Distinct types of uterine adenomyosis based on laparoscopic and histopathologic criteria.

PURPOSE: To analyze laparoscopically treated cases of adenomyosis based on intraoperative and histopathology findings and to correlate different types with patients' presenting symptoms and characteristics, as well as with the surgical approach. MATERIALS AND METHODS: Sixty-eight women who underwent laparoscopic treatment of adenomyosis at a referral center for gynecological laparoscopy. RESULTS: Four distinct types of adenomyosis could be identified: diffuse, sclerotic, nodular, and cystic (54.5%, 13%, 28%, and 4.5% of cases, respectively). Menorrhagia as the main presenting symptom was significantly more frequent in patients with the diffuse type (84%) compared to those with sclerotic (44%) and nodular (37%) types (p = 0.025 andp = 0.001, respectively). All cases of cystic and nodular adenomyosis were treated by laparoscopic excision of the lesion. Eighty-nine percent of patients with sclerotic adenomyosis were treated with wide laparoscopic excision of the abnormal tissue. Eighty-one percent of patients with diffuse adenomyosis were treated with laparoscopic hysterectomy. CONCLUSIONS: Adenomyosis can be classified in four distinct types with differences in the presenting symptoms, as well as in the ideal surgical approach.

Reduced placental prolyl hydroxylase 3 mRNA expression in pregnancies affected by fetal growth restriction.

OBJECTIVE: To investigate the role of the hypoxia-inducible factor (HIF) pathway in fetal growth restriction (FGR). DESIGN: A case-control study. SETTING: Research laboratory and gynaecology clinic. SAMPLE: Twenty placentas from normal pregnancies and 20 from FGR pregnancies. METHODS: RNA extraction, cDNA synthesis, quantitative real-time polymerase chain reaction (qRT-PCR) assay, statistical analysis. MAIN OUTCOME MEASURES: mRNA expression of HIF-1α, HIF-2α and HIF-ß (ARNT), along with prolyl hydroxylase domain 3 (PHD3), which leads to proteasomal degradation of HIF-α subunits. RESULTS: No statistically significant differences in the transcription levels of ARNT and HIF-2α were found between FGR and normal placentas. By contrast, PHD3 and HIF-1α mRNA were downregulated in FGR placentas. PHD3 mRNA expression was associated with gestational age at delivery (P = 0.008), birthweight centile (P = 0.029) and abnormal umbilical artery (UA) Doppler measurements (P = 0.034). CONCLUSIONS: As PHD3 regulates the HIF-mediated hypoxic response in FGR, we deduce that fetal adaptation to hypoxia ranges from impaired to adequate, as observed by the gradient of PHD3 downregulation in relation to the severity of FGR.

Sonographic findings in severe fetomaternal transfusion.

Fetomaternal hemorrhage (FMH) or fetomaternal transfusion syndrome is the leakage of fetal red blood cells into the maternal circulation. Massive FMH can cause substantial fetal morbidity and mortality. Sonographic evidence of severe FMH syndrome includes fetal hydrops and other fetal anemia-related findings. The peak systolic velocity in the middle cerebral artery has extensively been used for the prediction of fetal anemia and for the timing of the first intrauterine intravascular transfusion (IIVT). We present a case of severe FMH syndrome that was diagnosed during the 24th week of pregnancy. A total of eight IIVT were performed. The actual increase in the fetal Hb after each transfusion was much lower than the expected. At 27 weeks of gestation, sonographic evaluation revealed areas of echogenicity around the posterior horns of the lateral ventricles suggesting ischemic damage. Due to these findings, no further IIVTs were offered and the fetus died a week later. The management of fetal anemia caused by severe FMH is difficult, and the anemic fetuses do not respond well to serial IIVTs as the transfer of blood to the maternal circulation continues.

A stillborn fetus with amniotic band syndrome and elevated levels of alpha-fetoprotein plus beta-human chorionic gonadotropin: a case report.

Amniotic band syndrome is an uncommon, congenital fetal abnormality with multiple disfiguring and disabling manifestations. A wide spectrum of clinical deformities are encountered and range from simple ring constrictions to major craniofacial and visceral defects. We report a case of constriction amniotic bands involving upper extremities and intrauterine fetal death due to strangulation of umbilical cord. Abnormally elevated levels of alpha-fetoprotein and beta-chorionic gonadotropin were detected at 17 weeks' gestation. They were probably caused by the loss of cutaneous integrity of the fetus (alpha-fetoprotein), and by the placental attempt to counteract the fetal growth restriction and hypoxia, due to the strangulation of umbilical cord by the amniotic bands (beta-chorionic gonadotropin).

Hydrops fetalis, thickened placenta and other sonographic findings in a low-level trisomy 21 mosaicism: a case report.

We report a case of trisomy 21 mosaicism detected upon amniocentesis in a 36-year-old woman. Ultrasound examination at 23 weeks' gestation showed a fetus with hydrops, pulmonary hypoplasia, oligohydramnios, thickened placenta, and intrauterine growth retardation. Cytogenetic analysis revealed low-percentage (6%) mosaicism for trisomy 21. Hydrops fetalis and thickened placenta are uncommon findings in fetuses affected by trisomy 21 mosaicism. A short review of the literature is given regarding the sonographic findings associated with trisomy 21 mosaicism, and the genetic counseling in such cases.

Intraabdominal umbilical vein dilatation and term delivery. A case report and review of the literature.

Dilatation of the fetal umbilical vein is a rare, most commonly isolated finding. Approximately 100 cases have been reported in the literature that describe different management approaches, especially regarding the time of delivery. We present a new case of umbilical vein dilatation diagnosed at 23 weeks' gestation as an isolated sonographic finding, in a fetus with short umbilical cord, delivered at 38 weeks' gestation. The clinical and sonographic features as well as the management options of this uncommon condition are shortly discussed.

A case report of recurrent anencephaly and literature review.

Anencephaly is a rare congenital anomaly in which the forebrain, meninges, vault of the skull, and scalp all fail to form. We report a case of a 32-year-old gravida 2 woman with an anencephalic fetus detected at the 21st gestational week. She had a history of an intrauterine fetal death of an anencephalic fetus at the 20th gestational week two years before. We present the case and briefly review the literature.

Hypomethylation along with increased H19 expression in placentas from pregnancies complicated with fetal growth restriction.

The expression of imprinted genes is regulated by epigenetic modifications, such as DNA methylation. Many imprinted genes are expressed in the placenta and affect nutrient transfer capacity of the placental exchange barrier. The H19 gene is abundantly expressed by the human placenta and is implicated in the pathogenesis of congenital growth disorders such as Beckwith-Wiedemann (BWS) and Silver-Russell (SRS) syndromes. The aim of this study was to investigate the role of DNA methylation on H19 transcription and imprinting, in the pathophysiology of fetal growth restriction (FGR). Thirty one and 17 placentas from FGR-complicated and normal pregnancies were collected, respectively. We studied gene transcription, genotyping and methylation analysis of the AluI H19 on exon 5 polymorphism. Placental expression levels of H19 were significantly increased in the FGR group. The H19 mRNA levels were similar between normal placental samples that demonstrated loss and maintenance of imprinting. Placentas from growth-restricted pregnancies had lower methylation levels compared to normals, in the H19 promoter region. We have demonstrated an increased H19 transcription in the FGR group of placentas. The hypomethylation of the H19 promoters is compatible with the aberrant expression. The association of these two findings is reported for the first time in placental tissues, however, its significance remains unknown. Whether the results of this study represent an adaptation of the placenta to hypoperfusion, or they are part of FGR pathophysiology has to be further investigated.

A randomized comparison between intravaginal misoprostol and prostaglandin E2 for labor induction.

OBJECTIVE: The aim of this randomized study was to compare the effectiveness, safety, and side effects of 6 h vaginal misoprostol versus vaginal prostaglandin E(2) (PGE(2)) for labor induction. STUDY DESIGN: Fifty microgram of misoprostol was given intravaginally in the misoprostol group (204 women), and 3 mg PGE(2) was given intravaginally in the PGE(2) group (211 women). In both groups, the dose was repeated every 6 h for a maximum of three doses, until active labor was achieved. Artificial rupture of membranes and oxytocin infusion was used during labor in both groups where it was indicated. RESULTS: The mean interval from the institution of labor induction to delivery was 11.3 +/- 8.6 h for the misoprostol group, and 15.7 +/- 9.3 h for PGE(2 )group (P < 0.05). In the misoprostol group, oxytocin was used less frequently, but there was a higher prevalence of tachysystole. No statistically significant differences were observed between the two groups as regard abnormal patterns of fetal heart rate, the mode of delivery, and the need for neonatal intervention. CONCLUSION: In conclusion, the intravaginal administration of 50 mug misoprostol at 6 h interval (maximum three doses) is comparable in safety, but more effective for induction of labor than 3 mg intravaginal PGE(2).