Showing papers in "Journal of Obstetrics and Gynaecology Research in 2007"

Cytokine profiles in serum and peritoneal fluid from infertile women with and without endometriosis

Abstract: OBJECTIVE To study the serum and peritoneal fluid cytokine profiles in infertile women with minimal/mild active endometriosis. METHODS Fifty-seven consecutive infertile women undergoing laparoscopy for unexplained infertility had peritoneal fluid and serum samples obtained at the time of laparoscopy. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-1 beta (IL-1 beta), vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), monocyte chemotatic protein-1 (MCP-1), RANTES, platelet derived growth factor (PDGF), soluble Fas (sFas), and soluble Fas Ligand (sFasL) in peritoneal fluid and serum were measured to compare the concentration in both biological fluids, in women who have minimal/mild red endometriosis using women with no endometriosis as controls. RESULTS Peritoneal fluid levels of MCP-1, IL-8 and IL-6 were significantly higher in the endometriosis group (P < 0.012, P = 0.003, and P = 0.015, respectively). There was no significant difference in the peritoneal fluid levels of IL-1 beta, TNF-alpha, RANTES, VEGF, PDGF, sFas and sFasL in the two groups. Although serum levels of IL-8 were higher in women with endometriosis, the difference was not significant (P = 0.07). Serum levels of PDGF, IL-6, RANTES, IL-1 beta, TNF-alpha, and sFas, were not significantly different in the two groups. CONCLUSION The elevated levels of MCP-1, IL-6, and IL-8 in peritoneal fluid but not serum may indicate the importance of local macrophage activating factors in the pathogenesis of endometriosis.

Placenta previa increta/percreta in Japan: A retrospective study of ultrasound findings, management and clinical course

Abstract: Aim: Placenta accreta is an abnormally firm attachment of placental villi to the uterine wall, which may cause postpartum hemorrhage resulting in maternal morbidity and mortality. The purpose of the present study was to clarify the incidence, clinical background and prognosis of placenta previa increta/percreta treated with different modalities in Japan. Methods: Medical records of cases with placenta previa increta/percreta in eight tertiary centers between January 1994 and December 2004 were reviewed. Placenta accreta without actual invasion into the myometrium confirmed by pathology was not included in placenta increta/percreta. Details of obstetric history, maternal background, ultrasonographical findings, the course of delivery, subsequent complications and management were noted. Results: Among the total of 59 008 deliveries, 45 261 were by the vaginal route (76.7%) and 13 747 by cesarean section (23.3%). In this study, 408 cases were diagnosed as placenta previa (0.69%), 18 of these being placenta increta and 5 placenta percreta. Only 1.1% of cases of placenta previa without prior cesarean section were increta/percreta, in contrast to 37% of placenta previa after prior cesarean sections. Mean intraoperation blood loss was 3630 ± 2216 g (increta) and 12 140 ± 8343 g (percreta). One patient with placenta previa percreta died of hemorrhage. Stepwise treatment (cesarean section without separation of the placenta, arterial embolization and hysterectomy) was applied for 4 cases, which had the least blood loss. Conclusions: Placenta previa increta/percreta is a life-threatening disease. Patients who undergo hysterectomy after uterine arterial embolization demonstrate reduced intraoperation blood loss, and this treatment should be incorporated to reduce maternal morbidity.

Impact of maternal body mass index on obstetric outcome

Abstract: The purpose of the present study was to correlate effect of maternal body mass index (BMI) on obstetric outcome. The studies conducted so far are from Western developed countries and there is a paucity of data from developing countries. A prospective evaluation was carried out of 380 women in one unit of a tertiary care teaching hospital in North India from May 2005 to June 2006 on the effect of maternal BMI on pregnancy outcome. BMI was calculated as weight (kg) divided by height (m2). BMI was used to characterize women as lean (BMI less than 19.8 kg/m2) normal (BMI 19.9-24.9 kg/m2) overweight (BMI 25-29.9 kg/m2) or obese (greater than or equal to 30 kg/m2). Forty-six women (12.1%) out of 380 were underweight 99 (26.1%) were overweight 30 (7.9%) were obese and the remaining 205 (53.9%) had normal BMI. Anemia (P = 0.02) and low birthweight (P = 0.008) was significantly present among lean women. Obese women had a significant risk for gestational diabetes (P = 0.0004) pre-eclampsia (P = 0.004)cesarean delivery (P = 0.01) and macrosomia (P = 0.02). Both lean and obese women carry a risk for adverse pregnancy outcome therefore pregnant women should maintain a normal BMI to achieve a healthy pregnancy outcome. (authors)

Total salpingectomy during abdominal hysterectomy: Effects on ovarian reserve and ovarian stromal blood flow

Abstract: The aim was to investigate the short- and medium-term consequences of performing total salpingectomy during abdominal hysterectomy (without oophorectomy) on certain ovarian reserve parameters and blood flow velocity measurements through the ovarian stroma. Twenty-four patients were recruited and randomized into two groups. Group 1 patients (n = 12) underwent total hysterectomy and complete excision of the fallopian tubes bilaterally. In group 2 (classical approach) fallopian tubes were removed partially leaving behind the neighboring paraovarian tissue. Pre- and postoperative (at 1 and 6 months) serum follicle stimulating hormone (FSH) luteinizing hormone (LH) estradiol values ovarian volume estimation by transvaginal ultrasound and ovarian stromal blood flow Doppler velocimetry were assessed during the early follicular phase. Mann-Whitney U-test Students t-test and Freidmans test were used for comparisons. Baseline data were similar across the groups (P > 0.05). Mean FSH LH estradiol values and ovarian volume were unchanged after both of the techniques. However mean pulsatility index resistance index and systole/diastole (S/D) ratio were significantly decreased in both groups compared to baseline values (group 1 P = 0.027 P = 0.018 and P = 0.013 respectively; group 2 P = 0.01 P = 0.002 and P = 0.0001 respectively). Postoperative decline in the mean pulsatility index was more pronounced (P = 0.02) in group 2 (partial removal). It appears that complete removal of fallopian tubes during hysterectomy has no advantageous effect on ovarian blood supply. It might be important to protect the ovarian blood supply as much as possible while performing hysterectomy in the reproductive period. (authors)

Placental mesenchymal dysplasia.

Abstract: Placental mesenchymal dysplasia is a very rare disorder in which the placenta is enlarged and contains cystic villi and dilated vasculature. The authors present a new case report of placental mesenchymal dysplasia with severe fetal growth restriction.

Clinical applications of anxiety, social support, stressors, and self-esteem measured during pregnancy and postpartum for screening postpartum depression in Thai women.

Abstract: The aim was to assess the clinical applications of anxiety social support stressors and self-esteem as well as the Postpartum Depression Risk Scale (PDRS) measured during pregnancy and postpartum for screening postpartum depression. A questionnaire regarding anxiety social support stressors and self-esteem was administered to 400 women during 36-40 weeks of gestation and 6-8 weeks postpartum prospectively using factor analysis. The enrolled women were interviewed 6-8 weeks postpartum by psychiatrists using a diagnostic system of the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV) for diagnosis of postpartum depression. Multiple logistic regression was used to identify the significant predictors for postpartum depression and then developed to be the PDRS and tested for clinical benefit. Of 400 enrolled women 40 (10%) were diagnosed with minor or major postpartum depression. After factor analysis 10 items of anxiety 10 items of social support four items of stressors and five items of self-esteem were identified with a standardized reliability coefficient of 0.85 0.82 0.81 and 0.82 during pregnancy and of 0.84 0.82 0.85 and 0.84 during the postpartum period respectively. During pregnancy a significant predictor was anxiety about postpartum depression but postpartum significant predictors were anxiety and social support which were generated to be PDRS. The clinical benefit of PDRS as a measure was better postpartum than during pregnancy. Anxiety and social support were identified as the predictors of postpartum depression. The development of the PDRS is clinically beneficial and useful during pregnancy and postpartum for the screening of postpartum depression in Thai women. (authors)

Clinical significance of pregnancies with circumvallate placenta

Abstract: Aim: This study examined the clinical significance of patients complicated by circumvallate placenta in comparison with patients with a normal placenta. Methods: Data were collected from 139 singleton deliveries complicated by circumvallate placenta and from 7666 unaffected controls managed at Japanese Red Cross Katsushika Maternity Hospital between 2002 and 2005. Results: The incidence of premature delivery, oligohydramnios, non-reassuring fetal status on cardiotocogram, placental abruption and intrauterine fetal death in patients complicated by circumvallate placenta were significantly higher than those in control patients. The odds ratio of placental abruption in patients complicated by circumvallate placenta was 13.1 (95% confidence limits: 5.65–30.2). Conclusion: A circumvallate placenta is associated with a higher incidence of serious perinatal complications such as placental abruption.

Role of endocrine and growth factors on the ovarian surface epithelium.

Abstract: Epithelial ovarian cancer is a highly fatal disease for which prevention strategies have been limited; in part because of our poor understanding of the underlying biology of its precursor, the ovarian surface epithelium (OSE). The OSE is a single layer of flat-to-cuboidal mesothelial cells that covers the surface of the ovary. Despite its inconspicuous appearance in vivo, it is believed that OSE cells actively participate in the cyclical ovulatory rupture and repair process. The continuous rupture of the OSE at ovulation and the subsequent proliferation to repair the wound renders the cells susceptible to genetic damage and malignant transformation. As the ovary is a rich source of multiple hormones, and normal OSE and ovarian carcinomas secrete and have receptors for hormones, growth factors and cytokines, these factors are strong candidates to regulate normal OSE physiology and the transformation and progression of ovarian cancers. In particular, alterations of hormone/growth factor production and receptor expression are common in ovarian tumors. This review summarizes the current knowledge in the field of endocrinology and its relationship to the biology and pathology of the OSE.

Subjective effect of magnetic resonance-guided focused ultrasound surgery for uterine fibroids.

Abstract: Aim: We treated 69 patients with symptomatic uterine fibroids using a magnetic resonance-guided focused ultrasound surgery (MRgFUS) system. Our objective was to determine the clinical outcome of MRgFUS, focusing on symptom improvement, with emphasis on the time and extent of improvement. Methods: Patients who would have been otherwise offered conventional surgery were considered for eligibility. They were asked to report their symptom severities before and after treatment on the same query form. The questionnaire, given 6 months after treatment, included a question asking when the patients' symptoms started to improve. Their fibroids were classified into three types according to the signal intensity on T2-weighted magnetic resonance images: type 1, low intensity as skeletal muscle, type 2, intermediate intensity, lower than myometrium but higher than skeletal muscle; and type 3, high intensity, the same as or higher than myometrium. Results: No severe adverse events occurred in any of the patients. Seven patients required alternative treatment after MRgFUS, with five of them having type 3 fibroids. Mean symptom scores were all reduced after MRgFUS, regardless of the symptom types. Frequent urination improved first, while heavy bleeding took longer to resolve than the other symptoms. Conclusion: MRgFUS is an effective and safe method for treating symptomatic uterine fibroids, especially for type 1 and type 2 fibroids. Type 3 fibroids, however, are difficult to treat using the current MRgFUS system.

Corpus luteum hemorrhage: Rare complication of congenital and acquired coagulation abnormalities

Abstract: Women taking anticoagulants or those with a clotting factor deficiency are at increased risk of corpus luteum rupture due to coagulation abnormalities and three such cases are described here. Case 1 was a 35-year-old woman with prosthetic mitral valve replacement who was on anticoagulant therapy, in whom hemoperitoneum secondary to ruptured corpus luteum was seen. Emergency laparotomy revealed 1.2 L of massive hemoperitoneum. Left salpingo-oophorectomy was performed. Case 2 was two episodes of hemoperitoneum from luteal cyst rupture in a young patient with the rare congenital factor X deficiency. This patient was managed conservatively with fresh frozen plasma and blood transfusion. This is the first case of congenital factor X deficiency manifested as luteal rupture to be managed conservatively. Case 3 was two episodes of hemoperitoneum from luteal cyst rupture in a patient with antiphospholipid antibody syndrome who was on oral anticoagulants. Laparotomy was done twice with left salpingo-oophorectomy in the first instance and partial excision of the right ovary in the second instance. Hemoperitoneum secondary to rupture of the corpus luteum should be considered in the differential diagnosis of acute abdominal pain in women with congenital and acquired coagulation deficiencies.

Schwannoma in the retroperitoneum.

Abstract: Schwannoma (neurilemmoma) is a peripheral nerve sheath tumor and commonly occurs singularly on the head, neck, and trunk. Giant schwannoma is rarely located on the retroperitoneum and pelvic cavity. The majority of symptoms caused by the tumor are due to the effect of its mass. Surgical resection is enough to treat the tumor. Schwannoma is reported usually as benign, and despite incomplete resection of the tumor, the risk of recurrence and metastasis is low. A schwannoma on the retroperitoneum that was preoperatively misdiagnosed as a malignant adnexal mass in a 60-year-old menopausal woman is presented, with a brief review of the literature.

Maternal circulating interferon-γ and interleukin-6 as biomarkers of Th1/Th2 immune status throughout pregnancy

Abstract: Aim: T cells may be classified as T helper type 1 (Th1) cells, which synthesize cytokines inducing cellular immunity, or T helper type 2 (Th2), which synthesize cytokines inducing humoral immunity. According to the Th1/Th2 paradigm, it has been postulated that successful pregnancy induces an immune Th2 bias, but it is not yet clear how Th1 and Th2 systems vary simultaneously throughout the pregnancy. Methods: Using maternal circulating interferon-γ (IFN-γ) and interleukin-6 (IL-6) as biomarkers of Th1 and Th2 cytokines, respectively, we examined the variation of circulating Th1/Th2 ratio in 35 healthy pregnant women from 10 to 40 weeks of pregnancy. Results: With increasing gestational age, maternal circulating levels of IFN-γ decrease, whereas those of IL-6 increase. The IFN-γ/IL-6 ratio switches around the 19th week of pregnancy. Conclusions: Our results suggest that maternal systemic IFN-γ and IL-6 concentrations may be biomarkers of Th1/Th2 immune status during pregnancy. Moreover, our findings showed that contrary to the Th1/Th2 paradigm, the Th1 bias may be prevailing at the beginning of pregnancy, balanced in the middle of pregnancy and supplanted by the Th2 bias at the end of pregnancy.

Ureteral catheter placement for prevention of ureteral injury during laparoscopic hysterectomy.

Abstract: Aim: Ureteral injury is among the most devastating complications of gynecologic surgery. Estimated incidence of ureteral injury during laparoscopic hysterectomy is 2.6–35 times (0.2–6.0%) that in abdominal hysterectomy. We investigated preoperative ureteral catheter (UC) placement as a way to prevent ureteral injury in laparoscopic hysterectomy. Methods: Clinical records of 94 women who underwent laparoscopic hysterectomy between February 2006 and January 2007 in Yazaki Hospital, Kanagawa, Japan, were reviewed retrospectively. Thirty-four patients between February and June 2006 underwent the surgery without ureteral catheterization and 60 patients between July 2006 and January 2007 underwent surgery with ureteral catheterization. Clinical outcomes were statistically compared between the two groups. Results: The average time required for catheter insertion was 9.35 min. The ureter in which the catheter was placed was visualized clearly. In one patient, whose left ureter was deviated by a massive myoma, catheter insertion was not possible. No complications arose from catheter placement except for minor complaints including low back pain, urinary discomfort, and transient hamaturia. While one injury occurred in a patient without ureteral catheterization (1/34), no ureteral injury occurred in any patient with ureteral catheterization (0/60). Operative time, total blood loss, and hospital stay were not significantly different between the two groups. Conclusions: UC placement is simple, helping to prevent ureteral injury during laparoscopic hysterectomy and enhancing safety of this procedure.

Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation : Potential prediction and prevention of cord prolapse

Abstract: Aim: We evaluated the efficacy of antepartum screening for cord presentation by trans-vaginal ultrasonography (TVS) on predicting and preventing umbilical cord prolapse (UCP) in term breech delivery. Methods: We investigated every woman with a breech-presenting fetus for cord presentation by weekly TVS after 36 weeks of gestation since 1995. If the cord was found in advance of fetal presenting parts, we recommended her to undergo elective cesarean section to avoid UCP. We studied the incidence of cord presentation by TVS and the clinical courses of the cases with it for 198 women who delivered breech after 36 weeks from 1995 to 2005 (group A). Further, the incidence of UCP was compared between group A and another 230 women who delivered breech at term from 1983 to 1994 (group B). Results: Cord presentation was detected by TVS at least once in eight (4%) group A patients. Seven of them underwent elective cesarean section and, in six of these (86%), cord presentation was still found at the time of operation. The eighth patient became free of cord presentation at the later examinations and delivered vaginally without UCP. A hundred and twenty-one (61%) women in group A and 159 (69%) women in group B delivered vaginally. No UCP occurred in group A, while it occurred in 10 (4%) cases of group B (P < 0.01), and one baby died of it. Conclusions: Detection of cord presentation by TVS has a potential to predict and reduce UCP in breech delivery at term.

Hysteroscopy after uterine fibroid embolization in women of fertile age

Abstract: Uterine artery embolization for fibroids is a controversial issue for women with incomplete reproductive plans. Ovarian failure and uterine infection are the most dreaded complications of this procedure. The purpose of the present study was to assess the types and the frequency of intrauterine abnormalities and the histological features of the endometrium after embolization. Uterine artery embolization was performed on 51 women (average age 34.5 years) with intramural fibroid/s larger than 4 cm. Hysteroscopy and endometrial biopsy was performed from 3 to 9 months later in the luteal phase of the cycle. Despite all women having no major symptoms prior to hysteroscopy only 19 (37%) had completely normal hysteroscopic findings. There was intrauterine protrusion of fibroid/s in 19 cases (37%) yellowish coloration of the endometrium in 14 (28%) intrauterine or cervical adhesions in seven (14%) and communication between the myoma and the uterine cavity in five cases (10%). A normal functional endometrium was histologically verified in 44 women of 49 (90%) who could be evaluated. Regressive changes (necrosis or hyalinization) of leiomyoma or of indefinite origin were found in 17 patients and embolization particles in five including one patient with microspheres inside the endometrial vessel. No case of Asherman syndrome or endometrial atrophy was observed. The frequency of abnormal hysteroscopic findings after embolization is surprisingly high. The clinical significance reversibility and impact on fertility of abnormal hysteroscopic findings after embolization remain unclear. Regardless hysteroscopy should be strongly recommended to all patients after uterine fibroid embolization prior to conception. (authors)

Pregnancy outcome in hyperemesis gravidarum and the effect of laboratory clinical indicators of hyperemesis severity.

Abstract: Authors: Tan PC, Jacob R, Quek KF, Omar SZ Objective: To determine pregnancy outcome in hyperemesis gravidarum and the effect of metabolic, biochemical, hematological and clinical indicators of disease severity on outcome. Study Design: A retrospective study based on 166 women hospitalized for confirmed hyperemesis gravidarum from January 2004 to January 2005. For each woman, three controls matched for age, parity and ethnicity were obtained from our 2004 birth register. The effects of laboratory indicators of hyperemesis severity were separately analyzed within the hyperemesis gravidarum study group. Outcome measures include stillbirths, Apgar score, mode of delivery, low birthweight, preterm delivery, labor induction, pregnancy induced hypertension and gestational diabetes. Analysis was by t-test, Fisher’s exact test and multivariable logistic regression analysis. Results: Women with hyperemesis had similar pregnancy outcome compared to controls. In the analysis of laboratory indicators of hyperemesis severity and pregnancy outcomes, hypokalemia (adjusted odds ratio [AOR] 2.7: 95% confidence interval [CI] 1.0–6.8) was associated with emergency operative delivery, high creatinine (odds ratio 4.4: 95% CI 1.3–15) with labor induction and raised gamma glutamyltransferase (AOR 7.5: 95% CI 1.2–46) with the development of gestational diabetes. Conclusions: Hyperemesis gravidarum per se was not associated adverse pregnancy outcome. Hypokalemia, high creatinine and raised gamma glutamyltransferase in women with hyperemesis gravidarum were associated with adverse pregnancy outcome.

Metabolic syndrome in females with polycystic ovary syndrome and International Diabetes Federation criteria

Abstract: Aim: To find out the incidence of metabolic syndrome (MS) in females with polycystic ovary syndrome (PCOS) and to assess the metabolic risk factors as per the definition of International Diabetes Federation. Methods: One hundred and seventeen females (39 adolescents and 78 adults) diagnosed with PCOS underwent assessments clinically and by appropriate laboratory tests for the evidence of MS, as per the criteria laid down by International Diabetes Federation. Results: MS was diagnosed in 54 cases (46.2%), of which 43.6% were adolescents and 47.4% were adults (difference not statistically significant). MS in females with PCOS had significantly higher body mass index compared to those who did not have MS, irrespective of age. Abnormalities in both the lipids were more common than fasting glucose abnormalities. Conclusion: MS was found in 46.2% of females with PCOS, with both adolescents and adults being similarly affected. Dyslipidaemia is more common than impaired fasting glucose and finding one risk factor should prompt the clinician to search for other risk factors. All females with PCOS should undergo periodic screening for MS.

Re-evaluation of the true rate of hepatitis C virus mother-to-child transmission and its novel risk factors based on our two prospective studies

Abstract: Objective: To re-evaluate the true hepatitis C virus (HCV) mother-to-child transmission (MTCT) rate and its novel risk factors. Study Design: A comparative study based on our own two prospective studies done during the two periods, ‘early’ (1989–1994) and ‘recent’ (1995–2004). Results: All carrier infants became HCV RNA-positive within 3 months after birth. The MTCT and de-carrier rates were, respectively, higher (14.2%) and lower (16.7%) in the recent period, although liver dysfunction of carrier infants was found very frequently (66.7%) in both groups. MTCT occurred significantly when the maternal viral load, serum alanine aminotransferase (sALT) levels and blood loss at delivery were, respectively, more than 105 copies/mL, 110 IU/L, and 500 g. No MTCT was found when elective cesarean section was done. Conclusions: The true HCV MTCT and de-carrier rates were found to be much higher and lower than those reported previously. The maternal liver dysfunction (sALT ≥110 IU/mL) and blood loss (≥500 g) at delivery are the next risk factors to maternal viral load (≥105 copies/mL) for MTCT.

Immune concept of human papillomaviruses and related antigens in local cancer milieu of human cervical neoplasia.

Abstract: It is presently the right time for clarifying human papillomavirus (HPV)-associated cellular immunity and clinical implications before global HPV vaccination programs begin. Infection with oncogenic HPV associates with the progression of cervical neoplasia. Both cellular and humoral immune responses are essential for the clearance of HPV-associated cervical lesions. There is increasing evidence that the immune system plays a pivotal role in determining the outcome of HPV infection. Viruses and associated neoplastic cells are proposed to have evolved mechanisms to avoid immune attack. T-cell-mediated immune responses against oncogenic HPV are believed to play a central role in cervical carcinogenesis. The presence of HPV-specific cytotoxic T lymphocytes (CTL) in a majority of human cervical cancer patients provides an approach for further study of their functional role in modulating this malignancy. Tumor-infiltrating lymphocytes (TIL) develop as manifestations of the recognition and defense against malignant cells by the host immune system. Cancer cells may overcome immune surveillance, either by downregulating the proliferation of HPV-specific CTL, or altering the effector compositions of immune cells against HPV infections. TIL in the tumor microenvironment can be functionally inhibited and lose the ability of clonal proliferation as a result of depressed expression of IL-2Ralpha. The upregulation of inhibitory signaling relates to the modulation of the virus- and/or tumor-specific immune responses. Alteration of host genetic susceptibility may also lead to abnormal immune response as a general genomic instability resulting from virus persistence. Induction of HPV-specific immune responses is anticipated as an intimate point for the treatment of cervical neoplasia.

Laparoscopy should be strongly considered for women with unexplained infertility.

Abstract: Aim: Women with unexplained infertility frequently become pregnant after diagnostic laparoscopy. In this study the effect of laparoscopic surgery on such women was evaluated by the pregnancy rate after laparoscopic surgery. Methods: A total of 47 unexplained infertile women underwent laparoscopic evaluation during the period August 2002 to January 2005 in our center. The percentage of positive laparoscopic findings and the pregnancy rate after laparoscopy were calculated. The patients were divided into 5 subgroups according to maternal age, pregnancy rates were calculated for each group, and compared with the outcome of assisted reproductive technology (ART) treatment for the same age groups. Results: In 87.2% of the women, laparoscopy revealed abnormal findings; endometriosis lesions, peritubal adhesions and tubal obstructions were found in 21, 17 and 3 cases, respectively. After laparoscopy 23 achieved pregnancy (pregnancy rate: 48.9%). The pregnancy rates of the groups at the age of 25 years old or less, 26–30, 31–35, 36–40 and over 41 years old were 100%, 75.0%, 45.5%, 27.2% and 0%, respectively. In the case of the 26–30 years old group, the pregnancy rate after laparoscopy was significantly higher than that in the ART treatment group (33.3%, P < 0.05). Conclusions: Laparoscopy should be strongly considered for examining women with unexplained infertility.

Recent advances in non-invasive prenatal DNA diagnosis through analysis of maternal blood.

Abstract: Prenatal diagnosis of aneuploidy and single-gene disorders is usually performed by collecting fetal samples through amniocentesis or chorionic villus sampling. However, these invasive procedures are associated with some degree of risk to the fetus and/or mother. Therefore, in recent years, considerable effort has been made to develop non-invasive prenatal diagnostic procedures. One potential non-invasive approach involves analysis of cell-free fetal DNA in maternal plasma or serum. Another approach utilizes fetal cells within the maternal circulation as a source of fetal DNA. At the present time, fetal gender and fetal RhD blood type within RhD-negative pregnant women can be reliably determined through analysis of maternal plasma. Furthermore, genetic alterations can be diagnosed in the maternal plasma when the mother does not have the alterations. However, the diagnosis of maternally inherited genetic disease and aneuploidy is limited using this approach. Non-invasive prenatal diagnosis through examination of intact fetal cells circulating within maternal blood can be used to diagnose a full range of genetic disorders. Since only a limited number of fetal cells circulate within maternal blood, procedures to enrich the cells and enable single cell analysis with high sensitivity are required. Recently, separation methods, including a lectin-based method and autoimage analyzing, have been developed, which have improved the sensitivity of genetic analysis. This progress has supported the possibility of non-invasive prenatal diagnosis of genetic disorders. In the present article, we discuss recent advances in the field of non-invasive prenatal diagnosis.

Ectopic ovary: a case of autoamputated ovary with mature cystic teratoma into the cul-de-sac.

Abstract: An ovary with a mature cystic teratoma which was autoamputated into the cul-de-sac and confirmed by laparoscopy is described. A 24-year-old woman with a history of chronic pelvic pain for 5 years presented with left abdominal pain. Magnetic resonance imaging revealed a left ovarian mass of 5 cm in diameter. The pain was relieved spontaneously after a few weeks. Laparoscopy was performed 5 months later. The mass was identified in the cul-de-sac partly enveloped in the omentum without any ligamentous or direct connection with the pelvic organs. There was no left ovary in its proper anatomical location. Histopathologic study revealed a mature cystic teratoma with viable ovarian tissue. These findings suggested autoamputation of the ovary either by inflammation or torsion, which is one of the mechanisms for the formation of an ectopic ovary.

Antenatal diagnosis of placenta previa accreta in patients with previous cesarean scar.

Abstract: Aim: To determine the accuracy of transabdominal and transvaginal gray-scale and color Doppler in diagnosing placenta previa accreta in patients with previous cesarean sections. Methods: Twenty-one patients who had undergone previous cesarean sections and were confirmed to have partial or total placenta previa in the current pregnancy were subjected to ultrasound examinations after the 28th week of gestation. Specific ultrasound features were looked for on gray-scale ultrasound and color Doppler examination of the placenta and its interphase with the uterus and the bladder. Results: Seven of the 21 patients had ultrasound evidence of placenta accreta and all were later confirmed to have placenta previa accreta intraoperatively. The gray-scale positive findings were present in six out of the seven patients. The most prominent gray scale feature to suggest placenta accreta was the presence of multiple lakes that represent dilated vessels extending from the placenta through the myometrium. All seven patients had features of placenta accreta when examined with color Doppler. The most prominent color Doppler feature present in all seven patients was the presence of interphase hypervascularity with abnormal vessels linking the placenta to the bladder. The sensitivity and specificity of antenatal ultrasound diagnosis of placenta previa accreta was 100%. Conclusion: Antenatal diagnosis of placenta previa accreta can be made with a thorough ultrasound examination of the placenta in patients with previous cesarean scar and placenta previa.

Cervical intraepithelial neoplasia II-III with endocervical cone margin involvement after cervical loop conization: Is there any predictor for residual disease?

Abstract: Aim: To determine the clinicopathological predictors for residual disease in women who have had cervical intraepithelial neoplasia (CIN) II-III with endocervical cone margin involvement after loop electrosurgical excision procedure (LEEP). Methods: All of the women who had CIN II-III on LEEP specimens with endocervical margin involvement, and underwent subsequent surgical treatment including repeat LEEP or hysterectomy at Chiang Mai University Hospital between May 2003 and June 2006 were reviewed. Results: During the study period, 85 women who matched the study inclusion were identified. The mean age was 48.6 years. Fifty-two women (61.2%) were postmenopausal. The most common Pap smear before LEEP was high-grade squamous intraepithelial lesion (HSIL) (65.9%), followed by squamous cell carcinoma (21.2%). Twenty-five women (29.4%) had concurrent ectocervical and endocervical cone margin involvement. Residual disease was noted in 44 women (51.8%, 95%CI = 40.7–62.7) of whom six had unrecognized invasive squamous cell carcinoma, while the remaining 38 had CIN II-III. Only extensive endocervical cone margin involvement (3–4 quadrants) was noted as the significantly independent predictor for residual disease (aOR = 14.2, 95% CI = 3.6–55.8; P < 0.001). Conclusion: Extensive endocervical cone margin involvement after LEEP for CIN II-III is a strong predictor for residual disease. Therefore, the number of involved quadrants should be evaluated to plan further management.

Relaparotomy after cesarean delivery: experience from an Indian teaching hospital.

Abstract: The aim was analysis of cases requiring relaparotomy following cesarean delivery (within 6 weeks of surgery). This was a retrospective observational study set in a teaching institution in Kolkata India of 66 cases requiring relaparotomy following cesarean delivery. Over a period of 3 years from 1 January 2002 to 31 December 2004 12 967 cesarean deliveries were done. During the same period 66 cases had repeat laparotomy. Of these 43 cases followed cesarean delivery at the institution itself while 23 had had a cesarean delivery at a peripheral hospital. Post-partum hemorrhage in 28 cases (42.4%) and rectus sheath hematoma in 18 cases (27.3%) were the leading indications for relaparotomy. Of these 66 cases 63 (95.5%) had intrapartum cesarean delivery while three (4.5%) had an elective operation. Procedures undertaken at relaparotomy were resuturing of uterine incision in 22 cases (33.3%) uterine artery ligation in 19 cases (28.8%) and drainage of hematoma in 18 cases (27.3%). A third laparotomy was needed in 13 cases (19.6%) of which 11 were due to secondary post-partum hemorrhage. There were eight maternal deaths following relaparotomy. Repeat laparotomy within 6 weeks of cesarean delivery was required following 1 in 300 cases done in an Indian teaching hospital. The majority of these were preventable and could have been avoided if adequate attention had been paid at the time of the primary surgery. (authors)

Decrease and dysfunction of endothelial progenitor cells in umbilical cord blood with maternal pre-eclampsia

Abstract: Background: The pre-eclampsia is characterized by placental defective angiogenesis and maternal vascular/endothelial dysfunction. Recently, the decrease and senescence of endothelial progenitor cells (EPC) has been observed in maternal circulation with pre-eclampsia. Given the essential involvement of EPC in neovascularization and reendothelialization, we investigate whether or not the depletion of EPC is existent in placental/fetal circulation with maternal pre-eclampsia. Methods: Samples of venous cord blood were collected during the labor of preeclamptic mothers (n = 14) and normotensive controls (n = 10). Circulating EPC were enumerated as AC133+/KDR+ cells via fluorescence-activated cell sorting (FACS) analysis. Additionally, EPC were expanded in vitro and identified by DiI-acLDL uptake and lectin staining by direct fluorescent staining under a laser scanning confocal microscope. EPC proliferation, migration and vasculogenesis activities were determined by MTT, modified Boyden chamber assay and in vitro vasculogenensis assay. Result: The placental/fetal circulating EPC numbers were significantly decreased in the pre-eclampsia group compared with the control (median, 200; range, 100–440 cells/mL vs 390; 270–440 cells/mL, P < 0.001), and after in vitro cultivation the numbers of EPC also decreased in pre-eclampsia group (19.5; 5.0–32.0 vs 39.5; 31.2–52.0 EPC/×200 field; P < 0.001). Both circulating EPC and cultivated EPC were inversely correlated with cord blood level of soluble fms-like tyrosine kinase 1 (sFlt-1). In addition, the EPC from patients with pre-eclampsia were significantly impaired in their proliferation, migration and vasculogenesis capacities. Conclusion: The present study documented the decrease and dysfunction of placental/fetal circulating EPC in patients with pre-eclampsia. The alteration is probably associated with the increased sFlt-1 levels in the umbilical cord blood.

Comparison of the use of electrothermal bipolar vessel sealer with harmonic scalpel in total laparoscopic hysterectomy.

Abstract: The aim of the present study was to compare the use of electrothermal bipolar vessel sealer (EBVS) with harmonic scalpel (HS) during total laparoscopic hysterectomy with respect to operation time estimated blood loss and related complications. A retrospective study was conducted in the university hospital. Forty patients who underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy were enrolled. Nineteen hysterectomies were performed with HS and in 21 patients the same surgeons used EBVS. Data about the characteristics of the patients operation time estimated blood loss uterine weights related complications and length of hospital stay were registered and compared. Mean procedure time and estimated blood loss were significantly less in the EBVS arm (59.57 ± 3.71 vs 90.95 ± 5.73 min P < 0.001; 87.76 ± 25.48 vs 152.63 ± 60.90 mL; P < 0.001 respectively). The change in hemoglobin and hematocrit values was found to be more significant in the HS group. EBVS was found to be less time-consuming and caused less bleeding when compared with HS. (authors)

Prospective randomized study of oxytocin discontinuation after the active stage of labor is established

Abstract: The aim was to investigate the effects of discontinuing oxytocin infusion on labor outcomes once the active stage of labor is established. This is a prospective study involving 342 pregnant women who underwent labor induction at our institution. Patients were randomly divided into two groups. In the first group oxytocin was discontinued at the beginning of the active phase of labor and in the other group oxytocin was administered until delivery. Duration of the active phase and the second stage of labor were longer in the oxytocin-discontinued group; however this was not statistically significant. The rate of uterine hyperstimulation was significantly higher in oxytocin-continued group (P 0.05). Discontinuing oxytocin infusion once the active stage of labor is established may be an alternative protocol in developing countries where the conditions for fetal monitoring and emergency cesarean section are less available. (authors)

Major complications and outcome of diagnostic and operative transvaginal hydrolaparoscopy.

Abstract: Aim: Transvaginal hydrolaparoscopy (THL) has recently been developed as a less invasive alternative to conventional laparoscopy. There are some reports that described the usefulness and prognostic value of diagnostic THL in infertile women. Moreover, operative THL such as ovarian drilling for unovulatory women with polycystic ovarian syndrome (PCOS) to induce ovulation has also been found to be as effective as that by conventional laparoscopy. The risk of bowel injury and sepsis by transvaginal access with culdoscopy was higher than that with laparoscopy in the previous reports. The purpose of the present study was to examine the risk of diagnostic and operative THL according to two case studies with a literature review. Methods: The authors carried out diagnostic or operative THL in 177 infertile women, aged 22–43 years. Major complications during THL and a review of the literature were analyzed. Results: Two cases of bowel injury were diagnosed during diagnostic THL. No complication occurred during operative THL. In total, the incidence of bowel injury was 1.1%. The injuries were diagnosed during THL and treated expectantly under strict conditions in both cases. Ten studies in the literature reported a total of 4232 procedures, including 26 bowel injuries (0.61%) and one perforation of a retroflexed uterus (0.02%). Conclusions: The usefulness of THL for diagnostic and operative purposes is in no doubt. However, informed consent should be obtained and vigilance before and during THL should be maintained, although it can be done on an outpatient clinic basis.

Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor.

Abstract: Aim To assess the effectiveness of oral misoprostol compared with methylergometrine in the prevention of primary post-partum hemorrhage during the third stage of labor. Methods This was a randomized controlled trial of 864 singleton low-risk pregnant women. The outcomes were total blood loss, duration of the third stage of labor and peripartal change in hematocrit. Comparisons were by the chi2-test and Student t-test. Relative risks were calculated for side-effects profile. A P-value of less than 0.05 was statistically significant. Results The biodata of all the participants were similar. The mean blood loss for the misoprostol and methylergometrine groups was 191.6 +/- 134.5 mL and 246.0 +/- 175.5 mL, respectively (95% CI: -79.3 to -39.5 mL). The mean duration of the third stage of labor was 19.6 +/- 2.4 min and 9.4 +/- 3.3 min in the misoprostol and methylergometrine groups, respectively (95% CI: 9.82-10.58 min). More subjects had blood loss >500 mL, 42 (9.7%) versus 6 (1.4%), and peripartal hematocrit change greater than 10%, 38 (8.8%) versus 5 (1.2%), in the methylergometrine group than in the misoprostol group, respectively. Also, more subjects received additional oxytocic in the methylergometrine group, compared to the misoprostol group (80 [18.5%] versus 33 [7.6%] patients, respectively). Conclusions Orally administered misoprostol was more effective in reducing blood loss during the third stage of labor than intramuscular methylergometrine. However, there were more subjects in the misoprostol group in whom duration of the third stage of labor was greater than 15 min and who also had manual placental removal than in the methylergometrine group.