- Management of intra-abdominally translocated contraceptive devices, is surgery the only way to treat this problem? [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):480-486
- This study was a multi-centre retrospective review of patients with uterine perforation caused by intrauterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year pe...
This study was a multi-centre retrospective review of patients with uterine perforation caused by intrauterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year period. Among them, five were asymptomatic and the rest were symptomatic. Asymptomatic patients were managed conservatively, except in one case in which the patient requested surgery because she also wanted a tubal ligation. Symptomatic patients all underwent surgery. All the surgeries were elective and all the surgical procedures were initiated laparoscopically. There were seven complications in the surgically managed group: conversion to laparotomy (n = 3), bowel injury (n = 2), bladder injury (n = 1), and wound infection (n = 1). Mild and severe adhesions (81.8%), and abscess (18.1%) formation related to translocated IUD (TIUD) were observed during surgery. All the patients were uneventful at 1 to 5 years of follow-up. A TIUD, by causing adhesions, complicates future laparoscopic surgery and increases the likelihood of conversion to laparotomy. While surgery is indicated to prevent TIUD-induced adhesive complications, it may also be the cause of both adhesions and complications, resulting in a vicious cycle. Some asymptomatic women, especially elderly patients with comorbidities, may not need or may be better managed without treatment. Impact statement In this study we try to find an answer for the question of "Should removal of a translocated intrauterine contraceptive device (TIUD) routinely be performed even if patients are asymptomatic?" From only the theoretical point of view there were some reports supporting conservative management in asymptomatic patients. The other studies addressing this issue were case reports including few patients with a short-term follow-up. The novelties of the present study include multi-centre design, detailed clinical and surgical information about the patients and the long period of follow-up. Most clinicians have limited experiences in managing TIUD because perforation is a rare event. So it can be difficult to know exactly what the surgeon will encounter intraoperatively. We undertook this study with the aim of providing a perspective about patients with TIUD for those faced with this situation. This is a descriptive study reporting 15 cases of TIUDs and management. Asymptomatic patients were managed conservatively, and symptomatic patients were operated. There are important implications resulting from this study that in asymptomatic patients leaving the IUD in place may be a reasonable option, mostly as the risk of surgical intervention is quite high with a high rate of complications with surgical management.
- Extravasating uterine pseudoaneurysm: A rare cause of postpartum haemorrhage. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):416-420
- Postpartum haemorrhage (PPH) remains one of the leading causes of maternal death worldwide and can be classified as either immediate (primary) or delayed (secondary) according to the onset time - bef...
Postpartum haemorrhage (PPH) remains one of the leading causes of maternal death worldwide and can be classified as either immediate (primary) or delayed (secondary) according to the onset time - before or after 24 hours postpartum. Uterine pseudoaneurysm is a rare cause of PPH that has been suggested to arise from abnormal vascular regression and a recurrent vascular healing state, such as a vascular stricture and relaxation with thrombin deposits after placental expulsion. With advances in multidetector computed tomography, 3D-computed tomography with angiography can aid in identifying the location and originating vessels of the pseudoaneurysm via fast and clear 3D images. Once a bleeding pseudoaneurysm is diagnosed as the cause of PPH, conservative management is frequently unsuccessful in controlling bleeding. Transcatheter uterine arterial embolisation appears to be the treatment of choice in haemodynamically stable women.
- A review of the open laparoscopic Hasson technique and retrieval of adnexal specimen via umbilicus. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):487-491
- Laparoscopic entry techniques vary amongst surgeons and gynaecologists, with gynaecologists favouring Veress needle entry. Recent RCOG/BSGE recommendations have recommended retrieval of ovarian masse...
Laparoscopic entry techniques vary amongst surgeons and gynaecologists, with gynaecologists favouring Veress needle entry. Recent RCOG/BSGE recommendations have recommended retrieval of ovarian masses via the umbilical port with resultant less postoperative pain and a faster retrieval time than with retrieval through lateral ports of the same size. This is a prospective observational study reviewing the Hasson entry technique and the introduction of retrieval of specimens via the umbilicus in patients scheduled for a laparoscopy procedure at our day surgery unit. We found no immediate or major surgical complications and all specimens were successfully retrieved through the umbilicus. Pain scores were low. We recommend the technique for extirpative gynaecological surgery. Impact Statement This study confirms that conversion from the closed Veress to the open Hasson technique is achievable in a university hospital setting. Operator confidence during the learning phase is enhanced by the use of ultrasound to locate and measure the depth of the umbilical ligament. Retrieval of benign adnexal specimens through the umbilicus was very satisfactory.
- The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: A single-institute study. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):510-513
- The therapeutic value of para-aortic lymphadenectomy (PAL) in women with endometrial cancer (EC) remains uncertain. We retrospectively analysed 25 patients with stage IIIc EC (17 stage IIIC1; 8 IIIC2...
The therapeutic value of para-aortic lymphadenectomy (PAL) in women with endometrial cancer (EC) remains uncertain. We retrospectively analysed 25 patients with stage IIIc EC (17 stage IIIC1; 8 IIIC2) who were treated in our institution. All subjects had undergone pelvic lymphadenectomies in which para-aortic nodes were sampled, or removed only when these nodes were enlarged. Sampling of para-aortic nodes or PAL was performed in all patients with stage IIIC2 disease and one of 17 with stage IIIC1 disease. Para-aortic lymph nodes were the most frequent site of recurrence in stage IIIC1 patients, but no such recurrences occurred in stage IIIC2 patients. Overall survival tended to be shorter in stage IIIC1 patients than stage IIIC2 patients. Our findings indicate that PAL improves the outcomes of patients with EC and high risk of para-aortic lymph node metastasis, such as those with positive pelvic lymph nodes or enlargement of para-aortic lymph nodes. Impact statement Para-aortic lymph node (PALN) metastases are important prognostic factors in endometrial cancer. Overall survival of patients with stage IIIC1 disease is generally longer than for those with stage IIIC2 disease. Retrospective studies - but no prospective studies - have suggested that para-aortic lymphadenectomy (PAL) provides a survival benefit. In our institution, we had performed PAL or para-aortic sampling for patients with enlarged PALNs; therefore, as most IIIC1 patients had no enlarged PALNs, they underwent pelvic lymphadenectomy only, whereas all IIIC2 patients had enlarged PALNs and underwent pelvic lymphadenectomy and PAL or PALN sampling in addition to pelvic lymphadenectomy. However, under this policy, survival of stage IIIC1 patients was not better than for stage IIIC2 patients. Our retrospective study indicates a survival benefit for PAL in patients with pelvic node-positive or enlarged PALN. PAL warrants a prospective randomised trial to see whether it should be a standard treatment in these patients.
- Ultrasonic elastography exploration of the foetal brain: A case of atypical choroid plexus papilloma. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):525-527
- Effects of 1alpha, 25-dihydroxyvitamin D3 on programmed cell death of Ishikawa endometrial cancer cells through ezrin phosphorylation. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):503-509
- This study investigated the effects of 1α, 25-dihydroxyvitamin D3-induced cell death and its underlying molecular mechanisms in Ishikawa endometrial carcinoma cells. The effects of 1α, 25-dihydroxyvi...
This study investigated the effects of 1α, 25-dihydroxyvitamin D3-induced cell death and its underlying molecular mechanisms in Ishikawa endometrial carcinoma cells. The effects of 1α, 25-dihydroxyvitamin D3 on Ishikawa cells were examined by 3-[4,5-dimethylthiazol-2-yl]-2.5-diphenyl-tetrazolium bromide, thiazolyl blue (MTT) assay. 1α, 25-dihydroxyvitamin D3 was shown to induce programmed cell death in Ishikawa endometrial carcinoma cells by activation of caspase-3 and caspase-9, along with elevation of Bcl-2 and Bcl-xL. Cell viability was reduced by 1α, 25-dihydroxyvitamin D3 in a concentration-dependent manner up to 2.5 μM. In addition, ezrin phosphorylation increased with the 1α, 25-dihydroxyvitamin D3 concentration (0-0.5 μM). The protein level of caspase-9 was increased by 1α, 25-dihydroxyvitamin D3 up to 0.5 μM. This is the first report regarding the efficacy and molecular mechanisms underlying the effects of 1α, 25-dihydroxyvitamin D3 in endometrial cancer cells. Our findings indicate that 1α, 25-dihydroxyvitamin D3 induces endometrial cancer cell death in a concentration-dependent manner. Impact statement Up to date, there is no report about the efficacy and molecular underlying mechanisms on the effect of vitamin D3 in endometrial cancer cells. Our findings indicate that 1α, 25-dihydroxyvitamin D3. which is an active metabolite of vitamin D3, induces Ishikawa endometrial cancer cell death in a concentration-dependent manner by activation of caspase-3 and -9, along with elevation of Bcl-2 and Bcl-xL. In addition, the same concentration of 1α, 25-dihydroxyvitamin D3 that provoked apoptotic signals caused phosphorylation of ezrin at threonine 567 in a VDR-dependent manner. This study suggests that 1α, 25-dihydroxyvitamin D3 within the optimal range (0.5 uM) would induce apoptosis through Fas-ezrin-caspase-3, -8, -9 signalling axis which may be a critical cell death regulator in Ishikawa endometrial cancer cell. Further study will be more interesting to address molecular connections or prove this critical optimal concentration range of vitamin D.
- Expression of matrix metalloproteinase-9 and its substrate level in patients with premature rupture of membranes. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):441-445
- In this study, 30 case of patients with full-term premature membrane rupture and another 30 cases of full-term delivered subject without premature rupture of membranes (PROM) were selected to explore...
In this study, 30 case of patients with full-term premature membrane rupture and another 30 cases of full-term delivered subject without premature rupture of membranes (PROM) were selected to explore the relationship between premature membrane rupture with matrix metalloproteinase 9 (MMP-9) and its substrate level. Results showed the plasma zinc, MMP-9 in serum and amniotic fluid increased in patients with PROM; their type IV collagen in serum and foetal membrane decreased. Increased Zinc ion concentration results in increased concentration of MMP-9, a zinc-dependent enzyme; the degradation of type IV collagen by MMP-9 might be the potential mechanism of premature rupture of membranes in full-term pregnant women.
- The role of ovarian reserve markers in prediction of clinical pregnancy. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):492-497
- To evaluate the role of ovarian reserve markers in the prediction of clinical pregnancy and embryo transfer accomplishment among poor responder IVF applicants. 304 female poor responder IVF applicant...
To evaluate the role of ovarian reserve markers in the prediction of clinical pregnancy and embryo transfer accomplishment among poor responder IVF applicants. 304 female poor responder IVF applicants were included in this prospective cohort study conducted at the IVF-unit. Antral follicle count, FSH, LH, E2, AMH and IVF outcomes were compared in pregnant and non-pregnant groups as well as in ET vs. non-ET groups. The number of retrieved oocytes was significantly correlated positively with AMH and AFC, and negatively with FSH and age. Quartiles of FSH and AFC were similar to the rate of pregnancy. Quartiles of AMH (<25%/25-75% and <25%/>75%) were statistically significant. Mean serum levels for AMH were significantly lower in the non-ET group. Our findings seem to indicate that day 3 AMH values can predict ET accomplishment with a sensitivity of 96% and a specificity of 35%. Quartiles of AMH <25% (< 0.21 ng/mL) can predict the IVF results among poor responder IVF applicants. Impact statement Various cut-off values have been determined for day 3 serum AMH values. These values help to determine the groups that are expected to give normal, high or low response to stimulation and decide the treatment options. In contrast to other groups of patients, poor responders cannot reach the embryo transfer stage for several reasons. These are; absence of a mature oocyte after oocyte pick-up, fertilisation failure without male factor or poor embryo quality. In the present study; a cut-off value of 0.33 ng/mL for the prediction of ET accomplishment in poor responder patients was determined with a sensitivity of 96%. Additionally, clinical pregnancy could not be achieved under the value of 0.21 ng/mL day 3 AMH values. It is important to clarify the embryo transfer success of poor responder patients prior to expected treatment success. Pre-treatment counselling for these patients would lessen the disappointment that may develop after treatment. The cost-effectiveness of treatments below these AMH values can be determined by further studies.
- BMI at early puerperium: Body image, eating attitudes and mood states. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):428-434
- The present study was aimed to verify if body weight could influence self-perception, in terms of body image, mood states, dissatisfaction with physical appearance and risk of eating disorders. In pa...
The present study was aimed to verify if body weight could influence self-perception, in terms of body image, mood states, dissatisfaction with physical appearance and risk of eating disorders. In particular, we evaluated the differences between women of normal weight vs. overweight and obese during the delicate phase of puerperium to verify if there were different emotional structures, linked to BMI. Thirty-two women, 16 normal-weight and 16 overweight or obese, belonging to the Department of Obstetrics and Gynaecology of the University Hospital, were individually interviewed. The Body Uneasiness Test (BUT), the Eating Disorder Inventory (EDI) and the Profile of Mood States (POMS) were used for the evaluation. Findings showed that the BMI in puerperium is significantly correlated to mood states and body perception. Furthermore, significant differences emerged in eating attitudes and behaviours, in specific aspects related to the weight gain phobia and the body shape perception, symptoms classically associated with the risk of developing an eating disorder.
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- The magnitude and factors related to facility-based maternal mortality in Mozambique. [Journal Article]
- JOJ Obstet Gynaecol 2017; 37(4):464-470
- Facility-based maternal mortality remains an important public health problem in Mozambique. A number of factors associated with health system functioning can be described behind the occurrence of the...
Facility-based maternal mortality remains an important public health problem in Mozambique. A number of factors associated with health system functioning can be described behind the occurrence of these deaths. This paper aimed to evaluate the magnitude of the health facility-based maternal mortality, its geographical distribution and to assess the health facility factors implicated in the occurrence of these deaths. A secondary analysis was done on data from the survey on maternal health needs performed by the Ministry of Health of Mozambique in 2008. During the study period 2.198 maternal deaths occurred out of 312.537 deliveries. According to the applied model the availability of Maternal and Child Health (MCH) nurses performing Emergency Obstetric Care functions was related to the reduction of facility-based maternal mortality by 40%. No significant effects were observed for the availability of medical doctors, surgical technicians and critical delivery room equipment. Impact statement Is largely known that the availability of skilled attendants assisting every delivery and providing Emergency Obstetric Care services during the pregnancy, labor and Childbirth is key for maternal mortality reduction. This study add the differentiation on the impact of different cadres of health services providers working on maternal and child health services on the facility based maternal mortality. In this setting the study proven the high impact of the midlevel skilled maternal and child health nurses on the reduction of maternal mortality. Another important add from this study is the use of facility based maternal mortality data to inform the management process of maternal healthcare services. The findings from this study have potential to impact on the decision of staffing prioritization in setting like the study setting. The findings support the policy choice to improve the availability of maternal and child health nurses.