The use of super-selective uterine artery branch embolization and methotrexate in cervical pregnancy - case reports and literature review

Cervical ectopic pregnancy (CEP) is one of the rarest types of ectopic pregnancy. Early detection of such cases increases the chances of conservative treatment and fertility preservation. Within 6 weeks of each other, 2 women were admitted to the OB/GYN Department with cervical ectopic pregnancies. They were successfully treated with a double dose of methotrexate and super-selective uterine artery branch embolization (SUABE). Taking into account health and economic considerations, for instance the optimal recovery time, and lower costs of operating theater time, laboratory testing and outpatient observation, it seems that safe, minimally invasive, fertility-saving, effective systemic administration of MTX in combination with SUABE, can be a rational alternative to cervical ectopic pregnancy treatment.

Noninvasive, in vivo assessment of the cervical microcirculation using incident dark field imaging

AIM

This study evaluates the feasibility of handheld vital microscopy for noninvasive, objective assessment of the microcirculation of the human uterine cervix. We qualitatively and quantitatively describe the microcirculation in healthy subjects in order to provide a basis for its application in cervical pathology.

METHODS

Incident dark field imaging was used to image the microcirculation in four quadrants of the uterine ectocervix in ten healthy participants. If the squamocolumnar junction was visible, measurements were repeated on the endocervical columnar epithelium as well. Image acquisition time was recorded and participants scored the experienced level of discomfort. Angioarchitecture was classified according to Weber's classification. Quantitative parameters included capillary density (CD), total and perfused vessel density (TVD, PVD), proportion of perfused vessels (PPV) and microvascular flow index (MFI).

RESULTS

Image acquisition was easy, fast and well tolerated. Angioarchitecture was characterized by two distinctive and organized patterns; capillary loops underneath the squamous epithelium of the ectocervix and vascular networks underneath the columnar epithelium. In the image sequences containing capillary loops, mean CD was 33.2 cpll/mm² (95% CI 28.2-38.2 cpll/mm²). In the image sequences with vascular networks, mean TVD was 12.5 mm/mm² (95% CI 11.2-13.77 mm/mm²), mean PVD was 12.2 (95% CI 11.0-13.5 mm/mm²), MFI was 3 and PPV was 100%.

CONCLUSIONS

Incident dark field imaging allows for noninvasive, real time visualization and objective evaluation and quantification of the microcirculation of the uterine cervix. The organized vascular patterns and optimal perfusion observed in healthy subjects allow for comparison with cervical pathology, for example in patients with cervical dysplasia or cervical cancer.

Cervical varices: An unusual source of first-trimester hemorrhage

Endocervical varices are a rare cause of obstetrical hemorrhage. Usually presenting in the second and third trimesters, bleeding varices often require pregnancy termination or indicated preterm birth via cesarean delivery. Our patient experienced variceal hemorrhage at 12 weeks' gestation in a dichorionic twin pregnancy conceived through in vitro fertilization. A low-lying placenta resolved at 19 weeks followed by variceal regression at 22 weeks' gestation. Endocervical varices causing first-trimester hemorrhage may regress with resolution of a coexisting low placental implantation, permitting planned vaginal delivery, despite progressive hemodynamic changes of pregnancy. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:218-221, 2018.

Spectral CT imaging in cervical computed tomography angiography: comparison of spectral CT monochromatic imaging and conventional CT polychromatic imaging

OBJECTIVE

To compare the image quality of spectral CT monochromatic imaging and conventional CT polychromatic imaging for analysing CTAs in patients with cervical cancer.

METHODS

In this IRB approved prospective study, 60 patients who had been diagnosed with cervical cancer underwent pelvic arterial CTA between May 2013 and July 2013. They were randomly divided into two groups; one group (30 patients) received 120 kVp polychromatic imaging (conventional CT group) and the other group (30 patients) received spectral CT imaging (spectral CT group), while all patients in both the groups received injections of 1 ml/kg of contrast agent. A total of 101 sets of monochromatic images (40-140 keV) were obtained via data reconstruction in the spectral CT group, and the monochromatic images with the best contrast-to-noise ratio (CNR) between the common iliac artery and pelvic fat (i.e. the best monochromatic energy) were selected. The best monochromatic images for the spectral CT group and the polychromatic images for the conventional CT group were postprocessed and visualised in MIP, VR and CPR mode. The CT attenuation value, noise and CNR of bilateral common iliac arteries were measured with the best monochromatic energy, as well as with 70 keV, in the spectral CT group and in the conventional CT group. The quality of the CT images was evaluated with a 5-point scale. The CTDIvol and the dose-length product (DLP) of the two groups were measured, and the results were statistically analysed.

RESULTS

When images were at 50±1 keV, the common iliac artery and pelvic fat had the highest CNR, which was 72.00% higher than the images at 70 keV (P=.001) in the spectral group, and thus, the images at 50±1 keV were considered to have the best monochromatic energy. The average CT value of the internal iliac artery, which had the best monochromatic energy from the spectral CT group, was higher than that of the images from the conventional CT group (603.96±62.68 vs 251.24±28.77; P<.001), and the differences in the CNR (73.97±11.83 vs 45.21±16.63) and the subjective score (3.10±1.73 vs 2.80±1.63) were statistically significant (both P<.05). There were no significant differences in the CTDIvol (10.48±2.86 vs 12.38±1.88 mGy) or the DLP (317.76±95.50 vs 332.25±21.25 mGy cm) between the spectral and the conventional CT groups.

CONCLUSION

Monochromatic spectral CT imaging has excellent soft tissue contrast and good spatial resolution and can visualise the arteries and branches supplying the tumours more clearly in patients with cervical cancer. Compared with polychromatic images, monochromatic spectral CT images are higher quality, which helps the treatment of patients with cervical cancer.

Characterization of Vascular Endothelial Growth Factor (VEGF) in the Uterine Cervix over Pregnancy: Effects of Denervation and Implications for Cervical Ripening

Bilateral neurectomy of the pelvic nerve (BLPN) that carries uterine cervix-related sensory nerves induces dystocia, and administration of its vasoactive neuropeptides induces changes in the cervical microvasculature, resembling those that occur in the ripening cervix. This study was designed to test the hypothesis that (a) the cervix of pregnant rats expresses vascular endothelial growth factor (VEGF) and components of the angiogenic signaling pathway [VEGF receptors (Flt-1, KDR), activity of protein kinase B, Akt (phosphorylated Akt), and endothelial nitric oxide synthase (eNOS)] and von Willebrand Factor (vWF) and that these molecules undergo changes with pregnancy, and (b) bilateral pelvic neurectomy (BLPN) alters levels of VEGF concentration in the cervix. Using RT-PCR and sequencing, two VEGF isoforms, 120 and 164, were identified in the rat cervix. VEGF, VEGF receptor-1 (Flt-1), eNOS, and vWF immunoreactivities (ir) were localized in the microvasculature of cervical stroma. Their protein levels increased during pregnancy but decreased to control levels by 2 days postpartum. VEGF receptor-2 (KDR)-ir was confined to the epithelium of the endocervix. BLPN downregulated levels of VEGF by a third. Therefore, the components of the angiogenic signaling pathway are expressed in the cervix and change over pregnancy. Furthermore, angiogenic and sensory neuronal factors may be important in regulating the dynamic microvasculature in the ripening cervix and may subsequently play a role in cervical ripening and the birth process.

Intravoxel incoherent motion diffusion weighted MRI of cervical cancer - Correlated with tumor differentiation and perfusion

OBJECTIVES

To investigate the value of parameters derived from IVIM model in grading of uterine cervical cancer and the relationship between perfusion parameters derived from IVIM and that from DCE-MRI.

METHODS

Parameters of DWI (ADC, D, f, D*) and semi-quantitative parameters of DCE-MRI (Slop, Maxslop, CER, Washout, AUC90) were assessed in 24 female with cervical cancers. Except for ROIs encompassed all of the area of tumors in axial plane (A_all), ROIs on tumor edge (A_peri) and tumor center (A_central) were drawn. All of the parameters were compared among three pathology grades. Perfusion parameters derived from IVIM were correlated with that from DCE-MRI.

RESULTS

For G1, G2 and G3 tumors, on tumor edge ADC=(1.03±0.11), (1.05±0.10), (0.90±0.05)×10(-3)mm(2)/s, D=(0.80±0.11), (0.78±0.07), (0.69±0.06)×10(-3)mm(2)/s, and f=(0.19±0.03), (0.22±0.02), (0.24±0.03). The differences among groups were significant (P<0.05). On tumor center, ADC=(0.90±0.10), (0.85±0.03), (0.80±0.07)×10(-3)mm(2)/s with significant differences (P=0.027). The other parameter, D and f of tumor center, as well as D* of all tumor areas, were of no statistic significance. Most of the DCE-MRI parameters negatively correlated with tumor volume. Although the correlation between f and slop was statistic significant, R=0.277 meant a negligible correlation. f had week correlation with Maxslop, CER and AUC90 (R=0.361, 0.400 and 0.405; P<0.001). D* showed no statistic significant correlation with all of the DCE parameters.

CONCLUSION

IVIM model could possibly be used to evaluate tumor differentiation and perfusion, providing an alternative for DCE-MRI.

STRUCTURAL BASIS OF THE VASCULAR HEMOSTATIC MECHANISM IN THE UTERINE CERVIX

The objective of the study was to investigate the angioarchitectonics and the functional morphology of the vessels of the cervix and to clarify the role of structural features of these vessels in preventing hemorrhaging in parturition during cervical dilatation. Cervixes uteri were obtained from corpses of 30 women of various ages and 5 ablated at labor. Series of histotopographical specimens of the cervixes were processed using histological and histochemical methods. Peculiar features of the angioarchitectonics, histotopography and structure of cervical vessels were encountered. Arteries penetrating the cervix are surrounded by tight muffs of anastomizing veins that are closely adjacent to the arteries. In other cases, the arteries are located within the lumen of veins--"vessels within vessels". Cervical arteries make up subendocervical convolutions. During pregnancy, smooth muscle "cushions" develop in the vessels. The cervix is pierced by a network of veins that divide the cervical tissue into separate stromal "lobules". This peculiar vascular architecture might be important structural basis of the vascular hemostatic mechanism in the neck of the uterus triggered by labor. It prevents vessel rupture, hemorrhaging and amniotic fluid and air embolism during cervical dilatation. The venous network that passes through the cervix makes it easy for the separate stromal "lobules" of the cervix to move relative to each other during cervical dilatation.

Bleeding after laparoscopic supracervical hysterectomy managed with cervical artery embolization. A case report

BACKGROUND

Postoperative bleeding is a known complication after laparoscopic supracervical hysterectomy (LASH), and trachelectomy is the traditional management of significant bleeding.

CASE

We present the case of a patient with significant postoperative bleeding 1 month after LASH, resulting in symptomatic anemia requiring blood transfusion. Gelfoam embolization of the bilateral cervical arteries was successful in stopping the bleeding. The patient had no further bleeding and had resolution of anemia at 6 months postprocedure.

CONCLUSION

Our case demonstrates a successful multidisciplinary and minimally invasive approach to management of postoperative bleeding with bilateral cervical artery embolization and should be considered as a potential treatment option.

Normal reference of cervical blood perfusion in pregnancy

OBJECTIVE

To develop normal reference of cervical blood perfusion in pregnancy by using 3D power Doppler-derived FMBV at 16 to 24 weeks gestation.

MATERIAL AND METHOD

The present prospective cohort study recruited the normal singleton pregnant women at 16 to 24 weeks gestation who had antenatal care and midtrimester ultrasound screening at Ramathibodi Hospital between June and September 2012. Transvaginal ultrasound (TVU) measurements of cervical length (CL), cervical volume (CV), vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were performed. The pregnant women with multifetuses, severe fetal anomalies, unknown delivery status, abortion, stillbirth, and preterm birth were excluded from the present study.

RESULTS

The authors recruited 168 cases but 25 cases were excluded. Only 143 cases were included into the study. The mean of gestational age at ultrasound examination and delivery was 21 and 39 weeks respectively. There were no perinatal morbidity and mortality in the present study. The average values of cervical profiles of CL, CV VI, FI, and VFI were 4.2 cm, 31.6 cm3, 6.4, 38.9, and 2.6 respectively.

CONCLUSION

The normal reference of cervical blood perfusion in Thai pregnant women was established. The VI, FI, and VFI of the normal term singleton pregnancy at 16 to 24 weeks gestation were 6.4, 38.9, and 2.6 respectively.

Hemoglobin parameters from diffuse reflectance data

Tissue vasculature is altered when cancer develops. Consequently, noninvasive methods of monitoring blood vessel size, density, and oxygenation would be valuable. Simple spectroscopy employing fiber optic probes to measure backscattering can potentially determine hemoglobin parameters. However, heterogeneity of blood distribution, the dependence of the tissue-volume-sampled on scattering and absorption, and the potential compression of tissue all hinder the accurate determination of hemoglobin parameters. We address each of these issues. A simple derivation of a correction factor for the absorption coefficient, μa, is presented. This correction factor depends not only on the vessel size, as others have shown, but also on the density of blood vessels. Monte Carlo simulations were used to determine the dependence of an effective pathlength of light through tissue which is parameterized as a ninth-order polynomial function of μa. The hemoglobin bands of backscattering spectra of cervical tissue are fit using these expressions to obtain effective blood vessel size and density, tissue hemoglobin concentration, and oxygenation. Hemoglobin concentration and vessel density were found to depend on the pressure applied during in vivo acquisition of the spectra. It is also shown that determined vessel size depends on the blood hemoglobin concentration used.

Three-dimensional power Doppler ultrasound in cervical carcinoma: monitoring treatment response to radiotherapy

OBJECTIVES

To investigate, using three-dimensional power Doppler ultrasound (3D-PDU), alterations in cervical intratumoral vascularization during and after radiotherapy.

METHODS

Between 2004 and 2009 we enrolled into the study 37 patients with FIGO Stages IB1-IIB cervical carcinoma who were undergoing radiotherapy. Serial 3D-PDU scans were performed during treatment, providing ultrasonographic measurement of tumor size, vascularization index, flow index and vascularization flow index, as well as monthly for 3 months post-treatment and tri-monthly thereafter, until vascularity was undetectable on two consecutive occasions. Physical examination, cervical cytology and serum marker evaluation were performed every 3-6 months for the first 5 years following treatment. Patients evaluated after a 2-year tumor-free interval and those with clinically assessed positive findings at follow-up underwent 3D-PDU to detect possible local disease.

RESULTS

A total of 329 3D-PDU scans were performed in the 37 women. Cervical tumors and intratumoral vascularization disappeared within 3 months following radiotherapy, except in one patient with persistent disease. Nine patients had disease relapse, in four of whom the recurrence was local. In three of these four, there was recurrence of tumor and vascularization after a complete response. At follow-up, 3D-PDU detected local disease with 75.0% sensitivity and 98.5% specificity, while serum markers detected local disease among 34 patients with squamous cell carcinoma with 20.0% sensitivity and 77.3% specificity.

CONCLUSIONS

Compared with serum markers in cervical squamous cell carcinoma, 3D-PDU has higher sensitivity and specificity for detecting local recurrence or persistence in cervical carcinoma. Thus, 3D-PDU combined with clinical assessment may be a new and safe method for monitoring radiotherapy treatment response and detecting local recurrence.

Vascular endothelial growth factor induces growth of uterine cervix and immune cell recruitment in mice

Knowledge of uterine cervical epithelial biology and factors that influence its events may be critical in understanding the process of cervical remodeling (CR). Here, we examine the impact of exogenous vascular endothelial growth factor (VEGF) on uterine cervical epithelial growth in mice (nonpregnant and pregnant) treated with VEGF agents (recombinant and inhibitor) using a variety of morphological and molecular techniques. Exogenous VEGF altered various uterine cervical epithelial cellular events, including marked induction of growth, edema, increase in inter-epithelial paracellular space, and recruitment of immune cells to the outer surface of epithelial cells (cervical lumen). We conclude that VEGF induces multiple alterations in the uterine cervical epithelial tissues that may play a role in local immune surveillance and uterine cervical growth during CR.

Blood supply of human uterine cervix - a SEM study

AIM

The main goal of this study was assessment of vascular structure of human uterine cervix.

MATERIALS AND METHODS

The study was carried out on 25 human uteri of females aged 25-45, collected upon autopsy. Vessels were injected with synthetic resin, next corroded and coated with gold, finally observed using scanning electron microscope.

RESULTS

On a sagittal section we have distinguished several zones in the vascular picture of the uterine cervix consisted of differently arranged veins, arteries, arterioles and capillaries. Due to technical reasons we were unable to receive a picture of vascular composition of cervical uterine canal on transverse section.

CONCLUSIONS

Scanning elector microscopy is a method which might be applied to study the structure of human uterine cervix.

[Preoperative sonovue contrast color Doppler in patients with cervical cancer. Preliminary report]

OBJECTIVE

Angiogenesis has gained much attention in oncology in recent years. The purpose of this pilot study was to describe the preoperative sonographic patterns of SonoVue Contrast-Doppler ultrasound and the standard Color Dopper ultrasound of cervical cancer tumor angiogenesis.

MATERIALS AND METHODS

This is a prospective observational study. The study included fifteen patients with proven cervical cancer.

RESULTS

Contrast Doppler US after the SonoVue injection gave a good picture of the intense intralesional tumor angiogenesis. Of the 15 patients with FIGO stage lb1 Contrast-sonography showed 12 patients stage Ib1, 1-stage Ib2, 1-stage IIb and 1-stage Iva at final diagnosis.

CONCLUSIONS

SonoVue Contrast Doppler Ultrasound gave a better definition of the margins of the neoplastic lesions in the cervical cancer Because contrast agents increase the sensitivity of detection of parametrial invasion and lymph node metastases, they could pay an important role in the evaluation of uterine cervical cancer

[Blood supply as a factor regulating pacemaker activity of the rat uterine horn]

Effect of ischemia of the uterine artery supplying with blood the main rhythmogenic zone (the ovarian region) of the uterine horn on parameters of activity both of this locus and of all subsequent pacemaker areas up to the uterine cervix was studied in non-pregnant rats. The most pronounced changes in characteristics of the activity (amplitude, frequency, and burst genesis duration) were revealed in the ovarian horn end. The uterine corpus and the horn cervical end were less affected by ischemia. Meanwhile, under these conditions, amplitude of the slow-wave oscillations rose more than 1.5 times. The obtained data allow us to conclude about the presence of a certain connection between the horn ovarian end and the uterine cervix. Morphological studies have revealed strong vascularization of the upper part of uterine horn.

Oxygenation in cervical cancer and normal uterine cervix assessed using blood oxygenation level-dependent (BOLD) MRI at 3T

Hypoxia is reported to be a biomarker for poor prognosis in cervical cancer. However, a practical noninvasive method is needed for the routine clinical evaluation of tumor hypoxia. This study examined the potential use of blood oxygenation level-dependent (BOLD) contrast MRI as a noninvasive technique to assess tumor vascular oxygenation at 3T. Following Institutional Review Board-approved informed consent and in compliance with the Health Insurance Portability and Accountability Act, successful results were achieved in nine patients with locally advanced cervical cancer [International Federation of Gynecology and Obstetrics (FIGO) stage IIA to IVA] and three normal volunteers. In the first four patients, dynamic T₂*-weighted MRI was performed in the transaxial plane using a multi-shot echo planar imaging sequence whilst patients breathed room air followed by oxygen (15 dm³/min). Later, a multi-echo gradient echo examination was added to provide quantitative R₂* measurements. The baseline T₂*-weighted signal intensity was quite stable, but increased to various extents in tumors on initiation of oxygen breathing. The signal in normal uterus increased significantly, whereas that in the iliacus muscle did not change. R₂* responded significantly in healthy uterus, cervix and eight cervical tumors. This preliminary study demonstrates that BOLD MRI of cervical cancer at 3T is feasible. However, more patients must be evaluated and followed clinically before any prognostic value can be determined.

Vascular architecture of the human uterine cervix, as assessed in light- and scanning electron microscopy

BACKGROUND

The aim of this study was to visualise and describe the vasculature of the human uterine cervix.

MATERIAL AND METHODS

The material for this study was obtained from women (age between 20 to 45 years) during autopsy. The material was collected not later than 24 h post-mortem. This study was performed using uteri from cadavers of menstruating nulliparas (33 uteri) and menstruating multiparas (27 uteri). Collected uteri were perfused via the afferent vessels with Mercox resin (for corrosion-casting and SEM assessment) or acrylic paint solution (light microscopy assessment). The research protocol was approved by the Jagiellonian University Ethics Committee (registry KBET/121/8/2007).

RESULTS

In all cases bilateral cervical branches (1-4), originating from the uterine artery, were found. Both in the vaginal and supravaginal parts of the cervix, four distinct vascular zones were found. In the pericanalar zone ran small veins, responsible for draining the mucosal capillaries. Both in the muscular layer, as well as in the pericanalar zone, arterioles, and venules passed close to each other, often adjoining.

CONCLUSIONS

This study does not confirm the existence of a single cervicovaginal artery, but shows that the vascular supply of the cervix comes from several vessels. It also introduces the idea of two systems, responsible for draining blood from the mucosal capillaries. Neither assessment in light microscopy nor in SEM revealed any differences between multiparas and nulliparas, regarding the vascular architecture of the cervix.

Cervical blood perfusion assessed using power Doppler-derived estimation of fractional moving blood volume: a reproducibility study

OBJECTIVE

To evaluate the reproducibility of estimation of power Doppler-derived fractional moving blood volume (FMBV) in the uterine cervix of women with uncomplicated pregnancies.

METHODS

Two experienced operators evaluated 30 uncomplicated singleton pregnancies at 20-24 weeks of gestation. The PDU box was positioned in a mid-sagittal view of the cervix, including the internal os and external os, in the same plane as that in which cervical length is measured. Two consecutive examinations were performed by each operator, in each of which the cervical length was measured and five consecutive good-quality images with PDU information were obtained. The region of interest (ROI) (cervix) was delineated offline and FMBV, which expresses the percentage of blood occupying the ROI, was calculated with purpose-designed software. Intra- and interobserver intraclass correlation coefficients (ICCs) and mean differences with 95% limits of agreement (LOA) were calculated.

RESULTS

The median gestational age at examination was 22 + 0 weeks. Measurements (median ± SD) obtained for cervical length and FMBV were as follows: Operator A: 37 ± 7.4 mm and 8.11 ± 2.9%; Operator B: 37.5 ± 9.3 mm and 7.9 ± 3.3%, respectively. The intra- and interobserver ICCs for FMBV were 0.88 (95% CI, 0.75-0.94) and 0.82 (95% CI, 0.64-0.94), respectively. There was a mean difference in FMBV measurement between operators of - 0.2 ± 1.75% (95% LOA, - 3.7 to 3.2%).

CONCLUSIONS

Reproducible assessment of cervical blood perfusion through estimation of FMBV can be achieved while cervical length is being measured.

Cervical varices complicated by thrombosis in pregnancy

We present a case of a 36-year-old pregnant woman with varicose veins of the uterine cervix diagnosed during the second trimester. The cervical tissue was completely replaced with dilated venous plexus. Therapeutic decisions were further complicated by the presence of blood clots within the dilated vessels. Pregnancy proceeded uneventfully, no bleeding occurred and the patient underwent a planned Cesarean delivery. This is the first reported case in the medical literature where the rare phenomenon of cervical varices was accompanied by thrombosis.

[The morphological features of the nervous and vascular components of communication systems in the cervix uteri]

The investigation has indicated the presence of adrenergic and cholinergic autonomic nerve terminals (ANT) in the tissues of squamous cell carcinomas of the cervix uteri in a tumor growth area and contralaterally. Heterogeneity of the local neuromediator background in the tumor growth area and contralaterally may be explained, by studying the specific features of the cell microenvironment of ANT.

Colposcopically observed vascular changes in the cervix in relation to the hormonal levels and menstrual cycle

OBJECTIVE

We assessed colposcopically observed vascular changes occurring in the cervix in relation to cyclical hormonal variation in healthy women.

MATERIALS AND METHODS

Thirty women with regular menstrual cycles and willing to remain sexually abstinent during a menstrual cycle were enrolled. Colposcopy was performed during the peak of the estrogen and progesterone levels.

RESULTS

The mean (+/-SD) diameter of the largest visible blood vessel differed significantly between the estrogenic phase (0.38 +/- 0.14 mm) as compared with the progestogenic phase (0.47 +/- 0.12 mm; p <.01). The blood vessels were more prominent and dense and had a well-defined outline during the progestogenic phase than the estrogenic phase; however, these differences were not statistically significant. There was borderline increase in the interleukin 8 level during the estrogenic phase.

CONCLUSIONS

Physiological changes of increased vascularity of the cervix observed colposcopically during the progestogenic phase are normal. If such changes do not correspond to the menstrual cycle phase in women using vaginal microbicides in early-phase clinical trials, presence of inflammatory markers should be evaluated. Elevated interleukin 8 during the estrogenic phase needs further evaluation.

Transvaginal ligation of the cervical branches of the uterine artery and injection of vasopressin in a cervical pregnancy as an initial step to controlling hemorrhage: a case report

BACKGROUND

Hemorrhage from a cervical pregnancy is a time-sensitive matter. Effective temporization measures for the initial management of this hemorrhage have not previously been reported in the literature.

CASE

A 43-year-old woman, gravida 0, underwent in vitro fertilization and embryo transfer. She subsequently presented to the office with sudden onset of vaginal hemorrhage due to a cervical pregnancy. Cervical artery sutures were placed, and a cervical vasoconstricting agent was injected, at which point the patient's bleeding stopped. She then underwent successful treatment with dilation and curettage.

CONCLUSION

Conservative measures to manage hemorrhage due to cervical pregnancy can be initiated, with possible rapid establishment of hemostasis until definitive treatment can be achieved.

Correlation of traditional point a with anatomic location of uterine artery and ureter in cancer of the uterine cervix

PURPOSE

Point A, used for dose specification for intracavitary brachytherapy for cervical cancer, is the point at which the uterine artery and ureter cross. This study assessed compatibility of commonly used traditional point A (TPA) and actual anatomic point A (APA).

METHODS AND MATERIALS

We visualized and placed radiopaque clips at the APA during pelvic and paraaortic lymphadenectomy in 11 patients with cervical carcinoma. Orthogonal and oblique radiographs were obtained after insertion of brachytherapy applicators. We measured the distance between the TPA and APA and estimated the brachytherapy dose to each of the two points.

RESULTS

A total of 64 brachytherapy treatments were performed. The mean distances between the TPA and APA were 5.2 +/- 1.0 cm on the right and 5.4 +/- 1.1 cm on the left. The estimated brachytherapy doses delivered to the APA as a percentage of the presumed 500-cGy fraction size to the TPA were 35.2% (176.6 +/- 59.0 cGy) on the right and 30.0% (150.2 +/- 42.9 cGy) on the left. The marked discrepancy in the position of the two points was not related to individual kinetic variations during brachytherapy treatment, tumor size, or bladder filling.

CONCLUSIONS

The conventional TPA does not provide an accurate estimate of the APA determined during lymphadenectomy, indicating a need to reevaluate the current practice for determining the brachytherapy prescription for cervical cancer. (ClinicalTrials.gov Identifier, NCT00319462).

Cervical varix with placenta previa totalis

A cervical varix during pregnancy is a very rare complication. It can lead to hemorrhage and may result in significant morbidity. Furthermore, appropriate management has not yet been established. We present a case of a cervical varix with placenta previa totalis. A 30-year-old woman with placenta previa totalis also had a cervical varix without bleeding. At 32 weeks' gestation, massive hemorrhage from the cervical varix occurred. A vaginal pack controlled the bleeding, and a cesarean section was subsequently carried out because of uncontrollable uterine contractions. A 1655 g female infant was delivered; the estimated blood loss was 1814 mL. The cervical varix decreased dramatically in size. In conclusion, presented herein is a rare case of a cervical varix, which had a successful outcome.

Mast cell degranulation in rat uterine cervix during pregnancy correlates with expression of vascular endothelial growth factor mRNA and angiogenesis

Vascular growth of the uterine cervix during pregnancy is associated with mast cell (MC) degranulation. To better understand the mechanism underlying this process, uterine cervices of intact pregnant rats were dissected and endothelial cell proliferation was measured by a bromodeoxyuridine incorporation technique. Total vascular endothelial growth factor (VEGF) mRNA expression and the relative abundance of VEGF splice variants (120, 164, and 188) were determined by RT-PCR. VEGF protein expression was evaluated by immunohistochemistry. To investigate the role of MCs on cervical angiogenesis, a second set of pregnant animals were treated with an MC stabilizer (disodium cromoglycate) to inhibit MC degranulation. Furthermore, 17β-estradiol (E2) serum levels were established by RIA. In intact pregnant rats, VEGF mRNA expression was positively correlated with endothelial cell proliferation and circulating E2levels. All selected splice variants ofVEGFgene were detected and their relative abundance did not show any change throughout pregnancy. Animals treated with disodium cromoglycate showed a decrease in endothelial cell proliferation and in VEGF mRNA expression compared with controls. Relative abundance of VEGF mRNA splice variants and E2serum levels showed no differences between these experimental groups. These results show a time-dependent correlation between VEGF mRNA expression and E2serum levels in the uterine cervix of intact pregnant rats, while MC stabilizer-treated animals reduced the VEGF expression without modifying E2serum levels. We suggest that cervical angiogenesis during pregnancy could be regulated by a mechanism which involves endogenous E2and chemical mediators stored in MC granules via a VEGF-dependent pathway.

Fatal stroke in a young cocaine drug addict: chemical hair analysis and cervical artery examination twenty months after death

We present a case of a 26-year-old female who died of acute cerebral infarction after thrombosis of the left internal carotid artery, conceivably related to cocaine use. The forensic examination was performed only twenty months post-mortem. Revaluation of clinical data was carried out after exhumation and forensic autopsy examination were done, including anatomic dissection of cervical vessels and histological and toxicological analyses. Interestingly, comparative histological examination of cervical arteries was more useful in determining the putative site of vascular damage than gross and histological examination of the brain itself, although the state of preservation of tissues was poor. In conclusion, when a vascular accident is suspected or has to be demonstrated, we suggest performing comparative histological examinations of selected artery samples, even several months after death.

Reference data representative of normal findings at three-dimensional power Doppler ultrasound examination of the cervix from 17 to 41 gestational weeks

OBJECTIVES

To develop normal reference ranges for cervical volume and vascular indices using three-dimensional (3D) power Doppler ultrasonography from 17 to 41 gestational weeks.

METHODS

This was a cross-sectional study of 352 nulliparous and 291 parous women who delivered at term and underwent transvaginal 3D power Doppler ultrasound examination of the cervix once at 17 to 41 weeks' gestation. We examined approximately 25 women in each gestational week. Cervical volume, vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated.

RESULTS

There was no change in cervical volume between 17 and 40 weeks' gestation. At 41 weeks cervical volume was slightly smaller than it was at 17-40 weeks (P=0.03 for nulliparous women and P=0.08 for parous women). The cervical volume was larger in parous than it was in nulliparous women (median 38 cm3 vs. 32 cm3 at 17-40 weeks, P<0.0001; median 31 cm3 vs. 22 cm3 at 41 gestational weeks, P=0.288). FI did not differ between nulliparous and parous women and remained unchanged between 17 and 41 weeks' gestation (median 30.6, range 21.2-55.2). VI and VFI did not change consistently from 17 to 41 weeks, but the values were higher in parous than they were in nulliparous women at 17-30 weeks (median VI 5.3% vs. 3.1%, P<0.0001; median VFI 1.6 vs. 0.9, P<0.0001). At 31-41 gestational weeks the median VI for all women irrespective of parity was 4.9% and the median VFI was 1.4.

CONCLUSION

Reference values for cervical volume and blood flow indices as assessed by 3D power Doppler ultrasonography have been established for the second half of pregnancy. These lay the basis for studies of pathological conditions.

Intra- and interobserver agreement on cervical volume and flow indices during pregnancy using transvaginal 3-dimensional ultrasonography and Doppler angiography

OBJECTIVES

To assess intra- and interobserver agreement in cervical volume and flow indices measurements.

METHOD

We prospectively examined 126 patients by two seperate observers using transvaginal 3D gray-scale and power Doppler ultrasound. The two acquired volume datasets were analyzed using the VOCAL imaging program for assessing cervical volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI). Reproducibility of volume and vascularity measurement was assessed by calculating intraclass (intra-CC) and interclass (inter-CC) correlation coefficients (ICCs).

RESULTS

Both intraobserver and interobserver cervical volume measurements were in perfect agreement with intra-CC values of 0.95, 0.96 for both examiners and with an inter-CC value of 0.95. Intraobserver agreement for VI, FI and VFI measurements were as good as the interobserver agreement for VI, and VFI measurements were adequate but less for FI measurements (inter-CC 0.67). Overall, volumetric data were more reliably acquirable than power Doppler measurements.

CONCLUSIONS

3D ultrasound gray-scale and power Doppler measurement of cervical volume and vascularization have acceptable intra- and interobserver variations and thus may be used in clinical research of cervical physiology and pathophysiology during pregnancy.

Three-dimensional ultrasound assessment of the cervix for predicting time to spontaneous onset of labor and time to delivery in prolonged pregnancy

OBJECTIVES

To determine whether three-dimensional (3D) ultrasound including power Doppler examination of the cervix is useful for predicting time to spontaneous onset of labor or time to delivery in prolonged pregnancy.

METHODS

A prospective study was conducted in 60 women who went into spontaneous labor. All underwent transvaginal 3D power Doppler ultrasound examination of the cervix immediately before a prolonged-pregnancy check-up at > or = 41 + 5 gestational weeks. Univariate and multivariate logistic regression analysis was used to determine which of the following variables predicted spontaneous onset of labor > 24 h and > 48 h and vaginal delivery > 48 h and > 60 h: length, anteroposterior (AP) diameter and width of the cervix and of any cervical funneling; cervical volume (cm3); vascularization index (VI); flow index (FI); vascularization flow index (VFI); parity; and Bishop score. Multivariate logistic regression analysis was carried out both with and without Bishop score as a predictive variable. Receiver-operating characteristics (ROC) curves were used to describe the diagnostic performance of the tests.

RESULTS

The areas under the ROC curves for Bishop score, cervical length, and logistic regression models did not differ significantly (areas ranging from 0.72 to 0.82). If Bishop score was not included in the logistic regression model, cervical length, VI and FI independently predicted delivery > 48 h, the likelihood increasing with increasing cervical length, decreasing VI and increasing FI.

CONCLUSIONS

In prolonged pregnancy cervical vascularization as estimated by 3D power Doppler ultrasound is related to time to delivery > 48 h, but the likelihood of delivery > 48 h can be predicted equally well using Bishop score alone or sonographic cervical length alone.

Abdominal radical trachelectomy: two new surgical techniques for the conservation of uterine arteries

The objective of this study was to develop two new techniques for the conservation of uterine arteries in abdominal radical trachelectomy. Abdominal trachelectomy with conservation of uterine arteries was performed in two patients with cervical carcinoma. In the first case, the internal iliac artery was divided at 2.0 cm from the bifurcation of the common iliac artery. The internal iliac artery and uterine artery were skeletonized along their lengths to the lateral cervix. The dissected internal iliac artery was then reanastomosed following the radical trachelectomy. In the second case, the technique was similar to that of the first except that the internal iliac artery was not divided. Intraoperative observation and postoperative color Doppler ultrasound were used to confirm the patency of the uterine arteries. The operative time of the two patients was 390 min. and 350 min, respectively. Doppler flow studies demonstrated that the uterine arteries were patent in both cases. Resistance index of the left and the right uterine artery was 0.58 and 0.61, respectively, in the first case, and 0.60 and 0.63, respectively, in the second case. Reanastomosis of the internal iliac arteries or skeletonization of the internal iliac arteries are both feasible methods to conserve the uterine arteries during abdominal radical trachelectomy.

Lymph node metastasis and lymph vascular space invasion in microinvasive squamous cell carcinoma of the uterine cervix

The objective of this study was to determine whether the depth of invasion was related to lymph vascular space invasion (LVSI) and lymph node metastasis and whether there was a correlation between LVSI and lymph node metastasis in stage IA cervical cancer. The medical records, including surgical notes and pathologic reports, of 202 patients with microinvasive squamous cell carcinoma of the uterine cervix were reviewed retrospectively. There was a positive correlation between the depth of invasion and the LVSI, and the incidence of lymph node metastasis was slightly higher than those reported hitherto for stage IA1 cervical cancer, especially in the depth of invasion of 1-3 mm group. However, among four patients with lymph node metastasis, only two patients had positive LVSI. There was no definite correlation between LVSI and lymph node metastasis. LVSI could not identify the patients with high risk for lymph node metastasis.

Cervical varix as a cause of vaginal bleeding during pregnancy: prenatal diagnosis by color Doppler ultrasonography

Vaginal bleeding during pregnancy is a risk factor for adverse pregnancy outcome. Beyond 20 weeks of gestation, the most frequent causes of bleeding associated with maternal and perinatal morbidity and mortality are placenta previa and placental abruption. Cervical varix during pregnancy is a rare condition. To our knowledge, only six cases have been reported in the literature. Most of these cases were associated with preterm birth and high maternal morbidity. The optimal management and mode of delivery remain undetermined. We report a case of cervical varix diagnosed by transvaginal ultrasound at 21 weeks of gestation. The pregnancy was complicated by several episodes of vaginal bleeding and the patient delivered at 32 weeks. Color and power Doppler examination of the cervix played a key role in establishing the diagnosis.

Uterine artery embolization in the management of vaginal bleeding from cervical pregnancy: a case series

OBJECTIVE

To report our experience of selective embolotherapy in 8 consecutive patients with cervical pregnancy (CxP) presenting with vaginal bleeding.

STUDY DESIGN

A total of 9 selective pelvic embolization procedures were performed on 8 patients with CxP, either as an emergency, for control of vaginal hemorrhage (2 patients), or on a nonemergency basis, for moderate vaginal bleeding (6 patients). One patient underwent 2 embolization procedures, once for each indication.

RESULTS

Successful hemostasis was obtained in both emergency cases. In 3 of the nonemergency cases, the CxP rapidly resolved. In the 3 other nonemergency cases, elevated beta-human chorionic gonadotropin levels persisted, with a new episode of vaginal bleeding in 2 patients 2 and 4 weeks later, respectively; the bleeding resolved after the administration of methotrexate. Significant vaginal hemorrhage occurred 4 weeks later in the third patient and responded to repeat embolotherapy. One patient required a blood transfusion. The uterus was preserved in all 8 patients. One patient was lost to follow-up, but normal menses resumed in all 7 of the others; and 2 patients had subsequent successful pregnancies.

CONCLUSION

Embolotherapy is effective in treating and preventing vaginal hemorrhage associated with CxP while allowing uterine preservation. Along with methotrexate and other medical treatment of CxP, we recommend routine use of embolization in patients presenting with vaginal bleeding.

Unaltered innervation of the human cervix uteri in contrast to the corpus during pregnancy and labor as revealed by PGP 9.5 immunohistochemistry

OBJECTIVE

To examine the occurrence of the general neuronal marker protein gene product 9.5 (PGP 9.5) in the human corpus (isthmus region) and the cervix uteri during pregnancy and parturition

STUDY DESIGN

Biopsies were taken from the upper edge of the hysterotomy during caesarean section (CS) at term (n=5), in labor (n=5) and from the corresponding area in the non-pregnant uterus after hysterectomy (n=5). Cervical biopsies were obtained transvaginally from the anterior cervical lip. Serial cryostate sections were prepared for immunohistochemistry using polyclonal antibodies to PGP 9.5.

RESULTS

Nerve fibers displaying PGP 9.5 immunoreactivity were observed in all sections from the three groups examined. They were identified in muscle tissue, in the stroma, and around blood vessel walls. A 30-fold decline of immunoreactive nerve fibers was observed in the isthmus part of the corpus uteri at term compared to the non-pregnant. There were no significant differences between the immunoreactivity in the cervix uteri of the three groups

CONCLUSIONS

The innervation of the cervix uteri is dense and unaltered throughout pregnancy and labor. In contrast, the corpus is almost denervated. Further studies are needed to clarify the reason and the impact of these findings.

Safe resectoscopic evacuation of a 10-week viable cervical pregnancy after transfemoral bilateral uterine artery embolization

OBJECTIVE

To describe therapy of a 10.5-week viable cervical pregnancy.

DESIGN

Case report.

SETTING

An academic medical center.

PATIENT(S)

A 38-year-old women with cervical pregnancy.

INTERVENTION(S)

Transfemoral bilateral uterine artery embolization followed by resectoscopic evacuation of the gestational products.

MAIN OUTCOME MEASURE(S)

Resolution of products of conception and serum beta-hCG levels.

RESULT(S)

Successful outcome with minimal maternal morbidity and preservation of the uterus.

CONCLUSION(S)

Uterine artery embolotherapy followed by resectoscopic evacuation of cervical pregnancy minimized morbidity and preserved the uterus.

Three-dimensional power Doppler ultrasound assessment of the cervix for the prediction of successful induction of labor with prostaglandin in prolonged pregnancy

OBJECTIVE

The purpose of this study was to determine whether 3-dimensional (3D) power Doppler ultrasound examination of the cervix can predict the success of labor induction with prostaglandin in prolonged pregnancy.

METHODS

A prospective study was conducted with 36 women undergoing labor induction with prostaglandin at 41 gestational weeks 5 days and later. All 36 women underwent a transvaginal 2-dimensional gray scale ultrasound examination and a 3D power Doppler ultrasound examination of the cervix immediately before a planned post-term checkup. The analyzed variables were length, anterior-posterior diameter, and width of the cervix and any cervical funneling, cervical volume (in cubic centimeters), vascularization index, flow index, vascularization flow index, parity, and Bishop score. Results were compared among women with start of labor at 12 hours or less and more than 12 hours after application of the first prostaglandin suppository and among women who had delivery at 24 hours or less and more than 24 hours after the start of induction.

RESULTS

Sonographically measured cervical length was shorter (mean, 1.8 versus 2.4 cm; P = .04), the Bishop score was higher (median, 5 versus 3; P = .02), and more women were parous (70% versus 37%; P = .05) among women who were in labor within 12 hours than in those who were not. The Bishop score was higher (median, 4 versus 2; P = .03) and more women were parous (69% versus 23%; P = .01) among women who had delivery at 24 hours or less than among those who did not. Cervical volume and the results of the 3D power Doppler ultrasound examination did not differ among women with different outcomes of labor induction.

CONCLUSIONS

In women undergoing induction of labor with prostaglandin at 41 gestational weeks 5 days or later, sonographic cervical length, Bishop score, and parity are related to the success of labor induction, whereas cervical volume and the results of the 3D power Doppler examination are not.

The Relationship of Glands to Thick-Wall Blood Vessels as a Marker of Invasion in Endocervical Adenocarcinoma

The recognition of early invasion in endocervical adenocarcinomas can be difficult. We evaluated the proximity of endocervical glands and their pattern of infiltration in relation to thick-wall blood vessels as potential markers of invasion in a series of invasive endocervical adenocarcinomas removed by cone biopsy or hysterectomy. Routinely stained slides were examined from 50 invasive endocervical adenocarcinomas (37 of usual type and 13 of minimal deviation type), 26 noninvasive lesions (14 cases of adenocarcinoma in situ, 7 cases of hyperplasia, 4 cases of tunnel clusters, 1 adenomyoma), and 20 normal cervices, including 7 with deep nabothian cysts. The range of vessel wall thickness using an ocular micrometer was recorded in each specimen. A blood vessel with a wall > or =36-microm thick was defined as thick-walled. Both the blood vessel wall thickness and distance to the closest gland was recorded for each case. The median distance from a thick-wall blood vessel to a gland in the invasive tumors was 30 microm compared with 168 microm in the noninvasive group. In both groups, the measured blood vessel wall had a median thickness of 42 microm. The pattern of infiltration of glands around the thick-wall vessels was classified as "circumferential," in which multiple glands circumferentially enveloped the vessel, or "molded," in which single or multiple distorted glands were molded around the vessel. The circumferential and molded patterns were identified in 35 (70%) and 10 (20%) of 50 invasive adenocarcinomas, respectively. Of the 26 lesions in the noninvasive group, only 3 (6%) had a circumferential pattern and none had a molded pattern. Importantly, none of the cases in the noninvasive group showed either pattern in the presence of glandular atypia. In conclusion, close proximity of glands to thick-wall blood vessels (distance from the closest gland to a thick-wall vessel less than or equal to the thickness of the vessel wall) seems to be a useful feature in the diagnosis of invasive endocervical adenocarcinoma. This feature, in combination with certain glandular growth patterns and cytologic atypia, can be highly suggestive, if not diagnostic, of invasive carcinoma.

Angiogenesis in squamous intraepithelial neoplasia of the uterine cervix in HIV-seropositive women

OBJECTIVES

This study aimed to quantify angiogenesis in squamous intraepithelial lesions of the uterine cervix in seropositive HIV patients as well as to establish a relationship between vascular density and variations in the CD4+ lymphocyte titer and the viral load of human immunodeficiency virus (HIV).

METHODS

125 patients, 55 HIV seropositive and 70 seronegative, were allocated with respect to grade of squamous intraepithelial lesion (SIL). The obtained samples were stained with an immunohistochemical marker for CD34 antigen and vessel counts were performed in ten consecutive fields at 400x magnification. The seropositive HIV patients were distributed into groups according to the CD4+ index and HIV viral load.

RESULTS

Seropositive HIV patients presented a higher mean vascular density (MVD) than the control group, even in the absence of cervical intraepithelial lesions. High- and low-grade lesions in the presence of HIV seropositivity presented higher MVD than that found in seronegative HIV patients. There was no significant variation in the MVD and CD4+ count ratio or viral RNA-HIV load, except for high-grade (H)SIL.

CONCLUSIONS

Infection with HIV influenced angiogenesis of uterine cervix in the presence of squamous intraepithelial lesions and more significantly in HSIL.

Asymptomatic vasculitis of the uterine cervix in presence of cervical intraepithelial neoplasia grade III

CASE REPORT

A 34-year-old woman was diagnosed to have a high-grade cervical intraepithelial neoplasia and was treated by large loop excision of the transformation zone. Histology of the excised cone confirmed the diagnosis but also showed evidence of vasculitis of medium-sized vessels of the cervix. The woman was referred to a physician to rule out underlying systemic disease. Extensive laboratory and clinical screening was negative.

DISCUSSION

The clinical significance and management of asymptomatic isolated vasculitis of the uterine cervix are discussed.

Histopathological changes of cervical tissue in women with systemic sclerosis

Systemic sclerosis is a connective tissue disease that can affect almost any organ of the body. The clinical aspects of systemic sclerosis on the reproductive system have been studied in large series, and an increased rate of cesarean section has been reported. For this reason, in the present study the histopathological features of cervical specimens of hysterectomyzed women with systemic sclerosis were evaluated. An increased frequency of vascular and stromal abnormalities in cervical specimens of women with systemic sclerosis were observed. Vascular medial hypertrophy, intimal thickening, and fibrosis were more often encountered in the cervical specimens of the patients with systemic sclerosis. Some of the histopathological features also showed correlation with the clinical profile of the disease. The patients with vascular medial hypertrophy in their cervical specimens were older, had a higher Rodnan score, and had longer duration of the disease. In contrast to vascular medial hypertrophy, periadventitial edema was found in the cervical specimens of the patients who were younger, had a lower Rodnan score, and had shorter duration of the disease. It was concluded that the problems that are seen in common obstetric and gynecological practices in patients with systemic sclerosis may be explained by these tissue abnormalities.

Cervical varix accompanied by placenta previa in twin pregnancy

BACKGROUND

Uterine cervical varix is a rare complication in pregnant women and can be the cause of obstetric hemorrhage in the vagina resulting in adverse events for both the mother and fetus.

CASE

A 34-year-old Japanese woman was hospitalized at 18 weeks gestation because of cervical varix and placenta previa. Prophylactic tocolysis successfully controlled the obstetric hemorrhage. At 27 weeks gestation, emergent cesarean section was performed because of intractable hemorrhage from the marginal placenta previa. Intraabdominal findings revealed no vascular malformation of the uterus, and the operation was performed uneventfully. A speculum examination of the vagina and cervix at 1 month postpartum were unremarkable.

CONCLUSION

It is important to recognize the clinical features and available treatments for cervical varix.

Cytomegalovirus infection of the cervix: morphological observations in five cases of a possibly under-recognised condition

AIMS

Histologically diagnosed cytomegalovirus (CMV) infection of the cervix is rare and the associated morphological features are not well described. This study describes histopathological findings in five biopsies from four patients with CMV cervicitis.

METHODS

CMV inclusions were identified in five cervical biopsies from four patients in a single institution over eight months. The clinical notes were reviewed, the morphological features documented, and immunohistochemical staining for CMV performed. CMV immunohistochemical staining was also performed on 30 consecutive cervical biopsies in which inclusions were not seen histologically.

RESULTS

None of the patients was immunocompromised but one was postnatal. Numbers of CMV inclusions ranged from occasional to abundant and they were located mainly in endocervical glandular epithelial cells but also in endothelial and mesenchymal cells. Inclusions were not seen in squamous cells. Inclusions were eosinophilic and were intracytoplasmic rather than intranuclear. They were positive immunohistochemically for CMV. Associated morphological features included fibrin thrombi within small blood vessels (three cases), dense active inflammatory infiltrates (five cases), lymphoid follicles (two cases), vacuolation of glandular epithelial cells (two cases), and reactive changes in glandular epithelial cells (two cases). CMV inclusions were not identified in the 30 additional cases that underwent immunohistochemical staining.

CONCLUSIONS

CMV infection of the cervix may be more common than is thought. Patients are usually immunocompetent and require no treatment. Morphological features such as a dense inflammatory cell infiltrate with lymphoid follicles, and especially fibrin thrombi within small vessels, should alert the pathologist to look closely for the pathognomonic CMV inclusion bodies.

Mast cells degranulation affects angiogenesis in the rat uterine cervix during pregnancy

During pregnancy, it is essential that sufficient nutrients are supplied by the vascular system to support the dramatic modifications of the rat uterine cervix. Angiogenesis refers to the growth of new blood vessels from pre-existing microcirculation and mast cells have been associated with this process. This study examined the modifications of the vascular compartment and the distribution of mast cells on cervical tissue during pregnancy. Using disodium cromoglycate as a mast cell stabilizer, we determined the effects of the mast cell degranulation on cervical angiogenesis. Mast cell distribution and their degranulation status were evaluated by immunohistochemistry. Endothelial cell proliferation was measured by bromodeoxyuridine incorporation. Vascular areas (absolute and relative) and maturation indices were assessed by quantitative immunohistochemistry of von Willebrand factor and alpha-smooth muscle actin respectively. Mast cells were predominantly observed during the first half of pregnancy in the perivascular zones. The values of bromodeoxyuridine incorporation, absolute vascular area and vascular maturation index exhibited a significant increase throughout pregnancy. All animals that received mast cell stabilizer showed more than 40% of non-degranulated mast cells. Treated rats exhibited a decrease in endothelial proliferation and in relative vascular area; in addition, a large proportion of mature blood vessels was observed, suggesting a diminished level of new vessel formation. The effects of the mast cell stabilizer were sustained beyond the end of treatment. This is the first report that brings evidence that mast cell degranulation could be a necessary process to contribute to the normal angiogenesis of the rat cervix during pregnancy. Further investigations are needed to elucidate the possible implications of abnormal vascular development of the uterine cervix on the physiological process of ripening and parturition.

A Life-Threatening Event: Uterine Cervical Arteriovenous Malformation

BACKGROUND

Uterine cervical arteriovenous malformation is a rare cause of vaginal bleeding.

CASE

A 32-year-old multigravida presented with severe vaginal bleeding originating in the cervix, which resulted in a hypovolemic shock. Attempts to control the bleeding included hysterectomy, pelvic arterial embolization, and upper vaginectomy. Each proved unsuccessful. Histopathologic examination revealed an arteriovenous malformation. Despite local packing, suturing of the vault area, and brachytherapy to the vaginal vault, bleeding persisted. Treatment with GnRH agonist and tranexamic acid stopped the bleeding.

CONCLUSION

Severe vaginal bleeding can be the result of cervical arteriovenous malformation, and GnRH agonist may be used for treatment.

Angiogenic properties of carcinoma in situ and microinvasive carcinoma of the uterine cervix

Neovascularization is a critical step in the growth, progression and metastasis of tumors. The degree of angiogenesis may correlate with disease stage and provide prognostic information in various neoplasms. Microvessel density was studied in 24 patients with severe cervical intraepithelial neoplasias, 15 patients with microinvasive carcinomas (International Federation of Gynecology and Obstetrics IA1) and 15 healthy controls who had undergone hysterectomy for benign conditions. The microvessel density (MVD) in microinvasive squamous cell carcinomas was 40 +/- 2.42 (mean +/- SD) and in squamous carcinomas in situ (CIS) 20.41 +/- 2.29 (p < 0.05). Among patients with CIS and controls (13.33 +/- 1.59) there was also a significant difference in the number of vessels (p < 0.05). No significant correlation was found in relation to depth of invasion and histological grade of the microinvasive carcinomas. It is concluded that microinvasive squamous cell cervical carcinoma is an angiogenetic disorder and it seems that the onset of angiogenesis is an early event, usually in a preinvasive stage.

The progestative effect of the levonorgestrel-releasing intrauterine system--when does it manifest?

The objective of the study was to evaluate, clinically and sonographically, the time required for the progestative effect of the levonorgestrel-releasing intrauterine system (IUS, Mirena) to be manifested. Doppler flow of the cervical branch and spiral artery of the uterine artery, as well as the endometrial width (up to day 10 of the cycle), were evaluated in 36 women carrying levonorgestrel-releasing IUS 1-2 months after insertion of the device compared to 4-6 months after insertion. The rate of intermenstrual bleeding was reduced from 44% during the first 2 months, to only 8% of women after 4-6 months of use. Complete cessation of menstrual bleeding occurred in 5% after 2 months and in 66% after 4-6 months following insertion. While there was no change in the Doppler flow in the cervical branch of the uterine artery between both groups, there was a significant reduction in the subendometrial flow in the spiral artery. This observation was reinforced by the demonstration of significant reduction in endometrial thickness in the following 4 months of use. The present study has demonstrated that the local progestative effect of the levonorgestrel-releasing IUS on the endometrium is already manifested within a period of 3 months and over after insertion.

[Intact cervical pregnancy]

The authors describe a case of intact cervical pregnancy in a 24-year-old secundigravida. The patient was treated successfully with Methotrexate. Conservative treatment is the first choice in the therapy of uncomplicated cervical pregnancy. Conservative and operative therapeutic procedures are discussed.

[Case report: Treatment with arterial embolization in a destroyed cervical pregnancy]

Cervical pregnancy is a rare form of ectopic pregnancy. It is frequently associated with extensive hemorrhage, which, in severe cases, may be stopped only by hysterectomy. We report a case of a destroyed cervical pregnancy simulating cervical cancer. The patient was conservatively managed with simple selective uterine artery embolization without methotrexate administration. Her vaginal bleeding ceased after embolization. No additional treatment was given. The patient resumed normal menstruation two months after embolization.