The added value of conventional defecography and MRI defecography in clinical decision making on treatment for posterior compartment prolapse.

INTRODUCTION AND HYPOTHESIS: Conventional defecography and MRI defecography can be requested as an additional test for diagnosing and differentiating the type of posterior compartment prolapse and/or obstructive defecation disorders. The objective of this study was to determine the added value of conventional defecography, conventional defecography and MRI defecography for clinical decision-making on treatment for patients with posterior compartment prolapse. METHODS: Four gynecologists were asked to fill in their treatment plan per patient for 32 cases for three different steps. Step 1 consisted of information on the anamnesis and physical examination (POP-Q). Step 2 consisted of Step 1, including conventional defecography (group A) or MRI defecography (group B). In Step 3, all gynecologists received the information on Step 1 including both conventional defecography and MRI defecography. Data analysis solely focused on the assessment of changes in the gynecological treatment plan of the posterior compartment. RESULTS: After Step 2 a change in treatment plan occurred in 37% and 48% of the women in groups A and B, respectively. Accordingly, after Step 3 (including all imaging data), a change in treatment plan occurred in 19% and 52% of the women in groups A and B, respectively. A change within the surgery group (when a different type of surgery was selected) was seen for a total of 11 cases in group A and 20 in group B in all steps combined. CONCLUSIONS: Both conventional defecography and MRI defecography had an large effect on the treatment plan for patients with posterior compartment prolapse. The dedicated added value of the imaging modality individually cannot be concluded yet.

[Cesarean scar pregnancy]. / Ectopische zwangerschap in litteken van keizersnede.

BACKGROUND: A rare, but potentially life-threatening complication of a Cesarean section is a so-called Cesarean scar pregnancy (CSP). This concerns an ectopic pregnancy, where the implantation takes place in a niche of the Cesarean section scar. CASE DESCRIPTION: We describe the case of a 29-year-old pregnant woman (G5P3), who after a amenorrhoea period of 6 weeks was referred to us by a midwife because the sonography showed an empty uterus. She had previously undergone two Cesarean sections. During transvaginal sonography we observed a small amiotic sac in the Cesarean section scar, lacking a clear heart rhythm. CONCLUSION: Since there are no general guidelines for the treatment of CSP, a patient-specific approach should be taken to determine optimal management. There is, however, a clear preference to terminate the pregnancy as soon as possible.

Underestimation of pelvic organ prolapse in the supine straining position, based on magnetic resonance imaging findings.

OBJECTIVE: Pelvic organ prolapse (POP) is clinically diagnosed in the supine position, where the effect of gravity is simulated by having the patients put strain on their pelvic floor. The objective of this study was to determine the degree of POP underestimation in the supine position based on magnetic resonance imaging (MRI) findings. METHODS: This prospective study was conducted with symptomatic POP grade ≥ 2 patients. Fifteen female patients were examined with an MRI system that allows supine and upright imaging. The differences between supine and upright in distances of the bladder neck, cervix, and pouch of Douglas from the pubococcygeal line (PCL) were estimated, together with changes in the genital hiatal area. Patients were scanned at rest and during straining. All distances were compared using the Wilcoxon ranking test. RESULTS: All mean distances from the PCL increased from the supine-strain to the upright-rest and from the supine-strain to the upright-strain position. These distances were found in the supine and upright positions: the bladder descended 1.3 cm to 1.4 cm, the cervix 1.1 cm to 2.2 cm, and the pouch of Douglas 0.8 cm to 1.5 cm respectively (all p values <0.05). The hiatal area was larger in the upright-strain position (mean 42.0 cm2; SD ±14.8) than during the supine-strain position (mean 33.5 cm2; SD ±14.5), with a p value of 0.02. CONCLUSION: Upright MRI scanning of patients with POP grade ≥ 2 both at rest and during straining shows a significantly larger extent of the prolapse than that observed during supine straining.

Species differences in the effect of pregnancy on lymphocyte cytokine production between human and rat.

In the present study, we evaluated whether lymphocyte cytokine production during human and rat pregnancy shifts toward T helper cell type 2 (Th2) cytokine production. Therefore, blood samples were taken during the follicular and luteal phase and during pregnancy in rats and humans. Whole blood was ex vivo-stimulated with phorbol 12-myristate 13-acetate and calcium ionophore and intracellular interferon-gamma (IFN-gamma) and interleukin (IL)-4 production, and the percentage of cells in the various lymphocyte populations was measured using flow cytometry. Rats and humans adapted their immune responses to pregnancy but have different strategies: During human pregnancy, the percentage of lymphocytes producing IFN-gamma was decreased, and the percentage IL-4-producing lymphocytes was not affected. The rat adapts its immune response to pregnancy by decreasing the total number of the various lymphocyte populations, and the percentage of IFN-gamma- or IL-4-producing lymphocytes was not affected or increased (% IFN-gamma-producing cytotoxic lymphocytes). It is speculated that during rat pregnancy, there is no need to decrease the number of IFN-gamma-producing lymphocytes, as in nonpregnant rats, the total number of IFN-gamma-producing lymphocytes after stimulation is relatively low, and there is no necessity for a further decrease. In nonpregnant humans, the percentage IFN-gamma-producing lymphocytes is much higher and probably dangerous for pregnancy, and therefore, this percentage needs to decrease during pregnancy. In conclusion, although the data from humans concur with the Th1/Th2 paradigm, the data from rats do not concur with this paradigm. The present studies therefore challenge the classical Th1/Th2 paradigm during pregnancy.

Endotoxin-induced cytokine production of monocytes of third-trimester pregnant women compared with women in the follicular phase of the menstrual cycle.

OBJECTIVE: Little is known about the function of the innate immune response during pregnancy. We therefore investigated monocyte cytokine production, as a measure of monocyte function, in pregnant women compared with nonpregnant women. STUDY DESIGN: Whole blood of women in the follicular phase (day 5-6) and of healthy pregnant women (30 weeks) was collected and stimulated with endotoxin (2 microg/mL). After incubation for 4 hours (37 degrees C, 5% carbon dioxide), red blood cells were lysed and white blood cells were permeabilized, followed by staining with anti-CD14 (fluorescein isothiocyanate labeled) and with phycoerythrin-labeled tumor necrosis factor-alpha, interleukin-1beta, or interleukin-12. The cells were analyzed by flow cytometry after fixation. Results are expressed as a percentage cytokine producing cells after endotoxin stimulation. Statistical analysis was performed with the Mann-Whitney U test (P <.05). RESULTS: Compared with the percentage endotoxin-induced cytokine producing peripheral monocytes in women in the follicular phase, this percentage in pregnancy was decreased for interleukin-12 (mean 6.63 +/- 1.34 vs 3.34 +/- 0.87, P <.05) and tumor necrosis factor-alpha (mean 50.20 +/- 5.80 vs 31.29 +/- 5.57, P >.05). No significant difference was seen in the production of interleukin-1beta (mean 58.22 +/- 11.09 vs 47.18 +/- 7.88, P >.05). CONCLUSION: The percentage of interleukin-12 and tumor necrosis factor-alpha producing monocytes is decreased in pregnant women compared with nonpregnant women, suggesting that pregnancy is a proinflammatory state.

Cytokine production in natural killer cells and lymphocytes in pregnant women compared with women in the follicular phase of the ovarian cycle.

OBJECTIVE: To test whether peripheral natural killer (NK) cells, helper T cells, and cytotoxic lymphocytes of pregnant women shift from a type 1 cytokine production toward a type 2 cytokine production as compared with these cells in women in the follicular phase. DESIGN: Prospective study. SETTING: Outpatient clinic. PATIENT(S): Healthy nullipara at 30 weeks' amenorrhea and healthy nonpregnant women in their follicular phase. INTERVENTION(S): Samples of whole blood were stimulated with phorbol myristate acetate (PMA; Sigma Chemical Co., St. Louis, MO) and Ca-ionophore in the presence of monensin (Sigma). Lymphocytes were stained with alpha-CD3, alpha-CD8, and alpha-interferon gamma (IFN-gamma) alpha-interleukin 2 (IL-2), IL-4, or IL-10. Analysis was performed by flow cytometry. Statistical evaluation was done with the Mann-Whitney U test. MAIN OUTCOME MEASURE(S): Percentage NK cells, helper lymphocytes, and cytotoxic lymphocytes that were producing IFN-gamma, IL-2, IL-4, or IL-10. RESULT(S): There is a statistically significant decrease in the percentage of NK cells, and helper and cytotoxic lymphocytes that produced IFN-gamma in pregnant women when compared with women in the follicular phase. There is also a statistically significant decrease in the percentage of helper lymphocytes producing IL-2 in pregnant women compared with nonpregnant women. CONCLUSION(S): We found a decrease in type 1 cytokine production with no change in type 2 cytokine production after in vitro stimulation of "pregnant" NK cells and lymphocytes as compared with "nonpregnant" NK cells and lymphocytes. We suggest that NK cell and lymphocyte response are shifted away from a type 1 immune response during pregnancy.