Ultrasound for diagnosis of postpartum retained products of conception-How accurate we are?

OBJECTIVE: Postpartum retained products of conception (RPOC) can cause short- and long-term complications. Diagnosis is based on ultrasound examination and treated with hysteroscopy. This study evaluated the size of RPOC that can be related to a positive pathology result for residua. MATERIALS AND METHODS: This retrospective cohort study included women who underwent hysteroscopy for postpartum RPOC diagnosed by ultrasound, 4/2014-4/2022. Demographics, intrapartum, sonographic, intraoperative, and post-operative data were retrieved. We generated a ROC curve and found 7 mm was the statistically sonographic value for positive pathology for RPOC. Data between women with sonographic RPOC ≤ 7 mm and > 7 mm were compared. Positive and negative predictive values were calculated for RPOC pathology proved which was measured by ultrasound. RESULTS: Among 212 patients who underwent hysteroscopy due to suspected RPOC on ultrasound, 20 (9.4%) women had residua ≤ 7 mm and 192 (90.6%) had residua > 7 mm. The most common complaint was vaginal bleeding in 128 cases (60.4%); more so in the residua > 7 mm group (62.5% vs. 40%, p = .05). Among women with residua ≤ 7 mm, the interval from delivery to hysteroscopy was longer (117.4 ± 74.7 days vs. 78.8 ± 68.8 days, respectively; p = .02). Positive pathology was more frequent when residua was > 7 mm. PPV for diagnosis of 7 mm RPOC during pathology examination was 75.3% and NPV 50%. CONCLUSIONS: Sonographic evaluation after RPOC showed that residua > 7 mm was statistically correlated with positive RPOC in pathology and PPV of 75% and NPV of 50%. Due to the high NPV and low complication rate of office hysteroscopy, clinicians should consider intervention when any RPOC are measured during sonographic examination to reduce known long-term complications.

Correlation between Mediterranean diet, bowel function, and isolated posterior vaginal defect: A cross-sectional study.

OBJECTIVE: Isolated posterior prolapse is a unique entity that was previously linked to chronic obstructive defecation. Our objective is to evaluate the relationship of low adherence to a Mediterranean diet (LAMD) with bowel dysfunction and isolated posterior compartment prolapse (IPCP). METHODS: This multicenter, cross-sectional study compared the dietary outcomes (validated Mediterranean diet [MD] questionnaire) of women who underwent pelvic organ prolapse (POP) repair surgery between August 2020 and October 2021. RESULTS: Among 204 patients enrolled, 108 (52.9%) patients adhered to the MD and 96 (47.0%) did not. Among the LAMD patients, increased symptoms of constipation (P = 0.047) and higher body mass index (P < 0.001) were more prevalent. Surgical repairs of the posterior compartment, combined (P = 0.033) and isolated (P = 0.021), were more prevalent in the LAMD group. Prolapse of all compartments except the apical compartment was found to be more prevalent in the LAMD group. Multivariate logistic regression analysis was found to be significant as a protective factor for the primary outcome (IPCP). CONCLUSION: Low adherence to a Mediterranean diet displays a higher prevalence of posterior vaginal defects, both isolated and combined. Hence, we can conclude that LAMD and subsequent bowel dysfunction are significant contributory factors to the prolapse of the posterior vaginal compartment.

Can obesity impact mesh exposure rate after mid-urethral sling operation? Medium term follow-up.

OBJECTIVE: To study mesh exposure rates among obese (BMI ≥ 30 kg/m2) vs non-obese women after mid-urethral sling (MUS) operation. STUDY DESIGN: This retrospective cohort study included all patients who underwent MUS surgery for stress urinary incontinence April 2014-April 2021 in a tertiary-level university hospital. Data from obese and non-obese patients were compared. RESULTS: A total of 120 (41 %) obese patients and 172 (59 %) non-obese patients who had mid-urethral sling surgery were compared. Of the cohort, 265 (90.7 %) underwent TVT-obturator, 15 (5.1 %) mini-sling TVT, and 12 (4.1 %) retro-pubic TVT. Diabetes mellitus was significantly more prevalent in the obese group (p =.01), without other demographic differences. Mesh post-operative exposure rate was 5.4 % during the study. The obese group had lower incidence of mesh exposure than the non-obese group (1.6 % vs 8.1 % respectively, p =.018). Mean follow-up was 51 months (range 8-87 months) without significant differences between groups (49.9 ± 21.2 vs 51.5 ± 22.3, p =.548). Pelvic organ prolapse, cystocele, and rectocele stages were significantly higher in non-obese patients. Similar numbers of post-menopausal women were in each group. CONCLUSION: This follow-up after MUS surgery showed an association between obesity and lower rate of mesh exposure. Further research is needed to evaluate correlations between estrogen and mesh exposure.

Chemoenzymatic labeling of DNA methylation patterns for single-molecule epigenetic mapping.

DNA methylation, specifically, methylation of cytosine (C) nucleotides at the 5-carbon position (5-mC), is the most studied and significant epigenetic modification. Here we developed a chemoenzymatic procedure to fluorescently label non-methylated cytosines in CpG context, allowing epigenetic profiling of single DNA molecules spanning hundreds of thousands of base pairs. We used a CpG methyltransferase with a synthetic S-adenosyl-l-methionine cofactor analog to transfer an azide to cytosines instead of the natural methyl group. A fluorophore was then clicked onto the DNA, reporting on the amount and position of non-methylated CpGs. We found that labeling efficiency was increased up to 2-fold by the addition of a nucleosidase, presumably by degrading the inactive by-product of the cofactor after labeling, preventing its inhibitory effect. We used the method to determine the decline in global DNA methylation in a chronic lymphocytic leukemia patient and then performed whole-genome methylation mapping of the model plant Arabidopsis thaliana. Our genome maps show high concordance with published bisulfite sequencing methylation maps. Although mapping resolution is limited by optical detection to 500-1000 bp, the labeled DNA molecules produced by this approach are hundreds of thousands of base pairs long, allowing access to long repetitive and structurally variable genomic regions.

Comparison of subjective long-term follow-up after mid-urethral sling in obese and non-obese patients.

OBJECTIVE: Obesity is a key factor for stress urinary incontinence. Our aim was to evaluate the long-term, subjective surgical satisfaction rate among obese (BMI ≥ 30) women after mid-urethral sling (MUS) procedure in a tertiary-level university hospital. STUDY DESIGN: This retrospective, case-control study compared the outcomes of obese and non-obese patients who underwent MUS surgery for stress urinary incontinence (SUI), March 2014-January 2020. Patients were followed-up using Urogenital Distress Inventory-6 (UDI-6) and Patient Global Impression of Improvement (PGI-I) telephone questionnaires. RESULTS: Among 264 patients who had MUS surgery, 107 (40.6%) patients with BMI ≥ 30 kg/m2 were matched with 157 (59.4%) non-obese patients (BMI < 30 kg/m2). Mean follow-up was 41.4 (8-73) months. Obese women had higher post-operative urinary symptom scores in UDI-6 (32.3 vs. 25.7, p =.015) and PGI-I questionnaires (2.9 ± 1.7 vs. 2.3 ± 1.7, p =.03). More patients in the obese group (p =.03) had urinary stress symptoms. Subjective failures (PGI-I ≥ 4) totaled 46 (17.4%), 18 in obese and 28 in non-obese patients, giving cure rates of 83.2% and 82.2%, respectively (p = 1). CONCLUSION: Although obese patients had higher UDI-6 scores, an interpretation of this score did not show an increase in distress due to urinary incontinence symptoms (>33.33 points).

"What you see is what you get"-abnormal endometrial sonographic findings are sufficient for direct surgical hysteroscopy: Retrospective cohort study.

OBJECTIVE: To evaluate the possibility of referring women with uterine polyps larger than 1.5 cm directly to surgical hysteroscopy. METHODS: This retrospective cohort study included all women referred to a university-affiliated tertiary medical center for hysteroscopy, with the diagnosis of endometrial polyp, from 01/2013 to 05/2016. Women were referred for surgical hysteroscopy based on TVUS findings. PPV of TVUS for detecting intrauterine polyps was evaluated relating to pathology as gold standard, with sub-group analysis relating to polyp size and other parameters. RESULTS: We selected 1.5 cm as a cutoff size for subgroup analysis of endometrial polyps. PPV of TVUS for the entire cohort of 295 cases eligible for analysis, was 79.3%. TVUS describing polyps ≥1.5 cm had PPV of 92.1%, higher than the PPV for smaller polyps. Among post-menopausal women in this group, PPV was as high as 96.2%. Use of doppler or saline was found to improve PPV in the entire cohort. Indication for performing TVUS did not affect the PPV. CONCLUSION: TVUS describing polyps ≥1.5 cm may suffice for direct referral of women to surgical hysteroscopy. A personalized approach based on the initial diagnosis may avoid unnecessary invasive procedures for patients.

A novel method for office aspiration curettage in cases of retained products of conception: A randomized controlled trial.

INTRODUCTION: Missed abortion can be treated with medication or aspiration curettage. A Karman aspiration cannula is another option. We evaluated its success in evacuating retained products of conception (RPOC) based on symptoms, endometrial thickness, endometrial irregularity, and blood flow seen on Doppler ultrasound (indicative of placenta). MATERIAL AND METHODS: This prospective, randomized, nonblinded trial was conducted in a university-affiliated medical center. It included 40 women diagnosed with missed abortion and two failed courses of 600 µg buccal misoprostol, one  week apart, randomly assigned to treatment or controls. One week after the second misoprostol course, immediately after evaluating endometrial thickness, endometrial irregularity using Doppler ultrasound, and with blood flow indicative of RPOC, women in the aspiration group underwent endometrial suction with a Karman aspiration cannula. The 5-6 mm cannula attached to a 60 mL syringe was inserted into the uterus under ultrasound guidance. The contents were aspirated until the uterus was empty. Control group patients did not receive additional treatment. All were scheduled for ambulatory, operative hysteroscopy under anesthesia 1 month later (departmental protocol). On that day, all women with RPOC on Doppler ultrasound underwent hysteroscopy. Bleeding days, days with pain, pain according to visual analog scale, length of hospitalization, and infection rate were recorded. NIH clinical trial registration number NCT02917785. RESULTS: In the study group, 90% did not need hysteroscopy, compared with 50% of controls (p = 0.014). No complications were noted. At all visits, we used Doppler ultrasound to exclude or confirm RPOC. Pathology revealed RPOC in all women who underwent aspiration. Average visual analog scale score for office aspiration (n = 20) was 4.9 ± 3.6. vs. 6.3 ± 3.4 for the first (p = 0.157) and 4.7 ± 3.3 for the second (p = 0.836) misoprostol treatment cycle. The treatment group experienced 6.1 days of bleeding and the control group experienced 1.4 days (p = .006). CONCLUSIONS: Based on our criteria of diagnosing RPOC according to symptoms, endometrial thickness, endometrial irregularity, and blood flow indicative of placental tissue seen on Doppler ultrasound and histo-pathological confirmation, aspiration using Karman cannula can be an effective therapeutic approach. It may be a safe alternative for women with RPOC after misoprostol failure.

Did COVID-19 quarantine redirect habitual patient visits in the gynecology emergency room?

OBJECTIVE: COVID-19 pandemic caused a dramatic decline in the gynecology emergency department (ED) visits. The Israeli government took a determined step of quarantine to suppress and control the spread. This study evaluates the effect of the COVID -19 quarantine on gynecology emergency department (ED) visits compared to the previous year. MATERIALS AND METHODS: A retrospective case-control study was conducted during the first half-year of the COVID-19 pandemic and focused on the quarantine during April. In order to identify differences in the population's epidemiology and changes in the amount and type of emergency gynecological visits and surgeries, we compared patients during April 2020 (COVID-19 quarantine) to those who visited the gynecology ED during April 2019. RESULTS: During January-June 2020 period, there was an overall 3707 patient visits in the gynecology ED, which represents a 22.8% decrease in patient visits compared to the previous year (2019, 4803 patients). There was a 36% decrease in the gynecology ED visits during the quarantine period. Patient demographics were similar between groups. Visits of nulliparous women were more common in the study group (p = .0001) and self-referral (p = .017). More post-operative complications and fewer patients with abdominal pain were admitted to the study group (p = .034 and p = .054, respectively). During the study, the hospitalization rate did not change 18.2% vs. 17.5% (p = 0.768). Hospitalization duration was significantly longer in the COVID-19 quarantine (2.8 ± 1.3 vs. 3.1 ± 1.5, p < 0.001). There was no significant difference among surgical procedure incidents. CONCLUSION: Visits in the gynecology ED service decreased during the COVID-19 quarantine without compromising the treatment of gynecology emergencies. Many gynecologic complaints can be managed in community care settings without referral to an ED.

Sonographic Signs of Adenomyosis in Women with Endometriosis Are Associated with Infertility.

We compared the prevalence of ultrasound signs of adenomyosis in women with endometriosis who underwent surgery to those who were managed conservatively. This was a retrospective study of women evaluated at a tertiary endometriosis referral center who underwent 2D/3D transvaginal ultrasound. Adenomyosis diagnosis was based on the presence of at least three sonographic signs. The study group subsequently underwent laparoscopic surgery while the control group continued conservative management. Statistical analysis compared the two groups for demographics, symptoms, clinical data, and sonographic findings. The study and control groups included 244 and 158 women, respectively. The presence of any, 3+, or 5+ sonographic signs of adenomyosis was significantly more prevalent in the study group (OR = 1.93-2.7, p < 0.004, 95% CI; 1.24-4.09). After controlling for age, for all findings but linear striations, the OR for having a specific feature was higher in the study group. Women in the study group with ≥ 5 sonographic signs of adenomyosis had more than twice the risk of experiencing infertility (OR = 2.31, p = 0.012, 95% CI; 1.20-4.45). Sonographic signs of adenomyosis are more prevalent in women with symptomatic endometriosis who underwent surgery compared with those who continued conservative management. Women with 5+ findings have a significantly increased risk of infertility. Adenomyosis on ultrasound should be considered in the management decisions regarding these patients.

DIO3, the thyroid hormone inactivating enzyme, promotes tumorigenesis and metabolic reprogramming in high grade serous ovarian cancer.

High grade serous ovarian cancer (HGSOC) is the most lethal gynecologic malignancy with a need for better understanding the disease pathogenesis. The biologically active thyroid hormone, T3, is considered a tumor suppressor by promoting cell differentiation and mitochondrial respiration. Tumors evolved a strategy to avoid these anticancer actions by expressing the T3 catabolizing enzyme, Deiodinase type 3 (DIO3). This stimulates cancer proliferation and aerobic glycolysis (Warburg effect). We identified DIO3 expression in HGSOC cell lines, tumor tissues from mice and human patients, fallopian tube (FT) premalignant lesion and secretory cells of normal FT, considered the disease site-of-origin. Stable DIO3 knockdown (DIO3-KD) in HGSOC cells led to increased T3 bioavailability and demonstrated induced apoptosis and attenuated proliferation, migration, colony formation, oncogenic signaling, Warburg effect and tumor growth in mice. Proteomics analysis further indicated alterations in an array of cancer-relevant proteins, the majority of which are involved in tumor suppression and metabolism. Collectively this study establishes the functional role of DIO3 in facilitating tumorigenesis and metabolic reprogramming, and proposes this enzyme as a promising target for inhibition in HGSOC.

Verbal analgesia is as good as oral tramadol prior to intrauterine device (IUD) insertion, among nulliparous women: A randomized controlled trial.

OBJECTIVE: To compare two pain management strategies: oral tramadol or a verbal analgesia technique during insertion of an intrauterine device (IUD) among nulliparous women. STUDY DESIGN: In this randomized, controlled trial, 54 nulliparous women undergoing insertion of a levonorgestrel-releasing intrauterine device (IUD), from December 2015 to December 2018 were randomized to receive oral tramadol for analgesia or verbal analgesia prior to IUD insertion. Demographic data, clinical symptoms, visual analogue scale (VAS) and complications were reviewed from patient records. RESULTS: There was no difference between the two groups regarding gravidity, age, smoking or body mass index. No significant differences were detected between the groups regarding the procedure, including ease of insertion (p = .415), number of insertion attempts (p = .514) and complications during the insertion (p = .150). Mean pain level by VAS was 4.5 ± 1.6 (range 2-8) for the tramadol group and 4.8 ± 2.4 (0-10) for the verbal analgesia group (p = .610). There was no spontaneous ejection of the IUD in either group, and no endometritis or discomfort that resulted in IUD removal. CONCLUSION: There was no benefit in using oral tramadol for analgesia prior to IUD insertion among nulliparous women. Verbal analgesia can be a suitable technique for this process and clinicians should become more familiar with its use.

Gestational Diabetes Type 2: Variation in High-Density Lipoproteins Composition and Function.

Aims: Class A2 gestational diabetes mellitus (GDMA2) has short- and long-term effects on the mother and child. These may include abnormalities of placentation, damage to endothelial cells and cardiovascular disease. This research investigated the function and composition of high-density lipoproteins (HDL) among women with GDMA2 and their fetuses. Methods: Thirty pregnant women were recruited during admission for delivery. The function and expression of HDL, paraoxonase1 (PON1) and apolipoprotein A1 (APOA1) in the blood samples and the placental tissue were evaluated. The effect of HDL on migration of endothelial cells was measured in vitro. Results: Compared to normal pregnancy (NP), APOA1 in the maternal plasma of women with GDMA2 was decreased. More APOA1 and PON1 were released from HDL of women with GDMA2, compared to NP. Placental APOA1 and PON1 were decreased in GDMA2. For endothelial cells stimulated with TNFα, HDL cell migration was decreased when cells were evaluated with NP-HDL, as compared to GDMA2-HDL. Conclusions: GDMA2 affects the composition and function of HDL in plasma. Changes in HDL commonly seen in GDMA2 were observed in maternal and placental samples, but not in cord samples. These results might indicate a placental role in protecting the fetus by preserving the components and functions of HDL and require further investigation.

The identification of nuclear αvß3 integrin in ovarian cancer: non-paradigmal localization with cancer promoting actions.

Nuclear translocation of transmembrane proteins was reported in high-grade serous ovarian cancer (HGSOC), a highly aggressive gynecological malignancy. Although the membrane receptor αvß3 integrin is amply expressed in HGSOC and involved in disease progression, its nuclear localization was never demonstrated. Nuclear αvß3 was explored in HGSOC cells (OVCAR3, KURAMOCHI, and JHOS4), nuclear localization signal (NLS) modified ß3 OVCAR3, Chinese hamster ovaries (CHO-K1) and human embryonic kidney (HEK293) before/after transfections with ß3/ß1 integrins. We used the ImageStream technology, Western blots (WB), co immunoprecipitations (Co-IP), confocal immunofluorescence (IF) microscopy, flow cytometry for cell counts and cell cycle, wound healing assays and proteomics analyses. Fresh/archived tumor tissues were collected from nine HGSOC patients and normal ovarian and fallopian tube (FT) tissues from eight nononcological patients and assessed for nuclear αvß3 by WB, confocal IF microscopy and immunohistochemistry (IHC). We identified nuclear αvß3 in HGSOC cells and tissues, but not in normal ovaries and FTs. The nuclear integrin was Tyr 759 phosphorylated and functionally active. Nuclear αvß3 enriched OVCAR3 cells demonstrated induced proliferation and oncogenic signaling, intact colony formation ability and inhibited migration. Proteomics analyses revealed a network of nuclear αvß3-bound proteins, many of which with key cancer-relevant activities. Identification of atypical nuclear localization of the αvß3 integrin in HGSOC challenges the prevalent conception that the setting in which this receptor exerts its pleiotropic actions is exclusively at the cell membrane. This discovery proposes αvß3 moonlighting functions and may improve our understanding of the molecular basis of ovarian cancer pathogenesis.

Ovarian size as a risk factor for recurrent adnexal torsion: Smaller is not better.

AIM: To investigate characteristics and risk factors for recurrent adnexal torsion (AT). METHODS: Retrospective cohort study in a university-affiliated medical center included 320 Women with AT verified by laparoscopy, from January 2005 through January 2017. Demographic data, clinical symptoms, surgical findings and treatment were retrospectively reviewed from patient records. Data from primary and secondary AT of patients in the recurrent torsion group was compared to those with single torsion, to evaluate risk factors for recurrent AT. RESULTS: Two hundred and sixty seven (83.4%) patients had a single event of AT and 53 (16.5%) had recurrent AT. Patients with recurrent torsion had significantly fewer previous non-gynecologic surgeries (4.3% and 9.8% of the study groups vs 32.2% of the control group, P = 0.001 for both). Ovarian size was significantly smaller in the recurrent torsion groups (47.5 mm and 48.3 mm vs 63.9 mm, P = 0.045 and P = 0.012, respectively). Polycystic ovary was significantly more common in the recurrent AT group (P = 0.028 and P = 0.005), with risk ratio 4.4 (95% confidence interval, 1.66 to 11.63). Ovaries without any specific findings were also more common among recurrent AT cases (P = 0.001 for both groups). Logistic regression analysis demonstrated that smaller ovarian size is an independent risk factor for recurrent AT. CONCLUSION: Recurrent torsion correlated with fewer previous surgeries, small ovarian mass, polycystic ovaries and ovaries without specific findings, which might indicate that additional pathophysiological factors contribute to the recurrent event. Ovarian fixation might be recommended in patients with primary torsion of normal or polycystic ovaries.

Is post hysterectomy adnexal torsion a complication of laparoscopic approach? A retrospective cohort study.

OBJECTIVE: To investigate the correlation between the hysterectomy's surgical approach and post hysterectomy adnexal torsion. STUDY DESIGN: Retrospective cohort study of patients with diagnosed adnexal torsion after hysterectomy (abdominal, vaginal and laparoscopic approaches) in a tertiary care medical center from 2007 through 2017 was done. Demographic data, clinical symptoms, type of previous hysterectomy, surgical findings and treatment were retrospectively reviewed from patient records. To calculate the risk of post-hysterectomy adnexal torsion (PHAH) and evaluate its association with type of hysterectomy, we used a national hysterectomy registry that included all hysterectomy done in region of our medical centre. RESULTS: Eight cases of AT after hysterectomy were operated during the study period, seven after laparoscopic and one after vaginal hysterectomy. Torsion occurred a mean of 27.25 ±â€¯16.65 months (range 3-60 months) after surgery. Mean patient age at AT was 45 ±â€¯4.6 years. All patients presented with abdominal pain, five (62.5%) had nausea and vomiting and one had diarrhoea. Laparoscopic findings revealed ovarian torsion in 5 cases, fallopian tube torsion in one and torsion of the adnexa in two cases. The national hysterectomy registry in the geographic region of our hospital summarized 705 patients with laparoscopic hysterectomy with adnexal preservation. The prevalence of post-laparoscopic hysterectomy adnexal torsion was significant high than after other types of hysterectomy (P < 0.05). CONCLUSION: PHAT occurs more frequently after laparoscopic hysterectomy then after other approaches. Measures for prevention of adnexal torsion should be considered during the primary surgery.

Microvesicle Proteomic Profiling of Uterine Liquid Biopsy for Ovarian Cancer Early Detection.

High-grade ovarian cancer (HGOC) is the leading cause of mortality from gynecological malignancies, because of diagnosis at a metastatic stage. Current screening options fail to improve mortality because of the absence of early-stage-specific biomarkers. We postulated that a liquid biopsy, such as utero-tubal lavage (UtL), may identify localized lesions better than systemic approaches of serum/plasma analysis. Further, while mutation-based assays are challenged by the rarity of tumor DNA within nonmutated DNA, analyzing the proteomic profile, is expected to enable earlier detection, as it reveals perturbations in both the tumor as well as in its microenvironment. To attain deep proteomic coverage and overcome the high dynamic range of this body fluid, we applied our method for microvesicle proteomics to the UtL samples. Liquid biopsies from HGOC patients (n = 49) and controls (n = 127) were divided into a discovery and validation sets. Data-dependent analysis of the samples on the Q-Exactive mass spectrometer provided depth of 8578 UtL proteins in total, and on average ∼3000 proteins per sample. We used support vector machine algorithms for sample classification, and crossed three feature-selection algorithms, to construct and validate a 9-protein classifier with 70% sensitivity and 76.2% specificity. The signature correctly identified all Stage I lesions. These results demonstrate the potential power of microvesicle-based proteomic biomarkers for early cancer diagnosis.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study.

STUDY OBJECTIVE: To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy. DESIGN: A retrospective case-control study (Canadian Task Force classification II-2). SETTING: A tertiary care academic medical center. MEASUREMENTS AND MAIN RESULTS: The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012). CONCLUSION: Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

Epigenetic Optical Mapping of 5-Hydroxymethylcytosine in Nanochannel Arrays.

The epigenetic mark 5-hydroxymethylcytosine (5-hmC) is a distinct product of active DNA demethylation that is linked to gene regulation, development, and disease. In particular, 5-hmC levels dramatically decline in many cancers, potentially serving as an epigenetic biomarker. The noise associated with next-generation 5-hmC sequencing hinders reliable analysis of low 5-hmC containing tissues such as blood and malignant tumors. Additionally, genome-wide 5-hmC profiles generated by short-read sequencing are limited in providing long-range epigenetic information relevant to highly variable genomic regions, such as the 3.7 Mbp disease-related Human Leukocyte Antigen (HLA) region. We present a long-read, highly sensitive single-molecule mapping technology that generates hybrid genetic/epigenetic profiles of native chromosomal DNA. The genome-wide distribution of 5-hmC in human peripheral blood cells correlates well with 5-hmC DNA immunoprecipitation (hMeDIP) sequencing. However, the long single-molecule read-length of 100 kbp to 1 Mbp produces 5-hmC profiles across variable genomic regions that failed to show up in the sequencing data. In addition, optical 5-hmC mapping shows a strong correlation between the 5-hmC density in gene bodies and the corresponding level of gene expression. The single-molecule concept provides information on the distribution and coexistence of 5-hmC signals at multiple genomic loci on the same genomic DNA molecule, revealing long-range correlations and cell-to-cell epigenetic variation.

Selective nanopore sequencing of human BRCA1 by Cas9-assisted targeting of chromosome segments (CATCH).

Next generation sequencing (NGS) is challenged by structural and copy number variations larger than the typical read length of several hundred bases. Third-generation sequencing platforms such as single-molecule real-time (SMRT) and nanopore sequencing provide longer reads and are able to characterize variations that are undetected in NGS data. Nevertheless, these technologies suffer from inherent low throughput which prohibits deep sequencing at reasonable cost without target enrichment. Here, we optimized Cas9-Assisted Targeting of CHromosome segments (CATCH) for nanopore sequencing of the breast cancer gene BRCA1. A 200 kb target containing the 80 kb BRCA1 gene body and its flanking regions was isolated intact from primary human peripheral blood cells, allowing long-range amplification and long-read nanopore sequencing. The target was enriched 237-fold and sequenced at up to 70× coverage on a single flow-cell. Overall performance and single-nucleotide polymorphism (SNP) calling were directly compared to Illumina sequencing of the same enriched sample, highlighting the benefits of CATCH for targeted sequencing. The CATCH enrichment scheme only requires knowledge of the target flanking sequence for Cas9 cleavage while providing contiguous data across both coding and non-coding sequence and holds promise for characterization of complex disease-related or highly variable genomic regions.