The potential perinatal origin of placentation disorders in the young primigravida.

The fetus is exposed to high plasma concentrations of unbound estrogens and progesterone throughout pregnancy. However, secretory or decidual changes in the fetal uterus occur relatively infrequently before birth, suggesting a variable endometrial progesterone response at the time of birth. Arguably, partial progesterone resistance that persists into adolescent years may compromise the physiological transformation of the spiral arteries and predispose for defective placentation in the case of pregnancy. Decidualization of the endometrial stromal compartment and junctional zone myometrium precedes trophoblast invasion. It represents the first step in the process of spiral artery remodeling needed to establish effective uteroplacental blood flow by midpregnancy. The major obstetric syndromes caused by impaired placental bed spiral artery remodeling are prevalent in teenage pregnancies, including preeclampsia, fetal growth restriction, and spontaneous preterm labor. Preconditioning of the uterus in response to cyclic menstruation during adolescence may be critical to achieve full uterine responsiveness to hormonal cues. Understanding the mechanisms of functional maturation of the uterus during the early reproductive years may yield novel insights into the major obstetric syndromes.

Comparison of the ESHRE-ESGE and ASRM classifications of Müllerian duct anomalies in everyday practice.

STUDY QUESTION: Does the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) classification of female genital tract malformations significantly increase the frequency of septate uterus diagnosis relative to the American Society for Reproductive Medicine (ASRM) classification? SUMMARY ANSWER: Use of the ESHRE-ESGE classification, compared with the ASRM classification, significantly increased the frequency of septate uterus recognition. WHAT IS KNOWN ALREADY: The ESHRE-ESGE criteria were supposed to eliminate the subjective diagnoses of septate uterus by the ASRM criteria and replace the complementary absolute morphometric criteria. However, the clinical value of the ESHRE-ESGE classification in daily practice is difficult to appreciate. The application of the ESHRE-ESGE criteria has resulted in a significantly increased recognition of residual septum after hysteroscopic metroplasty, with a possible risk of overdiagnosis of septate uterus and problems for its management. STUDY DESIGN, SIZE, AND DURATION: A prospective observational study was performed with 261 women consecutively enrolled between June and September 2013. PARTICIPANTS/MATERIALS, SETTING, AND METHODS: Non-pregnant women of reproductive age presented for evaluation to a private medical center. A gynecological examination and 3D ultrasonography were performed to assess the anatomy of the uterus, cervix and vagina. Congenital anomalies were diagnosed using the ASRM classification with additional morphometric criteria as well as with the ESHRE-ESGE classification. We compared the frequency and concordance of diagnoses of septate uterus and all congenital malformations of the uterus according to both classifications. The morphological characteristics of septate uterus recognized by both criteria were compared. MAIN RESULTS AND ROLE OF CHANCE: Of the 261 patients enrolled in this study, septate uterus was diagnosed in 44 (16.9%) and 16 (6.1%) patients using the ESGE-ESHRE and ASRM criteria, respectively [relative risk (RR)ESHRE-ESGE:ASRM 2.74; 95% confidence interval (CI), 1.6-4.72; P < 0.01]. At least one congenital anomaly were diagnosed in 58 (22.2%) and 43 (16.5%) patients using the ESHRE-ESGE and ASRM classifications (RRESHRE-ESGE:ASRM, 1.35; 95% CI, 0.95-1.92, P = 0.1), respectively. The two criteria had moderate strength of agreement in the diagnosis of septate uterus (κ = 0.45, P < 0.01). There was good agreement in differentiation between anomaly and norm between the two assessment criteria (κ = 0.79, P < 0.01). The percentages of all congenital malformations and results of the differentiation between the anomaly and norm were obtained after excluding the confounding original ESHRE-ESGE criterion of dysmorphic uterus (internal indentation <50% uterine wall thickness). The morphology of septa identified by the ESHRE-ESGE [length of internal fundal indentation (mm): median 10.7; lower-upper quartile, 8.1-20] significantly differed (P < 0.01) from that identified by the ASRM criteria [length of internal fundal indentation (mm): median, 21.1; lower-upper quartile, 18.8-33.1]. Internal fundal indentation in 16 out of 44 (36.4%) cases was <1 cm in the septate uterus by ESHRE-ESGE and met the criteria for normal uterus by ASRM. LIMITATIONS AND REASONS FOR CAUTION: The study participants were women who visited a diagnostic and treatment center specialized in uterine congenital malformations for a medical assessment, not from the general public. WIDER IMPLICATIONS OF THE FINDINGS: Septate uterus diagnosis by ESHRE-ESGE was quantitatively dominated by morphological states corresponding to arcuate uterus or cases that were not diagnosed as congenital malformations by ASRM. Relative overdiagnosis of septate uterus by ESHRE-ESGE in these cases may lead to unnecessary overtreatment without the expected benefits. The ESHRE-ESGE classification criteria should be redefined due to confusions in the methodology. Until the criteria are revised, septate uterus should not be diagnosed using this classification system and it should not be used as an eligibility criterion for hysteroscopic metroplasty. STUDY FUNDING/COMPETING INTERESTS: This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interests to declare.

Fetal hydrometrocolpos, uterus didelphys with low vaginal and anal atresia: difficulties in differentiation from a complex cloacal malformation: a case report.

Hydrometrocolpos, occurring in approximately 1/6000 newborn girls, can be caused by a stenotic urogenital sinus, a severe cloacal malformation, but also by other conditions such as an imperforate hymen, a midline vaginal septum and vaginal atresia. The prenatal differential diagnosis of this wide spectrum of conditions is not easy and requires a multidisciplinary approach with follow-up scans and MRI to access the severity of the condition. A non-consanguineous couple was referred in the first pregnancy at 30 weeks. The father, 30 years of age, of Kaukasian origin, and the mother of Asian origin, 26 years of age. Ultrasound at 30 weeks revealed ambiguous genitalia (with suspicion of clitoral hypertrophy), a septated structure located behind the bladder compatible with hydrometrocolpos with a uterine malformation (uterus didelphys), a single umbilical artery, mild ascites and growth on the tenth centile. The differential diagnosis included a vaginal atresia, a urogenital sinus and a more severe cloacal malformation. After serial scans, MRI and counselling by an experienced surgeon the preferential diagnosis of a cloacal malformation was made and a late pregnancy termination was performed. Pathological examination revealed: low vaginal atresia with uterus didelphys, anal atresia with rectovaginal fistula and a normal urinary tractus. The differential diagnosis between hydrometrocolpos due to vaginal atresia or due to a more severe cloacal malformation is not straightforward. Care should be taken in decision making and counselling patients with these complex prenatal malformations.

Early gestational intrauterine infection induces postnatal lung inflammation and arrests lung development in a rat model.

OBJECTIVE: In order to investigate the early gestational inflammation effect on the prenatal and postnatal lung development, identification of the proinflammatory cytokines (IL-1ß and TNF-α), genes implicated in angiogenesis (Vascular endothelial growth factor [VEGF], fms-like tyrosine kinase-1 [Flt-1], fetal liver kinase-1 [Flk-1]), and surfactant proteins (SPs) were observed. METHODS: Escherichia coli (E. coli) was inoculated into uterine cervix of pregnant rats at embryonic day 15 (E15) during pseudoglandular period of lung development and the control group was inoculated with normal saline. IL-1ß, TNF-α, VEGF, Flt-1, Flk-1, SP-A, and SP-B mRNA in pup's lung at E17, 19, 21 and postnatal day (P) 1, 3, 7, 14 were quantified by real-time RT-PCR. Western blot or immunohistochemistry analysis was also performed for the evaluation of VEGF, Flk-1, Flt-1, and SP-A expression in pup's lung. RESULTS: Compared with the control group, the fetal lung of the E. coli-treated group was more immature, the postnatal lung development was impaired marked by less alveoli, fewer secondary septa, and thicker alveolar wall. The lung weight and lung/body weight ratio were lower in the E. coli-treated group pups. IL-1ß and TNF-α mRNA were increased significantly in E. coli-treated pup's lung after birth, but no significant difference of IL-1ß and TNF-α mRNA levels in fetal lung were found between the two groups. SP-A expression was depressed at E17, E19, and E21 after intrauterine E. coli treated, accompanied with lower SP-B mRNA level at E19 and E21. Furthermore, intrauterine E. coli treated reduced the VEGF mRNA and protein levels in the fetal lung at E17 and E19, while the expression of Flt-1 and Flk-1 were higher at P7, P14 and P1, P7, P14, respectively, compared to the controls. CONCLUSIONS: These results suggested early gestational intrauterine E. coli infection could induce a postnatal pulmonary inflammation and might arrest the alveolarization in developing lung which was involved with the VEGF signaling. However, intrauterine E. coli infection could not induce the increase of proinflammatory cytokines in fetal lung and might fail to accelerate the maturation of fetal lung.

Hydatid of morgagni with torsion diagnosed during cesarean delivery. A case report.

BACKGROUND: Hydatids of Morgagni are benign, pedunculated, cystic structures arising from müllerian vestiges below the fallopian tube near the fimbria. They usually are of no clinical significance unless the pedicle becomes twisted and infarction occurs. CASE: A 39-year-old primigravida at 41 weeks and 5 days' gestation underwent primary cesarean delivery for macrosomia and failure to descend during labor. A 4 x 3-cm hydatid of Morgagni with torsion of the pedicle was found on the left fallopian tube. Ligation of the pedicle and excision of the infarcted cyst were performed. Histology of the specimen demonstrated cuboidal epithelium with extensive hemorrhage and necrosis, consistent with an infarcted hydatid of Morgagni. All pain and symptoms experienced by the patient during the previous day were associated with the onset of labor. No specific left lower quadrant pain was reported. CONCLUSION: Hydatids of Morgagni are common findings at pelvic surgery and usually of no clinical significance. Torsion of a hydatid of Morgagni is rarely reported and most likely is a rare occurrence. In this patient, torsion of the hydatid of Morgagni was possibly pregnancy related, and symptoms associated with torsion were probably masked by labor pain.

True uterine diverticulum. A partial müllerian duct duplication?

True uterine diverticulum is an exceedingly rare entity. We report only the second case, to our knowledge, of a nulliparous uterus containing a diverticulum communicating with the endometrial cavity. True uterine diverticula probably arise from a localized duplication of the distal Müllerian duct on one side. They may be confused pathologically with uterine sacculations of pregnancy, but tend to have thicker walls. Associated conditions include "ectopic" pregnancy in the diverticulum, dysmenorrhea, and abnormal uterine bleeding.