The role of fibroblast growth factor 2 in patients with uterine smooth muscle tumors: an immunohistochemical study.

OBJECTIVE: Fibroblast growth factor 2 (FGF-2) is considered to be a potent stimulator of angiogenesis and seems therefore to play an important role in the growth of tumors. We compared the immunohistochemical profile of FGF-2 in patients with uterine leiomyomas, smooth muscle tumors of uncertain malignant potential (STUMP) and leiomyosarcoma (LMS). Furthermore, we tried to clarify the prognostic role of FGF-2 in uterine leiomyosarcoma. STUDY DESIGN: FGF-2 expression was investigated by immunohistochemistry from paraffin-embedded tissue in 26 patients with leiomyoma, in 24 cases with STUMP and in 21 patients with LMS. The immunohistochemical profile of these 3 tumor entities was compared and regarding LMS correlated with different clinicopathologic parameters. RESULTS: FGF-2 was expressed in 85% of leiomyomas, in 88% of STUMP and in 57% of LMS. Significant differences regarding the frequency of FGF-2 expression were observed between leiomyoma and LMS as well as between STUMP and LMS (p<0.05). In uterine LMS FGF-2 expression was statistically more frequent in cases with high histological grade (p<0.05). Furthermore, FGF-2 positive tumors demonstrated a statistically significant higher rate of recurrence disease and tumor progression (p=0.005). Disease free as well as overall survival was significantly shortened in patients with FGF-2 positive compared to FGF-2 negative tumors (p<0.05). CONCLUSION: The significant correlation between FGF-2 expression and high histological grade indicates that FGF-2 might work as a negative predictive factor. Higher rates of recurrence disease as well as shortened disease free and overall survival among FGF-2 positive LMS support the potential role as prognosticator for poor clinical outcome.

The impact of GnRH agonists in patients with endometriosis on prolactin and sex hormone levels: a pilot study.

OBJECTIVE: Gonadotropin releasing hormone agonists (GnRHa) decrease the expression of growth factors involved in the development of human endometriotic tissue. As endometriosis has been found to be associated with a mild increase in prolactin (PRL) serum levels, we aimed to evaluate changes in PRL serum levels as well as other hormones relevant to endometriosis and infertility during long-term administration of GnRHas in women with endometriosis. STUDY DESIGN: In this prospective pilot study we obtained blood samples on the first day of leuporeline administration and then subsequently after 4, 8 and 12 weeks in 22 patients. RESULTS: Median PRL levels were unchanged after 4 weeks, but significantly decreased 8 and 12 weeks after the first leuporeline administration (p1=0.085, p2=0.020, p3=0.001). There was no significant decrease in serum anti-Mullerian hormone (AMH) levels over the whole period of down regulation with leuporeline (p1-3>0.05). CONCLUSION: Our data support the hypothesis that the decrease of PRL levels might contribute to the known effect of GnRH treatment in patients with endometriosis via suppression of VEGF expression in endometriotic lesions. Moreover this study lends support to the thesis that AMH remains stable under GnRHa therapy and therefore can be also used as a marker of ovarian function prior to IVF-stimulation during down regulation.

The impact of thyroid function on intrauterine insemination outcome--a retrospective analysis.

BACKGROUND: Hashimoto's thyroiditis is the most common endocrinopathy in premenopausal women, and is associated with various gynecological problems, including recurrent miscarriage and unexplained infertility. A possible influence of Hashimoto's thyroiditis on the success of intrauterine insemination seems likely, but has not been evaluated as yet. Therefore, the aim of our study was to retrospectively analyze the impact on intrauterine insemination outcome of thyroid function and markers suggestive for Hashimoto's thyroiditis. METHODS: Retrospective cohort study in a tertiary care center of 540 women who underwent Intrauterine Insemination. The clinical pregnancy rate was the main outcome parameters. The following possible influencing factors were tested: thyroid-stimulating hormone (TSH); thyroid autoantibodies; age; body mass index; type of sterility (primary/secondary); parity; male factor; presence of PCO syndrome; ovulation induction; ovarian stimulation; and current thyroid medication. RESULTS: The overall clinical pregnancy rate was 6.9% (37/540). Age, thyroid hormone supplementation for thyroid-stimulating hormone (TSH) levels>2.5 micro-IU/ml, and ovulation induction with HCG were significantly predictive in the multivariate analysis (p<0.05) as influencing factors for the pregnancy rate after intrauterine insemination. CONCLUSIONS: Women undergoing intrauterine insemination seem to benefit from a strict thyroid hormone supplementation regimen in order to achieve lower TSH levels.

Perioperative androstenedione kinetics in women undergoing laparoscopic ovarian drilling: a prospective study.

We evaluated perioperative androstenedione levels in laparoscopic ovarian drilling (LOD) for polycystic ovary syndrome (PCOS) and whether an intraoperative androstenedione change was predictive for spontaneous ovulation. In a prospective study, 21 anovulatory women with clomiphene citrate-resistant PCOS who underwent LOD and eight female controls who underwent diagnostic laparoscopy for infertility were included. Perioperatively, blood was drawn one day before surgery, directly before skin incision, ten minutes after surgery, and after two days. Within three months, spontaneous ovulation occurred in 15 women (71.4 %). For both the PCOS and the control group, an androstenedione increase was found from one day before surgery to skin incision (p < 0.05). In PCOS women, there was an intraoperative androstenedione decrease (median 3.5, IQR 2.2-4.8 vs. median 2.6, IQR 1.4-2.6 ng/ml, p = 0.002). In multivariate analysis, only higher preoperative androstenedione (odds ratio, OR 6.53) and luteinizing hormone levels (OR 7.31), as well as secondary infertility (OR 5.40), were associated with higher rates of postoperative spontaneous ovulation (p < 0.001). Androstendione declines significantly during LOD. However, intraoperative kinetics are not useful for the prediction of spontaneous ovulation after LOD, in contrast to preoperative androstenedione and LH levels, as well as a history of previous pregnancies.

Relaxin and gonadal steroid receptors in uterosacral ligaments of women with and without pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This study evaluates the expression of estrogen receptor isoforms alpha (ERα) and beta (ERß), progesterone receptor (PR), and relaxin receptor isoforms 1 and 2 (LGR7, LGR8) in uterosacral ligament (USL) tissue of women with pelvic organ prolapse and controls. METHODS: Tissue samples of USL from women with and without pelvic organ prolapse (POP) were subjected to immunohistochemistry against ERα, ERß, PR, and LGR7 proteins. The respective mRNA expression as well as of LGR8 was assessed by quantitative real-time polymerase chain reaction. RESULTS: The cellular distribution of the receptor proteins was different due to cell types, independent of POP: ERα and PR were found in smooth muscle cells, but not in endothelial cells, whereas ERß was found in endothelial cells, but not in connective tissue. ERα, ERß, PR, and LGR7 mRNAs could be detected in all patients of both groups. ERα mRNA expression was significantly and ERß mRNA borderline significantly higher in USL of patients with POP: ERα: p < 0.001, ERß: p = 0.057. CONCLUSIONS: Enhanced effects of estrogen via altered mRNA expression patterns of ERα and ERß--but not those of progesterone--may exist in USL of patients affected by POP. A local effect of relaxin needs to be further clarified because of this first report of prevalent ligamental expression of LGR7.

A modified technique of laparoscopic ovarian drilling for polycystic ovary syndrome using the monopolar hook electrode.

The aim of our study was to review our experience with a modified technique of laparoscopic ovarian drilling (LOD) using a monopolar hook electrode. We retrospectively included 38 clomiphene-resistant women with polycystic ovary syndrome undergoing LOD. A laparoscopic monopolar hook electrode was used to make three to six incisions in the ovarian capsule. It resulted in a rate of spontaneous ovulation of 75.8%, an overall one-year pregnancy rate of 80.6% and a subsequent live birth rate of 67.7%. We consider our LOD technique using the monopolar hook electrode practicable. Whether it leads to a more extensive destruction of the ovarian capsule and thereby of the ovarian reserve remains open.

Bipolar vessel sealing increases operative safety in laparoscopic-assisted vaginal hysterectomy.

BACKGROUND: To compare laparoscopic-assisted vaginal hysterectomy (LAVH) with and without bipolar vessel sealing (BVS) using the LigaSure™ device by meanings of intra- and postoperative course. METHODS: In a retrospective case-control study 362 female patients (mean age 54.3 ± 9.5 years) were included who underwent LAVH with (n = 252) and without (n = 110) use of BVS. Intra- and postoperative courses and adverse events were evaluated. RESULTS: A shorter mean operating time was found for LAVH with the use of BVS (65.28 ± 16.33 min) when compared with LAVH without the use of BVS (83.73 ± 21.53 min, P < 0.005). The mean postoperative stay did not differ significantly between the two groups (P > 0.05); 15 out of 251 (6.0%) patients were found to have adverse events during or after LAVH with the use of BVS in contrast to 16 out of 110 (14.5%) patients during or after LAVH without the use of BVS (P < 0.05). Following the use of BVS significantly less patients reported postoperative pain for more than 7 days after the operation in contrast to the use of sutures (0/251 [0%] vs. 3/110 [2.7%], respectively, P < 0.05). CONCLUSION: The use of LigaSure™ is effective in decreasing operating time, the overall complication rate and postoperative pain.

Elevated antithyroid peroxidase antibodies indicating Hashimoto's thyroiditis are associated with the treatment response in infertile women with polycystic ovary syndrome.

In infertile women suffering from polycystic ovary syndrome (PCOS), anti-thyroid peroxidase antibodies values exceeding the upper level of normal were found in significantly more clomiphene citrate resistant patients compared clomiphene citrate responders and metformin responders. Thus, elevated antiTPO levels are associated with poor treatment response in infertile women who suffer from PCOS.

Laparoscopic ovarian tissue harvesting for cryopreservation: an effective and safe procedure for fertility preservation.

OBJECTIVE: To critically review our experience with the method of laparoscopic ovarian tissue harvesting for ovarian cryopreservation. STUDY DESIGN: In a retrospective cohort study 85 patients undergoing surgery for cryopreservation of ovarian tissue were included. One random ovarian cortical slice was histologically examined in order to determine the presence of primordial follicles and to detect possible malignant cells. Selective microbiological culture techniques from swabs were taken from all slices immediately after excision. Intra- and postoperative courses, histological and microbiological findings were evaluated. RESULTS: Eighty-five patients underwent cryopreservation of ovarian tissue, mostly for malignant diseases (78/85, 91.8%). Sixty patients (70.6%) underwent laparoscopy for ovarian tissue harvesting only, without any additional surgical procedure. The median operating time was 30 min (range 10-75 min). The intraoperative course was uneventful in these patients. In two patients slight postoperative increases in C-reactive protein levels were found. Microbiological examination revealed no contamination apart from one case revealing sporadic Propionibacterium acnes. Histological examination revealed intact ovarian tissue with primordial follicles in 81/85 patients (95.3%). CONCLUSION: Laparoscopy is a safe and effective procedure for ovarian tissue harvesting. We suggest microbiological and histological testing of ovarian tissue as mandatory tools to guarantee safety regarding ovarian tissue transplantation.

Pregnancy outcome in women with polycystic ovary syndrome comparing the effects of laparoscopic ovarian drilling and clomiphene citrate stimulation in women pre-treated with metformin: a retrospective study.

BACKGROUND: Ovarian stimulation in women with polycystic ovary syndrome (PCOS) increases the risk for perinatal complications. Ovulation induction by laparoscopic ovarian drilling (LOD) might improve the overall pregnancy outcomes. The aim of our study was to assess the adverse events or effects on pregnancy of LOD and clomiphene citrate (CC) stimulation in patients who received metformin. SETTING: Academic research institution. We retrospectively analyzed the courses of 40 spontaneous pregnancies after LOD for CC-resistance, 40 pregnancies after CC stimulation, and 40 pregnancies after metformin treatment alone. Patients in the LOD and the CC groups had been pre-treated with Metformin. Primary outcome parameters were: the rate of multiple pregnancies; the rate of early pregnancy losses/miscarriages; the development of gestational diabetes, pregnancy-induced hypertension, and preeclampsia/HELLP-syndrome; premature delivery; and birth weight. RESULTS: The rate of twin pregnancies did not differ between the CC group (12.5%), the LOD group (7.5%), and the metformin only group (2.5%, p=0.239). Seventeen women suffered an early miscarriage. There were no differences with regard to the rates of gestational diabetes, pregnancy-induced hypertension, preeclampsia, and preterm delivery. By analyzing all pregnancy complications together, the overall pregnancy complication rate was highest in the CC group (70.0%, 28/40), followed by the LOD group (45.0%, 18/40), and the metformin only group (47.5%, 19/40; p=0.047). CONCLUSIONS: CC, but not LOD, increases the complication rate in pregnant patients who received metformin.

Ovarian tissue cryopreservation for non-malignant indications.

BACKGROUND: Ovarian tissue cryopreservation (OTC) is not restricted to patients suffering from malignancies. Benign haematopoietic diseases such as autoimmune diseases and others have been mentioned to be feasible indications. The aim of our study was to demonstrate that surgery for OTC is a safe procedure for fertility preservation in patients with non-malignant diseases. METHODS: In a retrospective cohort study intra- and postoperative courses were evaluated. Histological examination of one random ovarian cortical slice was performed to determine the presence of primordial follicles. Immediately after the excision, microbiological culture techniques from swabs were taken from all slices. RESULTS: Seven of 85 patients (8.2%) have undergone surgery for OTC for non-malignant indications. All patients had an uncomplicated intraoperative course. A median number of 12 cortical stripes were excised and cryopreserved (range 7-17). Only for one patient an adverse event was found which was not related to laparoscopy for OTC. All patients having undergone routine laparoscopy for OTC only could be released from hospital on the first postoperative day. Selective microbiological tests showed negative results in all cases. Histological examinations revealed intact ovarian tissue with primordial follicles in 6/7 patients. CONCLUSION: Whether surgery for OTC in patients with non-malignant indications is feasible from an ethical point of view remains open. However, laparoscopy for ovarian tissue harvesting is a safe procedure for patients undergoing cytotoxic treatment for benign diseases.

Luteinizing hormone and androstendione are independent predictors of ovulation after laparoscopic ovarian drilling: a retrospective cohort study.

BACKGROUND: Our objective was to investigate luteinizing hormone, follicle-stimulating hormone, testosterone, and androstenedione as predicitve markers for ovulation after laparoscopic ovarian drilling. METHODS: We retrospectively analyzed 100 clompihen-resistant patients with the polycystic ovary syndrome who underwent laparoscopic ovarian drilling at our department. The main outcome measure was spontaneous postoperative ovulation within three months after laparoscopic ovarian drilling. In order to predict spontaneous ovulation, we tested the following parameters by use of a univariate followed by a multivariate regression model: Preoperative serum levels of LH, FSH, testosterone, and androstenedione as well as patients' age and body mass index. In addition, we focused on pregnancy and life birth rates. RESULTS: Spontaneous ovulation was documented in 71/100 patients (71.0%). In a univariate and multivariate analysis, luteinizing hormone (OR 1.58, 95%CI: 1.30-1.92) and androstenedione (OR 3.03, 95%CI: 1.20-7.67), but not follicle-stimulating hormone and testosterone were independent predictors of ovulation. Using a cut-off for luteinizing hormone and androstenedione of 12.1 IU/l and 3.26 ng/ml, respectively, spontaneous ovulation was observed in 63/70 (90.0%) and 36/42 patients (85.7%) with elevated and in 8/30 (26.7%) and 35/58 (60.3%) patients with low luteinizing hormone and androstenedione levels, respectively. The sensitivity, specificity, positive and negative predictive values for luteinizing hormone and androstendione as predictors of spontaneous ovulation after ovarian drilling were 88.7% (95%CI: 79.0-95.0%), 75.9% (95%CI: 56.5-89.7%), 90.0% (95%CI: 80.5-95.8%), and 73.3% (95%CI: 54.1-87.7%) for luteinizing hormone, and 50.7% (95%CI: 38.6-62.8%), 79.3% (95%CI: 60.3-92.0%), 85.7% (95%CI: 71.5-94.6%), and 39.7% (95%CI: 27.0-53.4%) for androstenedione, respectively. Complete one-year follow-up was available for 74/100 patients (74%). We observed a one-year pregnancy rate and a resulting life-birth rate of 61% and 51%, respectively. CONCLUSIONS: Luteinizing hormone and androstenedione prior to laparoscopic ovarian drilling are independent predictors of spontaneous ovulation within three months of surgery. We suggest to preferentially performing laparoscopic ovarian drilling in patients with high luteinizing hormone and androstenedione levels.

Expression of thrombospondin 1 (TSP 1) in patients with uterine smooth muscle tumors: an immunohistochemical study.

OBJECTIVE: Angiogenesis is an essential component for tumor development regulated by both proangiogenic and antiangiogenic factors. Thrombospondin 1 (TSP 1) suppresses angiogenesis by inhibiting endothelial cell proliferation and inducing endothelial cell apoptosis. The aim of this study was to compare the expression of TSP 1 in cases with leiomyoma, uterine smooth muscle tumor of uncertain malignant potential (STUMP) and leiomyosarcoma (LMS). Furthermore, we evaluated the prognostic relevance of TSP 1 in uterine LMS. METHODS: TSP 1 expression was investigated by immunohistochemistry from paraffin-embedded tissue in 26 patients with leiomyoma, in 24 patients with STUMP and in 21 patients with LMS. Standard immunohistochemical techniques were used to study the expression of TSP 1 in 5-mum-thick tumor sections. TSP 1 expression was correlated with survival using the Kaplan-Meier method and log-rank test for univariate analysis. RESULTS: TSP 1 was expressed in 77% of leiomyomas, in 13% of STUMP and in 24% of LMS. A statistically significant difference regarding the frequency of TSP 1 expression was observed between leiomyoma and LMS (P < 0.05) as well as between leiomyoma and STUMP (P < 0.05), but not between LMS and STUMP (P > 0.05). Furthermore, a statistically significant correlation between vascular space involvement and TSP 1 expression was observed in patients with uterine LMS, with patients without vascular space involvement having more frequently TSP 1 positive tumors (P = 0.04). No statistically significant correlation between TSP 1 and clinical stage, age and recurrence disease could be detected (P > 0.05). CONCLUSIONS: We found that TSP 1 was more frequently expressed in leiomyoma compared to STUMP and LMS. Additionally, the statistically significant negative correlation between vascular space involvement and TSP 1 expression in patients with uterine LMS shows that TSP 1 might work as a predictive factor in patients with LMS. Further clinical studies are necessary to prove our results and to clarify the role of TSP 1 in uterine smooth muscle tumors.

Influence of labor induction on obstetric outcomes in patients with prolonged pregnancy: a comparison between elective labor induction and spontaneous onset of labor beyond term.

BACKGROUND: Prolonged pregnancy is the most frequent reason for induction of labor. This study aims to determine the effects of labor induction on delivery outcome and to quantify the risks of cesarean delivery associated with labor induction in post-date pregnancies. PATIENTS AND METHODS: This retrospective case-control study included a total of 205 women who reached 42 weeks' gestation (41 weeks and 3 days) between January 2002 and April 2004 and who were scheduled for induction of labor with vaginal prostaglandins. These cases were matched for age and parity with controls in spontaneous labor beyond 41 weeks' gestation. Women with any additional medical or obstetric risk factors were excluded from the study. Maternal, neonatal and delivery outcomes were the main variables of interest. RESULTS: During the study period the data of 410 women were available for analysis. Our data revealed that the use of amniotomy (p=0.02), oxytocin (p=0.006) and epidural analgesia (p=0.001) was increased significantly in the induction group compared with the control group of women with spontaneous onset of labor beyond term. The frequency of cesarean delivery and vacuum extraction was also significantly higher in the induction group (p=0.0001). The Bishop score before induction was an important factor that affected the delivery outcome, resulting in significantly higher rates of cesarean section and vacuum extraction when the score was unfavorable (p=0.0001). A univariate regression model revealed induction per se (p=0.0001), primiparity (p= 0.0001), increased maternal age (p=0.006) and an unfavorable Bishop score (p=0.0001) as statistically significant risk factors for cesarean section. In a multivariate logistic regression model, primiparity (p=0.03), increased maternal age (p=0.02) and an unfavorable Bishop score (p=0.01) remained independent risk factors for cesarean section. High infant birth weight was also an independent risk factor (p=0.03). CONCLUSIONS: Our data suggest that women undergoing labor induction because of prolonged pregnancy should be sufficiently informed regarding the risks of a cesarean section or a vacuum extraction. Furthermore, the option of elective cesarean section should be considered, particularly in primiparous women with an unfavorable cervix, higher age, and high estimated infant birth weight.

Expression of p16 protein in patients with uterine smooth muscle tumors: an immunohistochemical analysis.

OBJECTIVE: The loss of cell cycle control is a critical step in the development of neoplasia. The p16 protein has been identified as a tumor suppressor protein, which binds specifically to the cyclin-dependent kinase CDK-4, inhibiting the catalytic activity of the CDK4-cyclin D complex, and thereby acts as a negative cell cycle regulator. In the present study, we compared the expression of p16 protein in cases with leiomyoma, uterine smooth muscle tumor of uncertain malignant potential (STUMP), and leiomyosarcoma (LMS). METHODS: P16 expression was investigated by immunohistochemistry from paraffin-embedded tissue in 26 patients with leiomyoma, in 24 patients with STUMP, and in 21 patients with LMS. RESULTS: P16 was expressed in 12% of leiomyomas, in 21% of STUMP, and in 57% of LMS. A statistically significant difference regarding the frequency of p16 protein expression was observed between LMS and STUMP (P < 0.05) as well as between LMS and leiomyoma (P < 0.05), but not between STUMP and leiomyoma (P > 0.05). Likewise, the staining intensity did significantly differ between LMS and leiomyoma and between LMS and STUMP (P < 0.05), but no statistical significant difference was observed between STUMP and leiomyoma (P > 0.05). No statistically significant correlation between p16 expression and clinical stage, age, vascular space involvement, and recurrence disease could be found in patients with LMS (P > 0.05). Additionally, the overall survival did not significantly differ between p16-positive and p16-negative cases (P > 0.05). CONCLUSIONS: We found that p16 was more frequently and more strongly expressed in LMS compared to STUMP and leiomyoma. We therefore concluded that p16 might play an important role in sarcomagenesis. Furthermore, p16 might be a useful immunohistochemical marker, which could help to distinguish cases of smooth muscle tumors in which histologic features are ambiguous or borderline, but the use of p16 in a diagnostic setting should await further clinical studies and clarification of the mechanisms.

Ki-67 expression in patients with uterine leiomyomas, uterine smooth muscle tumors of uncertain malignant potential (STUMP) and uterine leiomyosarcomas (LMS).

BACKGROUND: The aim of the current study was to evaluate the expression of Ki-67 in uterine smooth muscle tumors, comparing leiomyomas, uterine smooth muscle tumors of uncertain malignant potential (STUMP) and uterine leiomyosarcomas (LMS) and to prove the accuracy of a Ki-67 expression as a useful parameter in the diagnosis of LMS. METHODS: Ki-67 was assessed using immunohistochemistry from paraffin-embedded tissue in 20 patients with uterine LMS, 22 cases of STUMP and 25 cases of leiomyomas. RESULTS: Ki-67 was present in 10/20 (50%) LMS, in 0/22 (0%) STUMP and in 2/25 (8%) leiomyomas. Significant differences regarding the frequency of Ki-67 expression were observed between LMS and STUMP (p = 0.0001) as well as between LMS and leiomyomas (p = 0.002), but not between STUMP and leiomyomas (p = 0.491). Likewise, the staining intensity differed significantly between LMS and leiomyomas (p = 0.018) as well as between LMS and STUMP (p = 0.002), but not between STUMP and leiomyomas (p = 0.368). CONCLUSIONS: Our results demonstrate that the significantly elevated Ki-67 antigen expression in LMS, which correlates well with the rapid growth of these malignant tumors, may be a useful immunohistochemical parameter to distinguish between cases of malignant smooth muscle tumors and those of uncertain or borderline histology.

Influence of the birth attendant on maternal and neonatal outcomes during normal vaginal delivery: a comparison between midwife and physician management.

BACKGROUND: The purpose of this study was to compare the obstetric outcome of low-risk maternity patients attended by certified midwives with that of low-risk maternity patients attended by obstetricians. PATIENTS AND METHODS: Obstetric outcome of 1352 midwife patients was compared with that of 1352 age- and parity-matched physician patients with normal spontaneous vaginal delivery at the Department of Obstetrics and Gynecology of the University Hospital Vienna during the period from January 1997 to July 2002. Our analysis was restricted to a sample of low-risk pregnant women. Women with medical or obstetric risk factors were excluded. RESULTS: A significant decrease in the use of oxytocin (p=0.0001) was observed in women who selected a midwife as their primary birth attendant compared with women in the physician group. In both groups most women gave birth in a supine position; however, significantly more alternative birth positions were used by midwife patients (p = 0.0001). Concerning perineal trauma, a significantly lower rate of episiotomies (p = 0.0001) and perineal tears of all degrees (p=0.006) were found in midwife patients. When analyzing severe postpartum hemorrhage and postpartum infections, there were no significant differences between the two groups (p > 0.05). Concerning neonatal outcome, there were no significant differences in APGAR score < 7 at 5 minutes (p > 0.05). Our data clearly show the ability of certified midwives to successfully provide prenatal care and delivery to low-risk maternity patients, with neonatal outcomes comparable to those of physician patients. The use of certified midwives supervised by obstetricians may provide the optimum model for perinatal care, particularly for those women who are low-risk maternity patients, leaving physicians free to attend to the high-risk elements of care.

Estrogen and progesterone receptor expression in patients with uterine smooth muscle tumors.

OBJECTIVE: To investigate the expression of estrogen and progesterone receptor in uterine leiomyomas, smooth muscle tumors of uncertain malignant potential (STUMP), and leiomyosarcomas (LMS), and to assess the correlation between steroid receptor expression and clinicopathologic parameters in LMS. DESIGN: Estrogen/progesterone receptor expression was investigated by immunohistochemistry. SETTING: Department of Gynecology and Obstetrics of the University Hospital of Vienna. PATIENT(S): Twenty-six women with leiomyoma, 24 with STUMP, and 21 with LMS of the uterus. INTERVENTION(S): Formalin-fixed, paraffin-embedded tissues were sectioned and stained. MAIN OUTCOME MEASURE(S): Number of tumor cells stained. RESULT(S): Significant differences regarding the frequency of estrogen receptor expression were observed between LMS and leiomyoma and STUMP and leiomyoma (P<.05). The progesterone receptor expression did significantly differ between LMS and STUMP (P=.05), and LMS and leiomyoma (P<.05). In uterine LMS, the relationship between estrogen/progesterone receptor expression and clinicopathologic parameters did not reach statistical significance (P>.05), and neither of the markers studied revealed prognostic significance (P>.05). CONCLUSION(S): The present study observed significant differences of steroid receptor expression between uterine leiomyoma, STUMP, and LMS. Our data indicate that the progesterone receptor may be an especially useful marker to distinguish cases of malignant smooth muscle tumors in which histological features are ambiguous or borderline.

Bcl-2 receptor expression in patients with uterine smooth muscle tumors: an immunohistochemical analysis comparing leiomyoma, uterine smooth muscle tumor of uncertain malignant potential, and leiomyosarcoma.

OBJECTIVE: Bcl-2 protein is an apoptosis-inhibiting gene product that prevents the normal course of apoptotic cell death in a variety of cells. Additionally, bcl-2 can promote cell replication by reducing the requirement for growth factors. This protein seems, therefore, to play an important role in the growth of tumors. Our aim was to investigate the different expression of bcl-2 in uterine leiomyomas, smooth muscle tumors of uncertain malignant potential (STUMP), and leiomyosarcomas (LMS). Furthermore, the correlation between bcl-2 expression and various clinicopathologic parameters in leiomyosarcomas was assessed to evaluate its prognostic value. METHODS: This study included 26 cases of leiomyoma, 22 cases of STUMP, and 21 cases of LMS of the uterus. Bcl-2 expression was investigated by immunohistochemistry from paraffin-embedded tissue. The immunohistochemical findings were compared and correlated with different clinicopathologic parameters. Clinical information, including follow-up data, was obtained from the database of the Department of Gynecology and Obstetrics. RESULTS: Bcl-2 was present in 12 of 21 LMS, eight of 22 STUMP, and 20 of 25 leiomyomas. Significant differences regarding the frequency of bcl-2 expression and the staining intensity were observed between LMS and leiomyoma as well as between STUMP and leiomyoma (P <.05) but not between LMS and STUMP (P >.05). Regarding the outcome of uterine LMS, patients with bcl-2 positive tumors showed less vascular space involvement and longer overall survival (P <.05). CONCLUSION: Bcl-2 was expressed more frequently and more strongly in leiomyomas compared with LMS and STUMP. Regarding the outcome of uterine LMS, patients with bcl-2-positive tumors showed less vascular space involvement and longer overall survival. The stronger bcl-2 expression in benign leiomyomas and the better clinical outcome of bcl-2-positive LMS indicate that this protein seems to act as a good prognostic factor. Further studies including larger numbers of patients are necessary to establish bcl-2 as a routine marker for improved prognosis in malignant uterine smooth muscle tumors.

Bcl-2 expression and other clinicopathologic parameters in uterine leiomyosarcoma.

BACKGROUND: The bcl-2 protein, which is involved in cell-cycle regulation and apoptosis, seems to play an important role in the growth of tumors. Until recently, only one study described the frequent expression of bcl-2 in uterine leiomyosarcomas (LMS) and indicated its important prognostic role. Thus, the aims of the present study were to examine bcl-2 expression in patients with uterine LMS and to determine if the expression of this protein would influence the prognosis. In addition, a possible association between bcl-2 expression and various clinicopathologic parameters was evaluated. PATIENTS AND METHODS: Bcl-2 expression was investigated using immunohistochemical techniques on paraffin-embedded tissue from 21 patients with uterine LMS. The immunohistochemical findings were correlated with different clinicopathologic parameters (FIGO stage, age, vascular-space involvement and recurrence of disease) of the patients. RESULTS: Bcl-2 was expressed in 57% (12/21) of uterine LMS: 3/12 (25%) stained weakly positive, 3/12 (25%) stained moderately positive and 6/12 (50%) stained strongly positive. Nine (43%) cases were negative. Evaluation of the correlation between bcl-2 expression and several clinicopathologic parameters identified a significant negative correlation between vascular-space involvement and bcl-2 expression (p=0.04). The relationship between bcl-2 expression and FIGO stage, age and recurrence of disease did not reach statistical significance. A univariate Cox model revealed significantly longer overall survival in women with bcl-2-positive LMS compared with women with bcl-2-negative LMS (p=0.03). CONCLUSIONS: Significant negative correlation was found between bcl-2 expression and vascular-space involvement and improved survival rates in patients with bcl-2-positive tumors. Though limited by the small number of patients, these data indicate the role of bcl-2 expression in uterine LMS.