Combined Use of Cerclage, Obstetric Pessary, and Micronised Progesterone in Recurrent Miscarriage

World Journal of Gynecology & Womens Health

In recent years, the use of progesterone, cerclage, and obstetric pessaries in patients with cervical incompetence has been studied extensively. However, there have not been any published reports of combined use of these methods. Here, we describe a case of successful combined use of cerclage, obstetric pessary, and micronised progesterone for preterm birth prevention in a nulliparous woman with recurrent miscarriage.

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Trophoblastic Disease During the Third Trimester of Pregnancy: Ultrasonic Diagnostic, Clinical Case and Perinatal Outcomes

Gynecology and Womens Health

Trophoblastic disease (TFD) considers rare tumors arising preferentially in reproductive age women. TFD is a relatively rare pathology and occurs at a rate of 1 in 22000 to 1 in 100000 pregnancies [1-3]. Trophoblastic tumors are always associated with pregnancy and can manifest both during pregnancy and after its completion (from several days to several years). The concept of “trophoblastic disease” unites several interconnected various forms of pathological condition of trophoblast: a hydatidiform mole, an invasive mole, choriocarcinoma, a placental bed tumor and an epithelioid trophoblastic tumor [2].
These tumours are rare, and they appear when cells in the womb start proliferating. Early diagnosis of GTD is essential for successful management while preserving fertility.
Malignant trophoblastic tumors (TT) are distinguished by high aggressiveness, rapid metastasis but, at the same time, high cure rates only with chemotherapy, even in the presence of distant metastases [4-6]. Various forms of TFD are considered by oncogynecologists as a single etiopathogenetic process [7]. The incidence of successful treatment of invasive forms of TFD, including choriocarcinoma, according to various authors, exceeds 80–90% [2]. After the cure of TFD, reproductive function is preserved in the absolute majority of young women.

The special properties of the ovarium, the effect of viruses (in particular, the influenza virus) on the trophoblast, immunological factors, increased hyaluronidase activity, chromosomal aberrations, and protein deficiency appear among the etiological prerequisites for TFD [8,9].

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Fetal Assessment in the 21st Century

Gynecology and Womens Health

Placental insufficiency remains the major reason for fetal hypoxia and accounts for 20-40% of perinatal mortality. There is no unanimity of opinion in the obstetrical community concerning the use of available tests of fetal well-being. These antepartum tests may be divided into three major groups:
a. Fetal heart rate assessment (NST, OCT).
b. Assessments of fetal biophysical activities other than fetal heart rate (fetal breathing movements, fetal gross body movements, fetal tone, and assessment of amniotic fluid volume).

c. Evaluation of maternal-fetal circulation (Doppler assessment of uterine, umbilical and major fetal vessels).

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Investigation of Leptin Receptor and eNOS Gene Polymorphisms in Preeclamptic Umbilical Cords

Gynecology and Womens Health

Background: Preeclampsia occurs in the umbilical artery with proteinuria and edema accompanying pregnancy-induced hypertension. Vasoconstriction results in severe complications such as intrauterine growth restriction, preterm birth, fetal death due to decreased uteroplacental blood flow. Preeclampsia may cause perinatal mortality and morbidity and it is one of the most important causes of maternal mortality. The etiology and pathogenesis of preeclampsia, which is present in 7,18% of all pregnancies, has not yet been elucidated. However, it is thought that one of the causes of pathogenesis may be caused by possible changes in the synthesis of endothelial nitric oxide synthase (eNOS) mediated nitric oxide (NO). DNA sequencing studies revealed many single nucleotide polymorphisms (SNPs) in the promoter region, exons and introns of this gene. T-786C SNP is found in the promoter region of the eNOS gene. There are several agents affecting eNOS activity in preeclampsia. Leptin is one of these agents. The exact reason of why leptin, which is a vasodilator agent, has no effect on preeclamptic pregnancies, is not known yet. However, it is thought that the leptin receptor gene Lys109Arg SNP in exon4 and Gly223Arg SNP in exon6 may affect receptor function and signaling.
Materials and methods: We investigated polymorphisms of eNOS and leptin receptor genes with HRM and PCR-RFLP techniques.
Results: Both analyses showed no SNPs in exon4 of leptin receptor (LEPR) gene in preeclampsia patients suggesting that there should be no relationship with exon4 of LEPR gene and preeclampsia. We found that there were SNPs in promoter region of eNOS gene and exon6 of LEPR gene.

Conclusion: HRM and PCR-RFLP gave different number of SNPs, these SNPs of these genes could be related with preeclampsia. This study is a preliminary step for our next molecular studies although few numbers of the samples were included. Increasing the number of samples would give the statistically significant results.

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A Special Case Report of Aggressive Hemorrhage in Posterior Vaginal Fornix DIE

Gynecology and Womens Health

Deep infiltrating endometriosis (DIE) is defined by the presence of endometrial implants, fibrosis, and muscular hyperplasia below the peritoneum, invading the tissue to a depth of more than 5 mm [1]. Deep endometriosis involves, in descending order of frequency, the uterosacral ligaments (USL), the rectosigmoid colon, the vagina, and the bladder [2]. Pain and infertility are the main manifestations of DIE, including dysmenorrhea pain, chronic pelvic pain, dyspareunia, defecation pain, dysuria and back pain. DIE lesions are deep infiltration, severe pain symptoms, poor conservative treatment, difficult surgery, pelvic adhesions, and high risk of surgical accessory injury. It has been a difficult point in clinical treatment of endometriosis and gynecological laparoscopic surgery, there is no unified clinical type and treatment specifications [3-4]. This paper reported a special case of recurrent vaginal hemorrhage caused by posterior vaginal fornix DIE.

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Preventing Anal Sphincter Tears During Delivery. An Update from Scandinavia

Gynecology and Womens Health

A common outcome of vaginal delivery is perineal trauma. The most serious among these injuries are third- and fourthdegree lacerations or obstetric anal sphincter injuries. Studies have reported that 30–50% of women with these lacerations experience anal incontinence. Symptoms of anal incontinence may affect a woman’s social, psychological, and sexual life; moreover, a previous anal sphincter injury can increase the risk of recurrence in subsequent deliveries. Therefore, it is important to prevent these injuries.

The frequency of anal sphincter injuries varies a lot between countries in Europe. The highest rates are being reported from Switzerland, Iceland, Sweden and Denmark, and a frequency counting to 6 % of all vaginal deliveries is reported. The lowest rates are usually found in Eastern Europe, Israel, Italy, and Finland where the tear rates have been below 1 % but even close to 0.5 %.

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Maternal and Perinatal Outcomes Among Women Underwent Second-Stage Versus First-Stage Caesarean Delivery at Ibrahim Malik Hospital in Sudan

Gynecology and Womens Health

Background: Second-stage caesarean is more technically difficult due to deep engagement of the fetal head, and this is associated with increased risk of maternal morbidity such as (surgical injuries and intra-operative hemorrhage) as well as fetal morbidity such as (hypoxia and fetal injury).
Objective: To determine maternal and perinatal outcome associated with caesarean sections performed in the second versus first stages of labor.
Methodology: It was observational cross sectional -hospital based study carried out in Ibrahim Malik Hospital in Khartoum State, Sudan, in the period from October 2015 to October 2016. Six hundred women were enrolled in this study. 200 women were undergoing second stage caesarean section for variable indications, while 400 women underwent first stage caesarean section.
Results: We found that women who underwent caesarean delivery in the second stage of labor had greater risk of maternal morbidity than those who underwent caesarean delivery in the first stage of labor. The rate of Bleeding >1000 ml (16.0% vs. 0.7.5%), extension of the uterine incision (20.5% vs. 6.25%), bladder injury (4.0% vs. 1.25%). The rate of fetal injury during delivery (5.5% vs. 2.0%), FSB (4.5% vs. 2.25%), admission to the neonatal intensive care unit (18.0% vs. 12.5%), neonatal sepsis (3.5% vs. 1.5%) and early neo- natal death (2.0% vs. 2.25%).

Conclusion: Intra operative bleeding, adhesion, bladder injury, caesarian hysterectomy, perinatal asphyxia, FSB, birth trauma, NICU admission and low Apgar score were most morbidity related to 2^nd stage cesarean delivery.

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Chromosome 16 Mutations and Congenital Genitourinary Malformations

Gynecology and Womens Health

Posterior urethral valve (PUV) disorder is an obstructive anomaly of the genitourinary tract. Found only in males, this condition is caused by an obstructing membrane in the posterior valve of the urethra. During the early stages of embryogenesis, the most caudal end of the wolffian duct is absorbed into the primitive cloaca, forming the posterior urethral folds [1]. In fetuses with PUV, the development of these structures is arrested resulting in fusion of these primitive folds, leading to an obstruction of the outflow of urine. This pathologic finding presents on a spectrum of varying degrees, wherein the obstruction may cause only mild symptoms and present as late as early infancy or cause severe and irreversible damage during early fetal development. In this case, we investigate the possible association between chromosome 16 and the development of the renal system, and the potential for congenital malformation in the setting of genetic alteration.

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Achieving Tumor Free Margins: Intraoperative Pathology Consultation to Lower Re-Excision Rates at a Community Hospital

Gynecology and Womens Health

Objective: Achieving tumor free margins in a single surgery is the primary goal for breast conserving therapy (BCT). It is not uncommon for these patients to undergo more than one operation for positive margins. Within our patient population, lumpectomies requiring re-excision had gross pathological findings that could have warranted further margin excision at the index surgery.
Material and Methods: 579 patients who underwent lumpectomy were reviewed retrospectively from 2010 to 2017. 478 cases of ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) were included. 91 patients underwent re-excision. Gross specimen findings that came within 2mm margins for DCIS and ink-on-tumor for IDC were considered potentially avoidable re-excisions based on the Society of Surgical Oncology-American Society for Radiation Oncology Consensus Guideline on margins. 35 cases of 91 re-excisions were found to have positive margins on gross pathologic evaluation.

Results and conclusion: The re-excision rate from 2010 to 2017 was calculated to be 19% with an average of 11 women each year. 38% of these patients had grossly positive margins. The re-excision rate according to types of histopathology was 28% for DCIS, 55% for IDC, and 53% for combined DCIS-IDC. The re-excision rate for BCT is 25% in the US. Re-excision surgery has the potential for added discomfort, surgical complications, increased health care cost, and additional emotional stress for patients. Our re-excision rate could have been reduced from 19% to 12%, by over one-third, if intra-operative pathology consultation had been utilized, with the highest impact in patients with IDC and combined DCIS-IDC.

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Biosimilar FSH Preparations Versus Highly Purified Urinary FSH for Simple Ovulation Induction in Infertile Women with Polycystic Ovary Syndrome

World Journal of Gynecology & Womens Health

Objective: To compare the efficacy of biosimilar FSH preparations and highly purified urinary FSH in ovulation induction in PCOs infertile women.
Patients and Methods: 100 infertile women with PCOs had been included in the study. Patients were randomly classified according to ovulation induction drugs used into 2 groups (Group I: included 50 infertile women received biosimilar FSH preparations and Group II: included 50 infertile women received highly purified urinary FSH. All cases were monitored for follicular development by transvaginal ultrasound.
Results: There was a mildly statistically significant difference between biosimilar FSH preparations group and highly purified urinary FSH in the mean ±SD of gonadotrophins doses used, the duration of stimulation, the number of mature follicles (p<0.05), but there was a highly statistically significant in endometrial thickness at time of HCG triggering (p<0.01). There was a mildly statistically significant difference in pregnancy rates (p<0.05). There was a mildly statistically significant difference in development of hyperstimulation syndrome and twins’ pregnancies (p<0.05).

Conclusion: Biosimilar FSH preparations were better than the highly purified urinary FSH in ovulation induction in PCOs infertile women (short duration and low doses of stimulation, significant increase in growing follicles number, enhancement in endometrial thickness and increased pregnancy rate). So, this study recommends the use of biosimilar preparations of FSH in ovulation induction in PCOs infertile women.

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Uterine Rupture and Associated Factors During Labor Amongst Women Delivered in Saudi Hajjah Hospital in Hajjah City North West Yemen

Gynecology and Womens Health

Background: Uterine rupture lead to elevated maternal and neonatal mortality in a lot of rural places in the world, while in Yemen in both rural and urban places. This study was conducted aiming to determine the prevalence and risk factors of uterine rupture in women who delivered in Saudi Hospital in Hajjah city, Yemen.
Material and Methods: Service based cross sectional study was done. The data were obtained by filling standard questionnaire from 111 uterine rupture cases and 111 non-uterine rupture comparative controls.
Results: The 2-year period of record review in the obstetrics ward shows 3,457 deliveries were conducted 111 of them had uterine rupture (incidence: 1:31). The mean maternal age of females had uterine rupture was 26 years with SD 7.4 years. For risk factors of uterine rupture, there was a highly significant association between uterine rupture occurrence and parity (>5) (OR=3.4, pv< 0.001), illiteracy of females (OR=14.2, pv< 0.001), residence far from hospitals (OR= 2.6 times, pv< 0.001), poverty (OR= 29.2, pv< 0.001), attending ANC for less than 2 visits during pregnancy (OR=29.2, pv< 0.001), using uterotonic drugs to induce or augment labor (OR=4.3, pv = 0.01), home as initial place of deliveries (OR=6.8, pv< 0.001).

Conclusion: Uterine rupture is one of the major causes of maternal morbidity and mortality in our Hospital in Hajjah. The hospital should develop strong collaborative and integration methods with catchment of healthy facility and educative campaign to decrease prevalence of uterine rupture and its impact in the surrounding Hajjah governorate.

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Therapeutic Role of Dance in the Treatment of Endometriosis-Related Chronic Pelvic Pain: A Proofof- Concept Study

Gynecology and Womens Health 

Background: Endometriosis causes chronic pelvic pain in many of the women affected, which may not remit after surgery or pharmacological treatment. Physical exercise as complementary therapy has already shown to be beneficial QoL in some chronic diseases, including endometriosis, but has not hitherto tested in the form of dance.
Material and Methods: A prospective cohort-proof-of-concept, open-label study, was conducted during the first half of 2017 in a private gynecologic center in Barcelona (Spain). Participants attended 12 dance sessions along eight weeks and were followed for one month after the end of the therapy. 6 nulliparous women who had been preciously treated by one or more surgeries, without current evidence of endometriosis but complaining of endometriosis-related chronic pelvic pain were included in this proof-ofconcept study. Pain, QoL and anxiety and kinesiophobia parameters were measured along the study.
Results: Results showed a benefit for the QoL parameters, being significant for the SF-36, which improved in a 20.5% for its Mental Component Summary and in a 16.4% for its Physical Component Summary. The other parameters did not reach clinical significance although improvement outcomes were observed for Zung scale and Tampa scale of kinesiophobia. Pain outcomes, measured with the Endometriosis Associated Pelvic Pain scale, did not show a significant improvement along the study.

Conclusion: Although studies with more ambitious design are needed in order to extrapolate the results of this proof of concept, physical exercise seems to have a beneficial effect on QoL of women with endometriosis-related chronic pain.

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Ovarian Granulosa Cell Tumors: A Retrospective Study of 21 Cases and a Review of the Literature

Gynecology and Womens Health

Background: Granulosa cell tumors are rare tumors with a relatively favorable prognosis. The aim of this study was to report the epidemiologic, anatomo-clinical characteristics and to determine treatment modalities and survival rates.
Methods: We retrospectively analyzed data from patients treated for granulosa cell tumors in our hospital over a 17-year period (1998-2015).
Results: Twenty-one cases were retrieved. The median age was 52 years. The most common clinical manifestations at diagnosis were post-menopausal bleeding and pelvic pain. Mean tumor size was 10 cm. 76.2% of the patients were diagnosed with a stage I disease. One patient (4.8%) underwent unilateral salpingo-oophorectomy, 4 patients (19%) underwent a total hysterectomy with unilateral salpingo-oophorectomy, while 15 patients (71.4%) underwent a total hysterectomy with bilateral salpingo-oophorectomy. One patient had only a biopsy. Relapse rate was 14.3% and the latest recurrence was seen 60 months after surgery. Actuarial 10-year relapse free survival (RFS) and overall survival (OS) were 85.7% and 90.5% respectively.

Conclusion: Granulosa cell tumor of the ovary is an uncommon neoplasm. The adult form progresses slowly and is often diagnosed in an early stage of disease. Surgery is the mainstay of treatment. A prolonged post-therapeutic follow-up is necessary because very late recurrences have been reported.

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Placenta Percreta Presenting as an Acute Abdomen in Second Trimester of Pregnancy: Case Report from Middle East

World Journal of Gynecology and  Womens Health

Abnormal Placentation carries life-threatening consequences to the mother. Placenta percreta is a rare complication of pregnancy. It occurs mostly in the third trimester and presents with severe postpartum hemorrhage and placenta retention. It is rare in the second trimester of pregnancy. Placenta percreta is becoming more common as cesarean section and other uterine surgeries increase. The presence of a uterine scar remains a major risk factor. Clinical presentation is variable with Antepartum hemorrhage is a usual scenario. However, it is usually seen in the third trimester. The presentation here is rare since it occurred in the second trimester rendering clinical suspicion difficult as was evident in the case. We here present a rare presentation of placenta percreta occurring in the second trimester as an acute abdomen secondary to uterine rupture and intraabdominal hemorrhage. She had a life-saving total hysterectomy and good postoperative recovery period. This might be the first case to be presented from Middle east with such scenario. Careful evaluation of a pregnant lady with an acute abdomen must be done with consideration of abnormal placentation as a cause, especially in a patient with risk factors for abnormal placentation.

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Prenatal Diagnosis of Heart Rabdomioma. A Case Report

World Journal of Gynecology & Womens Health

We describe a case of a heart tumor diagnosed by ultrasound in a 20 week’s gestational age fetus with presumptive diagnosis of heart rabdomioma. The fetus was delivered by cesarean section because a previous section at 38 weeks of gestational age. At the evaluation of the new born, the diagnosis of rabdomioma was confirmed by echocardiogram. We report of a case of prenatal rabdomioma associated to maternal diagnosis of tuberous sclerosis.

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Management Strategy Change of Endometrial Hyperplasia

Gynecology and Womens Health

Endometrial hyperplasia refers to irregular proliferation of endometrial glands, combined with an increased proportion of gland and mesenchyme. This kind of disease generally results from reproductive endocrine disorder, which is closely related to long-term estrogen stimulation without progesterone antagonism. In recent years, the views on the treatment and management of endometrial hyperplasia have been updated and changed with the deepening of research. This paper mainly focuses on the following aspects: classification change of endometrial hyperplasia, indication change of diagnostic curettage, management change of endometrial hyperplasia.

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Ectopic Pregnancy in Cesarean Scar. Case Report

Gynecology and Womens Health

Ectopic pregnancy on the scar of a previous cesarean is a very rare entity with a prevalence ranging from 1: 1,800 to 1: 2,226 pregnancies and corresponds to only 6% of ectopic pregnancies in women with a previous cesarean section. Its increasing incidence in recent years is associated not only with the increase in the number of caesarean sections, but also with the increase of scarring in the endometrium due to uterine curettage, myomectomies, hysteroscopies, manual delivery of the placenta and assisted fertilization techniques. We present a case report of a patient with a serious complication due to this pathology.

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Should Labor be Routinely Induced from 39 Weeks of Gestation?

Gynecology & Womens Health

Extended delay in the onset of spontaneous labor at term continues to be a concern of practicing obstetricians due to the potential neonatal complications of post-maturity. The perinatal mortality rate is known to progressively increase from 40 weeks of gestation in otherwise uncomplicated pregnancies [1,2], but there have been conflicting reports regarding whether routine induction of labor would be associated with increased likelihood of primary c/section. One recent study addresses these issues and provides statistical evidence for the maternal benefits of elective induction of labor at 39 weeks of gestation without compromising fetal safety.

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