Copy number variation sequencing for the products of conception: What is the optimal testing strategy.

BACKGROUND: Copy number variation sequencing (CNV-seq) is crucial in prenatal diagnosis, but its limitations in detecting polyploidy, maternal cell contamination (MCC), and uniparental disomy (UPD) restrict its application in the analysis of products of conception (POCs). This study aimed to investigate an optimal genetic testing strategy for POCs in the era of CNV-seq. METHODS: CNV-seq and quantitative fluorescent polymerase chain reaction (QF-PCR) were performed in all 4,211 spontaneous miscarriage cases. Different testing strategies were compared and the optimal testing strategies were proposed. RESULTS: Of the 4,211 cases, 2561 (60.82%) exhibited clinically significant chromosomal abnormalities. CNV-seq alone, without QF-PCR, might misdiagnose 311 (7.39%) cases, including 278 polyploidy, 13 UPD, and 20 MCC. In 20 MCC cases identified by QF-PCR, CNV-seq successfully pinpointed the cause of miscarriage in 13 cases. Furthermore, in cases where QF-PCR suggested polyploidy, CNV-seq improved the diagnostic accuracy in 54 (1.28%) hypo/hypertriploidy cases. After comparing four different strategies, the sequential approach (initiating with CNV-seq followed by QF-PCR if necessary) emerged as advantageous, reducing approximately 70% of the cost associated with QF-PCR while maintaining result accuracy. CONCLUSIONS: We propose an initial CNV-seq followed by QF-PCR if needed-an efficient and cost-effective strategy for the genetic analysis of POCs.

Estradiol and intrauterine device treatment for moderate and severe intrauterine adhesions after transcervical resection.

OBJECTIVE: To explore the effect of 4 mg/day, 6 mg/day, and 8 mg/day estradiol alone or in combination with an intrauterine device (IUD) in patients with moderate and severe intrauterine adhesion (IUA) after transcervical resection of adhesion (TCRA). METHODS: Patients with moderate or severe IUA who reived 4 mg/day, 6 mg/day, and 8 mg/day estradiol alone or in combination with an intrauterine device (IUD) after TCRA in Women's Hospital, Zhejiang University School of Medicine, from March 2014 to December 2014 were enrolled in this retrospective case-control study. In group A, 14 patients received estradiol 4 mg/day + IUD after the first operation; in group B, 29 patients (group B0) received estradiol 6 mg/day after the first operation, and 73 patients (group B1) received estradiol 6 mg/day + IUD; in group C, 14 patients received estradiol 8 mg/day + IUD after the first operation. Referring to ESGE's IUA diagnostic classification method, 72 patients had moderate adhesion, and 58 cases had severe adhesion. Outpatient follow-up was performed at 1 and 23 months and after 1 year. The postoperative menstrual improvement, uterine cavity recovery, drug side effects at two to three months, and pregnancy situation at one year were recorded. RESULTS: There were no significant differences in age, BMI, and previous intrauterine operation times between the 3 groups (all p > 0.05). Compared with Group A, more patients in group C had severe IUA (p = 0.008). In addition, there were no differences in menstrual recovery, uterine cavity recovery, and pregnancy in one year between the 3 groups (p > 0.05) and between groups B0 and B1 (p > 0.05). In group B1, 51 (69.86%) patients had IUD incarceration. CONCLUSION: This data suggests that 4 mg/d doses of estrogen may have the same effect in improving the menstrual condition, uterine cavity morphology, and reproductive ability compared to a higher dosage (6 mg/day estrogen and 8 mg/day). In addition, the placement of IUD in the uterine cavity during TCRA may cause IUD incarceration, and the treatment results for the prevention of IUA are not better than without IUD.

Comparison of D&C and hysteroscopy after UAE in the treatment of cesarean scar pregnancy: A case-control study.

ABSTRACT: Cesarean scar pregnancy (CSP) stands for the severe complication secondary to cesarean section, and its incidence shows an increasing trend recently. However, no consensus has been reached about the CSP treatment. This study aims to explore the necessity of hysteroscopy (H/S) after preventive uterine artery embolization (UAE).A case-control report. The childbearing CSP patients with a cesarean section history were evaluated by ultrasonography, with a gestational age of less than 10 weeks. Thirty-four patients receiving dilation and curettage (D&C) after UAE were enrolled into the D&C group, whereas 46 undergoing H/S and curettage after UAE were enrolled into the H/S group.Differences in success rate and decrease in the ß-hCG level in serum on the second day of surgery were not significantly different between D&C and H/S groups (P > .05). Also, differences in side effect rate (except for the anesthesia-related side effects), intraoperative blood loss amount, postoperative bleeding time, and total length of hospital stay were not significant between 2 groups (P > .05). Compared with D&C group, H/S group had decreased postoperative length of hospital stay (P < .05), increased hospitalization cost (P < .05), and significantly elevated time of CSP mass disappearance (P < .05). In addition, 8 (18.19%) patients in H/S group developed anesthesia-related side effects.This study reveals no obvious difference between UAE + D&C and UAE + H/S in terms of the clinical efficacy and safety, except for the time of CSP mass disappearance and anesthesia-related side effects. The hospitalization cost is more expensive for UAE + H/S, but the postoperative length of stay is shorter for UAE + H/S. UAE + H/S is associated with the risk of anesthesia-associated side effects.

Three-year observational study of immediate post-abortion insertion versus menstrual insertion of etonogestrel contraceptive implant.

OBJECTIVE: This study aimed to estimate the difference in vaginal bleeding pattern, discontinuation rate, and satisfaction between immediate after abortion and menstrual insertions of etonogestrel contraceptive implants. STUDY DESIGN: Between May 2013 and November 2015, 66 women were recruited in the abortion group who selected etonogestrel implants as their contraceptive immediately after induced abortion. 84 women who underwent the placement of the etonogestrel implant during their menstrual period were enrolled as the menstrual group. The two groups participated in 3-year follow-up outpatient visits at 1, 6, 12, 24, and 36 months after implantation. The vaginal bleeding pattern, discontinuation rate, satisfaction rate were recorded and compared. RESULTS: No woman had pregnancy over the study period of 3 years. The incidence of amenorrhea/infrequent bleeding did not differ between the two groups after 12, 24, and 36 months of implantation (53.0% vs. 58.4%, 47.8% vs. 51.6%, and 48.6% vs. 55.6%, respectively). In the abortion group, the incidences of frequent/prolonged bleeding were 15.1%, 32.6%, and 27.0% after 12, 24, and 36 months of implantation, respectively, while the other group showed 27.3%, 25.8%, and 20.4%, respectively. After 12 and 24 months, the continuation use rates were 69.7% and 56.1% in the abortion group and 73.8% and 64.2% in the menstrual group. The 12-month satisfaction rate between abortion group and menstrual group was 69.6% versus 72.6%. Statistical analyses show that there was no difference in vaginal bleeding pattern, discontinuation rate or satisfaction between the two groups. CONCLUSIONS: Immediately post-abortion may be also a favorable time to undergo etonogestrel implantation.

Mifepristone regulates Tregs function mediated by dendritic cells through suppressing the expression of TGF-ß.

BACKGROUND: Previous studies have demonstrated that mifepristone in the daily low-dose affects the function of endometrium. These researches also implied an alteration of endometrium immune balance, which might be involved in regulating endometrial function. However, the detailed mechanisms remain to be further explored. METHODS: In this study, the expressions of CD80, CD86, and ICAM-1 in dendritic cells (DCs), which were stimulated with different concentrations of mifepristone (20, 65, and 200 nM), were detected by FACS. After that, we further evaluated the expression of Forkhead box P3 (FOXP3) and IL-10 in Tregs, which co-cultured with mifepristone treated DCs. In mechanism, we compared the indoleamine 2,3-dioxygenase (IDO) and TGF-ß expression with enzyme-linked immunosorbent assay (ELISA). RESULTS: The results indicated that mifepristone promoted the expressions of CD80, CD86, and ICAM-1 in a dosage dependent manner. Reversely, FOXP3 and IL-10 expression levels in Tregs co-cultured with mifepristone-treated DCs were significantly decreased compared with those co-cultured with nontreated DC. Furthermore, a significant reduce in IDO and TGF-ß expression was observed in DCs treated with mifepristone. By using the IDO inhibitor (1-methyl tryptophan, 1-MT) or TGF-b supplement, we confirmed that TGF-ß, but not IDO could rescue the downregulation of FOXP3 and IL-10 in Tregs co-cultured with mifepristone treated DCs. All of these results suggest that mifepristone may regulate DC function by decreasing TGF-ß expression, which further results in the downregulations of FOXP3 and IL-10 in Tregs. CONCLUSION: Therefore, our research provides a theoretical basis for a potentially clinical application of mifepristone as a novel contraceptive.

Low-dose mifepristone increased angiogenesis in a manner involving AQP1.

PURPOSE: To investigate the molecular mechanisms governing aquaporin-1 (AQP1)-mediated, mifepristone-induced angiogenesis and improve the understanding of low-dose mifepristone serving as an anti-implantation contraceptive drug. METHODS: Human umbilical vein endothelial cells (HUVECs) were used to explore the effects of different concentrations of mifepristone (0, 65, and 200 nmol/L) on the activity of angiogenesis. Forty-five pregnant mice during the "window of implantation" were treated with different concentrations of mifepristone. HUVECs' proliferation was examined using a methyl thiazolyl tetrazolium (MTT) assay. The microvessel density (MVD) and the expression of AQP1 in endometrium were determined with immunohistochemical methods. RESULTS: The MVD and the expression of AQP1 were significantly higher than controls. Mifepristone at 200 nmol/L significantly affected HUVECs' proliferation during culture over 12 h, and pretreatment with AQP1-specific siRNA significantly inhibited the mifepristone-enhanced cell proliferation. CONCLUSIONS: Low-dose mifepristone increased angiogenesis in a manner involving AQP1. This affords a new insight into the molecular mechanism underpinning the angiogenic effects of low-dose mifepristone.

Serum androgen profiles in women with premature ovarian insufficiency: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis aims to investigate serum androgen profiles (testosterone, dehydroepiandrosterone sulfate, androstenedione, and sex hormone-binding globulin) in women with premature ovarian failure and to establish if there is evidence of diminished androgen levels in these women. METHODS: Various Internet sources of PubMed, Cochrane library, and Medline were searched systematically until February, 2018. Out of a pool of 2,461 studies, after applying the inclusion/exclusion criterion, 14, 8, 10, and 9 studies were chosen for testosterone, dehydroepiandrosterone sulfate, androstenedione, and sex hormone-binding globulin, respectively, for this meta-analysis. The effect measure was the standardized mean difference with 95% confidence interval (95% CI) in a random-effects model. RESULTS: The testosterone concentrations in premature ovarian insufficiency were compared with fertile controls: stamdard mean difference (IV, random, 95% CI) -0.73 [-0.99, -0.46], P value < 0.05. The dehydroepiandrosterone sulfate concentrations in premature ovarian insufficiency compared to fertile controls: standard mean difference (IV, random, 95% CI) -0.65 [-0.92, -0.37], P value < 0.05. Androstenedione in premature ovarian insufficiency were compared with fertile controls: standard mean difference (IV, random, 95% CI) -1.09 [-1.71, -0.48], P value < 0.05. Sex hormone-binding globulin levels did not show statistical significance. The dehydroepiandrosterone sulfate levels were reduced in premature ovarian insufficiency cases, but still showed a higher level than in postmenopausal women. CONCLUSIONS: Women with premature ovarian insufficiency are at risk for decreased concentrations of testosterone, dehydroepiandrosterone sulfate, and androstenedione. Dehydroepiandrosterone sulfate levels were more reduced in postmenopausal controls when compared with premature ovarian insufficiency cases.

Roles of Mifepristone on the Regulation of Cytotoxic Lymphocytes and Regulatory T Cells.

OBJECTIVE: To investigate the immunologic function of mifepristone, which acts as a contraceptive drug at the level of the decidua. SETTING: In our hospital, 60 women (less than 63 days of amenorrhea) volunteered to terminate their pregnancies by the uterine suction evacuation method. Immunohistochemically, the transcription factor forkhead box P3 and granzyme B staining were performed to identify regulatory T cells and cytotoxic lymphocytes (CLs) in all operational subjects. CD8 (cytotoxic T cells marker) and CD56 (natural killer cells marker) staining were further performed in order to characterize the CLs subpopulations. RESULT: A significantly increased number of CLs was found in the decidua treated with mifepristone. CONCLUSION: Mifepristone increases the expression of CLs in the decidua, and it provides new insights into the immunologic function of mifepristone as a drug used for pregnancy termination.

Management of persistent caesarean scar pregnancy after curettage treatment failure.

BACKGROUND: Caesarean scar pregnancy (CSP) is a late serious complication of caesarean section. The incidence of CSP has increased worldwide in recent years. Early diagnosis and prompt therapy are crucial to avoid catastrophic complications. There are various strategies for CSP treatment, but there is no consensus on the best management for CSP. Dilation and curettage (D&C) and hysteroscopy are common and effective treatments with their advantages and disadvantages. No in-depth study of the clinical effects of hysteroscopic management of CSP after D&C treatment failure has been conducted. The purpose of this study is to evaluate the effectiveness and safety of hysteroscopic removal of residual CSP tissue (persistent CSP) as a rescue after failed D&C management. METHODS: This is a retrospective clinical research study. Forty-five patients underwent operative hysteroscopy to remove the residual gestational tissue in the caesarean scar after failed D&C treatment. The clinical characteristics and outcomes of hysteroscopic surgeries of 45 CSP cases were investigated. All data analyses were conducted with SPSS 17.0. RESULTS: Forty-three CSP cases after unsuccessful curettage treatment were successfully treated by operative hysteroscopy. The estimated intraoperative blood loss was 20.00 (10.00-500.00) mL, the hysteroscopic operating time was 20.00 (15.00-45.00) min, the decline of serum ß-hCG the day after surgery was 71.91 ± 14.05%, the total hospitalisation time was 7.87 ± 2.26 days, the medical cost was 13,682.71 ± 3553.77 China Yuan (CNY), the time of bleeding after surgery was 7.42 ± 2.48 days, and the time of serum ß-hCG resolution after surgery was 13.84 ± 9.83 days. Follow-up after discharge demonstrated that there were no severe complications for any patients. CONCLUSIONS: Hysteroscopy therapy could treat persistent CSP effectively and safely after curettage treatment failure. Therapy should be individualised, and the risks and cost of the hysteroscopy procedure and anaesthesia must be considered and fully discussed with the patients before surgery.

Research on the expression of integrin ß3 and leukaemia inhibitory factor in the decidua of women with cesarean scar pregnancy.

BACKGROUND: Cesarean scar pregnancy (CSP) is a late serious complication of cesarean section. There has been an increase in the incidence of CSP worldwide in recent years. It's a life-threatening condition because of the high risk of uncontrolled hemorrhage and uterine rupture. The mechanism of CSP is still unclear. The endometrial receptivity might be different in the cesarean scar between CSP and normal pregnancies. Endometrial expression of integrin ß3 and LIF positively correlates with endometrial receptivity and embryo implantation. The purpose of the study is to explore the mechanism of CSP. METHODS: The EnVision two-step immunohistochemical staining technique was used to detect the expression of integrin ß3 and LIF in the decidua of women with CSP (20 cases) and normal pregnancies (20 cases). The distribution and staining intensity of integrin ß3 and LIF in the two groups were observed. Observation of the staining were done using microscope within five randomly selected high-power fields (HPF, 10 × 40). All data analyses were conducted with SPSS 17.0 and the statistical significance was set at P <0.05. RESULTS: The decidua in the different parts of both two groups that stained with the anti-integrin ß3 and anti-LIF antibody: most of the integrin ß3 and LIF positive cells were located in glandular epithelium. The expression intensity of integrin ß3 in the cesarean scar in CSP group was significant higher than the uterine cavity in CSP group and the cesarean scar in normal pregnancy group. It's similar with the uterine cavity in normal pregnancy group. The expression intensity of LIF in the cesarean scar in CSP group was significant higher than the uterine cavity in CSP group and the cesarean scar in normal pregnancy group. It's significant lower than the uterine cavity in normal pregnancy group. CONCLUSIONS: The decidual integrin ß3 and LIF might play an important role in the mechanism of CSP. The increase expression of integrin ß3 and LIF in the cesarean scar decidua might be associated with embryo implantation in cesarean scar. The occurrence of CSP might be related to the changes of endometrial receptivity in local cesarean scar.

Two cervical preparation regimens prior to surgical abortion at 10-14 weeks of gestation: A randomized clinical trial.

BACKGROUND: The aim of the study was to determine whether same-day cervical preparation with an osmotic dilator and misoprostol was as effective and safe as overnight cervical preparation for surgical abortions at 10-14 weeks. METHODS: Seventy women seeking surgical abortion at 10-14 weeks were allocated to receive one osmotic dilator 16-17 h or 6-7 h prior to an abortion. All women received misoprostol 400 µg orally 2 h before the abortion. RESULTS: The abortion time of the same-day group was 7.42 ± 1.73 min, and that of the overnight group was 8.00 ± 2.19 min (p = 0.23). The blood loss volume of the same-day group was 20.6 ± 10.6 mL, and that of the overnight group was 16.3 ± 7.0 mL (p = 0.55). The degree of cervical dilation for the same-day group was inferior to the overnight group (p = 0.02). CONCLUSIONS: Same-day cervical preparation with misoprostol and an osmotic dilator shortens the hospitalization days, suggesting same-day cervical preparation is safe, effective, and feasible for surgical abortion at 10-14 weeks of gestation.

LncRNA-MEG3 inhibits cell proliferation of endometrial carcinoma by repressing Notch signaling.

BACKGROUND: The long non-coding RNA MEG3 has shown functional role as a tumor suppressor in many cancer types, excluding endometrial carcinoma (EC). Thus, this study tried to reveal the MEG3 dysregulation in EC samples and potential functional mechanism due to its regulation on Notch signaling pathway. METHODS: The expression profiles of MEG3 and two Notch signaling molecules, Notch1 and Hes1, were detected in both EC tissues and cell lines through real time PCR and western blot analysis. Lentiviral vector carrying whole MEG3 transcript or shRNA targeting MEG3 (shMEG3) was transfected for MEG3 dysfunction studies, and cell proliferation was analyzed through MTT and colony-formation assays. Xenograft models were also established by subcutaneous implantation and tumor growth was compared under MEG3 dysregulation. RESULTS: Significant downregulation of MEG3 was observed in EC samples compared to control, while the protein levels of Notch1 and Hes1 were both upregulated. Cell proliferation was obviously inhibited by MEG3 overexpression, while opposite improved result was obtained in MEG3 knockout cells. Interestingly, MEG3-induced changes could be reversed by Notch1 regulators. Moreover, MEG3 overexpressing tumors showed strongly repressed growth in vivo, along with Notch signaling inhibition. CONCLUSION: Downregulated MEG3 exhibited an anti-proliferative role in EC by repressing Notch signaling pathway.

Endometrial adenocarcinoma in spontaneous abortion: two cases and review of the literature.

OBJECTIVES: To report two extremely rare cases of endometrial adenocarcinoma established during the first trimester. CASE PRESENTATION: A 40-year-old (gravida 0, para 0) and 33-year-old (gravida 4, para 0) woman, were diagnosed with a well-differentiated adenocarcinoma after a dilatation and curettage (D&C) for spontaneous abortions at 8 and 9 gestational weeks, respectively. CONCLUSIONS: Thirty-six cases of pregnancy-associated endometrial cancer and 20 cases of first trimester pregnancy concurrent with endometrial carcinoma have been reported as present cases in the literature. Interestingly, 15 including our two cases were detected for spontaneous abortions in first-trimester suggesting a causal correlation between endometrial adenocarcinoma and spontaneous abortions. Repeated D&C and progesterone administration may be appropriate for patients who wish to preserve fertility.

Curettage or operative hysteroscopy in the treatment of cesarean scar pregnancy.

OBJECTIVES: To compare the clinical effects of dilatation and curettage (D&C) regimen and operative hysteroscopy coupled with curettage regimen in the treatment of cesarean scar pregnancy (CSP) following preventive uterine artery embolization (UAE). MATERIALS AND METHODS: Thirty-three women were treated with D&C after UAE (group A) and 33 women were treated with operative hysteroscopy coupled with curettage after UAE (group B). The clinical outcomes of the two groups were compared. RESULTS: There was no significant difference between the two groups with respect to the success rate, the intraoperative blood loss, the hysterectomy rate, the hospitalization time, the decline of serum ß-hCG after surgery, the time of serum ß-hCG resolution, the time of vaginal bleeding after surgery, the time to CSP mass disappearance, and the subsequent intrauterine pregnancies. The hospitalization cost in group B was higher than group A. CONCLUSIONS: Both D&C and operative hysteroscopy coupled with curettage were successful in terminating a CSP. Hysteroscopy coupled with curettage regimen did not have significant advantages and good prognosis in dealing with the gestational sac type of CSP following preventive UAE compared with D&C regimen. Treatment should be individualized and several conditions must be considered.

Pregnancy luteoma followed with massive ascites and elevated CA125 after ovulation induction therapy: a case report and review of literatures.

OBJECTIVES: To report a rare case of ovarian tumor with an unusual presentation; an ovarian pregnancy luteoma with massive ascites and elevated CA125 after ovulation induction therapy. CASE PRESENTATION: A 26-year-old pregnant woman complained lower abdominal distension. Ultrasound imaging showed a solid tumor in the right adexna and massive ascites. The blood test showed elevated serum level of CA125 and androgens. The patient underwent the right salpingo-oophorectomy, and then the results of blood test were normal and ascites disappeared. CONCLUSIONS: pregnancy luteoma followed with massive ascites and increased CA125 after ovulation induction therapy is a very rare case. It is important to provide appropriate medical/surgical intervention without disturbing the pregnancy iatrogenically or causing unnecessary maternal morbidity.

An immunohistochemical study of CD83- and CD1a-positive dendritic cells in the decidua of women with recurrent spontaneous abortion.

BACKGROUND: There are more and more women with recurrent spontaneous abortion (RSA). The mechanism of RSA is still unclear. Immunological factors have been postulated to play a role in the etiology of RSA. Dendritic cells (DCs) are the most potent antigen-presenting cells in the immune system, and the decidual DCs may take part in the occurrence of RSA. The difference in maturity status of decidual DCs among women with RSA and women with normal pregnancies is worthy of studying for its application to prevention and therapy. METHODS: The EnVision two-step immunohistochemical staining technique was used to detect the expression of CD83 and CD1a in the decidua of women with RSA (30 cases) and normal pregnancies (30 cases). The maturity status, distribution and quantity of DCs in the two groups were observed. Observation of the staining and cell counting were done using microscope within 30 randomly selected high-power fields (HPF, 40 × 10). All data analyses were conducted with SPSS 17.0 and the statistical significance was set at P <0.05. RESULTS: The decidua from the two groups contained DCs that stained with the anti-CD83 and anti-CD1a antibody. Most of the decidual CD83(+)DCs from two groups were located in the stroma. There were more CD83(+)DCs clustered with other DCs in the stroma from women with RSA than normal pregnancies. Most of the CD1a(+)DCs in the decidua from the two groups are located close to maternal glandular epithelium. No difference in the location of CD1a(+)DCs was found in the decidua between two groups. The number of decidual CD83(+)DCs was statistically significantly higher in RSA women than in normal early pregnant women (14.20 ± 13.34/30 HPF versus 4.77 ± 2.64/30 HPF; t = 3.800, P = 0.001). The number of CD1a(+)DCs in the decidua was statistically significantly lower in RSA women compared with normal early pregnant women (3.97 ± 3.75/30 HPF versus 7.60 ± 6.08/30 HPF; t = 2.786, P = 0.008). CONCLUSIONS: These findings suggest that the increase in the number of mature DCs and the decrease in the quantity of immature DCs in the decidua may be related to RSA. The maturation of decidual DCs may play an important role in the pathogenesis of RSA.

Mixed ovarian germ cell tumor composed of immature teratoma, yolk sac tumor and embryonal carcinoma.

We report the case of a 19-year-old woman experiencing lower abdominal distension and pain. Laboratory tests indicated elevated serum levels of Alpha-Fetoprotein (AFP) and human Chorionic Gonadotropin (hCG). A large mass was detected in the abdomen by physical examination and by transvaginal ultrasonography. Exploratory laparotomy was performed, and a smooth-surfaced, spherical, solid tumor was found on the left ovary, measuring 11.5 x 9.9 x 6.9 cm. Histological evaluation revealed that the tumor consisted of a combination of immature teratoma, Yolk Sac Tumor, and embryonal carcinoma; this is a very rare combination in mixed germ cell tumors.

Caesarean scar choriocarcinoma: a case report and review of the literature.

OBJECTIVE: To report the clinical characteristics, pathologic findings and treatments of a patient with a Caesarean scar choriocarcinoma. PATIENT HISTORY: A 22-year-old woman had a diagnosis of primary gestational choriocarcinoma in a uterine Caesarean scar misdiagnosed as a normal Caesarean scar pregnancy. The patient underwent selective uterine artery embolization coupled with methotrexate arterial injection, along with dilatation and curettage of the uterine Caesarean scar. Finally, she received eight courses of multiagent chemotherapy. The reproductive function of the patient was preserved. CONCLUSIONS: Primary gestational choriocarcinoma out of the uterine corpus is a rare disease. A Caesarean scar choriocarcinoma is an extremely unusual example of this entity because of its unique position. To the best of our knowledge, this is the first report of this phenomenon. Our experience and a literature review suggest that a clinical diagnosis of a primary gestational choriocarcinoma of the uterine Caesarean scar is difficult to make, and uterine artery embolization is beneficial to prevent massive bleeding before curettage.

Identifying risk factors for recurrent cesarean scar pregnancy: a case-control study.

OBJECTIVE: To investigate risk factors for recurrent cesarean scar pregnancies. DESIGN: Case-control study. SETTING: University hospital. PATIENT(S): Twenty-one women with recurrent cesarean scar pregnancies and 42 women with single cesarean scar pregnancies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Risk factors and historical factors that might be predisposing factors in recurrent cesarean scar pregnancy. RESULT(S): The risk factors of recurrent cesarean scar pregnancy were cesarean delivery history in rural community hospitals (odds ratio [OR] 4.75), thinner lower uterine segment (≤5 mm; OR 7.10), gestational sac bulging into the uterovesical fold (OR 6.25), history of irregular vaginal bleeding or lower abdominal pain in an earlier cesarean scar pregnancy (OR 3.52), and early termination (≤56 days) of the first cesarean scar pregnancy (OR 5.85). CONCLUSION(S): These findings provide evidence for the prevention of recurrent cesarean scar pregnancy and early diagnosis of the disease. Early recognition and diagnosis of this disease might be feasible because of the identifiable risk factors. Clinicians should be aware of the possible existence of recurrence. An accurate and prompt diagnosis is crucial to avoid catastrophic complications such as uterine rupture, massive vaginal bleeding and placenta previa/accreta, which might lead to hysterectomy.

Elevated expression levels of matrix metalloproteinase-9 in placental villi and tissue inhibitor of metalloproteinase-2 in decidua are associated with prolonged bleeding after mifepristone-misoprostol medical abortion.

OBJECTIVE: To determine whether the expression levels of matrix metalloproteinases 2 and 9 (MMP-2 and -9) and tissue inhibitors of metalloproteinases 1 and 2 (TIMP-1 and -2) in the villi and the decidua are associated with prolonged bleeding after medical abortion. DESIGN: Case-controlled study. SETTING: University hospital. PATIENT(S): Mifepristone-misoprostol medical abortion patients were divided into two groups (20 women each) based on the length of time (>14 or ≤14 days) of bleeding after the abortion. INTERVENTION(S): Discharged villi and deciduas were collected. MAIN OUTCOME MEASURE(S): The expression levels of MMP-2 and -9 and TIMP-1 and -2 in the villi and deciduas were assessed with semiquantitative immunohistochemistry. RESULT(S): The median semiquantitative immunohistochemistry staining index (SI) scores for MMP-9 expression in the villi were elevated in the bleeding group compared with the control group (median SI scores 0.31 and 0.03, respectively). TIMP-2 expression was elevated in the decidua in the bleeding group compared with the control group (median SI scores 1.00 and 0.20, respectively). No significant differences were observed between the two groups in the expression levels of MMP-2 in the villi or of MMP-2, MMP-9, or TIMP-1 or of the ratios of MMP-9/TIMP-1 or MMP-2/TIMP-2 in the decidua. CONCLUSION(S): Elevated expression levels of MMP-9 in the villi and of TIMP-2 in the decidua were associated with prolonged bleeding after medical abortion.