Tubo-ovarian abscess with sepsis in a nonagenarian woman: a case report and literature review.

BACKGROUND: A complete infectious focus survey relies on a thorough physical examination as well as a pelvic examination. Tubo-ovarian abscess, though less likely to occur in senior women, may become a life-threatening disease requiring emergent surgery. Hence, clinical awareness and aggressive management are warranted to avoid delayed diagnosis and subsequent complications. CASE PRESENTATION: We report a post-menopausal woman presented with sepsis of unknown origin, which turned out to be a huge tubo-ovarian abscess. Although tubo-ovarian abscess mostly occurs in women of fertile age, it is likely that the immune status of our post-menopausal patient was compromised because of old age and uremia. Moreover, due to underlying dementia, she could not express her discomfort in the early stage. Her sepsis resolved after a unilateral salpingo-oophorectomy surgery and antibiotic treatment. It is crucial to exclude pelvic inflammatory disease (PID) if no specific source of infection can be identified. CONCLUSIONS: Rupture of the tubo-ovarian abscess is a condition of high mortality rate. Although tubo-ovarian abscess is more likely to develop in patients aged 15-25 years old, the tubo-ovarian abscess should be listed as a differential diagnosis in all post-menopausal women, especially those who are immunocompromised or with a palpable pelvic mass, to enable timely management and better prognosis.

Impaired responsiveness of platelets to epinephrine due to α2A adrenoreceptor deficiency in Male Chinese.

Epinephrine is known as a weak, but important, agonist for platelet activation. It has been reported that the responsiveness of platelets to epinephrine was markedly impaired in 6% of Caucasians and in 16% of Japanese. The purpose of this study was to screen and characterize this abnormality in healthy Taiwanese Chinese volunteers. We used aggregometry, flow cytometry and platelet function analyzer (PFA)-100 system to assess in 50 healthy male volunteers the responsiveness of platelets to epinephrine stimulation. Using α2A adrenoceptor antagonist BRL44408 maleate competition and a [(3)H]yohimbin binding assay, we evaluated α2A adrenoceptors on platelets. The aggregation of platelets after stimulation with 10 µM of epinephrine indicated two distinct groups of study participants: 24 (48.0%) good- and 26 (52.0%) impaired-responders to epinephrine. Flow cytometric analysis of platelets after stimulated with 1 µM epinephrine showed that glycoprotein (GP) IIb/IIIa and P-selectin expression of epinephrine good- and impaired-responders were 27.1 ± 11.0% vs. 9.9 ± 5.4% (p = 0.003) and 12.2 ± 6.2% vs. 3.6 ± 3.5% (p < 0.001), respectively. The PFA-100 system showed that epinephrine-impaired-responders had a longer collagen-epinephrine induced closure time. Good-responder platelets incubated with BRL44408 maleate had an impaired response to epinephrine stimulation. [(3)H]yohimbine binding studies showed fewer α2A adrenoreceptors on the platelets of epinephrine-impaired-responders than on those of good-responders. The prevalence of impaired responsiveness to epinephrine was high and probably due to α2A adrenoreceptor deficiency in male Taiwanese Chinese.

The relationship between serum CA-125 level and recurrence in surgical stage I endometrial cancer patients.

BACKGROUND: The majority of patients diagnosed with early stage endometrial cancer have a favorable prognosis; however, approximately 10% to 15% experience a recurrence. Therefore, the aim of the present study was to evaluate whether postoperative carbohydrate antigen 125 (CA-125) levels could be used to predict recurrence and recurrence-free survival (RFS) in patients with surgical stage I endometrial cancer. METHODS: We enrolled a total of 518 patients with stage I endometrial cancer who underwent surgical treatment between January 2010 and March 2019. Serum CA-125 levels were measured prior to surgery, as well as 6 to 12 months after surgery. Subsequently, the correlations between the CA-125 levels, cancer recurrence, and RFS were analyzed. RESULTS: Although the preoperative CA-125 level was not associated with the risk of cancer recurrence, the postoperative CA-125 level was found to be the only independent predictor of recurrence in both univariate and multivariate analyses. Additionally, we found that a postoperative CA-125 cutoff value of 13.75 U/mL yielded the best sensitivity and specificity for predicting cancer recurrence. Patients with a postoperative CA-125 level ≥13.75 U/mL, and those with a level <13.75 U/mL, had a median time to recurrence and a 5-year RFS rate of 35.5 vs 50.5 months and 84.7 vs 94.4%, respectively. Additionally, postoperative CA-125 levels were not found to be correlated with preoperative levels. CONCLUSION: In patients with stage I endometrial cancer, a postoperative CA-125 level ≥13.75 U/mL was found to be significantly correlated with a higher recurrence rate, as well as a shorter RFS. Therefore, obtaining a follow-up CA-125 level within 6 to 12 months after staging surgery may be a promising noninvasive biomarker for predicting recurrence.

Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy.

OBJECTIVE: On the basis of outcome data from concurrent chemoradiotherapy (CCRT) for locally advanced cervical squamous cell carcinoma, the authors developed a nomogram for predicting survival outcome. STUDY DESIGN: Two hundred fifty-one eligible patients with International Federation of Gynecology and Obstetrics stage IIB-IVA squamous cell carcinoma of the uterine cervix who underwent CCRT were included for the construction of the nomogram. Predictor variables included age, serum squamous cell carcinoma antigen, tumor size, parametrium invasion, hydronephrosis, bladder/rectum invasion, and lymph node metastases. Internal validation of the nomogram was performed. RESULTS: A nomogram for predicting the 5 year overall survival for these patients was constructed on the basis of a Cox regression model from 7 parameters. The concordance index was 0.69. CONCLUSION: This nomogram is a predictive tool, upon external validation, that can be used to counsel patients in predicting outcomes. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.

Using dinoprostone vaginal insert for induction of labor: A single institute experience.

OBJECTIVE: To evaluate the factors associated with the successful induction of labor (IOL) in women treated with dinoprostone slow-released vaginal insert. MATERIAL AND METHODS: A retrospective study was conducted between June 2017 and December 2017, enrolling 65 patients who underwent dinoprostone slow-released vaginal insert-induced labor. The correlation between the characteristics of the pregnant women and its success, as well as perinatal complications and adverse outcomes were analyzed. RESULTS: Fifty-three of 65 (81.5%) achieved a successful vaginal delivery. Only multi-parous pregnant women were an independent predictor factor for successful induction after dinoprostone slow-released vaginal insert, since all of them succeeded after this strategy treatment (100%, n = 18), compared to 74.5% (35/47) of successful rate in the nulliparous pregnant women with a statistically significant difference (p = 0.018). There were no adverse events occurred in both mothers and their offspring. CONCLUSION: Dinoprostone slow-released vaginal insert is a good choice for multiparous pregnant women who need IOL, regardless of which reasons are indicated. For nulliparous women, more studies might be needed to evaluate the effectiveness of PGE2 for IOL.

Optimal approach for management of postpartum vulva hematoma: Report of three cases.

OBJECTIVE: Vulvar hematomas though common in obstetrical practice can rapidly evolve into a life-threatening condition if not managed appropriately. Depending on clinical status and medical facility, conservative management, surgical debridement, or vessel-occlusion strategy can be considered. CASE REPORT: Case 1 was a 28 year-old pregnant woman. Increasing hematoma over 12 cm in size was noted on postpartum Day 2. Debridement and arterial embolization were done. Case 2 was a referred woman at age of 30 who delivered at a local obstetric clinic. Debridement was performed successfully. Case 3 was a 23 year-old woman with postpartum bilateral hematoma. Drop in hemoglobin level prompted the medical team to transfer and airlift the patient for arterial embolization and subsequent vulva debridement. CONCLUSION: Optimal management of hematoma is dependent on maternal hemodynamic condition, bleeding status, and availability of interventional radiology.

Clinical application of Lin's biopsy grasper for intrauterine targeted biopsy and polypectomy during office hysteroscopy.

OBJECTIVE: Hysteroscopy has widely been used for diagnosis of the uterine cavity; however, target biopsy has often been difficult in part to the inherent limitations of ancillary instruments. Lin's biopsy grasper was specifically designed to work in conjunction with a flexible hysteroscope to obtain intrauterine biopsy under transabdominal sonography. Herein, we share our clinical experience in the management of endometrial abnormalities with the use of Lin's biopsy grasper during office-based hysteroscopy. MATERIALS AND METHODS: From February 2006 to November 2016, the use of Lin's biopsy grasper for tissue biopsy was attempted on 126 cases. We retrospectively recorded and analyzed the patients' preoperative characteristics and biopsy outcomes to demonstrate the feasibility and efficacy of Lin's biopsy grasper. RESULTS: Out of the one hundred and twenty-six enrolled patients, satisfactory targeted biopsies were achieved; including high diagnostic rate (92.1%, with 116 cases confirmed histologically) and adequate tissue retrieval (77.8%, with 98 cases obtaining optimal specimen volume). All patients tolerated the procedure without analgesics or anesthesia. CONCLUSION: Diagnostic flexible hysteroscopy combined with the use of Lin's biopsy grasper has proven to be an effective tool for intrauterine evaluation and obtaining tissue sample.

Copy number variation profile in noninvasive prenatal testing (NIPT) can identify co-existing maternal malignancies: Case reports and a literature review.

OBJECTIVE: The coexistence of maternal malignancy and pregnancy has received increasing attention in Noninvasive prenatal testing (NIPT) studies. Malignancy in pregnant women potentially affects the copy number variation (CNV) profile in NIPT results. Only one case of hematologic cancer has been reported in a Hong-Kong pregnant women, and solid tumors have never been reported in pregnant Chinese women. CASE REPORT: The patients with dysgerminoma and cervical cancer showed aberrant chromosomal aneuploidies in NIPT and concordant patterns of genome disruption in tumor tissues. The genomic aberrations in the gastric cancer patient had similar copy number variation pattern of gastric cancer. CONCLUSION: The findings in this study and the literature review further validate the effect of maternal malignancy on the copy number variation profile in NIPT data and strengthen the possibility of detecting malignant tumors with NIPT in the future.

Magnetic resonance imaging as a diagnostic tool in pregnancy with appendiceal abscess.

Abdominal pain presenting itself during pregnancy may be multifactorial, requiring immediate attention and care. In cases of intractable pain without obstetrical condition, surgical abdominal exploration is widely advised. However, we present a case where a 30-year-old, gravida 1, para 0, female complained of persistent right abdominal pain during her 25th week of pregnancy. Ultrasound revealed a right upper quadrant cystic mass and magnetic resonance imaging was arranged with compatible findings. Final impression of appendiceal abscess was determined. Broad-spectrum antibiotics were administered and the patient was discharged in stable condition after 10 days of conservative treatment. She delivered a healthy baby boy at her 40th week of gestation uneventfully.

Cytogenetic anomalies in hyaline vascular Castleman disease: report of two cases with reappraisal of histogenesis.

The pathogenesis of hyaline vascular Castleman disease (HVCD) is poorly understood. Although generally considered reactive in nature, a subset of cases has been shown to harbor focal proliferations of stromal cells, such as follicular dendritic cell (FDC) and angiomyoid proliferations. We report two typical cases of HVCD with cytogenetic anomalies: one was t(1;22)(qter;q13) and the other was t(7;8)(q37.3;q12) in cultured stromal cells, as demonstrated by conventional cytogenetic analysis. The cultured cells were immunoreactive for smooth muscle actin but negative for CD21, CD31, and CD34, and ultrastructurally possessed thin filaments (5-7.5 nm) with dense bodies, and pinocytotic vesicles, characteristic of smooth muscle cells. The lack of monoclonality of lymphoid cells in lesional tissues by immunohistochemical and molecular analyses also supports the origin of these anomalies from the stromal cells, most likely myoid cells. Moreover, the absence of overt stromal proliferations suggests that cytogenetic changes in stromal cells of HVCD precede histologic evidence of stromal overgrowth, which may account for the occurrence of angiomyoid proliferations arising in some cases of HVCD. Further studies with more cases are needed to decipher whether part or even most of HVCD cases bear genetic changes in the beginning of the disease without morphologically stromal overgrowth.

Delivery of double singleton pregnancies in a woman with a double uterus, double cervix, and complete septate vagina.

Uterine anomalies involving a double uterus, double cervix, also known as didelphys uterus, and complete septate vagina are rarely seen and have an associated fertility problem. However, artificial reproductive technology with embryo transfers can help solve this fertility challenge. Conception in the uterus in just one side is commonly seen for embryos, which are always transferred through the usually used (dilated) vagina. We here present a patient with the above uterine anomaly who conceived with the aid of in vitro fertilization and embryo transfer to both uterine cavities under general anesthesia, which resulted in successful double singleton pregnancies with one fetus in each uterus. With intensive prenatal care, the pregnancy course for each fetus was rather uneventful. Although both fetuses were in cephalic presentation, cesarean section was performed at the 39(th) week of gestation with good outcomes in order to preclude anticipated difficulties if the baby had been delivered through the rarely dilated vagina. However, order of birth between the two fetuses was a crucial decision during the operation.

Pregnancy outcome of systemic lupus erythematosus in relation to lupus activity before and during pregnancy.

BACKGROUND: To analyze the pregnancy complications and pregnancy outcome relating to the disease activity of systemic lupus erythematosus before conception and during pregnancy. METHODS: Seventy-two pregnancies were collected in a single tertiary medical center within a 5-year period. Twelve pregnancies were terminated due to various causes in the first half of pregnancy. Analysis of pregnancy complications and pregnancy outcome relating to the lupus activity before conception and during pregnancy was made among the remaining 60 pregnancies with gestational length > 26 weeks. The assessment of lupus activity was based on the routine monitoring, including urine routine, white blood cell count, hemoglobin and platelet count, erythrocyte sediment rate, serum titers of C3, C4, and double-stranded DNA. Monitoring of renal function with daily urinary protein loss and clearance rate of creatinine was needed when worsened nephropathy was suspected. RESULTS: The etiologies of the terminated pregnancies were deteriorated nephropathy (6 cases), involvement of central nervous system (1 case), unwanted pregnancy due to drug exposure (3 cases), and two early intrauterine fetal deaths (both during the 23(rd) week of gestation). Pregnancy complications were related to the lupus activity before conception [odds ratio = 0.238, 95% confidence interval (CI) = 0.073, 0.778, p = 0.014] and during pregnancy (odds ratio = 0.153, 95% CI = 0.031, 0.754, p = 0.012). Meanwhile, pregnancy outcome significantly related to the lupus activity of the preconception period and during pregnancy. The gestational length was significantly longer in the pregnancies with remitted lupus activity either before conception (38.2 ± 1.6 weeks vs. 36.3 ± 3.4 weeks, p = 0.011 and 95% CI = -3.454, -0.478) or during pregnancy (38.2 ± 1.6 weeks vs. 35.2 ± 3.8 weeks, p = 0.005 and with 95% CI = -4.988, -1.005). Significant relationships were also found between newborn birth weights and lupus activity preconceptionally (2940 ± 389 g vs. 2448 ± 674 g, p = 0.002 and 95% CI = -792, -192) and after having conceived (2960 ± 383 g vs. 2136 ± 585 g, p < 0.001 and 95% CI = -1081, -568). Multivariate analysis showed that lupus remission during pregnancy was correlated with a significantly longer gestation, since pregnant women with active lupus had a three-fold greater risk of preterm deliveries (hazard ratio = 3.022, 95% CI = 1.261, 7.242) compared with pregnant women without active lupus. CONCLUSION: In order to reduce the incidence of pregnancy complication, especially preterm delivery, and to gain good pregnancy outcome, good preparation before conception and good control of the disease during pregnancy are mandatory.

Uterus didelphys with cervical agenesis associated with adenomyosis, a leiomyoma and ovarian endometriosis. A case report.

BACKGROUND: Elevated level of serum CA-125 was detected in a 48-year-old woman who was diagnosed with a lateral fusion defect in association with congenital agenesis of the uterine cervix. This unusual case combined two developmental anomalies of the müllerian duct. CASE REPORT: A 48-year-old woman consulted our outpatient department due to persistent abdominal pain for six months. Bimanual pelvic examination showed absence of the cervix, an anteverted uterus and a 6-cm, left adnexal mass. Ultrasound and computed tomography revealed a uterus didelphys with a 3-cm cystic mass over the right ovary. Serum level of CA-125 was 641.4 U/mL. The patient underwent exploratory laparotomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathology confirmed adenomyosis and a leiomyoma of the uterus with functional endometrium in conjunction with endometriosis of the right ovary. CONCLUSION: Multiple müllerian anomalies associated with adenomyosis and endometriosis should be considered in patients presenting with primary amenorrhea. Thorough evaluation, careful planning, fertility preservation and postoperative outcomes should be reviewed.

Umbilical artery Doppler velocimetry in normal pregnancies from 11(+0) to 13(+6) gestational weeks: a Taiwanese study.

OBJECTIVE: The aim of this study is to investigate the relationship between umbilical artery flow and gestational age (GA) at 11-13(+6) weeks in normal pregnancy in the Taiwanese population. MATERIALS AND METHODS: Two hundred and fifty-three normal singleton pregnancies with GA ranging from 11 to 13(+6) weeks were included in this study. The velocity of systolic, diastolic, and pulsatility index (PI) of the umbilical artery, and the mean velocity of the umbilical vein were recorded. RESULTS: One hundred and eighty-seven participants fulfilling the inclusion and exclusion criteria were analyzed. The mean maternal age was 31 (range 19-45) years, with a corresponding GA of 12(+4) (range 11-13(+6)) weeks. The absence of end-diastolic velocity of the umbilical artery was observed in most of our cases (90.1%). No significant change was found in the vascular indices with GA for the mean velocity of the umbilical vein (mean velocity = 0.923 × GA - 1.594, r = 0.1497, p = 0.115). The systolic velocity of the umbilical artery and PI, however, behaved differently from the other variables. There was a significant increase in systolic velocity with GA [systolic wave (S wave) velocity = 0.237 × GA + 2.267; r = 0.149, p = 0.041]. By contrast, the PI showed a significant decrease in relation to the GA (PI = -0.016 × GA + 4.068; r = 0.196, p = 0.007). CONCLUSION: The S-wave velocity of the umbilical artery increased with GA. By contrast, the PI of the umbilical artery showed a decreasing trend with GA. This may ensure optimal placental perfusion, which is necessary to accommodate the increased blood flow to the developing fetus. Furthermore, an absence of end-diastolic velocity in the first trimester and early second trimester was usually seen.

Fetal maxillary and mandibular length in normal pregnancies from 11 weeks' to 13(+6) weeks' gestation: a Taiwanese study.

OBJECTIVES: This study aims to establish the normal range of maxillary and mandibular lengths within the Taiwanese population at 11(+0) weeks to 13(+6) weeks of gestation in normal singleton pregnancy as a reference value for prenatal ultrasonographic examinations. MATERIALS AND METHODS: We examined nuchal translucency in 269 normal singleton pregnancies, with the gestational age ranging from 11 weeks to 13(+6) weeks in this study. Fetal biometric measurements, with an emphasis on maxillary and mandibular lengths, were obtained from the patients during consecutive routine prenatal ultrasonographic examinations. RESULTS: Maxillary and mandibular lengths were recorded successfully in 191 patients and 179 patients, respectively. The mean maternal age was 31 years (range 19-45 years), with a corresponding gestational age of 12 + 4 weeks (range, 11(+0)-13(+6) weeks). A first-degree correlation was found to exist between the gestational age and maxillary length (r = 0.596; p < 0.0001; y = 1.491 × GA - 10.523) as well as mandibular length (r = 0.465; p < 0.0001; y = 1.050 × GA - 6.50). CONCLUSION: Normative data for ultrasonographic measurements of maxillary and mandibular lengths within the Taiwanese population were presented. Our data can serve as a reference value in congenital anomaly screening during prenatal examination.