-grade inflammation may in the future offer the opportunity for the formulation of novel therapeutic strategies and individualized therapy for these patients.

Pathogenesis of endometriosis: the role of genetics, inflammation and oxidative stress

INTRODUCTION

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity.

MATERIALS AND METHODS

The etiology of this multifactorial disease is still unresolved and an increasing number of studies suggest that genetic, hormonal, environmental, immunological and oxidative factors may all play an important role in the pathogenesis of this disorder.

CONCLUSIONS

In this literature review, inflammatory activity, oxidative stress as well as genetic abnormalities and mutations have been studied in an effort to identify factors predisposing to endometriosis.

A rare case of umbilical and vaginal metastasis from endometrial cancer--review of the literature

INTRODUCTION

Metastases from primary endometrial cancer to the umbilicus are extremely rare. This unusual site of metastases has been described as Sister Joseph's nodule.

MATERIAL AND METHOD

We present a case of a 73-year-old Caucasian woman with a BMI of 30, type II diabetes mellitus, hypertension, and umbilical and vaginal metastasis of endometroid endometrial adenocarcinoma (FIGO Stage IIIa, G2). Total abdominal hysterectomy and bilateral salpingo-oophorectomy by Pfannenstiel dissection, had been performed eight months before. The size of the umbilical mass was 2 x 2 cm. A second laparotomy including full recession of the umbilical ring, omentectomy, bilateral inguinal lymph nodes and excision of the upper one-third of the vagina was performed. Histological diagnosis revealed metastases of the same origin with her primary disease.

CONCLUSION

The exact mechanism of implantation of cancer cells at the site of the umbilical ring is still unclear. Perhaps malignant cells penetrated the thickness of the uterine wall and spread intraperitoneally to reach the umbilical ring. The exfoliation of cells from the primary tumor via the fallopian tubes could be another possible explanation. Unfortunately, the presence of umbilical metastasis is a poor prognostic feature and sign of advanced neoplastic disease. The survival rate of these patients is influenced by the type of treatment and time of the diagnosis.

Uterine tamponade balloon for the management of massive hemorrhage during cesarean section due to placenta previa/increta

OBJECTIVE

Uterine tamponade with the Bakri catheter is effectively used as a treatment in postpartum hemorrhage and as a means to prevent fertility.

CASE

We present a case of a 40-year-old pregnant woman who had a massive hemorrhage during cesarean section who was successfully treated with a tamponade balloon. Furthermore, we comment on a similar technique--Logothetopoulos pack--which was first developed and used in our department in the early years of the previous century.

CONCLUSION

A conservative technique such as the Bakri catheter is an alternative intermediate step to control postpartum hemorrhage when pharmaceutical methods fail and before proceeding to obstetric hysterectomy.

Female genital mutilation in Greece

The number of migrants and refugees with a female genital mutilation (FGM) living in Greece is rising. This study explores the characteristics and psychosexual issues of women with FGM who were examined in the 2nd Department of Obstetrics and Gynecology, University of Athens Medical School, Greece during the year 2009. The women were asked to fill out an anonymous questionnaire asking for demographic data, obstetric history, current complaints, and psychosexual problems. The results are presented and discussed, as FGM is a new reality for Greece. Healthcare providers have to familiarize themselves with issues related to FGM and improve their skills in transcultural care, so as to manage and support women with FGM adequately.

Management of ASCUS findings in Papanicolaou smears. A retrospective study

AIM

Atypical squamous cells of undetermined significance (ASCUS) are a cervical cytologic finding category suggestive but not definitive of squamous intraepithelial lesions. ASCUS remains an incompletely described entity and accounts for even 5%-10% of reported Papanicolaou (Pap) smears. The management of women with such cytologic findings remains controversial. The aim of this study was to evaluate the cytology laboratory findings with regards to ASCUS diagnosis, using cervical Pap smears, and colposcopic biopsies, as well as their management.

MATERIALS AND METHODS

This is a retrospective study of patients with ASCUS Pap smears taken during the period January 2010 - December 2010 in the Second Department of Obstetrics and Gynecology, Aretaieion Hospital.

RESULTS

During the study period, 657 Pap smears were examined at the Aretaieion Hospital; moreover, seven patients, whose Pap smears were cytologically diagnosed with ASCUS, were referred from other clinics, providing a total of 42 cases with a descriptive diagnosis of ASCUS for review. Of the 42 cases, eight were not studied because they were either lost in follow-up or they did not have available data. The remaining 34/42 patients were evaluated by colposcopic examination and directed biopsies where necessary. The ratio of ASCUS to low-grade squamous intraepithelial lesion (LGSIL), high-grade squamous cell intraepithelial lesion (HGSIL) or squamous cell carcinoma (SCC) was 5/34, 1/34, and 0/34, respectively. In the 34 ASCUS cases evaluated by colposcopy, the age distribution varied from 22 to 54 years. Eight of 34 cases did not have a child, 7/34 were primigravida, 18/34 were secondi-gravida, and 1/34 had four children. Four out of 34 cases were postmenopausal, 3/34 referred no history of abnormal bleeding, 21/34 were smokers, 6/34 used oral contraceptives, 2/34 used intrauterine devices, 1/34 took replacement of hormones, 4/34 had prior abnormal Pap smears human papillomavirus (HPV), or 1/34 had previous cancer (breast cancer). Colposcopy was inconclusive in 4/34 patients, while 8/34 cases were negative for Schiller and acetic acid tests and also had normal colposcopy. Infectious organisms were found in 8/34 patients with ASCUS, including actinomyces (1/8), trichomonas (5/8), and candida albicans (2/8). Histologic tests revealed 16/34 koilocytosis cases, 5/34 LGSIL, 1/34 HGSIL, and 0/34 SCC.

CONCLUSION

The dilemma in the management of patients with an ASCUS diagnosis still exists as a significant problem for clinicians.

Three-dimensional ultrasound and three-dimensional power Doppler improve the preoperative evaluation of complex benign ovarian lesions

PURPOSE OF INVESTIGATION

To evaluate the diagnostic accuracy of three-dimensional ultrasound (3D-US) and three-dimensional power-Doppler (3DPD-US) as adjuncts to conventional B-mode-US in evaluation of complex benign ovarian lesions.

METHODS

Transvaginal B-mode-US, 3D-US and 3DPD-US were performed in 29 patients with unilateral ovarian lesion. Patients were classified as low or high risk for malignancy according to a standardized scoring system composed of ten morphological and vascular parameters. Preoperative scores were matched to the histological results and the diagnostic performance of the scoring system was calculated.

RESULTS

Seven out of the 16 cases of endometriomas (44%) were graded as low risk masses according to B-mode-US, while the addition of 3D-US and 3DPD-US increased the accuracy to 56% and 94%, respectively. All dermoid cysts were classified as high risk cases by B-mode-US, but 3D-US and 3DPD-US correctly classified 14% and 57% of cases, respectively. The use of B-mode-US, 3D-US and 3DPD-US correctly classified all four cystadenomas. Only the use of 3DPD-US correctly classified one out of two hemorrhagic corpus luteum cases, whereas the other imaging modalities characterized these lesions as high risk. The overall diagnostic accuracy increased from 38%, 48%, ana 83% with the application of B-mode-US alone, or combined with 3D-US and 3DPD-US, respectively.

CONCLUSION

Conventional ultrasound supplemented with 3D-US and 3DPD-US and the evaluation of findings according to a specific scoring system can facilitate the preoperative classification of complex benign ovarian lesions.

Intrauterine inflammation and preterm delivery

Spontaneous preterm delivery, prematurity, and low birth weight due to prematurity account for a great part of neonatal morbidity and mortality. Specifically, chronic amniotic fluid inflammation may cause preterm labor, with the involvement of different mediators that produce diverse aspects of the inflammatory response. Although bacteria are considered to be the main trigger for intrauterine infection/inflammation, viral infections also appear to be involved. Recently, molecular genetic techniques have helped us better understand the underlying pathophysiologic processes. This is especially important because epidemiological and experimental studies indicate that intrauterine infection and inflammation constitute a risk factor for adverse neurological outcome in preterm infants. Chronic subclinical chorioamnionitis associated with preterm birth can also modify lung development. Although no current clinical strategy is aimed at adapting the maternofetal inflammatory response, immunomodulators may serve as a future intervention in preterm embryos.

Perinatal mortality in diabetic pregnancy

Perinatal mortality rate (PMR) is one of the most important perinatal health indicators. PMR in diabetic pregnancies varies throughout the world and is higher than the background PMR. The prevalence of pregestational diabetes is increasing and is associated with an elevated risk of congenital malformations, macrosomia, preeclampsia, and preterm delivery. The incidence of PMR in preexisting diabetes mellitus ranges considerably, with congenital abnormalities and preterm labor the main factors contributing to the higher PMR. Women with gestational diabetes mellitus or impaired glucose tolerance are a mixed group that may have low to a high PMR, especially if they require insulin in their pregnancy. All the known diabetic women should plan their pregnancies and optimize glycemic control periconceptually and throughout pregnancy, as this reduces the frequency of congenital abnormalities, obstetric complications, and perinatal mortality.

Adrenomedullin concentration in second trimester amniotic fluid cannot be used as a predictor of preterm delivery

BACKGROUND

Adrenomedullin, secreted by decidua and trophoblast cells, is considered to participate in regulating uterine and placental blood flow, leading to control of placental hormonal secretion. Furthermore, adrenomedullin has an antimicrobial activity. The objective of this study was to determine whether adrenomedullin concentrations in midtrimester amniotic fluid can be used as a predictor of preterm delivery.

PATIENTS AND METHODS

Amniotic fluid samples were collected in a retrospective cross-matched study that included 362 women with singleton pregnancies who presented for genetic amniocentesis. Adrenomedullin concentrations were determined by ELISA in amniotic fluid taken from women with spontaneous preterm delivery (n=41) and maternal age-matched controls who had normal pregnancy at term (n=41).

RESULTS

No difference was found in adrenomedullin concentrations between women with spontaneous preterm delivery (median: 1.33 ng/ml, range: 0.36-8.53 ng/ml) and controls (median: 1.32 ng/ml, range: 0.33-4.07 ng/ml), nor between a subset of cases of preterm premature rupture of membranes (n=19) and their controls (n=19).

CONCLUSION

Adrenomedullin concentration in amniotic fluid cannot serve as a predictor of preterm delivery.

Doppler Assessment of the Intrauterine Growth-Restricted Fetus

The evaluation of fetal well-being by Doppler velocimetry in cases of intrauterine growth restriction (IUGR) is of great importance as it is very useful in detecting those IUGR fetuses that are at high risk because of hypoxemia. Several Doppler studies initially on fetal arteries and recently on the fetal venous system provide valuable information for the clinicians concerning the optimal time to deliver. Doppler sonography in combination with the other biophysical methods such as cardiotocogram and biophysical profile score should be used in everyday practice for the monitoring and appropriate management of the growth-restricted fetuses. The purpose of this review is to describe the current approaches in Doppler assessment of IUGR fetal circulation.

Hospital visiting in obstetrics and gynecology: a tool for the advancement of training

OBJECTIVE

To assess the improvement of obstetric and gynecologic training brought about by peer influence in Europe.

METHODS

In 1996, the European Board and College of Obstetrics and Gynecology (EBCOG) initiated a visiting process by international and local peers to improve training and decrease differences in health care standards.

RESULTS

A large number of visits of obstetrics and gynecology departments have been conducted across Europe at teaching hospitals by the Hospital Visiting Committee. Compliance with the structured approach of the visiting policy and problems met during these visits are reported.

CONCLUSION

The program focuses on the continuous improvement of the competencies of all persons trained in the obstetrics and gynecology departments of teaching hospitals throughout Europe. It also increases the understanding of diversity in training methods and can gradually lead to the convergence of training and health care standards in Europe.