New cases of accessory and cavitated uterine masses (ACUM): a significant cause of severe dysmenorrhea and recurrent pelvic pain in young women.

BACKGROUND: To raise awareness about the accessory and cavitated uterine masses (ACUM) with functional endometrium as a different entity from adult adenomyosis and to highlight the importance of a correct diagnosis, we studied four new cases of ACUM and 15 cases reported as juvenile cystic adenomyoma (JCA) by reviewing the literature from the last year. This entity is problematic because of a broad differential diagnosis, including rudimentary and cavitated uterine horns; and is generally underdiagnosed, being more frequent than previously thought. METHODS: We report four cases of young women who underwent surgery in our hospital from January to July 2011 after presenting with an ACUM. We also reviewed and tabulated the cases from literature beginning in 2010. Main outcome measures were diagnostic tools, surgical and histopathological findings and improvement of symptoms. RESULTS: The addition of the four cases reported here to the 15 published as JCA raises the total number of cases of ACUMs to 19, which is more than all of the cases reported prior to 2010. In our cases, it is interesting to highlight that one of them also had an adjacent accessory rudimentary tube and another had two ACUMs at the same location. All patients suffered from severe dysmenorrhea and pelvic pain and were young women. Suspicion, transvaginal ultrasound and magnetic resonance image were found to be the best diagnostic tools. Most of the cases were treated by laparoscopic tumorectomy. CONCLUSIONS: ACUMs are generally underdiagnosed and often reported as JCAs but they are not adenomyosis. Early surgical treatment involving the laparoscopic or laparotomic removal of the mass could prevent the usual prolonged suffering of these young women. In our opinion, this entity is a new variety of Müllerian anomaly.

Cervicovaginal agenesis: spontaneous gestation at term after previous reimplantation of the uterine corpus in a neovagina: Case Report.

We present an exceptional case of a patient with complete cervical atresia and total vaginal aplasia. After McIndoe vaginoplasty, cervicoitsmic resection with implantation and reimplantation of the uterine corpus in the neovagina, and conservative surgery for endometriosis, the patient had normal menstruations and became pregnant spontaneously. A Caesarean section was performed at week 36. This is the third published case report of a successful spontaneous pregnancy and Caesarean section at term in a patient with complete cervicovaginal aplasia, and the first published case study of a patient becoming pregnant after McIndoe vaginoplasty, cervicoistmic resection and utero-neovaginal anastomosis. Gestation developed successfully without cerclage. We recommend conservative surgery in patients with congenital cervical atresia. McIndoe vaginoplasty should be performed as soon as possible in adolescence if there is associated vaginal aplasia. Nevertheless, fibrotic stenosis can occur, even after several years and, therefore, additional operations and uterine reimplantation may be required.

Abdominal myomectomy: results of a simple operative technique.

OBJECTIVES: To report a simple and safe procedure of abdominal myomectomy and our results performing this technique. DESIGN: The operative technique comprises the incision on the most prominent part of the myoma, the use of a hooked clamp to hold the tumor, and a surgical knife to peel it, without removing the apparent excess of myometrium or serosa. SETTING: University Medical Centers and private practice. PATIENTS: Eighty patients, 9 of whom were operated between 10 and 26 weeks of pregnancy, 3 during cesarean section, and 22 others who had infertility. RESULTS: Myomectomy was performed successfully in all patients for whom it was scheduled. Eight of nine pregnant patients had successful deliveries at term. The cumulative 10-year reoccurrence and reoperation rates of life-table analysis were 38% and 18%, respectively. The cumulative conception rates were 100% for otherwise unexplained infertility at 2 years, and 63% and 79% at 5 years for all infertile and all patients attempting conception after myomectomy, respectively. An age > 30 years, infertility > 3 years, and multiple fibroids negatively affected these rates, whereas the use of an absorbable adhesion barrier (Interceed; Johnson & Johnson AB, Somerville, NJ) had a positive effect. CONCLUSIONS: This procedure is an appropriate alternative for most women who want to preserve or enhance fertility potential, and if necessary, for pregnant women.

Prolactin and its response to the luteinizing hormone-releasing hormone thyrotropin-releasing hormone test in patients with endometriosis before, during, and after treatment with danazol.

Basal levels of prolactin (PRL) were studied in 16 normal women and in 60 women with endometriosis, 37 of whom were infertile. In addition, the authors studied the response to an intravenous (IV) injection of luteinizing hormone-releasing hormone (LH-RH) (100 micrograms) plus thyrotropin-releasing hormone (TRH) (300 micrograms) in the 16 normal women and in 18 endometriosis patients, examining the basal PRL and thyrotropin, and at 15, 30, 45, 60, and 120 minutes after the IV bolus. After laparoscopy and/or conservative surgery, the patients were treated with danazol for 6 months and a second laparoscopy was performed. The LH-RH/TRH test was carried out in the third month of danazol treatment in 6 endometriosis patients and before the second laparoscopy in 11 patients. The results show that there was both an increase in the mean basal levels of PRL and in the percentage of cases of moderate hyperprolactinemia in endometriosis patients. There also was a greater rise in PRL with the LH-RH/TRH test in moderate and severe endometriosis. The PRL response was significantly greater in endometriosis than in normal women, and was not related to TSH response. Danazol treatment reduced significantly the PRL response. The PRL response before treatment was significantly higher in patients who after treatment showed persistent endometriosis at the second laparoscopy. This could suggest a lower effectiveness of danazol in patients with endometriosis and a PRL hyper-response to LH-RH/TRH.

Intraperitoneal and subcutaneous treatment of experimental endometriosis with recombinant human interferon-alpha-2b in a murine model.

OBJECTIVE: To determine the effect of human interferon (IFN)-alpha-2b on experimental endometriosis in rats. DESIGN: Experimental, controlled, double-blind randomized study. SETTING: Experimental surgery laboratory in a university department. ANIMAL(S): Ninety-six Wistar rats with endometriosis, induced by transplanting four endometrial fragments into the peritoneal cavity. INTERVENTION(S): One third of the animals served as controls (group A). The others were randomly divided into two groups and were given IFN-alpha-2b either as a single intraperitoneal dose (group B) or as three SC doses (on alternate days) (group C). MAIN OUTCOME MEASURE(S): Laparotomy was performed to measure the size of each implant at various times (days 0, 6, 12, 20, and 120 after treatment). RESULT(S): There were no differences among the groups in the size of the average implants before IFN was administered (17.3+/-6.7, 19.7+/-7.8, and 18.1+/-9.2 mm for groups A, B, and C, respectively). These values were significantly smaller after treatment in group B (14.9+/-8.0 mm) and group C (14.0+/-9.5 mm) than in the control group (17.6+/-7.5 mm) (P<.05). Intraperitoneal IFN produced an initial maximum decrease in the size of the implants (40% reduction on day 6), which diminished until day 20 (20%) and then was maintained on a plateau until day 120 (25%). By contrast, group C showed an initial minimal reduction (13% at day 6), which increased up to day 20 (19%), after which a plateau was reached (23% at day 120). Thus, the effects in both treatment groups were similar in the long term. CONCLUSION(S): Two short regimens of human IFN-alpha-2b reduced the size of experimental endometriosis in rats.

Experimentally induced endometriosis in rats: effect on fertility and the effects of pregnancy and lactation on the ectopic endometrial tissue.

OBJECTIVE: To investigate the repercussion of experimentally induced endometriosis on the fertility of Wistar rats and the effects of pregnancy and lactation on endometrial ectopic implants. DESIGN: Eight-five animals were used for the experiment. Experimental endometriosis was induced in 44 and the remaining 41 were sham-operated (control group). After evaluating the growth of the implants in a second laparotomy, all the animals were mated until finding sperm in vaginal smears. In third and fourth laparotomies during pregnancy and lactation, pregnancy rate was determined, and the implants were re-evaluated, being resected for histological study. Serum estradiol (E2) and progesterone (P) levels were also measured. RESULTS: The pregnancy rate in animals with endometriosis was 65.7% versus 100% in control group. No statistical differences in days of gestation and number of pups were found between the two groups. Ectopic implants underwent a significant regression during lactation period. Serum E2 and P levels and histological features sustained these findings. CONCLUSION: Experimentally induced endometriosis diminishes pregnancy rate in rats. It is not pregnancy, but the anestrus condition created by lactation that exerts a beneficial effect on experimentally induced endometriosis in rats.

Insulin, androgens, and obesity in women with and without polycystic ovary syndrome: a heterogeneous group of disorders.

OBJECTIVE: To analyze the correlations among insulin, androgens, body mass index (BMI), and other related metabolic anomalies in women with and without polycystic ovary syndrome (PCOS). DESIGN: Retrospective study of normal and obese women with and without PCOS. SETTING: Gynecologic endocrinology units of Elche, San Juan, and Alicante Hospitals and Hormone Laboratory at Alicante University Hospital ("Miguel Hernández" University). PATIENT(S): A total of 212 women were studied: 137 with PCOS and 75 without PCOS. INTERVENTION(S): BMI, gonadotropins, insulin, androgens (T, androstenedione, DHEAS), 17alpha-hydroxyprogesterone, sex hormone-binding globulin, and triglycerides were studied. Glycemia and insulin response to the tolerance test (GTT) with a 100-g oral glucose load were also assessed in 103 women. RESULT(S): A good correlation between insulin and BMI was found in normal and obese women without hormonal dysfunction and in patients with or without PCOS. Good correlations, although lower, between insulin and T, and BMI, insulin, and T with triglycerides were also found in patients with PCOS. These patients fell into clearly distinct categories: with or without insulin resistance and with or without obesity, but slim women with PCOS had insulin and metabolic variables similar to those without PCOS, and most obese women with PCOS were insulin-resistant and more hyperandrogenic and hypertriglyceridemic. CONCLUSION(S): Insulin, androgens, and BMI are related in women both with PCOS and without PCOS, especially in obese ones. Insulin and metabolic indices are similar in lean women with PCOS and those without PCOS, but obese women with PCOS are more insulin-resistant, hyperandrogenic, and hypertriglyceridemic. Three types of disorders can be distinguished: simple nonhyperandrogenic obesity, typical nonhyperinsulinemic PCOS, and insulin-resistant PCOS.

A comparative study on breech deliveries attended in 1992: hospital centers from Latin America versus Spain and Portugal.

OBJECTIVES: The first aim of this study was to compare the incidence and management of breech deliveries, as well as perinatal mortality rates, in centers from Latin America versus Spain and Portugal in Europe. A second aim of this study was to analyse the correlation between the rates of c-sections and perinatal mortality. METHODS: Data from 287 313 deliveries, 8,764 of which were singleton breech deliveries attended in 1992 in 30 centers from Latin America and 44 centers from Spain and Portugal, were provided by the doctors in charge of the obstetric services and analysed using a computer statistical package (R-sigma, Horus Hardware). RESULTS: The incidence of breech deliveries was lower in centers from Latin America than in Spain and Portugal, 2.6% vs. 3.7%, respectively, but the percentage of preterm breech deliveries was higher in the former (23% vs. 17%; P < 0.001). In the total number of deliveries, c-sections were performed more frequently in Latin America, but the perinatal mortality rates were triple those in Spain and Portugal. In breech presentations from both geographical areas nearly 70% of c-sections were performed. However, the perinatal mortality rates in breech presentations were more than twice those of the total number of deliveries in Latin America, and more than three times in Spain and Portugal. There was no correlation between percentage of c-sections and perinatal mortality rates in the different centers in Spain and Portugal, but this correlation was significantly negative in both all and breech deliveries from centers in Latin America. Breech deliveries were more frequently monitored and attended by a specialist in Spain and Portugal. CONCLUSIONS: Preterm deliveries, c-sections and perinatal mortality were more frequent, and the correlation between these two latter rates was significantly negative for both all and breech deliveries in Latin America. As long as basic health care is still an issue in certain countries, it seems that a high rate of c-sections could prevent or reduce perinatal mortality. Yet, in countries with better health care standards, there is probably no need to perform c-section in most breech presentations.

Breech presentation in Spain, 1992: a collaborative study.

OBJECTIVES: The goals of the present work were to study the incidence of breech deliveries in Spain, the causes for breech presentation and its management and the incidence of cesarean sections and its correlation with the perinatal mortality rates among different centers. STUDY DESIGN: Data from 102,038 deliveries, 3829 of which were singleton breech deliveries attended in 1992, were obtained from 40 hospital centers located in different autonomic communities of Spain and analyzed using a computer statistical package (R-sigma, Horus Hardware). RESULTS: The incidence of breech deliveries was 3.8%, although this proportion varied between different centers and regions. Up to 18% of the cases occurred in preterm. The most frequent causes were prematurity and uterine malformations. In its management, an increase in the tendency to perform elective cesarean section was noticed. The incidence of cesarean sections reached 14.9% of the total and 67.9% in breech deliveries. Perinatal mortality rate in breech deliveries was more than four times that of all deliveries, according to national standards, and more than three times according to international standards (47.8 versus 11.8 x 1000, and 24.7 versus 8 x 1000, respectively). The intrapartum and neonatal mortality in breech deliveries was 13 x 1000. No correlation between incidence of cesarean sections and perinatal mortality rates was found. Primiparity, deflexed head, macrosomia and prematurity were the most decisive parameters to indicate a cesarean section. Neither the external cephalic version nor the total breech extraction were common procedures. CONCLUSIONS: The incidence of breech deliveries is variable between different centers (1.7%-5.1%) and Spanish regions (3.3%-4.3%), with a mean of 3.8% in overall and 11.4% in preterm deliveries. There is a tendency to perform cesarean sections, especially in primiparae. There is no correlation between the percentage of cesarean sections in each center and the perinatal mortality rate. External cephalic version and total breech extraction were uncommon procedures.

Evaluation of variable decelerations of fetal heart rate with the deceleration index: influence of associated abnormal parameters and their relation to the state and evolution of the newborn.

The deceleration index of the Fetal heart rate (FHR) (Acién P. et al. (1979) J. Perinat Med 7, 7-18) was used to analyze 157 cardiotocographic registers that displayed variable deceleration during labor. We have related the deceleration index value to perinatal results and to other abnormal parameters of FHR. An increase in neonatal pathology was observed in the deceleration group compared to a group of 50 controls with normal FHR, when the deceleration index was greater than 150 and specially if it was greater than 200. The association of other abnormal parameters of FHR (especially absence of variability between or during decelerations, absence of transitory ascents, presence of tachycardia and, of less importance, absence of ascents at the beginning of deceleration or presence of overshoot acceleration following deceleration) yields a worse prognosis for the fetus than does an increased deceleration index alone. The deceleration index is a good method for evaluation of variable decelerations of FHR, and is well correlated to the condition of the newborn.

Individual and combined effects of triptoreline and gestrinone on experimental endometriosis in rats.

OBJECTIVES: To evaluate the effects of triptoreline, gestrinone, and both, on experimental endometriosis in rats. STUDY DESIGN: Experimental endometriosis was surgically induced in 225 Wistar rats. Of these, 202 rats showed at least one grown implant, 22 of which composed the control group, while 180 were treated with triptoreline, gestrinone, or both, for 28 days. The implants were evaluated again after 25 days. RESULTS: There were no changes in size in the control group. About 73% of the implants treated with triptoreline showed a high reduction (> 50%), vs. 51% with gestrinone (P < 0.0005) and 65% with both (P < 0.005). Triptoreline caused macroscopic resolution in 40% of the implants vs. 31% for gestrinone (not significant) and 26% for both substances (P < 0.05). In the triptoreline group, the mean size of the implants decreased by 65% between the 25th and 28th days, 58% between the 29th and the 35th, and 39% after the 36th day. This reduction was 51%, 36%, and 33%, respectively, in gestrinone group. CONCLUSIONS: Triptoreline was more effective than gestrinone, but perhaps not in the long run. Their association did not improve the results.

Hyperreactio luteinalis: intraoperative finding during a cesarean section in a twin pregnancy.

Bilateral ovarian enlargement can be found in the course of a cesarean section. It is necessary to keep in mind that hyperreactio luteinalis is a benign condition, because the appropriate management is conservative. We present an unexpected, intraoperatively diagnosed case of bilateral ovarian cystic-solid tumours (13 cm) in a twin pregnancy.

CA 125 levels in endometriosis patients before, during and after treatment with danazol or LHRH agonists.

The levels of CA 125 in the serum of 54 patients with endometriosis were measured before, during and after treatment with Danazol or LHRH analogues. Patients with minimal and mild endometriosis had mean pre-treatment values significantly higher than control subjects in the luteal phase of the cycle or postmenopausal women (p less than 0.05), but levels were within the overall control range. In contrast, 78.6% of patients with moderate or severe endometriosis had levels in excess of 30 mu/ml and the mean values for these groups were significantly elevated (p less than 0.005). Levels of CA 125 fell, to those found in normal controls, during treatment, but rose again following cessation of treatment. Six of 12 subjects whose follow-up values of CA 125 exceeded 30 U/ml had a proven recurrence of endometriosis, whilst only 2 of 31 patients with values less than 30 U/ml had laparoscopically proven recurrence.

Primary ovarian pregnancy with intrauterine device in situ.

A case of primary ovarian pregnancy associated with an intrauterine device in a multipara taking thyroglobulin is reported. The clinical signs and symptoms were identical to those of any ectopic pregnancy with tubal rupture and hemoperitoneum. The final diagnosis was based on the histopathological findings. The literature is reviewed and the association between IUD and ovarian pregnancy is discussed.

Benign intracardiac teratoma detected prenatally. Case report and review of the literature.

Primary cardiac tumors are rare and, until recently, were mostly incidental postmortem findings. Nowadays, due to the widespread use of prenatal ultrasound scans, we are able to diagnose them in utero. We present a case of an intracardiac teratoma diagnosed at 38 weeks, menstrual age. Previous scans had been normal. Labor was induced, and a female infant with an Apgar score of 9 and 4, at 1 and 5 min, was delivered. Her condition worsened rapidly. She died 16 h after birth. Necropsy was performed, and a cystic, mature teratoma of 4 cm was found in the interventricular septum, growing into the right ventricle. No other anomalies were found. This probably represents the first case of an intracardiac, benign teratoma diagnosed prenatally.

Perinatal morbidity and mortality in pregnancy hypertensive disorders: prognostic value of the clinical and laboratory findings.

In 521 pregnancies complicated by hypertensive disorders (PHD) and in 200 control cases, we studied the incidence of intrauterine growth retardation (IUGR), depression in the newborns, general morbidity of live newborns requiring admission and perinatal mortality. We also analyzed the relationship between these conditions and the type and severity of hypertension, gestational age, presence of symptoms of the classic EPH triad and of abnormal uric acid values, hemoconcentration, and low urinary estriol values. Perinatal mortality (especially antepartum) was significantly increased in severe pre-eclampsia, chronic hypertension and chronic hypertension with superimposed pregnancy-induced hypertension (PIH); in all the cases with PHD it was three times higher than that of the control group (59% versus 20% and five times higher than the global perinatal mortality of the 25,763 deliveries attended during the same period (12% General morbidity reached 44% in severe pre-eclampsia and 75% in antepartum eclampsia. But the preterminal deliveries were also more frequent in PHD, especially in severe pre-eclampsia-eclampsia. Nevertheless, the perinatal morbidity and mortality in general increased when proteinuria and edema plus proteinuria were associated with hypertension, and the incidence was significantly higher when proteinuria surpassed 100 mg/dl. Morbimortality also increased in the presence of hemoconcentration, hyperuricemia, and low estrioluria.

Single ectopic ureter opening into blind vagina, with renal dysplasia and associated utero-vaginal duplication.

A rare case of single ectopic ureter opening into a blind vagina with renal dysplasia and associated uterovaginal duplication is reported. The findings are interesting from the clinical diagnostic viewpoint and also contribute to our knowledge of the embryology of the female genitourinary system, especially concerning the origin of the vagina.

Advanced and unsuspected secondary abdominal pregnancy misdiagnosed before laparotomy.

A case of advanced secondary abdominal pregnancy is presented. It happened in a multiparous patient, a heroin addict and with a previous secondary amenorrhea. In spite of having been controlled through the whole pregnancy, the ectopic pregnancy was not diagnosed until a laparotomy was performed, several days after fetal death. After full extraction of the fetus and placenta, followed by left adnexectomy, the postoperatory evolution was normal. Hormonal and echographic studies and fetal monitorings are provided, and the diagnosis and treatment are discussed.

Aromatase expression in endometriotic tissues and cell cultures of patients with endometriosis.

Cytochrome P-450 aromatase is responsible for catalysing the conversion of androstendione into estrone, so its expression in endometriotic tissue could contribute to the development of endometriosis. The aims of this study were, on the one hand, to determine the presence of aromatase in eutopic and ectopic endometrium, healthy peritoneum, myometrium and leiomyomas from patients with (n = 61) and without endometriosis (n = 12) and, on the other hand, to determine the effect of peritoneal fluid (PF), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNFalpha) on aromatase activity from endometriotic stromal cells and subcutaneous adipocytes. After immunohistochemical analysis, aromatase expression was detected in the endometriotic tissue of 61% of patients, whereas the rest of the tissues, as well as those from disease-free women, were negative. Cell cultures were made to determine aromatase activity in endometriotic stromal cells and adipocytes. The addition of PF, TNFalpha and especially IL-6 (P < 0.05) stimulated the basal enzymatic activity observed in both cell types. Our findings confirm the presence of aromatase in endometriosis and probably the existence of a local estrogen production that may be stimulated by some factors such as cytokines present in the PF of these patients. Therefore, the use of aromatase inhibitors combined with immunomodulator agents could be a novel approach to be investigated in future clinical trials.