Placenta mórbidamente adherente asociada a malformaciones congénitas: reporte de caso / Morbidly adherent placenta associated with congenital malformations: a case report

INTRODUCCIÓN: Las alteraciones en la placentación son causa importante de morbilidad materna y neonatal y, en ocasiones, de mortalidad. La literatura científica menciona la posible asociación entre acretismo placentario y alteraciones en los parámetros bioquímicos para aneuploidía, sin descripciones de casos en que coincidan estos dos hallazgos. OBJETIVO: Este es un reporte de caso de una gestante con placenta percreta y producto con trisomía 13 REPORTE DE CASO: Gestante de 34 años, gesta 4 cesáreas 2, abortos 1, vivos 2, con embarazo de 20.4 semanas, sin antecedentes de importancia, con hallazgos en ecografía de iii nivel de alteraciones morfológicas en el sistema nervioso central, onfalocele, malformación cardiaca y deformidades en miembros. Con doppler de placenta que evidencia placenta mórbidamente adherida variedad percreta; hallazgos ecográficos confirmados con el estudio anatomopatológico. CONCLUSIONES: La trisomía 13 es una condición genética que debido a las múltiples malformaciones asociadas se considera incompatible con la vida, la placenta mórbidamente adherida se ha asociado con morbimortalidad neonatal y fetal, la no evidencia en la literatura de estas dos condiciones asociadas puede ser debido a la interrupción temprana de las gestaciones en las que se confirma el primer diagnóstico.

BACKGROUND: Alterations in placentation are an important cause of maternal and neonatal morbidity and, sometimes, deaths. The scientific literature mentions the possible association between placental accreta and alterations in the biochemical parameters for aneuploidy, without descriptions of cases in which these two findings coincide. OBJECTIVE: This is a case report of a pregnant woman with placenta percreta and trisomy 13, in which an ultrasound and pathological analysis were made. The use of keywords, in different databases, did not yield information that directly comply with these associations. CASE REPORT: A 34-year-old pregnant woman, G4C2A1V2 with a 20.4-week pregnancy, without significant medical records, with findings at III level ultrasound of morphological alterations of the central nervous system, omphalocele, cardiac malformation and limb deformities. Also, with placental Doppler that evidences morbidly adhered placenta variety percreta; ultrasound findings confirmed with the pathological study. CONCLUSION: The morbidly adhered placenta has been associated with neonatal and fetal mortality, in which some of the identified causes of fetal death are congenital anomalies. This way this case report allows for the first time to describe the association of placental accreta with aneuploidy, type trisomy 13, demonstrated by the morphological alterations of the pathological and karyotype study.

Office hysteroscopy in removing retained products of conception - a highly successful approach with minimal complications.

Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4-60), patient pain estimation with VAS was 2.3 (0-8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and ß-hCG levels up to 80 U/L did not affect the outcome.Impact statementWhat is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC.What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data.What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal.

miRNA-185 regulates the VEGFA signaling pathway in dairy cows with retained fetal membranes.

Retention of fetal membranes (RFM) of cows is an important reproductive disturbance, and is related to miRNAs. Vascular endothelial growth factor (VEGF)A, regulated by miRNA-185, can activate arachidonic acid (ARA) release via the VEGFA signaling pathway, which influences RFM. The aim of this study was to explore the pathogenic mechanism of RFM by investigating the regulatory relationship between miRNA-185 and the VEGFA signaling pathway. Serum samples of healthy Holstein dairy cows (n = 20) and RFM cows (n = 12), with a similar age, parity, weight, and milk yield, were collected to detect VEGFA and ARA concentrations at 6, 12, and 24 h after calving. Caruncle tissues were collected from healthy (n = 6) and RFM cows (n = 6) at 12 h after calving. Quantitative polymerase chain reaction (qPCR) and western blotting (WB) were performed to detect the mRNA and proteins levels, respectively, of genes involved in the VEGFA signaling pathway. Uterine caruncle epithelial (UCE) cells were cultured by the explant culture method, further purified, and subsequently treated with miRNA-185 mimics, miRNA-185 mimics + MEK inhibitor, or left untreated as a control for detection of the mRNA and protein levels of genes involved in the VEGFA signaling pathway. The cellular supernatant was collected for measurement of ARA levels at 12, 24 and 48 h after treatment. Serum levels of VEGFA and ARA from RFM cows were abnormally increased at 12 h after calving, as compared to those in healthy dairy cows. Expression levels of most of the investigated genes (VEGFA, PLC, PRK, RAF, MEK, MAPK, and PLA) were down-regulated in the caruncle tissue of RFM cows. However, P-p44/42 MAPK was up-regulated in the caruncle tissues of cows with RFM (p < .01). In UCE cells treated with the miRNA-185 mimics, expression of VEGFA, PLC, RAF, MEK, MAPK and PLA was significantly down-regulated, while that of P-p44/42 MAPK was significantly up-regulated. Expression of genes involved in the VEGFA signaling pathway was similar to that in the in vivo assay. In UCE cells treated with the miRNA-185 mimics + MEK inhibitors, expression of VEGFA, PLC, RAF, MEK, MAPK and P-p44/42 MAPK was significantly down-regulated, while that of PLA was significantly up-regulated. Meanwhile, the release of ARA was increased (p < .01). These results demonstrate that miRNA-185 can regulate the VEGFA signaling pathway, especially via abnormal expression of P-p44/42 MAPK, which influences the release of the fetal placenta after calving.

Conservative endovascular management of retained placenta accreta with marked vascularity after abortion or delivery.

OBJECTIVE: To report our experience on the value of transcatheter arterial embolization (TAE) or transcatheter arterial chemoembolization (TACE) for the uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery. STUDY DESIGN: Thirty-eight consecutive women with retained placenta accreta were retrospectively analyzed over a 5-year period. When elevated levels of serum ß-hCG (> 25 mIU/mL) were detected, TACE with dactinomycin was chosen for devascularization along with cytotoxic effects on active trophoblasts; in contrast, if the serum ß-hCG level was low (≤ 25 mIU/mL), TAE was chosen. After confirming devascularization, the additional need for hysteroscopic resection and systemic methotrexate administration was individually determined. RESULTS: The most frequent sign and symptom in the abortion group was significant hemorrhaging, while a hypervascular mass detected at a regular check-up was the most frequent in the delivery group. The median time elapsed between abortion and endovascular management was 36 days, and the median time elapsed after delivery was 31.5 days. TACE was performed more frequently than TAE in the abortion group, while TAE was the more frequent procedure in the delivery group. In 10 and 11 cases, after abortion and delivery, respectively, hysteroscopic resection was performed. Systemic methotrexate administration was additionally done in three and one cases after abortion and delivery, respectively. Uterine preservation was achieved in all cases. CONCLUSION: This case series emphasizes that endovascular embolization is an effective key intervention with or without additional therapies for uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery.

Clinical and imaging predictors of management in retained products of conception.

OBJECTIVES: To determine if clinical and ultrasound (US) imaging features help predict management in clinically suspected retained products of conception (RPOC). METHODS: 334 patients sonographically evaluated for RPOC were included in this IRB-approved retrospective study. Of the 334 patients, 176 had sonographic diagnosis of RPOC and comprised the final study group. Patients were managed expectantly, medically, or surgically in accordance with clinical judgment of treating physicians. Pelvic sonograms were retrospectively reviewed for endometrial stripe thickness and vascularity was graded on a 0-3 scale based on appearance relative to myometrium (Grade 0: no vascularity, Grade 1: minimal vascularity, Grade 2: moderate vascularity, Grade 3: marked vascularity). Clinical and imaging predictors of management were evaluated in univariate and multivariate analysis. RESULTS: Mean patient age was 29.6 years and mean gestational age was 17.4 weeks. Most (74.4%) women presented with vaginal bleeding. 83 patients (47.2%) were treated conservatively with expectant management, 42 (23.8%) were treated medically, and 51 (29.0%) required surgical intervention. Mean endometrial stripe thickness was 21.3 mm. 47 women (26.7%) had vascularity score of 0; 50 (28.4%) had score 1; 52 (29.6%) had score 2; and 27 (15.3%) had score 3. In univariate analysis, serum hemoglobin (Hb) (p < 0.0001), endometrial stripe thickness on US (p < 0.005), presenting symptoms (p = 0.03), and US vascularity score (p < 0.005) were statistically significant predictors of final management. In multivariate logistic regression, serum Hb (OR 0.69, 95% CI 0.55-0.86, p < 0.0009), endometrial stripe thickness (OR 1.08, 95% CI 1.04-1.12, p < 0.0001), and US vascularity score (OR 1.77, 95% CI 1.16-2.70, p < 0.01) were statistically significant predictors of need for surgery. CONCLUSIONS: Serum Hb, endometrial stripe thickness, and US vascularity score were significant predictors of clinical management, particularly the need for surgical intervention, in women with clinically suspected RPOC.

Differences in extracellular matrix remodeling in the placenta of mares that retain fetal membranes and mares that deliver fetal membranes physiologically.

INTRODUCTION: In mammals, placenta separation at term may involve degradation of the extracellular matrix by matrix metalloproteinases (MMPs). The activity of MMPs is modulated by TIMPs. We hypothesized that the placentas of mares that deliver fetal membranes physiologically and those that retain fetal membranes (FMR) differ in terms of histology; mRNA expression of MMP-2 and MMP-9; protein expression of MMP-2, MMP-9, and TIMP-2; and the potential activity of both MMPs. METHODS: Placenta biopsies were taken from mares (n = 9; 4 FMR, 5 controls) immediately after foal expulsion. Retention was defined as failure to expel all fetal membranes within 3 h of expulsion. All mares were monitored for time of expulsion. The degree of allantochorial/endometrial adhesion was determined in FMR mares, and biopsies from all mares were histologically examined. mRNA expression, protein immunolocalization, protein amount and potential enzyme activity were determined with RT-PCR, immunohistochemistry, Western Blotting and zymography, respectively. RESULTS: FMR mares had strong to extremely strong allantochorial/endometrial adhesion, and significantly more connective tissue in the allantochorial villi than controls. The range of MMP-2 mRNA expression levels was more than 13 times greater in FMR mares than in controls. Protein content of both MMPs and TIMP-2 differed significantly between groups. The range of potential MMP-2 and MMP-9 activity was larger in FMR mares, and MMP-2 potential activity was 1.4 times higher in controls (P = 0.02). DISCUSSION: These results indicate differences in extracellular matrix remodeling in FMR mares and controls, and suggest dysregulation of MMP expression and activation in FMR mares.

Sheehan syndrome: acute presentation with severe headache.

Postpartum headache is a common occurrence with a broad differential diagnosis. Sheehan syndrome, or postpartum pituitary necrosis, is not typically recognized as a cause of postpartum headache. We present a case of Sheehan syndrome that initially presented as severe headache after vaginal delivery complicated by retained placenta and postpartum hemorrhage. The patient was discharged home on postpartum day three but continued to have headaches and returned to hospital on postpartum day six with severe headache, failure to lactate, edema, dizziness, fatigue, nausea and vomiting. Cranial magnetic resonance imaging revealed pituitary infarction consistent with Sheehan syndrome. We discuss the differential diagnosis for postpartum headache, the pathophysiological features of Sheehan syndrome and headache as an atypical acute presentation.

Conservative management of placenta accreta: hysteroscopic resection of retained tissues.

STUDY OBJECTIVE: To evaluate the feasibility and the results of hysteroscopic removal of tissue after conservative management of retained placenta accreta. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: Twelve consecutive patients with hysteroscopic resection of retained tissues after conservative management of placenta accreta. INTERVENTION: Hysteroscopic removal of retained placenta tissue using a 24F bipolar resectoscope. MEASUREMENTS AND MAIN RESULTS: Twelve patients with retained placenta tissue, complete in 2 and partial in 10, were included. Mean retained placenta size on magnetic resonance imaging was 54 mm (range, 13-110 mm). Complete removal was achieved in all but 1 patient who underwent a secondary hysterectomy after the first incomplete hysteroscopic resection. Complete evacuation of the uterus was completed after 1 procedure in 5 patients, after 2 procedures in 2 patients, and after 3 procedures in 4 patients. All but 2 patients had normal menstrual bleeding after hysteroscopy. Four pregnancies occurred in our series, resulting in 1 ectopic pregnancy, 1 miscarriage, and 2 deliveries. CONCLUSION: Hysteroscopic resection of retained placenta seems to be a safe and effective procedure to prevent major complications and to preserve fertility in cases of conservative management of placenta accreta.

Nanobacteria and psammoma bodies: ultrastructural observations in a case of pathological placental calcification.

Nanobacteria are controversial infectious agents with nanometric size, the capacity to nucleate hydroxyapatite and grow in culture, and present in human diseases associated with calcification and psammoma bodies. The authors report a case of pathological placental calcifications associated with nanobacteria. Electron microscopy and electron energy loss spectroscopy imaging were used to recognize 160-nm-sized calcium-free bodies mainly presenting as extracellular fibrillary tangles and 500-nm-sized calcified bodies; they encrusted the syncito-trophoblast basal membrane and aggregated into miniaturized psammoma bodies. Nanobacteria may be composed of a prionoid protein with self-assembling and self-propagating abilities whose growth is associated with the formation of psammoma bodies.

Clinical and sonographic findings in suspected retained trophoblast after pregnancy do not predict the disorder.

STUDY OBJECTIVE: Our aim was to estimate whether there are clinical, sonographic, or intraoperative parameters that have good correlation with the final histologic study after hysteroscopic removal of suspected retained trophoblast of conception. DESIGN: Retrospective case control study (Canadian Classification II-2). SETTING: A tertiary referral hospital. PATIENTS: Sixty-four patients after hysteroscopic removal of suspected retained pregnancy material. INTERVENTIONS: We divided our patients into those with true trophoblast on histologic evaluation (group A, n=40) and patients with other histologic findings (group B, n=24). Clinical parameters, as well as sonographic evidence leading to hysteroscopy were correlated with final pathology report. MEASUREMENTS AND MAIN RESULTS: Age, obstetric history, type of obstetric event, and time between primary event and hysteroscopy were not statistically different between the true trophoblast and nontrophoblast groups. Clinical signs and symptoms (fever, bleeding, and abdominal pain), as well as sonographic findings (size of retained mass and Doppler flow) were not statistically different between the 2 groups and thus could not predict the final disease. The only parameter correlated significantly to final histologic findings was the intraoperative surgeon's opinion of the retained material. CONCLUSIONS: Various clinical parameters, as well as sonographic findings including the size of the mass and Doppler test results in patients with suspected retained trophoblast, do not predict the final diagnosis. The surgeon's opinion regarding the tissue seen during hysteroscopy is the only parameter tested that correlates well with the final histologic evaluation. Thus selective removal of retained trophoblast can be performed on the basis of the surgeon's opinion during the procedure, whereas further potentially harmful interventions (curettage) can be avoided when true trophoblast is not suspected to minimize complications.

Sequential methotrexate treatment with and estrogen and progestin in a retained adhesive placenta.

BACKGROUND: Hysterectomy is the definite and recommended treatment of a retained adhesive placenta. CASE: A 33-year-old woman at 38 weeks plus one day of gestation had a cesarean delivery due to previous history of myomectomy. On ultrasound placental retention was noted thus curettage was attempted two weeks postpartum but it induced moderate fresh bleeding. A contrast-enhanced computed tomography scan depicted the multiple vessels within the intrauterine mass and the absence of deep myometrial invasion. The patient received four doses of 50 mg of methotrexate intramuscularly every other day, alternating with four doses of 15 mg of folic acid. An attempt to evacuate the necrotic tissue along with withdrawal bleeding was successful after three courses of sequential conjugated estrogen (0.25 mg)-progestin (5 mg) therapy. CONCLUSION: The use of estrogen and progestogen together with methotrexate in combination may be simple and potentially effective for placenta accreta and placenta increta.

A study of endometritis causing repeat breeding of cycling iraqi buffalo cows.

The objectives of this study were to determine the non-specific aerobic and anaerobic bacterial causes of endometritis causing repeat breeding of cycling Iraqi buffalo cows at Nineveh province, validate diagnostic criteria for endometritis and to evaluate the treatment efficiency of using systemic or intra-uterine infusion of antibiotics for the treatment of endometritis. Data were collected from 60 buffalo cows with history of repeat breeding in different herds. All buffaloes were subjected to detailed clinical examination including external inspection, vaginoscopy and transrectal palpation of the cervix, uterus and ovaries. Swabs for bacteriology and biopsies for histopathology were collected from the uterine lumen from each cow. Character, odour and estimation of polymorphonuclear cells (PMN) of the vaginal mucus were scored. Blood samples were collected from cows for creatine kinase (CK) and aspartate aminotransferase (AST) measurement. Treatment conducted using oxytetracycline with tylosin in local intrauterine infusion or systemically with hormonal treatment. The most pre-disposing factor for uterine infection was retained placenta (13.3%). The most prevalent bacteria in uterine lumen were E. coli (23%), Archanobacterium pyogenes (13%) and Staphylococcus aureus (10%) were mostly isolated from buffaloes with repeat breeding. Vaginal mucus character score was associated with the bacterial growth density score. The difference in PMN was highly significant (p < 0.01) in animals with repeat breeding than control groups. In addition, PMNs was significantly (p < 0.01) correlated r = 0.894 with the character of vaginal discharge. High level of PMNs observed in buffaloes infected with A. pyogenes. Buffalo cows with endometritis had higher CK (321.47 +/- 39.06 vs 162.01 +/- 16.41 U/l) and AST (133.93 +/- 12.43 vs 97.01 +/- 6.86 U/l) activities (p < 0.05) than control-heifers, but no significant difference was observed between buffalo cows with endometritis in CK (321.47 +/- 39.06 vs 208.33 +/- 5.84) and AST (133.93 +/- 12.43 vs 156.17 +/- 9.65) activities than control-pluriparious. It could be concluded that A. pyogenes was the only non-specific uterine pathogen directly associated with severe endometrial lesions. Vaginoscopy examination combined with palpation of uterus increase the accuracy of diagnosing endometritis and cytogenic examination of uterine discharge is more reliable method of establishing the presence or absence of uterine inflammation in buffalo cows. Animals with repeat breeding (endometritis) showed clinical cure and improved pregnancy in all treatment groups with no significant difference. The use of oestradiol in repeat breeder cases has no effect in improving neither clinical cure rate nor pregnancy rate.

Role of clinical and ultrasound findings in the diagnosis of retained products of conception.

OBJECTIVE: To assess the role of clinical and ultrasound findings as predictors of retained products of conception (RPOC) in women with a suspicion of incomplete miscarriage. METHODS: This was a retrospective study of 91 patients admitted for suspected RPOC after spontaneous first-trimester miscarriage who were evacuated surgically, and for whom histopathological reports were available. All the women underwent transvaginal sonography after their miscarriage. The decision to evacuate the uterus was based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms and sonographic findings were recorded. Clinical and sonographic findings were compared with the histopathological reports and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of the endometrium for detecting the products of conception were assessed. RESULTS: Histopathological analysis confirmed the presence of chorionic villi in 55 women (60%) and decidua in 36 (40%). Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was a more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had a sensitivity of 78%, specificity of 100% and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC. Vaginal bleeding as a predictor of RPOC had a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively. The combination of hyperechoic material and/or vaginal bleeding increased the sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between the two groups. CONCLUSION: The ultrasound finding of hyperechoic material is the best predictor for diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.

A study on postpartum metritis in Iraqi buffalo cows: bacterial causes and treatment.

The objectives of the present study were to determine the relationship between bacteriological findings, clinical signs and histopathological changes in postpartum metritis. Evaluation of the treatment efficiency of using systemic or intra-uterine infusion of antibiotics with some hormonal preparations for the treatment of postpartum metritis. Data were collected from 50 buffalo cows with history of calving of more than 1 month. All buffaloes were subjected to detailed clinical examination including external inspection, vaginoscopy and transrectal palpation of the cervix, uterus and ovaries. Swabs for bacteriology and biopsies for histopathology were collected from uterine lumen from each buffalo included in the present study. Bacteria identified using API systems following aerobic and anaerobic cultures. Vaginal mucus scored for character, odour and estimation of polymorphonuclear cells (PMNs). Treatment conducted using oxytetracycline in local intrauterine infusion or systemically with hormonal treatment including prostaglandin F2 alpha (PGF2 alpha) and oestradiol benzoate. Results revealed that the most predisposing factor for postpartum uterine infection was retained placenta and toxic puerperal metritis. The most prevalent bacteria in uterine lumen were Escherichia coli, Archanobacterium pyogenes, Bacteroides fragilis and Fusobacterium necrophorum the most prevalent bacteria in buffaloes with postpartum metritis. A. pyogenes and F. necrophorum were an important pathogens causing severe uterine inflammation as found in histopathological examinations. Buffaloes with postpartum metritis showed good clinical cure when oxytetracycline injected systemically with PGF2 alpha. Intrauterine infusion of oxytetracycline had no advantage for the treatment of uterine infection in buffalo cows with postpartum metritis. PGF2 alpha improved clinical cure of buffaloes with postpartum metritis.

The value of measuring endometrial thickness and volume on transvaginal ultrasound scan for the diagnosis of incomplete miscarriage.

OBJECTIVE: To identify ultrasound measurements that are the best predictors of the presence of retained products of conception (RPOC) within the uterine cavity in women with clinical diagnosis of incomplete miscarriage. METHODS: This was a prospective observational study, set in a dedicated early pregnancy assessment unit in a London teaching hospital. Endometrial thickness and the volume of suspected retained products of conception were measured by transvaginal ultrasound scan preoperatively. Indications for surgical intervention were heavy vaginal bleeding or continuous bleeding lasting > 7 days. The main outcome measure was histological evidence of chorionic villi in surgical specimens. RESULTS: Among the patients, 109 (85%) had evidence of chorionic villi on histology, whilst decidua was only found in the remaining 19 (15%). There was no identifiable cut-off for endometrial thickness or volume that could be used to differentiate between retained products of conception and decidua. CONCLUSION: Measurements of endometrial thickness or volume on ultrasound scan are not good tests for diagnosing an incomplete miscarriage.

Extramedullary hematopoiesis in the endometrium.

Extramedullary hematopoiesis (EMH) in the endometrium is an extremely rare occurrence. Four of the eight previously reported cases were related to an underlying hematological disorder, although the remainder had no such relationship. We describe a case of endometrial EMH associated with retained products of conception after termination of pregnancy. Routinely and immunohistochemically stained slides revealed several collections of normoblasts and granulocytic precursors in the endometrium with synchronous chronic endometritis. Retained chorionic villi were also identified. The patient had no known history of a hematological disorder or systemic disease and no such abnormality was detected after detailed hematological work-up. Local effects of growth factors on circulating stem cells may play a pathogenetic role in this process, although an association with recent pregnancy in this case suggests that implantation of fetal hematopoietic elements from the fetus or yolk sac may be more likely.

The equine endometrial mast cell during the puerperal period: evaluation of mast cell numbers and types in comparison to other inflammatory changes.

Endometrial biopsies of 44 broodmares were histologically examined on days 3, 6, and 9 postpartum. The mares were subdivided into three groups according to the course of the puerperal period. In 29 mares, parturition and expulsion of the placenta was normal, six mares showed dystocia, and in nine mares, the placenta was retained for > 2 hours. Tissue samples were evaluated histologically, and the average numbers of granulocytes, lymphocytes, macrophages, siderophages, and mast cells was determined. Protease content of mast cells was examined with a double-enzyme immunohistochemical staining technique, using a histochemical reaction for chloroacetate esterase and fast blue to detect chymase activity and an immunohistochemical staining method with a polyclonal antibody and fast red for the detection of tryptase. Analyzing the cell numbers using the statistical software Statistica, a marked inflammatory reaction was observed in the endometrium postpartum. Although the number of granulocytes decreased during the first 9 days postpartum, the number of lymphocytes, macrophages, and siderophages increased. No significant difference in the number of any of these cell types could be demonstrated in the three different courses of the puerperal period, although the numbers of these cells seemed to be lower in mares with dystocia. In contrast with other cells, no change in the number of endometrial mast cells was observed during the puerperal period, but a significantly lower number were found in the endometrium of mares with retained placenta. The enzyme immunohistochemical double-labeling technique could demonstrate only tryptase-positive mast cells; no chymase activity was detectable in any endometrial mast cells. The number of mast cells detected with the metachromatic staining technique was significantly higher than that detected with double labeling. These results support the hypothesis that a sufficient number of mast cells may be necessary for a normal postnatal period and suggest a mast cell subtype in the equine endometrium that is tryptase and chymase negative.

[Fertility in mares after an disturbed as well as an undisturbed puerperium. Significance of histological and cytological examinations of the uterus]. / Fruchtbarkeit bei Stuten nach gestörtem bzw. ungestörtem Puerperium. Aussagekraft histologischer und zytologischer Untersuchungen des Uterus.

Because of the mare's ability to conceive very soon post partum a thoroughly performed control of the puerperal period is of particular importance. Cytological examinations of uterine content and histological examinations of uterine biopsy specimens provide more detailed information than microbiological examinations of uterine swabs. Uterine content and uterus biopsy specimens of 55 mares were examined histologically on days 3, 6 and 9 post partum. We observed a heavy polymorphonuclear reaction of the endometrium following disturbed puerperal processes especially in cases of retained placenta. This reaction of the endometrium as well as a delayed regeneration of the uterine epithelium and the uterine gland epithelium resulted in significantly lower fertility rates at the first post partum oestrus. In such cases the foal heat should therefore not be used for breeding.