Primary Resectoscopic Treatment of First-Trimester Miscarriage

OBJECTIVES

To determine the feasibility and safety of resectoscopic treatment for uterine evacuation of first-trimester miscarriage.

METHODS

A single-centre prospective study performed between April 2021 and October 2021 at a university-affiliated tertiary medical centre. Patients diagnosed with early miscarriage of up to 12 weeks from the last menstrual period were eligible for participation. Recruited patients underwent hysteroscopic uterine evacuation under general anaesthesia by a Versapoint 2 bipolar resectoscope 24Fr (Johnson and Johnson, Germany).

RESULTS

A total of 15 patients were recruited for the study. The procedural characteristics as well as intra- and postoperative adverse events were recorded. The mean duration of the procedure was 14.3 ± 3.7 minutes. The achievement of complete evacuation was recorded in all cases, and no adverse events occurred during any procedure. Post-procedure follow-up 6 weeks after treatment was conducted by office hysteroscopy in 10 women and by ultrasonography in 4 women. One woman had conceived prior to her scheduled follow-up visit. In total, 2 (13.3%) cases of retained products of conception were diagnosed during office hysteroscopy and they were removed by the "see-and-treat" technique without anaesthesia. The diagnosis was confirmed pathologically. No intrauterine adhesions were detected and none of the women required a second hysteroscopy under anaesthesia due to retained products of conception.

CONCLUSIONS

Hysteroscopic evacuation of first-trimester miscarriage by a standard resectoscope is a safe and feasible technique.

Decidual-tissue-resident memory T cells protect against nonprimary human cytomegalovirus infection at the maternal-fetal interface

Congenital cytomegalovirus (cCMV) is the most common intrauterine infection, leading to infant neurodevelopmental disabilities. An improved knowledge of correlates of protection against cCMV is needed to guide prevention strategies. Here, we employ an ex vivo model of human CMV (HCMV) infection in decidual tissues of women with and without preconception immunity against CMV, recapitulating nonprimary vs. primary infection at the authentic maternofetal transmission site. We show that decidual tissues of women with preconception immunity against CMV exhibit intrinsic resistance to HCMV, mounting a rapid activation of tissue-resident memory CD8+ and CD4+ T cells upon HCMV reinfection. We further reveal the role of HCMV-specific decidual-tissue-resident CD8+ T cells in local protection against nonprimary HCMV infection. The findings could inform the development of a vaccine against cCMV and provide insights for further studies of the integrity of immune defense against HCMV and other pathogens at the human maternal-fetal interface.

Conception rates after medical versus surgical evacuation of early miscarriage

OBJECTIVE

To compare short-term fertility rates after medical and surgical management of early miscarriage.

DESIGN

Observational cohort study.

SETTING

Academic tertiary-care medical center.

PATIENT(S)

A total of 203 patients were enrolled between June 2017 and May 2018, comprising 106 surgical evacuations and 97 medical evacuations.

INTERVENTION(S)

Either surgical or medical evacuation of the uterine cavity.

MAIN OUTCOME MEASURE(S)

Conception rates 6 months after miscarriage.

RESULT(S)

Conception rates 6 months after miscarriage among women who had attempted to become pregnant were similar between the medically and surgically evacuated groups (68.0% vs. 65.1%). There were no significant differences in background characteristics between the groups, apart from younger age and earlier gestational age among the medically treated group. There was no difference in the proportion of women using assisted reproductive technologies between the medically and surgically managed groups (15.5% vs. 12.6%, respectively). The median time-to-conception was 4 ± 2 months in both groups. Cumulative pregnancy rate 12 months after pregnancy loss, live birth rate, and repeat miscarriage rate also were similar between groups.

CONCLUSION(S)

Modality of uterine evacuation after early miscarriage does not affect short-term fertility outcomes.

Healthcare Utilization and Prevalence of Symptoms in Women with Menopause: A Real-World Analysis

Objective

Self-reported studies estimated that as many as 50-75% of women experience symptoms during menopause; however, limited real-world clinical data are available to support this observation. The electronic databases of Maccabi Healthcare Services were used to describe the prevalence of menopause symptoms in Israel and to characterize patients with regard to socioeconomic status, comorbidities and use of healthcare services.

Methods

Females aged 45-54 years diagnosed with menopausal symptoms (N=17,046, cumulative incidence of 8% during the study period) were identified from the Maccabi Healthcare Services electronic database and matched to female members without menopause symptoms, one-to-one on birth year and enumeration area.

Results

Symptomatic peri- and post-menopausal women, and particularly those under 52 years, were more likely to have a higher prevalence of comorbid conditions such as depression, anxiety, osteoporosis and insomnia in the year following index. Correspondingly, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors and hypnotic drug use were significantly higher in symptomatic women as was healthcare utilization including hospitalization (OR=1.10; 95% CI=1.00-1.20), primary care visits (1.90; 1.73-2.08), gynecologist visits (24.84; 22.36-27.59) and hysterectomy procedures (2.26; 1.63-3.14).

Conclusion

Medically documented menopausal symptoms are associated with increased burden of disease (particularly among women diagnosed with menopausal symptoms prior to age 52 years), healthcare utilization and greater likelihood of undergoing hysterectomy within one year of diagnosis. This burden is expected to rise further as awareness and social acceptance of peri- and post-menopausal symptoms increase.

Artemisone demonstrates synergistic antiviral activity in combination with approved and experimental drugs active against human cytomegalovirus

We have recently shown that the artemisinin derivative artemisone, which was screened against malaria in human clinical studies, is a potent inhibitor of human cytomegalovirus (HCMV). Here we evaluated the antiviral effect of artemisone when employed in 2-drug combinations with approved and experimental anti-HCMV agents. Using the Chou-Talalay method, we found that in-vitro combination of artemisone with cidofovir, brincidofovir, or with the HCMV UL97 inhibitor maribavir resulted in antiviral synergism and the combination of artemisone with ganciclovir or with the viral terminase inhibitors letermovir and BDCRB resulted in moderate synergism. Importantly, the combination of artemisone with maribavir demonstrated synergistic antiviral activity ex-vivo, in a clinically-relevant multicellular model of human placental tissues maintained in organ culture. Our findings provide the basis for the use of artemisone in synergistically acting drug combinations, to enhance viral control and reduce antiviral drug toxicities.

Mother knows best? Comparing primiparous parturients' expectations and predictions with actual birth outcomes

OBJECTIVE

The literature provides no clear evidence linking maternal optimism/pessimism to birth outcomes. Our objective was to determine whether maternal expectations and predictions regarding mode of delivery and epidural anesthesia aligned with birth outcomes.

METHODS

Primiparous, low-risk pregnant women at term filled in questionnaires in which they rated their chances of a vaginal delivery (VD) or a cesarean section (CS), and their intention to receive epidural anesthesia. Their responses were compared to actual outcomes.

RESULTS

Pre-birth perceptions of odds of delivery by a CS were significantly higher (P=0.04) among women who eventually had a vacuum extraction (VE) or CS as a result of an arrest disorder, compared with women who had a VD and those who had a CS or a VE due to non-reassuring fetal heart monitor. Intention to receive epidural anesthesia was significantly lower (P<0.001) among women who gave birth without it.

CONCLUSION

The pessimistic pre-birth perceptions of women of high odds for a CS may be related to an increased risk of arrest disorders of labor. However, the prenatal assessments of primiparous women are poor predictors of their demand for epidural anesthesia during labor. Larger-scale studies to determine whether pre-partum psychological interventions may contribute to the process of labor and improve obstetric outcomes are warranted.

[Upper extremity deep vein thrombosis following ovarian stimulation]

Upper extremity deep venous thrombosis (UEDVT) is uncommon as a spontaneous event in the general population and is associated with well-defined risk factors. Thromboembotic events are serious, but fortunately rare, complications following ovarian stimulation for IVF. A review of the Literature indicates that thromboembolic events after ovarian stimulation are usually associated with ovarian hyperstimulation syndrome (OHSS). The incidence of UEDVT is higher in women undergoing assisted reproductive technology (ART) compared to the general population. The incidence of this condition is estimated to be 0.08%-0.11% of treatment cycles. While lower extremity DVT may be considered a natural consequence of OHSS, given the diminished venous return secondary to enlarged ovaries and ascites, it is unclear why there appears to be a predilection for thrombi in the upper extremities in women undergoing ART. Early diagnosis and treatment is crucial for both maternal and fetal well-being. Since infertility treatment is becoming commonplace in today's society, women undergoing treatment and their clinicians should be better informed of the presentation and clinical course of UEDVT to enable early diagnosis and start treatment. Consideration must be given to screening patients at risk for OHSS for thrombophilias, as well as administrating prophylactic anticoagulation therapy to patients who develop OHSS.

Detection of measles virus by reverse-transcriptase polymerase chain reaction in a placenta

INTRODUCTION

Measles virus (MV) during pregnancy is associated with maternal morbidity and mortality and can put the fetus and newborn at risk of a wide range of complications. Reverse-transcriptase polymerase chain reaction (RT-PCR) for detecting MV in the placenta has not been reported.

CASE

A case of RT-PCR detection of MV in the placenta of a 38-year-old woman who presented with premature rupture of membranes at 16 weeks' gestation is presented.

Comparison of adnexal torsion between pregnant and nonpregnant women

OBJECTIVE

The purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women.

STUDY DESIGN

We conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed.

RESULTS

Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure.

CONCLUSION

Presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.

Association of statin therapy and the risk of atrial fibrillation in patients with a permanent pacemaker

BACKGROUND

Recent studies have shown conflicting results regarding a protective effect of statin therapy on atrial fibrillation (AF).

HYPOTHESIS

We sought to determine whether statins are effective in reducing the risk of developing arrhythmia in a cohort of 264 patients (49% women, mean age [+/-standard deviation] 71 [+/-12] years) with permanent pacemakers who are at high risk for AF.

METHODS

All patients who underwent implantation of a permanent pacemaker over a 3-year period were eligible for inclusion in the study. We excluded patients with AF at implantation, incomplete medication information, or less than a yearly follow-up visit. Atrial fibrillation was diagnosed by ECG documentation, pacemaker interrogation, and Holter monitoring. Statin treatment was verified through a central pharmacy-computerized database (for most patients) or by chart review. Of the 264 patients, 36% had coronary artery disease.

RESULTS

Atrial fibrillation developed in 70 patients (26%) at a median of 359 days post pacemaker implantation. The incidence rate for the first occurrence of AF post pacemaker implantation among patients treated and not treated with statins was 10.5 versus 9.8 events per 100 patient-years, respectively (p = 0.81). Even after controlling for baseline differences, the hazard ratio (HR) for developing AF among statin users did not achieve statistical significance (HR = 0.59 [0.31-1.12]).

CONCLUSIONS

We could not demonstrate that statin therapy had a protective effect against the risk of AF in patients implanted with a permanent pacemaker. The low prevalence of coronary artery disease in our patients may partly explain our results.

Photodynamic therapy of colorectal cancer using a new light source: from in vitro studies to a patient treatment

PURPOSE

Photodynamic therapy (PDT) is a relatively new alternative modality for palliation of rectal cancer. Current source of light for PDT are laser systems that are expensive and not necessarily needed for PDT. We evaluated a new nonlaser light source for PDT, Versa-Light.

METHODS AND RESULTS

In vitro PDT--CT26 murine colon carcinoma cells were incubated with aluminum phthalocyanine (AlPcS4) for 48 hours and subjected to photoradiation using Versa-Light, and viability was assessed. There was a significant decrease in viability of treated cells compared with controls. In vivo PDT--BALB/c mice were injected either subcutaneously or intrarectally with CT26 cancer cells. IP AlPcS4 (2.5 mg/kg) was injected when tumors were visible. After 24 hours, mice were subjected to photoradiation. Massive tumor necrosis in response to PDT was observed. PDT also prolonged survival of treated mice. Patient treatment--A 70-year-old woman with recurrent local rectal carcinoma received intravenous Photofrin II (2 mg/kg). After 48 and 96 hours, she was subjected to direct photoradiation. After the first light session, there was complete macroscopic disappearance of the tumor. Biopsies up to 10 weeks after the treatment showed no cancer cells in the treated area. Sixteen weeks later, a randomized biopsy from previous tumor site showed carcinoma cells.

CONCLUSIONS

We believe that Versa-Light, is a good light source for PDT. It was effective in both in vitro and animal studies. It can also be safely used for clinical PDT.