Giant uterine STUMP in pregnancy: A rare case report with preservation of fertility.

BACKGROUND: Smooth muscle tumors of uncertain malignant potential (STUMPs) are infrequent and represent an extremely rare cause of oligohydramnios in pregnant women. DESCRIPTION OF THE CASE: A 34-year-old woman at 25 weeks of gestation was referred with clinical features indicative of anemia. The transabdominal ultrasound revealed a fetus with appropriate growth for the gestational age, with oligohydramnios and a giant uterine mass. At 30 weeks of gestation, due to anhydramnios and repeated non-reassuring non-stress tests, a cesarean section was performed, followed by a myomectomy of a 9 kg mass. A neonate weighing 1,350 g was delivered (Apgar score 1΄: 4, 5΄: 7). The woman preserved her fertility and had an uneventful recovery during the puerperium, while the final histology revealed multiple STUMPs. The postoperative management included follow-up every six months for five years. CONCLUSION: This is the only reported case of a pregnant woman with STUMPs of this size that underwent myomectomy during the cesarean section and avoided hysterectomy. HIPPOKRATIA 2021, 25 (4):169-171.

Nerve sparing radical hysterectomy in early stage cervical cancer. Latest developments and review of the literature.

BACKGROUND: Cervical cancer is the second most common malignancy of the female genital tract worldwide. Radical hysterectomy with pelvic lymphadenectomy exemplifies the treatment of choice for early stage disease, whereas even if it is performed by gynaecologist-oncologist, still has the drawback of significant postoperative morbidity, especially for urinary bladder function. Nerve-sparing radical hysterectomy (NSRH) is a technique in which the neural part of the cardinal ligament which encloses the inferior hypogastric plexus, as well as the bladder branch (distal part of the plexus), remains intact. By this way, the bladder's innervation is safe and its functional recovery is more rapid. There is sufficient data to support the feasibility of the technique via laparotomy and laparoscopy, as well as the effectiveness related to the postoperative bladder dysfunction compared to conventional radical hysterectomy. On the other hand, the evidence related to survival outcomes is weak and derives from non-randomized trials. However, the low rate of local relapses after NSRH in early stage disease (IA2-IB1) with tumor diameter less than two cm makes the procedure suitable for this group of patients. CONCLUSION: According to the current evidence NSRH seems to be a suitable technique for gynaecologist-oncologist familiar with the method in early stage cervical cancer. It is a technique which improves significantly postoperative bladder recovery and the patients' quality of life (QoL), without compromising the oncological standard.

Effectiveness of sublingual use of 400 mcg prostaglandin E1 for first trimester surgical abortion according to parity: a retrospective study.

AIM: The aim of this paper was to evaluate the effectiveness of sublingual use of misoprostol in women undergoing first trimester surgical abortion. Special consideration was given in a sub-group analysis according to parity. METHODS: A retrospective study was conducted, enrolling patients during 2006-2009. Pregnancies less than 12 weeks of gestation were exclusively included. Our sample was divided in: group 1, in which we included women who had received 400 mcg of misoprostol sublingually two hours before surgical abortion and group 2, with no use of misoprostol. Cervical dilatation and estimated blood loss (EBL) were compared between the two groups. Moreover, a sub-group analysis of the former parameters was made separately in nulliparous and multiparous women. RESULTS: Out of 79 patients included, 48 (60.75%) received misoprostol, while 31 (39.25%) did not. Cervical dilatation was significantly higher in group 1 (6.4±2.1 mm vs. 4.7±1.7 mm in group 2, P=0.001), while EBL was significantly lower in the same group (105.0±22.1 mL vs. 120.3±24.2 mL for group 2, P=0.005). Concerning the sub-analysis, cervical dilatation was significantly increased and EBL was significantly lower in multiparous receiving misoprostol comparing with those who did not (P=0.001 and P=0.002, respectively). However, the same parameters did not differ significantly between the two sub-groups of nulliparous women. CONCLUSION: Sublingual administration of 400mcg misoprostol is effective concerning cervical ripening and EBL in women undergoing first trimester surgical abortion. According to the results of the present clinical trial prostaglandin E1 is more effective in multiparous group of women.

Biomarkers in pre-eclampsia: a novel approach to early detection of the disease.

Pre-eclampsia is a unique disorder of human pregnancy with a great impact on maternal and perinatal morbidity and mortality worldwide and especially in developing countries. The aetiology is still unknown and the pathophysiology of the disease is the subject of extensive investigation. Recently, much of the interest of the investigators for the prediction of pre-eclampsia has been aimed at measurable manifestations of abnormal placentation, endothelial dysfunction and feto-maternal unit perfusion. Biomarkers constitute a novel approach to an early detection of the disease. Low maternal serum levels of PAPP-A and PP13 early in pregnancy are predictive for emerging pre-eclampsia. On the other hand, increased levels of homocysteine, ADMA, sEng, leptin and sFlt-1 in the 1st trimester, signal the onset of the disease later in pregnancy. After the onset of pre-eclampsia, increased serum levels of PAPP-A, ADMA, homocysteine and sFlt-1 are associated with the severity of the disease. The identification of biomarkers which can contribute to the early detection of pre-eclampsia is essential. It could then be possible to apply better surveillance and treatment protocols in such patients.

Neonatal outcomes of late preterm deliveries with pre-eclampsia.

AIM: The aim of the study was to examine the impact of pre-eclampsia on neonatal outcomes of late preterm deliveries. METHODS: A retrospective study was conducted, enrolling pregnancies delivered between 34 0/7 and 36 6/7 weeks of gestation during the period 2004-2007 in a large tertiary center. Pregnancies were divided in group 1, including those complicated with pre-eclampsia and group 2, including normotensive cases. Epidemiological characteristics, mode of delivery and complications contributing in late preterm delivery were initially studied. Neonatal morbidity parameters of our interest included mean Apgar score in the 1st and 5th minute, admission to Neonatal Intensive Care Unit (NICU) and need for emergency intubation. Intrauterine growth retardation (IUGR), low birth weight (LBW) and very LBW (VLBW), respiratory distress syndrome (RDS), hypoglycemia, NICU infection, abnormal cerebral ultrasonographic findings and duration of NICU residence were also compared between the two groups. RESULTS: Out of 363 late preterm pregnancies, 29 (8%) were delivered because of pre-eclampsia. Mean gestational week and birth weight were significantly lower in group 1. The rate of elective caesarean section was also significantly higher in this group. The same observation was made concerning rates of IUGR, LBW and VLBW neonates. Furthermore, incidence of NICU admission and hypoglycemia were significantly higher in the group of infants born by pre-eclamptic mothers. Incidence of RDS and cerebral echo pathology were also higher, but without significant difference when compared to group 2. CONCLUSION: Neonatal adverse outcomes were increased in late preterm infants of pre-eclamptic women in comparison with those of normotensive women.

Amniocentesis-related adverse outcomes according to placental location and risk factors for fetal loss after midtrimester amniocentesis.

PURPOSE OF INVESTIGATION: Amniocentesis-related adverse outcomes in singleton pregnancies and possible risk factors for fetal loss after mid-trimester amniocentesis performed in a single institution were investigated. METHODS: Amniocentesis-related adverse outcomes such as insufficient aspiration of amniotic fluid (AF), repeated puncture, and aspiration of hemorrhagic AF after mid-trimester amniocentesis were reviewed, while special consideration was given according to the placental location. Fetal loss rate up to 24 weeks of gestation and risk factors related to fetal losses were also investigated. RESULTS: 5,948 cases with the inclusion criteria were analyzed. Advanced maternal age was the most common indication (53%) for amniocentesis. A need for repeated puncture was overall 2.1% (n = 128) and was associated with a fundal placental location. Aspiration of hemorrhagic amniotic fluid was observed in 3.7% (n = 222) and was significantly associated with an anterior or fundal placental position. Fetal loss rate was 0.3% and there was no relationship with advanced maternal age (> or = 35 years), gestational age at amniocentesis > 18 weeks, repeated procedure, aspiration of hemorrhagic AF or placental location. CONCLUSION: Anterior or fundal placental position is a risk factor for amniocentesis-related adverse outcomes, however without significant contribution to the fetal losses. Placental location, advanced maternal age, amniocentesis gestational age > 18 weeks, and the procedure's adverse outcomes seem to have no impact on fetal loss rate.

Parity affects pregnancy outcomes in women 35 and older.

PURPOSE OF INVESTIGATION: The objective of the study was to examine the impact of parity on pregnancy outcomes in women 35 years and older. METHODS: The study was a retrospective cohort of singleton pregnancies of women aged > or = 35 years old during the period 2004-2008. Women were divided in two groups: group 1 included primigravidas and group 2 those with at least one past labor. Epidemiological characteristics, obstetric and neonatal outcomes were analyzed using the t test and chi-square test. RESULTS: 816 out of 5834 (14%) cases involved women aging > or = 35 years, 234 (28.7%) of which were nulliparous and 582 (61.3%) multiparous. Rate of cesarean section was 2.4 fold higher for primigravidas (p < .0001). Fetal distress, prolonged labor and Neonate Intensive Care Unity (NICU) admission were also significantly higher in group 1. CONCLUSION: Adverse pregnancy outcomes were increased in primigravidas of 35 years and older compared to multigravidas of the same age.

Intravaginal misoprostol reduces intraoperative blood loss in minimally invasive myomectomy: a randomized clinical trial.

PURPOSE OF INVESTIGATION: We performed a randomized clinical trial to estimate whether preoperative use of misoprostol may reduce intraoperative blood loss of patients treated by minimally invasive surgery (MIS), such as laparoscopic (LM) or laparoscopically assisted myomectomy (LAM). METHODS: Sixty-seven menstruating patients with three or less myomas of a maximum diameter of 90 mm, scheduled for MIS, were randomly allocated to receive a preoperative single dose of intravaginal misoprostol or placebo. Sixty-four patients remained in the final analysis: 30 in the misoprostol (I) and 34 in the placebo group (II). Estimated blood loss (EBL), decline of postoperative hemoglobin (Hb) and side-effects of administered agent were the outcomes of main interest. RESULTS: The EBL was significantly higher in the placebo versus misoprostol group (217 +/- 74 vs 126 +/- 41, respectively). Similarly, the decline of postoperative Hb was significantly higher in group II (1.6 +/- 0.43) compared to group I (1 +/- 0.33). The operative time was comparable in both groups, while the rate of side-effects was similar between groups. CONCLUSION: The preoperative use of misoprostol in patients with uterine fibroids managed by minimally invasive surgery significantly reduces intraoperative blood loss. Misoprostol might be useful for the prevention of postoperative anemia in more extended minimal invasive interventions, such as myomectomy of large fibroids or laparoscopic hysterectomy.

Conservative management of young patients with endometrial highly-differentiated adenocarcinoma.

Endometrial cancer is uncommon in young women. However, almost 5% of patients are younger than 40 years old. Progestins such as medroxyprogesterone acetate (MPA) and megestrol acetate (MA), have been used as a fertility-sparing approach in this group of patients, with different dose regimens of cyclic (14 days every month) or continuous therapy successfully used. According to the present data, the overall response rate was 73% in a median time of 4 months (range 1-15 months). Endometrial biopsy every 3 months was the common approach to evaluate the patient's response during the treatment. The relapse rate was 36% in a median follow-up time of 22 months (range 6-73 months). Overall, 40% of patients who responded to the treatment successfully, conceived. Half of the patients used assisted reproductive technology to achieve an immediate pregnancy. Although, there are no definite recommendations concerning the conservative management of young patients with early stage endometrial cancer, progestin agents may be used in a selected group of patients for fertility-sparing reasons. After childbearing is completed, hysterectomy remains the standard treatment.

Epidemiological characteristics and trends of caesarean delivery in a University Hospital in Northern Greece.

BACKGROUND: Current obstetric practice is characterised by a continuous increase in caesarean section (CS) delivery rates. OBJECTIVE: Main purpose of our study was to estimate the overall and annual rates of CS in a University Hospital in Greece. METHODS: This was a retrospective chart review of all singleton pregnancies delivered by CS between 2004 and 2008 at a gestational age > 24 weeks. The overall and annual CS rates were calculated. The rate of elective (Group 1) and emergency CS (Group 2) , as well as the specific indications in the two groups of the study were also analyzed. RESULTS: Overall 5362 singleton pregnancies were delivered in the period of the study. The overall CS rate was 29.2% (n = 1564). The mean ±SD maternal age in years of the women delivered by CS was 29.65 ± 6.72 years, while it was 27.10 ±5.63 years for those who delivered vaginally (P<0.0001). The overall rates of elective and emergency CS were 18.2% and 11.0% respectively in the 5-year period of the study. The most common indication for an elective CS was a previous CS (63.1%), which remained almost stable during the period of the study. The main indication for emergency CS was foetal distress in the first three years of the study, while labour progress failure was the leading indication in the last two years. CONCLUSION: In this series, the overall CS rate was high. A previous caesarean delivery accounts for about one third of all cases and constitutes the leading indication for elective CS while foetal distress is the most common indication for an emergency caesarean section.

Previous cesarean section increases the risk for breech presentation at term pregnancy.

PURPOSE OF INVESTIGATION: The aim of the present study was to estimate the risk for breech presentation in women with singleton pregnancies at-term who had had at least one previous cesarean section (CS) versus at least one previous vaginal delivery. METHODS: Out of 4269 singleton pregnancies during the study period, 2008 met the inclusion criteria. The history, the number of previous CSs, as well as maternal age, parity, birth weight, gestational age, neonatal sex and placenta previa were used to estimate the risk for breech at term. RESULTS: The overall incidence of breech presentation was 3.2%, while 20% of the women had a history of at least one previous CS. The rate of breech presentation at term in singleton pregnancies after CS increased two-fold (5.3%) when compared to those with at least one previous vaginal delivery (2.6%), (p = 0.01) [OR 2.08 (95% CI, 1.23-3.52)], while the number of the previous CSs did not correlate with breech presentation (p = NS) [OR 0.86 (95% CI, 0.31-2.4)]. CONCLUSION: According to the present study, women with a history of at least one cesarean delivery have an increased risk for breech presentation in the subsequent singleton pregnancy at-term.

Genetics of polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a syndrome involving defects in primary cellular control mechanisms that result in the expression of chronic anovulation and hyperandrogenism. This syndrome has been for many years one of the most controversial entities in gynecological endocrinology. Polycystic ovary syndrome has been proven to be a familial condition. Although the role of genetic factors in PCOS is strongly supported, the genes that are involved in the etiology of the syndrome have not been fully investigated until now, as well as the environmental contribution in their expression. The heterogeneity of the syndrome entertains the mystery around this condition which concerns thousands of infertile women worldwide. Some genes have shown altered expression suggesting that the genetic abnormality in PCOS affects signal transduction pathways controlling steroidogenesis, steroid hormones action, gonadotrophin action and regulation, insulin action and secretion, energy homeostasis, chronic inflammation and others. The present review of the contemporary literature constitutes an effort to present all the trends in the current research for the etiology of polycystic ovary syndrome.

Outcome of laparoscopic sacrocolpopexy with anterior and posterior mesh.

AIM: The assessment of the postoperative outcome following laparoscopic sacrocolpopexy using anterior and posterior mesh. MATERIAL AND METHODS: In the study were included one hundred and ten women (mean age 62 years with range from 34 to 78) who had laparoscopic sarcoplexy the period 2001-2005. They were contacted and completed postal questionnaires more than one year after surgery and had a follow up in the uro-gynaecology clinic. RESULTS: The median follow up was 21 months. Eighty-three of them (75.4%) answered the postal questionnaire. Good satisfaction was defined as complete disappearance of all genito-urinary symptoms. Moderate satisfaction was defined as a partial disappearance of symptoms, or de novo less annoying symptoms. Dissatisfaction was defined as no change in symptoms, and /or de novo important symptoms. The overall rate of good satisfaction was 74.7% (62/83), moderate satisfaction 15.6% (13/83), and only 9.6% (8/83) were not satisfied. There was no statistical difference among the six different groups (sacrocolpopexy only, plus TVT, plus TVT and hysterectomy, sacrocolpopexy and previous hysterectomy, sacrocolpopexy and TVT with previous hysterectomy), concerning the pre and post operative clinical signs and post operative symptoms. There was a statistically significant difference (p=0.038) regarding dissatisfaction and prolapse relapse between the group that had a previous total hysterectomy combining sacrocolpopexy with TVT and all other groups. The most frequent post operative symptoms were stress incontinence, dysuria and constipation. No severe complications and mesh erosion were observed, despite the two cases of mesh detachment. CONCLUSIONS: Laparoscopic double synthetic mesh sacrocolpopexy seems to be a safe and effective treatment of genitourinary prolapse, with good overall long term outcomes and benefits of the minimal access approach. The presence of the remaining cervix after subtotal hysterectomy, seems to enhance the results of laparoscopic sacrocolpopexy.. Further randomised studies are needed to confirm our results and to compare this method to open and/or vaginal approach.

Operative vaginal delivery in singleton term pregnancies: short-term maternal and neonatal outcomes.

BACKGROUND: The rate of operative vaginal delivery has remained stable the last decade, however the rate of vacuum has increased against forceps application. Different maternal and neonatal outcomes have been proposed by many reports. The aim of the present study is to compare the short term maternal and neonatal outcomes between vacuum and forceps delivery. MATERIAL AND METHODS: We conducted a medical record review of live born singleton, vacuum and forceps-deliveries. Maternal and delivery characteristics were recorded. Maternal and neonatal outcomes were also assessed. Out of 7098 deliveries, 374 were instrument assisted, 324 were conducted by vacuum (86.7%) and 50 by forceps (13.3%). RESULTS: The incidence of 3rd degree lacerations and periurethral hematomas was similar between vacuum and forceps (3.4% vs. 2% and 0.3% vs 0% respectively), while perineal hematomas were more common in forceps compared with vacuum application (2% vs 0.3% respectively), albeit not significantly. The rate of neonates with Apgar scores

Clear cell ovarian carcinoma following polymyositis diagnosis: a case report and review of the literature.

BACKGROUND: The association of ovarian malignancy with dermatomyositis (DM) is well established from previous reports, while the relationship with polymyositis (PM) is rare. CASE REPORT: We report a case of a 50 years old nulliparous woman who developed clear cell ovarian cancer four years after the PM diagnosis. The patient presented with deep lower abdominal pain and distension. CA-125 was elevated and the preoperative MRI showed pelvic tumor occupying the Douglas pouch. Exploratory laparotomy revealed a gross mass of clear cell ovarian carcinoma. CONCLUSION: Physicians must be alert of the possibility of malignancy in patients with a previous diagnosis of polymyositis.

Immunohistochemical bcl-2 expression, p53 overexpression, PR and ER status in endometrial carcinoma and survival outcomes.

Immunohistochemical expression of bcl-2, p53, PR and ER in cases with endometrial carcinomas arrayed on a tissue microarray (TMA) was tested and correlated with clinicopathologic features, overall survival (OS), cancer-related survival (CRS) and disease-free survival (DFS). Seventy-seven patients with endometrial cancer were reviewed. Slides were evaluated by two pathologists blinded to patient clinical characteristics and survival data. Mean age of patients was 62.5 years (range 35-80), median follow up 60 months (range 9-120). Seventy-nine percent of patients were FIGO Stage I; 39% of the cases showed bcl-2 cytoplasmic staining and its expression was significantly correlated with low-grade tumor differentiation and age < or = 60 years. Nuclear p53 overexpression was detected in 23.4% of the cases and was significantly correlated with advanced stages (IIB-IV), non-endometrioid histology, nodal metastasis and advanced age (> 60 years). PR and ER were positive in 63.6% and 30% of the cases, respectively. Analysis of p53 overexpression and bcl-2 expression in relationship with PR and ER status showed a direct correlation between bcl-2 expression and PR positivity (p = 0.001). In a multivariate analysis FIGO staging was the only clinicopathologic parameter independently correlated with DFS. In conclusion p53 overexpression was directly associated with unfavorable clinicopathologic factors such as advanced stage, histologic subtype, advanced patient age and nodal metastasis. Bcl-2 expression was related with younger age, favorable grade and PR expression by tumor cells. Patient survival was not related to the tested biomarkers.

Role of lymphadenectomy and pelvic radiotherapy in patients with clinical FIGO stage I endometrial adenocarcinoma: An analysis of 208 patients.

Two hundred and eight patients with a clinical stage I endometrial carcinoma were studied (164 fulfilled the inclusion criteria). High risk was defined as nonendometrioid, or endometrioid tumors grade 3 (G3), or G2 with any or G1 with deep (>1/2) myometrial infiltration. The low-risk group consisted of the remaining patients. Surgical staging in the high-risk group included pelvic lymphadenectomy with para-aortic lymphadenectomy in selected cases. Twelve percent of the high-risk patients had nodal metastasis. Patients with low-risk (group A, n = 85) and high-risk disease confined to the uterus (group B, n = 57) did not receive adjuvant radiotherapy. Patients with nodal metastases (group C, n = 10) received postoperative irradiation. The total recurrence rate of the entire population was 12.5%, and the actuarial overall survival, disease-specific survival, and disease-free survival were 90%, 94%, and 88%, respectively. All patients with only vaginal relapse (n = 9) were cured locally with salvage radiotherapy until the date of analysis. The pelvic relapse rate was low as only one patient of group B recurred in the pelvis. In conclusion, lymphadenectomy remains indicated to better select patients at high risk of pelvic recurrence that may benefit from postoperative radiotherapy.

Pelvic lymphadenectomy as alternative to postoperative radiotherapy in high risk early stage endometrial cancer.

OBJECTIVE: The purpose of the study is to evaluate whether surgery followed by radiotherapy in high-risk patients of early stage endometrial cancer can be replaced by formal surgical staging. Cancer-related survival and recurrence-free survival (RFS) were the endpoints of the analysis. STUDY DESIGN: One hundred and eighteen patients with endometrioid endometrial adenocarcinoma between 1996-2003 were reviewed. Patients with incomplete follow-up and extrauterine spread excluded, leaving 78 women in the final analysis. Low-risk patients (n=37) (Grade 1, myometrial infiltration <1/2 or Grade 2, <1/3), treated by standard surgical procedure including total abdominal hysterectomy, bilateral salpingo-oophorectomy and peritoneal washing, while staging lymphadenectomy (n=24) or postoperative irradiation (n=17) was added in the high-risk group (Grade 1, >1/2 or Grade 2, >1/3 or Grade 3). RESULTS: The median age of patients was 65 years (range, 35-80 years) and the median follow-up 38 months (range, 9-98 months). The recurrence rate in low-risk patients was 2.7%, the cancer-related survival 97.5% and RFS 97%, while in the high-risk patients 12%, 93% and 88%, respectively. Comparing the therapeutic modalities (staging lymphadenectomy vs. postoperative irradiation) in the high-risk group the cancer-related survival and RFS was not differed (P=0.70, P=0.90, respectively). The high grade of the tumor was significantly correlated with RFS, while age, stage and myometrial infiltration were not. No moderate or severe complications developed after lymphadenectomy, while two moderate gastrointestinal complications occurred after adjuvant radiotherapy. CONCLUSION: According our results the low-risk patients of early stage endometrial adenocarcinoma had excellent survival with minimal intervention. The cancer-related survival and RFS in high-risk patients concerning the therapeutic modalities were comparable. Poor tumor differentiation was the most unfavorable prognostic factor related with RFS. Moderate complications developed only after postoperative radiotherapy.