GnRH receptor mediates lipid storage in female adipocytes via AMPK pathway.

Objective: Due to high levels of serum gonadotropin-releasing hormone (GnRH), perimenopausal or menopausal women, girls with central precocious puberty, women of polycystic ovary syndrome, and females receiving long-term GnRH agonist (GnRHa) treatment are at substantially higher risk of developing obesity. However, it remains poorly understood how GnRH affects body weight. Here, we explored whether the gonadotropin-releasing hormone receptor (GnRHR) was expressed in adipocytes and how GnRHR mediated lipid accumulation and the development of obesity. Methods: The samples were from 18 patients with benign tumors operated between 01/2018 and 06/2018 at the Women's Hospital School of Medicine Zhejiang University. Immunofluorescence, Western Blotting, and RT-PCR were used to detect whether the GnRH receptor was expressed in the specimens and human preadipocytes-subcutaneous (HPA-s). The GnRH receptor agonist diphereline with different concentrations was used to stimulate the HPA-s cells for 24, 48, and CCK-8 was used to detect cell proliferation. Oil red-O staining was used to detect lipid droplets in mature adipocytes. The phosphorylation of AMPK-Ser485/Thr172 was detected by Western Blotting. Results: GnRH receptor was expressed in all 18 human subcutaneous adipose tissue specimens. Cultured HPA-s expressed the GnRH receptor, and the expression increased during the process of cell maturation. The GnRH receptor agonist diphereline can stimulate the proliferation of HPA-s cells, which can advance the earliest occurrence of lipid droplets in HPA-s cells and the occurrence of lipid droplets in 50% cells by 1-2 days. Diphereline can stimulate the increase in the number of lipid droplets in mature adipocytes. The phosphorylation level of AMPK-Ser485/Thr172 in mature adipocytes was decreased by diphereline. Conclusion: The GnRH receptor was expressed in adipocytes. As adipocytes mature, GnRH receptor expression gradually increased. GnRHa stimulates the proliferation of HPA-s, promotes adipocyte maturation, increases the formation of lipid droplets in mature adipocytes, and inhibits the activation of the AMPK pathway in adipocytes. Our findings may elucidate the mechanism of obesity in these female populations and provide some evidence on how GnRH contributes to obesity. Additionally, these results provide theoretical support for further research on the mechanisms of obesity, thus enhancing our understanding of the functional diversity of GnRH and establishing a new theoretical basis for the impact of GnRH on metabolism.

[Research progress on biomarkers for endometriosis based on lipidomics].

The pathogenesis of endometriosis is not well understood at the moment, and the lack of effective biomarkers often leads to delayed diagnosis of the disease. Lipidomics provides a new approach for the diagnosis and prediction of endometriosis. Sphingomyelin, phosphatidylcholine and phosphatidylserine in peripheral blood, endometrial fluid, peritoneal fluid and follicular fluid have good diagnostic value for endometriosis and disease classification; the lipid metabolites in the eutopic endometrium tissue are expected to be biomarkers of early endometriosis; and the lipid metabolites in peripheral blood are also of great value for predicting endometriosis-related infertility. The development of lipidomics technique will further advance the progress on the pathogenesis, prediction, diagnosis and treatment of endometriosis.

[Progress on medical treatment in the management of adenomyosis].

Drug therapy plays an important role in alleviating the symptoms related to adenomyosis, improving the curative effect of surgery, delaying the progress of disease and promoting assisted reproduction. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first choice to control pain associated with adenomyosis, and are the only choice for patients with recent fertility requirements; steroid hormones, gonadotropin releasing hormone agonists and mifepristone can effectively relieve pain and control uterine bleeding, among which oral contraceptives, levonorgestrel-releasing intranterine system (Mirena) and dienogest are more effective and commonly used in clinic. Drug selection should be based on patient's age, symptoms, uterine size, fertility requirements and economical conditions. At present, there is no specific drug for adenomyosis, and symptoms are easy to recur after drug withdrawal, so the long-term drug use needs further study.

[Efficacy and adverse effects of levonorgestrel-releasing intrauterine system in treatment of adenomyosis].

OBJECTIVE: To evaluate the efficacy and adverse effects of levonorgestrel-releasing intrauterine system (Mirena) in the treatment of adenomyosis. METHODS: The clinical data of 75 patients with adenomyosis who had Mirena insertion in Women's Hospital,Zhejiang University School of Medicine from September 2013 to December 2013 were retrospectively analyzed. The patients were followed up to 39 months. The efficacy and adverse effects were assessed. RESULTS: Pictorial Blood Loss Assessment Chart (PBAC) scores were decreased significantly after Mirena insertion both in patients with menorrhea (118±13 vs. 29±33, P<0.01) and normal menstruation (82±15 vs. 14±13, P<0.01); the patients with menorrhea showed a more significant decrease in PBAC score than those with normal menstruation (90±35 vs. 69±19,P<0.01). The visual analogue scale (VAS) score decreased significantly after Mirena insertion compared with pre-treatment[7(6,7) vs. 1(0,2), P<0.01]. The expulsion of Mirena occurred in 18 cases (24.0%); 9 cases (12.0%) had no effect and 28 cases (37.3%) had changes of menstruation patterns. Multivariate Cox regression analysis showed that the expulsion of Mirena was not associated with post-treatment VAS score, PBAC score before and after treatment or menstrual stabilization time (all P>0.05). CONCLUSIONS: Mirena is effective and safe in the long term management of adenomyosis, but about one third patients may require further treatment because of the expulsion or ineffectiveness of Mirena.

[The second generation endometrial ablation (NovaSure) improves efficacy of levonorgestrel-releasing intrauterine system in management of adenomyosis].

OBJECTIVE: To determine the efficacy of second generation endometrial ablation (NovaSure) combined with levonorgestrel-releasing intrauterine system (Mirena) in the treatment of adenomyosis. METHODS: Clinical data of patients with adenomyosis admitted in Women's Hospital, Zhejiang University School of Medicine from January 2015 to December 2018 were retrospectively analyzed. Among 66 patients, 44 received Mirena placement only (control group) and 22 received Mirena placement and NovaSure treatment (study group). The menstruation blood loss, dysmenorrhea score, uterine size, expulsion rate of Mirena and the patients' satisfaction rate were assessed in two groups. RESULTS: There was a significant reduction in menstruation blood loss (P<0.05) and significant improvement in dysmenorrhea (P<0.05) after the treatment in both groups. The patients in study group had more marked improvement in menstruation blood loss than those in control group (P<0.05). The patients' satisfaction was higher and the expulsion rate of Mirena was lower in study group than that in control group (all P<0.05). The score of dysmenorrhea and the size of uterine had no significant difference between two groups (all P>0.05). CONCLUSIONS: NovaSure can improve the efficacy of Mirena in treatment of adenomyosis.

Clinical characteristics and salvage management of persistent cesarean scar pregnancy.

AIM: The study was conducted to illustrate the clinical characteristics and treatment outcomes of patients with persistent cesarean scar pregnancy (PCSP). METHODS: During a six-year period, 38 cases of PCSP were diagnosed and treated conservatively to preserve fertility. The clinical presentations, imaging findings and treatment outcomes of these patients were reviewed. RESULTS: Fourteen out of 38 women (37%) presenting with PCSP suffered heavy vaginal bleeding. Gestational age at diagnosis was 73.1 ± 21.7 days. The maximum diameter of the PCSP mass was 3.6 ± 1.6 cm. The presence of a rich vascular pattern in the area of the PCSP mass was detected by ultrasound in 33/38 (87%) patients. Six patients with a PCSP gestational age of 64.2 ± 6.2 days and a mass diameter of 2.5 ± 0.6 cm were successfully treated with medical treatment alone and 32 patients with a gestational age of 74.8 ± 23.1 days and a mass diameter of 3.8 ± 1.6 cm were successfully treated with surgical or combined treatment. CONCLUSIONS: Patients with PCSP are diagnosed at advanced gestational age and are more prone to heavy bleeding. Surgery is the main treatment for PCSP. Medical treatment of PCSP has become an attractive alternative, especially for hemodynamically stable patients with a PCSP mass with a maximum diameter of < 3.5 cm.

Mitochondrial DNA Haplogroup R Confers a Genetic Risk Factor for Intrauterine Adhesion in Han Women Population.

BACKGROUND: To determine whether a specific mitochondrial DNA (mtDNA) haplogroup is implicated in the pathogenesis of intrauterine adhesion (IUA). METHODS: Peripheral blood samples were collected from 486 women with (case group, n = 154) and without IUA (control group, n = 332) at the Women's Hospital, Zhejiang University School of Medicine. Genomic DNA was extracted from the blood, and the mtDNA haplogroups of Han women M, N and R were determined by sequencing hypervariable mtDNA segments and testing diagnostic polymorphisms in the mtDNA coding region. RESULTS: Women with mtDNA haplogroup R had an independently increased genetic risk factor for IUA with an OR 1.77 (95% CI 1.16-2.70, p = 0.009) compared with women without. Moreover, repeated intrauterine surgery within 1 month and number of intrauterine operations were both significantly associated with IUA (p < 0.001). CONCLUSIONS: These results suggest that mtDNA haplogroup R, one of the main mtDNA haplogroups in Han population, is a strong independent genetic risk factor for women with IUA.

[Association of menopausal specific fat distribution changes with metabolic risk factors].

OBJECTIVE: To investigate the association of menopausal specific fat distribution with metabolic risk factors. METHODS: Two hundred Chinese women including 110 premenopausal women aged 39.7±9.2 y and 90 postmenopausal women aged 55.4±4.6 years were enrolled. Total and regional fat depots including android fat and gynoid fat were measured by dual-energy X-ray absorptiometry. The differences of regional fat depot between pre-and post menopausal women were compared by covariate analysis. The association of regional fat changes with metabolic risk factors were analyzed by logistic models. RESULTS: Gynoid fat was significantly decreased in postmenopausal women after accounting for total fat changes. After adjusting covariates (including age, BMI, and %BF), the inverse associations of gynoid fat with metabolic risk factors still remained (OR=1.8-3.7,P<0.05). Furthermore, the interaction between menopause and gynoid fat was significantly in all logistic models (P<0.05). CONCLUSION: Android fat was increased whereas gynoid fat was decreased after menopause. Opposite to the detrimental effects of android fat, gynoid fat was inversely associated with metabolic risk factors, especially in postmenopausal women.

Clinical utility of serum reproductive hormones for the early diagnosis of ectopic pregnancy in the first trimester.

AIM: A tubal ectopic pregnancy (EP) in the first trimester remains a major life-threatening complication for the mother. We aim to determine whether serum reproductive hormones may be clinically useful in the early identification of a tubal EP. METHODS: A total of 109 age-matched patients with a serum ß-human chorionic gonadotropin (ß-hCG) concentration <2000 IU/L were enrolled, including 68 patients with a tubal EP, 22 with a viable intrauterine pregnancy (vIUP) and 19 with a non-viable intrauterine pregnancy (nIUP). Serum was collected during the first trimester of pregnancy and assayed for ß-hCG, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone (TE), progesterone (P), estradiol (E2) and prolactin (PRL) by using automated electrochemiluminescence immunoassays. RESULTS: Patients with an EP had significantly lower levels of daily ß-hCG variation (Δß-hCG/day), P and E2, and significantly higher levels of LH and FSH than IUP patients (P<0.05). As an EP diagnostic marker, progesterone demonstrated a sensitivity of 100% at the cutoff of 86.01 nmol/L. The combination of E2 with Δß-hCG/day reached a specificity of 100% for EP evaluation. To identify non-viable pregnancies (including EPs and nIUPs), progesterone demonstrated a sensitivity of 95.40% and a specificity of 90.91% at the cutoff of 63.2 nmol/L; the diagnostic power of the receiver operating curve was 0.9702. CONCLUSIONS: A combination of Δß-hCG/day, P and E2 may help distinguish EPs and nIUPs from vIUPs, facilitating earlier diagnosis and the timely implementation of medical treatment to prevent tubal rupture.

Long-Term Pregnancy Outcomes of Patients with Diffuse Adenomyosis after Double-Flap Adenomyomectomy.

Although many studies show that patients with diffuse adenomyosis who underwent fertility-sparing surgery can have a successful pregnancy, their pregnancy outcomes are still controversial. The objective of this study was to determine long-term pregnancy outcomes and possible influencing factors after double-flap adenomyomectomy for patients with diffuse adenomyosis. A total of 137 patients with diffuse adenomyosis who underwent double-flap adenomyomectomy between January 2011 and December 2019 were studied, and correlations between pregnancy outcomes and clinical data, including age and junctional zone measured by magnetic resonance imaging (JZmax-A), were analyzed. The results show that 56 patients (40.9%, 56/137) had 62 pregnancies, including 35 natural pregnancies and 27 assisted reproduction pregnancies, after operation. A univariate regression analysis showed that the pregnancy outcomes were related to age at surgery, visual analog scale (VAS) score of preoperative dysmenorrhea, parity experience, length of infertility, and postoperative JZmax-A. A multivariate regression analysis showed that age at surgery, VAS score of preoperative dysmenorrhea, and postoperative JZmax-A were the independent indicators correlated with pregnancy outcomes. A receiver operating characteristic curve analysis showed that postoperative JZmax-A was the most valuable indicator for predicting pregnancy outcomes. Cumulative pregnancy rates during the first 3 years were 70.1% and 20.9% in the postoperative JZmax-A ≤ 8.5 mm and the postoperative JZmax-A > 8.5 mm groups, respectively. In conclusion, double-flap adenomyomectomy could improve fertility for diffuse adenomyosis, and postoperative JZmax-A might be a promising indicator for predicting pregnancy outcomes.

Comparison of the effectiveness and pregnancy outcomes of labor induction with dinoprostone or single-balloon catheter in term nulliparous women with borderline oligohydramnios.

BACKGROUNDS: At present, there is no consensus on the induction methods in term pregnancy with borderline oligohydramnios. This study aimed to compare the effectiveness and pregnancy outcomes of labor induction with dinoprostone or single-balloon catheter (SBC) in term nulliparous women with borderline oligohydramnios. METHODS: We conducted a retrospective cohort study from January 2016 to November 2018. During the study period, a total of 244 cases were enrolled. Of these, 103 cases were selected for induction using dinoprostone and 141 cases were selected for induction with SBC. The pregnancy outcomes between the two groups were compared. Primary outcomes were successful vaginal delivery rates. Secondary outcomes were maternal and neonatal adverse events. Multivariate logistic regression was used to assess the risk factors for vaginal delivery failure in the two groups. RESULTS: The successful vaginal delivery rates were similar between the dinoprostone group and the SBC group (64.1% [66/103] vs. 59.6%, [84/141] P = 0.475), even after adjustment for potential confounding factors (adjusted odds ratio [aOR]: 1.07, 95% confidence interval [CI]: 0.57-2.00, P = 0.835). The incidence of intra-amniotic infection was lower in the dinoprostone group than in the SBC group (1.9% [2/103] vs. 7.8%, [11/141] P < 0.001), but the presence of non-reassuring fetal heart rate was higher in the dinoprostone group than in the SBC group (12.6% [13/103] vs. 0.7%, [1/141] P < 0.001). Multivariate logistic regression showed that nuchal cord was a risk factor for vaginal delivery failure after induction with dinoprostone (aOR: 6.71, 95% CI: 1.96-22.95). There were three factors related to vaginal delivery failure after induction with SBC, namely gestational age (aOR: 1.51, 95% CI: 1.07-2.14), body mass index (BMI) >30 kg/m2 (aOR: 2.98, 95% CI: 1.10-8.02), and fetal weight >3500 g (aOR: 2.49, 95% CI: 1.12-5.50). CONCLUSIONS: Term nulliparous women with borderline oligohydramnios have similar successful vaginal delivery rates after induction with dinoprostone or SBC, with their advantages and disadvantages. In women with nuchal cord, the risk of vaginal delivery failure is increased if dinoprostone is used in the induction of labor. BMI >30 kg/m2, large gestational age, and estimated fetal weight >3500 g are risk factors for vaginal delivery failure after induction with SBC.

[Management of cesarean scar pregnancy by hysteroscopy combined with uterine artery embolism].

OBJECTIVE: To investigate safety and efficacy of hysteroscopy in treatment of cesarean scar pregnancy (CSP). METHODS: From Aug. 2003 to Dec. 2011, 33 cases with CSP treated by hysteroscopy guided by transabdominal ultrasound or laparoscopy were studied retrospectively in Women's Hospital, School of Medicine, Zhejiang University. The clinical characteristics including gestational age, myometrial thickness anterior to the CSP, ß-hCG level before treatment, success rate, cure rate, operative time, blood loss, time of serum ß-hCG resolution and CSP mass clearance, and complication were collected and analyzed. RESULTS: Median gestational age was 54 days (range, 37 - 140 days). Median level of ß-hCG before treatment was 15 000 U/L (range, 3.3 - 151 747 U/L). Mean thickness of anterior myometrium was 3.3 mm. Twenty-nine cases underwent uterine artery embolism (UAE) before hysteroscopy. Pouch in the anterior uterine isthmus with gestation masses implanted were observed in 30 cases (91%, 30/33). CSP masses progressed toward the pouch or uterine cavity in all cases was removed by cutting wire loop electrode combined with curettage. The mean operative time was (34 ± 10) minutes. Both success rate and cure rate were 94% (31/33). Salvage methotrexate (MTX) therapy was administrated in one case. Complication occurred in three cases (9%, 3/33). Both massive hemorrhage rate and hysterectomy rate were performed in two cases (6%, 2/33). No uterine perforation occurred. The mean time of hCG resolution was (22 ± 10) days. The mean time of CSP mass clearance was (21 ± 12) days. Four pregnancies were achieved in four cases: one term pregnancy and three abortions. No recurrent CSP occurred. CONCLUSION: Management of CSP by hysteroscopy combined with UAE is safe and effective.

Blood tests for prediction of deep endometriosis: A case-control study.

BACKGROUND: Deep endometriosis (DE) is the most aggressive subtype of endometriosis. The diagnosis may be challenging, and no biomarkers that can discriminate women with DE from those without DE have been developed. AIM: To evaluate the role of blood hemostatic parameters and inflammatory indices in the prediction of DE. METHODS: This case-control study was performed at the Women's Hospital, Zhejiang University School of Medicine between January 2015 and December 2016. Women with DE and women with benign gynecologic disease (control group) eligible for gynecological surgery were enrolled. Routine plasma hemostatic parameters and inflammatory indices were obtained before surgery. Univariate and multivariate analysis were performed. Receiver operating characteristic (ROC) curves were generated, and areas under the curve (AUC) were calculated to assess the predictive values of the selected parameters. RESULTS: A total of 126 women were enrolled, including 31 with DE and 95 controls. Plasma fibrinogen (Fg, P < 0.01), international normalized ratio (P < 0.05), and C-reactive protein levels (P < 0.01) were significantly higher in women with DE compared with controls. Plasma hemoglobin (HB) levels (P < 0.05) and shortened thrombin time (P < 0.05) were significantly lower in women with DE than in controls. Plasma Fg levels [adjusted OR (aOR) 2.12, 95%confidence interval (CI): 1.31-3.75] and plasma HB levels (aOR 0.48, 95%CI: 0.29-0.78) were significantly associated with DE (both P < 0.05). ROC analysis showed that the diagnostic value of Fg or HB alone for DE was limited. The AUC of the combination of both markers as a dual marker index was 0.773 with improved sensitivity (67.7%) and specificity (78.9%) at cutoffs of 3.09 g/L and 126 g/L, respectively. CONCLUSION: The combination of Fg and HB was a reliable predictor of DE. A larger study is needed to confirm the findings.

Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy: A case report.

BACKGROUND: Heterotopic cesarean scar pregnancy (HCSP) is very rare and has a high risk of massive uterine bleeding. Preservation of concurrent intrauterine pregnancy (IUP) is one of the great challenges in the management of HCSP. No universal treatment protocol has been established when IUP is desired to be preserved. CASE SUMMARY: We report a case of HCSP at 8+ wk gestation in a 34-year-old woman with stable hemodynamics. A two-step intervention was applied. Selective embryo aspiration was performed first, and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later. Both steps were performed under ultrasound guidance. The patient had an uneventful course, and a healthy baby was delivered at 34+6 wk gestation. CONCLUSION: Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP. This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.

Transcriptome-Based Analysis Reveals Therapeutic Effects of Resveratrol on Endometriosis in aRat Model.

INTRODUCTION: Endometriosis (EMs) is associated with severe chronic pelvic pain and infertility and the development of improved EMs treatment options is an ongoing focus. In this study, we investigated the effects of resveratrol on EMs and analyzed transcriptional changes in the lesions of model rats before and after resveratrol treatment. METHODS: We established arat model of endometriosis through the trans-implantation of endometrial fragments to the peritoneal wall and then used resveratrol as treatment. We then analyzed the results using RNA sequencing of the lesion tissues of each of the model rats before resveratrol treatment and the reduced lesion tissues after the treatment. Examinations of anatomy, biochemistry, immunohistochemical staining and flow cytometry examinations were also conducted. Other trans-implanted rats were also given sham treatments as sham-treatment control and other untrans-implanted rats served as sham-operation controls. RESULTS: In addition to the obvious lesions observed in the model rats, there were significant differences in the glucose tolerance, macrophage M1/M2 polarization, and adipocyte sizes between the treated model rats and sham (control) rats. Resveratrol treatment in the model rats showed significant efficacy and positive therapeutic effect. Transcriptional analysis showed that the effects of resveratrol on the endometriosis model rats were manifested by alterations in the PPAR, insulin resistance, MAPK and PI3K/Akt signaling pathways. Correspondingly, changes in PPARγ activation, M1/M2 polarization and lipid metabolism were also detected after resveratrol treatment. DISCUSSION: Our study revealed that resveratrol treatment displayed efficient therapeutic effects for EMs model rats, probably through its important roles in anti-inflammation, immunoregulation and lipid-related metabolism regulation.

Lipidomic Alterations and PPARα Activation Induced by Resveratrol Lead to Reduction in Lesion Size in Endometriosis Models.

Endometriosis is an estrogen-dependent chronic inflammatory disease that affects approximately 10% of women of reproductive age and up to 50% of women with infertility. The heterogeneity of the disease makes accurate diagnosis and treatment a clinical challenge. In this study, we generated two models of endometriosis: the first in rats and the second using human ectopic endometrial stromal cells (HEcESCs) derived from the lesion tissues of endometriosis patients. We then applied resveratrol to assess its therapeutic potential. Resveratrol intervention had significant efficacy to attenuate lesion size and to rectify aberrant lipid profiles of model rats. Lipidomic analysis revealed significant lipidomic alterations, including notable increases of sphingolipids and decreases of both glycerolipids and most phospholipids. Upon resveratrol application, both proliferation capacity and invasiveness parameters decreased, and the early apoptosis proportion increased for HEcESCs. The activation of PPARα was also noted as a factor potentially contributing to recovery from endometriosis in both models. Our study provides valuable insight into the mechanisms of resveratrol in endometriosis and therefore strengthens the potential for optimizing resveratrol treatment for this disease.

Giant exophytic cystic adenomyosis with a levonorgestrel containing intrauterine device out of the uterine cavity after uterine myomectomy: A case report.

BACKGROUND: A cystic lesion arising from the myometrium of the uterus, termed as cystic adenomyosis, has chocolate-like, thick viscous contents and contains various amounts of endometrial stroma below the glandular epithelium. It is an extremely rare type of adenomyosis. CASE SUMMARY: Herein, we report an unusual case of a giant cystic mass in the pelvic cavity after uterine myomectomy. The patient complained of abnormal uterine bleeding and severe dysmenorrhea. After a levonorgestrel-containing intrauterine device (LNG-IUD) was inserted, her symptoms were greatly alleviated. However, the LNG-IUD was detected in the cystic cavity during the follow-up. For fear of the intrauterine device migrating into and damaging the surrounding viscera, surgical treatment was proposed. Therefore, laparoscopic resection of the lesion and removal of the LNG-IUD were performed and cystic adenomyosis with an LNG-IUD out of the uterine cavity was diagnosed. CONCLUSION: We believe that myomectomy breaking through the endometrial cavity may have been a predisposing factor for the development of cystic adenomyosis in this case.

Risk factors of persistent cesarean scar pregnancy after dilation and curettage: a matched case-control study.

OBJECTIVES: To investigate the risk factors of persistent cesarean scar pregnancy (PCSP) after dilation and curettage (D&C). MATERIALS AND METHODS: A retrospective, age-matched case-control study including 45 cases of PCSP patients after D&C was conducted between January 2013 and April 2018. For each case, 4 women who had been diagnosed with CSP and had the same age and same hospitalization period as the case group but no residual CSP tissue after D&C were selected as the controls (Control group, n = 180). Conditional logistic regression analysis was used to assess the risk factors of PCSP after D&C. RESULTS: After conditional logistic regression, the 3 factors associated with PCSP after D&C were maximum diameter of CSP mass (or gestational sac) ≥4.5 cm (adjusted odds ratio [aOR] 6.51, 95% CI 1.39-30.47), myometrial thickness at the implantation site <2 mm (aOR 3.58, 95% CI 1.37-9.38) and a ≤66.42% decrease rate in ß-hCG levels on the first day after D&C (aOR 18.58, 95% CI 5.80-59.57). ROC analysis showed that the indicator [(hCG0-hCG1)/hCG0*100%] has a good predictive value for PCSP, and the area under the curve (AUC) is 0.745; when the cut-off value is equal to 66.42%, the indicator has the best predictive value, with a sensitivity of 82.2% and a specificity of 67.7%. CONCLUSIONS: For these high-risk patients with PCSP, choosing individualized treatment options and proper management could reduce the incidence of PCSP.

Minimally-invasive management of intramural ectopic pregnancy: an eight-case series and literature review.

OBJECTIVE: Intramural pregnancy (IMP) is a rare type of ectopic pregnancy and potentially fatal. Early diagnosis and management of IMP are important to preserve patient fertility. Here, we describe the use of minimally-invasive surgery for early IMP. STUDY DESIGN: We retrospectively analyzed the clinical data of eight patients with IMP treated at our center (January 2010 to December 2018) and reviewed the literature describing minimally-invasive treatment of IMP. RESULTS: All eight patients had at least one risk factor for IMP. Two cases were confirmed by ultrasound, but ectopic pregnancy or gestational trophoblastic disease were initially suspected in the other cases. Surgery (laparoscopic in three patients, hysteroscopic in one patient, and laparoscopic combined with hysteroscopic in four patients) was successful in all cases, and all patients recovered well without complications. The literature review identified 14 articles describing 17 cases of IMP managed with minimally-invasive surgery. Laparoscopic surgery was used successfully as a sole treatment in 10 cases and after failure of hysteroscopic surgery in six cases. Only one case was treated with a combination of hysteroscopic surgery and methotrexate. Interestingly, one case at our center presented with a sinus connecting the gestational sac and uterine cavity and was treated successfully using hysteroscopic surgery during early pregnancy. CONCLUSIONS: Laparoscopic surgery is a feasible management option for most cases of early IMP. Hysteroscopic surgery may be appropriate for cases where a sinus connects the gestational sac with the uterine cavity or when cornual ectopic pregnancy needs to be excluded.