Prediction of bleeding in placenta accrete spectrum with lacunar surface: a novel aspect.

PURPOSE: Diagnosing the placenta accreta spectrum is crucial to prevent morbidities and mortalities among women with the suspicion of this pathology. We aim to evaluate novel ultrasonography markers for these patients in diagnosing and predicting prognosis. METHODS: This cross-sectional study was performed in a referral academic hospital. The population was composed of 51 pregnant women with a suspect of placenta accreta spectrum who had scheduled C-sections. Their primary information and past medical histories were documented. Then the ultrasonography markers, including the most bulging volume behind the bladder (area, perimeter, and volume), the Lacune (diameter, length, number, and surface of the largest lacuna obtained by multiplying the length by the width), the most considerable thickness of placenta on the cervix in patients with placenta previa, the most considerable thickness of the placenta behind the bladder, the Jellyfish sign, and sponge cervix were evaluated. Their comparison to the severity of the bleeding, the rate of the hysterectomy, and the following pathology of the placenta accreta spectrum were analyzed. RESULTS: The results showed that 17 (33.3%) of patients had severe bleeding (more than 2500 cc). The diameter, length, and surface of the largest lacunae limited to women with severe bleeding were 13.50 (5.5-21) mm, 20.50 (11-56) mm, 273.00 (60-1176) mm2, and they were 11.00 (5-24) mm, 16.25 (10-39) mm, and 176.25 (50-744) mm2 for women without severe bleeding (P value = 0.039, 0.027, 0.021). 13 (76.5%) women with severe bleeding had Jellyfish signs,16 (94.2%) had bulging on the cervix, and 10(58.8%) had a sponge cervix (P value = 0.046, 0.036, 0.006). Also, 34 (66.66%) patients needed hysterectomy. The diameter, length, and surface of the largest lacunae limited to women with hysterectomy were 12.00 (5-24) mm, 18.00 (11-56) mm, 231.00 (60-1176) mm2, and they were 9.00 (5-18) mm, 15.00 (10-28) mm, and 136.00(50-504) mm2 for women without hysterectomy (P value = 0.012, 0.070, 0.021). 24(70.6%) women with hysterectomy had Jellyfish signs, 29 (85.3%) of them had bulging on the cervix, and 15 (44.1%) had sponge cervix (P value = 0.05, 0.036, 0.028). The cut-off associated with the Lacunar surface was 163.5 mm2. Its sensitivity was 80%, and its specificity was 48% (P value = 0.021). CONCLUSION: The presence of single large lacunae could be a suitable predictive factor for bleeding in the placenta accreta spectrum; Moreover, there are some other US criteria, including the presence of a sponge cervix or the Jellyfish sign that are valuable predictive factors for negative outcomes for this spectrum, including hysterectomy.

Novel markers of Doppler ultrasonography in the placenta accreta spectrum to predict complications

Objective: Ultrasonography (US) is an acceptable tool to diagnose the placenta accreta spectrum (PAS) among pregnant women. However, the lack of a robust criteria for diagnosis and predicting the severity of the consequences facing pregnant women requires identification of novel biomarkers. Material and Methods: This prospective, cross-sectional study was performed on pregnant women with a probable diagnosis of PAS. Their demographic information, medical and surgical history, blood loss severity (severe ≥2500 mL) following hysterectomy, and the histopathology after the surgery were collected. In addition, the Doppler imaging of both uterine arteries, including the pulsatility index, resistance index, peak systolic velocity (PSV), the PSV of the posterior part of the bladder, cervix, the largest lacuna, and the posterior lacuna of the bladder were calculated by Doppler US. Data were analyzed to investigate the relationship between Doppler markers and the severity of PAS in terms of bleeding, hysterectomy, and histopathology. Results: Fifty-one women were enrolled with a mean age of 35.4±4.11 years and 17 (33.3%) had severe bleeding. There were significant differences between median (range) bladder PSV [57 (34-90) vs. 33 (20-64); p<0.001], cervix PSV [26 (0-63) vs. 18 (0-76); p=0.04] and left uterine artery [89 (81-135) vs. 68 (61-113); p=0.045] for women with and without severe bleeding, respectively. Thirty-four (66.66%) had hysterectomy. Comparison of bladder PSV, cervix PSV, and left uterine PSV for women with and without hysterectomy were 46 (20-90) vs. 39.5 (33-46) (p=0.005), 20 (0-76) vs. 20 (14-26) (p=0.013) and 68 (61-135) vs. 82 (63-101) (p=0.003), respectively. Conclusion: Bladder PSV, cervix PSV, and uterine PSV were significantly higher in pregnant women with PAS, and they may be useful diagnostic and prognostic markers.

The sequestosome 1 protein: therapeutic vulnerabilities in ovarian cancer

Ovarian cancer (OC) is the most deadly tumor that may develop in a woman's reproductive system. It is also one of the most common causes of death among those who have been diagnosed with cancer in women. An adapter protein known as sequestosome 1(SQSTM1) or p62 is primarily responsible for the transportation, degradation, and destruction of a wide variety of proteins. This adapter protein works in conjunction with the autophagy process as well as the ubiquitin proteasome degradation pathway. In addition, the ability of SQSTM1 to interact with multiple binding partners link SQSTM1 to various pathways in the context of antioxidant defense system and inflammation. In this review, we outline the processes underlying the control that SQSTM1 has on these pathways and how their dysregulation contributes to the development of OC. At the final, the therapeutic approaches based on SQSTM1 targeting have been discussed (AU)

The sequestosome 1 protein: therapeutic vulnerabilities in ovarian cancer.

Ovarian cancer (OC) is the most deadly tumor that may develop in a woman's reproductive system. It is also one of the most common causes of death among those who have been diagnosed with cancer in women. An adapter protein known as sequestosome 1(SQSTM1) or p62 is primarily responsible for the transportation, degradation, and destruction of a wide variety of proteins. This adapter protein works in conjunction with the autophagy process as well as the ubiquitin proteasome degradation pathway. In addition, the ability of SQSTM1 to interact with multiple binding partners link SQSTM1 to various pathways in the context of antioxidant defense system and inflammation. In this review, we outline the processes underlying the control that SQSTM1 has on these pathways and how their dysregulation contributes to the development of OC. At the final, the therapeutic approaches based on SQSTM1 targeting have been discussed.

The Role of Interferon (IFN)-γ in Extravillous Trophoblast Cell (EVT) Invasion and Preeclampsia Progression.

The involvement of the immune system in pregnancy is a controversial subject. The functions of T helper (Th) 1 and Th2 cells have been proposed, that Th1 cytokines promoting allograft rejection may impair pregnancy, whereas Th2-type cytokines suppressing Th1 responses improve allograft tolerance and hence embryonic survival. Maternal-fetal tolerance begins in the uterus; therefore, optimal adaptation to the fetus is the result of a complex interference. The invasion of extravillous trophoblast cells (EVTs) into the decidua and the inner third of the myometrium is essential for a healthy pregnancy. The mechanisms that influence trophoblast invasion are unknown; however, cytokines from uterine natural killer (uNK) cells, NKT cells, macrophages, and T cells appear to be involved. All these cells are major sources of interferon gamma (IFN-γ). Recent studies have shown that IFN-γ can inhibit EVT invasion via a mechanism dependent on an increase in EVT apoptosis and a decrease in matrix metalloproteinases (MMPs). Regarding controversies in this context, this study aimed to comprehensively review the role of IFN-γ and IFN-γ-producing cells in EVT invasion, successful pregnancy, and preeclampsia.

Comparison between the Efficacy of Nigella sativa-Honey and Clotrimazole on Vulvovaginal Candidiasis: A Randomized Clinical Trial.

Materials and Methods: This triple-blind, randomized controlled trial was conducted on eighty-four 18 to 49-year-old nonpregnant women from August 2019 to February 2020. The subjects were randomly divided into two groups after confirming the diagnosis of VVC infection through fungal culture. Clinical signs and symptoms and lab tests were recorded at baseline and 6-10 days after treatment. The treatment time for each group was seven nights. Results: There were no significant differences in clinical and laboratory evaluations between the two groups at the beginning of the study (P > 0.05). After treatment, secretion, redness, itching, and fungal culture improved in the two groups (P < 0.001), while pruritus (p = 0.013) and secretion (p = 0.025) in the control group significantly improved. In this trial, no patients showed drug-specific side effects. Conclusion: The results of this study show that the N. sativa-honey significantly improves the symptoms of VVC; thus, the application of N. sativa-honey can be considered as a complementary therapy in the treatment of VVC. This trial is registered with IRCT20190711044176N1.

Uterine torsion as an elusive obstetrical emergency in pregnancy: is there an association between gravid uterus torsion and Ehlers-Danlos syndrome?: a case report.

BACKGROUND: Timely diagnosis of uterine torsion can lead to acceptable maternal and fetal outcomes. This article presents the case of a 42-year-old pregnant woman, diagnosed with a rare 270° uterine torsion, in whom proper management led to good maternal outcomes but, unfortunately, severe prematurity and metabolic acidosis led to neonatal death. Moreover, the mother was clinically suspected for Ehlers-Danlos syndrome. CASE PRESENTATION: In December 2020, a 42-year-old pregnant Iranian woman, Gravid 3 para2 live2, at 30 weeks of gestation presented to the obstetric emergency department of Vali-Asr Hospital (Birjand, Iran) suffering from acute severe generalized abdominal pain, nausea, vomiting, and dizziness while she was hemodynamically unstable. After resuscitation, owing to persistent fetal bradycardia on fetal heart rate monitoring, she underwent an emergency cesarean section. Infra-umbilical midline skin incision was made, and when the abdominal cavity was opened, owing to abnormal appearance of the uterus, we further investigated the abdominopelvic cavity. Surprisingly, the uterus was dextrorotated by 270°. After uterine detorsion through a Kerr incision, a nonvigorous male baby was born with severe metabolic acidosis that led to his death soon after birth. Interestingly, we could find no predisposing factors such as pelvic abnormalities during surgery. Nevertheless, as her postoperative detailed physical examination revealed skin hyperextensibility, joint laxity, pelvic organ prolapse, and trivial exophthalmos, connective tissue disorders, mainly Ehlers-Danlos syndrome, were suspected. Unfortunately, for significant financial, cultural, and religious reasons, the patient refused to undergo further investigations. Additionally, despite severe congested uterus and subsequent uterine atony, timely diagnosis and anatomical correction of the gravid uterus before uterine incision prevented iatrogenic complications. The mother was discharged 2 days later without any postpartum complications. CONCLUSION: Although uterine torsion is an extremely rare condition during pregnancy, based on severe associated maternal and perinatal complications, it is important to take this diagnosis into consideration as an differential diagnosis. Moreover, connective tissue disorders seem to be a potential risk factor for uterine torsion, although further studies on this subject are required.

Idiopathic combined retinal vessels occlusion in a pregnant woman: a case report.

BACKGROUND: Ocular vascular occlusion is an extremely rare event, especially in the young population. This diagnosis is always associated with active systemic diseases in young adults and needs thrombophilia workup. Nevertheless, we present the case of a pregnant woman suffering from idiopathic combined central retinal vein and cilioretinal artery occlusion. CASE PRESENTATION: A 36-year-old pregnant Iranian woman at the 36th week of her second pregnancy complained of subacute unilateral painless decreased vision of her left eye. She had experienced a transient vision loss that lasted several minutes, but attacks gradually became more frequent and finally persistent over a several-day period. Finally combined central retinal vein and cilioretinal artery occlusion was established. Her visual acuity improved to 4/10 in a month without any ocular intervention except for a short duration of prophylactic dose enoxaparin, and the acuity reached 8/10 without any complications in the third month follow-up visit. At 1 year follow-up, the visual acuity had not changed and no macular edema was seen. CONCLUSIONS: Ocular vascular occlusion is extremely rare among young adults, and even rarer among pregnant women. According to this, any suspected retinal vascular event in this population should raise suspicion for underlying diseases such as hypertension, diabetes, autoimmune diseases, migraine, preeclampsia syndrome, and thrombophilia. However, as seen in this presented case, idiopathic ocular vascular occlusion events can occur also.

An unusual clinical manifestation of coronavirus disease 2019 in a woman with twin pregnancy: a case report.

BACKGROUND: Although coronavirus disease 2019 affects mainly the respiratory system, as time passes and our understanding of the disease improves, many nonrespiratory clinical manifestations such as thromboembolic events have been shown to occur with or without respiratory tract involvement. CASE PRESENTATION: We present the case of a 21-year-old gravid 3, live 1, abortion 1 Iranian woman pregnant with twins in her early first trimester. Her initial chief complaint was headache that gradually increased in intensity. Eventually, cerebral vein thrombosis was confirmed. Although the patient first manifested with neurological involvement, she developed upper respiratory symptoms soon after, and then nasopharyngeal polymerase chain reaction test returned positive. CONCLUSION: Any neurological complaints in pregnant women during the current coronavirus disease 2019 pandemic should raise suspicion for the presence of significant cerebral thrombotic or ischemic events, even if the patient has no complaint of respiratory tract involvement and/or when an initial nasopharyngeal polymerase chain reaction test is negative.

A giant early second-trimester placental chorioangioma associated with isolated proteinuria and histopathologically confirmed placental insufficiency, a novel association: A case report.

We present a case of giant chorioangioma at 18 weeks of gestation leading to fetal hypertrophic cardiomyopathy without other evidences of fetal volume overload and late-onset isolated proteinuria. Oligohydramnios developed at term and placental insufficiency was confirmed on histopathological examination and a nonanemic nonthrombocytopenic normal weight healthy baby was delivered.

Could Maternal Vitamin D Concentration Affect Cervical Length in Mid-Pregnancy? A Report From an Iranian Tertiary Center.

Objective: This descriptive-analytic cross-sectional study aimed to figure out whether maternal serum vitamin D concentration correlates with cervical length measurement in mid-gestation or not. Materials and methods: During Jun-Jan 2021, 213 pregnant women at 18-22 weeks of gestation were investigated. First, demographic features were obtained then, maternal serum vitamin D concentration was measured by enzyme-linked immunoassay and cervical length was measured via transvaginal sonography according to fetal maternal foundation guideline and appropriate statistical test was used to analyze the correlation between maternal vitamin D level and cervical length in mid-pregnancy. Results: It was shown that 29.6% and 25.4% of participants had vitamin D deficiency and insufficiency, respectively. Spearman's test found no significant correlation between maternal vitamin D level and cervical length in mid-pregnancy. Moreover, cervical length and maternal vitamin D level had no association with maternal BMI. Conclusion: Although maternal vitamin D level and its sufficiency status was not associated with cervical length in mid-pregnancy, as a trend toward decreased maternal serum vitamin D level by advancing gestational age was observed. It may be concluded that it is prolonged vitamin D deficiency during gestation that may lead to cervical length shortening and subsequent preterm delivery later in gestation.

Partial molar pregnancy with a normal live fetus and umbilical cord abnormalities: A novel association with long-term follow-up: A case report.

A euploid fetus in a partial molar pregnancy can develop umbilical cord abnormalities as pregnancy goes on. So, careful examination of the umbilical cord can determine fetuses at risk for ominous adverse effects.

Measuring fetal thymus size: a new method for diabetes screening in pregnancy.

Objective: To investigate the correlation between fetal thymus size and diabetes in pregnancy.Method: Fetal thymus size was assessed in 160 pregnant women with gestational age of 19-39 weeks. They included 80 diabetic (investigation group) and 80 nondiabetic (control group) women. Fetal thymus size was measured by thymic-thoracic ratio. We did this with dividing the thymus' anteroposterior diameter by anteroposterior of mediastinum.Results: Thymic-thoracic ratio was significantly smaller in fetuses of diabetic mothers compared to the nondiabetic group (p = .001). It remained significant after subgrouping diabetic mothers into overt diabetes, insulin-dependent gestational diabetes, and noninsulin-dependent gestational diabetes.Conclusion: Although thymus size was smaller in fetuses of diabetic pregnant women compared to nondiabetic pregnant women, it seems that thymic-thoracic ratio can be a predictor of diabetes and its other related adverse effects during pregnancy.

A rare presentation of pheochromocytoma in pregnancy: a case report.

BACKGROUND: Early diagnosis of pheochromocytoma and its proper management can lessen its mortality and morbidity. This case report describes a 24-year-old pregnant woman with an unusual presentation of pheochromocytoma. CASE PRESENTATION: An Iranian 24-year-old primigravid woman from Kordistan province was referred to our center with left flank pain at 37 weeks of gestation. She had a history of gestational diabetes mellitus since the 12th week of gestation which was managed by insulin administration. She also had a history of pulsatile bi-temporal headache for 2 years prior to her referral to us. She underwent complete abdominal and pelvic ultrasound imaging for her flank pain. This examination revealed a heterogeneous mass of 119 × 87 × 79 mm above her left kidney, highly suspicious of being an adrenal-originating tumor. Subsequently, we consulted an endocrinologist. She underwent abdominopelvic magnetic resonance imaging and her 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid were assessed. Finally, the diagnosis of pheochromocytoma was confirmed. She underwent a cesarean section and adrenal mass excision at the 40th week of gestation. This timely diagnosis resulted in her proper management and good maternal and neonatal treatment outcomes. CONCLUSIONS: Our patient had pheochromocytoma during pregnancy. She had no complaints about hypertension before or during pregnancy until giving birth to her child; her only symptoms were a vague left flank pain, gestational diabetes, and headaches for the past 2 years. The unusual symptom of flank pain led to timely diagnosis and a good treatment outcome.