Endometriosis resembling endometrial cancer in a postmenopausal patient.

Endometriosis occurs in 2-4% of postmenopausal women. There have been a few reports of endometriosis in women in whom neither history nor diagnostic imaging indicated the presence of this disease, either at reproductive age or after menopause. A case is described of an 84-year-old patient with extensive deep pelvic endometriosis imitating advanced neoplastic process.

Ovarian cancer diagnosed accidentally during treatment for ruptured ectopic pregnancy: is fertility-sparing surgery a viable alternative? Case report and review of the literature.

According to cancer incidence statistics, it is estimated that 226,000 women are diagnosed annually with epithelial ovarian cancer (EOC) and 140,000 die of the disease worldwide. Ovarian cancer represents the fourth leading cause of all cancer-related deaths in women, and the first cause of death among all gynecological malignancies. With the constant shift towards later parenthood, the growing incidence of EOC in women of reproductive age is noted. Most young EOC women are concerned with preserving their fertility despite oncological outcomes. Nowadays gynecologic oncologists are being asked to include into their decision-making processes the patients' desire for fertility preserving alternatives. The question remains whether it is possible to use fertility-sparing surgery (FSS) without compromising the survival. In the present report, the authors present a case of a 27-year-old patient with ovarian cancer accidentally diagnosed during surgical treatment of an ectopic pregnancy. In this paper, the proper selection of the patients for the conservative management, oncological safety, indications for subsequent chemotherapy, the risk of relapses, obstetrical outcomes, and further oncological control were analyzed based on the largest and most relevant series outcomes data and recommendations. Numerous recent studies have confirm that FSS in young women with early stage of epithelial ovarian cancer, who wish to preserve their childbearing potential, after appropriate selection, appears a viable and safe option. However, there is still a possibility of relapse and regular oncological control is strongly recommended.

Role of recombinant factor VIIa in the clinical management of severe postpartum hemorrhage: consensus among European experts.

OBJECTIVES: There have been significant advances in the medical management of severe postpartum hemorrhage (sPPH) over recent decades, which is reflected in numerous published guidelines. To date, many of the currently available national and international guidelines recommend recombinant factor VIIa (rFVIIa) to be used only at a very late stage in the course of sPPH, as a "last resort", before or after hysterectomy. Based on new safety data, rFVIIa has recently been approved by the European Medicines Agency (EMA) and Swissmedic for use in sPPH, if uterotonics are insufficient to achieve hemostasis, which in fact is significantly earlier in the course of postpartum hemorrhage (PPH). We therefore aimed to develop expert consensus guidance as a step toward standardizing care with the use of rFVIIa for clinicians managing women experiencing life-threatening sPPH. METHODS: The consensus process consisted of one face-to-face meeting with a group of nine experts, including eight obstetrician-gynecologists and a hematologist highly experienced in sPPH care in tertiary care perinatal centers. The panel was representative of multidisciplinary expertise in the European obstetrics community and provided consensus opinion in answer to pre-defined questions around clinical practice with rFVIIa in the management of sPPH. Recommendations have been based on current national and international guidelines, extensive clinical experience, and consensus opinion, as well as the availability of efficacy and new safety data. RESULTS: The expert panel developed 17 consensus statements in response to the 13 pre-defined questions on the use of rFVIIa in the management of sPPH including: available efficacy and safety data and the need for interdisciplinary expertise between obstetricians, anesthesiologists, and hematologists in the management of sPPH. Based on novel data, the experts recommend: (1) earlier administration of rFVIIa in patients with sPPH who do not respond to uterotonic administration to optimize the efficacy of rFVIIa; (2) the importance of hematological parameter prerequisites prior to the administration of rFVIIa to maximize efficacy; and (3) continued evaluation or initiation of further invasive procedures according to standard practice. Furthermore, recommendations on the timing of rFVIIa treatment within the sPPH management algorithm are outlined in a range of specified clinical scenarios and settings, including vaginal delivery, cesarean section, and smaller birthing units before transfer to a tertiary care center. The panel agreed that according to available, and new data, as well as real-world experience, there is no evidence that the use of rFVIIa in patients with sPPH increases the risk of thromboembolism. The authors acknowledge that there is still limited clinical effectiveness data, as well as pharmacoeconomic data, on the use of rFVIIa in sPPH, and recommend further clinical trials and efficacy investigation. CONCLUSIONS: This expert panel provides consensus guidance based on recently available data, clinical experience, and expert opinion, augmented by the recent approval of rFVIIa for use in sPPH by the EMA. These consensus statements are intended to support clinical care for sPPH and may help to provide the impetus and a starting point for updates to existing clinical practice guidelines.

Anti-Co(a) implicated in severe haemolytic disease of the foetus and newborn.

The Colton (Co(a)) antigen is of high frequency; its incidence in Caucasians is about 99.8%. Reports on haemolytic transfusion reactions and haemolytic disease of the foetus/newborn (HDFN) due to anti-Co(a) are rare. We report a severe HDFN due to anti-Co(a). The first child of the mother was healthy. The second died a few hours after delivery because of hydrops fetalis, likely due to HDFN; anti-Co(a) in the maternal serum, the father typed as Co(a+). The third pregnancy was followed up by the measurements of anti-Co(a) titre (additional antibodies were excluded), its functional activity by the chemiluminescence test (CLT) and the Doppler flow in the middle cerebral artery of the foetus. Increased values of antibody titre up to 128, the CLT to 30% and multiplex of median of the peak systolic velocity to 1.71 indicated haemolytic disease and the necessity for an intrauterine transfusion. The foetus received the maternal red blood cells (RBCs). Delivery had to be by Caesarean section for obstetrical reasons at 34-week gestation. The newborn (anti-Co(a) on red cells and in plasma, the rise of the bilirubin concentration up to 333 micromol L(-1)) had four exchange transfusions: the first of maternal RBCs, the remaining of donor's Co(a+) cells and one top-up transfusion. The baby was discharged in good health. Anti-Co(a) was responsible for severe HDFN. Proper monitoring during pregnancy and antenatal and post-natal therapy were successful. This is the second severe published HDFN due to anti-Co(a).

Prevalence of Cervical Infection With Human Papillomavirus of High Oncogenic Potential in Immunosuppressed Women on Renal Replacement Therapy With and Without Mammalian Target of Rapamycin Inhibitors.

BACKGROUND: Chronic immunosuppression constitutes a risk factor of human papillomavirus (HPV) related cervical cancer development. Maintenance immunosuppression with mammalian target of rapamycin (mTOR) inhibitors is associated with decreased incidence of de novo malignancies in kidney graft recipients. Recently published data suggest that mTOR inhibitors interfere with viral replication. The aim of the study was to assess if there is a difference in prevalence of HPV cervical infection in women on immunosuppressive regimens with or without mTOR inhibitors. MATERIAL AND METHODS: Cervical swabs taken from 64 immunosuppressed women on renal replacement therapy were analyzed for the presence of high-risk (HR) HPV DNA by means of an Amplicor HPV test and assessed taking into account the recorded data on mTOR inhibitor use. RESULTS: The testing revealed the presence of HR HPV DNA in none of the women that were treated with mTOR inhibitors and in 21.4% of patients that were administered immunosuppressive regimens without mTOR inhibitors (P = .08). Interestingly, 32% of women from the mTOR(-) group in contrast to 12.5% in the mTOR(+) group declared having had more than 2 lifetime sexual partners. CONCLUSIONS: Our results suggest that mTOR inhibitors might constitute a promising therapy modification in women at risk of HPV cervical malignancy development, but the effectiveness of such strategy requires further studies.

Delivery Method in Patients After Liver or Kidney Transplantation.

Pregnancy following renal or liver transplant is safe for the mother, fetus, and allograft if standard practice guidelines are strictly followed. Cesarean delivery is often required for the safety of the mother and child. The aim of this paper was the evaluation of delivery method in patients after liver (G1) and kidney transplantation (G2) in comparison with the population of healthy pregnant women (G0). MATERIALS: Retrospective analysis included 51 (G1) and 59 (G2) women who delivered between 2000 and 2016. Control group (G0) consisted of 170 nontransplanted patients, who delivered between 2014 and 2016. The results were compared using nonparametric and parametric tests (Fisher exact test, t test). The SAS 9.2 was used for the analysis. RESULTS: The rate of cesarean delivery was high in all pregnancies following kidney (G1 = 80.4%) or liver transplantation (G2 = 67.8%) compared with control group (G0 = 44.1%; P < .05). The most common indication for cesarean delivery in G1 was gestational hypertension/preeclampsia (n = 18; 43.9%), threatening intrauterine asphyxia (n = 12; 29.3%), and failure to progress (n = 2; 4.9%). The most common indications for cesarean delivery in G2 were threatening intrauterine asphyxia (n = 14; 35%), failure to progress (n = 9; 22.5%), and gestational hypertension/preeclampsia (n = 2; 5%). CONCLUSION: Cesarean delivery in patients after kidney or liver transplantation is performed mainly for obstetric reasons. The reported incidence of cesarean delivery in pregnancy following transplant is high, reflecting the high degree of clinical caution exercised in these patients.

In Vitro Fertilization and Pregnancy Outcomes Among Patients After Kidney Transplantation: Case Series and Single-Center Experience.

INTRODUCTION: Kidney transplantation (KTx) is the treatment of choice in patients with end-stage renal failure. Among various medical issues in female graft recipients, the need for maternity can become an overriding one. Gonadal dysfunction usually resolves within 6 months after transplantation; however, the prevalence of infertility is similar to this in the general population. MATERIALS AND METHODS: This case series describes the experience in infertility treatment and following perinatal care among KTx women who underwent successful in vitro fertilization (IVF). We followed three patients who previously received KTx and underwent IVF between 2014 and 2015. The 34-year-old (patient A) and 39-year-old (patient B) women received single KTx, and the 31-year-old (patient C) woman had received three previous transplantations. Patients A and C were diagnosed with primary tubal factor infertility, while patient B suffered from secondary idiopathic infertility. The stimulation protocols had no influence on their general condition nor graft function. Viable singleton pregnancies were confirmed in all cases. All newborns were born preterm, via cesarean section, as a consequence of severe preeclampsia. Patients A and C gave birth at 34th week of gestation (WG) (A: 1810 g and C: 2295 g), while patient B gave birth at 36th WG (2655 g). Other pregnancy complications were intrauterine growth restriction (patient A) and gestational diabetes mellitus (patient B). Although mild graft dysfunction was observed prior to delivery, all clinical measures and hypertension resolved during the puerperium. CONCLUSIONS: In these cases, pregnancy after KTx did not implicate persistent graft dysfunction. Regardless of the method of conception, pregnancy following KTx is associated with an increased incidence of complications, therefore it requires a multidisciplinary approach. IVF itself seems to be a safe procedure in KTx recipients if the pregnancy is advisable.

Low-dose hormonal contraception after liver transplantation.

OBJECTIVES: End-stage liver failure is associated with extremely reduced fertility. After liver transplantation, restoration of menstrual function is observed; thus effective contraceptive methods should be employed in patients who do not plan to conceive. The aim of this study was to assess tolerability and safety of hormonal contraceptives in female liver transplant recipients. MATERIALS AND METHODS: We retrospectively analyzed data on 15 female liver graft recipients, aged 24 to 35 years, who used hormonal contraceptives after liver transplantation for a time not shorter than 12 months. The period from grafting to administration of hormonal contraceptives varied from 6 months to 7 years. Biochemical parameters of liver function, fasting glucose levels, body mass index (BMI) as well as blood pressure were monitored at 0, 3, 6, and 12 months of therapy. Side effects of the treatment were noted on regular follow-up examinations. RESULTS: No case of pregnancy or graft rejection was observed on therapy. Changes of biochemical parameters were not significant (aspartate transferase 22.92 +/- 6.67 vs 25.54 +/- 7.90, alanine transferase 22.08 +/- 5.66 vs 24.27 +/- 7.57, total bilirubin 0.96 +/- 0.17 vs 1.02 +/- 0.15). Blood pressure and BMI remained stable in the group. None of the patients discontinued therapy for medical indications. CONCLUSION: Hormonal contraception was administered as soon as liver transplant function was stable. It was effective, well tolerated, and did not seem to impair graft function. However, a long-term prospective study is necessary to assess the safety of hormonal contraception in transplant recipients.

Operative treatment of endometrial hyperplasia in kidney graft recipients: report of seven cases.

OBJECTIVES: The high rate of abnormal uterine bleeding associated with endometrial hyperplasia has been observed in women after kidney transplantation. The great majority of these premalignant lesions regress after conservative treatment, mostly with progestagens. There are cases, however, of persistent or recurrent hyperplasia requiring operative treatment. MATERIALS AND METHODS: We report seven cases of endometrial hyperplasia in kidney graft recipients treated with hysterectomy after failure of conservative treatment. The presence of typical risk factors of endometrial hyperplasia and cancer were analyzed as well as their clinical courses and treatment methods. RESULTS: The age of the patients ranged from 35 to 50 years (mean, 42.7). Among typical risk factors, we observed obesity, diabetes, arterial hypertension, and nulliparity in the study group. All patients reported abnormal uterine bleeding and developed anemia. Women underwent two to four dilatation and curettage procedures. Progestagens (medroxyprogesterone or lynesterol) were administered for 3 to 9 months. The initial treatment was ineffective in two cases; in the remaining five cases endometrial hyperplasia recurred within 3 to 12 months. Pathologic findings after hysterectomy in all patients confirmed non-atypical endometrial hyperplasia. CONCLUSION: Hysterectomy is the treatment of last resort for premalignant endometrial lesions. It should be considered in all cases of recurrent or persistent endometrial hyperplasia. It may protect immunocompromised kidney graft recipients from heavy bleeding, severe anemia, and most of all, the of endometrial cancer development.

Oral and transdermal hormonal contraception in women after kidney transplantation.

AIM: The aim of the study was to assess the safety of low-dose oral or transdermal hormonal contraception in kidney recipients. MATERIALS AND METHODS: Twenty-six kidney recipients, aged 18 to 44 years (mean, 31.0) took low-dose contraceptive pills, and 10 kidney recipients, aged 22 to 36 years (mean, 31.4) used transdermal contraceptive systems. Contraception was administered for a period not shorter than 18 months. At the onset of therapy all patients showed stable graft function. The main indication for therapy was effective contraception. Additional indications were mild ovarian cysts and irregular or profuse menstruations. The pills consisted of 20 to 35 microg of etinyl estradiol and generation III progestogen. The contraceptive patch released 20 microg of etinyl estradiol and 150 microg of norelgesromin daily. RESULTS: No case of pregnancy was noted. Oral contraception was discontinued in two cases, in one case due to profound thrombophlebitis of the lower extremity and in the other case deterioration of liver function. No other side effects or symptoms of intolerance were reported. Hormonal contraception did not significantly influence body mass index, mean blood pressure, serum creatinine, or other biochemical parameters. CONCLUSION: Despite the presence of relative contraindications, mainly arterial hypertension and impaired liver function, hormonal contraception should be considered in female kidney recipients to be a highly effective contraceptive method that additionally regulates menstrual bleeding, protects from development of mild ovarian cysts and seems to positively influence women's well-being. The transdermal mode of administration may diminish the chance for drug interactions and therefore be safer for patients.

Mode of delivery in women after liver transplantation.

AIM: A high rate of cesarean sections has been reported among high-risk pregnancies in liver transplant recipients. The aim of this study was to analyze the course of deliveries and the indications for cesarean sections in women after liver transplantation. MATERIALS AND METHODS: From 2001 to 2006, we noted 21 deliveries in 17 liver recipients. The mean age of women was 27.9 +/- 6.6 years and the mean time from transplantation to pregnancy was 4.3 +/- 3.6 years. Most patients were primigravidas on tacrolimus-based immunosuppressive regimens. We retrospectively analyzed obstetric data regarding the delivery and the early puerperium. RESULTS: We noted 6 vaginal deliveries (29%) and 15 cesarean sections (71%). Mean gestational age in the group of vaginal deliveries was 37.6 +/- 2.2 weeks. No labor complications were noted. All neonates were delivered in a good state (Apgar score from 8 to 10 points) with mean birth weight of 2725 g. All cesarean sections were performed for obstetric indications: fetal distress, breech presentation, intrauterine growth retardation, or complications related to premature labor. Mean gestational age was 37.0 +/- 1.9 weeks. The Apgar scores ranged from 4 to 10 points; mean birth weight was 2787 g. The mean period of hospitalization after surgical labor was 4 days longer compared with the vaginal delivery group. CONCLUSION: The high rate of cesarean sections (71%) in liver recipients is associated with a great incidence of obstetric complications of pregnancy. Safe and uneventful vaginal delivery is possible with growing experience in the management of pregnant transplanted women.

Menstrual cycle and sex hormone profile in perimenopausal women after liver transplantation.

UNLABELLED: Excellent long-term outcomes of transplant patients let many female liver-recipients experience perimenopausal problems. This study assessed menstrual patterns and sex hormone profiles in women of perimenopausal age who experienced end-stage liver failure treated by transplantation (OLT). MATERIALS AND METHODS: Menstrual patterns, sex hormone profiles, and biochemical parameters of liver function were analyzed before and after OLT in 13 liver-transplanted patients of perimenopausal age. Nineteen healthy perimenopausal women served as controls. RESULTS: The most common abnormality of the menstrual cycle observed in the study group was secondary amenorrhea, which affected six liver-transplanted women. Three months after OLT amenorrhea was still observed in six patients, regular menstrual cycles in six and irregular bleeding in one graft recipient. One year after transplantation regular menstruations were noted in four, irregular bleeding in four, and secondary amenorrhea in five liver-transplanted women. Similar levels of follicle stimulating hormone, luteinizing hormone, prolactin, progesterone and testosterone as well as lower levels of estradiol and DHEA-sulfate were observed in patients with liver failure, both before and after grafting, compared with healthy women. After OLT E2 levels increased from 32.05 +/- 18.04 to 49.12 +/- 22.21. CONCLUSIONS: One year after OLT disturbances in menstrual patterns affect most (69%) perimenopausal female liver recipients. Both before and after OLT significantly lower levels of estradiol and DHEA-S were observed in transplanted patients compared with healthy controls. Hormonal therapy of amenorrhea or irregular menstruations may be required in that group of patients.

Outcome of four high-risk pregnancies in female liver transplant recipients on tacrolimus immunosuppression.

Pregnancies in women after liver transplantation are considered high risk due to the greater rate of complications observed in immunosuppressed graft recipients. We report successful outcomes of four high-risk pregnancies in female liver transplant recipients on tacrolimus-based immunosuppression. The patients, aged 23 to 32 years, at the time of conception were 12 to 59 months from transplantation (mean 30 months). Preterm labor was the most important pregnancy complication observed in these patients. One episode of acute graft rejection was observed. A variable demand for tacrolimus was noted during pregnancy. Despite complications all four pregnancies were successful. The mean gestational age at delivery was 34.4 weeks. The birth weight of the newborns varied from 1410 to 3490 g (mean 2303 g) and the mean Apgar score was 8. No structural malformations or early complications were observed in the newborns. Excluding the patient with acute rejection, the remaining three cases showed all liver parameters to remain stable.

Should We Be Concerned About Asymptomatic Adnexal Masses in Female Kidney and Liver Graft Recipients?

BACKGROUND: Pathological changes of uterine adnexa are frequently encountered in patients after solid-organ transplantation. The aim of the study was to evaluate the incidence of malignancies among recipients operated with the diagnosis of adnexal tumor with or without clinical symptoms. METHODS: We retrospectively analyzed data from 146 solid-organ recipients who underwent surgery in the First Department of Obstetrics and Gynecology, Medical University of Warsaw, in the years 2000 to 2014. Among them, we identified 80 patients of mean age 40.9 ± 11.1 years with suspected adnexal tumor. Data on symptoms reported by patients were compared with the results of histopathological examination after surgical treatment. RESULTS: Kidney recipients were 76.2% of the group studied (including 5 women after kidney and pancreas transplantation); the remaining 23.75% of patients were liver recipients (including 1 kidney and liver). The majority of patients (71.25%) reported no clinical symptoms. The remaining 28.75% of patients had clinical complaints, with the most common symptom being abdominal pain (in 60% of patients). Analysis of the results of histopathological examination revealed that in both groups, the most often encountered pathological findings were serous cystadenoma (33.3% and 47% of patients, respectively), endometrial cysts (24.6% and 21.7%, respectively), and functional cysts (22.8% and 17.3%, respectively). None of the asymptomatic patients were diagnosed as malignant, whereas 2 cases (both ovarian and fallopian tube cancer) were diagnosed among women who reported clinical symptoms. CONCLUSIONS: Observations of patients after organ transplantation indicate a recurring nature of adnexal changes, resulting in qualification for surgical treatment. The survey results suggest that solid-organ recipients with pathology in the uterine adnexa, with non-suspicious ultrasound image and not reporting clinical symptoms, could safely be subjected to clinical observation providing strict supervision.

Congenital Infections in Neonates of Women With Liver or Kidney Transplants.

BACKGROUND: Immunosuppressive therapy is associated with an increased risk of pregnancy complications and may have adverse effects for the newborn. The aim of this study was to determine the frequency and the type of early congenital infections and to assess typical markers of infections in neonates of liver and kidney recipients. METHODS: A retrospective analysis of 71 neonates born to either liver (39 cases) or kidney transplanted women (32 cases) was conducted. The rate and the type of newborns' infections as well as laboratory and bacteriologic markers of infections were analyzed. RESULTS: There was no significant difference in the frequency of congenital infections between the LT and KT groups (8 vs 7 cases; P = .879).). The rate of infections was not significantly higher in both groups compared with the general population. Infections were detected in 23.9%, 13.6%, and 26.6% of neonates born to mothers using tacrolimus, cyclosporine, and azathioprine respectively. No significant differences in white blood count or levels of neutrocytes and lymphocytes were observed between the groups. No abnormalities in white blood smear, but 1 case of leukopenia in the kidney transplant group, were detected. CONCLUSIONS: The rate of congenital infections in neonates of allograft recipients is not significantly higher than in the general population. Immunosuppressive regimens with azathioprine seem to carry the greatest risk, it is a little lower in the tacrolimus group, and cyclosporine-based regimens have the lowest risk of congenital infections. Differences were not statistically significant. Prenatal exposure to immunosuppressive agents seems not to be associated with any hematologic disturbances in white blood count and white blood smear.