Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus?

OBJECTIVES: To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three-dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)). METHODS: Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and provided to 15 experts (five clinicians, five surgeons and five sonologists). They were instructed to indicate whether they believed the uterus to be normal/arcuate (defined as normal uterine morphology or not clinically relevant degree of distortion caused by internal indentation) or septate (clinically relevant degree of distortion caused by internal indentation). Two other observers independently measured indentation depth, indentation angle and indentation-to-wall-thickness (I:WT) ratio. The agreement between experts was assessed using kappa, the interobserver reliability was assessed using the concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) and the best cut-off value was assessed using Youden's index, considering as the reference standard the choice made most often by the experts (CUME). RESULTS: There was good agreement between all experts (kappa, 0.62). There were 18 septate and 82 normal/arcuate uteri according to CUME; European Society of Human Reproduction and Embryology (ESHRE)-European Society for Gynaecological Endoscopy (ESGE) criteria (I:WT ratio > 50%) defined 80 septate and 20 normal/arcuate uteri, while American Society for Reproductive Medicine (ASRM) criteria defined five septate (depth > 15 mm and angle < 90°), 82 normal/arcuate (depth < 10 mm and angle > 90°) and 13 uteri that could not be classified (referred to as the gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa, 0.1); the agreement between ASRM criteria and CUME for septate was 87% (kappa, 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa, 0.93). Among the three measurements, the interobserver reproducibility of indentation depth (CCC, 0.99; 95% CI, 0.98-0.99) was better than both indentation angle (CCC, 0.96; 95% CI, 0.94-0.97) and I:WT ratio (CCC, 0.92; 95% CI, 0.90-0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good, with AUC between 0.96 and 1.00. The best cut-off values for these measurements to define septate uterus were: indentation depth ≥ 10 mm, indentation angle < 140° and I:WT ratio > 110% . CONCLUSIONS: The suggested ESHRE-ESGE cut-off value overestimates the prevalence of septate uterus while that of ASRM underestimates this prevalence, leaving in the gray-zone most of the uteri that experts considered as septate. We recommend considering indentation depth ≥ 10 mm as septate, since the measurement is simple and reliable and this criterion is in agreement with expert opinion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Acquired functional asplenia. Association with spontaneous rupture of the spleen and fatal spontaneous rupture of the liver in amyloidosis.

A 45-year-old woman who had lower extremity ecchymoses and vague abdominal and back complaints was found to have acquired functional asplenia manifested by Howell-Jolly bodies and poikilocytosis on peripheral blood smear. On spleen scan there was inability to take up radioactive colloid. Shortly thereafter, she was found to have a spontaneous rupture of the spleen. At operation, the spleen, liver, and periaortic lymph nodes were found to be diffusely involved with amyloidosis. Five months later, an acute, serious, intra-abdominal condition developed secondary to spontaneous rupture of the liver, and the patient died. To our knowledge, neither acquired functional asplenia nor spontaneous rupture of the liver has been reported previously in association with amyloidosis.

Prostaglandins modulate hormonal effects on rabbit myometrial alpha 1-adrenergic responses.

Estrogen increases the alpha 1-adrenergic contractile sensitivity of the rabbit uterus. Since estrogen treatment increases prostaglandin (PG) production by the perfused rabbit uterus, and PGs contribute to the alpha 1-adrenergic contractile response, we postulated that estrogen's effects on PG production or response may play a role in the increased alpha 1-adrenergic sensitivity induced by estrogen. We studied the effects of the eicosanoid synthesis inhibitor meclofenamate (60 microM) on the response to epinephrine (10(-9)-10(-5) M) of uterine strips from ovariectomized, mature, and estrogen-treated rabbits in terms of both contractile response and PGE2 and PGF2 alpha production. We also measured the contractile response to PGE2 and PGF2 alpha (both 10(-10)-10(-5) M) and KCl (70 mM) of uterine strips from these groups. We found that in the ovariectomized rabbits, meclofenamate decreased PG production, but did not alter the alpha 1-adrenergic sensitivity. In the mature rabbit uterus, meclofenamate decreased both PGE2 and PGF2 alpha production and reduced the alpha 1-adrenergic sensitivity. In the estrogen-treated rabbit uterus, meclofenamate decreased PGF2 alpha, but not PGE2, production and did not alter the alpha 1-adrenergic sensitivity. Finally, meclofenamate reduced the contractile response to KCl in all three groups, and exposure to PGE2 increased the contractile response to KCl in both the mature and estrogen-treated rabbits. We conclude that PGs play a role in the increase in the alpha 1-adrenergic sensitivity of the uterus in mature rabbits, and that this may be the result of an estrogen-mediated alteration in the postreceptor effects of PGs.

Criteria that indicate endometriosis is the cause of chronic pelvic pain.

Chronic pelvic pain and endometriosis remain two of the most perplexing problems in gynecology. In some women with both conditions, endometriosis might not be the cause of their pain. The problem is determining when the pain is caused by endometriosis. On the basis of clinical studies, I suggest three criteria that should be met before attributing chronic pelvic pain to endometriosis. First, the pelvic pain should be cyclic because endometriosis is a hormonally responsive disease. Second, endometriosis should be diagnosed surgically to avoid overdiagnosing this condition. Finally, medical or surgical treatment of endometriosis should result in prolonged pain relief. Application of these evidence-based criteria reminds us that endometriosis often can be asymptomatic, even in some women with chronic pelvic pain. These criteria might help gynecologists determine the women for whom surgical therapy will resolve the pain; however, only prospective evaluation can determine their ultimate usefulness.

Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse.

OBJECTIVE: Compare urogenital hiatus size in normal women and women with pelvic organ prolapse. METHODS: The sagittal and transverse urogenital hiatus diameters were measured and hiatus area calculated in 300 women whose support was scored using a modified Baden system. RESULTS: In women with normal support and without prior surgery, hiatus area was 5.4 cm2 (+/-1.71 standard deviation [SD], n = 197). In women with uncorrected clinical prolapse (grade 2-3), the area of the hiatus was enlarged (9.6 cm2 +/- 3.97, n = 34, P < .05) and became larger with progressive prolapse (grade 0, 5.4 cm2 +/- 1.71, n = 197; grade 1, 7.3 cm2 +/- 1.91, n = 27; grade 2, 8.3 cm2 +/- 2.45, n = 18; grade 3, 11.0 cm2 +/- 4.90, n = 16). When matched for age and parity, prolapse patients had a larger hiatus than normal women. Women with recurrent prolapse had a larger hiatus than cured women (13.3 cm2 +/- 3.86, n = 8 compared with 8.1 cm2 +/- 2.44, n = 16, P < .05) or women with recurrence after one operation (8.9 cm2 +/- 1.77, n = 18, P < .05). Hiatus size in patients surgically cured (8.3 cm2 +/- 2.44, n = 16) did not return to normal (5.4 cm2 +/- 1.71, n = 197, P < .05). Increasing area of the hiatus was correlated with an increase in anterior-posterior diameter (r2 = 0.9, P < .05), was less attributable to increased transverse diameter (r2 = 0.6, P < .05), and was not related to thickness of the perineal body (r2 = 0.0, P > .05). CONCLUSION: Increasing pelvic organ prolapse is associated with increasing urogenital hiatus size; the hiatus is larger after several failed operations than after successful surgery or single failure.

Selective management of abruptio placentae: a prospective study.

Antenatal diagnosis and selective management of abruptio placentae were studied prospectively over a 17-month period. Diagnosis was confirmed by placental inspection in 59 (1.3%) of 4545 deliveries. Among the 50 patients admitted with a living fetus, the diagnosis was made antenatally in 31 (62%). Fifteen were delivered vaginally and 16 by cesarean section. When these infants were compared to all other liveborn infants delivered during this period using a weight-adjusted chi 2 analysis, no significant difference was found in neonatal mortality or duration of hospitalization. There was a significant increase in the incidence of both respiratory distress syndrome and low Apgar scores among the study infants (P less than .005), but these increases were not correlated with mode of delivery or diagnosis-to-delivery interval. It is concluded that optimal fetal survival and an acceptable cesarean section rate may be obtained by selective management, especially in infants weighing more than 1500 g.

Laparoscopic secondary port conversion using a reusable blunt conical trocar.

BACKGROUND: During operative laparoscopy, large (10 mm or more) ancillary ports are often used for instrumentation and tissue removal. Although sharp pyramidal trocars can be used to place these ports, their use appears to increase the risk of vessel injury and herniation. We describe a simple and cost-effective technique for converting a 5-mm port to a 10- or 12-mm port using a blunt conical trocar. TECHNIQUE: When a larger port is required, a previously placed 5-mm port is removed, and the skin incision is lengthened. A reusable 10- or 12-mm blunt conical trocar with a threaded sleeve is placed through the incision. The fascial defect is located by probing and is dilated gently with the blunt tip. Once the tip is through the fascia, it is advanced through the peritoneal defect with a clockwise, twisting motion. Afterwards, the fascial defect is closed with a single, interrupted absorbable suture. EXPERIENCE: We have had no complications or difficulty when using this technique in 26 cases, either during or after surgery. CONCLUSION: A reusable blunt conical trocar is a simple, safe, and cost-effective instrument for converting a 5-mm laparoscopic port into a 10- or 12-mm port.

Cocaine blocks extraneuronal uptake of norepinephrine by the pregnant human uterus.

Premature labor is one of the most common complications associated with cocaine abuse during pregnancy. Still, the effect of cocaine on the pregnant uterus is largely unknown. Although inhibition of neuronal uptake is the most important effect of cocaine in most tissues, after mid-pregnancy, the uterus has few functioning adrenergic nerve endings. To determine whether cocaine has any effect on uptake during pregnancy, we evaluated the ability of the term pregnant human uterus to take up [3H]-norepinephrine (9 x 10(-8) mol/L) and the ability of cocaine (10(-6)-10(-8) mol/L) to block this uptake. Because d-propranolol has been shown to block the direct effects of cocaine on the pregnant rabbit uterus, we also evaluated the ability of d-propranolol (2 x 10(-6) mol/L) to block the effect of cocaine on catecholamine uptake. The ability of the Uptake 2 inhibitor hydrocortisone (2 x 10(-5) mol/L) to block catecholamine uptake was also studied. We found that [3H]-norepinephrine was taken up by both the pregnant myometrium and endometrium, and that cocaine blocked this uptake by up to 55% at concentrations as low as 10(-7) mol/L. D-propranolol had no effect on the ability of cocaine to block catecholamine uptake. Hydrocortisone blocked uptake by the endometrium by 15% but did not block uptake by the myometrium. We conclude that the pregnant human uterus at term retains the ability to take up catecholamines and that cocaine blocks this extraneuronal uptake. This may explain, in part, the association of cocaine use with premature labor.

Characterization of the effect of cocaine on catecholamine uptake by pregnant myometrium.

OBJECTIVE: To characterize the effect of cocaine on catecholamine uptake by myometrium from pregnant women. METHODS: Slices of myometrium obtained from nine women during elective cesarean delivery at term were incubated with [3H]-norepinephrine and various uptake inhibitors for 30 minutes. The radiolabeled material was extracted with perchloric acid, expressed as percent control (+/- standard error of the mean), and compared by one-factor analysis of variance and Fisher multiple range test. RESULTS: Myometrial uptake was inhibited by cocaine (42 +/- 9%) by neuronal (type 1) uptake inhibitors (desipramine 41 +/- 14%; N-ethylmaleimide 53 +/- 8%), and by extraneuronal (type 2) inhibitors (normetanephrine 56 +/- 19%; corticosterone 73 +/- 9%). When uptake inhibitors were used in combination with cocaine, uptake was not decreased further in the presence of neuronal inhibitors (desipramine plus cocaine 40 +/- 20%; N-ethylmaleimide plus cocaine 42 +/- 4%). However, the effect of cocaine appeared to be added to that of extraneuronal inhibitors (normetanephrine plus cocaine 25 +/- 14%; corticosterone plus cocaine 32 +/- 1%). CONCLUSION: Catecholamine uptake by myometrium in pregnant women appears to be both extraneuronal and neuronal in nature, and cocaine inhibits the neuronal portion of this uptake. This mechanism may play a role in the increased rate of premature delivery associated with cocaine abuse.

Decrease in myometrial beta-adrenergic receptors with prenatal cocaine use.

OBJECTIVE: To determine if cocaine use during pregnancy is associated with a reduction in the number or affinity of beta-adrenergic receptors in human myometrium. METHODS: Myometrium was obtained at cesarean delivery of five women who reported using cocaine during pregnancy and from ten controls. Saturation binding assays were performed on the myometrial membrane fractions using [125I]-cyanopindolol to determine beta-adrenergic receptor concentration and affinity. The percentages of beta 1- and beta 2-adrenergic receptors were determined in three cocaine users and four control patients by performing competition binding assays using the beta 2 antagonist ICI 118,551. Results were compared using unpaired Student t tests. RESULTS: Women who reported using cocaine during pregnancy had a significantly lower mean (+/- standard deviation) concentration of myometrial beta-adrenergic receptors than did controls (22 +/- 8 versus 52 +/- 23 fmol/mg protein, respectively). There was no difference in the receptor affinity constants between cocaine users and controls (16 +/- 2 pmol/L for both groups). The percentages of beta 1- and beta 2-adrenergic receptors in the myometrium of the cocaine-use group and control group were similar: 86 +/- 1% beta 2 in the cocaine-use group and 83 +/- 7% beta 2 in the control group. CONCLUSION: Cocaine use during pregnancy may be associated with a down-regulation of beta-adrenergic receptors in human myometrium. This could result in a decreased capacity for uterine relaxation and, consequently, a predisposition to preterm labor.

The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique.

OBJECTIVE: We evaluated the location of the umbilicus relative to the aortic bifurcation and the left common iliac vein where it crosses the midline. METHODS: Abdominal computed tomography images from 35 reproductive-age women were retrospectively reviewed to determine the location of the umbilicus. The results were correlated with body mass index using Pearson correlation coefficient and a two-tailed paired t test. RESULTS: The location of the umbilicus, but not the aortic bifurcation, was more caudal in heavier women and negatively correlated with body mass index. In nonobese women, the mean location of the umbilicus was 0.4 cm caudal to the aortic bifurcation, and was at or cephalad to the bifurcation in eight of 15 (53%). In overweight women, the mean umbilical location was 2.4 cm caudal to the bifurcation, and in obese women, 2.9 cm caudal to the bifurcation. In the last two groups of subjects, the umbilicus was located at the level of the bifurcation in six of 20 (30%). In every case, the umbilicus was located cephalad to where the common iliac vein crossed the midline. CONCLUSIONS: The umbilicus is often located at or cephalad to the aortic bifurcation, and consistently located cephalad to where the left common iliac vein crosses the midline. The laparoscopic approach should take these relationships into account to minimize injuries to major retroperitoneal vessels.

Hormonal treatment of an endometrial stromal nodule followed by local excision.

BACKGROUND: Endometrial stromal nodule is a rare subtype of endometrial stromal tumor. Although such nodules are benign, hysterectomy has been considered the treatment of choice, because evaluation of the margin is required for diagnosis. The similarity between low-grade stromal sarcoma and stromal nodule suggests that stromal nodules might respond to hormonal management. CASE: Twenty-one-year-old nulligravida, diagnosed with endometrial stromal nodule, which decreased in size with leuprolide acetate treatment, underwent local excision of the tumor with preservation of reproductive function. CONCLUSION: Hormonal therapy was successful in decreasing the size of this stromal nodule which allowed for conservative management.

Laparoscopic injury of abdominal wall blood vessels: a report of three cases.

BACKGROUND: Operative laparoscopy is being used for an increasing number of applications. Many of these innovative techniques require the insertion of large trocars through the anterior abdominal wall at points lateral to the midline. Because of the rich vascular supply of the anterior abdominal wall, the incidence of abdominal wall vessel injuries appears to be increased by these techniques. CASES: Three cases are reported in which abdominal wall blood vessels were injured during operative laparoscopy. Case 1 describes laceration of the inferior epigastric artery above the pubic crest. Despite initial hemostasis with a transabdominal suture ligation, postoperative blood loss necessitated transfusion and reoperation to control bleeding. Case 2 describes hematoma formation after unrecognized injury to one of the epigastric vessels. The hematoma resolved without sequelae with conservative treatment. Case 3 describes hematoma formation under a laparoscopic trocar incision lateral to the umbilicus that progressed to an abscess and was treated with drainage, irrigation, and antibiotics. CONCLUSIONS: Choosing appropriate trocar types and insertion sites based on a thorough understanding of anterior abdominal wall anatomy may minimize the risk of vessel injury during operative laparoscopy. However, because of anatomical variation, strategies for managing vessel injuries and their sequelae are also necessary.

Urologic laparoscopy with a new blunt-tipped trocar: safe, rapid access without the use of fascial sutures.

Fifteen patients underwent successful laparoscopic procedures where a new blunt-tipped trocar was used both to gain initial access to and to insufflate the abdominal cavity. The use of this new trocar obviates the need for the use of the Veress needle and appears to be both time-saving and possibly safer. Unlike the Hasson-type trocar, the blunt trocar technique does not require the use of fascial sutures for prevention of air leaks.

Blunt trocar laparoscopy.

A technique, termed blunt trocar laparoscopy, has been developed to avoid the use of both Veress needles and sharp primary trocars and to avoid carbon dioxide leakage without the use of fascial sutures. To evaluate this technique's effectiveness, the time required and the length of the skin incision was evaluated prospectively in 33 consecutive unselected patients and the results were compared with the patient's BMI. The blunt trocar technique took 3.5 +/- 1.3 minutes (mean +/- SD) to perform and the average incision length was 14 +/- 2 mm. Although the time of the procedure increased slightly with the BMI, even in the obese patients (BMI > 30 kg/m2; n = 10), the average time for the procedure was only 4.0 +/- 1.6 minutes. No carbon dioxide leakage or complications occurred in any patient. The results of this study indicate that a blunt trocar technique may be a useful and relatively quick alternative approach for laparoscopy.

Microsurgical reversal of female sterilization.

PIP: As mentioned recently in an excellent article by Dr. Gomel, intraoperative chromopertubation is an invaluable aid in reconstructive tubal surgery. Unfortunately, the inherent clumsiness and risk of infection associated with the transcervical approach he advocates and the difficulty involved in placing and maintaining a rigid needle tipe in the uterine cavity transfundally make both of these commonly-used techniques less than optimal. Recently we developed a modification of the conventional transfundal method of intraoperative chromopertubation that seems to circumvent these difficulties. In place of an 18-gauge needle, we use an 18- or 20-gauge Teflon intravenous catheter to enter the uterine cavity. The catheter-needle unit is placed through the fundus to a point thought to be in the uterine cavity, and the catheter is gently slid off the needle. If resistance is met, the catheter tip is most likely in the myometrium, and it is repositioned until the catheter does slide off easily. Alternatively, the needle-catheter unit can be placed at full length into the uterus and the needle withdrawn. At this point, the catheter is slowly withdrawn while an attempt is made at dye injection. When injection can be accomplished with minimal resistance, the tip is in the uterine cavity, and the catheter can then be advanced further into this space if desired. Now, with the aid of a lower uterine segment clamp, a length of intravenous extension tubing and a syringe, tubal patency can be fully evaluated. In addition, the catheter can be left in place throughout the repair with a minimal amount of trauma in order that at the end of the case, repeat dye injection can be done to evaluate the integrity of the repair. Also, gentle hydropertubation with an appropriate therapeutic solution can be carried out at this time if desired.^ieng

Motility longevity of sperm samples processed for intrauterine insemination.

This study demonstrates that sperm from men with male factor infertility and sperm obtained by electroejaculation have reduced motility longevity when compared with normal specimens. After 24 hours, normal samples lost only 34% of initial motility, whereas male factor patients lost 48%, and electroejaculation patients dropped 66%. Based on these data and previous clinical studies of insemination timing, it is recommended that sperm retrieval and artificial insemination for male factor infertility, especially when electroejaculation is necessary, be performed 24 to 36 hours after urinary detection of the LH surge or as close to the time of ovulation as possible.

Inhibition of adhesion reformation in the rabbit model by meclofenamate: an inhibitor of both prostaglandin and leukotriene production.

OBJECTIVE: To determine the relative ability of meclofenamate sodium, a water-soluble inhibitor of both prostaglandin and leukotriene synthesis, to inhibit adhesion reformation. DESIGN: Prospective, randomized study in a rabbit model. INTERVENTIONS: Laparotomies were performed on mature New Zealand White rabbits, and each uterine horn was devascularized and traumatized with unipolar electrocautery. One week later, adhesions were microsurgically lysed. Each rabbit was randomly assigned to one of five different groups, and different solutions or an adhesion barrier were placed into the peritoneal cavities before closure: [1] control, 40 mL of normal saline (n = 8); [2] meclofenamate, 1.75 mg/mL in 40 mL of normal saline (n = 7); [3] Hyskon, 40 mL of 32% dextran-70 (n = 6); [4] meclofenamate 1.75 mg/mL in 40 mL of 32% dextran-70 (n = 6); and [5] TC-7, 40 mL of normal saline plus oxidized regenerated cellulose fabric, Interceed, placed over the site of adhesion lysis (n = 6). Two weeks later, adhesion reformation was scored according to percent involvement of each uterine horn (0 to 4), and adhesion density (0 to 1) and compared using a one-factor analysis of variance. RESULTS: Adhesion reformation was greatest in the control group (mean score +/- SEM, 3.7 +/- 0.4) and was decreased, but not significantly, in the Hyskon group (2.7 +/- 0.4). Compared with the control group, reformation was significantly decreased in the meclofenamate group (2.3 +/- 0.2), the TC-7 group (2.0 +/- 0.5), and the meclofenamate/Hyskon group (1.1 +/- 0.3). This last group was also decreased compared with the meclofenamate and Hyskon groups. CONCLUSION: Meclofenamate significantly inhibits adhesion reformation in the rabbit model, especially when used in combination with a 32% dextran-70 solution.

Transcervical tubal cannulation: a comparison of two techniques.

Transcervical tubal cannulation using tactile guidance has a similar rate of successful cannulation compared with that with US guidance (78% versus 73%) but takes less time to perform (2.3 +/- 1.8 minutes versus 8.7 +/- 6.2 minutes, mean +/- SD) and is associated with less pain and bleeding. This appears to be because of the design of the Labotect tubal cannulation set that uses a special speculum and tenaculum to straighten the uterus before insertion of the guide cannula and a less traumatic ball-tipped guide catheter.

Kallmann's syndrome: pregnancy achieved through gamete intrafallopian transfer.

This case report describes the use of GIFT to achieve pregnancy for a man with Kallmann's syndrome who obtained only marginal sperm counts with both the pulsatile GnRH infusion pump and gonadotropin injections. Failure of this man to achieve a pregnancy with hormonal therapy alone and in combination with IUI suggests that assisted reproductive technologies should be considered in male patients with Kallmann's syndrome when suboptimal sperm concentrations are achieved despite exogenous hormonal stimulation.