Cerclage in complete placenta previa preventing preterm labor: A rare case report.

Placenta previa often leads to antepartum hemorrhage, which warrants the patient for emergency room admission. The bleeding occurs mainly due to cervical dilation, which could be caused by cervical incompetence. Cervical cerclage has been considered as the primary treatment for cervical incompetence. However, evidence is lacking for its application in placenta previa. Here, we present a case of a 30-year-old pregnant woman diagnosed with complete placenta previa where a good obstetrical outcome could be achieved. The patient had antepartum hemorrhage during the 21st week of gestational age due to cervical dilation in a complete placenta previa case. An emergency cerclage using McDonald's technique was then performed, which prolonged the pregnancy to the 34th week of gestation. The patient had cesarean section and delivered a healthy baby girl weighing 2190 g. The mother and the baby had an uneventful recovery and were discharged after 2 days of hospitalization.

Pilot Study on the Effect of a Single Topical Application of Trichloroacetic Acid 85% on Normal Cervical Tissue.

Background: Early detection and treatment of cervical intraepithelial neoplasia (CIN) through a "see and treat" approach is a pillar of cervical cancer prevention programs in developing countries such as Indonesia. One of the major challenges faced is the limited N2O or CO2 gas supply for cryotherapy. Thus, an alternative therapeutic method such as trichloroacetic acid (TCA) topical application is needed as an alternative solution. The effectiveness of this therapy will depend on its destructive effect on eliminating the whole lesion in CIN. Objective: To estimate the extent of damage in the normal cervical tissue after a single topical application of 85% TCA solution. Design and Methods: This research was an intervention study carried out by applying ±5 ml of 85% TCA solution into the cervix of 40 patients scheduled for total hysterectomy for indications other than cervical pathology 24 h before surgery. The extent of tissue destruction was determined microscopically using histopathological specimens. The study protocol is registered at www.clinicaltrial.gov (ID NCT04911075). Results: In the final analysis, 39 subjects were included. The necrotic area was detected at the superficial layer, accompanied by the full epithelial erosion thickness. In addition, there were also fibrotic areas resembling burned tissue in the stroma. The mean depth of destruction was 1.16 ± 0.01 mm in the anterior lip and 1.01 ± 0.06 mm in the posterior lip. There was no significant depth difference between the anterior and posterior lips (p ≥0.05). Moreover, the 85% TCA topical application was tolerable, as represented by the fact that the vast majority (82.1%) of participants experienced pain with a visual analog scale score of <4. Conclusion: Single dose of TCA 85% in topical solution was able to destroy the normal cervical tissue with a deeper mean depth than the mean depth of CIN III in squamous epithelium.

Comparison of Magnetic Resonance Imaging and Ultrasonography in Tumor Size: Evaluation of Equality in Advanced Cervical Cancer Patients.

Background: Cervical cancer is the fourth most common cancer among women worldwide. In Indonesia, cervical cancer is the second most frequent disease related to cancer. Based on staging system criteria, clinical findings are the main criteria to determine cervical cancer stage. In the revised version of the Federation of Gynecology and Obstetrics staging system criteria for cervical cancer, radiological examination for pretreatment evaluation in gynecological malignancies has been used in routine modalities. Magnetic resonance imaging (MRI) and ultrasonography (USG) are commonly used in the presurgery determination of tumor size and the follow-up of cervical cancer patients. Tumor size determines cancer stage which influences the treatment and the survival. The equality of diagnostic accuracy was compared for MRI and ultrasound in this study for tumor size evaluation of cervical cancer patients. Methods: This was a prospective study including 195 patients with cervical cancer Stage IIIB in Dr. Cipto Mangunkusumo Hospital from 2016 to 2018. The tumor sizes and stages of cervical cancer were assessed on MRI and ultrasound. This study evaluated diagnostic accuracy between MRI and US. The sensitivity and specificity were compared by using McNemar test. Results: The result of the study showed that from 195 patients, 76 patients fulfilled the study inclusion criteria. There is a significant difference in assessing tumor size in cervical cancer patients between ultrasound and MRI (mean, 1.72 cm; P < 0.0001). US had 82% sensitivity, 88% specificity, and 82% diagnostic accuracy (P = 0.003, McNemar test). Conclusion: Ultrasound examination showed a comparable accuracy to MRI for assessing tumor size in cervical cancer. US is an affordable and feasible diagnostic staging tool with accuracy comparable to MRI.

Early Gestational Age Placenta Accreta Case Report: Can We Avoid Missed Diagnosis?

BACKGROUND Placenta accreta is an abnormal invasive placenta that can be life-threatening because of the risk of hemorrhage. Its incidence has increased due to high cesarean delivery rates. Early gestational age placenta accreta is difficult to diagnose and misdiagnosis can lead to inappropriate treatment. CASE REPORT Patient 1, a 34-year-old woman (para 2 abortus 1) with 2 previous cesarean deliveries, was referred to our department for vaginal bleeding and abdominal pain. She received 2 curettages for blighted ovum; then, ultrasound examination found uterus perforation and fluid in the Douglas cavity. Exploratory laparotomy confirmed uterine perforation, and a hysterectomy was performed. Histopathological examination revealed placenta accreta. Patient 2, a 35-year-old woman (para 3) with 3 previous cesarean deliveries, was treated at a previous hospital for vaginal bleeding and stomach enlargement. She received serial chemotherapy for gestational trophoblastic neoplasia. Ultrasound examination showed a nonhomogeneous opacity in the lower uterine corpus with color score 4. Total abdominal hysterectomy was performed, and histopathological examination revealed placenta accreta. Patient 3, a 32-year-old woman (para 2) with 2 previous cesarean deliveries, had irregular vaginal bleeding suspected as gestational trophoblastic neoplasia due to ultrasound examination and positive beta-human chorionic gonadotropin. Ultrasound and MRI examination showed enlargement with nonhomogeneous opacity, color score 4, and bridging vessels. Due to our previous experience, we suspected it was a placenta accreta and performed a hysterectomy. The histopathology result indicated placenta accreta. CONCLUSIONS The key point in diagnosing placenta accreta properly is to evaluate the morphometric changes based on the structure using imaging like ultrasound. Collection and analysis of these data enables precise diagnosis in early gestational age placenta accreta.

Peritoneal tuberculosis mimicking advanced ovarian cancer case report: Laparoscopy as diagnostic modality.

INTRODUCTION AND IMPORTANCE: Peritoneal Tuberculosis is one of extrapulmonary tuberculosis that occurs in 1-2% of patients, its incidence is higher in developing countries. It is very difficult to diagnosed and can mimic advanced ovarian cases. Making an accurate diagnosis is vital, laparoscopy is a great modality for this purpose. CASE PRESENTATION: A 36 years-old woman got referred with abdominal distention and weight loss from an internist and digestive surgeon. The abdominal computed tomography said thickening of the stomach wall with ascites. Ultrasound concluded the uterus, ovary, and endometrium within normal. The CA 125 levels elevated to 1200 U/mL and the complete blood count was normal. We were making diagnosis of peritoneal tuberculosis, peritoneal carcinomatosis, and advanced ovarian cancer. We did the diagnostic laparoscopic and taking a biopsy sample, ascites with peritoneal carcinomatosis and omental cake were found, the peritoneal cavity was covered by miliary nodules. Histopathology results concluded peritoneal tuberculosis without malignancy signs. The patient was treated with tuberculosis drugs. The follow-up evaluations show significant clinical improvement. CLINICAL DISCUSSION: When facing patients with massive ascites and elevated CA 125 without any ovary enlargement, a gynecologist should think that it may be a peritoneal TB case with peritoneal carcinomatosis and advance ovarian cancer possibility as differential diagnosis especially in developing countries. An exact diagnosis can be made using laparoscopy and histopathology examination. CONCLUSION: Laparoscopy is the best modality to differentiate between peritoneal tuberculosis, peritoneal carcinomatosis, and advance ovarian cancer. The benefits are direct visualization and could take a biopsy for histology examination.

IN-SILICO dynamic analysis of Sulawesi propolis as anti-endometriosis drug: Interaction study with TNF alpha receptor, NF-kB, estrogen receptor, progesterone receptor and prostaglandin receptor.

INTRODUCTION: Endometriosis is a disease that impacts around 10% of all women in reproductive age, with pelvic pain and infertility as its main clinical features. Current medical treatment targeting lowering estrogen activity has not shown sufficient result due its side effects and reproductive function suppression. Propolis has been widely studied, showing anti inflammation and pro-apoptosis property, that could potentially be used in the treatment of endometriosis. This study investigates the interaction between Sulawesi Propolis' active components and receptors and protein related to endometriosis pathogenesis. METHODS: Active components of Sulawesi Propolis were initially identified with their targeted protein receptors. Lipinski rules were used to screen potential components. The ligands and proteins were tested using Autodock program to predict the most active compound and possible binding sites between propolis and some target proteins associated with inflammatory and apoptotic activity in endometriosis models. Receptor modelling is then performed using Swiss-Model. RESULTS: These active components of Sulawesi Propolis showed a strong binding potential towards TNF- α, NF-kb, Estrogen-α, Estrogen-ß, progesterone B, PGE2 EP2 and EP3 subtype respectively: Sanggenon C, Sanggenon H, Epicryptoacetalide, Chrysin-7-O-ß-D-glucopyranodside, Irilone, Polydatin and Epicryptoacetalide. Compared to its negative ligand, Sulawesi Propolis displayed a stronger binding capacity to TNF-α, Estrogen-α, and Progesterone B receptors. CONCLUSION: Sulawesi Propolis has the ability to interact with receptors related to reproductive function, apoptotic reactions and inflammatory processes, a significant factor associated with the pathogenesis of endometriosis.

Case report: Caesarean scar endometriosis - A rare entity.

INTRODUCTION AND IMPORTANCE: Caesarean scar endometriosis (CSE) is a rare form of endometriosis due to previous surgical scars from obstetrical and gynecological procedures. The incidence of CSE was 0.08% and quite difficult to diagnose. CASE PRESENTATION: A 37-year-old multiparous woman came with intermittent pain in her lower left abdominal region and lump with a bluish color and solid consistency on the left side of the caesarean scar. Ultrasounds findings show a solid mass, measured 45 × 40 × 39 mm with neovascularization color score: 4. In April 2021, we performed mass resection, intraoperatively we found solid mass with no adhesion and infiltration found. Histological examination results confirm external endometriosis from the mass and the fascia was free from endometriosis. The symptoms reported relief after the procedure. CLINICAL DISCUSSION: Scar endometriosis is largely related to previous abdominal surgery like caesarean section, the mass increase in size during menses and becomes symptomatic. CSE develop ranging 12 months to 21 years and could mimic other hernias or tumor, that's why careful and precise examination is needed. The imaging modality we use in this case was ultrasonography which is the best and most accessible, reliable and cost-effective to diagnose. We performed large surgical excision of the lesion with reconstruction of damaged tissue to prevent recurrence and conversion to malignancy. CONCLUSION: Caesarean scar endometriosis should be considered in women of reproductive age with lower abdominal pain and/or mass at the caesarean scar from previous delivery or following obstetric-gynecologic surgery.

Skin metastases originated from cervical cancer: A rare case report.

INTRODUCTION: Metastases in cervical cancer could be spread through direct local invasion, lymphatic dissemination, or hematogenous dissemination. The most common sites of distant metastases are lungs, bone, and liver. Skin metastases from cervical cancer are categorized as a rare occurrence of metastases. This rarity of the cases has led us to report it. CASE DESCRIPTION: A 66-year-old multiparous woman diagnosed with stage IIA cervical cancer seven years ago, then she came into our outpatient clinic complained about a brownish white color mass on the left side of the neck that keeps getting bigger over time came from a skin lesion. The lesion was first treated with topical steroid but there was no improvement. Biopsy was done and the result showed a carcinoma metastasis that led to adenosquamous carcinoma or cervical adenocarcinoma. The patient went through chemoradiation with biosensitizer paclitaxel 120 mg/m2 for six cycles, which began in August 2019 until October 2019. The treatment progress showed a promising result. We observed the patient during treatment until two months after finishing the treatment. At the last visit, the patient came to our outpatient clinic, the mass size decreased significantly, and the skin showed an excellent regeneration sign. CONCLUSION: The physicians should always consider the patient's history and pay more attention to skin lesions in patients with a history of cervical cancer. The physicians should also perform a thorough physical examination and biopsy to confirm the diagnosis.

Early stage epithelial ovarian cancer metastasis through peritoneal fluid circulation.

BACKGROUND: Although epithelial ovarian cancer (EOC) spreads through peritoneal circulation, all patients with clinical early-stage ovarian cancer (OC) benefit from routine surgical staging is still unclear. METHODS: This cross-sectional study used data from medical records of patients with clinical early-stage EOC who received complete surgical staging from 2006 to 2016 at our hospital. We excluded patients with non-epithelial OC or with stage IV disease. RESULTS: Among 50 patients with clinical early-stage EOC who underwent surgical staging, biopsies showed EOC cells in peritoneal fluid for 12 patients (24%), in peritoneal tissue for ten patients (20%), and omental tissue for eight patients (16%). Of those 50 patients, 40 patients had undergone peritoneal biopsies, and the other five patients also had omental biopsies. The results showed that only one (2.5%) from 40 patients with peritoneal biopsy and three (6.7%) from 45 patients with omental biopsy had no visible nodules. From cytology examination, 3 out of 26 patients (11.5%) showed positive cytology from peritoneal washing. CONCLUSIONS: Routine peritoneal biopsies do not seem advantageous for patients with clinical early-stage EOC as negative visible nodules with positive biopsy results were only 1 in 40 cases. However, further study with a larger cohort is needed to obtain more information on peritoneal fluid metastasis patterns.

Rapidly recurring ovarian fibrosarcoma after optimal debulking surgery in a 46-year-old woman.

Ovarian fibrosarcoma is an extremely rare tumour with no universally accepted guidelines for treatment. We present a 46-year-old nulliparous woman with ovarian fibrosarcoma who mainly presented with a painful abdominal enlargement. Optimal debulking surgery was performed, and a specimen of the tumour was examined. A frozen section examined during surgery revealed spindle cell morphology, raising the suspicion of ovarian fibrosarcoma, which was later confirmed by immunohistochemistry staining. Our patient refused to undergo chemotherapy and died 3 months after surgery due to tumour recurrence. Although no clear consensus exists for administering chemotherapy for fibrosarcoma, some published case reports have shown a lower chance of recurrence and better prognosis in patients who undergo chemotherapy compared with our patient.

Biocurcumin as Radiosensitiser for Cervical Cancer Study (BRACES): A Double-Blind Randomised Placebo-Controlled Trial.

Cervical cancer is a leading cause of death among women worldwide, particularly in Indonesia. The main treatment of advanced-stage cervical cancer is radiation; however, the outcomes do not meet the required expectations. [1,7-Bis(4-hydroxy-3-methoxyphenyl)-1,6-heptadiene-3,5dione] has been reported in several studies for its potency in cancer therapy. This study aims to investigate the clinical and molecular [(malondialdehyde (MDA) and NF-κB levels] effects, apoptotic index, and safety of Biocurcumin (BCM-95) as a radiosensitiser in cervical cancer. In this double-blind placebo randomised-controlled trial, we randomised 121 patients into 2 groups (BCM-95 or placebo). MDA and their NF-κB levels and apoptotic index were measured before and after administering 24 Gy of radiation. MDA was identified using Wills' method, whereas NF-κB was identified via ELISA. The apoptotic index was identified using TUNEL and DAPI staining. The clinical response was classified based on the RECIST. MDA levels before radiation were similar between both groups in per protocol and intention-to-treat (ITT) analyses (p = 0.53 and p = 0.16, respectively). After radiation, MDA levels increased in both groups with no significant differences in per protocol and ITT analyses (p = 0.52 and p = 0.18, respectively). NF-κB levels before radiation were similar between the two groups in per protocol and ITT analyses (p = 0.92 and p = 0.98, respectively). After radiation, the BCM-95 group showed an increase in the NF-κB levels compared with the placebo group in per protocol analysis but not in ITT analysis (p = 0.018 and p = 0.42, respectively). The BCM-95 group had a higher apoptotic index before radiation in per protocol analysis but not in ITT analysis (p = 0.01 and p = 0.61, respectively). After radiation, the apoptotic index remained higher in the BCM-95 group in per protocol analysis but not in ITT analysis (p = 0.04 and p = 0.91, respectively). There was no significant difference in complete response between the groups (per protocol, p = 0.61; ITT analysis, p = 0.90). Although BCM-95 can regulate ROS, NF-κB, and apoptosis in human cervical cancer, it is not significant. Therefore, BCM-95 does not improve clinical response to radiation treatment.

Recurrent endometrial stromal sarcoma in the abdominal wall following a total hysterectomy: A rare case report.

INTRODUCTION: High-grade endometrial stromal sarcoma (HG-ESS) is a rare pathological type of uterine sarcoma. Over 80 % of affected patients would experience recurrences within a few years of initial presentation. Such case is rare and therefore, we need to report the case including the management. Information on performing good surgical techniques is important. CASE PRESENTATION: A 55-year-old female patient was referred after having a total hysterectomy and bilateral salphingoophorectomy at a private hospital. Results of pathologic examination showed that the patient had HG-ESS. The patient subsequently received adjuvant chemotherapy. The regimens used were Carboplatin (AUC-6) and Paclitaxel (175 mg/m2). Within five months following the chemotherapy, she complained rapid abdominal enlargement, which was a clinically mobile palpable solid mass at the level of the navel. Imaging findings suggested recurrent endometrial stromal sarcoma in the abdominal wall. Wide excision and frozen section, which were continued with mesh insertion and abdominal wall reconstruction, were then performed. DISCUSSION: Recurrence develops in one-half to two-third of patients with HG-ESS. It has been reported that the sites of recurrence usually include multiple lung metastases, peritoneal metastases, and/or local recurrences. There is currently no standard therapy for patients with recurrence of the disease as HG-ESS is a rare clinical entity. Treatment has been defined based on experiences gained from retrospective case reports. CONCLUSION: Successful management of patients with recurrent abdominal wall HG-ESS requires interdisciplinary and interprofessional teamwork. Multi-centre prospective trials are required to develop a guideline of optimal treatment for the disease entity, particularly the recurrence.

Case report: Unpredictable nature of tubal cancer.

INTRODUCTION: Primary tubal cancer is very rare, most are diagnosed intra and post operatively. Histopathology is vital in determining the cancer origin. Here we present a case of fallopian tube cancer with clinical presentation mimicking endometrial origin. CASE DESCRIPTION: A 74-year old patient came with complaints of intermittent post-menopausal bleeding and pelvic pain. The patient had several investigations using Ultrasonography, Hysteroscopy-guided biopsy, and Magnetic Resonance Imaging. Pre-operative diagnosis was endometrial cancer based on histopathology of endometrial biopsy during hysteroscopy. Explorative laparotomy, total abdominal hysterectomy, bilateral salphingo-oophorectomy, pelvic and para-aortic lymph node dissection were then performed, and the tumor samples were sent to the histopathology laboratory. It was found that the post-operative diagnosis was in fact primary fallopian tube cancer stage IIB. CONCLUSION: For patients with gynecological malignancies, rare cases such as fallopian tube cancer should never be overlooked as a differential diagnosis.

Evidence-based case report: How to deal with unpredicted endometriosis nodule closed to ureter and rectum during laparoscopy.

INTRODUCTION: Endometriosis is characterized by the growth of endometrial-like tissue within and outside the pelvic cavity. Peritoneum nodules invaded more than 5 mm representing the commonest form of deep infiltrating endometriosis nodules might challenge inexperienced operator due to its location near ureter and the rectum. The aim is to provide important steps on how to deal with unexpected peritoneal endometrial nodules located closed to ureter and rectum. PRESENTATION OF CASE: A 43-year-old female underwent laparoscopic cystectomy after being diagnosed to have right endometriosis cyst. The researchers found multiple endometriosis nodules located closed to rectum and ureter after performing cystectomy. A search was conducted on PubMed® with the keywords of "Peritoneal endometriosis nodule" AND "rectovaginal endometriosis nodule" AND "Surgical ablation" OR "Surgical excision" AND "Laparoscopy" AND "Pelvic pain". Reference lists of relevant articles were searched for other possible relevant studies. After selecting the articles, the critical review was performed based on a standardized appraisal form for the treatment study. DISCUSSION: Three eligible studies were appraised to assess the surgery outcome (dyspareunia), based on ablation and excision criteria. The pain was decreased during 6 months of follow up, with no difference in both techniques. The minimal requirement to remove the posterior nodules is knowledge of pelvic retroperitoneal anatomy. CONCLUSION: In all endometriosis cases which require surgery will need to be performed by an experienced operator. If rectovaginal endometriosis nodule was unexpectedly found during intraoperative and recognition of rectum and ureter must be done, knowledge of retroperitoneal anatomy is required.

Pharmacokinetic Profile of Curcumin and Nanocurcumin in Plasma, Ovary, and Other Tissues.

BACKGROUND: Curcumin is a natural diphenolic compound that is currently being investigated for various cancers, including ovarian cancer. Clinical application of curcumin has been limited due to its low solubility and bioavailability and rapid metabolism and degradation at physiological pH. Particle size is one factor that can affect the absorption process, which thus increases compound solubility and transport across the membrane. This study was conducted to determine the effects of modifying the particle size of curcumin on its pharmacokinetic parameters in blood and other organs. METHODS: Female Sprague Dawley rats were administered a single oral dose of 500 mg/kg curcumin or nanocurcumin. Blood samples were collected at 10, 15, 30, 45, 75, and 120 min, and ovaries, livers, kidneys, and colons were collected at 180 min. The levels of curcumin in plasma and organs were determined using UPLC-MS/MS, and the pharmacokinetic parameters were evaluated. RESULTS: Curcumin levels were detectable and measurable in plasma and organs of rats that were administered curcumin or nanocurcumin. Overall, no statistically significant differences were found in pharmacokinetic parameters between curcumin and nanocurcumin groups in both plasma and organs, except for ovaries. The curcumin levels in plasma, liver, kidney, and colon in the curcumin group were higher than those in the nanocurcumin group. However, curcumin concentrations in ovaries in the nanocurcumin group were 3.6 times higher than those in the curcumin group. CONCLUSION: Particle size reduction of curcumin did not increase the concentration of curcumin in the plasma but increased its distribution in the ovaries.

Modified Cervicography and Visual Inspection With Acetic Acid as an Alternative Screening Method for Cervical Precancerous Lesions.

BACKGROUND: We compared the diagnostic accuracy between visual inspection with acetic acid (VIA) and modified cervicography as an alternative screening method for cervical precancerous lesions. METHODS: A diagnostic cross-sectional study was performed at the outpatient clinic at an Indonesian national referral hospital from February until April 2015. We collected samples from patients who sequentially underwent VIA examination, modified cervicography, and colposcopy. RESULTS: A total of 185 patients were included in this study. Modified cervicography showed positive results in 7.6% of patients, while 7.0% of patients had a VIA positive result. This is compared to 5.4% of patients showing abnormal colposcopy results. From those results, we obtained that sensitivity and specificity of VIA were 96.0% and 90.9%. Meanwhile, sensitivity and specificity of modified cervicography were 97.7% and 90.9%, respectively, compared to colposcopy as a gold standard. CONCLUSIONS: Modified cervicography and VIA are reliable tools for cervical cancer screening, with comparable sensitivity and specificity. Modified cervicography can be used as a supplementary tool to improve the documentation of VIA and as an alternative to VIA alone.

Cervical cancer prevention program in Jakarta, Indonesia: See and Treat model in developing country.

OBJECTIVE: The purpose of this study was to describe the implementation of single visit approach or See-visual inspection of the cervix with acetic acid (VIA)-and Treat-immediate cryotherapy in the VIA positive cases-model for the cervical cancer prevention in Jakarta, Indonesia. METHODS: An observational study in community setting for See and Treat program was conducted in Jakarta from 2007 until 2010. The program used a proactive and coordinative with VIA and cryotherapy (Proactive-VO) model with comprehensive approach that consists of five pillars 1) area preparation, 2) training, 3) awareness, 4) VIA and cryotherapy, and 5) referral. RESULTS: There were 2,216 people trained, consist of 641 general practitioners, 678 midwives, 610 public health cadres and 287 key people from the society. They were trained for five days followed by refreshing and evaluation program to ensure the quality of the test providers. In total, 22,989 women had been screened. The VIA test-positive rate was 4.21% (970/22,989). In this positive group, immediate cryotherapy was performed in 654 women (67.4%). CONCLUSION: See and Treat program was successfully implemented in Jakarta area. The Proactive-VO model is a promising way to screen and treat precancerous lesions in low resource setting.