Are There Predictors of Early Diagnosis of Endometriosis Based on Clinical Profile? A Retrospective Study.

Objectives: Significant delays occur in referring cases for care of endometriosis, despite women suffering for years. This study was conducted to assess whether there is a specific symptom profile characteristic of endometriosis to alert physicians for earlier referrals. Methods: In this retrospective observational cohort study, patient data of the women who attended Sultan Qaboos University Hospital from January 2011 to December 2019 with a diagnosis of endometriosis was collected from the hospital's electronic data archive and analyzed. Results: Cases of N = 262 endometriosis patients were studied. The diagnosis was surgical in 198 (75.6%) of patients and the remaining 64 (24.4%) were diagnosed by clinical assessment and imaging. The mean age at diagnosis was 30.7±6.8 years (range = 15-51). The presence of ovarian endometrioma on ultrasound served as an alert for earlier referral. The mean age at diagnosis for those who had an endometrioma was 30.3±6.7 years and 32.4±7.1 years for those without an endometrioma without a significant difference. The mean age at diagnosis for those who did not have pain was 31.2 years and those with pain was 30.0 years (p =0.894; CI: -2.58-2.91). Among the 163 married women in the sample, 88 (54.0%) had primary infertility, and 31 (19.0%) had secondary infertility. There was no significant difference between the groups in the mean age at diagnosis (analysis of variance test; p =0.056). Over the nine-year period, diagnosis was made at progressively younger ages (p =0.047). Conclusions: Based on this study, no specific symptom profile appears to predict an early diagnosis of endometriosis. However, over the years the diagnosis of endometriosis is made earlier likely due to increasing awareness of women and their physicians about the disease.

Vaginal Myomectomy for Prolapsed Submucous Fibroid: It is Not Only About Size.

Leiomyoma of the uterus, also called fibroids, are common in women. In this case report, we describe the case of a nulliparous woman with a large, prolapsed submucous uterine leiomyoma of 10 × 11 cm was vaginally impacted. The aim is to highlight the challenges in managing such uncommon clinical scenario focusing on the factors predicting the success of vaginal myomectomy including the size of the myoma but also the role of vaginal laxity to allow the steps of devascularization, detachment, and removal of the myoma. We also describe the preoperative and intraoperative methods that can be used to minimize intraoperative blood loss and enhance the safety and feasibility of the surgical procedure. Gonadotropin therapy was not applicable in our patient, and other treatments were also unavailable such as temporary ligation of uterine arteries, while others were unsuccessful like devascularization by hysteroscopy, twisting, and ligation of the pedicle. The final resort used in our case was morcellation of the myoma with intact pedicle, which should be attempted by experienced gynecologic surgeons only.

High Levels of IgA Antibodies to Helicobacter Pylori among Omani Women during Pregnancy and after Delivery.

BACKGROUND: Helicobacter pylori (H. pylori), is a common infection in pregnant women accompanied by variations in the levels of the IgM, IgA and IgG antibody isotypes. The variations of anti-H. pylori antibodies during and after pregnancy, and the extent of protection they provide to the mother and the fetus are not completely understood. OBJECTIVES: To investigate the changes of the anti-H. pylori IgM, IgA and IgG levels in healthy Omani pregnant women during pregnancy and 3 months after delivery. METHODS: Serum samples obtained from 70 Omani healthy pregnant women, with no history of autoimmune diseases, were tested for anti-H. pylori IgM, IgA and IgG in the first trimester of pregnancy and 3 months after delivery. In parallel and as a control group, sera obtained from a group of 70 healthy non-pregnant Omani women were tested. The levels of anti-H. pylori IgM, IgA and IgG were measured using standard Enzyme Linked Immunosorbent Assays (ELISAs). RESULTS: Anti-H. pylori IgA levels were found to be significantly higher during pregnancy (p=0.046) and after delivery (p=0.02) when compared to the control group. Moreover, a significant increase in the levels of anti-H. pylori IgM, IgA and IgG was detected after delivery (p=0.002) when compared to the levels during pregnancy. CONCLUSION: Pregnancy is associated with an increase in the levels of anti-H. pylori IgA antibodies. In addition, anti-H. pylori IgM, IgG and IgA antibody levels increase after delivery.

Submyomatous Cornual Pregnancy: Managed surgically after failed medical management.

Cornual pregnancy constitutes an emergency while its diagnosis and management remain a challenge. Anatomical abnormalities in the uterus, such as fibroids in the cornual region, make the management even more difficult. A nulliparous patient presented with an ectopic pregnancy at the right cornua under a huge fibroid. Despite multiple doses of methotrexate for a cornual ectopic gestation, the serum beta human chorionic gonadotropin (ß-hcG) levels doubled on the fifth day and a viable fetus was demonstrated on imaging. Thus surgical intervention in the form of laparoscopy followed by laparotomy, myomectomy of a large cornual fibroid and cornuostomy was performed. The serum beta human chorionic gonadotropin result was negative three weeks later. Surgical intervention in the form of myomectomy and cornuostomy was necessary to preserve fertility in this unusual presentation of cornual ectopic pregnancy.

"Laparoscopic excision of a large ovarian cyst herniating into the inguinal canal: a rare presentation".

Inguinal hernia repair is one of the most common operation in surgical practice. Despite its common occurrence, hernia often poses a surgical dilemma even for a skilled surgeon. The unexpected hernial content constitutes one of these cases. Although the often-reported, unusual contents of a hernia sac include ovary, fallopian tube, vermiform appendix, Meckel diverticulum, and urinary bladder, the herniation of a large ovarian cyst into the inguinal canal has been hardly reported. Majority of the ovarian cysts are asymptomatic or present with vague lower abdominal pain, whereas the presentation of a large ovarian cyst as an inguinolabial swelling as in our patient is extremely rare. We present here one of the few reported cases of a laparoscopic excision of a large ovarian cyst herniating into the inguinal canal and discuss the pathogenesis of an ovarian cyst as hernial content, the advantages and concerns of a laparoscopic approach in resecting large ovarian cysts, and simultaneous management of the inguinal hernia.

Tubal surgery.

Today, reproductive surgery has a limited place. In selected cases such as young women with a history of pelvic inflammatory disease, pelvic adhesions, and endometriosis, surgery could be considered. Most operations can be performed by laparoscopy; these include tubal anastomosis that yields a high pregnancy rate. On the other hand, women over the age of 37 with a long history of infertility or those who require a laparotomy are better treated with in-vitro fertilization. For women with hydrosalpinx undergoing IVF, salpingectomy is the best treatment option. It increases the chance of pregnancy and live birth rates and decreases the miscarriage rate.

Vaginal vault dehiscence after hysterectomy.

STUDY OBJECTIVE: The purpose of our study was to evaluate factors predisposing vault dehiscence after hysterectomy and its manifestation. DESIGN: Case series and review of the literature (Canadian Task Force classification II-3). SETTING: Multicenter study. PATIENTS: Retrospective analysis of 16 unpublished cases of vaginal vault dehiscence after total laparoscopic hysterectomy from physicians who participated in the exchange on the topic of vaginal vault dehiscence at the American Association of Gynecologic Laparoscopists Endo Exchange List (group A) and review of 38 reported cases in the literature (group B). INTERVENTIONS: The participating physicians were asked to complete a detailed questionnaire related to vault dehiscence. In addition, we performed literature search using the keywords "vault dehiscence," "vaginal vault dehiscence," "vault prolapse," and "hysterectomy," and conducted the search in MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews. MEASUREMENTS AND MAIN RESULTS: We estimated risk factors and characteristic features for vaginal vault dehiscence. The incidence of vault dehiscence was higher after laparoscopic hysterectomy (1.14%) than after abdominal hysterectomy (0.10%, p <.0001, OR 11.5) and after vaginal hysterectomy (0.14%, p <.001, OR 8.3). The time interval between hysterectomy and occurrence of vault dehiscence in the laparoscopic group (8.4 +/- 1.2 weeks) was significantly shorter than in the abdominal hysterectomy (112.7 +/- 75.1 weeks, p = .01) and in vaginal hysterectomy (136.5 +/- 32.2 weeks, p <.0001) groups, respectively. It appears that sexual intercourse was the main triggering event for vault dehiscence (58.8%). Vaginal bleeding (50%) and vaginal evisceration (48.1%) were the main symptoms. CONCLUSION: Our data suggest that vaginal vault dehiscence is rare but may occur more often after laparoscopic hysterectomy than after other hysterectomy approaches. Whether it is related to the technique of laparoscopic suturing is unclear. Other risk factors such as early resumption of regular activities and sexual intercourse may play a role.