Horner's syndrome and epidural anesthesia in labor and cesarean section.

Homer's syndrome (HS) is based on dysfunction of symphathetic nervous system at the cervical canal. The signs of the syndrome occur on the same side as the lesion of the sympathetic trunk and include: a constricted pupil, a weak-droopy eyelid, apparent decreased sweating, and with or without inset eyeball. HS has been observed as a rare complication of epidural anaesthesia in obstetrics during labour or cesarean section. In parturients, it warrants further investigation as other serious causes must be excluded, such as pancoast tumours, thoracic aortic aneurysms, carotid dissection, neuroblastoma, and brainstem vascular malformation. Management involves early diagnosis of the underlying benign condition while treatment is based on appropriate conservative observation, as most often the syndrome resolves spontaneously. However in very rare cases immediate medical or surgical management is needed.

Immunohistochemical expression of MTA1 and MTA3 in placental tissue of normal and preeclamptic pregnancies.

PURPOSE: The aim of this preliminary study was to evaluate and compare MTAI andMTA3 antigens expression in normal and preeclamptic placentas in order to demonstrate their possible functional relationship during pathogenesis of preeclampsia. MATERIALS AND METHODS: A series including 20 paraffin-embedded placentas, ten of which originated from normal patients and ten from preeclamptic patients, that were examined by immunohistochemistry using the polyclonal antibodies MTAI and MTA3. RESULTS: The results of this study showed a positive nuclear staining reaction against MTAI and MTA3 in both normal and preeclamptic placentas. However, in preeclamptic chorionic villi, cytotrophoblast and syncytiotrophoblast cells demonstrated increased expression of MTAI and MTA3 than in normal ones. CONCLUSION: The present observations indicate a potential role for MTAI and MTA3 for normal human placental function, playing an essential role in the pathogenesis of preeclampsia. Nevertheless, the precise relationship between these antigens' expression and pathological pregnancies remains to be elucidated.

ANTIMÜLLERIAN HORMONE AS INDICATOR OF OVARIAN DYSFUNCTION.

AIM: The purpose of this study was to examine various hormonal, biochemical and environmental factors (i.e., smoking and alcohol intake) and to investigate their possible correlation to the development of polycystic ovary syndrome (PCOS). The main objective was to evaluate the associations between hormonal profile and the antimüllerian hormone (AMH) levels in PCOS patients and their relation to environmental factors. PATIENTS AND METHODS: In two gynecological clinics, 38 women with PCOS (defined according to the Rotterdam criteria) were enrolled and observed in relation to AMH, follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T), Δ4-androstendione (Δ4-A), dehydroepiandrosterone sulfate (DHEA-S) and glucose plasma concentrations. Obesity, smoking and alcohol exposure were also studied. RESULTS: AMH, T, Δ4-Α, DHEA-S, LH and FSH were increased in 76.3%, 50%, 31.8%, 23.7%, 21% and 18.4% of the patients, respectively. The LH/FSH ratio and glucose concentrations increased abnormally in 18.4% and 15.8% of the patients, respectively. AMH and T levels were both increased in 47.4% of the patients whereas both AMH and LH levels increased in 21% of the patients. Smoking, alcohol intake, obesity and glucose concentrations were not associated with AMH concentrations. On the contrary, high levels of T and LH were linked to higher levels of AMH. FSH concentrations were not increased in these patients. CONCLUSION: AMH is an important hormonal parameter for the diagnosis of PCOS. Larger clinical controlled studies are necessary in an effort to further investigate the inclusion of AMH measurement in the diagnostic criteria of PCOS.

Brenner tumour of the ovary--an incidental histological finding.

Brenner tumours of the ovary are uncommon neoplasms and mostly benign. There is general agreement that Brenner tumors are derived from the surface epithelium of the ovary or the pelvic mesothelium through transitional cell metaplasia. It is essential to categorise these tumours as benign, borderline or malignant type as the biologic behaviour and choice of surgery differs in all of the three categories. The authors report a case of Brenner tumour that had only a single area with a beginning indistinct stroma vessel invasion. However the presence of characteristic epithelial nests, fibromatous stroma, and marked cytological metaplasia without atypia provided important clues to the correct diagnosis--proof of a benign tumour.

Presentation of a patient with in situ amelanotic melanoma of the vulva.

Amelanotic malignant melanoma of the vulva is extremely rare. The authors describe here a case of amelanotic malignant melanoma of the vulva, occurring in a 71-year-old woman without any clinical symptoms. The woman had a small nodular lesion in the left labia majora. Local excision was performed. Histological examination revealed an in situ malignant melanoma without any evidence of invasive disease. All suspicious lesions in the vulva region, even if there are no clinical symptoms, should be biopsied, and if an in-situ melanoma is identified, partial or total vulvectomy should be considered.

[Pharmacological Thromboprophylaxis during Pregnancy and the Puerperium: Recommendations from Current Guidelines and their Critical Comparison]. / Medikamentöse Thromboembolie-Prophylaxe in Schwangerschaft und Wochenbett: neue Leitlinienempfehlungen & kritischer Leitlinienvergleich.

Venous thromboembolism (VTE) is one of the leading causes of maternal deaths worldwide. Due to the increasing number of pregnant women with risk factors, the incidence of VTE has risen over the past decades. Mortality and morbidity of VTE are potentially preventable, since more than two-thirds of these women have identifiable risk factors and may benefit from appropriate thromboprophylaxis. The cornerstones for prevention of VTE are the individual and careful assessment of preexisting and new-onset/transient risk factors during pregnancy as well as before and after delivery and a risk-stratified pharmacological thromboprophylaxis. Current recommendations for thromboprophylaxis must rely on consensus statements and expert opinions. The recently published German AWMF-Guideline 003/001 and the Green-top Guideline No. 37a from the Royal College of Obstetricians and Gynaecologists (RCOG) are discussed. The RCOG Guideline recommends antenatal thromboprophylaxis in women with previous VTE, high-risk thrombophilia or in the presence of ≥ 4 risk factors from the beginning of pregnancy, in women with 3 current risk factors from 28 weeks of gestation. After delivery women with intermediate risk should receive prophylactic LMWH for at least 10 days and women with high risk for 6 weeks postnatally. All women who have had an elective caesarean section and who have>1 additional risk factor should be given prophylactic NMH as well as all women who have had a caesarean section in labour or an emergency caesarean section. At the onset of labour, in case of any vaginal bleeding, prior to scheduled labour induction or at least 12 h before an elective caesarean section, antenatal LMWH prophylaxis should be discontinued. LMWH prophylaxis can be continued 4-6 h after vaginal delivery and 6-12 h after caesarean delivery when women do not have an increased risk of haemorrhage. Current guidelines recommend weight-based LMWH.

The effectiveness of misoprostol or dinoprostone in neonatal outcome after labour induction in post-term nulliparas.

OBJECTIVE: The object of this study was to investigate the efficacy of vaginal administration of misoprostol versus dinoprostone in neonatal outcome. MATERIALS AND METHODS: The first Group A included 77 pregnant women, who requested pregnancy termination one week after labour term and received vaginally misoprostol 50 µg, while the other 69 pregnant women in Group B were vaginally administrated three mg dinoprostone. According to the authors' protocol this procedure was repeated after six hours for a maximum of two times. RESULTS: The labour duration was longer in Group B (p = 0.000), while the APGAR score was better in Group A (p = 0.015). In Group A the labour modus was as follows: 86.9% normal vaginal labour, 3.8% vacuum extraction, and 9.3% cesarean section, while in Group B it was 82.83% normal vaginal labour, 3.07% vacuum extraction, and 14.1% cesarean section. CONCLUSION: Misoprostol has advantages according to neonatal outcome compared to administration of dinoprostone.

Diagnostic approach and therapeutic management in early-stage endometrial cancer.

OBJECTIVE: The effectiveness of pelvic and para-aortic lymphadenectomy in the morbidity of patients affected by early-stage endometrial carcinoma (EC) is the subject of this study. STUDY DESIGN: Ninety-two cases with endometrial cancer that underwent para-aortic and pelvic lymphadenectomy, from June 1995 to June 2006, were studied and compared with 30 cases of patients with endometrial cancer without lymphadenectomy. RESULTS: According to the results, systematic pelvic and para-aortic lymphadenectomies improved disease-free and overall survival rates among the patients with endometrial cancer. The mean number of removed para-aortic lymph nodes was 19.01 +/- 5.88, whereas the mean number of removed iliac lymph nodes was 32.94 +/- 6.69. Forty-two and 31 metastatic iliac and para-aortic nodes were found, respectively. No surgery-related deaths and major intraoperative injuries occurred. The frequency and the type of postoperative complications were not affected by the performance of lymphadenectomy. The morbidity rate was 6.2%, similar to the group without lymphadenectomy (5.79%). No recurrence occurred in the group with lymphadenectomy, while in the other group the recurrence rate was 23.3%. CONCLUSIONS: Lymph nodes metastases can be observed in early stages of EC. Pelvic and para-aortic lymphadenectomies seems to provide profound information about the Stage of the disease and the patient's survival, identifying which patients are suitable for supplementary treatment, without significant clinical increase of morbidity.

Pelvic splenosis: A systematic review of the literature.

Background: Splenosis is the presence of ectopic autotransplantation of splenic tissue in various compartments of the human body, occurring after rupture of the splenic parenchyma. Methods: A systematic PubMed and Scopus search was conducted. Results: The mean age of the patients was 51.7 years. The majority of patients were of female gender. An emergency presentation was noted in 30 out of 85 patients, having abdominal pain as main symptom. The principal reason for splenectomy were traffic accidents. The time span between splenectomy and the initial symptoms ranged between 1 and 57 years. The most frequent symptom at presentation of pelvic splenosis was abdominal pain. Almost a quarter of the included patients were without any symptom. Presence of extrapelvic splenosis was de-scripted in almost half of the included patients. With regards to the type of treatment provided, exploratory laparotomy, laparoscopic surgical exploration / laparoscopy, robotic removal of splenium and watchful waiting, were performed in 35 (41.2%), 32 (37.6%), 3 (3.5%) and 15 (16.3%) patients, respectively. No fatality was reported. Conclusion: Pelvic splenosis is a rare clinical condition. It may mimic several clinical conditions and mislead diagnosis. The clinical history of splenectomy for trauma or different other reasons may es-tablish diagnosis and exclude other morbidities. Excision and complete removal of pelvic splenosis nodules is not always necessary and it depends on the clinical symptomatology. Careful imaging and precise assessment with the assistance of nuclear medicine may lead to correct diagnosis and avoid unnecessary surgical interventions.

The contribution of laparoscopy to the diagnosis of adnexal masses in young and premenopausal women.

The purpose of this retrospective study was to investigate the contribution of laparoscopy to the diagnosis of adnexal masses in young and premenopausal women, in whom surgery was deemed necessary, between the years 2002-2008. A total of 130 young and premenopausal women scheduled for surgery for an adnexal mass with a diameter of 5-10 cm underwent transvaginal ultrasound (US) examination prior to surgery. Laparoscopic management was successfully completed for 118 of the 130 patients in this study; however, 12 required conversion of laparoscopy to laparotomy due to endometriosis with extensive bowel adhesions, or suspected ovarian malignancy and peritoneal implants. One hundred and twenty-four patients (95.38%) had benign lesions, four (3.07%) had borderline tumors and two patients had malignant lesions (1.53%). We found a statistically significant association between laparoscopic and histological findings. Laparoscopic diagnosis of adnexal masses suspicious at US may help avoid many laparotomies for the treatment of benign ovarian disorders.

A retrospective analysis of twenty-eight borderline ovarian tumours in adolescent girls.

The aim of this retrospective study was to evaluate the clinical reproductive outcome and the rate of recurrence of low malignant ovarian tumors in adolescent girls after conservative surgical treatment by laparoscopy or laparotomy. We report 28 cases of borderline ovarian tumors (BOTs), that were surgically treated from 1990 to 2006 at the Obstetrical and Gynecological Department of Democritus University in Greece and the Aschaffenburg Teaching Hospital in Germany. All patient information was obtained by reviewing hospital records. BOT lesions in teenagers were associated with variable non-specific presenting symptoms. Ultrasonographic investigations can be helpful in the early diagnosis of BOTs in teenage girls. Most of the patients were diagnosed at an early stage. Available data of our study indicate that in these patients, fertility, pregnancy outcome and survival remain excellent.

The contribution of anaesthesia modus on reducing blood loss during caesarean section.

The purpose of this study was to compare the effects of general anaesthesia (GA) and regional anaesthesia (RA) on the blood loss during caesarean section. We report on 161 patients undergoing both elective and emergency caesarean section at the Obstetrical Department of Democritus University of Thrace. In the majority (113 women, 70.2%) GA was used, while in 48 women (29.8%) RA was used. No significant differences were found in the demographic characteristics of the study women in the two groups. Although the preoperative Hgb and Hct levels did not differ significantly in the two groups RA vs GA, the postoperative Hgb and Hct levels were significantly lower in women who were subjected to GA compared to those who were subjected to RA (p < 0.05). The study showed that there is greater reduction in blood loss with RA compared to GA during caesarean section.

A 15-year report of pathological and benign ovarian tumors in teenagers.

The purpose of this retrospective study was to determine the frequency, clinical aspects and surgical management of ovarian masses in 52 adolescent patients, in whom surgery was deemed necessary, from 1991-2006. We considered age, symptoms, ultrasound investigations, CA 125 levels, family history, operative treatment, surgical complications tumor size, histopathological examinations, pregnancy rate and follow-up. Ovarian lesions in teenagers include a broad array of pathologic diagnoses that have variable and non-specific presenting symptoms. The most common presenting complaint was abdominal pain in 34 (65.4%). Forty-seven patients (90.4%) had benign lesions, two (3.8%) had borderline tumors and three patients had malignant lesions (5.8%). Most of the patients who wanted to conceive subsequently did so. For benign ovarian disorders the operation should be designed to optimize future fertility while in patients with malignancy, complete staging and resection of the lesion should be the first concern.

TV sonographic assessment in postmenopausal women with bleeding.

The aim of this study was to evaluate retrospectively the usefulness of transvaginal sonography for the detection of endometrial disease in postmenopausal women with bleeding. This study involved 275 postmenopausal women aged 47-81 years (median 62). None of them were on hormone replacement therapy and all had had amenorrhea for more than one year. Concerning the age of the study patients, we confirm that endometrial cancer occurs at any age, but more commonly in ages above 58 years. Transvaginal sonography was performed in all women. About 89.2% of malignant diseases were discovered in the study women whose endometrial thickness was above 4 mm, but we also found endometrial cancer in 10.2% of the cases in women whose endometrial thickness was below 4 mm. In postmenopausal symptomatic women premalignant or malignant causes of bleeding can not be excluded with just transvaginal ultrasound.

Uterine sarcoma: a report of 57 cases over a 16-year period analysis.

Uterine sarcomas comprese approximately 4-9% of all uterine malignant tumors with a poor prognosis. We report 57 cases of sarcoma originating in the uterus treated from 1990 to 2006 at the Department of Obstetrics and Gynecology of Democritus University of Thrace, Greece and the Department of Obstetrics and Gynecology of Aschaffenburg Hospital, Germany. The median age of occurrence was 49 years with the commonest symptom being abnormal uterine bleeding. Forty-nine patients underwent a total hysterectomy and bilateral salpingo-oophorectomy whereas 17 cases underwent radical lymphadenectomy. During the last followup (December 2006), six patients were alive and well with no evidence of disease, 23 patients had died of undercurrent disease, and 28 were alive with recurrence of disease. These rare cancers can be aggressive, and account for a greatly disproportionate number of deaths from uterine cancers. Treatment for this rare disease should be performed according to international protocols in order to have the most updated information.

Irregular dental structures in a benign ovarian cystic teratoma (dermoid cyst): case report.

Mature cystic teratomas, often referred to as dermoid cysts, are the most common germ cell tumors of the ovary in women of reproductive age. The gross pathologic appearance of a dermoid cysts is characteristic. Hair follicles, skin glands, muscle, and other tissues lie within the cyst wall. We present a case of a dermoid cyst ovarian tumor in a 24-your-old patient with a tooth lying on each wall. The mass was laparoscopically removed by ovarian cystectomy.

Misoprostol and first trimester pregnancy termination.

OBJECTIVE: To investigate the efficacy of vaginal administration of 800 microg misoprostol as a single dose without performing post expulsion systematic curettage in first trimester pregnancy termination. METHOD: 113 women, aged 16-44, who requested first trimester pregnancy termination, received 800 microg of vaginal misoprostol. All examined women were divided into two groups depending on gestation age. The first group included of 67 women with up to nine weeks and the second of 46 with up to 12 weeks of pregnancy. RESULTS: Abortion occurred within 24 hours and was completed in 74.3% of the cases. The mean induction-abortion interval was 5.9 +/- 1.7 hours (median 5.5 hours). Side-effects were experienced by 24 women (21.2%). There was no significant difference between groups in the success rate, induction-abortion interval, number of previous deliveries and side-effects. CONCLUSION: Misoprostol is an effective agent for first trimester medical termination.

Laparoscopic treatment of ovarian dermoid cysts.

Dermoid cysts are the most common germ cell tumors of the ovary in women of reproductive age. We report 67 cases of patients with dermoid cysts (mean age, 31.31 years) originating from the ovary treated from 1994 to 2006 at the Obstetrics and Gynecology Department of Aschaffenburg Hospital-Clinic in Germany. Most patients (60) underwent cyst removal. In two patients salpingo-oophorectomy was performed and in five partial oophorectomy was performed. Additional surgery ensuing laparotomy was never necessary. None of the patients had long-term postoperative complications. Two patients were at nine and 15 weeks of gestation and postoperatively were well following termination of pregnancy. In a group of 43 women, who desired pregnancy, 37 pregnancies resulted. The overall intrauterine pregnancy rate was 83.7%; one patient had an ectopic pregnancy (2.32%). To receive more information on this disease, treatment should be performed according to international protocols.

Attitudes towards contraception in three different populations.

OBJECTIVE: To investigate contraceptive behavior of women belonging to three different ethnic and/or socioeconomic populations as well as to evaluate the main sources of information concerning contraception in each population. METHODS: 150 Muslim women living in Germany (group A), 120 Muslim women living in Thrace, Greece (group B) and 140 Christian Orthodox women living in Thrace, Greece were enrolled in the study. Attitudes concerning contraceptive practices were assessed by means of a questionnaire. Demographic and socioeconomic characteristics of each group were compared with the method of contraception used. Statistical analysis was performed using one-way analysis of variance (ANOVA), followed by Turkey's test, chi-square test and multiple logistic regression analysis. RESULTS: The contraceptive pill (41.7%), the condom (35.1%), periodic abstinence (24.4%) and interrupted coitus were the most common methods of contraception. The gynecologist (23.4%), the family consultant (12.0%) and the sexual partner (10.2%) were the most usual sources of information. The use of contraceptive pills was more frequent among Muslims from Germany and Christians from Greece (p < 0.001), while the use of condoms was more frequent among Christians from Greece (p = 0.019). The use of IUDs was more frequent among Muslims from Germany and Greece (p = 0.039). CONCLUSIONS: Our study results reveal that there are behavioral differences between race/ethnic groups and minorities regarding contraceptive practices, probably due to different cultural, socioeconomic and educational factors.

[Treatment of leiomyomas with uterine artery embolization. Review of literature].

Embolization of the uterine artery represents a widely accepted invasive method for treatment of fibroids. It is indicated for women in perimenopause with symptomatic leiomyomas who do not require preservation of their fertility functions. The method should be used with caution excluding infectious diseases and malignancies. A experienced interventional radiologist is needed for the completion of the method. Complications are infrequent with rate reaching almost 5%. Few knowledge exists about pregnancy outcomes after uterine artery embolization. For this reason it should be used with caution in young women with symptomatic leiomyomas willing to conceive.