Assessment of the clinical benefits of prenatal screening for toxoplasmosis in southern Taiwan.

OBJECTIVE: The present study aimed to investigate the seroprevalence and risk factors for toxoplasmosis among pregnant women in southern Taiwan and to determine the clinical benefits of screening for the same. MATERIALS AND METHODS: The current study included 458 pregnant women who received prenatal care from the first trimester at the Kaohsiung and Chiayi Chang Gung Memorial Hospitals during the time period from 2014 to 2015. Serological tests performed to detect the presence of Toxoplasma IgG and IgM antibodies. Amniocentesis was scheduled and real-time polymerase chain reaction (PCR) was employed to detect Toxoplasma DNA. Moreover, the maternal characteristics and risk factors, perinatal outcomes related to the seropositivity for Toxoplasma infection were analyzed. RESULTS: Among the pregnant patients included in the current study, 39/458 (8.5%) were IgG+ and 2/458 (0.6%) were IgM+. The present study analyzed the maternal characteristics and risk factors, perinatal outcome pertaining to the IgG seropositive group by means of the multiple logistic regression analysis revealed a female predominance (10.8%), compared to the males (6.4%), (adjusted OR = 0.48 (95%, 0.24-0.98), P = 0.043∗). The number cases with gestational age above 37 weeks at the time of delivery was significantly lower, compared to the cases below 37 weeks (adjusted OR = 0.32 (0.12-0.94), P = 0.038∗). Among one case with low avidity cannot exclude recent infection, the amniocentesis did not show any evidence of vertical transmission. CONCLUSION: The scenario may not warrant general screening and the results will not influence the clinical decisions. Although the present study failed to identify the maternal risk factors related to Toxoplasma infection, the results imply that health education is essential, owing to the slightly higher rate of preterm delivery in the IgG seropositive group.

Seroprevalence and risk factors for cytomegalovirus infection among pregnant women in southern Taiwan, 2014-2015.

OBJECTIVE: To investigate the seroprevalence of and risk factors for cytomegalovirus (CMV) infection among pregnant women in southern Taiwan. MATERIALS AND METHODS: From 2014 to 2015, pregnant women undergoing their first prenatal care visit participated in this study at Kaohsiung Chang Gung Memorial Hospital and Chiayi Chang Gung Memorial Hospital. A serologic test was performed for anti-CMV IgG/IgM. Transabdominal amniocentesis was scheduled for those with seropositive anti-CMV IgM. Extraction of CMV DNA was performed via real-time polymerase chain reaction (PCR). Maternal sociodemographic characteristics and risk factors for CMV seropositivity were analyzed. RESULTS: A total of 539 pregnant women undergoing their first prenatal visit were included. Eighty-three pregnant women were excluded for delivering at other hospitals. The overall seroprevalence rate of anti-CMV IgG in the remaining 456 cases was 87.28%. The seroprevalence rates of anti-CMV IgG(+)/IgM(+) and IgG(+)/IgM(-) were 1.32% and 85.96%, respectively. According to the anti-CMV IgG avidity test, only 3 pregnant women (0.65%) had primary CMV infection. Two of them underwent amniocentesis, and the results for both were negative for CMV DNA. According to the logistic regression analysis, the seropositivity of anti-CMV IgG was significantly associated with maternal age ≥30 (adjusted OR = 2.08, 95% CI: 1.10-3.94, p = 0.025) and the seropositivity of anti-CMV IgM was significantly associated with gestational weeks ≥37 when delivery (adjusted OR = 7.81, 95% CI: 1.23-49.58, p = 0.029). CONCLUSION: In southern Taiwan, among pregnant women, the CMV seroprevalence was high (87.28%), but the rate of primary CMV infection was very low (0.65%). Pregnant women aged more than 30 years had a significant risk of CMV seropositivity.

Levonorgestrel intrauterine system for the treatment of intermenstrual spotting in patients with previous cesarean delivery scar defect.

AIM: To evaluate the efficacy of levonorgestrel 52 mg intrauterine system for intermenstrual bleeding in patients with previous cesarean delivery scar defects (PCDSs). METHODS: The medical records of 28 consecutive patients with previous cesarean delivery scar defect and intermenstrual bleeding who had undergone conservative treatment with levonorgestrel 52 mg intrauterine system were reviewed. The efficacy of treatment and frequency of adverse events were measured retrospectively. RESULTS: After 1 year of treatment, 22 patients (78.6%) reported an improvement in symptoms. The mean duration of menstruation were 18 and 5 days before and after treatment, respectively. No uterine perforations or pelvic inflammatory diseases occurred during or after the insertion procedures. Eighteen (64.3%) patients did not experience any adverse events, and the patients with adverse events reported that they could be managed by adjusting their medications or observation. CONCLUSION: Levonorgestrel intrauterine system may have a role in the safe and effective management of intermenstrual spotting in patients with PCDSs.

Specific hysteroscopic findings can efficiently distinguish the differences between malignant and benign endometrial polyps.

OBJECTIVE: To evaluate differences in hysteroscopic findings between benign endometrial polyps and endometrial cancer. MATERIALS AND METHODS: From January 2012 to December 2016, we extracted 179 cases with endometrial polyps from 3066 women who underwent hysteroscopy followed by dilatation and curettage or transcervical resection, with 154 and 25 cases of benign and malignant endometrial polyps, respectively. Clinical characteristics, histopathological and hysteroscopic findings of the women were evaluated retrospectively. RESULTS: The hysteroscopic findings of malignant polyps were hyper-vascular (72%, 18/25), ulcerative (64%, 16/25) and polyps with irregular surfaces (24%, 6/25). In contrast, pedunculate small growths with smooth surfaces were usually seen in the benign endometrial polyps (38.3%, 59/154). Hyper-vascular (OR: 142.6, 95% CI: 25.98-783.4) and polyps with irregular surfaces (OR: 12.02, 95% CI: 1.765-81.83) in hysteroscopic findings were significant strong predictors of endometrial polyps with endometrial cancer. Hysteroscopic findings of ulcerative changes were most strongly associated with a diagnosis of malignant polyps, with sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of 64.0%, 100%, 94.5%, and 100%, respectively. CONCLUSION: Women with hysteroscopic findings of endometrial polyps with hyper-vascular, ulcerative, and polyps with irregular surfaces had a high likelihood of endometrial cancer. A target biopsy of the polyps with these specific appearances should be performed to exclude malignant lesions.

The effects of "unilateral midurethral sling cut down" in women with voiding dysfunctions after anti-incontinence surgery.

PURPOSES: Midurethral synthetic sling (MUS) placement via either the retropubic or transobturator route is the standard surgical procedure for women with stress urinary incontinence. However, a small portion of patients experienced voiding dysfunction after the surgery, which was debilitating to their quality of life. Our study was aimed at demonstrating the effectiveness of the unilateral sling cut down for post-midurethral sling (MUS) voiding dysfunction and, secondarily, at evaluating the changes in urodynamic parameters. METHODS: We retrospectively reviewed the charts of patients who received unilateral midurethral sling cut down for voiding dysfunction after an MUS procedure. The cut-down procedures were performed at the urethral meatus, in the 9 or 3 o'clock direction. Preoperative and postoperative subjective and objective parameters were compared to evaluate the outcome of the cut-down procedures. RESULTS: We selected 15 patients who underwent unilateral MUS cut down for voiding dysfunction after anti-incontinence procedures with various MUSs. The cut-down procedures were performed at a median interval of 7.1 months after sling insertion. The subjective results of the Patient Global Impression of Improvement (PGI-I) after the cut-down procedure showed an overall satisfaction of 93.33%. After the cut-down procedure, the median flow rate increased from 14.8 to 22 ml/s (P > 0.05), and the post-void residual urine volume decreased from 193.5 to 35.0 ml (P < 0.05). All patients attained continence after the cut-down procedures. CONCLUSIONS: Unilateral MUS cut down is effective in the management of voiding dysfunction after anti-incontinence surgery, with a low risk of recurrence of urinary incontinence.

Survival benefit of sphingosin-1-phosphate and receptors expressions in breast cancer patients.

Sphingosine-1-phosphate (S1P) is a bioactive lipid that exerts various pathophysiological functions through binding to its receptor family (S1PRs). Since first report of the breast cancer (BCA) promoting function by S1P production (through the function of sphingosine kinases) and S1P/S1PR signaling, their antagonists have never been successfully progress to clinics after three decades. Taking advantage of bioinformatics linking to gene expression to disease prognosis, we examined the impact of associated genes in BCA patients. We found high gene expressions involved in S1P anabolism suppressed disease progression of patients who are basal cell type BCA or receiving adjuvant therapy. In addition, S1PRs expression also suppressed disease progress of multiple categories of BCA patient progression. This result is contradictory to tumor promoter role of S1P/S1PRs which revealed in the literature. Further examination by directly adding S1P in BCA cells found a cell growth suppression function, which act via the expression of S1PR1. In conclusion, our study is the first evidence claiming a survival benefit function of S1P/S1PR signaling in BCA patients, which might explain the obstacle of relative antagonist apply in clinics.

Validation of the traditional Chinese version of the prolapse quality of life questionnaire (P-QOL) in a Mandarin-speaking Taiwanese population.

OBJECTIVE: To validate the traditional Chinese translated version of the prolapse quality of life questionnaire (P-QOL). MATERIALS AND METHODS: The P-QOL questionnaire was translated into traditional Chinese characters and administered to women recruited from gynecologic outpatient clinics of Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. After the test-retest reliability and internal consistency were established in a pilot study, all participants completed the P-QOL questionnaire and were examined in the lithotomy position using the Pelvic Organ Prolapse Quantification System (POP-Q). The construct validity was assessed by comparing symptom scores and quality-of-life domain scores between symptomatic and asymptomatic women. RESULTS: Of the 244 women recruited, 159 were symptomatic for pelvic organ prolapse, and 85 were asymptomatic. The test-retest reliability confirmed a significant positive monotonic correlation between the total scores of each domain (n = 30, Spearman's rho was from 0.411 to 0.888, p < 0.05 of all). All items achieved a Cronbach α > 0.80 showing good internal consistency. Among the 18 symptom questions, the scores differed significantly between symptomatic and asymptomatic women for 12/18 symptom questions. These 12 questions referred to the prolapse/vaginal symptoms. All the quality of life domains differed significantly (p < 0.05) between symptomatic and asymptomatic women except for the domain of sleep/energy (p = 0.108). CONCLUSION: The traditional Chinese language version of the P-QOL is a reliable instrument for the assessment of symptom severity and impact on quality of life in women with pelvic organ prolapse.

Evaluation of the single-incision Elevate system to treat pelvic organ prolapse: follow-up from 15 to 45 months.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the 2-year clinical outcomes of pelvic reconstructive surgery with the single-incision Elevate system (American Medical Systems, Minnetonka, MN, USA). METHODS: This retrospective study was conducted from November 2010 to August 2013, and included 210 patients with pelvic organ prolapse stage 3 or 4 who underwent pelvic reconstructive surgery with an Elevate system and were followed for 1 to 3 years postoperatively. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7) and multi-channel urodynamic examinations. Anatomical success was defined as postoperative POP-Q stage 0 or I. RESULTS: The anatomical success rates were 95 % for the anterior vaginal wall, 99 % for the posterior vaginal wall and 94 % for the apical vaginal wall after a median 27 months of follow-up. POP-Q, UDI-6 and IIQ-7 scores, maximal flow rate and post-voiding residual urine all improved significantly after surgery. Complications included 1 case of internal bleeding, 4 cases of mesh exposure, 5 cases of recurrent prolapse that required salvage operations, and 3 cases of urine retention that required intermittent catheterization. There were no bladder or bowel injuries during surgery. CONCLUSIONS: Pelvic reconstructive surgery with the Elevate system yielded good anatomical outcomes and symptom improvement after 2 years of follow-up.

Medium-term comparison of uterus preservation versus hysterectomy in pelvic organ prolapse treatment with Prolift™ mesh.

INTRODUCTION AND HYPOTHESIS: We conducted a medium-term assessment of clinical outcomes and complications after surgical repair of pelvic organ prolapse (POP) using Prolift™ mesh, and sought to determine whether concomitant hysterectomy clinically influenced the outcome of pelvic reconstruction in patients without a prior history of urogenital surgery. METHODS: Patients diagnosed with POP-Q stage 3/4 uterine prolapse at a tertiary referral urogynecology unit in South Taiwan who had undergone POP repair with Prolift mesh from May 2007 to July 2010 were identified by chart review. Concomitant hysterectomy was performed in 24 patients (hysterectomy group), and uterus-sparing surgery in 78 (uterus-sparing group) Preoperative and postoperative subjective assessments of urinary and prolapse symptoms, objective POP-Q score, urodynamic examination, and postoperative adverse events were compared between the groups. RESULTS: The mean follow-up periods were 25.7 months (range 6.2 - 73.1 months) and 31.7 months (range 6.0 - 78.4 months) in the concomitant hysterectomy and uterus-sparing groups, respectively. There were no between-group differences in functional and anatomic outcomes after surgery. No statistically significant differences were found in postoperative adverse events between the groups. CONCLUSIONS: Pelvic reconstruction using Prolift with concomitant hysterectomy and uterus-sparing surgery have similar anatomic and functional results at 2.5 years. Therefore, we consider uterus-sparing surgery to be an alternative to hysterectomy in uterine prolapse repair.

Outcomes of primary surgical evacuation during the first trimester in different types of implantation in women with cesarean scar pregnancy.

OBJECTIVE: To assess the efficacy and safety of primary surgical evacuation therapy for cesarean scar pregnancy (CSP) of the first trimester, and to evaluate its possible prognostic factors. DESIGN: Retrospective consecutive cohort study. SETTING: Tertiary care university hospital. SUBJECT(S): A cohort of patients with CSP and clear ultrasound images who underwent primary surgical evacuation from January 2000 to December 2012. INTERVENTION(S): Patients fulfilling the ultrasound criteria of CSP were further classified into superficial and deep groups according to their implantation locations and extents. The final decision on the method of treatment, including methotrexate chemotherapy, surgical evacuation, and others, was made by the patients after consultation with the physician. Pretreatment patient characteristics were compared in the patients with superficial and deep implantation, as were the results after primary surgical evacuation. MAIN OUTCOME MEASURE(S): Rates of successful treatment by primary surgical evacuation of CSP and the need for salvage intervention in the patients with deep and superficial implantation. RESULT(S): Forty-eight CSP patients who had sufficient data and imaging for analysis were enrolled. Of these 48 cases, 26 in the superficial group and 14 in the deep group were willing to undergo primary surgical evacuation. Blood loss and need for salvage intervention were significantly lower in the patients with superficial implantation. Surgical evacuation was successful in 23 of 26 patients (88.5%) with superficial implantation and in 8 of 14 patients (57.1%) with deep implantation. Patients who failed primary surgical evacuation showed complete recovery, with uterus preservation, after salvage interventions, including laparoscopic surgery, angioembolization, and laparotomy. CONCLUSION(S): Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment. Primary single-step surgical evacuation was successful in most patients with superficial implantation, but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation.

Parental smoking during pregnancy and its association with low birth weight, small for gestational age, and preterm birth offspring: a birth cohort study.

BACKGROUND: Intrauterine exposure to tobacco smoke has been discerned as an important risk factor for low birth weight (LBW), small for gestational age (SGA), and preterm birth infants. In this cohort study, we investigated the association of the amount of parental smoking during the different pregnancy stages with birth weight and the incidence of preterm delivery. METHODS: Our study population was acquired from the Taiwan Birth Cohort Study. Between June 2005 and July 2006, 21,248 postpartum women were interviewed 6 months after their deliveries by a structured questionnaire. The parents were divided into four groups according to the amount of smoking during preconception, the first trimester, and the second and third trimesters. The relationships of parental smoking with gestational age and birth weight during the different pregnancy stages were assessed using multivariate linear regression. Multiple logistic regression analyses were performed to estimate the odds ratios and 95% confidence intervals of preterm delivery, LBW, and SGA infants during the different parental smoking status and the different pregnancy stages. RESULTS: After adjusting for the physical and socioeconomic status of the parents and for paternal smoking during the same period, we found that maternal smoking decreased birth weight. Compared with the nonsmoking groups, all the maternal smoking groups had higher incidences of LBW, SGA, and preterm birth infants, especially when the mothers smoked >20 cigarettes/day. The association of paternal smoking with LBW, SGA, and preterm birth infants was insignificant. CONCLUSION: Maternal smoking is responsible for increased incidences of LBW and preterm delivery of babies, and therefore, smoking cessation/reduction should be advised to pregnant women to reduce morbidities in their neonates. Further studies are needed to clarify the correlation of fetal health with passive smoking, including exposure to environmental tobacco smoke and to other smokers in the family.

Concomitant trocar-guided transvaginal mesh surgery with a midurethral sling in treating advanced pelvic organ prolapse associated with stress or occult stress urinary incontinence.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and feasibility of concomitant trocar-guided transvaginal mesh (TVM) surgery with a midurethral sling (MUS) for treating women with advanced pelvic organ prolapse (POP) and stress urinary incontinence (SUI) or occult SUI (OSUI). MATERIALS AND METHODS: Eighty-nine women with advanced POP and SUI or OSUI were retrospectively enrolled. The Total Prolift and Tension-free Vaginal Tape-Obturator Systems were used for trocar-guided TVM surgery and MUS. Patients received regular follow-up at 1 week, and 1 month, 3 months, 6 months, and 12 months postoperatively, and then annually thereafter. The endpoints were the success rate for POP, and perioperative and postoperative complications. Functional outcomes were the presence of voiding difficulty, persistent or de novo overactive bladder symptoms, postoperative SUI, and paresthesia. RESULTS: The median follow-up period was 35 months (range, 12-50 months). Within the follow-up period, 84 patients (94.4%) were objectively cured, five patients (5.6%) had vaginal apical mesh exposure, 29 individuals (32.6%) had persistent or de novo overactive bladder symptoms, six individuals (22.5%) had de novo SUI (two were found by urodynamics), and nine individuals (10.1%) had voiding difficulties (two were found by urodynamics). In addition, the vaginal hysterectomy group had greater blood loss, longer operation times, and a higher mesh erosion rate compared to the uterine suspension group. CONCLUSION: Concomitant trocar-guided TVM surgery and MUS with the use of total Prolift and Tension-free Vaginal Tape-Obturator offer good efficacy in treating women with advanced POP and SUI or OSUI. The vaginal hysterectomy group had more perioperative complications.

Comparison of short-term outcomes following pelvic reconstruction with Perigee and Apogee systems: hysterectomy or not?

INTRODUCTION AND HYPOTHESIS: This study aims to compare the surgical outcomes between hysterectomy and uterine preservation in pelvic reconstruction with Perigee and Apogee systems for severe pelvic organ prolapse. METHODS: Ninety-one women who have undergone transvaginal pelvic reconstructive surgery with Perigee and Apogee systems for severe pelvic organ prolapse were divided into two groups: hysterectomy (n = 39) and uterine preservation (n = 52). The pre-operative and post-operative assessments include subjective urinary and prolapse symptoms, objective pelvic organ prolapse quantification (POP-Q) system, urodynamic examination, and complications. RESULTS: The mean follow-up period was 8.9 months (range, 0.9-26.5). There were no anatomical differences between the two groups other than a longer perineal body in the hysterectomy group (3.9 vs. 3.6, p < 0.05) and a longer total vaginal length in the uterine preservation group (8.2 vs. 7.8, p < 0.05). Preservation of uterus has significantly reduced operative time, blood loss, and days of urine indwelling catheter (p < 0.001). CONCLUSIONS: Hysterectomy and uterine preservation have comparable anatomical outcomes and post-operative complications in pelvic reconstruction with Perigee and Apogee systems at short-term follow-up.

Working hours and risk of gestational hypertension and pre-eclampsia.

BACKGROUND: The potential impact of employment on maternal health, particularly in relation to gestational hypertension and pre-eclampsia, has been subject to research. However, there is limited evidence on associations between shift work and long working hours on the incidence of these conditions. AIMS: To evaluate potential associations between maternal shift work and long working hours during pregnancy and gestational hypertension or pre-eclampsia. METHODS: Multistage stratified systematic sampling was used to recruit 24 200 post-partum women from the Taiwan national birth registration database in 2005. Subjects underwent home interview 6 months after their deliveries by structured questionnaire to obtain characteristics of maternal employment and potential confounders. Diagnosis of gestational hypertension and pre-eclampsia was obtained from the birth registration. RESULTS: There was no association between employment status and gestational hypertension or pre-eclampsia. Also, no significant association between gestational hypertension or pre-eclampsia and maternal shift work or long working hours during pregnancy was found in all or primiparous women. CONCLUSIONS: There was no convincing evidence that maternal shift work or long working hours had a higher risk of gestational hypertension or pre-eclampsia. However, further research is warranted to confirm these negative findings.