Adrenal Gland Necrosis in Pregnancy: How to Manage? Case Series at Nantes University Hospital and Literature Review.

Adrenal necrosis is a rare but serious cause of abdominal pain of thrombotic origin during pregnancy. There is often a delay in diagnosis and treatment. The objective was to specify the clinical and paraclinical signs suggestive of adrenal necrosis, making it possible to improve the delay in diagnostic. The secondary objective was to establish a multidisciplinary protocol regarding management. This is a case report of pregnant women with a radiological diagnosis of adrenal gland necrosis. In parallel, we carried out a systematic review in the same period. We studied these patients' clinical, biological and radiological data. We included eight patients with a computed tomography scan diagnosis of adrenal necrosis and fifteen articles in the literature describing twenty-four cases. All the patients presented with the same symptoms. The treatment was based on curative anticoagulation. The diagnosis of adrenal gland necrosis is worth suggesting in view of the array of sudden morphine-resistant abdominal pain associated with a biological inflammatory syndrome. The diagnosis is based on the computed tomography scan. Three to six months of curative anticoagulation is recommended as well as a thrombophilia and endocrinological assessment to rule out adrenal insufficiency.

Risk Factors for Carbetocin Failure after a Cesarean Section: Is Obesity One of Them?

Obese pregnant women have increased rates of fetal macrosomia, long labor, and cesarean sections, which lead to an increased risk of postpartum hemorrhage (PPH). Carbetocin is useful for the prevention of PPH after a cesarean section. Our study aimed to investigate predictors of carbetocin failure after a cesarean section, and specifically whether obesity is associated with carbetocin failure. We retrospectively analyzed all women who received carbetocin after a cesarean section. Carbetocin failure was defined as changes in hematocrit and hemoglobin, blood loss ≥ 1000 mL, and the need for an additional uterotonic agent or second-line therapies for persistent PPH. Univariate and multivariate analyses were performed to investigate predictors of carbetocin failure. The study included 600 women, with 131 (21.8%) obese women. Overall, 44 (7.3%) carbetocin failures were reported, and rates of obese women were similar between groups (carbetocin failure, 11.4% vs. 22.9%; p = 0.08). Previous PPH (p < 0.001), a cesarean section during labor (p = 0.01), cervical ripening (p = 0.02), and birthweight (p = 0.01) were significantly different between groups. In the multivariable logistic regression analysis adjusted for potential confounders, cervical ripening (adjusted odds ratio (OR) 2.23, 95% confidence interval (CI) 1.01-4.80), compared with spontaneous labor, was significantly associated with carbetocin failure. Obesity was not associated with carbetocin failure after cesarean sections.

HE4 in the Diagnostic Approach of Endometrial Cancer in Patients with Postmenopausal Bleeding, the METRODEC Protocol: Protocol for a Multicenter Prospective Study.

BACKGROUND: Endometrial cancer is the most common pelvic gynecological cancer in France. The most frequent symptom is post-menopausal bleeding and is one of the primary reasons for consultation in gynecological emergencies. The treatment is very codified and consists of a surgical intervention for anatomopathological analysis. The latter is frequently reassuring. These interventions are often performed in mild situations and there is currently no element to be sufficiently reassuring to avoid surgery. This study aims to explore the sensitivity of an innovative marker: Human Epididymis 4 (HE4) in the diagnosis approach of endometrial cancer in case of postmenopausal bleedings. METHODS: This is a prospective multicenter diagnostic study with three centers involved. Inclusion criteria are any patient with post-menopausal bleeding who is to undergo hysteroscopy, endometrial biopsy, or endometrial resection. In accordance with the recommendations for the management of post-menopausal bleedings, the medical conduct consists of performing a clinical examination, an ultrasound and, in general, even in case of paraclinical examination reassuring, an anatomopathological analysis. This pathological analysis can be obtained in several ways: biopsy, hysteroscopy-curettage (which is the most frequently performed surgery), and hysterectomy. Our protocol consists of taking a blood sample from each woman who will undergo one of the interventions mentioned above. The dosage of HE4 and CA125 requires the withdrawal of an additional heparinized tube during the preoperative assessment usually performed. This research is therefore classified as non-interventional. The primary outcome is to evaluate the sensitivity of the HE4 marker in patients with postmenopausal bleeding in the diagnosis of endometrial cancer. The secondary outcomes are other parameters (specificity, VPP, VPN) of HE4, Evaluating the diagnostic capabilities of the CA125 marker alone and associated with HE4, as well as those of the REM and REM-B algorithms. We aim to include 100 patients over a period of one year in three centers. DISCUSSION: As of now, there is no biological marker used in routine practice in the diagnosis of endometrial cancer. The ultimate goal of HE4 in endometrial cancer is to avoid surgery for those who are identified as non-sick. This study is the precursor of others for use in routine practice, HE4 would represent a great help to diagnosis if our study demonstrates it as reliable in the management of these patients and avoid many unnecessary and risky surgeries.

Endometrial cancer: A systematic review of HE4, REM and REM-B.

INTRODUCTION: Endometrial cancer, one of the most frequent pelvic gynecologic cancer worldwide, currently has no biomarker used to assess it in daily practice. Nonetheless, human epididymis 4 (HE4) appears to offer the best prospects, alone or combined with CA125. This study sought to systematically review the work on HE4 from the first publications in 2008 until now. MATERIAL AND METHODS: Two independent reviewers searched the PubMed database with the terms "HE4″, "endometrial cancer", "endometrial carcinoma", and HE4 or human epididymis protein 4. Only original clinical research articles and meta-analyses, published in English, were included, with literature reviews and case reports excluded. RESULTS: Studies were organized into 3 categories: diagnosis, prognosis, and recurrence/survival. Overall we identified 117 articles dealing with HE4 and endometrial cancer and selected 52 relevant texts: 46 articles, 6 meta-analyses. The sensitivity of HE4 for the diagnosis of endometrial cancer varied from 44.2% to 91% and its specificity from 65.5 to 100%, versus 24.1 to 71.5% and from 65.6 to 100% for CA125. Two meta-analyses of their combination produced areas under the curve (AUC): 0.83 and 0.86. Two available algorithms - the REM (risk of endometrial malignancy) and REM-B (risk of endometrial malignancy associated with BMI) scores - require more study. HE4 is also strongly associated with prognostic factors such as myometrial invasion, tumor grade, FIGO stage, and lymph node involvement. It also predicts recurrence and can serve as a monitoring tool, as reported by a 2018 meta-analysis with a hazard ratio of 2.15 (P < 0.001). CONCLUSION: HE4, alone or associated with CA125, appears to be an important tool in the management of endometrial cancer, initially for diagnosis, but for assessing prognosis and survival. Other prospective and multicenter studies are necessary to confirm these hopes and be able to recommend the use of HE4 in regular practice.