The effect of coexisting uterine myomas on clinico-pathological variables of endometrial carcinoma.

PURPOSE: To assess the prevalence of leiomyomas in patients with endometrial carcinoma (EC) and the association of their presence with clinico-pathological variables and with survival. MATERIALS AND METHODS: A retrospective chart review was conducted of all endometrial carcinoma (EC) patients diagnosed and treated in the present institution between 2002 and 2008. Selected clinical data were abstracted from medical records. Pathological data such as the presence of myomas (any size), tumor grade, depth of myometrial invasion presence of lymphovascular space involvement (LVSI), and the presence of metastases, are based on the original pathology report. RESULTS: Coexisting myomas were found in 74 (56.9%) of 130 EC patients diagnosed during the study period. No significant difference with regard to age, histological type, stage, grade, depth of myometrial invasion, LVSI, lymph node involvement, and presence of metastases (other than lymph node involvement) was found between patients without and with myomas. There was also no significant difference in survival of EC patients without and with coexistent myomas. CONCLUSION: The present data seem to indicate that the presence of myomas does not affect clinico-pathological variables of EC patients nor their survival.

Risk factors for rape re-victimisation: a retrospective analysis.

Sexual re-victimisation refers to a pattern in which the sexual assault victim has an increased risk of subsequent victimisation relative to an individual who was never victimised. The purpose of our study was to identify risks factors for a second rape, the severest form of sexual re-victimisation. All rape victims treated at the First Regional Israeli Center for Sexual Assault Victims between October 2000 and July 2010 were included in this retrospective analysis. We compared characteristics of 53 rape victims who were victimised twice to those of 1,939 rape victims who were victimised once. We identified several risk factors for a second rape, which can be used in prevention programmes. These are: psychiatric background, history of social services involvement, adulthood, non-virginity and minority ethnicity.

Effect of vaginal progesterone, administered to prevent preterm birth, on impedance to blood flow in fetal and uterine circulation.

OBJECTIVE: To evaluate the effect on the maternal and fetal circulation of progesterone administered to prevent preterm birth. METHODS: We used an observational cohort study design. The study group included 44 women at 18-32 weeks' gestation who presented with an episode of preterm labor, with or without history of delivery before 34 weeks' gestation, or an incidental finding of short cervix (≤ 25 mm). Doppler flow assessment of the umbilical artery, fetal middle cerebral artery and uterine arteries was performed before and 24 h after vaginal administration of progesterone. RESULTS: Seventeen (38.6%) women gave birth before term, but only nine (20.4%) did so before 34 weeks' gestation. Following progesterone treatment, there was a statistically significant decrease in the pulsatility index of the fetal middle cerebral artery (mean reduction, 18.2%; mean change in pulsatility index, 0.44 (95% CI, 0.25-0.63), P < 0.001), with no changes in the other vessels. Comparison of the women who gave birth before with those who delivered at term yielded no significant differences in Doppler flow parameters in any vessel examined, either before or after progesterone treatment. CONCLUSION: Treatment with vaginal progesterone is associated with a lower pulsatility index in the fetal middle cerebral artery, suggesting a vasodilatory effect on the fetal circulation.

Combining flow cytometry and gfp reporter gene for quantitative evaluation of Pectpbacterium carotovorum ssp. carotovorum in Ornithogalum dubium plantlets.

AIMS: Ornithogalum dubium is a natural host of the soft rot pathogen Pectobacterium carotovorum ssp. carotovorum (Pcc). The present study was aimed to develop a quantification system for Pcc expressing a gfp reporter gene, using fluorescent activated cell sorter (FACS) in planta. METHODS AND RESULTS: Several calibration steps were required to distinctly gate the GFP-labelled bacteria at FL1 mode and count the bacteria. To validate the bacterial counts obtained by FACS analysis, an internal standard of polystyrene green fluorescent microsphere beads was employed, resulting in high correlation with serial dilutions and plate counting. This allowed quantification of the bacteria, with no further need to culture, dilute or plate the cells. Micropropagation tools were developed to produce uniform plantlets of O. dubium, which were either inoculated with increasing concentrations of Pcc or elicited for resistance towards Pcc using methyl jasmonate. The rapid counting procedure allowed recovering, gating and counting the bacterial population in planta, separately from the plant cells background and from the microsphere beads. CONCLUSIONS: The FACS based quantification approach of Pcc was found accurate, reproducible and time saving, thus useful for counting bacteria in planta. SIGNIFICANCE AND IMPACT OF THE STUDY: The combination of time- and cost-saving approach for Pcc quantification with efficient screening tools during early stages of micropropagation may facilitate the preliminary process of selection for resistant cultivars.

Fasting does not precipitate onset of labour.

This retrospective observational study examined whether fasting (the 'Yom Kippur effect') precipitates labour. Birth rates of Yom Kippur (a fasting festival) were compared with those of other festivals that are observed (Tisha B'Av) and not observed (1st day of Passover) by fasting during a 4-year period. Compared with the mean birth rate, the number of births that occurred 1 day after Yom Kippur was increased (p = 0.023). A significant decrease in the number of births during Tisha B'Av (p = 0.044) and a significant increase in the number of births 2 days after Tisha B'Av (p = 0.009) was observed. Two days prior to the 1st day of Passover, a significant decrease in the number of births was also observed (p = 0.034). Contrary to previous reports, the present study does not confirm an association between a 1-day long fast and increased birth rate in the 24-h period after breaking of the fast.

Cox-2 immunohistochemical expression in epithelial ovarian carcinoma and platin sensitivity.

PURPOSE: The aim of the study was to assess whether COX-2 expression in epithelial ovarian carcinoma (EOC) tissue can distinguish between platin-sensitive and platin-resistant tumors. METHODS: Clinical and histological data were obtained from medical records of EOC patients diagnosed between the years 1995 and 2005. Patients in complete clinical remission for > 6 months after discontinuation of first-line chemotherapy were considered to be platin-sensitive. Survival of < or = 2 and > 5 years after diagnosis was considered as short- and long-term survival, respectively. Immunohistochemistry staining was performed on deparaffinized sections of tissue blocks obtained at first surgery. The intensity of staining and the percentage of stained cells was assessed by two pathologists blinded to clinical data and a scoring index was calculated. RESULTS: Among 79 patients a positive stain (> 10% of cells stained) was observed in 61 (77.2%). No statistically significant association between distribution of platin sensitivity and immunohistochemical COX-2 staining parameters was observed, although the rate of long-term survival was significantly higher among platin-sensitive then among platin-resistant/unresponsive patients. CONCLUSIONS: Immunohistochemically determined COX-2 expression in EOC is not associated with platin sensitivity and survival.

Sonographic characteristics of the uterine cavity following first-trimester uterine evacuation.

OBJECTIVE: To characterize the sonographic appearance of the uterine cavity after first-trimester uterine evacuation and to follow the evolution of these findings in an attempt to reduce the number of unnecessary surgical interventions following evacuation. METHODS: We studied retrospectively the sonographic characteristics of the uterine cavity in 599 women, 5-8 days after first-trimester uterine evacuation. The patients were grouped according to the sonographic appearance of the uterine cavity. Patients with abnormal sonographic patterns were followed weekly until sonographic resolution. RESULTS: Group 1 included 351 (58.6%) women with normal endometrium; Group 2 included 130 (21.7%) women with hypoechoic endometrial content only; Group 3 included 69 (11.5%) patients with mixed type (hypoechoic and hyperechoic) endometrial content; Group 4 included 49 (8.2%) patients with hyperechoic endometrial content only. The time needed until the uterine cavity was considered normal was significantly longer in Group 4 (median, 12 days) compared with Groups 3 and 2 (8 and 9 days, respectively, P < 0.0001). The duration of vaginal bleeding after the surgical procedure was longer in Group 4 (median, 10 days) compared with Groups 3, 2 and 1 (9, 7 and 5 days, respectively, P < 0.0001). Clinically, the patients were divided into two groups: asymptomatic (575 patients) and symptomatic (24 patients). The thickness of the abnormal endometrial content in the asymptomatic patients gradually decreased until normalization, around the time of menstruation. There was no such change in the symptomatic patients, who eventually needed surgical intervention. CONCLUSIONS: An abnormal intrauterine sonographic pattern 5-8 days following first-trimester uterine evacuation is common and usually resolves spontaneously around menses. Therefore, in asymptomatic patients, we recommend a conservative approach.

Platin sensitivity and long-term survival in Stage III epithelial ovarian cancer patients.

PURPOSE: The aim of the present study was to assess the effect of platin sensitivity on long-term survival of Stage III epithelial ovarian cancer (EOC) patients. METHODS: The records of all histologically confirmed Stage III EOC and PPC patients diagnosed during 1995-2006 were reviewed. A comparison of selected characteristics was made between long-term (> 5 years) and short-term (< 3 years) survivors. RESULTS: Among 58 Stage III patients, 20 had long-term and 18 short-term survival. The rate of platin sensitive patients in long-term survivors was significantly higher than in short-term survivors (95.0% vs 27.8%, p < 0.001). The sensitivity and specificity of platin sensitivity for long-term survival was 95% and 72.2%, respectively, and the positive and negative predictive value was 79.2% and 92.8%, respectively. No statistically significant difference between the groups was found with regard to other selected characteristics. CONCLUSION: The rate of platin sensitive patients was significantly higher among long-term survivors than among short-term survivors but the specificity and positive predictive value of platin sensitivity for long-term survival prediction were relatively low precluding its practical clinical use.

Favorable outcome following emergency second trimester cerclage.

BACKGROUND: To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes. METHODS: A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16-27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients. RESULTS: Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3+/-6.5 vs 9.3+/-4.8 weeks, p=0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6+/-4.6 vs 29.5+/-3.2 weeks, p=0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p=0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p=0.2). CONCLUSIONS: Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.

Intra-uterine fluid collection in postmenopuasal women with cervical stenosis.

OBJECTIVES: The aim of the study was to assess the clinical significance of intra-uterine fluid collection in postmenopausal women with cervical stenosis with and without vaginal bleeding. METHODS: A group of 82 consecutive postmenopausal women with cervical stenosis and sonographically confirmed intra-uterine fluid collection underwent D&C with or without hysteroscopy. Diagnostic hysteroscopy was performed in all patients with an endometrial thickness (ET) was greater than 8mm, or with irregular endometrium at any degree of ET. The patients were divided and evaluated prospectively into two groups according to the presence or absence of postmenopausal bleeding (PMB). Twenty-six women were with PMB and 56 women were asymptomatic. RESULTS: The groups were similar as far as endometrial thickness and histopathological results were concerned. Atrophic endometrium was found in 69 patients (84%), 23 in the PMB group (89%) and 46 in the other group (82%), proliferative endometrium in 7 (9%) and endometrial polyps were found in 35 patients (43%), 12 in the PMB group (46%) and 23 in the other group (41%). When ET was > or =8 mm, in 93% of the cases an endometrial polyp was found (25 out of 27). No case of endometrial cancer was found. A premalignant condition was diagnosed in one patient with an endometrial polyp in the PMB group. All patients with endometrial thickness of less than 3 mm in ultrasound had atrophic endometrium. The incidence of intrauterine pathology increased with the increasing thickness of endometrium as observed by ultrasound. CONCLUSIONS: The presence of intra-uterine fluid collection in postmenopausal patients with cervical stenosis seems to be a benign condition. Normal endometrium of less than 3mm observed by ultrasound in postmenopausal women without vaginal bleeding does not necessarily need further surgical investigation.

Rupture of the pregnant uterus.

Ninety-three incidents of uterine rupture are reviewed. There is a distinct difference in both the fetal and maternal outcome between the group with a previously scarred uterus and the group with no previous scarring. Rupture of the unscarred uterus is a more dramatic event. The most common etiologic factors appear to be oxytocin, cephalopelvic disproportion, grand multiparity, and abruptio placentae. Abruptio placentae was diagnosed in almost half the maternal deaths. When the uterine tear is longitudinal, the maternal and fetal prognosis is relatively poor. Fetal mortality is much higher in patients with an unscarred uterus. Hysterectomy was more commonly performed in this group. Rupture of a previously scarred uterus is usually incomplete and the tear is transverse. Maternal and fetal prognosis is much better and repair of the uterus with sterilization is more often feasible in this situation.

GnRH analogue-induced uterine shrinkage enabling a vaginal hysterectomy and repair in large leiomyomatous uteri.

Gonadotropin-releasing hormone (GnRH) analogue was used to reduce large leiomyomas in three young women who were scheduled to have an abdominal hysterectomy and vaginal plastic repair. Significant size decrease due to the hormonal treatment enabled safe vaginal hysterectomy and repair.

Outcome of continued pregnancies after first- and second-trimester cervical dilatation by laminaria tents.

In 21 pregnant women (seven in the first trimester and 14 in the second trimester), laminaria tents inserted for induction of elective abortion were removed after dilatation had been achieved, but upon the patient's request, the abortion was not carried out. Four patients again changed their minds and had uncomplicated induced abortion after reinsertion of the laminaria tents. Seventeen patients continued their pregnancies: Fourteen had term deliveries, two had premature deliveries, and one had a spontaneous abortion at 10 weeks' gestation, 2 weeks after laminaria removal. None of the patients suffered infectious morbidity, including three untreated patients with positive cervical cultures for chlamydia, who experienced normal pregnancies and deliveries.

Augmentation of bupivacaine analgesia in labor by epidural morphine.

The analgesic properties and motor effect of epidural 0.25% bupivacaine (8 mL) were compared with those of epidural morphine (2 mg in 10 mL saline) followed by 8 mL of 0.25% bupivacaine. The study was performed on two groups of parturients (30 in each group) in active labor. Pain relief in the morphine-bupivacaine group lasted for a mean of 131.1 minutes (SD +/- 49.8) as opposed to the plain bupivacaine group -57 minutes (SD +/- 15.28). Satisfaction from analgesia in the morphine-bupivacaine group was higher as well. Motor involvement was not seen in either group. Perineal pain relief in the postpartum period lasted for a mean of 16 hours and 40 minutes in the morphine-bupivacaine group. It was concluded that the concomitant use of epidural morphine augmented the analgesic effect of 0.25% bupivacaine without motor effect.

The effect of total abdominal hysterectomy on bladder function in asymptomatic women.

The effect of total abdominal hysterectomy as treatment for benign conditions on the postoperative incidence of urinary symptoms and abnormal urodynamic findings was evaluated in 16 premenopausal women who lacked urinary symptoms preoperatively. The urodynamic evaluation was performed preoperatively, at 4 weeks, and again at 4 months after surgery. No clinical symptoms of frequency, nocturia, urgency, or urge or stress incontinence were found postoperatively. There were no significant differences from the preoperative values for cystometry, uroflometry, and urethral pressure profiles. Urinary dysfunction should not be a consequence of an uncomplicated total abdominal hysterectomy for benign conditions in women who were previously free of urinary symptoms.

Epidural analgesia for planned vaginal delivery following previous cesarean section.

The effect of lumbar epidural on the course of labor, delivery, and outcome was studied in 115 parturients with a previous cesarean section who were given a trial of vaginal delivery. One hundred three women were multiparous and 12 were grandmultiparous. Uterine contractions and fetal heart rate (FHR) were monitored continuously in all patients. Epidural block was performed using 8 mL of 0.35% bupivacaine without adrenaline. Supplemental doses were administered through an indwelling catheter. At the beginning of the second stage, 10 mL of 0.25% bupivacaine was added in the sitting position. Forty-eight women delivered spontaneously and 54 had an assisted second stage. Thirteen women delivered by a repeat low segmental cesarean section; dehiscence was observed in only one woman. Fetal outcome was satisfactory and similar to that of the authors' general parturient population.

The effect of treatment on experimentally produced endometrial peritoneal implants.

Endometriosis was induced surgically by implanting pieces of endometrium in the uterine mesenteries of 50 rats. Their fertility was then assessed after various treatments. Ten rats with endometriosis were treated with microsurgical excision of implants, 10 with high-frequency diathermy, 10 with danazol, and 10 with intraperitoneal indomethacin. Ten more rats had implants that were left untreated. The results were compared with those of ten rats that had sham surgery with implantation of fat in the uterine mesenteries. Reproductive performance was better in control animals with sham surgery than in animals with endometrial implants. Maximum restoration of fertility was achieved with indomethacin. Microsurgery and danazol therapy both were effective in preventing residual endometriosis, but the animals tended to be less fertile after treatment. Adhesions were most pronounced after diathermy and least pronounced after microsurgery or indomethacin therapy. In rats treated with indomethacin, persistent endometriotic cysts were invariably smaller near the site of intraperitoneal injection: this suggests a local antiprostaglandin effect.

Congenital anomalies of the müllerian system.

Congenital anomalies of the müllerian system, the most common of which are uterine malformations, are associated with fertility problems. Multifactorial polygenic and familial factors are involved in their formation. The result may be deficient development (agenesis, rudimentary horn, unicornuate uterus), nonfusion (didelphys or bicornuate uterus), or defective canalization of the müllerian ducts (septate uterus). The principal diagnostic procedures include HSG, laparoscopy, hysteroscopy, and US. The clinical presentation varies from symptoms of obstruction of the menstrual flow in adolescence to hypomenorrhea and fertility problems in adult life. Repeated fetal loss, after excluding other reasons, is usually the indication for surgical intervention. Uterine septa should be resected hysteroscopically. A prophylactic cerclage has been suggested by various authors, including those of this work, in cases of symmetric uterine anomalies, especially bicornuate uteri, as a simple and effective treatment to be tried before embarking on major surgery such as metroplasty.

Mifepristone (RU486) alone or in combination with a prostaglandin analogue for termination of early pregnancy: a review.

The availability of a medical mode of termination of early pregnancy by the administration of RU486, an antiprogesterone alone, or in combination with one of the PG analogues significantly reduces the maternal morbidity and mortality associated with the classical surgical abortion. RU486 given alone in early pregnancy induces complete abortion in 60% to 85% of cases, and when combined with prostaglandin analogues, gemeprost or sulprostone, reaches a success rate of 95% to 99%. RU486 may also be of potential value in the medical treatment of ectopic pregnancy. Its use as a postcoital contraception is suggested, but further research is required to determine whether RU486 can be used on a once-a-month basis for contraception.

PIP: This review of trials of RU-486 with prostaglandin for termination of early pregnancy begins with a summary of experimental and conventional early abortion techniques, introduces RU-486 with explanations of its mechanism of action, pharmacology, effects on adrenocortical receptors, the hypothalamic axis, and endometrium and ends with a discussion of its use in ectopic pregnancy and post-coital contraception. RU-486 acts by stabilizing the progesterone receptor so it cannot signal its DNA site to effect hormone action. Its peak plasma level is achieved in 2 hours, with a half life of 20 hours. RU-486 has anti-glucocorticoid effects at high doses. It also inhibits gonadotropin secretion in a dose-dependent manner, blocking ovulation. The main use of RU=-486 is in early pregnancy termination, a procedure termed contragestion, a consequence of its anti-progesterone action on the endometrium. Given alone, it is effective only 60-73% of pregnant women. Supplemented with an injection of Sulprostone, or a vaginal suppository of Gemeprost, both prostaglandin analogs, RU-486 typically will induce abortion in 96% of women up to 7 weeks pregnant. The abortion interval depends of prostaglandin dose. About 1% of women fail to abort, about 2% are incomplete, and 1% require treatment for hemorrhage, in a French trial of 2115 women. RU-486 has been used to manage ectopic pregnancy in preliminary studies. It is also being investigated as a postcoital agent, and appears to be effective from midcycle through the premenstrual phase, a wider window than current medical methods.