clinical and experimental obstetrics & gynecology · weight loss of 0.7 kg/month during the...

Vol. XL, no. 4, 2013 ISSN: 0390-6663

CLINICAL AND EXPERIMENTAL

OBSTETRICS & GYNECOLOGYan International Journal

Editors-in-ChiefM. Marchetti J.H. Check

Montréal (CND) Camden, NJ (USA)

Assistant EditorA. Sinopoli

Toronto (CND)

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brief reports, in the fields of Gynecology, Obstetrics, Fetal Medicine, Gynecological Endocrinology and related subjects. (Fertility

and Sterility, Menopause, Uro-gynecology, Ultrasound in Obstetrics and Gynecology, Sexually Transmitted Diseases, Reproductive

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Founding EditorA. Onnis

Montréal (CND)

ORIGINAL ARTICLES

Reproductive Biology SectionPrevention of first-trimester miscarriage with dextroamphetamine sulfate treatment in women with

recurrent miscarriage following embryo transfer - case report

J.H. Check, R. Chern, B. Katsoff - Camden, NJ, USATwo nulliparous women with recurrent miscarriages despite in vitro fertilization-embryo transfer successfully completed their

first trimester with treatment with sympathomimetic amines.

Secondary amenorrhea despite normal endometrial development with secretory changes and absence of

uterine synechiae – a second case of the endometrial compaction – apoptosis syndrome

J.H. Check, R. Cohen - Camden, NJ, USAAmenorrhea was found related to endometrial compaction and/or apoptosis despite adequate endometrial proliferation and normal

progesterone induced secretory changes.

Human spermatozoa antigens in unexplained infertility

L. Karakoc Sokmensuer, B. Demir, D. Zeybek, E. Asan, S. Gunalp - Istanbul, TURKEYThe identification and characterization of antigens present in sperm cells, crucial for the diagnosis and treatment of unexplained

infertility, are evaluated.

The practical role of anti-Müllerian hormone in assisted reproduction

C. Siristatidis, M. Trivella, C. Chrelias, N. Vrachnis, A. Drakeley, D. Kassanos - Athens, GREECEThe anti-Müllerian hormone has a pragmatic role in predicting the success of assisted fertilization.

General SectionRole of exclusive breastfeeding in energy balance and weight loss during the first six months postpartum

A. Antonakou, D. Papoutsis, I. Panou, A. Chiou, A.L. Matalas - Athens, GREECEExclusively breastfeeding women manage to lose weight as part of natural process of energy cost of lactation.

Association of serum levels of vascular endothelial growth factor and early ectopic pregnancy

M.O. Fernandes da Silva, J. Elito Jr., S. Daher, L. Camano, A. Fernandes Moron - São Paulo, BRAZILVascular endothelial growth factor is studied as a possible discriminating factor between ectopic pregnancy and miscarriage

from normal pregnancy.

Chronic pelvic pain: evaluation of the epidemiology, baseline demographics, and clinical variables via a

prospective and multidisciplinary approach

A.B. Hooker, B.R. van Moorst, E.P. van Haarst, N.A.M. van Ootegehem, D.K.E. van Dijken, M.H.B. Heres

- Amstelveen , THE NETHERLANDSAn integrated approach in cases of chronic pelvic pain is necessary to avoid unnecessary intervention and achieve a higher quality of life.

Comparison of the classic TVT and TVT-Secur

H.S.O. Abduljabbar, H.M.A. Al-Shamrany, S.F. Al-Basri, H.H. Abduljabar, D.A. Tawati, S.P. Owidhah -

Jeddah, KINGDOM OF SAUDI ARABIAThe effectiveness and safety of tension-free vaginal tape and classic tension vaginal tape are compared.

Contents Clinical and Experimental Obstetrics & Gynecology - Vol. XL, no. 4, 2013

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Contents 467

Expression of regulatory T and helper T cells in peripheral blood of patients with pregnancy-induced

hypertension

X. Cao, L.L. Wang, X. Luo - Shenyang City, CHINAAbnormal expression of regulatory T cells and helper T cells was found in patients affected by pregnancy-induced

hypertension.

Semi-automatic Sono T measurement of nuchal translucency

F. Bonilla-Musoles, F. Raga, F. Bonilla Jr., J.C. Castillo, N.G. Osborne, O. Caballero - Valencia, SPAINSemi-automatic nuchal traslucency measurements is reproducible and comparable to conventional 2D ultrasound technique,

even if further research is required.

mtDNA4977 deletion is not a common feature in patients with premature ovarian failure and primary

infertility

A. Bojarska-Junak, A. Semczuk, E. Grywalska, J. Roliński, L. Putowski - Lublin, POLANDmtDNA 4977 deletion is not a common finding in peripheral blood leukocytes of patients affected by premature ovarian failure

and primary infertility.

Unmet needs and knowledge of postpartum contraception in Italian women

C. Bastianelli, M. Farris, G. Benagiano, G. D’Andrea - Rome, ITALYThe knowledge of pregnant women on contraception during postpartum was analyzed.

Cerebral and renal abscess and retino-choroiditis secondary to candida albicans in preterm infants: eight

case retrospective study

G.H. Wang, C.L. Dai, Y.F. Liu, Y.M. Li - Changchun, CHINA

Preterm infants with extreme-low birth-weight are very often susceptible to fungal candida albicans infection.

New horizons in the non-invasive diagnosis of endometriosis

F. Patacchiola, A. D’Alfonso, A. Di Fonso, G. Di Febbo, S. Di Giovanni, A. Carta, G. Carta - L’Aquila,ITALYPeripheral biomarkers' clinical value is considered as non-invasive diagnosis of endometriosis.

The role of serum adiponectin levels in women with polycystic ovarian syndrome

H. Itoh, Y. Kawano, Y. Furukawa, H. Matsumoto, A. Yuge, H. Narahara - Yufu, JAPANThe possible link between adiposity and insulin resistance may be adiponectin, that can play an important role in the pathogenesis

of polycystic ovarian syndrome.

Does tension-free vaginal tape and tension-free vaginal tape-obturator affect urodynamics? Comparison

of the two techniques

F. Gungor Ugurlucan, H. Ayyildiz Erkan, C. Yasa, O. Yalcin - Istanbul, TURKEYTwo different operative techniques for stress urinary incontinence are compared.

Effect of short-term tibolone treatment on risk markers for cardiovascular disease in healthy

postmenopausal women: a randomized controlled study

A. Traianos, D. Vavilis, A. Makedos, A. Karkanaki, K. Ravanos, N. Prapas, B.C. Tarlatzis - Thessaloniki,GREECEShort-term tobolone treatment in healthy postmenopausal women exerts a mixed action, acting beneficially in some markers and

detrimentally in others.

Transvaginal removal of ectopic pregnancy tissue and repair of uterine defect for cesarean scar

pregnancy

Z. Wang, L. Shan, H. Xiong - Shenzhen, CHINATransvaginal removal of ectopic pregnancy tissue and repairing of a uterine defect is effective for cesarean scar pregnancy.

Threatened miscarriage in the first trimester and retrochorial hematomas: sonographic evaluation and

significance

V. Soldo, N. Cutura, M. Zamurovic - Belgrade, SERBIAThe localization of retrochorial hematomas is determinant for spontaneous miscarriages.

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Does carbon dioxide pneumoperitoneum altering pressure levels lead to ultrastructural damage of

fallopian tube and ovary?

K. Beyhan, O. Gogsen, C. Gulumser, M. Barıs, Z. Hulusi, K. Gulten, K. Esra - Ankara, TURKEYPneumoperitoneum may cause ischemia-reperfusion damage in ovarian cortex correlated with the amount of pressure.

Behaviour of lab parameters and neonatal weight loss in relation to neonatal breathing movements and

cord clamping time

U. Indraccolo, R. Santafata, P.L. Palazzetti, R. Di Iorio, S.R. Indraccolo - Rome, ITALYNeonatal weight loss is conditioned by breathing movements.

Role of psychological intervention in fetoscopic laser surgery of twin-to-twin transfusion syndrome

L.X. Li, Y. Gao, S.L. Xu - Hangzhou, CHINAPsychological support is essential for the mother before and during fetoscopic laser surgery.

Role of environmental organochlorinated pollutants in the development of endometriosis

M.G. Porpora, S. Resta, E. Fugetta, P. Storelli, F. Megiorni, L. Manganaro, E. De Felip - Rome, ITALYAn overview of epidemiological studies on the relationship between endometriosis and exposure to persistent organochlorinated

pollutants is provided.

Corticotropin-releasing hormone and progesterone plasma levels association with the onset and

progression of labor

F. Stamatelou, E. Deligeoroglou, N. Vrachnis, S. Iliodromiti, Z. Iliodromiti, S. Sifakis, G. Farmakides, G.

Creatsas - Athens, GREECEProgesterone and corticotropin-releasing hormone increase with labor progression and subsequently decrease in the immediate

period.

Operative hysteroscopy preserving virginity: a new technique

C. Yalcinkaya, H. Kalayci, E. Simsek, C.T. Iskender, H.A. Parlakgumus - Adana, TURKEYA new hysteroscopic operative technique that allows the preservation of virginity is presented.

Investigation on delivery analgesia effect of combined spinal epidural anesthesia plus Doula and safety of

mother and baby

Bi-Bo. Feng, Lei Wang, Jian-Jun Zhai - Beijing, CHINAThe delivery analgesia method of self-control and spinal epidural epidural anesthesia, plus Doula, has a rapid and continuos

effect throughout labor, without consequences on mother and fetus.

Balloon tamponade for prevention and treatment of vaginal hemorrhages in gynecology

G. Ghirardini, C. Alboni - Sassuolo, ITALYThe preliminary experience of balloon tamponade with a new device in emergency vaginal bleeding is reported.

Prevalence of women’s worries, anxiety, and depression during pregnancy in a public hospital setting in

Greece

K. Gourounti, F. Anagnostopoulos, K. Lykeridou, F. Griva, G. Vaslamatzis - Athens, GREECEAntenatal depressive symptoms are evaluated with the aim to avoid postpartum depression.

Preventive nursing of neonatal clavicular fracture in midwifery: a report of six cases and review of the

literature

Y. Xiang, D. Luo, P. Mao - Changsha, CHINADystocia and improper midwifery manner are the two major reasons which lead to newborn clavicular fractures.

The expression of glutathione peroxidase-1 and the anabolism of collagen regulation pathway

transforming growth factor-β1-connective tissue growth factor in women with uterine prolapse and the

clinic significance

B.S. Li, L. Hong, J. Min, D.B. Wu, M. Hu, W.J. Guo - Wuhan, CHINAThe hypothesis that the mechanism of pelvic organ prolapse may be the oxidation-antioxidation system disequilibrium is

provided.

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Female pseudohermaphroditism associated with maternal steroid cell tumor, not otherwise specified of the

ovary: a case report and literature review

K. Hasegawa, Y. Minami, H. Inuzuka, S. Oe, R. Kato, K. Tsukada, Y. Udagawa, M. Kuroda - Toyoake, JAPANA rare case of pseudohermaphroditism in a female newborn and maternal steroid cell tumor is reported.

Placenta accreta: conservative approach

G. Di Luigi, F. Patacchiola, L. Di Stefano, A. D’Alfonso, A. Carta, G. Carta - L’Aquila, ITALYA case of conservative approach with uterine artery embolization and multidose methotrexate for placenta previa accreta is

described.

Rectus abdominal muscle endometriosis in a patient with cesarian scar: case report

L. Şahin, O. Dinçel, B. Aydın Türk - Adiyaman, TURKEYA case of endometrioma of abdominal wall, treated with local excision, is described.

Uterine multiple leiomyomas complicated by extensive mucoid degeneration: case report

L. Yu, N. Yin, J. Guo - Chongqing, CHINADiagnosis, treatment, and follow-up of a rare case of multiple uterine leiomyomatosis with mucoid degeneration are discussed.

Detection of unruptured ovarian pregnancy subsequently successfully treated by conservative laparoscopic

surgery: a case report and review of the literature

H. Tsubamoto, Y. Wakimoto, R. Wada, R. Takeyama, Y. Ito, K. Harada - Hyogo, JAPANA case of coexistence of gestational sac and lutein cyst, conservatively treated by laparoscopy, is presented.

Reversible posterior leukoencephalopathy syndrome in pregnancy: a case report

F. Patacchiola, V. Franchi, G. Di Febbo, A. Carta, G. Carta - L’Aquila, ITALYIn the present case series the association of posterior reversible encephalopathy syndrome with toxemia in pregnancy is

established.

Ovarian torsion associated with cessation of hormonal treatment for polycystic ovarian syndrome: a case

report

M. Murakami, E. Takiguchi, S. Hayashi, Y. Nakagawa, T. Iwasa - Kagawa, JAPANA case of ovarian torsion after treatment for ovarian polycystic syndrome is reported.

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CASE REPORTS

Executive Board:

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PETER BOSZE, M.D. - P.O. Box 46 - Budapest 1301 (Hungary)

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Introduction

There is a wide variety of chronic disorders described

involving multiple physiological systems that are refrac-

tory to “standard” therapies, but respond quickly and

effectively to treatment with sympathomimetic amines [1,

2]. These disorders include marked relief of chronic

pelvic pain, whether it is of bladder origin as in intersti-

tial cystitis or chronic pelvic pain or dysmenorrhea as seen

in endometriosis [3-5].

Interstitial cystitis can be diagnosed prior to develop-

ment of inflammatory changes that can be detected by

cystoscopy by performing a potassium sensitivity test [6].

Installation of a potassium solution into the bladder in a

person without this disorder will not evoke pain but severe

burning pain ensues in a person with interstitial cystitis

because the bladder mucosa no longer prevents an effec-

tive barrier to inhibit the absorption of potassium into the

bladder wall [6].

One of the important functions of the sympathetic nervous

system is to diminish cellular permeability [2]. Thus it is the

authors’ belief that the etiology for the vast variety of pain

syndromes in different areas of the body, i.e., headaches,

backaches, fibromyalgia, gastrointestinal system, not to

mention the pelvis, and dramatic relief of these syndromes

by treating these disorders with dextroamphetamine sulfate,

is by correcting the cellular permeability defect and thus

inhibiting the absorption of chemical toxins into the tissues

which causes the pain [2, 5].

The possibility exists that increased cellular permeabil-

ity may allow the absorption of chemical toxins into the

endometrium which could impair implantation even fol-

lowing in vitro fertilization-embryo transfer (IVF-ET).

The authors describe two cases that had failed to suc-

cessfully conceive following several IVF-ET cycles that

were finally successful when sympathomimetic amine

therapy was added.

Case Report

Case 1The woman first presented to this reproductive endocrine

practice for infertility at age 40. She had a history of one previ-

ous pregnancy with a different male partner at age 25 but had a

miscarriage. She had been trying to conceive with her present

husband for 3.5 years. She had failed to conceive at another

infertility center after three cycles of follicle-maturing drugs and

intrauterine insemination (IUI) and two cycles of IVF-ET. Her

menstrual cycles were regular, her fallopian tubes were patent,

and her husband had a perfectly normal semen analysis.

With her first IVF-ET cycle at our institution, she had 25

oocytes retrieved. Twenty-two were metaphase II and 17 fertil-

ized. Three day three embryos [6, 9, 10] with very little frag-

mentation were transferred on day 3. Thirteen embryos were

frozen (nine at the 2 pronuclear stage and four multi-cell ones).

A pregnancy was achieved but she had a first-trimester sponta-

neous abortion related to a triploidy.

There were 15 oocytes retrieved on her second cycle and 14

were metaphase II. She fertilized 13 oocytes although six were

allowed to cleave to day 3, there was only one with six blas-

tomeres and the other two had four cells. She conceived and

again had a first-trimester miscarriage.

She next had a frozen ET. This resulted in a pregnancy and the

beta-human chorionic gonadotropin level doubled appropriately

to 1,303 mIU/ml, but three days later only reached 1,739Revised manuscript accepted for publication May 24, 2012

471Original Articles

Reproductive Biology Section

Prevention of first-trimester miscarriage with

dextroamphetamine sulfate treatment in women with recurrent

miscarriage following embryo transfer - case report

J.H. Check, R. Chern, B. Katsoff

The University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at CamdenCooper Hospital/University Medical Center, Department of Obstetrics and Gynecology

Division of Reproductive Endocrinology & Infertility, Camden, NJ (USA)

Summary

Purpose: To present a novel approach to prevent miscarriage by treatment with sympathomimetic amines. Materials and Methods:Two women undergoing in vitro fertilization-embryo transfer (IVF-ET) with a history of recurrent miscarriage even in IVF-ET cycles

were treated with dextroamphetamine sulfate prior to their next IVF-ET cycles. Results: Both women successfully completed their

first trimester. One woman delivered a live baby and one had neonatal death related to prematurity secondary to severe pre-eclamp-

sia. Conclusions: Sympathomimetic amines therapy may prove to be an effective therapy to prevent recurrent miscarriage especially

in women who have failed despite progesterone therapy, and where no other etiologic factors have been determined.

Key words: Embryo transfer; Sympathomimetic amines; Recurrent miscarriage; Dextroamphetamine sulfate.

Clin. Exp. Obst. & Gyn. - ISSN: 0390-6663

XXXIX, n. 2, 2012

J.H. Check, R. Chern, B. Katsoff472

mIU/ml. Ultrasound showed an anembryonic gestational sac.

She had transferred three embryos-one 8-cell and two 5-cell

embryos.

She then had her third IVF-ET cycle with our group at age

41.6 and conceived. However, she had another first-trimester

miscarriage. Chromosome analysis of the aborted fetus found a

normal male.

Following the miscarriage of a chromosomally normal fetus,

despite aggressive progesterone therapy, and the unavailability

of lymphocyte immunotherapy, the authors provided the option

of sympathomimetic amine therapy to accompany her next

frozen ET.

She was started on dextroamphetamine sulfate extended

release capsule daily and conceived again following her next

frozen ET. She successfully completed her second trimester.

Unfortunately she developed severe pre-eclampsia in her last

trimester and delivered preterm and the baby subsequently died.

She had continued the sympathomimetic amine therapy and

progesterone.

Case 2

A couple had ten years of unprotected intercourse and

no live babies. Once they sought the opinion of an infer-

tility specialist because of their difficulty in conceiving,

the problem was thought to be secondary to severe

oligoasthenozoospermia.

When they failed to conceive after 12 cycles of IUI,

they decided to do IVF-ET at another IVF-ET center. She

conceived three times and had first-trimester spontaneous

miscarriages each time. They could no longer afford IVF-

ET, so they opted for insemination with donor sperm. She

conceived three more times but also had three more first-

trimester losses.

The couple came to this infertility center to consider

another IVF-ET cycle with her husband’s sperm using

intracytoplasmic sperm injection (ICSI). However, they

especially consulted the authors for a possible new con-

sideration on how to prevent another miscarriage (i.e., so

far six pregnancies and six first-trimester miscarriages.

All the standard tests for recurrent miscarriage had been

performed, e.g., thyroid tests and tests for coagulation dis-

orders and infections. She was offered sympathomimetic

amine therapy.

She started dextroamphetamine sulfate extended release

capsules 15 mg daily. She proceeded with another IVF-ET

cycle. Despite taking 300 IU of follicle-stimulating

hormone (FSH) with 150 IU of luteinizing hormone (LH),

she did not respond very well with only five metaphase II

oocytes retrieved. Three fertilized but only two cleaved to

day 3. She conceived a singleton pregnancy following ET

and delivered a full-term healthy baby. She remained on

the dextroamphetamine sulfate throughout the pregnancy.

She was 36.8 years of age on the day of her oocyte

retrieval.

Discussion

One cannot state with certainty that these successful

pregnancies were the result of the treatment with dex-

troamphetamine sulfate. Nevertheless considering the

many pregnancy losses of these two women and the clear-

cut benefit of this therapy for various pain syndromes, it

seems probable that it could have prevented first-trimester

miscarriage. These case reports should hopefully stimu-

late controlled prospective studies to evaluate the poten-

tial of this novel therapy. Dextroamphetamine sulfate in

normal pharmacologic dosage is not considered to be a

human teratogen [7-9].

Case 1 was age 42 and was nulliparous so that she was

at greater risk for pre-eclampsia. However, women with

this sympathetic nervous system hypofunction defect are

more prone to edema related to the inability to compen-

sate for the increase in hydrostatic pressure by diminish-

ing capillary permeability leading to transudation from

intravascular to extravascular space [10, 11]. Thus it is

possible that women who are more prone to miscarriage

because of sympathetic nervous system hypofunction

allow the absorption of toxic material into the

endometrium. It remains to be seen in further studies if

this therapy allows progression to the last trimester and if

pre-eclampsia will be more frequent.

References

[1] Check J.H., Katsoff D., Kaplan H., Liss J., Boimel P.: “A disorder

of sympathomimetic amines leading to increased vascular perme-

ability may be the etiologic factor in various treatment refractory

health problems in women”. Med. Hypothesis, 2008, 70, 671.

[2] Check J.H., Cohen R., Katsoff B., Check D.: “Hypofunction of the

sympathetic nervous system is an etiologic factor for a wide variety

of chronic treatment refractory pathologic disorders which all

respond to therapy with sympathomimetic amines”. Med. Hypoth.,2011, 77, 717.

[3] Check J.H., Katsoff B., Citerone T., Bonnes E.: “A novel highly

effective treatment of interstitial cystitis causing chronic pelvic

pain of bladder origin: case reports”. Clin. Exp. Obstet. Gynecol.,2005, 32, 247.

[4] Check J.H., Wilson C.: “Dramatic relief of chronic pelvic pain with

treatment with sympathomimetic amines – case report”. Clin. Exp.Obstet. Gynecol., 2007, 34, 55.

[5] Check J.H., Cohen R.: “Chronic pelvic pain – traditional and novel

therapies: Part II medical therapy”. Clin. Exp. Obstet. Gynecol.,2011, 38, 113.

[6] Parsons C.L., Dell J., Stanford E.J., Bullen M., Kahn B.S., Waxell

T., Koziol J.A.: “Increased prevalence of interstitial cystitis: previ-

ously unrecognized urologic and gynecologic cases identified using

a new symptom questionnaire and intravesical potassium sensitiv-

ity”. Urology, 2002, 60, 573.

[7] Chernoff G.F., Jones K.L.: “Fetal preventive medicine: teratogens

and the unborn baby”. Pediatr. Ann., 1981, 10, 210.

[8] Kalter H., Warkany J.: “Congenital malformations (second of two

parts)”. N. Engl. J. Med., 1983, 308, 491.

[9] Zierler S.: “Maternal drugs and congenital heart disease”. Obstet.Gynecol., 1985, 65, 155.

[10] Streeten D.H.P.: “Idiopathic edema: pathogenesis, clinical features

and treatment”. Metabolism, 1978, 27, 353.

[11] Check J.H., Shanis B.S., Shapse D., Adelson H.G.: “A randomized

study comparing two diuretics, a converting enzyme inhibitor, and

a sympathomimetic amine on weight loss in diet failure patients”.

Endoc. Pract., 1995, 1, 323.

Address reprint requests to:

J.H. CHECK, M.D., Ph.D.

7447 Old York Road

Melrose Park, PA 19027 (USA)

e-mail: [email protected]

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Introduction

Amenorrhea in the presence of normal estrogen, either

with normal ovulation or failure to menstruate despite

withdrawal of exogenous progesterone, is usually second-

ary to endometrial synechiae, i.e., Asherman’s syndrome.

However, there are rare cases in humans where despite

the production of adequate estrogen without evidence of

uterine synechiae, menstruation does not occur [1]. In the

aforementioned case, the woman ovulated as evidenced

by a rise in serum progesterone and even had a normal

luteal phase endometrial biopsy, but no menses. Hys-

teroscopy was normal [1].

Some animals, such as rabbits, sheep, and hamsters

have hypertrophy and degeneration of uterine luminal

epithelium in response to estrogen and progestins;

however they do not menstruate but undergo a process of

cell destruction by apoptosis [2]. These animals lack the

spiral arterioles that are responsible for menstrual flow in

primates [2]. Thus the aforementioned case may have a

situation analogous to rabbits, sheep, and hamsters.

Indeed histological studies in the human species con-

cluded that the marked reduction in endometrial thickness

from the immediate pre-ovulation state to shortly post-men-

struation may be primarily due to loss of fluid and the result

of apoptosis of the spongy layer [3]. Another study in

humans concluded that in most cases, an appreciable frac-

tion of the stratum spongiosum actually disintegrates but

endometrial tissue superficial to the basal layer remains in

situ at the end of menstruation [4]. Very heavy vs. very light

menses (or no menses) in ovulating women may be thus

related to the extent of endometrial shedding [4].

A review of the literature found no new articles with

similar findings (normal ovulation but amenorrhea

without a known uterine factor e.g., obstruction to outflow

or intrauterine adhesions). Another case of apparent

endometrial apoptosis or compaction without shedding is

now reported.

Case Report

A 22-year-old female consulted us because of a history of

primary amenorrhea, despite normal sexual development at the

appropriate age. Amenorrhea occurred despite documented normal

ovulation at the age of 17, as evidenced by both serum proges-

terone and endometrial biopsy. Ultrasounds showed a normal

uterine cavity with endometrial thickness reaching 10-12 mm.

More evidence of folliculogenesis was the fact that she had a

tendency to develop ovarian cysts and had five laparoscopes to

remove ovarian cysts. When she presented at the age of 22, she

wanted to know the nature of her problem and to determine if

pregnancy was possible. She added that a recent attempt to stim-

ulate her to ovulate with gonadotropins, follicle stimulating

hormone (FSH), and luteinizing hormone (LH) combination

failed to stimulate folliculogenesis.

The following serum studies were obtained: low estradiol - <

10 pg/ml, low FSH of < 0.7 mIU/ml, low LH < 0.2 mIU/ml, cor-

Secondary amenorrhea despite normal endometrial

development with secretory changes and absence of uterine

synechiae – a second case of the endometrial compaction –

apoptosis syndrome

J.H. Check1,2, R. Cohen3

1The University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at CamdenCooper Hospital/University Medical Center, Department of Obstetrics and Gynecology

Division of Reproductive Endocrinology & Infertility, Camden, NJ2Cooper Medical School of Rowan University, Department of Obstetrics and Gynecology,

Division of Reproductive Endocrinology & Infertility, Camden, NJ3Philadelphia College of Osteopathic Medicine, Department of Obstetrics and Gynecology, Philadelphia, PA (USA)

Summary

Purpose: To report the second case of amenorrhea related to endometrial compaction apoptosis syndrome. Materials and Methods:A female with secondary amenorrhea was evaluated with sonography, hysteroscopy, serum estradiol and progesterone levels, serum

luteinizing hormone (LH), follicle stimulating hormone (FSH), and endometrial biopsy. Results: Initially she was found to be ovula-

tory. However she did not menstruate despite the development of adequate endometrial thickness and a normal secretory endometrial

biopsy. Hysterosalpingogram failed to detect synechial. Subsequently she developed hypogonadotropic hypogonadism, but she still

failed to menstruate despite estrogen followed by progesterone. Conclusions: Amenorrhea can occur despite secretory endometrial

changes without a uterine abnormality.

Key words: Amenorrhea; Normal uterine cavity; Endometrial compaction; Endometrial apoptosis.


XXXIX, n. 2, 2012

Revised manuscript accepted for publication October 11, 2012

J.H. Check, R. Cohen474

tisol 25.3 mcg/dl (normal 4.0-22.0 mcg/dl), dehydroepiandros-

terone sulfate – 185 mcg/dl (normal 45-320 mcg/dl), free thy-

roxine 1.0 ng/dl (normal 0.8-1.8 ng/dl), thyroid stimulating

hormone 2.36 mIU/l (normal < 2.5 mIU/l), and prolactin 20.9

ng/ml (normal 2-20.0 ng/ml).

A pelvic sonogram revealed the right ovary to measure 16 x

17 x 16 mm and the left one to measure 21 x 19 x 22 mm. No

antral sized follicles were seen and only a few pre-antral sized

ones of two to three mm were noted.

With six mg/day of estradiol for 18 days, she developed a 14-

mm endometrial thickness. She continued the estradiol while

adding 10 mg medroxyprogesterone acetate for 14 days,

however menses did not ensue.

Her endometrial echo pattern immediately prior to starting

progesterone was triple-line and one week later on progesterone

converted to the appropriate homogeneous hyperechogenic

pattern [5, 6].

Discussion

Though her estrogen deficiency related to her apparent

isolated gonadotropin deficiency (but not related to sig-

nificant hyperprolactinemia) would result in amenorrhea,

her development of secondary amenorrhea despite previ-

ous ovulation with no apparent uterine synechiae is con-

sistent with the diagnosis of endometrial compaction –

apoptosis syndrome that has only been reported once

before [1]. Further confirmation was her failure to men-

struate despite high-dosage estrogen followed by prog-

estins which allowed endometrial proliferation but no

shedding. Evidence that this problem is not related to

progesterone receptor deficiency or inadequacy was

excluded by the development of a secretory endometrium.

Her failure to ovulate despite a course of exogenous

gonadotropins including LH and FSH could have two pos-

sible explanations. Sometimes, hypogonadotropic hypogo-

nadism needs a prolonged course of exposure to

gonadotropins in high-dosage before a response is seen

even with estrogen priming. With no insurance coverage

for these expensive drugs and failure to show a typical

response to a moderate dosage, the therapy was discontin-

ued. Sometimes this resistance may be related to associ-

ated growth hormone deficiency and the addition of

growth hormone can allow response to less gonadotropins,

but eventually with a high enough dosage and time of

exposure, one will typically see a response [7]. Unfortu-

nately though the young woman wanted to conceive, she

would have to wait until she acquired the needed funds or

the needed insurance coverage.

The question arises as to whether conception is even

possible (the first case report chose not to try to con-

ceive since her husband had a vasectomy). This author

has seen one previous case of secondary amenorrhea

related to endometrial compaction – apoptosis syn-

drome (unreported) and she did in fact have a success-

ful pregnancy.

In the present case, it is possible that the multiple

ovarian surgeries have damaged the ovaries and she

would have shown an increased serum FSH related to

diminished oocyte reserve, if there had not developed an

independent hypothalamic pituitary problem. Thus, the

frustrating thing for the patient without insurance is that

there is no guarantee that following high-dose exoge-

nous gonadotropins that she will even respond. It is

interesting that in another case of amenorrhea related to

a uterine defect, i.g., congenital absence of the uterus,

which is usually associated with normal estrogen and

ovulation, she also had accompanying hypogonadotropic

hypogonadism [8].

References

[1] Check J.H., Shanis B.S., Stanley C., Chase J.S., Nazari A., Wu C.H.:

“Amenorrhea in an ovulatory woman despite a normal uterine

cavity: Case report”. Am. J. Obstet. Gynecol., 1989, 160, 598.

[2] Sandow B.A., West N.B., Norman R.L., Brenner R.M.: “Hormonal

control of apoptosis in hamster uterine luminal epithelium”. Am. J.Anat., 1979, 156, 15.

[3] Bartelmez G.W.: “Histological studies on the menstruating mucous

membrane of the human uterus”. Contrib. Embryol., 1933, 142, 142.

[4] McLennan C.E., Rydell A.H.: “Extent of endometrial shedding

during normal menstruation”. Obstet. Gynecol., 1965, 26, 605.

[5] Check J.H., Dietterich C., Lurie D.: “Non-homogeneous hypere-

chogenic pattern 3 days after embryo transfer is associated with

lower pregnancy rates”. Hum. Reprod., 2000, 15, 1069.

[6] Check J.H., Gandica R., Dietterich C., Lurie D.: “Evaluation of a

nonhomogeneous endometrial echo pattern in the midluteal phase as

a potential factor associated with unexplained infertility”. Fertil-Steril., 2003, 79, 590.

[7] Check J.H.: “The future trends of induction of ovulation”. MinveraEndocrinol., 2010, 35, 227.

[8] Check J.H., Weisberg M., Laeger J.: “Sexual infantilism accompa-

nied by congenital absence of the uterus and vagina: case report”.

Am. J. Obstet. Gynecol., 1983, 145, 633.


J.H. CHECK, M.D., Ph.D.

7447 Old York Road

Melrose Park, PA 19027 (USA)


475

Introduction

Fertilization is a complex process involving numerous

molecules, cell-cell, and cell-matrix interactions. For suc-

cessful fertilization, the spermatozoa must undergo a

cascade of events including capacitation, hyperactivation,

acrosome reaction, binding to the zona pellucida, pene-

tration through the zona pellucida, and fusion with the

plasma membrane of oocytes [1]. Several families of

molecules such as complement regulatory proteins,

tetraspans, ADAM proteins, integrins, and others have

been shown to be involved in this process [2]. Most of

these molecules are not restricted to the reproductive

system, but also play essential roles in a variety of

immune reactions. Thus the function of these molecules

is still unclear and the mechanisms controlling this

complex event is not yet completely understood. Chemo-

taxis and activation of reactive oxygen intermediates

(ROI) are also important components of the fertilization

process; consequently, chemotactic factors and their

receptors on spermatozoa are under intensive investiga-

tion [3-5].

Unexplained infertility (UI) refers to a diagnosis made

in couples where standard investigations including semen

analysis, tests of ovulation, and tubal patency are normal.

UI still accounts for some 10% to 25 % of all cases of

infertility. The pathophysiology of unexplained male

infertility is still poorly understood, and various diagnos-

tic tests are unable to determine the underlying cause of

sperm dysfunction. Most possible causes of UI seems to

be any disorder in the molecular interactions between

sperm and oocyte in the reproductive environment [6, 7].

Thus any information on these molecules and/or their

functions is of critical importance. The authors attempted

to determine the antigenic profile of spermatozoa of

normal individuals and UI patients at the light-

microscopy level using several monoclonal antibodies

(mAbs), some of which are reactive with previously

reported antigens, while some others are introduced in

the present study. The aim of this study was to determine

and compare the immunolocalization of these antigens in

normal and UI groups. In the future, the authors intend to

extend these studies to the ultrastructural level for more

precise localization.

Materials and Methods

The human semen samples were collected in sterile plastic

containers through masturbation by unexplained infertile

patients (n = 20) each with three consecutive conception failures

on intrauterine insemination (IUI) attending the ART clinic in

Hacettepe University Medical School, as well as from healthy

proven-fertile donors (n = 6) after an abstinence of three to five

days. The ejaculates were allowed to liquefy for 30 minutes, and

semen parameters were analyzed according to World Health

Organization (WHO) guidelines [8].

Sperm counts of UI subjects were similar to those of men of

the proven-fertile group. It was ensured that each subject in both

groups was married and lived with his spouse for two or more

years without any recorded conception. All spouses were found

normal after strict gynecological assessment. The controls had at

least one child and had routine semen analysis within the normal

range, according to WHO 1999 guidelines. Necessary approval

was given by the institutional review board to perform the study.

After initial wash with human tubal fluid (HTF) medium, the

spermatozoa were smeared onto a clean glass slide coated with

gelatine and the smear was allowed to dry at room temperature.

Slides were fixed in methanol for ten minutes and air-dried for

at least 30 minutes. Slides were then incubated for 60 minutes


XXXIX, n. 2, 2012


Human spermatozoa antigens in unexplained infertility

L. Karakoc Sokmensuer1,2, B. Demir3, D. Zeybek2, E. Asan2, S. Gunalp1

1Department of Obstetrics and Gynecology, 2Department of Histology & Embryology, Hacettepe University, Faculty of Medicine, Ankara3Department of Gynecology and Obstetrics, Haseki Training and Research Hospital, Istanbul (Turkey)

Summary

Objective: To determine and compare the immunolocalization of functionally important antigens in human spermatozoa in an unex-

plained infertility (UI) group. Materials and Methods: In this study, the sperm samples of 20 patients undergoing evaluation belong-

ing to normozoospermic group, whose primary reason of infertility was under investigation for this purpose, were screened. CD46,

CD55 and CD52, CD69, CD98, fMLP, HI307, and 80280 were stained on the spermatozoa through indirect immunofluorescence tech-

nique. Results: In addition to CD46, CD55, and CD52 antigens, which are known to be localized on human spermatozoa, significant

immunolocalization of several novel antigens including: CD52, CD69, CD98, fMLP, HI307, and 80280 were determined on the sper-

matozoa of the unexplained infertility group, possibly reflecting important roles in the pathophysiology of such unresolved clinical

situations. Conclusion: Identification and characterization of antigens present on sperm cells is crucial for understanding of the diag-

nosis and treatment of unexplained infertility. Further studies were conducted to evaluate a possible correlation between the expres-

sion of these antigens and clinical outcomes in different well-defined infertility groups.

Key words: Spermatozoa; Surface antigens; Unexplained infertility; Immunofluorescence.

L. Karakoc Sokmensuer, B. Demir, D. Zeybek, E. Asan, S. Gunalp476

with primary mAbs (Table 1). After washing in 0.01M phos-

phate buffered saline (PBS) pH 7.4, the slides were covered with

mouse immunoglobulins/FITC labelled secondary antibody,

except for CD52 monoclonal antibody for 30 minutes, washed

in PBS 3 for ten minutes and covered by one drop of propidium

iodide/antifade solution. Anti-rabbit IgG-FITCH secondary anti-

body was used for CD52 monoclonal antibody. Immunofluores-

cent labelled sections were then examined and photographed

using a microscope.

Results

Complement regulatory/related proteins

CD46Membrane cofactor protein (MCP; CD46) represented

one of the most strongly-expressed antigens in human

sperm. Extensive expression of this antigen in both groups

provided a positive control for this technique. The main

site of localization of the antigen was the acrosomal com-

partment of the sperm head (Figures 1A, B). In the control

(normal) group a similar reaction was present. In the sper-

matozoa exhibiting abnormal head morphology (swollen

or irregularly enlarged), a crescent-shaped reaction was

confined to the tip of sperm head possibly representing an

abnormal acrosome (Figures 1C-E).

CD52CAMPATH-1 antigen exhibited a unique expression on

the post-acrosomal membrane region in the UI group

(Figures 2A, B). A similar but weaker reaction was

observed in the control group (Figure 2C). There was also

a weak reaction on the midpiece and initial segment of

sperm tail in some spermatozoa of the control group

(Figures 2D, E).

CD55Decay accelerating factor (DAF) was expressed in the

acrosomal region, midpiece, and the tail of the spermato-

zoa in the UI group being most strong in the midpiece

(Figures 3A, B). There was a restricted reaction in the

midpiece in some samples of the control group (Figure

3C). A weaker reaction was present in the acrosomal

region in the control group (Figures 3D, E).

Activation antigens

CD69Activation inducer molecule (AIM) was expressed in

the acrosomal region, equatorial segment, midpiece, and

tail in the UI group, being stronger in the equatorial

segment and midpiece (Figures 4A, B). There was no sig-

nificant reaction in the control group (Figure 4C).

CD98Activation antigen 4F2 was expressed in the acrosomal

region, midpiece, and tail in the majority of the sperma-

tozoa in the UI group (Figure 5A). Both diffuse and

patchy reaction patterns were present in the acrosomal

region (Figures 5B, C). However different staining pat-

terns were also observed in this group. In some of the

spermatozoa, the reaction was confined to the midpiece

and tail regions and absent in the acrosome (Figure 5D).

No significant reaction was observed in the control group

(Figure 5E).

Novel mAbs from human leukocyte differentiation antigens(HLDA) 7th and 8th Workshop blind panels

5F1(fMLP)This antigen was another example of a very unique

expression in the UI group. The reaction was present on

the equatorial segment, being stronger at both edges, and

in the midpiece resembling the corners of a triangle

(Figures 6A, B). In some spermatozoa, a patchy reaction

was present also in the acrosomal region (Figures 6C, D).

There was a moderate reaction in the tail as well. No sig-

nificant reaction was observed in the control group

(Figure 6E).

80280In the UI group, the acrosomal region was diffusely

stained. There was also a moderate reaction in the tail

(Figure 7). No significant reaction was seen in the control

group.

HI307The main reactive site for this antigen in the UI group

was the midpiece and the tail (Figure 8A). Reaction inten-

sity in the midpiece was quite strong (Figure 8B). No sig-

nificant reaction was seen in the control group.

Discussion

Characterization of cell differentiation and maturation

relies on structural observations and/or cell specific

expression of specific transmembrane or cytoplasmic

antigens. However data arising from recent studies

revealed that different cell types share a number of anti-

gens which have recently been classified into several

familes of proteins according to their molecular struc-

tures and/or functions. Thus investigators work on anti-

Table 1. — Monoclonal antibodies used.Primary antibody Clone Isotype

CD46 122-2 mG1

CD52 FL-61 mG1

CD55 BRIC216 mG1

CD69 UN6 mG-2a

CD98 MEM-108 mG1

5F1 5F1 n/a

80280 n/a n/a

HI307 HI307 n/a

Human spermatozoa antigens in unexplained infertility 477

gens on the cell groups of their interest for two main

goals: (i) determination of antigens which are specific to

a cell reflecting their differentiation/maturation state for

their characterization; (ii) determination of antigens with

known functions in other systems of the organism to

obtain evidence of a similar function in the cells of inter-

Figure 1. — Localization of CD46. a, b: CD46 localization on the acrosomal compartment of the spermatozoa head in the UI group;

c, d, e: acrosomal localization of CD46 in the control group.

Figure 2. — Localization of CD52. a, b: CD52 antigen localization on the post-acrosomal membrane region in the UI group; c: post-

acrosomal membrane CD52 expression in the control group; d, e: weak CD52 reaction on the midpiece and initial segment of tail in

some spermatozoa of the control group.

Figure 3. — Localization of CD55. a: CD55 localization on the acrosomal region, midpiece, and tail of the spermatozoa in the UI

group; b: strong reactivity with CD55 in the midpiece of the spermatozoa in the UI group; c: restricted CD55 reaction on the mid-

piece in some samples of the control group; d, e: weaker CD 55 reaction on the acrosomal region in the control group.


est. Regarding the yet unsettled mechanisms of the

complex reproduction process, the authors studied the

antigenic profile of spermatozoa belonging to fertile and

unexplained infertility groups to obtain some evidence to

direct further studies. For this purpose, they used both

monoclonal antibodies to known antigens and some

others which have not been studied on spermatozoa pre-

viously and obtained valuable data. Following a screen-

ing study using large numbers of monoclonal antibodies,

only those of interest which provide initial findings to

explain some of the mechanisms leading to IU are pre-

sented in this paper.

Expression of complement regulatory proteins CD46,

CD55, and CD59 on inner acrosomal membrane of sper-

matozoa has been previously reported [9-15]. The

authors studied CD46 and CD55 expression together

with CD52, a GPI-anchored surface glycoprotein, which

is also known to be expressed on spermatozoa for com-

parison of spermatozoa from fertile and UI groups, also

serving as a positive control. Both CD46 and CD55 were

expressed on the acrosome in control and IU groups,

however the intensity of CD55 expression in the fertile

group is relatively weaker. CD46 is strongly expressed

also on the spermatozoa with structural abnormalities,

reflecting the structural deformities of the acrosomal

vesicle. Thus CD46 antigen can be considered as a con-

stitutive antigen being present in the spermatozoa, also

providing a positive control for the technique used.

CD55 expression shared variations, especially in the

control group as a sign of maturational change reflecting

the heterogeneity of the spermatozoa population in the

smears. In the control group, reaction intensity was

weaker in the acrosomal region, being the strongest in

the midpiece in both groups. This observation leads to a

conclusion that strong expression of CD55 on acrosome

may be involved in a mechanism leading to IU, which

should be confirmed.

CD52 (CAMPATH-1) antigen is known as an antigen

exclusively expressed by immune system cells and epi-

didymal cells transferred on spermatozoa [16-21].

Recently, this antigen was also shown on the mature

cumulus cell mass [22]. In the present study, CD52 was

shown on the post-acrosomal region of the spermatozoa in

both groups. A significant expression on the midpiece in

some spermatozoa of the control group was also evident.

The localization of CD52 antigen strongly suggests a spe-

cific role for this molecule in sperm-oocyte contact, espe-

cially through their glycan moieties. Further ultrastruc-

tural studies should provide added evidence for this

suggestion.

CD69 (activation inducer molecule) is a type II trans-

membrane glycoprotein with a lectin domain being

mainly expressed on activated immune system cells,

similar to CD52 [23, 24]. Expression of this antigen on

spermatozoa, functioning as a signal transmitter on sper-

matozoa, has not previously been reported. This antigen

was expressed on the acrosome, equatorial segment, mid-

piece, and tail of the spermatozoa in the IU group while

no significant expression was determined in the control

group. Thus, CD69 is another candidate molecule leading

to signals initiating some mechanisms that result in IU.

CD98 (4F2), another activation antigen, was also

broadly expressed in the spermatozoa of the IU group,

however its expression was extensively variable when

compared to the other antigens examined. It is reported to

be expressed by a number of activated cells including neo-

plastic ones [25-28]. It is also expressed by trophoblastic

lineage (the authors’ unpublished observations). The func-

tion of this molecule is not entirely known, however it is

believed to serve as an amino acid transporter in some

cells. Expression of this antigen in the IU group, but not

in the fertile group, apparently reflects a deviation in

sperm activation leading to IU.

Another antigen with a unique expression on the sper-

matozoa of the IU group, which has not previously been

reported was fMLP. The fMLP receptor family represents

a group of molecules that receive recently chemotactic

signals from bacteria and mitochondria [29, 30]. Although

it is postulated that members of this receptor family direct

leukocyte traffic, their physiological role is poorly under-

stood.

Presence of such receptors on sperm is not previously

reported. The authors determined a unique expression of

this antigen on the spermatozoa of the IU group, however

no significant reaction was determined in spermatozoa of

the fertile-normal group. This finding apparently reflects

Figure 4. — Localization of CD69. a, b: CD69 localization on the acrosomal region, equatorial segment, midpiece and tail in the UI

group; c: no significant CD69 reaction in the control group.

Figure 5. — Localization of 4F2. a: 4F2 localization in the acrosomal region, midpiece and tail in the majority of the spermatozoa

in the UI group; b: 4F2 expression in the midpiece and tail regions being absent on the acrosome in UI group; c, d: both diffuse and

patchy staining patterns with 4F2 in the acrosomal region in UI group; e: no significant reaction with 4F2 in the control group.

Figure 6. — Localization of 5F1. a, b: 5F1 localization on the equatorial segment being stronger at both edges and in the midpiece

resembling the corners of a triangle in the UI group; c: patchy staining pattern with 5F1 in the acrosomal region in the UI group; d:

moderate 5F1 reaction in the tail of the sperm in the UI group; e: no significant reaction in the control group

Figure 7. — Localization of 80280. Diffuse acrosomal and moderate tail staining with 80280 in UI group

Figure 8. — a, b: localization of HI307. HI307 reactivity on the midpiece and tail in the UI group.

All scale bars represent five µm.


a targeting mechanism for the spermatozoa of IU patients

leading to a decreased number of normal spermatozoa

incapable of fertilization.

Another novel mAbs from HLDA (human leukocyte

differentiation antigens) 7th and 8th Workshop blind panels

was 80280. In the UI group the acrosomal region was dif-

fusely stained. There was also a moderate reaction in the

tail. No significant reaction was seen in the control group.

Further studies on the characterization of this antigen rec-

ognized by this antibody need to be evaluated.

Human leukocyte antigens (HLA) coded by human

major histocompatibility complex on chromosome 6 rep-

resents a group of transmembrane glycoproteins carrying

out immunological recognition function [31]. Previous

reports on studies in different species including humans,

display controversial findings regarding their expression

[32-35]. The authors detected a significant reaction with

an anti-MHC Class II monoclonal antibody on the post-

acrosomal zone, midpiece, and tail of the spermatozoa

reflecting a possible non-immunological function for

these molecules.

In conclusion, as discussed briefly above, most of the

antigens the authors studied were related to the immune

system, but were also present on spermatozoa. Though the

function of reproductive and immune systems are sepa-

rate, some overlapping molecular mechanisms for similar

functions in the organism are not really surprising and has

been demonstrated for the neuro-endocrine system. Infor-

mation on such molecules will help to better understand

their functions, assisting in revealing the physiological

mechanisms in the complex process of both systems. The

findings of the present study for CD52, CD69, CD98,

80280, and fMLP will lead to further studies including

immuno-electron microscopy for the precise localisation

of the antigens, comparison of patient groups of unex-

plained infertility, and some functional studies.

Acknowledgements

This project is supported by the Hacettepe University Research

Foundation, Ankara, Turkey, with Grant number: 05 01 101 010.

Preliminary data of this project was partly presented in Amer-

ican Society of Reproductive Medicine 62nd Annual Meeting in

USA and 16th International Microscopy Congress in Japan in

2006.

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L. KARAKOC SOKMENSUER, M.D.

Ziya Gokalp Cad. Cemre Sok

9/4 06420 Kolej, Ankara (Turkey)


482


XXXIX, n. 2, 2012

The practical role of anti-Müllerian hormone

in assisted reproduction

C. Siristatidis1, M. Trivella2, C. Chrelias1, N. Vrachnis3, A. Drakeley4, D. Kassanos1

1Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, University of Athens, “Attikon” Hospital, Chaidari2Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Oxford

3Second Department of Obstetrics and Gynecology, University of Athens, “Aretaieion” Hospital, Athens4Hewitt Centre, Liverpool Women’s Hospital, Liverpool (United Kingdom)

Summary

The objective of this study was to offer a brief critical summary of the literature on the role of AMH in the subfertility work up and

during ART, while exploring its role in predicting ART success.

Key words: IVF/ICSI outcome; Ovarian reserve; AMH/ART.

Introduction

The primary goal in assisted reproduction is the contin-

uous improvement of the “take home baby” rate. It would

be greatly aided by the ability to anticipate how a woman

will respond to ovarian stimulation and to predict her

chances of pregnancy. The ideal way to achieve this would

be to acquire advanced knowledge, that is, to be able to pre-

dict the response before a woman enters the cycle of mul-

tiple assisted reproduction technology (ART) - especially in

vitro fertilization (IVF) - attempts. A meticulous pre-treat-

ment workup would help, but only if a prognostic marker

were available. Despite extensive research in the area, such

a marker remains elusive [1].

Over the last ten years or so, anti-Müllerian hormone

(AMH), has being investigated as a putative marker [1,2].

AMH is a dimeric glycoprotein, acting on tissue growth and

differentiation. AMH has shown great potential as a prog-

nostic marker of ovarian reserve and the ability to identify

both extremes of ovarian stimulation [2]. Theoretically,

AMH could help to dynamically facilitate the planning of

women’s reproductive life in addition to predicting for whom

IVF treatment is more likely to work [2]. There is no reliable

proof though that it can directly contribute to assisted repro-

duction’s primary aim, the “take home baby” rate, hence in

this context it isn’t an efficient marker in its own right [3,4].

Current clinical value of AMHIn clinical practice, AMH is useful in the prediction of

poor response and also of hyper-response during ART

[2,3,5]. It can additionally provide useful information on

the risk of pitfalls during ovarian stimulation for ART, thus

saving couples time and heartache, and guiding them fast to

the justified “next step” decision of acquiring oocyte do-

nation or adoption.

Many researchers, using a variety of statistical methods,

have attempted to determine significant AMH measure-

ments cut points for pregnancy and live births:

Gleicher et al. [3] used receiver operating characteristic

(ROC) curves and reported that a uniform cut-off value for

significantly improved live-birth rates independent of age

stands at AMH = 1.05 ng/ml, with values of AMH ≤ 0.04 and

0.41 - 1.05 ng/ml relating to very low and increased pregnancy

potential, respectively. Crucially, the authors did not report on

which day in the stimulation cycle was AMH measured. Kini

et al. [4] instead of reporting cut points, compared retrospec-

tively the median AMH levels between women who achieved

cumulative ongoing pregnancy and those who did not. They

found that in the former, the median AMH level at day 6 was

significantly higher. Gnoth et al. [5] employed discriminated

analyses and used a calculated cutoff point based on mini-

mized false positive and false negative results, concluding that

levels of ≤ 1.26 ng/ml were highly predictive of poor ovarian

response. In patients with PCOS, Kaya et al. [6] reported that

the best day-3 AMH cut-off values for fertilization and clini-

cal pregnancy rates were reported at 3.01 and 3.20 ng/ml, re-

spectively, with the sensitivity and specificity of the method

exceeding 72% for both. However, the study included only 60

patients and the analysis had a priori divided the sample into

three groups using the 25th, and 75th percentiles as cutpoints.

Similarly, Xi et al. [7] used these cutpoints and proceeded to

make group comparisons of reproductive outcomes in 164

polycystic ovarian syndrome (PCOS) patients.

It would be ideal if derived cut points for early detection

of reduced ovarian response were available to clinicians,

so that they could advise appropriately and guide the deci-

sion-making of treatment options. Unfortunately, none of

these techniques stands up to statistical scrutiny for a vari-

ety of reasons; the statistical analysis of these is beyond the

scope of this communication. Furthermore, different ana-

lytical strategies render any comparisons unfeasible.Revised manuscript accepted for publication September 1, 2012

C. Siristatidis, M. Trivella, C. Chrelias, N. Vrachnis, A. Drakeley, D. Kassanos 483

In terms of AMH’s power to qualitatively assess the re-

sponse to ovarian stimulation and the outcomes of ART, the

literature is contradictory. While a positive correlation be-

tween AMH levels in the serum (weaker) or follicular fluid

(stronger) with oocyte quality and embryo morphology

[2,8] has been reported, the relationship has not been con-

firmed by others [9].

In summary, the available data on the relationship be-

tween AMH and pregnancy prediction are of limited value.

This is not surprising since, clinically, there is no known

marker reflecting directly the oocyte quality and the ensuing

embryo. It is not straightforward to delve into such a rela-

tionship as there are a number of parameters involved, the

interplay of which is not yet fully understood. So far it can

only be quantified retrospectively following a live birth. The

clinical value of AMH is certainly getting stronger, but a

clinical model based solely on AMH is unlikely to be de-

veloped. An ideal strategy would be a systematic review and

meta-analysis of all prediction studies, but given the current

variability in reporting, this does not seem feasible.

The power of AMH in predicting outcomesFrom the hormonal tests, AMH’s assumed superiority lies

on the fact that it directly reflects the number of pre-antral

follicles and the earlier stages of follicle development

[2,4,10]. Together with antral follicle count (AFC), AMH is

considered as the marker with the highest biological plau-

sibility for ovarian reserve [2,11] and demonstrates less in-

dividual intra- and inter-cycle variation. However, when

predicting poor or high response and pregnancy rates, it has

demonstrated a sensitivity of 76% and a specificity of 86%

in sub-fertile couples [2,3].

Broekmans et al. [1] carried out a comprehensive system-

atic review of each available putative marker, both separately

and as part of a model, with respect to three outcomes of in-

terest; accuracy of poor response prediction, accuracy of non-

pregnancy, and clinical value. They found that no marker

was significantly better than another, and where models were

involved it was not possible to calculate individual model

summary statistics for meta-analysis as each model was con-

structed in a different way, and/or inadequate levels of sen-

sitivity and specificity were chosen. The models, as always,

were especially poor in predicting pregnancy.

AMH shows limited power in predicting pregnancy. Sur-

prisingly, a recent retrospective analysis showed that with

extremely low serum AMH levels, moderate, but reason-

able pregnancy and live birth rates are still possible, indi-

cating that even in the presence of extremely low AMH

levels, ART should not be withheld [12].

The future role of AMH

Individualization of ART stimulation protocols with or with-out modeling

With an increasing number of women delaying motherhood

until their thirties, there is a growing need for simple, low-

cost biological markers that can offer individual guidance on

when is best to plan a family. The future clinical role of any

of these markers may be found in the individualization of

ART stimulation protocols [13,14]. It is behind this novel field

of personalization of treatment that the desired rise in ART

outcomes may be hidden. A prospective cohort study by Nel-

son et al. [13] demonstrated the capability of AMH alone in

individualized treatment strategies for ovarian stimulation, re-

sulting in reduced clinical risk, optimized treatment burden

and maintained pregnancy rates. Similarly, a more recent ret-

rospective study of 769 women receiving IVF, found that in-

dividualized protocols resulted in reduced adverse effects and

costs [14]. In this respect, AMH appears to have an impor-

tant role to play. This may even comprise a multitasking role,

ranging from helping to discriminate between non- or hyper-

response, cycle cancellation, and ovarian hyperstimulation

syndrome, to regimen, dose and protocol formation, and pos-

sible alteration throughout cycles.

This individualized approach is perhaps a superior avenue

not only for utilizing to the maximum AMH’s characteris-

tics, but also involving a number of other markers that hith-

erto proved inadequate prognosticators on their own;

woman’s age, the hormone-based FSH blood test, estradiol

and inhibin B, the ultrasound markers AFC, ovarian volume

and blood flow, the clomiphene citrate challenge test, the

exogenous FSH and the gonadotropin agonist test from

stimulation tests [1]. This arsenal of ovarian reserve and out-

come prediction tests, along with AMH has, without much

success, been put through its paces using a variety of statis-

tical techniques, often of questionable robustness, either in

a univariate or a multivariable setting [2,15-18]. Especially,

worrying is the use of a priori chosen cut points in ROC

curves, multivariate analyses adjusting for a multitude of

combinations of markers (from the list mentioned earlier),

discriminant analysis, and adjusted logistic regression.

However, there is extensive literature warning against

adopting random categorizing levels, or those yielding the

best p-value [19]. Hence, in this respect individualized mod-

els, evolved through a validated process, may well be the

best both biologically and statistically.

Finally, construction of new mathematical architectures

based on artificial neural networks seems promising. AMH

could serve as one of the trustworthiest input factors to

build the network, which after proper training could raise

the predictive power of the whole model [20]. However, at

the moment attempts to combine individual markers into

suitable models with, or without AMH, have also proved

inconclusive.

Treatment denialThere is a lack of adequate data in defining when and

how women need to start worrying for their fecundity and

runs in parallel to the uncertainty of whether and when

medical staff should deny treatment based on AMH values.

It has been proposed that AMH should be used only with

The practical role of anti-Müllerian hormone in assisted reproduction484

very low cut-off values in order to minimize the occurrence

of false positive tests [4,13]; in addition, the added value of

AMH assay to chronological age is minimal [2,3], although

reports are relating it with diminished ovarian reserve in

young women [21].

Conclusion

The current literature of prognostic factors in assisted re-

production is rather diverse and inconclusive. The study

variability hence prevents the possibility of combining all

prediction studies into a meta-analysis, leaving the data scat-

tered and thus unusable. AMH has emerged as a relatively

suitable marker for predicting ART outcomes. It has super-

seded other traditional tests, but it has definite limitations

when used on its own. While acknowledging the limitations

is the first step, the combination of AMH with other known

prognostic markers, such as woman’s age and AFC, into

models, preferably individualized, provides a clear direc-

tion for the future. There are however certain caveats though

that should be adhered to; the hypotheses should be verified

through well-designed prospective studies, validated and ro-

bust statistical methods should be used for the construction

of the models, and a consented attempt to homogenize the

reporting mechanisms of such studies should be promoted.

References

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C. SIRISTATIDIS, M.D., PH.D.

Rimini 1, Chaidari,

GR-12462, Athens (Greece)


485

Introduction

The period of breastfeeding is the stage in a woman’s

life with the greatest energy demands, even greater than

those during pregnancy [1]. The production of milk just

up to the fourth month of lactation represents a sum of

energy equal to the total energy cost of the nine months of

pregnancy [2]. Lactation requires an increased intake of

nutrients and excess fat gained throughout pregnancy is

generally considered to be the main supply of extra energy

needed for lactation. After delivery, many women

although willing to lose weight, fear that restricting their

dietary intake can lead to a reduction in their milk’s

volume and quality [3]. This is why they may choose to

increase their energy intake more than recommended

during the lactation period [3].

This study was designed to assess the energy intake,

energy expenditure, and weight changes of Greek mothers

who exclusively breastfeed their offspring for the first six

months postpartum. It is the first study to research and

describe the Greek data in this field.


Inclusion, exclusion criteria, and outcomes This was a prospective observational study with a cohort of n =

64 pregnant women delivering healthy full-term neonates (> 37

weeks, weight > 2.5 Kg) in private maternity hospitals of Athens,

Greece. All participants stated their intention to exclusively

breastfeed their infants for up to six months and were followed up

until the sixth month of lactation. Mothers who were following

specific diet because of diabetes or hypertension, or were taking

medicines known to influence their appetite were excluded.

Main outcome measures were to assess the lactating mothers’

energy intake (EI), energy expenditure (EE), energy balance

(EB), as well as body weight changes at first, third, and sixth

month of lactation. Secondary outcome was to evaluate any pos-

sible correlations of these with maternal characteristics.

Study protocol

Data collection

At the initial meeting, study requirements were clearly

explained to the participants and an information sheet was given

describing the goals of the study. They were asked to sign a

written informed consent form. Ethical approval was obtained

by Harokopio University Ethics Committee.

Participants were asked to fill in a questionnaire with demo-

graphic, socio-economic, and obstetric data. Three home visits

during the morning hours, were made by a member of the

research group at first month (i.e.: 25-30 days postpartum) and

at the beginning of the third and sixth month of lactation. Weight

and height were measured with subjects wearing only underwear

and using a digital electronic balance (range 0.1 - 150 Kg) and

a tape measure (range 0 - 200 cm). Body mass index (BMI)

(kg/m2) was thus calculated.

Energy intake was assessed at first, third, and sixth month of

lactation by giving lactating mothers a three-day dietary record

to complete. Prior to diet-record keeping, the mothers were thor-

oughly instructed on how to fill in their food consumption, how

to measure portions of food, and how important it was not to

miss out any food or snack. They were also advised not to

change their habitual diet during the three days of recording.

Mothers recorded the type and amount of food and beverages

consumed for two consecutive weekdays and one weekend day,


XXXIX, n. 2, 2012

Revised manuscript accepted for publication September 20, 2012

Role of exclusive breastfeeding in energy balance

and weight loss during the first six months postpartum

A. Antonakou1,2, D. Papoutsis3, I. Panou1, A. Chiou1, A.L. Matalas1

1Department of the Science of Dietetics-Nutrition, Harokopio University of Athens, Athens (Greece)2Department of Midwifery, School of Health and Medical Care, Alexandreio Technological Institute of Thessaloniki, Thessaloniki (Greece)

3Department of Obstetrics and Gynaecology, Royal Shrewsbury Hospital Shrewsbury (United Kingdom)

Summary

Purpose: To investigate the energy intake (EI), energy expenditure (EE), and body weight changes of solely breastfeeding women

during the first six months postpartum. Materials and Methods: This is a prospective observational study of lactating women (n = 64).

Three-day dietary records were filled in to assess EI. EE was calculated with a short physical activity questionnaire. Energy cost of milk

production was not included in EE estimation. Results: Daily EI and EE for the six-month period was 2,000 Kcal and 1,870 Kcal, re-

spectively. Women had a positive energy balance throughout the study period. Nevertheless, they had a significant weight loss of 0.7

kg/month by the first trimester of lactation, but a non-significant weight loss of 0.5 kg/month by the second trimester. Overall, women

lost 86% of the weight gained during pregnancy. Conclusion: Exclusively breastfeeding women manage to lose weight during the first

six months postpartum as part of the natural process of energy cost of lactation.

Key words: Energy intake; Weight change; Lactation.

General Section

A. Antonakou, D. Papoutsis, I. Panou, A. Chiou, A.L. Matalas486

using standard household measures (cups, tablespoons, etc). On

site, a member of the research team reviewed the records with

the respondent to clarify entries, number and size of servings,

and forgotten foods. Clarification of foods involved the use of

food models, pictures, and measuring devices.

Energy expenditure was assessed at the above time points by

asking women in this study to fill in a short physical activity

questionnaire (Harokopio physical activity questionnaire-

HAPAQ). HAPAQ is a questionnaire that consists of 22 items,

which examine physical activity of the respondent and is based

on previous work done by Ainsworth et al. [4]. HAPAQ has been

validated for both men and women by comparing its outcomes

against the activity monitored by an accelerometer [5].

Data processing

Energy intake was estimated by using an appropriate diet

analysis software to assess food intake data for their energy and

macro-nutrient intake. Traditional Greek foods were also

included in the food database.

Energy expenditure as estimated by HAPAQ was the sum of

basal metabolic rate and physical activity cost. The energy cost for

milk production was not included in the estimations of energy

expenditure, due to great variations in women’s reports regarding

the duration of breastfeeding during the day. Energy intake and

energy expenditure were both adjusted for body weight in order

to evaluate their correlation with body weight changes.

Energy balance was determined by energy intake and energy

expenditure, as defined previously without the energy cost for

milk production. If EB is positive, this indicates that energy

intake is greater than energy expenditure. If EB is positive and

there is an established body weight loss of women during lacta-

tion, then this finding should be attributed to the energy cost for

milk production, although it was not calculated and included in

the energy expenditure estimation.

Pre-pregnancy weight (PPW) was derived from women’s

medical records and kept at the maternity hospitals where they

delivered. Permission to access those records was secured from

the clinic’s executive board. PPW was taken as a baseline in

order to estimate body weight changes at first, third, and sixth

month of lactation. In addition, the rate of body weight change

between the first and third and third and sixth month of lactation

was calculated to assess body weight loss during lactation.

Statistical analysis Descriptive characteristics of investigated variables were

expressed as mean ± standard deviation. Correlation between EI

and body weight changes with parameters of interest was evalu-

ated by computing Spearman’s correlation coefficient. Evaluation

of body weight changes, EI, EE, and EB changes were calculated

using paired-samples t-test and applying Bonferroni corrections to

reduce the possibility of type II error. Comparisons were done in

pairs because sample sizes were unequal at the three time points

of measurement. Equality of means within the three measure-

ments (first, third, and six months) for the parameters of interest

was tested with repeated measures analysis of variance (ANOVA).The level of significance was defined at p < 0.05. Statistical analy-

sis was performed using SPSS version 17.0 software.

Results

Population characteristics-EI and EELactating mothers’ mean age was 32.5 ± 3.1 years (25-39

years) and 78.1% were nulliparous. All subjects were

married and almost all were employed (93.7%), while two-

thirds (65.6%) had a university degree. Mothers’ mean pre-

pregnancy BMI (ppBMI) was 22.2 ± 4.1 kg/m2 and 10/64

(15.6%) were classified as overweight or obese (BMI > 25).

From the 64 mothers who entered the study, 39 (60.9%)

continued to exclusively breastfeed up to the third month

and only 24 (37.5%) up to the sixth month postpartum.

Lactating mothers’ mean daily energy intake during the

first, third, and sixth month of lactation was 1,999.8 ± 452.3

kcal, 2,031.7 ± 464.7 kcal, and 2,048.7 ± 558.8 kcal, respec-

tively. Energy intake did not show any statistically signifi-

cant difference among the three time points measured. The

three-day dietary records indicated that protein contributed

an average of 14.9%-16.2%, while lipids provided 36.5%-

38.5% of the daily EI, with 16% being monounsaturated fat.

Daily energy expenditure did not differ significantly among

the three time points of the study (Table 1).

Body weight changes during lactationThe 64 women that were recruited for the study had a

mean PPW of Bpp = 62.2 ± 11.5 kg (45 - 106). Mean

weight increase during pregnancy was 15 ± 5.9 kg (0 -

Table 1. — Energy intake, energy expenditure, and energybalance at first, third, and sixth month of lactation (resultsobtained from repeated measures ANOVA). The energy cost oflactation was not included.

1st month 3rd month 6th month p value

(n = 64) (n = 39) (n = 24)

Energy intake

(kcal) 1,999.8 ± 452.3 2,031.7 ± 464.7 2,048.7 ± 558.8 NS

Energy expenditure

(kcal) 1,865.7 ± 315.8 1,866.8 ± 375.1 1,882.8 ± 326.8 NS

Energy balance

(kcal) 134.1 ± 548.3 164.9 ± 480.2 165.9 ± 583.2 NS

*NS = Non significant (p > 0.05).

Table 2. — Body weight changes at first (n = 64), third (n =39), and sixth (n = 24) month of lactation.

First month of lactation (n = 64)

1st month (B1) p value

Weight (kg) 68.7 ± 15.4

B1-PPW (kg) 6.6 ± 4.9 < 0.001

B1-Weight at delivery (kg) -8.5 ± 2.9 < 0.001

Third month of lactation (n = 39)

1st month (B1) 3rd month p value

Weight (kg) 68.6 ± 12.5 67.2 ± 12.8 NS

Weight-PPW (kg) 5.7 ± 5.1 5.3 ± 4.7 0.001

Weight-Weight at delivery (kg) -8.4 ± 2.6 -9.8 ± 3.4 0.001

EI (kcal) 2,023.9 ± 402.8 2,031.7 ± 464.7 NS

EE (kcal) 1,863.1 ± 343.9 1,866.8 ± 375.1 NS

EB (kcal) 160.8 ± 508.6 164.9 ± 480.2 NS

Sixth month of lactation (n = 24)

1st month 3rd month 6th month p value

Weight (kg) 69.1 ± 8.8 67.4 ± 9.1 66.3 ± 11.7 0.03

Weight-PPW (kg) 5.5 ± 5.9 3.9 ± 5.4 2.8 ± 4.9 0.02

Weight-Weight

at delivery (kg) -8.2 ± 2.6 -9.8 ± 3.8 -11.1 ± 4.1 0.04

EI (kcal) 2,048.7 ± 558.8 2,464.2 ± 456.8 2,048.7 ± 558.8 NS

EE (kcal) 1,882.8 ± 326.8 1,918.2 ± 323.9 1,882.8 ± 326.8 NS

EB (kcal) 317.6 ± 466.3 545.9 ± 448.4 182.7 ± 667.6 NS

*NS = Non significant (p > 0.05).

Role of exclusive breastfeeding in energy balance and weight loss during the first six months postpartum 487

30). The mean weight increase between the first month

postpartum and their PPW was 6.6 ± 4.9 kg (p < 0.001).

The 39 mothers who continued to breastfeed until the

third month postpartum had a mean PPW of Bpp = 62.9

± 13.2 kg (45 - 106). The mean weight increase between

the third month and PPW was 5.3 ± 4.7 kg (p < 0.001).

By the third month mothers were weighing an average of

1.5 ± 2.4 kg less than during the first month of lactation

(p = 0.004). In other words, weight loss for women who

continued to breastfeed (n = 39) during the first trimester

was significant and was estimated to be 0.7 kg/month.

Finally, the 24 mothers who continued to breastfeed their

babies for six months had a mean PPW of Bpp = 63.5 ±

13.1 kg (47 - 106). The mean weight increase between the

sixth month of lactation and PPW was 2.8 ± 4.9 kg (p =

0.02). At six months mothers were weighing an average

of 1.3 ± 2.5 kg less than during the third month of lacta-

tion (NS: p = 0.06). This signifies that weight loss during

the second trimester postpartum for women who contin-

ued to breastfeed (n = 24) until the sixth month was non-

statistically significant and was shown to be 0.5 kg/month.

Mothers’ BMI at first, third, and sixth month postpartum

was 24.6 ± 4 kg/m2, 24.2 ± 4.5 kg/m2, and 23.5 ± 3.5

kg/m2, respectively. It is noteworthy that BMI changes are

also significant during the first three months of lactation

(p < 0.001), whereas they do not manage to gain statisti-

cal significance over the second trimester. During the first

six months postpartum, women managed to lose an

average of 85.6% of the weight gained during pregnancy.

Correlations Spearman’s correlation coefficients were used to correlate

energy intake and body weight changes with maternal char-

acteristics. Energy intake was correlated positively at first

month of lactation with parity and negatively with the

weight increase during pregnancy. There were no significant

correlations with age, educational level, number of ciga-

rettes smoked, and ppBMI. Weight change at the end of the

first, third, and sixth month of lactation in comparison to

PPW had a significant positive correlation with the number

of cigarettes smoked per day. There was also a significant

negative correlation with PPW and ppBMI, and finally a

significant positive correlation with the weight increase

during pregnancy. There were no significant correlations

with age, educational level, and number of children.

Discussion

This study was conducted in a sample of 64 mothers,

who were exclusively breastfeeding their infants for a

time period of six months. In this group, 60.9% (39/64)

continued to exclusively breastfeed up to the third month

and 37.5% (24/64) up to the sixth month postpartum.

Samples of similar size have also been reported by other

researchers in the past for the same follow-up period of

six months [6, 7].

This study is one of very few studies designed to assess

the EI, EE, and weight changes of south-Mediterranean

lactating mothers. Specifically, daily EI was found to be

an average of 1,970 - 2,100 kcal (28 - 31 kcal/kg,) similar

to the EI mentioned in studies from other countries [6, 8-

10]. Maternal EI well-covered what is considered to be the

energy requirements during exclusive breastfeeding [11-

13]. It was also noted that mothers had a relatively high

daily fat intake of 36.5% - 38.5% of EI, while 16% was

monounsaturated fat, probably due to the variety of foods

consumed by the mothers of the sample, which were rich

in monounsaturated and total fat. These findings are in

accordance with literature concerning other south Euro-

pean populations’ habitual diets [14]. The mean daily EE

(energy cost of milk production not included) was approx-

imately 1,870 kcal during the first six months of lactation,

and did not differ significantly throughout the study

period. In other studies as well, EE was also similar

throughout the entire period of lactation [8].

Results show that over the six-month period, mothers of

the sample had a positive energy balance. Nevertheless, a

significant weight loss was indeed achieved at the end of

the six-month period of 11.1 ± 4.1 kg in comparison to the

body weight women had at their delivery (Table 2). During

the first six months postpartum, it was estimated that

women managed to lose an average of 85.6% of the weight

gained during pregnancy. However, at the end of the six

months women retained an average of 2.8 ± 4.9 kg in com-

parison to their pp weight. This finding is in accordance

with other reports, which indicates that mothers do return

to their pp weight after longer than six month periods of

observation (9, 12, or 18 months postpartum) [15-17]. Sta-

tistical analysis showed that women had a significant

weight loss of 0.7 kg/month during the first trimester of

lactation, which was followed by a non-significant weight

loss of 0.5 kg/month during the second trimester of lacta-

tion. This degree of weight loss is also in accordance with

previous findings [18]. Weight loss of ~0.5 kg/month

during lactation is considered to be common and safe [19].

Furthermore, a review of 17 studies has shown that well-

nourished mothers lose weight with a rate of 0.8 kg/month,

while undernourished ones with a rate of only 0.1

kg/month [20]. In literature, mothers lose more weight

during the second trimester of lactation and not during the

first trimester as the present study showed [15, 21]. In

those reports however, larger cohort samples were used.

Perhaps if a larger number of women had continued to

breastfeed (> 24/64) beyond the third month postpartum in

this study, then statistical significance might have also

been achieved for weight loss in the second trimester.

The fact that mean energy balance was kept positive

throughout the entire study period, but at the same time

women were losing weight, leads to the conclusion that

this weight loss was probably due to the energy cost of

lactation, which was not measured in this protocol. On

review of literature, during the first six months of exclu-

sive breastfeeding, mean daily energy cost for milk pro-

duction is estimated to be approximately 2,800 KJ (or 675

kcal) [22, 23] and mean daily breast milk production is

considered similar among women of different cultural and

socio-economic background [6].

A. Antonakou, D. Papoutsis, I. Panou, A. Chiou, A.L. Matalas488

The present study bears some limitations and con-

straints that need to be addressed. Firstly, a random

sample was used which was restrained to women who

gave birth at the area of the capital, Athens. Secondly, an

additional limitation was the small sample size. The study

initially recruited 64 women, however only 24 of them

continued breastfeeding and hence remained in the study

until the end. Other similar studies, which also did not use

a control group and followed up mothers for ≤ six months,

had larger sample sizes [16, 18, 24]. Next, the energy

expenditure was not measured by experimental methods,

as in previous studies, but with use of physical activity

questionnaires, where energy cost of lactation was not

measured. Concerning the use of three-day dietary

records, it is generally highly-regarded for its validity by

numerous researchers that have used them for similar

studies [10, 25]. However, there is always the risk of

under-reporting foods with a low nutrient density and

over-reporting “healthy” food groups, especially by

women who are overweight [23]. Such discrepancies

together with the large number of tests carried out and the

small sample size may have resulted in type I error and

findings that may not be entirely applicable to a represen-

tative population [26].

On literature review and to the best of the authors’

knowledge, this study is the first to assess the EI, EE, and

weight changes of Greek mothers who exclusively

breastfed for the first six months postpartum. Therefore it

provides additional knowledge with regards to the

changes of EI throughout the lactation period, an issue

that was not fully investigated by previous research. This

study has shown that in exclusively breastfeeding women

with usual physical activity postpartum, normal energy

intake, and without basal metabolic rate disorders, EE

comprising of basal metabolic rate and physical activity

almost fully compensates EI. The authors can presume

therefore that weight loss recorded postpartum in exclu-

sive breastfeeding women can be attributed to the energy

cost of lactation.

The practical implications of this study includes the fact

that health professionals have additional data to properly

counsel women to follow an appropriate diet without

exaggerations in dietary EI and to perform normal physi-

cal activity. Hypocaloric diets and excessive physical

activity may be well-avoided during exclusive breastfeed-

ing, since they are not necessary for weight loss purposes.

In this way mothers do not need to follow strict diets, the

amount and quality of breast milk is not disrupted, and

weight loss can be achieved as part of the natural process

of energy cost of lactation.

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penditure of healthy Swedish women during pregnancy and lacta-

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ternal weight and body fat depots in lactating vs nonlactating

women”. Am. J. Clin. Nutr., 1989, 49, 259.

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Hautvast J.G.: “Changes in energy expenditure, anthropometry, and

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A. ANTONAKOU, PhD.

88 Zagoriou Str., Ilion

13123 (Greece)


489

Introduction

The incidence of ectopic pregnancy (EP) has dramati-

cally increased over the last two decades and accounts for

1.5% - 2% of all pregnancies [1]. Although the mortality

related to EP has decreased significantly, it is the most

important cause of maternal death in the first trimester

accounting for 9% - 13% of all pregnancy-related deaths

[2-4].

Treatment of EP has changed over the years and a con-

servative approach (medical treatment with methotrexate,

expectant management, and salpingostomy by laparoscopy)

now predominates [5, 6]. Early diagnosis is important in

order to allow conservative treatment options [6-8].

In spite of a high-resolution vaginal ultrasound and

highly-sensitive quantitative beta-human chorionic

gonadotropin (β-hCG) assays, at first presentation, an EP

can be difficult to diagnose at an early stage; 36.4% of all

cases do not exhibit adnexal tenderness, and nine percent

report no pain [9]. For this reason, a serum biomarker of

tubal implantation, which could accurately identify an EP

at first presentation, would be a major clinical advance.

Several markers have been investigated for early diagno-

sis of EP [10].

For the establishment of a viable pregnancy, implanta-

tion and placentation are the early and crucial processes,

both accompanied by angiogenesis, for which vascular

endothelial growth factor (VEGF) is mainly accountable

and plays a key role [11]. Several authors hypothesized

that implantation of the conceptus within the oviduct

might increase VEGF production as a form of accommo-

dation to the hypoxic unfavorable environment [4, 8, 12,

13]. Therefore, serum VEGF could distinguish an EP

from a miscarriage [8, 12, 13].

The aim of the study was to determine the serum levels

of VEGF and compare them in cases of EP, miscarriage,

and normal pregnancy (NP).


PatientsThe study group was comprised of 35 women with EP con-

firmed by transvaginal ultrasound (TVUS) or at surgery and ges-

tational age under 7.5 weeks. The inclusion criteria were the

presence at TVUS of an extra-ovarian adnexal mass in women

with a suspected EP (amenorrhea, uterine bleeding, and pain)

with positive β-hCG test. The exclusion criteria were non-tubal

EP (intrauterine, cervical, cesarean scar, ovarian, interstitial, and

abdominal) and the suspect cases of early EP not confirmed by

TVUS.

The control group consisted of 15 women with miscarriage

and gestational age less than 7.5 weeks. The diagnosis was per-

formed by means of serial β-hCG measurements and by TVUS.

The criteria for ultrasound confirmation of a failure pregnancy

were the absence of a visible yolk sac with a mean sac diameter

of 13 mm, the absence of a visible embryo with a mean sac of

20 mm, the absence of cardiac motion with an embryo measur-

ing five mm or more, or the presence of an empty amnion.

The other control group was composed of 22 women with NP

and gestational age less than 7.5 weeks. The TVUS confirmed a

viable intrauterine pregnancy.

Association of serum levels of vascular endothelial growth

factor and early ectopic pregnancy

M.O. Fernandes da Silva, J. Elito Jr., S. Daher, L. Camano, A. Fernandes Moron

Department of Obstetrics of the Universidade Federal de São Paulo, São Paulo (Brazil)

Summary

Background: This study evaluated serum vascular endothelial growth factor (VEGF) concentrations in women with ectopic pregnancy

(EP), miscarriage, and normal pregnancy (NP). Materials and Methods: This was a case-control study comparing serum VEGF con-

centrations among 72 women with ectopic pregnancy (n = 35), miscarriage (n = 15), and normal pregnancy (n = 22) matched for ges-

tational age. For the determination of serum VEGF concentration a solid phase sandwich enzyme-linked immunosorbent assay (ELISA)

was used. Patients were stratified according to serum VEGF above or below 200 pg/ml. Results: The serum level of VEGF was signif-

icantly higher in women with EP (median 211.1 pg/ml; range 5-1,017.0 pg/ml) than in women with normal pregnancy (median 5 pg/ml;

range 5-310.6 pg/ml) p < 0.0001. Serum VEGF concentrations did not show any statistically significant difference between women with

miscarriage (median 231.9 pg/ml; range 5-813.7 pg/ml) and EP (median 211.1 pg/ml; range 5-1,017.0 pg/ml). When threshold con-

centrations of serum VEGF level > 200 pg/ml were used, an EP could be distinguished from a normal pregnancy with a sensitivity of

51.4%, a specificity of 90.9%, and a positive predictive value of 90%. Between EP and miscarriage, the sensitivity was 51.4%, speci-

ficity 42.8%, and a positive predictive value of 69.2%. Conclusions: Serum VEGF could not distinguish an EP from a miscarriage.

However, serum VEGF concentrations could discriminate a normal intrauterine pregnancy (IUP) from an unviable pregnancy (EP or

miscarriage).

Key words: Ectopic pregnancy; Miscarriage; Normal pregnancy; VEGF.


XXXIX, n. 2, 2012

Revised manuscript accepted for publication November 29, 2012

M.O. Fernandes da Silva, J. Elito Jr., S. Daher, L. Camano, A. Fernandes Moron490

In all groups, blood samples were collected as soon as anam-

nesis suggested a possible patient for the study. When there was

doubt in diagnosis of any patient, she was followed up with

TVUS and serial quantitative β-hCG, until the authors were

certain which group could match her.

The three groups: EP (n = 35), miscarriage (n = 15), and NP

(n = 22) were matched for gestational age (by date of last men-

strual period and ultrasound findings).

This work has been approved by the Ethics Committee of the

Universidade Federal de São Paulo. All patients agreed with the

study and signed Informed consent.

Serum assayAll blood samples were collected, before treatment, by periph-

eral venous puncture, and immediately centrifuged at 1,000 rpm

for ten minutes, and the supernatants were stored at –80°C until

assayed. For the determination of serum VEGF concentration, a

solid phase sandwich enzyme-linked immunosorbent assay

(ELISA) was used, which involved two kinds of highly specific

antibodies (human VEGF) specific for the human molecule.

Statistical analysisData are presented as median and range (minimum,

maximum). The three groups were compared using the Kruskal-

Wallis test and the Mann-Whitney U test with Bonferroni’s cor-

rection. Results were considered significant when p < 0.05. The

statistical analysis was performed using SPSS r12.

Results

The mean (± SD) gestational age was similar in the

three groups of women: 47.6 ± 4.8 days, 48.3 ± 4.9 days,

49.7 ± 4.3 days for the EP, miscarriage and NP groups,

respectively.

The serum level of VEGF was significantly higher in

women with EP (median 211.1 pg/ml; range 5 – 1,017.0

pg/ml) than in women with NP (median 5 pg/ml; range 5 –

310.6 pg/ml) p < 0.0001 (Table 1).

In this study, the median VEGF level among women with

EP (median 211.1 pg/ml; range 5 – 1017 pg/ml) and mis-

carriage (median 231.9 pg/ml; range 5 – 813.7 pg/ml) was

not statistically significant (Table 1).

When cut-off concentrations of 200 pg/ml for VEGF

were used, EP could be distinguished from NP with a sen-

sitivity of 51.4%, a specificity of 90.9%, and a positive pre-

dictive value of 90%. Between EP and miscarriage, the

sensitivity was 51.4%, specificity 42.8%, and positive pre-

dictive value of 69.2%.

Discussion

The evidences found in the present study suggest that

serum VEGF levels are higher in women with EP than in

those with NP of comparable gestational age (p < 0.0001).

The median of the VEGF serum values in EP was (211.1

pg/ml, n = 35) that is similar to the levels measured by

Daniel et al. (226.8 pg/ml, n = 20), by Kucera-Sliutz et al.(211.2 pg/ml, n = 42), by Mueller et al. (203.6 pg/ml, n =

43), by Daponte et al. (227.2 pg/ml, n = 27) and differ

from the study of Ugurlu et al. (55.2 pg/ml, n = 28).

The comparison of serum VEGF concentration between

EP and NP demonstrated in several studies that the levels

of VEGF are higher in EP [4, 8, 14] similarly to the

present results. However, other authors showed no differ-

ence between both groups [3].

The current results support, that serum VEGF may dis-

tinguish EP from NP. Therefore, early diagnosis of EP

could be suspected in a high probability when the serum

VEGF concentration is higher.

The crucial point is the discrimination between ectopic

and abnormal intrauterine pregnancy. In this work,

accordingly to previous studies, serum concentrations of

VEGF in women with EP were higher than in those with

miscarriage, but these concentrations did not show any

statistically significant difference between the two [8, 12-

15].

When threshold concentrations of a serum VEGF level

> 200 pg/ml were used in previous studies, EP could be

distinguished from a NP with a sensitivity of 88%, speci-

ficity of 100%, and a positive predictive value of 100%

[8], however, in the current study, these corresponding

values were 51.4%, 90.9%, and 90%, respectively. For the

discrimination between EP and miscarriage, Daniel et al.found a sensitivity of 60%, a specificity of 80%, and a

positive predictive value of 86%, when a cut-off of 200

pg/ml of serum VEGF concentration was used [12].

Another study found a sensitivity of 87.5%, a specificity

of 75%, and a positive predictive value of 77.8% [8]. The

corresponding values of another study were 56.1%,

51.2%, and 53.5%, respectively [14]. For discrimination

between EP and miscarriage the present authors found a

sensitivity of 51.4%, a specificity of 42.8%, and a positive

predictive value of 69.2%. On the other hand, serum

VEGF levels can distinguish an EP from a NP with a

specificity of 90.9% and a positive predictive value of

90%.

Serum VEGF initially seemed to be a very helpful

serum marker for EP [8, 12, 13]. Furthermore, other

reports showed the limitation of serum VEGF to distin-

guish an EP from a miscarriage [14, 15].

Recently a study has shown that using a two-step algo-

rithm with four markers (progesterone, VEGF, inhibin A,

and activin A), it was possible to achieve 99% accuracy

when diagnosing EP [16]. This suggests that even if

VEGF is not important alone, it could be helpful in asso-

ciation with other markers.

It is important to point out that TVUS used as a routine

diagnostic method for EP demonstrated to have a sensi-

Table 1. — Serum VEGF concentrations in women with EP,abnormal IUP, and normal IUP. Values are mean ± SD andmedian values with ranges.VEGF (pg/ml) EP Abnormal IUP Normal IUP

(n = 35) (n = 15) (n = 22)

Mean 297.5 299.6 39.9

Standard deviation 259.4 278.3 91.4

Median 211.1 231.9 5

Min 5 5 5

Max 1,017 813.7 310.6

p < 0.0001 between normal IUP and the other two groups (EP and abnormal IUP).

Association of serum levels of vascular endothelial growth factor and early ectopic pregnancy 491

tivity and specificity to detect EP of 90.9% and 99.9%,

with positive and negative predictive values of 93.5% and

99.8%, respectively [17].

In the present authors’ point of view, serum VEGF

measurement could be useful in the diagnosis of EP. In

this way a single serum VEGF measure could discrimi-

nate a viable from an unviable pregnancy in early stages

of gestation. In this phase a single β-hCG measurement

could not discriminate an EP from a miscarriage and in

this situation repeated β-hCG measurements with inter-

vals of 48 hours are necessary. A single serum proges-

terone measurement could not discriminate between EP

and miscarriage according to meta-analysis [18]. TVUS,

sometimes, could not identify the exact site of the implan-

tation in early stages of pregnancy. Despite the fact that

serum VEGF concentration is not very specific in the

early diagnosis of EP, it could discriminate the viable

pregnancy from an unviable one. This aspect is very rele-

vant since it helps the diagnosis of the cases with major

risk of complication.

Conclusions

Accordingly to the present results, VEGF levels could

not distinguish an EP from a miscarriage. However, serum

VEGF concentrations could discriminate a normal from

an unviable pregnancy (EP or miscarriage).

Acknowledgments

This work was financially supported by FAPESP (Fundação

de Amparo a Pesquisa do Estado de São Paulo – The Founda-

tion of the Assistance for Research in the State of São Paulo /

Brazil).

References

[1] Centers for Disease Control and Prevention. Ectopic pregnancy -

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[3] Gerton G.L., Fan X.J., Chittams J., Sammel M., Hummel A.,

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N.A.: “Novel placental and nonplacental serum markers in ectopic

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[5] Yao M., Tulandi T.: “Current status of surgical and nonsurgical

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[8] Felemban A., Sammour A., Tulandi T.: “Serum vascular endothe-

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[9] Tay J.I., Moore J., Walker J.J.: “Ectopic pregnancy”. West J. Med.,2000, 173, 131. Review.

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[11] Nowacek G.E., Meyer W.R., McMahon M.J., Thorp J.R., Wells

S.R.: “Diagnostic value of cervical fetal fibronectin in detecting

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and LIF for differentiating between ectopic and abnormal intrauter-

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[14] Ugurlu E.N., Ozaksit G., Karaer A., Zulfikaroglu E., Atalay A.,

Ugur M.: “The value of vascular endothelial growth factor, preg-

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[15] Kucera-Sliutz E., Schiebel I., Konig F., Leodolter S., Sliutz G.,

Koelbl H.: “Vascular endothelial growth factor (VEGF) and dis-

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[16] Rausch M.E., Sammel M.D., Takacs P., Chung K., Shaunik A.,

Barnhart K.T.: “Development of multiple marker test for ectopic

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[17] Condous G., Okaro E., Khalid A., Lu C., Van Huffel S., Timmer-

man D., Bourne T.: “The accuracy of transvaginal ultrasonography

for the diagnosis of ectopic pregnancy prior to surgery”. Hum.Reprod., 2005, 20, 1404.

[18] Mol B.W., Lijmer J.G., Ankum W.M., van der Veen F., Bossuyt

P.M.: “The accuracy of single serum progesterone measurement in

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M.O. FERNANDES DA SILVA, M.D.

Department of Obstetrics of the

Universidade Federal de São Paulo

Av. Dr. Paulo de Moraes 1671, ap. 12

Piracicaba SP, CEP 13.400-853 (Brazil)


492

Introduction

Chronic pelvic pain (CPP) is a frequent and widespread

disorder. The estimated prevalence in the general female

population is 15%, with the highest prevalence up to 24%

in women of reproductive age [1-3]. The most used clini-

cal definition is a continuous or intermittent, non-menstrual

and non-cyclic pelvic pain, lasting for at least six months.

The pain is of sufficient severity or intensity to interfere

with daily activities and is often unresponsive to regular

treatment [4-7].

The aetiology and pathogenesis of CPP is poorly under-

stood and as a result, effective diagnostic evaluation and

interventions remain scarce [8]. About 60% of women

never receive a specific diagnosis for their pain [9, 10]. Any

abdominal-pelvic structure may be involved, especially or-

gans of the genital tract, blood vessels, muscle and fasciae

of the abdominal wall, pelvic floor, and gastrointestinal

tract [8].

Women with CPP have a great tendency to utilize health-

care resources and undergo exhaustive diagnostic evalua-

tions without revealing an obvious cause [5]. Even if

abnormalities are detected, they are mostly coincidental and

not causative [11]. Forty to 50 percent of performed gy-

naecological laparoscopies and 12% of hysterectomies are

performed because of CPP [1, 12-15].

There is a lack of published data evaluating the epidemi-

ology of women with CPP; there are no guidelines for eval-

uation and treatment. The authors present an extensive de-

scription of the evaluation of women with CPP who con-

sulted their multidisciplinary team.


Since 2007, a multidisciplinary chronic pelvic pain team (CPP

team) is active at the gynaecological outpatient department of

the Sint Lucas Andreas Hospital. The aim of the team was to

analyse, evaluate, and advise women with CPP, while avoiding

prolonged suffering and hopefully reducing the number of undue

surgical interventions. Because of its observational and anony-

mous character, this study was exempted from approval by the

Institutional Review Board. The CPP team consisted of an urol-

ogist, gynaecologist, gastro-enterologist, psychologist-sexolo-

gist, and physical therapist as permanent members with experi-

ence in treating women with CPP.

After referral, but before consultation, women were asked to

complete questionnaires; women had to be capable to read and

understand the Dutch language. The self-administered question-

naire was the first step in the analysis and consisted of different

parts. The general part covers baseline demographic characteris-

tics and socio-economic status. The medical part covers clinical

and obstetric history, previous operations, current and past treat-

ment, and medication use. Pain-related variables included onset,

intensity, duration, association, character, and modifying factors.

Pain characteristics were measured by a composed questionnaire

and by the McGill Pain Questionnaire Dutch Language Version

(MPQ-DLV), which is a validated self-questionnaire for meas-

uring sensory and affective components of pain [16, 17].

The Dutch language version of the Symptom Checklist-

Revised (SCL-90-R) was used to assess physical and psy-

Chronic pelvic pain: evaluation of the epidemiology, baseline

demographics, and clinical variables via a prospective

and multidisciplinary approach

A.B. Hooker1,4, B.R. van Moorst1, E.P. van Haarst2, N.A.M. van Ootegehem1,3

D.K.E. van Dijken1, M.H.B. Heres1

1Department of Obstetrics and Gynaecology, 2Department of Urology and 3Department of Gastro-enterology and Hepatology,Sint Lucas Andreas Hospital (SLAZ), Amsterdam; 4Department of Obstetrics and Gynaecology, Zaans Medical Center (ZMC), Zaandam;

5Department of Gastro-enterology and Hepatology, Amstelland Hospital, Amstelveen (The Netherlands)

Summary

Background: Chronic pelvic pain (CPP) is a common clinical condition with significant impact on quality of life. The etiology and

pathogenesis of CPP is poorly understood. Materials and Methods: To examine the epidemiology, base line demographics, and clini-

cal variables, women with CPP were prospectively analysed by an integrated and synchronised approach. Results: Of the 89 women with

CPP analysed, the majority were assessed earlier, had a variety of surgical interventions and used pharmacological agents. Irritable

bowel syndrome, dysfunction of the pelvic floor musculoskeletal system, and physical or sexual abuse were the most common diag-

nosed etiologies. Evaluation revealed an increased level of psychological impairment. Discussion: CPP is a debilitating clinical condi-

tion and a result of complex interaction between different contributing factors. Patients will benefit from an orchestrated,

multidisciplinary, and synchronized approach with attention paid to the different domains of pain. Treatment is mostly not curative; avoid-

ing profound suffering despite persisting pain should be the goal.

Key words: Chronic pelvic pain; Diagnosis; Risk factors; Evaluation; Treatment; Therapy.


XXXIX, n. 2, 2012


A.B. Hooker, B.R. van Moorst, E.P. van Haarst, N.A.M. van Ootegehem, D.K.E. van Dijken, M.H.B. Heres 493

chopathological symptoms [18, 19]. The SCL-90-R is a vali-

dated 90-item multidimensional self-report symptom inventory

using a five point rating scale. The statements are assigned to

eight different dimensions: somatization, obsession-compulsion,

interpersonal sensitivity, depression, anxiety, hostility, phobic

anxiety, paranoid ideation, and psychoticism. The degree of psy-

chological distress/impairment is reported by the Global Sever-

ity Index (GSI): the value of all 90 items (range 90-450). Sub-

scales of the the SCL-90-R and the GSI were compared with the

reference score of a normal female and a chronic pain popula-

tion using the unpaired t-test. Statistical significance was deter-

mined at p < 0.05.

Inventarisation and treatment In the inventarisation phase, all women were individually

evaluated by each team member. A thorough exploration of the

pain and restrictions was performed including medical, social,

and cultural history. Physiological characteristics, including

history of traumas, were obtained by the psychologist-sexolo-

gist. This was done through a semi-structured interview with a

fairly open framework, which allowed for focused conversa-

tional two-way communication. Subsequent investigations, such

as ultrasonography of the abdomen, sigmoidoscopy, and/or

colonoscopy, radiography, gastroscopy, cystoscopy, and/or uro-

dynamic study were performed if necessary.

The work-up of women with CPP consisted of complete blood

count, serum chemistry, sedimentation rate, urine microscopy, and

culture. A bladder diary was required, including frequency-

volume chart. Vaginal and endocervical swabs for culture and

chlamydia trachomatis PCR were taken. Transvaginal ultrasonog-

raphy (TVUS) for screening of the vagina, tubes, uterus, and

ovaries was performed. Uroflowmetry was performed and the

post-voided residue was estimated by a bladderscan.

After all CPP-team members reviewed each woman, a final

multidisciplinary meeting was arranged to review and generate

multi-disciplinary diagnosis, advice, and treatment proposal. If

necessary, women were referred for additional analysis and

treatment. Otherwise, the advice and treatment was directed at

pain control and reassurance. In a last visit, the results of the

evaluation were thoroughly discussed and explained to the

women by the gynaecologist.

Results

From January 2007 to January 2009, 108 women were

referred to the outpatient department for evaluation. Nine-

teen women had to be excluded from this analysis; two

women did not meet the definition of CPP, whereas multi-

disciplinary advice could not be provided to 17 women due

to incomplete evaluation. Finally, 89 women with CPP

were included.

The mean age was 37.5 year (SD 10.1), ranging from 17 to

61 years. The majority, 68 women (76%) had Dutch nation-

ality, although 45 women (51%) were first-generation and 16

(18%) second-generation immigrants. Twenty-nine women

(33%) were nulliparous and 73 (82%) were premenopausal.

The characteristics of the women are shown in Table 1.

Seventy-five women (84%) used pharmacological agents

before consultation, including laxatives in 64 women (72%)

and analgesics (opiates and non-opiates) in 63 women (71%).

Sixty-six women (74%) were previously evaluated in sec-

ondary or tertiary care because of CPP and only 26 women

Table 1. — Baseline characteristics of the 89 women analysedby the chronic pelvic pain team.Characteristic n Percentage (%)

Age (years)< 25 14 15.7

26 – 35 23 25.8

36 – 45 35 39.3

46 – 55 13 14.6

> 56 4 4.5

NationalityDutch 68 76.4

Mediterranean 15 16.9

Other 6 6.7

Marital statusSingle / living apart 34 38.2

Married / living together 46 51.7

Separated / divorced 9 10.1

Living situationAlone 20 16.9

Alone with children 13 10.1

With spouse (and children) 46 67.8

With parents 6 6.7

Other 4 4.5

Parity None 29 32.6

1 17 19.1

2 23 25.8

> 2 20 22.5

Religion No religion 31 34.8

Islamic 30 33.7

Christian 20 22.5

Other 8 9.0

EducationPrimary school 13 14.6

Lower secondary school 26 29.2

Higher secondary school 11 12.4

Higher professional education 24 27.0

University 4 4.5

No education 4 4.5

Unknown 7 7.9

Employment Full-time 26 29.2

Social security 26 29.2

Part-time 14 15.7

Unemployment 11 12.4

Student 4 4.5

Disability insurance 5 5.6

Other 3 3.3

Stages of reproductivity Premenopausal 73 82.0

Perimenopausal 14 15.7

Postmenopausal 2 2.2

Unknown 1 1.1

Medicationa

No medication 14 15.7

Laxative 64 71.9

Analgesic (including opiates) 63 70.8

Paracetamol 40 44.9

Non-steroidal anti-inflammatory drugs 34 38.2

Opiates 11 12.4

Hormonal / contraceptives 18 20.2

Antidepressants 17 19.1

Benzodiazepines 12 13.5

Antacids / H2- receptor antagonists 7 7.9

Chronic pelvic pain: evaluation of the epidemiology, baseline demographics, and clinical variables via a prospective and etc.494

(29%) had no prior surgery. Laparoscopy was the most per-

formed procedure in 49 women (55%); in 23 (26%) within

24 months before evaluation and in eight (9%) repeatedly.

However, it was not completely clear whether all surgical

interventions were only indicated because of CPP. In the

majority of procedures, no abnormalities were detected; ad-

hesions were detected in 15 cases (17%), endometriosis in

nine (10%), myoma uteri in three, and benign ovarian cyst

in two cases. Irritable bowel syndrome (IBS) was the most

diagnosed etiology in 24 women (27%); adhesions, en-

dometriosis, and myoma uteri in 15 (17%), 10 (11%), and

seven (8%) women respectively.

Evaluation In the work-up, 11 women (13%) had an elevated sedi-

mentation rate, without signs of a clinical infection. The

median duration of pain was 36 months, interquartile range

16-96 months. Thirty-eight women (43%) reported pain du-

ration of more than four years. Seventy-two respondents

(81%) had pain for at least three days a week and 45 (51%)

had daily pain. The pain had a varying course in 39 women

(44%) and was moderate to severe in 82 (81%), as meas-

ured by MPQ-DLV. The pain characteristics and details are

presented in Table 2.

Forty-six women (52%) required additional investigation

to rule out somatic disorders. Seventy-four procedures were

performed. Ultrasonography of the abdomen was the most

performed examination in 22 women (23%); the other in-

vestigations were performed in 23 women (25 %). In the 67

women previously evaluated, 62 abnormalities were detected

in 38 women (57%); in the 22 women not previously

analysed, 12 abnormalities were detected in seven (27%).

The examinations performed, as well as the detected abnor-

malities, are shown in Table 3.

Urology Urine analysis, including urine culture of all women, re-

vealed no abnormalities. Twenty-four women (27%) had a

Table 1. — Baseline characteristics of the 89 women analysedby the chronic pelvic pain team.Characteristic n Percentage (%)

Prior surgeryNone 26 29.2

Appendectomy 12 13.5

Laparoscopy 49 55.1

No anomalies 24 49.0

Adhesions 9 18.4

Endometriosis 4 8.2

Uterine fibroids 3 6.1

Benign ovarian cyst 2 4.1

Unknown 7 14.3

Hysterectomy 10 11.2

Cesarean section 12 13.5

Miscarriage 6 6.7

Induced abortion 12 13.5

Diagnosisb

Irritable bowel syndrome (IBS) 24 27

Adhesions 15 16.9

Endometriosis 10 11.2

Myoma uteri 7 7.9

a All used medication were registered; mostly more than one medication was used.

b More than one diagnosis was possible.

Table 2. — Pain characteristics as reported by the 89 womenanalysed by the chronic pelvic pain team.Pain characteristic n Percentage (%)

Duration of pain (in years)< 1 20 22.5

1 to < 2 17 19.1

2 to < 4 14 15.7

> 4 38 42.7

Pain descriptionContinuous 51 57.3

Non-continuous 33 37.1

Other 5 5.6

Pain localisation Left lower abdomen 17 19.1

Right lower abdomen 26 29.2

Left and right lower abdomen 24 27.0

Other 22 24.7

Pain type Boring 30 33.7

Cutting 27 30.3

Cramping 9 10.1

Burning 7 7.9

Other 16 18.0

Pain correlationa

No correlation 44 49.4

Menstruation 19 21.3

Meal 14 15.7

Exertion 13 14.6

Voiding 12 13.5

Defecation 9 10.1

Stress/tension 6 6.7

Other 38 42.7

Pain onset Sudden 40 45.5

Gradual 44 49.4

Other 4 5.6

Pain onsetUnexpected 49 55.1

After pregnancy/delivery 18 20.2

After operation 8 9.0

After illness 3 3.4

Other 11 12.4

Pain courseVarying 39 43.8

Increasing 34 38.2

Identical 14 15.7

Other 2 2.2

Severity Light 7 7.9

Moderate 40 44.9

Severe 32 36.0

Unknown 10 11.2

Pain frequency Daily 45 50.6

5 to 6 days / week 19 21.3

3 to 4 days / week 8 9.0

< 2 days / week 3 3.4

Unknown 14 15.7

a More than one correlation could be present.


sense of urgency when needing to urinate; 15 (17%) had urge-

incontinence. A sense of hesitation was reported by 16 women

(18%) and dysuria by 22 (25%). Recurrent bladder infection

was reported by 28 women (32%). The frequency-volume

chart showed an abnormal urine volume in 23 women; 45

(51%) reported a urine frequency of at least eight times/day.

In 58 women (65%) no abnormalities could be detected dur-

ing urological evaluation. Dysfunction of the musculoskele-

tal pelvic floor was the most diagnosed etiology in 24 women

(27%) based on uroflowmetry; a combination of urine flow,

a striking abnormal flow pattern, and volume. Other detected

urologic abnormalities included overactive bladder (n = 3).

Gynaecology Dyspareunia was the most reported abnormality by 48

respondents (54%) and dysmenorrhea by 24 (27%). One

woman had a positive culture for chlamydia trachomatis,

while two had a candida infection, and all were treated. In

36 women (40%), no abnormalities were detected during

gynaecological evaluation, while musculoskeletal pelvic

floor dysfunction and provoked vulvodynia were diagnosed

in 29 (33%) and 19 women (21%), respectively. Other gy-

naecological abnormalities included endometriosis (n = 4),

myoma uteri (n = 4), adenomyosis (n = 3), and other ab-

normalities (n = 2).

Gastro-enterology Constipation was reported by 58 women (65%), followed

by nausea, diarrhea, and heartburn in 21, 20, and 13 women,

respectively. In 13 women (15%) no abnormalities could be

detected during evaluation. Fifty-one women (57%) were di-

agnosed with IBS according to the Rome II criteria [20].

Other detected pathology included peptic ulcer (n = 6), di-

verticulosis (n = 2), inflammatory bowel disease (n = 1), and

colorectal cancer (n = 1).

Table 3. — Additional examinations performed in the 89women evaluated by the chronic pelvic pain team.Patient evaluated n Percentage (%)

No additional investigations 43 48.3

Additional investigations a 46 51.7

Performed investigations n Percentage (%)

Total procedures 74 100

Cystoscopy 13 17.6

No abnormalities 12 16.2

Cystitis 1 1.4

Abdominal radiography 12 16.2


Coprostasis 3 4.1

Ultrasonography abdomen 22 29.7


Connective tissue disease 1 1.4

Pancreas abnormality 1 1.4

Other 2 2.7

Gastroscopy 11 14.9


Peptic ulcer disease/gastritis 6 8.1

Diaphragmatic hernia 2 2.7

Sigmoidoscopy / Colonoscopy b 16 21.6


Hemorrhoids 5 6.8

Anal fissures 1 1.4

Polyps 3 4.1

Colorectal cancer 1 1.4

Diverticulosis 2 2.7

Inflammatory bowel disease (IBD) 1 1.4

a Some patients had more than one additional investigation; a total of 74 investi-

gations were performed in 46 patients.

b One patient had both polyps and diverticulosis.

Table 5. — Diagnosis and treatment proposed to the 89patients by the chronic pelvic pain team. Diagnosis n Percentage (%)

Irritable bowel syndrome (IBS) 51 57.3

Pelvic floor musculoskeletal disorders 50 56.2

Physical or sexual abuse 50 56.2

Vulvodynia (provoked) 29 32.5

Somatic diagnosis suspected (referral) 10 11.2

Peptic ulcer disease 6 6.7

Endometriosis 4 4.5

Myoma uteri 4 4.5

Adenomyosis 3 3.4

Overactive bladder 3 3.4

Diaphragmatic hernia 2 2.2

Diverticuar disease 2 2.2

Inflammatory bowel disease 1 1.1

Colorectal cancer 1 1.1

Other 2 2.2

Treatment advice n Percentage (%)

Physiotherapy and/or counseling 52 58.4

Pharmacological 51 57.3

– Analgesic 2 2.2

– Hormonal/contraceptives 2 2.2

– Laxative 36 40.4

– Other 11 12.4

Physiotherapy 50 56.2

Referral to other specialist 10 11.2

No treatment 5 5.6

Surgical treatment/evaluation 4 4.5

– Laparoscopy 3 3.4

– Hysteroscopy 1 1.1

Other 2 2.2

Table 4. — SCL-90-R scores of 89 women evaluated by thechronic pelvic pain team.Dimensions Study group Normal population Chronic pain

(n = 82) (n = 577) population

(n = 2450)

Mean (SD) Mean (SD) Mean (SD)

Anxiety 19.2 (8.1) 14.6 (5.7)* 15.4 (6.3)*

Agoraphobia 10.2 (4.8) 8.7 (3.4)* 9.1 (4.0)#

Depression 32.8 (13.7) 23.8 (8.6)* 28.4 (11.4)*

Somatization 29.5 (10.1) 18.7 (7.1)* 24.9 (7.9)#

Insufficiency 18.6 (7.3) 14.1 (5.1)# 17.9 (6.4)*

Sensitivity 28.7 (11.8) 26.3 (8.8)* 25.2 (9.1)*

Hostility 9.5 (4.2) 17.6 (2.4)* 8.2 (3.1)*

Insomnia 14.3 (5.3) 5.2 (2.8)* 7.4 (3.7)*

GSI 167 (55.1) 128.9 (36.4)* 148.6 (45.5)*

GSI: global severity index. Difference between groups was measured with the

unpaired t-test. Statistical significance: * p < 0.001, # p < 0.05.


Psycho-sexologyA history of sexual and/or physical abuse was reported

by 50 women (56%); 28 (32%) reported affective depriva-

tion, physical/verbal abuse or neglect, and 18 women

(20%) reported domestic violence or assault, while 11

(12%) reported both. A history of childhood or adult sexual

abuse was reported by 38 women (43%). Rape of violation

was reported by 31 women (35%). The combination of sex-

ual abuse and physical or emotional abuse was reported by

20 women (23%). Support, counselling, and therapy were

provided to 50 women (56%).

Dyspareunia was reported by 73 women (82%); pro-

found, superficial, and combined in respectively 63, 59, and

49 women. Vulvodynia, based on characteristic findings in

history and gynaecological examination was diagnosed in

29 women (33%). Thirteen women (15%) reported to have

no sexual relations. Decreased desire for sexual activity

was reported by 43 women (57%) and decreased or im-

paired excitement by 38 (50%) women. Pelvic pain after

or during intercourse was reported by 48 women (54%);

after orgasm by 40 (45%) women.

The SCL-90-R scores of 82 women (92%) of this study

group are presented in Table 4. All the dimensions of the

SCL-90 and the GSI, the degree of psychological distress

impairment, were all significantly elevated compared to a

general female and chronic pain population.

Treatment proposalThe multi-disciplinary diagnosed etiologies were IBS in

51 women (57%), followed by pelvic floor musculoskele-

tal dysfunction in 50 (56%), and physical and/or sexual

abuse in 50 women (56%). The other etiologies are pre-

sented in Table 5. Fourteen women (15.7%) were referred

for further analysis or surgical treatment.

The majority of women, 51 (57%), received a combina-

tion therapy, 29 (33%) received mono-therapy, while five

(6%) women were considered untreatable. The most pro-

vided treatment proposal included counselling or psy-

chotherapy in 52 women (58%), followed by pelvic floor

physiotherapy in 51 (57%), and pharmacotherapy in 50

(56%). The other proposals are shown in Table 5.

Discussion

This prospective study reports the epidemiology of

women with CPP, concentrating on the baseline demo-

graphic and clinical variables, evaluated by a pragmatic and

clinically-fixed protocol. Questionnaires were the first step

in the evaluation.

The median pain duration was 36 months while 43% had

pain for at least four years and 81% at least three days a

week, a group with long lasting discomfort. Before con-

sultation, 74% of the women were evaluated because of

CPP, while 71% underwent a variety of surgical interven-

tions without revealing a definitive cause for their pain.

When pain is long-lasting, it becomes a disease with its

own physiopathology, involving multiple systems, leading

to psychological impairement [8]. A thorough evaluation is

advised as unrecognized or undetected abnormalities can

be present, even in women previously evaluated. However,

abnormalities may be coincidental rather than causal or sec-

ondary.

The final multidisciplinary diagnosis and treatment ad-

vice was generated, based on detailed evaluation of the pa-

tient and identification of all possible factors. The most

diagnosed etiologies were IBS in 57%, pelvic floor mus-

culoskeletal disorders in 56%, and psychosexual dysfunc-

tion in 56%. Treatment aims to stop or reduce the severity

of pain and exacerbations. Opioid analgesics should gen-

erally be discouraged due to the risk of dependence. Other

pharmacological agents include (combined) oral contra-

ceptive, laxatives, and anti-depressants.

Surgery can be used as a diagnostic tool but only after

consultation and evaluation by different specialists [21-23].

Laparoscopy does not appear to affect either pain symp-

toms or quality of life at long term [23, 24]. There is still no

consensus in the role of adhesions in generating CPP; they

constitute a very common finding [25]. Hysterectomy is

often performed but almost 40% will have persistent and

three to five percent worsening of pain [3]. Treatment of

anxiety and depression in women with CPP improves the

quality of life [26]. Pelvic floor training is effective, re-

sulting in significant relief and improvement [27, 28].

CPP is not a diagnosis but a description of a long-lasting

condition; the single most common indication for referral to

the gynaecologist [3, 11, 21]. The reported prevalence of

CPP varies according to several variables, but the rate is

similar to that of asthma, migraine headaches, and chronic

back pain [1, 29, 30]. Women with CPP are mostly man-

aged by primary care physicians and only 30%-40% are re-

ferred for further evaluation [1, 9, 11].

Women were individually analysed by all team members

for several reasons. First, exploration of the medical his-

tory is crucial and of the upmost importance, mostly being

more indicative than several diagnostic investigations [11].

Second, the etiology of CPP is often complex with pres-

ence of associated disorders. The combination of medical

history combined with multidisciplinary examination rules

out gross pathology and can prevent unnecessary diagnos-

tic and invasive interventions [31]. Finally, the physician-

patient relationship is positively influenced, which

encourages advice and treatment compliance.

The diagnostic label a women receives depends on vari-

ous factors, including age, symptoms, tract involvement,

presentation, result of performed evaluation, and investi-

gations [21]. A complex interaction between different fac-

tors exists and treatment of only some of them will lead to

incomplete relief and frustration of both patient and clini-

cian [11, 32]. In line with other reports, the most frequently

reported etiologies in the present cohort were non-gyneco-

logic, while most women were referred to a gynaecologist

for evaluation [5, 11, 31]. The results obtained by a multi-

disciplinary approach are significantly better compared to

traditional treatment by a gynecologist alone [33].

CPP is related to low-self-esteem, physical, sexual, and

emotional abuse, domestic violence, low marital satisfac-

tion, anxiety, depression, and somatic symptoms with a


high correlation between anxiety and depression in the

same woman [5, 26, 34, 35]. It is unclear whether pain, de-

pression, and anxiety are related to the specific diagnosis of

CPP or if they better correlate to the presence of a chronic

secondary illness.

Women with CPP have an increased level of psycholog-

ical impairment/distress as shown by SCL-90 and by the

GSI, and compared to a normal female and chronic pain

population, the degree of psychological suffering is signif-

icant elevated (Table 4). Medical specialist cannot be ex-

pected to conduct a thorough psychological evaluation.

However, they have an important role in identifying women

who may benefit from psychological assessment and treat-

ment [11].

Endometriosis, generally associated with cyclic symp-

toms, is considered a different entity with specific diag-

nostic and therapeutic strategies, although it was diagnosed

in four women. Interstitial cystitis has intentionally not

been diagnosed, as it is a syndrome of unknown etiology

without pathognomonic diagnostic findings [36, 37]. A sys-

tematic review did not demonstrate apparent differences

between multi-treatment modalities and placebo [38]. As

such, this diagnosis is not particularly helpful in women

with CPP.

Women with CPP are generally recognized as difficult to

evaluate, diagnose, and treat, mainly because of the com-

plexity and the different components of the condition [23].

Women are often referred because they are dissatisfied with

provided care and feel dismissed [21, 39-41]. CPP is a

costly condition; in addition to the frequent use of health-

care resources, 15% of women report absence from work,

while 45% report decreased productivity [1]. The treatment

of women with CPP should focus towards restoring normal

function and control of pain, minimizing disability and en-

hancing quality of life [31, 40].

The present study has several strengths and from a clin-

ical point of view, important implications. This is the first

prospective study in which the epidemiology of women

with CPP is systematically reported. Potential components,

including psycho-social ones related to the onset, mainte-

nance, and clinical course of CPP were analysed in the eval-

uation with validated instruments. However, interpretations

of these findings cannot be generalised to all women with

CPP because the study was conducted in a highly-selected

population.

Conclusion

CPP is a debilitating condition among women with a con-

siderable impact on quality of life and is a result of a com-

plex interaction between multiple factors. Individuals with

CPP have a long history of pain, psychiatric suffering, de-

creased productivity, and diagnostic evaluations. Identifi-

cation of relevant components of CPP by an integrated

approach leads to a better evaluation compared to analysis

by individual specialists alone. Treatment is mostly not cur-

ative and achievement of a higher quality of life despite

persisting pain should be the goal; managing rather than

curing. Further research is necessary to establish the rela-

tionship between demographic, clinical, and pain variables

and long-term outcome.

Acknowledgments

The authors thank Mieke C. Raadgers and Hedda van Pelt

(physiotherapists) for protocol development and data manage-

ment; Sicco Scherjon and Fedde Scheele (gynaecologists) for re-

viewing earlier versions of this manuscript.

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A.B. HOOKER, M.D.

Sint Lucas Andreas Hospital

Department of Obstetrics and Gynaecology

Zaans Medical Center


Koningin Julianaplein 58

P.O. box 210. Zaandam, NL 1500 EE

e-mail: [email protected];

[email protected]; [email protected]

499

Introduction

Urinary incontinence is involuntary leakage of urine [1].

It is a common problem among adult women; the overall

prevalence of 40% and between six to ten percent of

women with severe incontinence. It is well-known that

urinary incontinence is more common in women than in

men [2]. Stress urinary incontinence (SUI), being the most

common type of urinary incontinence in women, is due to

insufficient strength of the pelvic floor muscles. It is

defined as the complaint of involuntary leakage of small

amount of urine as a result of increased intra-abdominal

pressure and thus increased pressure on the bladder due to

effort, exertion, sneezing or coughing [1-3].

Tension-free vaginal tape (TVT) is a well-established

surgical procedure for the treatment of female SUI. It was

first described by Ulmsten in 1996, which is based on a

mid-urethral tape support, which is accepted as effective

and safe surgical technique [4-6].

Bladder penetration, urinary outlet obstruction, poten-

tial bowel penetration, intraoperative bleeding, and post-

operative infections are known complications of the clas-

sical TVT [5-13].

TVT-Secur was designed to reduce the undesired com-

plications and to minimize the operative procedure as

much as possible. This device is composed of an eight-cm

long polypropylene mesh and is introduced by a metallic

inserter, while no exit skin cuts are required [5].

The aim is to present the authors’ experience of using a

minimally invasive sub-urethral tape in form of either the

classic TVT, and TVT-Secur and to evaluate and compare

complications and short- and long-term results.


A retrospective study of 230 patients suffering from SUI had

TVT or TVT-Secur procedures performed at King Abdulaziz

University Hospital (KAUH) and United Doctor Hospital

(UDH) from March 1, 2007 until July 3, 2010 were analyzed and

studied.

Inclusion criteria were: urinary incontinence symptoms with

no intrinsic sphincteric deficiency, based on subjective com-

plaints, objective clinical signs, and confirmed in some cases

with urodynamic diagnosis including cystometry, uroflowmetry,

and stress test. An age of at least 30 years and patients desiring

surgical correction of SUI. The exclusion criteria were: post-

void residual volume > 100 cc and desired future childbearing.

History of bleeding diathesis or current anti-coagulation therapy,

current genitourinary fistula or urethral diverticulum, reversible

cause of incontinence (i.e. drug effect), and contraindication to

surgery.

All the procedures were performed after receiving consents

from the patients, informing them that tape would be positioned

to elevate the bladder. The type of operation and whether TVT

or TVT-Secur was to be utilized were selected according to the

surgeon’s preference and experience. All patients were given

prophylactic antibiotics and were subjected to an iodine antisep-

tic vaginal wash prior to commencement of the operation.

The mode of anesthesia depended on patient request and the

surgeon’s preference. Foley catheter was placed in all cases


XXXIX, n. 2, 2012


Comparison of the classic TVT and TVT-Secur

H.S.O. Abduljabbar1, H.M.A. Al-Shamrany1, S.F. Al-Basri1, H.H. Abduljabar2,

D.A. Tawati2, S.P. Owidhah1

1Department of Obstetrics & Gynecology, Medical College, King Abdul Aziz University, Jeddah, (Kingdom of Saudi Arabia)2Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg MB (Canada)

Summary

Background and aims: Tension-free vaginal tape (TVT) is a well-established surgical procedure for the treatment of female stress uri-

nary incontinence (SUI) and TVT-Secur was designed to reduce the undesired complications and to minimize the operative procedure as

much as possible. Aim: To present the authors’ experience in using the classic TVT and TVT-Secur and to evaluate and compare compli-

cations and short- and long-term results. Materials and Methods: A retrospective study and analysis of 230 patients presented with SUI at

King Abdulaziz University Hospital (KAUH) and United Doctor Hospital (UDH) from March 1, 2007 until July 3, 2010. Classical TVT

and TVT-Secur with or without associated operation were performed. All patients were controlled at six months and complications, as well

as objective results, have been reported. The study was approved by ethical committee of KAUH. Results: All patients with SUI admitted

to KAUH and UDH for sub-urethral tape were analyzed (230 patients); 149 had classical TVT and 81 had TVT-Secur. Their age ranged

from 30 years to 73 years with a mean of 49.8 years and std of 9.4. Their parity ranged from two to 15 with a mean of 6.2 and std of 2.4.

One hundred eighty patients had SUI and 50 patients had mixed incontinence. The type of anesthesia used was general anesthesia in 69.6%

(160) of cases and regional anesthesia in form of epidural or spine in 30.4% (70) of cases. Operative complications revealed a bladder per-

foration in 3.5% (eight) of cases and 2.2% had bleeding of more than 200 ml, and 53 patients which contribute to 23% had retention and

required a catheter for 48 hours or more. After three months, it was observed that erosion of the mesh occurred in three cases. Fourteen cases

(7%) continue to have SUI failure rate. Conclusion: The classical TVT and TVT-Secur were found to be very effective, easy, and safe pro-

cedures and with excellent results.

Key words: TVT; TVT; Secure urinary stress incontinence; Sling procedures.

H.S.O. Abduljabbar, H.M.A. Al-Shamrany, S.F. Al-Basri, H.H. Abduljabar, D.A. Tawati, S.P. Owidhah500

and cystoscopy was performed in all patients that underwent

classical TVT but not TVT-Secur. Patients presenting with sig-

nificant cystocele or rectocele were managed with anterior or

posterior colporrhaphies (anterior and posterior) as required.

Intraoperative and postoperative complications were

recorded. All patients were personally contacted through inter-

view after six months of the operation and then before writing

this paper. Failure was defined as persistent complaints of SUI

reported by the patients and then clinically confirmed that it

conditioned the quality of life. Minimal residual leakage, not

deteriorating the patient’s quality of life as reported by the

patients, was not considered as therapeutic failure. The study

was approved by ethical committee of KAUH.

The Statistical Package for the Social Sciences (SPSS) 15.0

software was used to analyze data using t-test, chi-square test,

and K independent sample (Kruskal-Wallis Test) were used

when appropriate. A p value of < 0.05 was considered to be sta-

tistically signficant.

Results

Out of 230 patients, 149 had classical TVT and 81 had

TVT-Secur and their age ranged from 30 to 73 years,

with a mean of 49.8 years and std of 9.4. Their parity

ranged from two to 15 with a mean of 6.2 and std of 2.4.

One hundred eighty patients had SUI and 50 had

mixed incontinence. Thirty percent of patients had past

medical history in form of hypertension and diabetes and

23.5% had past surgical history. Fifty-eight patients

(25.2%) had urinary tract infection treated with antibi-

otics. Out of 230 patients 175 patients (76.1%) had a

confirmed diagnosis of either SUI or mixed by urody-

namic testing.

One hundred sixty patients (69.6%) out of 230 had the

procedure performed under spinal or epidural anesthesia

and 70 patients (30.4%) had it under general anesthesia.

Table 1 shows the comparisons of the age in years and

parity which was not statistically significant. The opera-

tive time in minutes, hospital stay in days, and the

number of days needed to keep the catheter between the

two groups of patients who had classical TVT and those

who had TVT-Secur using t-test were statistically signif-

icant (p = 0.001).

One hundred forty-eight patients had either classical

TVT or TVT-Secur without concomitent gynecological

surgery and 54 patients underwent anterior and posterior

repair and only 28 patients underwent posterior repair

Table 2.

Out of 230 patients, 161 had no complications and 53

patients had voiding difficulties that required prolonged

catheterization; most of this type of complication

occurred in the group who had classical TVT. The fre-

quency of complications were not statistically signifi-

cant with (p = value 0.05) between the group who had

Classical TVT and TVT-Secur but the type of complica-

tion were different (Table 3).

The complications were more common in patients who

had concomitant surgery than patients who had TVT

alone and this was statistically significant (p = 0.001)

Table 4.

Discussion

The mid-urethral slings like TVT, TVT-Obturator

(TVT-O), and TVT-Secur became very popular proce-

dures among surgeons specializing in female pelvic

reconstructive techniques and had gained experience in

treating SUI. These procedures are simple and have

excellent results.

Table 1. — Age, parity, duration of operation, hospital stay,catheterization in TVT and TVT-Secur groups.Variable Type of Number Mean Std. p

operation deviation

Age (years) TVT 149 50.8 9.9

TVT Secur 81 48.1 8.3 0.03*

Parity TVT 149 6.1 2.4

TVT Secur 81 6.2 2.5 0.9*

Duration of TVT 149 70.8 21.5

operation (min) TVT Secur 81 51.4 13.7 0.001**

Hospital stay TVT 149 4.8 2.8

(days) TVT Secur 81 2.5 1.2 0.001**

Catheterization TVT 149 4.0 5.9

(days) TVT Secur 81 1.1 0.8 0.001**

*Statstically not significant; **Statistically significant.

Table 2. — Classical TVT and TVT-Secur and concomitentsurgery.

Classifical TVT TVT-Secur Total

Proceedure only 97 51 148

With anterior and posterior repair 40 14 54

With posterior repair 12 16 28

Total 149 81 230

Table 3. — Complication in classic TVT and TVT-Secur.No Classical TVT TVT-Secur %

No complications 161 100 61 70

Voiding problem, urinary retention 53 38 15 23

Bladder perforation 8 8 0 3.5

Retropubic hematoma, bleeding 5 2 3 2.2

Tape “mesh” erosions of

vaginal wall 3 1 2 1.3

Total 230 149 81 100

0.51*

*Not significant.

Table 4. — Complication in relation to concomitent procedure.Procedure A & P Post.

only repair repair

No complications 113 26 22 161

Voiding problem

(urinary retention) 19 28 6 53

Bladder perforation 8 0 0 8

Retropubic hematoma,

bleeding 0 2 3 5

Tape (mesh) erosions

of vaginal wall 0 1 2 3

Total 140 57 33 230

A & P repair = anterior and posterior repair; post. repair = posterior repair; p value 0.001:

statistically significant.

Comparison of the classic TVT and TVT-Secur 501

The experience at the present institution suggest that

TVT And TVT-Secur are easy to master and minimally

invasive with respect to tissue handling. It had been

reported by Rackley et al., that complications and surgi-

cal outcomes were similar to the present results and

found that patient selection was important to minimize

the potential morbidity, avoid patient’s mortality, and

produce a high-rate of durable success [14].

Neuman reported the complications and early follow-

up of TVT and TVT-Secur. TVT-Secur was associated

with early safety and efficacy problems. Intraoperative

complications associated with the TVT, such as bladder

penetration and postoperative complications, such as

thigh pain and bladder outlet obstruction, may be

reduced with TVT-Secur [15]. He also reported a com-

parison of two anti-incontinence operations: TVT and

the TVT-O. The surgeons' learning curves of these two

minimally invasive surgical procedures for the treatment

of female SUI was comparable. The safety and cost-

effectiveness of TVT are well-established. TVT-O, was

designed to overcome some of TVT-related operative

complications. TVT-O patients seem to have less intra-

operative and postoperative complications than the TVT

patients. However, long-term comparative data collec-

tion is required prior to drawing solid conclusions con-

cerning the superiority of one of these two operative

techniques [16].

Tommaselli et al., in their study to reduce complica-

tions of transobturator TVT, single-incision devices were

introduced in the last years. A comparison between TVT-

O and TVT-Secur techniques in terms of efficacy and

safety, showed no differences in terms of cure rate

between the two groups (81.6% vs 83.8%). Complica-

tion rate in the TVT-secur group was lower (8.1%) than

in the TVT-O group (15.8%), but not significant. So both

techniques seem to be effective and safe, with a low inci-

dence of complications in both groups [17].

In another study by Oliveira et al. to evaluate the

short-term surgical complications and results of a TVT

system and TVT-Secur, in the treatment of SUI, it con-

cluded that TVT-Secur is a simple and safe treatment for

female SUI, but before recommending this sling as a

first choice for treating SUI, TVT-Secur must pass the

test of time and comparative studies with conventional

slings [18].

Conclusion

The classical TVT and TVT Secur were found to be

very effective, easy, and safe procedures and with excel-

lent results. The complications were found to be more in

patients who had concomitant surgery of the TVT.

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Nappi C.: “Efficacy and safety of TVT-O and TVT-Secur in the treat-

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[18] Oliveira R., Silva A., Pinto R., Silva J., Silva C., Guimarães M. etal.: “Short-term assessment of a tension-free vaginal tape for treat-

ing female stress urinary incontinence”. BJU Int., 2009, 104, 225.


H.S.O. ABDULJABBAR, M.D.

Department of Obstetrics & Gynecology

Medical College

King Abdul Aziz University

P.O. Box 80215

Jeddah 21452 (Kingdom of Saudi Arabia)

e-mail [email protected]

502

Introduction

Pregnancy-induced hypertension (PIH) is a disease oc-

curring in late pregnancy. In severe cases, there may be

fetal growth retardation, maternal placental abruption, pre-

mature birth, and postpartum hemorrhage, which is one of

the main causes leading to the death of pregnant women

and perinatals in China. Immune factors have a close rela-

tion to the onset of PIH. In recent years, according to the

study involving maternal immune process in gestation,

regulatory T cells were gradually recognized as the regu-

lator of Th1 and Th2 cells [1-4]. CD4+ CD25

+ Treg is a

unique subtype of CD4+T [5], of which the main function

is to inhibit the autoreactive T cells from immune re-

sponse, the activation of conventional T cells, and to pro-

mote the secretion of inhibitory cytokine, as well as to

preserve the homeostasis of the body and induce tolerance

to grafts. CD4+ CD25

+ Foxp3+Treg are the Foxp3 tran-

scription-factor of X chromosome which is necessary for

the development, growth, and function of CD4+ CD25

+

Treg. Expression of CD4+ CD25

+ Treg and CD4+ CD25

+

Foxp3+Treg in the maternal peripheral blood during vari-

ous stages of pregnancy plays an inhibitory effect on ma-

ternal immunological rejection to a semi-allogeneic fetus

during the dominant control of fetal-maternal immune.

Under normal conditions, the absolute number of CD4+

CD25+Treg and CD4

+ CD25+ Foxp3+Treg in peripheral

blood during pregnancy increases and dynamically

changes. The preservation of normal pregnancy depends

on the stability of the immune balance, which once has

been broken, pathological pregnancy will occur. According

to recent findings [6, 7], the onset of PIH was closely-re-

lated to the imbalance of maternal immune, although there

are few researches or reports addressing regulatory T cells

in peripheral blood of PIH patients. In this research, the

expression of regulatory T cells and helper T cells in the

peripheral blood was studied to determine the possible im-

mune mechanism in PIH.


Twenty-seven patients with a systolic blood pressure ≥ 140 mm

Hg and a diastolic blood pressure ≥ 90 mm Hg or urine protein

from - to ++++ after 20 weeks gestation in the present obstetrics

department from January 2009 to December 2009 were consecu-

tively selected for PIH. This study was conducted in accordance

with the declaration of Helsinki and approved from the Ethics

Committee of the Fourth Affiliated Hospital of China Medical

University. Written informed consent was obtained from all par-

ticipants. Exclusion criteria included: patients recently suffering

from acute and/or chronic infectious diseases, patients with au-

toimmune diseases, patients with reproductive tract infections

which was confirmed by TORCH, chlamydia and mycoplasma

examination, and patients suffering from liver, kidney, and sys-

temic blood diseases. Twenty healthy pregnant women hospital-

ized simultaneously were selected as the control group.

Descriptive statistics about patients and control groups were sum-

marized in Table 1 with similar mean age and mean gestational

age (all p > 0.05).

Fasting cubital venous blood was obtained, centrifuged at 2,500

r/min for ten min to separate the serum and stored at -70°C. Type

FC-500-MPL of flow cytometry was utilized to detect regulatory

Tin peripheral blood (CD4+ CD25

+Treg and CD4+ CD25

+

Foxp3+Treg). Indirect immunofluorescence was used to determine

the level of regulatory T in peripheral blood (CD+

3, CD+

4, CD+

8,

and CD+

4/CD+

8).

SPSS 10.0 was adopted for data analysis. Data were expressed

as mean ± SD. T-test was used for comparison between groups. A

p < 0.05 was considered statistically significant.

Expression of regulatory T and helper T cells in peripheral

blood of patients with pregnancy-induced hypertension

X. Cao, L.L. Wang, X. Luo

Department of Obstetrics, The Fourth Affiliated Hospital of China Medical University, Shenyang City, Liaoning Provence (China)

Summary

Objective: To analyze the expression of regulatory T cells and helper T cells in peripheral blood of patients with pregnancy-induced

hypertension (PIH). Materials and Methods: Twenty-seven patients hospitalized with PIH were consecutively collected for detection

of regulatory T cells (CD4+ CD25+ Treg and CD4+ CD25+ Foxp3+Treg) and helper T (CD+3, CD+4, CD+8, CD+4/CD+8) cells in

peripheral blood. Meanwhile, 20 normal hospitalized pregnant women served as the control group. Results: In the comparison of reg-

ulatory T cells, the level of serum CD4+ CD25+ Treg and CD4+ CD25+ Foxp3+Treg in PIH group was significantly lower than con-

trol group (all p < 0.05). In the comparison of help T cells, the expression level of serum CD+4/CD+8 in PIH group was obviously higher

than control group, while the expression level of CD+8 was significantly lower than control group (all p < 0.05). Conclusions: There

were obvious abnormal expressions of regulatory T cell and helper T cells in peripheral blood of patients with PIH.

Key words: Pregnancy-induced hypertension; Regulatory T cells/peripheral blood; Helper T cells/peripheral blood.


XXXIX, n. 2, 2012

Revised manuscript accepted for publication December 6, 2012

X. Cao, L.L. Wang, X. Luo 503

Results

Expression levels of peripheral bloodThe comparison of the expression levels of peripheral

blood CD+

3, CD+

4, CD+

8, and CD+

4/CD+

8 between two

groups: the results suggested that the expression level of

peripheral blood CD+

4/CD+

8 in PIH group was higher than

control group, while the expression level of CD+8 was lower

than control group (all p < 0.05) (Table 2).

Expression levels of peripheral bloodThe comparison of the expression levels of peripheral

blood CD4+ CD25

+ Treg, and CD4+ CD25

+ Foxp3+Treg be-

tween two groups: the expression levels of peripheral

blood CD4+ CD25

+ Treg and CD4+ CD25

+ Foxp3+Treg

were significantly lower than control group (all p < 0.01)

(Table 3).

Discussion

Immune factors have a close relation to the onset of PIH.

According to the recent findings [8-10], regulatory T cells

played an important role in the balance between the regu-

lation of human peripheral immune tolerance and response

to the immunological stress caused by infection. It is well

known that pregnancy induces enhancement of immuno-

suppression to ensure the stable growth of the fetus. Nu-

merous Foxp3 related factors played an important role as

immunosuppression factor [11-13]. According to other

studies, CD4+ CD25

+ Treg played an important role in preg-

nancy maintenance [14, 15]. It was also confirmed that its

expression was enhanced during normal pregnancy imply-

ing the immunosuppressive effect of T cells for the preser-

vation of pregnancy [16-18]. Therefore, it was proposed

that the onset of PIH was closely related to the disruption

of maternal immune balance during pregnancy. The results

in this study showed that the expression level of serum

CD4+ CD25

+ Treg, CD4+ CD25

+ Foxp3+Treg and CD+

8 was

significantly decreased while the expression level of

CD+

4/CD+

8 significantly increased in PIH group in line

with other reports [6, 9]. Treg cells suppress the response of

immune system to its own and foreign antigens mainly

through the “active” way, but the amount and functional

changes of CD4+ CD25

+ Treg in patients with PIH still re-

main unknown. Previous studies [19, 20] reported that the

number of CD4+ CD25

+ Treg cells in peripheral blood of

PIH patients was significantly decreased when compared

with normal pregnancy or normal non-pregnant women,

suggesting that the decreased expression of Foxp3 in PIH

women was probably related to the reduction of CD4+

CD25+ Treg cells’ number. After further analysis, it was

found that T lymphocytes cells of these patients that were

activated, followed the lack of regulatory cells, especially

reducing Treg cells leading to maternal immune rejection

towards the fetus. It is believed that the significant decrease

of Treg cells in PIH patients affecting the immunomodula-

tory in the third trimester, prompted a shift in the Thl/Th2

balance from Th2 to Thl and disrupted maternal-fetal im-

mune tolerance, resulting in decreased immunosuppressive

protection from embryonic antigen and embryonic suscep-

tibility to immune attack. Therefore, a series of pathophys-

iological changes occurred including the onset and

progression of PIH.

In conclusion, Treg cells, which are important im-

munoregulatory cells, have the effect of inducing maternal

immune tolerance and preserving internal environment sta-

bility. There are significantly lower expressions and ab-

solute amounts of CD4+ CD25

+ Treg in peripheral blood in

pregnant women, which might be one of the causes of PIH.

It is believed that producing more CD4+ CD25

+ Treg cells

via different ways and the balance between regulatory T

cells and effector T cells may become a new option for the

treatment of PIH.

References

[1] Tilburgs T., Roelen D.L., van der Mast B.J., de Groot-Swings G.M.,

Kleijburg C., Scherjon S.A. et al.: “Evidence for a selective migra-

tion of fetus-specific CD4+ CD25 bright regulatory T cells from the

peripheral blood to the decidua in human pregnancy”. J. Immunol.,2008, 180, 5737.

[2] Krishnan L., Guilbert L.J., Russell A.S., Wegmann T.G., Mosmann

T.R., Belosevic M.: “Pregnancy impairs resistance of C57BL/6 mice

to Leishmania major infection and causes decreased antigen-specific

IFNgamma response and increased production of T helper 2 cy-

tokines”. J. Immunol., 1996, 156, 644.

[3] Piccinni M.P., Beloni L., Livi C., Maggi E., Scarselli G., Romagnani

S.: “Defective production of both leukemia inhibitory factor and type

2 T-helper cytokines by decidual T cells in unexplained recurrent

abortions”. Nat. Med., 1998, 4, 1020.

Table 1. — General information of the two groups.

Group Age in yearsMean age Gestational age Mean gestational

in years in weeks age in weeks

PIH group

(n = 27) 25 - 39 29.12 ± 5.39 36 - 40 37.91 ± 3.66

Control group

(n = 20) 24 - 37 28.64 ± 4.72 35 - 39 38.23 ± 3.25

Table 2. — The comparison of the expression levels ofperipheral blood CD+

3, CD+4, CD+

8, and CD+4/ CD+

8between the two groups.Group CD+

3 CD+

4 CD+

8 CD+

4 /CD+

8

PIH group

(n = 27) 66.28 ± 9.34 35.62 ± 4.53 21.80 ± 3.25a 1.78 ± 0.25b

Control group

(n = 20) 67.79 ± 10.55 36.17 ± 4.88 27.72 ± 3.64 1.39 ± 0.17

ap < 0.05, bp < 0.01 (compared with control group).

Table 3. — The comparison of the expression levels ofperipheral blood CD4+ CD25+ Treg, and CD4+ CD25+

Foxp3+Treg between the two groups.Group CD4

+ CD25+ Treg CD4

+ CD25+ Foxp3+Treg

PIH group (n = 27) 9.06 ± 2.56b 2.27 ± 0.85b

Control group (n = 20) 14.82 ± 3.35 3.98 ± 1.26

ap < 0.05, bp < 0.01 (compared with control group).

Expression of regulatory T and helper T cells in peripheral blood of patients with pregnancy-induced hypertension504

[4] Wegmann T.G., Lin H., Guilbert L., Mosmann T.R.: “Bidirectional cy-

tokine interactions in the maternal-fetal relationship: is successful

pregnancy a TH2 phenomenon?”. Immunol. Today, 1993, 14, 353.

[5] Saito S., Nakashima A., Shima T., Ito M.: “Th1/Th2/Th17 and reg-

ulatory T-cell paradigm in pregnancy”. Am. J. Reprod. Immunol.,2010, 63, 601.

[6] Sasaki Y., Darmochwakl-Kolam D., Suzuki D., Sakai M., Ito M., Shima

T. et al.: “Proportion of peripheral blood and decidual CD4+CD25+ reg-

ulatory T cells in preeclampsis”. Clin. Exp. Immunol., 2007, 149, 139.

[7] Cao W.P., Qian Q.J., Wen J.: “The research progression is between

CD4+CD25+Treg and hypertensive disorders in pregnancy”. Mat.Child Health Care China, 2008, 23, 3783.

[8] Prins J.R., Boelens H.M., Heimweg J., Van der Heide S., Dubois

A.E., Van Oosterhout A.J. et al.: “Preeclampsia is associated with

lower percentages of regulatory T cells in maternal blood”. Hyper-tens Pregnancy, 2009, 28, 300.

[9] Santner-Nanan B., Peek M.J., Khanam R., Richarts L., Zhu E.,

Fazekas de St Groth B. et al.: “Systemic increase in the ratio be-

tween Foxp3+ and IL-17-producing CD4+ T cells in healthy preg-

nancy but not in preeclampsia”. J. Immunol., 2009, 183, 7023.

[10] Sasaki Y., Sakai M., Miyazaki S., Higuma S., Shiozaki A., Saito S.:

“Decidual and peripheral blood CD4+ CD25 regulatory T cells in

early pregnancy subjects and spontaneous abortion cases”. Mol.Hum. Reprod., 2004, 10, 347.

[11] Sakaguchi S., Wing K., Onishi Y., Prieto-Martin P., Yamaguchi T.:

“Regulatory T cells: how do they suppress immune responses?”. Int.Immunol., 2009, 21, 1105.

[12] Shevach E.M.: “Mechanisms of foxp3+ T regulatory cell-mediated

suppression”. Immunity, 2009, 30, 636.

[13] Vignali D.A., Collison L.W., Workman C.J.: “How regulatory T cells

work”. Nat. Rev., 2008, 8, 523.

[14] Aluvihare V.R., Kallikourdis M., Betz A.G.: “Regulatory T cells me-

diate maternal tolerance to the fetus”. Nat. Immunol., 2004, 5, 266.

[15] Kahn D.A., Baltimore D.: “Pregnancy induces a fetal antigenspe-

cific maternal T regulatory cell response that contributes to toler-

ance”. Proc. Natl. Acad. Sci. USA, 2010, 107, 9299.

[16] Belkaid Y.: “Regulatory T cells and infection: a dangerous neces-

sity”. Nat. Rev., 2007, 7, 875.

[17] Johanns T.M., Ertelt J.M., Rowe J.H., Way S.S.: “Regulatory T cell

suppressive potency dictates the balance between bacterial prolifer-

ation and clearance during persistent Salmonella infection”. PLoSPathog., 2010, 6, online 2010 August 12. doi 10137/Jour-

nal.ppat1001043.

[18] Suvas S., Rouse B.T.: “Treg control of antimicrobial T cell re-

sponses”. Curr. Opin. Immunol., 2006, 18, 344.

[19] Zhao S.Y., Liu Y.S.: “The correlation between regulatory T cells and

hypertensive disorders in pregnancy”. J. Int. ReproductiveHealth/Fam Plan, 2006, 25, 153.

[20] Steinborn A., Haensch G.M., Mahnke K., Schmitt E., Toermer A.,

Meuer S. et al.: “Distinct subsets of regulatory T cells during preg-

nancy: is the imbalance of these subsets involved in the pathogene-

sis of preeclampsia?”. Clin. Immunol., 2008, 129, 401.


X. CAO, M.D.

Department of Obstetrics

The Fourth Affiliated Hospital of China

Medical University,

No. 4 Chongshan East Road

Huanggu District, Shenyang City

Liaoning Provence 110032 (China)


505

Introduction

Nuchal translucency (NT) measurement, detection of

presence or absence of nasal bone, and evaluation of the

characteristics of vascular flow in the ductus venosus, are

highly sensitive screening tools for trisomy 21, for other

major chromosomal defects, for congenital structural

anomalies, for heart defects, and for adverse pregnancy out-

come that results from other etiologies [1].

Using properly-measured NT alone allows prenatal de-

tection of over 70% of cases of trisomy 21. Using NT in

combination with maternal serum alpha-fetoprotein (AFP),

pregnancy-associated plasma protein A (PAPP-A), and free

beta-human chorionic gonadotropin β-hCG, provides effi-

cient Down’s syndrome risk assessment, with a detection

rate of 80%-87% (five percent false-positive rate), and also

allows earlier diagnosis of fetal aneuploidies [2, 3].

NT measurement is well-standardized for two-dimen-

sional ultrasonography (2D US) [2, 4]. Errors in measure-

ment may have a significant effect on risk assessment.

To improve reliability and to avoid errors, new US meas-

urement modes such as:

– three/four dimensional (3D/4D) surface [5-18],

– volume calculation with virtual organ computer-aided

analysis (VOCAL),

– automated volume count (AVC) [19, 20],

– semi-automatic systems [1, 21-28] and

– HDlive [29, 30] (Figure 1) have been tested.

Volume measurement of the nuchal area has been re-

ported [19, 20] and provides more detailed information

when the shape of a target object, such as an hygroma colli,

is irregular on a 2D image [20].

Only a small number of studies [1, 8, 24, 25, 27, 28]

have been reported on the potential benefits of using a

semi-automated approach in NT measurement. Six of the

references are scientific papers, all with a small sample

size, and one is an editorial [26]. All of them indicate that

the experience is too small and it is not possible to recom-

mend its use.

The aims of this study were: to evaluate the clinical use-

fulness of semi-automated distances using a 3D Sono T

software and to establish if the measurements using either

2D or Sono T have significant differences, in order to jus-

tify a high-economic inversion with the new software.


2D and 3D NT mid-sagittal measurements were performed in 63

patients with normal singleton pregnancies at gestational ages be-

tween 11 weeks and 13 weeks + six days. 2D US and Sono T soft-

ware were then employed to calculate the maximum NT width. All

measurements were acquired trans-abdominally.

Although the sample size is small (as the other publications), it

is mathematically sufficient. This investigation obtained the ap-

proval from the Ethics Committee from the “Fundación para la

Investigación del Hospital Clínico Universitario de Valencia,

(Spain)”. All patients signed informed consent.

Semi-automatic measurements were performed using the Sono

NT function in a mid-sagittal section determined by conventional

2D US.The operator placed the region of interest (ROI) in the most

representative section of the nuchal area. The upper calliper was lo-

cated on the inner border of the upper echogenic line and the lower

calliper was placed on the inner border of the lower echogenic line

(on-to-on measurement). The maximum vertical distance was au-

tomatically selected (Figure 1) [25].

Abnormal fetuses with enlarged NT and fetuses in the prone

position were excluded from the initial enrolment.

In each one of these, the authors measured NT in mm by one

operator, using 2D (NT1) and Sono T software (NT2). Manual

measurement of NT was performed according to the Fetal Medi-

cine Foundation (FMF) guidelines [4].

Statistical analysis The repeatability of the observations provided by both opera-

tors was compared by calculating the 95% ranges of agreement

over the differences [31]. This measurement is used by the British

Standards Institution [32] to define the repeatability coefficient.

Likewise, the point estimate of this difference and the 95% con-

Semi-automatic Sono T measurement of nuchal translucency

F. Bonilla-Musoles1, F. Raga1, F. Bonilla Jr.1, J.C. Castillo1, N.G. Osborne2, O. Caballero1

1Department of Obstetrics and Gynecology, University of Valencia, School of Medicine, Valencia (Spain)2Hospital Materno Infantil José Domingo De Obaldía, David, Chiriquí (Republica of Panama)

Summary

A prospective study of 63 singleton pregnancies between 11 + 0 and 13 + 6 weeks gestation underwent semi-automatic nuchal translu-

cency (NT) measurement and were compared with two-dimensional ultrasonography (2D US). Inter-observer variation and the re-

peatability were evaluated. Sono T automatically achieves mid-sagittal plane views and measures the maximum NT thickness.

Measurements have less inter-observer variation (CI = -0.13, -0.04) when compared with 2D measurements (CI = -0.45, 0.28). It is re-

producible and comparable to conventional 2D US technique for NT measurement. However, incorporating Sono T into routine prac-

tice requires further program refinements in order to reduce erroneous NT measurements.

Key words: 2D/3D; HDlive US; Semi-automatic Sono T; Nuchal translucency measurements.


XXXIX, n. 2, 2012


F. Bonilla-Musoles, F. Raga, F. Bonilla Jr., J.C. Castillo, N.G. Osborne, O. Caballero506

fidence interval was calculated. This method was applied for NT

measurements (NT1 vs NT2). Measurements were compared with

values of the FMF. All calculations were made with the Statistics

R, version 2.12.2 software [33].

Results

Two measurements, one of the NT in mm using 2D

(NT1), and one using Sono T software (NT2), were carried

out from observations on 63 patients.

Figure 2 shows NT1 (2D) and NT2 (Sono T) measure-

ments with a confidence interval of 90%, according to the

values of the FMF [4].

Figure 3 shows the differences between NT1 (2D) and

NT2 (Sono T) with respect to the percentile 50 of FMF. The

authors conclude that both technique measurements are not

significantly different from percentile 50 of FMF.

As can be seen in Figure 3, there is an association be-

tween the two measurements since Pearson’s correlation is

r = 0.9. The measurement of differences between the tech-

niques was a calculation of a range where disagreements

occurred in 95% ranges of agreement [27, 28]. With more

than 50 observations, it was based on the mean of the ob-

served differences (d) and the standard deviation of these

differences (sdiff). Defined as d ±1.96·sdiff. In this case,

the interval obtained [-0.45, 0.28] indicates no significant

differences between two measurements.

The confidence interval for the values (d, [d± sdiff/root

(n)]) is [-0.13, -0.04], which indicates that there is a bias in

the measurements of both operators. This means that a 2D

technique with an interval of -0.024 provides values that

are significantly lower than the values obtained with Sono

T, with a +0.06 interval.

Discussion

Unfortunately, fetuses are not always properly posi-

tioned for technically adequate NT measurements (only

Figure 1. — To the left Sono T showing the two red lines located in the inner border of both NT membranes (on to on measurement,

yellow arrow). The computer automatically measures the distance, appearing in the screen (same figure below right). To the right

transvaginal sonogram HD live. Upper right: transparency mode. Lower right different position of light source producing different

surface shadowing providing splendid image quality.

Semi-automatic Sono T measurement of nuchal translucency 507

10%-20% with the standard 2D abdominal or vaginal, ap-

proaches) [6]. Sonographers spend valuable time waiting

(often unsuccessfully) for the fetus to move into an optimal

position [19]. Moreover, when measurements obtained

with 2D/3D have been compared, it has been observed that

the 2D observations were often not realized in the optimal

plane [6, 9].

In order to improve NT measurements, other technolo-

gies have been used:

The introduction of 3D US measurements created high

expectations. Data from two decades were used for differ-

ential diagnoses between NT and hygroma colli [10, 11].

Later on, measurements between 2D and 3D were com-

pared and values were attached to inter- and intra-observer

visualization and reproducibility [11].

Refering to the semi-automatic methods, they have also

been reported years ago [21, 22] and were not incorporated

in the software of ultrasound machines. These methods are

based on tracing the inner borders of the nuchal membrane,

and consequently, they do not avoid the problem of under-

estimation of NT width associated with increased image

magnification.

There are six recent reports similar to these in studies that

used Sono T software [1, 8, 24, 25, 27, 28]. There is also

one update, a state of the art report that raises many ques-

tions [26]. They all suggest that fetal NT measurement

might afford some benefits.

Some like Moratalla et al. [1] compare the inter- and

intra-observer variability with traditional measurement.

Both variables were reduced with the automatic method.

The standard deviation of measurement was ten times

lower using a semi-automatic compared with a manual

method (0.0149 mm vs 0.109 mm), and the semi-automatic

method had an extremely high intra-class correlation coef-

ficient of 0.98 mm. Others like Abele et al. [25] conclude

that results are much better when obtained by “experts.”

They conclude that there is little evidence of any benefit in

terms of measurement error variability when compared

with manual methods.

A third group, Grangé et al. [24], suggests, curiously, that

the only benefit would be obtained when this technology

is used by less experienced operators and when they work

with images of poorer quality.

Finally, a fourth group [8] comparing the differences be-

tween “experts” and “beginners” observed that the differ-

ences with 2D were significant but were not with Sono T

Figure 2. — Values of NT1 (2D) and NT2 (Sono T) vs NT media

according to the values of the Fetal Medical Foundation (4).

Figure 3. — Left: relation Observer 1 (2D) vs Observer 2 NT (Sono T). Right: NT differences between observers.

F. Bonilla-Musoles, F. Raga, F. Bonilla Jr., J.C. Castillo, N.G. Osborne, O. Caballero508

measurements.They recommend, as the present authors do,

that Sono T be employed when experienced operators are

not available.

Crude errors are generated in these measurements if the

ROI box encompasses more of the nuchal area than strictly

the margins of NT. It therefore remains operator-dependent

[25].

Automatic measurement failed in 18.4% cases (the pro-

gram was unable to acquire the correct mid-sagittal plane in

13.1% of cases or the caliper was misplaced in 5.3% of

cases). [27, 28].

Manual skills are sufficient for reliable and reproducible

NT measurements until proven otherwise with other clini-

cal studies.

Widespread use of semi-automatic NT measurements,

which is only now taking off as part of many national

healthcare guidelines, could also lead to confusion at this

critical time, thereby undermining 19 years of effort, ex-

emplary teaching programs, and quality assessment proj-

ects [26]. Whether the new technologies Sono NT [24-26],

AVC, and VOCAL [27, 28] can replace the current manual

2D methods, and whether the minimal tenths and hun-

dredths of a mm differences in measurements are of inter-

est, are yet to be determined.

Perhaps the new semi-automatic systems that evaluate the

maximum distance over a 3D volume will be able to solve

this problem [8, 27, 28]. However, the authors have not been

able to see any evidence that this will be the case. At this

time, these inconveniences stand in the way of universal

unanimity in the use of these new 3D modes, since data are

not available for them as is the case with 2D methods.

Conclusions

This work supports normal measurements between the

gestational ages of 11 and 13 weeks + six days for Sono T

as is the case with other reports [1, 8, 24, 25, 27, 28]. It is

evident that semi-automatic measurements require further

research [26] before definitive recommendations can be

made [8, 27, 28]. The initial expectations for 3D US, AVC,

and Sono T have yet to be fulfilled [1, 26-28].

References

[1] Moratalla J., Pintoffl K., Minekawa R., Lachmann R., Wright D.,

Nicolaides K.H.: “Semi-automated system for measurement of

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tation. Fetal Medicine Foundation First trimester Screening Group”.

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[5] Shaw S.W., Hsieh T.T., Hsu J.J., Lee C.L., Cheng P.J.: “Measure-

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F. BONILLA-MUSOLES, M.D.

University of Valencia

Department of Obstetrics and Gynecology

School of Medicine

Blasco Ibañez, 17

46010 Valencia (Spain)


510

Introduction

In recent years more and more women decide to become

pregnant after the age of 35 [1]. Postponing pregnancy

causes difficulties in having offspring, mainly as a result of

age-related disadvantageous changes. Further more, the ca-

pacity of oocyte fertilization and the endometrial receptiv-

ity decrease [2].

A significant effort has been made to “stop the biological

clock” and to preserve fertility in older patients. Unfortu-

nately, the results of these attempts have not yet been sat-

isfactory. Moreover, premature ovarian failure (POF)

constitutes nowadays a problem as serious as primary in-

fertility [3].

Mitochondria take part in cellular respiration and their

function has a significant influence on the normal func-

tioning of the gamete [4, 5]. Mitochondrial DNA (mtDNA)

is a double-stranded chain, which, in humans is 16.6 kb

long. Almost each cell in the human body contains around

1,000 mitochondria, and every mitochondrion has two to

ten copies of mtDNA. Studies on mtDNA conducted over

the last 30 years, have led to the conclusion that anomalies

within mtDNA are related with fertility disorders in women

[6, 7]. It is possible, that POF may be associated with a de-

creased oxidative phosphorylation, which is observed in

the majority of cells in an aging body [8].

Over 150 types of rearrangements have been found in

human mtDNA. The most common deletions are the fol-

lowing deletions: mtDNA4977, mtDNA7436, and mtDNA10422

[9]. The mtDNA4977 deletion occurs within the limits of the

so-called “hot spot” in 8,468 and 13,446 nucleotide posi-

tions and is also called “common deletion” [10].

The mtDNA4977 deletion causes removal of the following

genes: Fo-F1-ATPase (ATPase 6 and 8), cytochrome oxidase(CO III), and oxidoreductase NADH-CoQ, which play a piv-

otal role in the oxidative phosphorylation and therefore

mainly results from mitochondrial function [11]. It has been

observed that in women over the age of 38 years, the granu-

losa cells within the follicles have a lower proportion of mi-

tochondria with normal DNA [12]. It is possible that the

age-related loss of mitochondrial function results from dele-

tion or point mutations within mtDNA. Hsieh et al. [11, 13]

suggested that some of the mutations within the mtDNA of

an oocyte may be responsible for failures in oocyte fertiliza-

tion. However, to the best of the authors’ knowledge, none of

the researchers described the mtDNA4977 mutations in pe-

ripheral blood leukocytes of women suffering from POF and

primary infertility.

The objective of the study was to investigate the incidence

of mtDNA4977 deletion in peripheral blood leukocytes of pa-

tients diagnosed with POF and primary infertility.


The study subjects comprised of 17 patients with POF and 32

patients with primary infertility. The control group consisted of

31 age-matched fertile (confirmed by at least one pregnancy) in-

dividuals. All participants underwent a complete examination and

history, including family diseases, at the Second Depart ment of

Gynecology of the Lublin Medical University in Lublin, (Poland).

None of them mentioned fertility problems in family anamnesis.

Among the fertile patients, 15 of them had one birth, seven had

two births, five had three births, and four had a miscarriage. The

study was approved by the Ethical Committee of the Medical Uni-

versity of Lublin. Informed consent was collected from all the

persons enrolled.

Positive (endometrial cancer with mtDNA4977 deletion [14]) and

negative (water instead of sample) controls were used in all ex-

periments.

mtDNA4977 deletion is not a common feature in patients

with premature ovarian failure and primary infertility

A. Bojarska-Junak1, A. Semczuk2, E. Grywalska1, J. Roliński1, L. Putowski3

1Department of Clinical Immunology, 2Second Department of Gynecology, and 3Department of Gynecology and Gynecological Endocrinology, Lublin Medical University, Lublin (Poland)

Summary

The aim of the current study was to investigate the incidence of mtDNA4977 deletion in peripheral blood leukocytes of patients diag-

nosed with premature ovarian failure (POF) and primary infertility. The study group consisted of 17 patients with POF, 32 women with

primary infertility, and 31 fertile women with the prevalence of the mtDNA4977 deletion using the reverse transcription-polymerase

chain reaction (RT-PCR) based technology. None of the patients affected by POF revealed mtDNA4977 deletion. This deletion was de-

tected only in one 26-year-old infertile patient. No significant difference in relation to mtDNA4977 deletion was reported between the

groups investigated (p > 0.05). In conclusion, mtDNA4977 deletion is not a common finding in peripheral blood leukocytes of women

affected by POF and primary infertility. The occurrence of mtDNA4977 deletion in women between 20 and 39 years of age may not in-

crease with increasing patients’ age, independently of their fertility status.

Key words: mtDNA4977; Premature ovarian failure; Primary infertility.


XXXIX, n. 2, 2012


A. Bojarska-Junak, A. Semczuk, E. Grywalska, J. Roliński, L. Putowski 511

Blood in an amount of two ml was sampled from an antecubital

vein in each of the study individuals in the morning after an

overnight fasting and was quickly deposited into a plastic tube

containing ethylenediaminetetraacetic acid (EDTA). Leukocytes

were immediately separated from plasma as the buffy coat in a

Ficoll gradient and were immediately forwarded to DNA isola-

tion.

The use of polymerase chain reaction (PCR) Master Mix re-

duced tube-to-tube difference caused by differences in the amount

of enzyme. Molecular probes were used (Table 1); the probe for

mtDNAtotal was labelled with reporter VIC. The probe for

mtDNA4977 was 6-carboxyfluorescein (FAM).

Total DNA from whole blood (5x106 leukocytes) was ex-

tracted. Following extraction, DNA was quantified and quali-

fied by UV spectrophotometric analysis. Template DNA

included 50-100 ng of DNA extracted from leukocytes. Reac-

tion mixtures included 0.25μµM forward and reverse primers,

200 nM probe, and 1x PCR Universal Master Mix for a final

volume of 50 µl. All experiments were performed under “mul-

tiplex” conditions. Primers and probes for both mtDNAtotal and

mtDNA4977 were present in each reaction (Table 1). The real-

time PCR reactions were run on a 7300 Real-Time PCR biosys-

tem. Cycling temperatures and times were 50°C for two

minutes, 95°C for ten minutes, 95°C for 15 seconds, and 60°C

for one minute.

Data were collected and analyzed using 7300 Real-Time PCR

System. Data were also normalized to mtDNAtotal amplified from

the cellular sample using the delta comparative threshold cycle

(CT) method. The CT value is the parameter used for quantifying

the amount of target template in the given reaction well. Delta CT(∅CT) for sample was the difference between the CT values of

the mtDNA4977 and mtDNAtotal (used as reference): ∅CT sample

= CT (FAM) – CT (VIC).The PCR-products were purified and separated on a 1.2%

agarose gel at 50 V in 1X TBE buffer, and the products were visu-

alized by ethidium bromide staining and photographed. DNA bands

were analyzed densitometrically using an appropriate software, and

the intensity of the mtDNA bands were measured. If the sample

was positive, the percentage of deleted mtDNA4977, with respect to

wild-type mtDNA, was determined by the ratio between the deleted

and wild-type mtDNA band densities.

Kruskal Wallis ANOVA, U-Mann-Whitney test, and Statistica

ver. 9.0 PL software were applied to statistical analysis and p <0.05 was considered significant. All results are showed as means

± standard deviation, medians, maximum and minimum.

Results

The current study investigated peripheral blood samples

collected from 17 patients with POF, 32 individuals with

primary infertility, and 31 fertile women. The character-

istics of the study subjects are listed at Table 2. The age

matched with no other health problems for the prevalence

of the mtDNA4977 deletion using the PCR-based method-

ology. None of the patients affected by POF revealed

mtDNA4977 deletion. This deletion was detected only in a

26-year-old infertile patient. No significant difference be-

tween groups investigated in relation to mtDNA4977 dele-

tion was noted (p > 0.05) Figure 1 presents a graphical

demonstration of real-time PCR data from 13 representa-

tive patients – 12 patients without mtDNA4977 deletion

(wells from one to 12), one patients (well 13) with dele-

tion, and a negative control (well 14).

Discussion

POF is a frequently occurring condition. The prevalence of

POF in women below 40 years of age is one to two percent

and in those below 30 years of age is 0.1%. It leads to the ab-

sence of menstrual period, hypoestrogenism, and elevated

levels of gonadotropins. It has been observed that POF oc-

curs in 10%-28% of women suffering from primary amen-

orrhea and in 4%-18% of those with its secondary form [15,

16]. It is worth mentioning that a major component of this

disorder may remain unsolved as a result of low awareness

among women who do not consider a loss of menstruation

before the age of 40 to be a serious medical condition re-

quiring gynecological consultation. Other causes of the lack

of monthly menstruation, such as pregnancy, hyperpro-

Table 1. — Primer sequences used in the experiments.Name Sequence Dye

Primer pairs for mtDNAtotal

mtDNA1307FOR 5’-GTA CCC ACG TAA AGA CGT TAG G-3’

mtDNA1433REV 5’-TAC TGC TAA ATC CAC CTT CG-3’

Primer pair for mtDNA4977

mtDNAdel49778416 5’-CCT TAC ACT ATT CCT CAT CAC C-3’

mtDNAdel49778542 5’-TGT GGT CTT TGG AGT AGA AAC C-3’

Molecular probe

Pr-total14977 CCC ATG AGG TGG CAA GAA AT VIC

Pr-del14977(T) TGG CAG CCT AGC ATT AGC AGT FAM

Pr-del14977(G) TGG CAG CCT AGC ATT AGC AGG FAM

Table 2. — Clinical characteristics of the patients with POF,primary infertility, and the control group.

Patients Patients Control

with POF with primary group

infertility

Number of individuals 17 32 31

Age Mean ± SD 30.14 ± 5.32 31.44 ± 3.89 31.52 ± 4.02

(years) Median 31 32 31

Minimum - maximum 20-36 21-39 24-39

Menarche Mean ± SD 14.50 ± 1.09 13.85 ± 1.54 13.28 ± 1.17

(years) Median 15 14 13


Weight Mean ± SD 60.90 ± 11.81 60.13 ± 12.79 63.61 ± 7.02

(kg) Median 60 58 63


Height Mean ± SD 163.13 ± 7.57 164.30 ± 6.36 165.57 ± 5.46

(cm) Median 163 164 164

Minimum - maximum 145-171 150-179 156-177

BMI Mean ± SD 22.83 ± 4.12† 22.18 ± 4.05 19.19 ± 1.83†

(kg/m2) Median 22.5 21.27 19.29

Minimum - maximum 17.60-34.29 15.99-33.22 14.24-21.51

17β-estradiol Mean ± SD 32.02 ± 15.28 81.85 ± 53.95 36.31 ± 12.58

(pmol/l)a Median 20 81.85 38.40

Minimum - maximum 1.87-66.20 43.70-120.00 20.00-52.90

FSH Mean ± SD 45.98 ± 28.82* 6.59 ± 2.25* 6.39 ± 1.84*

(IU/l)a Median 39.9 6.16 6.51

Minimum - maximum 14.40-107.46 3.74-11.40 3.70-9.57

LH Mean ± SD 20.91 ± 18.67†# 6.36 ± 3.59† 5.99 ± 2.36#

(IU/l) Median 15.10 5.04 6.10

Minimum - maximum 1.00-77.20 3.50-12.90 2.75-9.5

FSH/LH Mean ± SD 2.80 ± 1.94#* 1.08 ± 0.45# 1.08 ± 0.58*

ratio Median 2.15 1.09 0.84

Minimum - maximum 1.17-8.68 0.48-1.71 0.61-2.37

†p < 0.05; #p < 0.01; *p < 0.001; a measured at the second day of the follicular phase.

BMI = body mass index; FSH = follicle-stimulating hormone; LH = luteinizing hormone.

mtDNA4977 deletion is not a common feature in patients with premature ovarian failure and primary infertility512

lactinemia occurring due to the drug-induced or spontaneous

diminution of the dopaminergic hypothalamus activity, or

because of adenomas of the pituitary gland, thyroid dys-

function, and POF, have to be excluded. Women should be

checked for POF when amenorrhea persists for at least three

to six months, and when the level of FSH exceeds 40 mIU/ml

in at least two tests separated by at least a couple of months.

Intermittent ovarian function must be excluded, as it gives

similar symptoms, such as hypoestrogenism (less than 50

pg/ml) and high gonadotropins levels, along with the absence

of follicles or loss of their function [16, 17]. The loss of the

ability to conceive is mainly a result of the absence of ovar-

ian follicles, or, less frequently, the fact that the existing fol-

licles are unable to respond to stimulation.

The present study aimed to establish the frequency of

mtDNA4977 deletion in patients with POF and primary in-

fertility in comparison to healthy women. Furthermore, as

the normal structure of the cell membrane is lost, the dam-

aged mitochondria may release proteins that induce apop-

tosis, such as cytochrome C [18]. These phenomena have

been proved in observations of a mouse model. By means

of microinjection, normal mitochondria were inserted into

mice’s oocytes, which prevented them from apoptosis [19].

Tsai et al. [20] presented the effects of mitochondrial DNA

variations in cumulus cells upon in vitro fertilization and

embryo transfer outcomes. Pregnancy tests were positively

correlated with younger age, better-transferred embryo

qualities, and lower dmtDNA-delta5Kb (mtDNA4977 dele-

tion) ratios in cumulus cells. These authors concluded that

mtDNA4977 status in granulosa cells might be a potential

tool for oocyte evaluation and embryo selections during invitro fertilization [21]. Although Keefe et al. [21] suggested

that the common deletion may serve as a marker of oocyte

senescence, others failed to conform these observations [22,

23]. Most of the previous studies have shown that the inci-

dence of 4977bp deletion was significantly higher in older

women. This observation is in line with the hypothesis that

there is an age-related accumulation of mtDNA rearrange-

ments in human oocytes. However, none of the scientists

checked if deletions occur in somatic cells, such as leuko-

cytes of infertile patients. Unfortunately, the present data

definitely reported that POF and primary infertility are not

associated with the presence of deletion within mtDNA4977

in peripheral blood leukocytes. In findings among 80 pa-

tients, only one deletion revealed that the age-related effect

on occurrence of the mtDNA4977 is not apparent between

the ages of 20 to 39 and may be spontaneously present.

The objective of the study of Tong et al. [24] was to de-

termine if mitochondrial DNA polymerase gamma dele-

tions were associated with spontaneous 46,XX primary

ovarian insufficiency. Among 201 examined women, they

found only one case of heterozygosity for a polymerase

gamma, suggesting that this was not a common genetic eti-

ology for this form of infertility [24]. The present results

confirm these observations.

The authors conducted this study on peripheral blood

leukocytes with the use of highly-sensitive technique. To

the best of their knowledge, there are only a few studies fo-

cused on the mentioned data. A significantly higher inci-

dence of mtDNA4977 in peripheral blood leukocytes was

observed in coronary artery disease patients with respect to

healthy subjects; even the examined group was not so large

as in this study (65 vs 80) [25]. Iwai et al. [26] examined

the effect of green tea enriched with catechins on the pres-

ence of the mtDNA4977 deletion mutation in human leuko-

cytes obtained from ten healthy young females (median age

20.8 years, similar to this study group). They found that

mutation was present in nine participants before drinking

the tea and after the experiment; the mutation was noticed

in none of the participants. Perhaps the dietary habits and

other yet unknown predictors are more connected with

mtDNA state than other conditions, including fertility. Cur-

rent study was performed on the second day of the follicu-

lar phase in all participants and subsequently further

research is necessary to assess a possible relationship, if it

exists, between mtDNA4977 state and menstrual cycle.

Figure 1. — Graphical demonstration of real-time PCR data

from 13 representative patients [12 without mutation (wells from

1 to 12) and one patient (well 13) with mutation, well 14 – neg-

ative control]. A: In this view, normalized reporter (Rn) is

graphed vs the cycle. B: ΔRn is Rn minus the baseline, graphed

vs the cycle of PCR. C: CT vs well position.

Rn vs cycle

Delta Rn vs cycle

Ct vs well position

Cycle number

Cycle number

Well position

A. Bojarska-Junak, A. Semczuk, E. Grywalska, J. Roliński, L. Putowski 513

Acknowlegment

This study was supported by research grant no. 1.2.2.1, PBZ-

MEiN-8/2/2006 from State Funds for Scientific Research,

Poland (to L.P.).

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[26] Iwai K., Iwamura Y., Yamashita S., Wadano Y., Mesaki N.: “Effect

of tea catechins on mitochondrial DNA 4977-bp deletions in

human leucocytes”. Mutat. Res., 2006, 595, 191.


A. SEMCZUK, M.D. Ph.D.

Professor of Obstetrics and Gynecology

at the Lublin Medical University,

8 Jaczewski Street,

20-954, Lublin (Poland)


514

Introduction

Pregnancy and childbirth are fundamental events in the

life of most women and in the majority of them these

events change priorities, attitudes, and lifestyle. This is

particularly true when dealing with future contraception.

During pregnancy and in the postpartum period, women

have been found to be more receptive to discussions with

their care providers regarding the provision of methods

capable of delaying or preventing altogether the occur-

rence of another pregnancy [1]. Thus, clinic visits during

pregnancy and puerperium provide a unique opportunity

to counsel women; this is indispensable since, in many

cases, even if the woman has utilized a contraceptive

method before a planned pregnancy, this previous method

may no longer be desirable or ideal after childbirth [1, 2].

Unfortunately, despite the great opportunity to provide

advice during antenatal care visits on postpartum contra-

ception, caregivers often miss this opportunity. Even

immediately after delivery the issue of future contracep-

tion is often neglected. For instance, a survey conducted

some 15 years ago in Edinburgh showed that only 50% of

new mothers received a contraceptive supply when

leaving the hospital. The same study reported that only a

scanty four percent of women were given an opportunity

to discuss postpartum contraception and this was usually

a brief, limited encounter before leaving the hospital [3].

Even when postpartum programs are in place, their

appropriateness has been questioned and, indeed, more

attention needs to be given to this issue because postpar-

tum contraception is vital to ensure adequate birth

spacing, a major component of every effort to improve

maternal and infant health. It has been estimated that

globally implementing a two-year birth interval would

avoid some 100,000 maternal deaths every year and also

significantly reduce abortion rates [4].

Over ten years ago, in a large multinational survey of 27

countries, Ross and Winfrey [5] estimated that many post-

partum women had unmet family planning needs, includ-

ing a significant lack of information regarding postpartum

contraception and optimal available methods. Obviously,

this lack of information varies with geographical areas,

education and social class, but substantial improvements

are mandatory everywhere. For instance, in the Russian

Federation, Vikhlyaeva et al. [6] have shown that a major

improvement in counseling services for post-delivery con-

traception is necessary both in the maternity hospitals and

in local family planning centers.

While many studies have evaluated patient satisfaction

with specific contraceptive methods, few have focused on

contraceptive needs of peripartum women [1, 2, 7, 8]. In

a recent study, Glazer et al. [9] investigated 175 postpar-

tum women attending an American University hospital

out-patient clinic, asking whether contraceptive advice

was offered either at ante- or postpartum. They found that

three-quarters of the respondent (77%) had discussed

future contraception before delivery and 87% did so

during postpartum. Interestingly, 23% of the subjects

would have elected immediate post-placental intrauterine

device (IUD) placement if available, although at follow-

up contacts four to six months after delivery, only five

percent reported using an IUD, 29% were using no con-

traception, and 32% utilized a method which was not

highly effective. This indicates that even in a tertiary

urban hospital in the USA, there can be an unmet need for

contraception, at least during postpartum.

Unmet needs and knowledge of postpartum contraception

in Italian women

C. Bastianelli1, M. Farris1,2, G. Benagiano1, G. D’Andrea1

1Department of Gynecological-Obstetrical and UrologicalSciences, “Sapienza” University of Rome, Rome2AIED, Italian Association for Demographic Education, Rome (Italy)

Summary

Purpose of investigation: Clinic visits during pregnancy and puerperium provide a unique opportunity to counsel women on contra-

ception practices. With the aim of evaluating postpartum contraceptive attitudes among urban women attending an antenatal care cen-

ter and delivering in the same facility, a structured questionnaire was administered to assess desired and received information on

contraception in the postpartum period. Results: A total of 436 consecutive interviews were collected during the study period. Pre-

gnancy was unplanned in 39% of the women interviewed. Overall, 269 women (61.7%) had decided to use a method of family plan-

ning during postpartum. Among the 112 women who stated they did not want to use a method during postpartum, almost 50% stated

that they “did not think they needed it”, due to a perceived lack of real risk. Of the 436 women interviewed, only 5.5 % women ackno-

wledged that they had received information on contraceptive use. Conclusion: The present study indicates a need for ante- and po-

stpartum counseling of women even in urban areas of Italy..

Key words: Postpartum contraception; Contraception attitudes; Hormonal contraception; Intrauterine contraception; Contraceptive

needs; Contraception unmet needs.


XXXIX, n. 2, 2012

Revised manuscript accepted for publication August 7, 2012

C. Bastianelli, M. Farris, G. Benagiano, G. D’Andrea 515

Several investigations have been conducted on the deli-

cate issue of counseling adolescents pre- and postpartum,

as well as on reasons for contraceptive non-use among

young women who have had a delivery; these investiga-

tions are important for a proper understanding of adoles-

cent attitudes and for reducing teenage pregnancy [10-13].

In 2007, Lemay et al. investigated non-use of contracep-

tion prior to first pregnancy among adolescent mothers and

listed as reasons: denial, not planning to have sex, not con-

sidering the consequences of unprotected sex, and wanting

to become pregnant. They concluded that in the USA, ado-

lescents favored routine discussions of the topic, parental

involvement, exchange of information between young

mothers and teenagers at risk, and media campaigns [14].

Recently, Lopez et al.[15] have conducted a Cochrane

review of existing data on “education for contraceptive

use by women after childbirth.” They found eight trials

meeting their initial criteria for inclusion. On further

analysis, there were only two studies evaluating short-

term interventions with sufficient data and statistical

power and both showed a positive effect on contraceptive

use. They also analyzed four programs with multiple con-

tacts: two showed more contraceptive use, fewer preg-

nancies or births among adolescents when there were

enhanced services, and a structured home-visiting

program. A group in Taiwan has now defined a “theory-

based interactive postpartum sexual health education

program” aimed at enhancing effective contraceptive

behaviors in postpartum women with a follow-up over

three months. They randomized 250 women into three

groups. The first group received the full intervention

program that utilized strategies matching participants’

learning preparedness, as determined by a “transtheoreti-

cal” model including health education. The second group

received only a pamphlet and the third group (used as con-

trols) received routine education. The study proved that

this new approach was capable of enhancing postpartum

contraceptive self-efficacy and effective contraceptive

behavior in participating women.

In Italy in 1978, after the passing of legislation permit-

ting voluntary pregnancy termination [16], the Ministry of

Health has been mandated by Parliament to draw-up

annual reports providing full information on legal abor-

tions (e.g. number of abortions, abortions’ rates, and

number of repeated abortions) and the most recent report,

once again indicates that women who already had one

pregnancy are at higher risk of a new pregnancy, thereby

showing lack of postpartum counseling.

With the aim of evaluating postpartum contraceptive

attitudes among urban women attending an antenatal care

center and delivering in the same facility, a study was

designed to assess desired and received information on

contraception in the postpartum period.


All consenting pregnant or puerperal women admitted to the

Department of Obstetrics, Gynecology and Urology at the Poli-

clinico Umberto I° Hospital, of the “Sapienza”, University of

Rome were interviewed during the period from January 2009 to

December 2009.

The Ethics Committee of the Hospital approved the study and

individual informed consent was obtained after study character-

istics. and the questionnaire were verbally explained to prospec-

tive participants. General characteristics were recorded even for

those who did not accept to participate to the study.

Considering an alpha level of 0.05 and a statistical power of

0.80, the minimum sample size required was 213. The sample

size was then adjusted to compensate for a non-response rate of

20%. Thus a minimum final sample size of 256 was established.

Statistical analysis was performed using SPSS (version 15), cat-

egorical variables were compared with chi-square test and Fisher

exact test, as appropriate, while continuous variables were com-

pared using t test. A p value of < 0.05 was considered signifi-

cant.

A self-administered structured questionnaire with closed ques-

tions was utilized for the interviews. The questionnaire was

organized in seven sections: general demographic characteris-

tics; obstetric history and breastfeeding attitudes; previous con-

traceptive usage; intention to use a contraceptive method after

delivery; knowledge of contraception in general and of specific

postpartum contraceptive modalities; information received on

postpartum contraception; factors that influenced their inten-

tions, as well as their intended contraceptive choices. Additional

information was obtained on whether their pregnancy was

planned or not, whether the woman attended a hospital or a

private clinic for antenatal care, and if she attended a prepara-

tory course before delivery. The questionnaire was first admin-

istered in a pilot study and then validated.

The mean time for filling the questionnaire was estimated to

be approximately 15 minutes.

Results

During the study period, 1,760 women gave birth at the

Department Obstetrics, Gynecology and Urology. A total

of 436 consecutive interviews were collected during the

study period, 284 respondents were pregnant, while 152

were puerperal women. Of these, 36.9% has been fol-

lowed during pregnancy by the outpatient obstetrics

service of the Department, 30% by a private physician,

20% by public clinic, and the last 13.1% by the obstetric

clinic of a different hospital.

The mean age of respondents was 31.7 ± 6.08 years

(SD) with a range of 18-41 years.

Non-respondents were similar to respondents for

general demographic characteristics and obstetrical

history.

Overall, pregnancy was planned in 61% of the women

interviewed, while in 39% it was unplanned (266 and 170,

respectively).

As indicated in Figure 1, among women below 25 years

of age, the vast majority of pregnancies (84.8%) were

unplanned; this proportion decreased with age and

reached a minimum (24.8%) among women aged 30-34

years, increasing again thereafter.

Table 1 shows that overall, 269 women (61.7%) had

decided to use a method of family planning during the

postpartum, with 112 (25.7%) opting or having opted for

no contraception and 55 (12.6%) undecided. Of the three

variables and many categories listed in Table 1, the only

Unmet needs and knowledge of postpartum contraception in Italian women516

ones that showed a significant association with the inten-

tion to use a contraceptive in postpartum were: previous

contraceptive use (p = 0.0001), having received a higher

education (diploma; p = 0.04), and paradoxically being of

Catholic religion (p = 0.05). However, it must be pointed

out that only some 12% of all participating women were

non-Catholic, with 7.5% being Orthodox Christians.

The overwhelming majority of subjects wanting to use

a method of contraception during the postpartum (220 or

81.8%) gave the need to achieve a proper “birth spacing”

as the reason. Only 13 (4.8%) stated that they had com-

pleted their project for a family, with 36 (13.4%) being

unable to provide any specific reason (Table 2).

An analysis of postpartum contraceptive choices made

by women who wanted to use a method during postpar-

tum, indicated that the vast majority (82%) preferred the

use of combined hormonal contraceptives. Intrauterine

contraception was selected by some eight percent of the

subjects, while 4.8% stated that they would use a barrier

method.

Among the 112 women who did not want to use a

method during postpartum, almost 50% (54 or 48.2%)

stated that they “did not think they needed it”, due to a

perceived lack of real risk (Table 3).

With regard to medical permissibility of using a contra-

ceptive method while breastfeeding, 87% of the women

stated that they were not aware of the existence of

methods that could be safely used during this period

(Table 4).

Among women who did not believe that a contraceptive

method could be used during postpartum, as stated above,

almost half felt that – at any rate – they were not at risk.

Of the 436 women interviewed, four did not provide

information on contraceptive methods to be used during

the postpartum period. In addition, only 24 women (5.5%

of the 432 that gave an answer) acknowledged that they

had received information on contraceptive use; most of

Table 1. — Association between variables (age, educationreligion) and intention to use contraception (n. 436). Variables Intention to use a contraceptive

Yes No Do not Total p value

% n % n % n %* n

Age< 25 47.8 22 32.6 15 19.6 9 10.55 46

25-29 83.2 94 15.0 17 1.8 2 25.91 113

30-34 41.1 53 30.2 39 28.7 37 29.58 129

35-39 72.0 85 22.0 26 6.0 7 27.06 118

> 40 50.0 15 50.0 15 0.0 0 6.88 30

ReligionNo 100 35 0.0 0 0.0 0 8.02 5

Catholic 61.6 215 26.6 86 13.7 48 80.04 349 0.05

Orthodox 24.2 8 60.6 20 15.1 5 7.56 33

Protestant 0.0 0 100 4 0.0 0 0.91 4

Evangelic 0.0 0 100 2 0.0 0 0.45 2

Muslim 100 9 0.0 0 0.0 0 2.06 9

Buddhists 0.0 0 0.0 0 100 2 0.45 2

Hinduist 100 2 0.0 0 0.0 0 0.45 2

EducationNo/Primary 0.0 0 100 4 0.0 0 4

Secondary 60.0 60 40.0 40 0.0 0 100

Diploma 66.8 153 62.4 143 14.4 33 229 0.04

University 54.4 56 24.3 25 21.3 22 103

Previous contraceptive useYes 77.3 215 18.0 50 4.7 13 278 0.0001

No 43.2 54 40.8 51 16.0 20 125

No answer 0.0 0 33.3 11 66.6 22 33

Total 61.7 269 25.7 112 12.6 55 436

* Percentage of 436 women.

Table 2. — Reasons for wanting to use contraception duringthe postpartum period (n. = 269). Reason n %

Birth Spacing 220 81.8

Completed family 13 4.8

Other 36 13.4

Table 3. — Contraceptive choices for the postpartum period.% n

Total “yes” 269

Hormonal 81.78 220

Intrauterine device 7.80 21

Barrier methods 4.83 13

Sterilization 0.74 2

Did not know which method 4.83 13

Total “no” 112

No, does not think to need it 48.21 54

No, willing to have a new pregnancy 31.25 35

No, previous negative experience 15.17 17

No, no reason given 5.35 6

Total “do not know” 55

Table 4. — Knowledge that contraception can be used duringbreastfeeding.

% n

Yes, hormonal 17.54 10

Yes, intrauterine device 49.12 28

Yes, barrier methods 42.10 24

Yes, natural 5.62 3

Total “yes” 13.07 57

Total “no” 84.86 370

Did not answer 2.06 9

Figure 1. — Proportion of postpartum women who had planned

pregnancy (by age).

C. Bastianelli, M. Farris, G. Benagiano, G. D’Andrea 517

them (21) from their obstetrician, with three who found

useful information in the media (Table 5). All these sub-

jects were among the 220 women who wanted to use hor-

monal contraception.

No statistically significant difference was observed

between pregnant and puerperal subjects in ‘intention to

use contraception’, with a preference for hormonal

methods (p = 0.02).

Parity was significantly related to intention to use a con-

traceptive: women with a prior pregnancy being more

likely to wanting to use contraception in postpartum (p =

0.0048) (Table 6)

Discussion

In the Industrial world, many believe that a pregnancy

is the result of careful planning; yet, data from the Global

Health Council indicate that, of the 205 million pregnan-

cies occurring annually worldwide, between 60 and 80

million are unplanned. In addition, more than half of the

millions of unwanted pregnancies are terminated by elec-

tive abortion, a high proportion of which, are performed

in developing countries under unsafe conditions [17].

The present study found that, overall, pregnancy was

unplanned in almost 39% of the women interviewed; this

percentage rose to almost 85 among those below 25 years

of age. Almost two-thirds of them opted for a method of

family planning during the postpartum period, giving as

the main reason the need to properly “space” pregnancies.

In their vast majority, these women preferred oral contra-

ception. Almost half the women who did not want to use

contraception during the postpartum believed that the risk

of another pregnancy was negligible, although they were

not even aware of the Lactational Amenorrhea Method

(LAM). This was evidenced by the fact that among the

13% of women who knew that a method could be used

during breastfeeding, not a single one mentioned LAM.

Finally, only 15.8% of 152 women interviewed during

postpartum had received information regarding contra-

ceptive use during the ante- or postpartum periods, mostly

from their obstetrician. This finding is particularly prob-

lematic when considering that the overwhelming majority

of women interviewed (86.2%) stated that they would

have appreciated receiving such information. Thus, the

present study indicates a need for ante- and postpartum

counseling of women even in urban areas of Italy.

It is also important to reflect on the high proportion

(almost 50%) of women interviewed who did not believe

that they needed contraception after birth of their baby,

due to a lack of perception of risk of another pregnancy.

Many and diverse reasons have been given to explain

the high rate of unintended pregnancies even in Western

countries; they include: lack of patient education, ineffec-

tive or inconsistent use of contraceptive methods,

unplanned sexual activity, and contraceptive failure. In

this connection, a paper just published attempted to assess

in a sample of 248 women, their knowledge of health risks

connected with pregnancy, and how such an evaluation

compared to their estimates of the risks of oral contracep-

tives. This investigation found that over 75% of respon-

dents rated oral contraceptives as more hazardous than

pregnancy and, intriguingly, women with greater levels of

education were more likely to believe that oral contracep-

tives were riskier than pregnancy [18]. The study did not

address the question of whether these misconceptions

would lead to non-use of contraception in the postpartum

period, but the inference seems obvious.

One of the aforementioned reasons seems especially

relevant for the postpartum period: lack of proper educa-

tion and information. Back in 2003, a comparative study

was performed in the USA on contraceptive information

received after delivery. Whereas all women in the inter-

vention group received an information booklet during

their postpartum stay at the hospital, one-third of those in

the control group reported having received some kind of

written information. The study concluded that the simple

distribution of written material about contraceptive

options during postpartum increases the ability of a

woman to make an informed decision regarding future

pregnancies [19].

The already mentioned recent, careful review of the lit-

erature on this subject concluded that educating women

during the postpartum period led to increased contracep-

tive use and fewer unplanned pregnancies. Interestingly,

the review found that both short-term and multiple-

contact interventions were effective; however, data on

short-term intervention did not always show improve-

ment. Longer-term actions seemed to hold promise and

were not necessarily more costly, although – by definition

– they were more complex and not ubiquitously applica-

ble [15].

Several national studies have addressed the issue of pro-

viding postpartum contraception: in Finland a study found

out that the most common contraceptive method recom-

mended by physicians and nurses to breastfeeding women

was the condom, followed by progestin-only pills and

intrauterine contraception. Only a few health operators

recommended LAM, and only some 10% inserted an IUD

postpartum [20]. In Nigeria, a study found that more than

50% of the women surveyed intended to use contraception

Table 5. — Contraceptive counselling during pregnancy.% N

Yes 5.50 24

No 93.57 408

Did not answer 0.98 4

Table 6. — Relationship between intention to use contraceptionand parity.Parity Yes No Total p value

% N % N

0 64.3 166 35.7 92 258

1 78.7 100 21.3 27 127 p = 0.0048

> 1 66.6 34 33.3 17 51

Unmet needs and knowledge of postpartum contraception in Italian women518

after delivery. Their preference went to condoms (38.3%)

followed by intrauterine devices (11.5%). Advanced age

and high parity significantly predicted intention to use

postpartum contraception. Also counseling by doctors and

nurses increased the intention to use postpartum contra-

ceptives, stressing – once again – the importance of

family planning counseling and education [21].

In Turkey, after postpartum counseling, one-third of the

women involved in a study decided to use intrauterine

contraception, followed by condoms (16%), injectable

progestins (11%), oral contraceptives (5%), and coitus

interruptus (5%). However, one-fourth of the women still

decided against the use of contraception during puer-

perium. Authors concluded that, in spite of postpartum

counseling, a high majority of the women appeared to use

traditional and less effective methods [22].

In conclusion, available evidence indicates that initia-

tion of effective contraceptive methods is often delayed

after childbirth. In order to promote better postpartum

contraception practice, it is necessary to educate physi-

cians, nurses and women. This can be better achieved

through widespread distribution of updated evidence-

based guidelines for health operators and of educational

material for pregnant and postpartum women.

References

[1] Cwiak C., Gellasch T., Zieman M.: “Peripartum contraceptive atti-

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[2] Evans A.: “Postpartum contraception”. Women’s Health Med.,2005, 2, 23.

[3] Glasier A.F., Logan J., McGlew T.J.: “Who gives advice about

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[7] Oddens B.J.: “Women’s satisfaction with birth control: a popula-

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[8] Rosenfeld J.A., Zahorik P.M., Saint W., Murphy G.. : “Women’s

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[14] Lemay C.A., Suzanne B., Cashman S,B., Elfenbein D,S,, Marianne

E., Felice M.E.: “Adolescent mothers’ attitudes toward contracep-

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[15] Lopez L.M., Hiller J.E., Grimes D.A.: “Education for contraceptive

use by women after childbirth”. Cochrane Database Syst. Rev.,2010, CD001863. doi: 10.1002/14651858.CD001863.pub2.

[16] Ministero della Salute.: “Relazione del Ministro della salute sulla

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[18] Nelson A.L., Rezvan A.: “A pilot study of women's knowledge of

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[20] Sannisto T., Kosunen E.: “Initiation of postpartum contraception: A

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[21] Adegbola O., Okunowo A.: “Intended postpartum contraceptive

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M, FARRIS, M.D.

AIED

Via Toscana 30,

00187 Rome (Italy)


519

Introduction

The neonatal intensive care unit (NICU) is rapidly devel-

oping. The application of mechanical ventilation, nutritional

support through peripherally inserted central catheter

(PICC), umbilical artery and vein catheters, and broad-spec-

trum antibiotics has increased the survival of the very-low-

birth-weight (VLBW) and the extremely-low-birth-weight

(ELBW) infants. However, fungi have become part of the

major pathogens leading to the late-onset infection of

VLBW and the ELBW infants. Genus candida accounts for

the majority of invasive fungal infection (IFI). Since it is

difficult to differentiate disseminated infection of can-

didemia from bacteremia, early diagnosis and prompt man-

agement of fungal infection are delayed. The delay and the

properties of adherence and proliferation lead to the dis-

semination to multiple end organs like brain, kidney, lung,

intestinal tract, heart, eye, liver and joints. To assess the tis-

sues and organs commonly involved and the clinical fea-

tures in the IFI of candida albicans in the preterm infants, the

authors retrospectively studied a case series of eight preterm

children who developed IFI with positive blood culture for

candida albicans and complications of cerebral abscess,

renal abscess or retino-choroiditis.


PatientsRetrospective studies were done in eight cases diagnosed as can-

dida albicans IFI between January 2011 and February 2012 in the

First Hospital of Jilin University. This study was conducted in ac-

cordance with the Declaration of Helsinki and was conducted with

approval from the Ethics Committee of First Hospital of Jilin Uni-

versity. Written informed consent was also obtained from all par-

ticipants. All cases were preterm infants, with the gestational age

of 27 to 32 weeks, birth weight of 940 g to 2,200 g, and main pre-

existing conditions of premature and respiratory distress syndrome

(RDS). One case was ELBW infant, two cases were VLBW in-

fants, and the other five were low-birth-weight (LBW) infants.

Five cases required invasive mechanical ventilation. All infants re-

ceived nutritional support through PICC for 15 to 53 days. Positive

blood cultures for fungi occurred between days 7 to 40 after ad-

mission. The catheters were all removed as soon as possible after

the positive culture. Table 1 summarizes the clinical data.

Imaging evaluationEight preterm infants who developed IFI with positive blood

culture accepted selected imaging evaluation like cerebral mag-

netic resonance imaging (MRI), renal ultrasonography, renal com-

puter tomography (CT), and indirect ophthalmoscopy

examination. Cerebral abscesses were detected by cerebral MRI

in six infants. The observations of the cerebral MRI: multiple

punctate, relatively small, disseminated wide lesions performed

higher signal in bilateral frontal, temporal, occipital, and parietal

lobes (Figure 1). After the administration of fluconazole for four

to six weeks, multiple cerebral abscesses disappeared after one to

two months. Five cases developed renal systemic fungal infec-

tion, among which one had renal abscess. Kidney CT showed en-

larged bilateral kidneys, with multiple well-defined, low-density

parenchymal lesions. Renal Doppler ultrasonography showed

multiple parenchymal echoless areas in bilateral kidneys. Punctate

hyperechoic areas were detected in the renal pelvis (Figure 2).

Three cases were complicated with fungal retino-choroiditis.

Fluffy white retinal balls were detected by indirect ophthal-

moscopy (Figure 3).

Cerebral and renal abscess and retino-choroiditis secondary

to candida albicans in preterm infants:

eight case retrospective study

G.H. Wang, C.L. Dai, Y.F. Liu, Y.M. Li1

1 Department of Pediatrics, First Hospital of Jilin University, Changchun (China)

Summary

Objectives: To assess the tissues and organs commonly involved and the clinical features in the invasive fungal infection (IFI) of can-

dida albicans in the preterm infants. Materials and Methods: Eight preterm infants who developed IFI with positive blood culture for can-

dida albicans were retrospectively studied. All infants received selected clinical and laboratory parameters evaluation, such as blood culture,

cerebral magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) biochemical test, routine urine test, urine culture, renal ultra-

sonography, renal computer tomography (CT), and fundus examination. The re-examinations were performed after one to two months fol-

low-up. Results: Cerebral abscesses were detected in six infants. Five cases developed renal systemic fungal infection, among which one

had renal abscess. Three cases were complicated with fungal retino-choroiditis. Conclusions: Preterm infants, especially very-low-birth-

weight (VLBW) and extremely-low-birth-weight (ELBW) infants are susceptible to fungi. The majority of preterm late-onset fungal in-

fections are due to candida albicans. The organs commonly involved in the IFI of candida albicans are central nervous system (CNS),

kidney and fundus, among which renal systemic fungal infection are prone to recur, calling for a prolonged anti-fungi treatment course.

Key words: Candida albicans; Preterm neonates; Invasive fungal infection; Cerebral abscess; Renal abscess; Retino-choroiditis.



XXXIX, n. 2, 2012


Table 1. — Clinical data of eight preterm infants.Case number 1 2 3 4 5 6 7 8

Gestational age (weeks) 30 28+6 30 32 28 32+4 32+4 27

Birth weight (kg) 1.68 1.8 1.64 2.2 1.44 1.65 1.42 0.94

Pre-existing condition Premature; Premature; Premature; Premature; Premature; Premature; Premature; Premature;

RDS twins RDS RDS; BPD RDS; PDA; twins twins twins; RDS;

Premature; Premature; PDA; BPD

Nutritional support 20 25 18 15 50 15 12 53

through PICC (days)

Ventilation support (days) 10 3 7 52 60

Timing of positive blood 18 16 11 22 15 40 7 21

culture (days)

Organs involved Brain; Fundus Brain Brain; Kidney Brain; Brain; Brain

Kidney; Kidney; Kidney; Kidney;

Fundus Fundus

Course of anti-fungi 32 28 28 56 45 35 14 35

medication (days)

Outcome Recurred Recovered Recovered Recovered Recovered Recovered Recovered Died

NOTE: RDS: respiratory distress syndrome; PDA: patent ductus arteriosus; BPD: bronchopulmonary dysplasia; Recurrenced cases: renal systemic infection recurred.

Figure 1. — Fungal cerebral abscesses. Case 7: T2-weighted dark flare cerebral MRI. A, B: the multiple punctate lesions performed

higher signal in bilateral frontal, temporal, occipital, and parietal lobes. C, D: one month later, the multiple punctate higher signal le-

sions disappeared.

Figure 2. — Renal systemic fungal infection complicated with kidney abscess. Case 7: Kidney CT and renal Doppler ultrasonography.

A, B: kidney CT showing enlarged bilateral kidneys, with multiple well-defined, low-density parenchymal lesions. High-density mass

in the bilateral renal pelvis and upper nephritic ducts. C, D: renal Doppler ultrasonography showing multiple parenchymal echoless areas

in bilateral kidneys. Punctate hyperechoic areas in the renal pelvis.

Cerebral and renal abscess and retino-choroiditis secondary to candida albicans in preterm infants: eight case retrospective study 521

Figure 3 — Fungal retino-choroiditis. Case 7: indirect ophthalmoscopy examination showing fluffy white retinal balls.

Results

Cerebral abscesses were detected in six infants (Figure

1). Five cases developed renal systemic fungal infection,

among which one had renal abscess (Figure 2). Three cases

were complicated with fungal retino-choroiditis (Figure 3).

Discussion

NICUs are rapidly developing. The application of me-

chanical ventilation, nutritional support through PICC, um-

bilical artery and vein catheters, and broad-spectrum

antibiotics has increased the survival of the VLBW and the

ELBW infants. However, fungi had become part of the

major pathogens leading to the late-onset infection of

VLBW and the ELBW infants. Genus candida accounts for

the majority of IFI. Since it was difficult to differentiate

disseminated infection of candidemia from bacteremia,

early diagnosis and prompt management of fungal infec-

tion were delayed. The delay and the properties of adher-

ence and proliferation lead to the dissemination to multiple

end-organs like brain, kidney, lung, intestinal tract, heart,

eye, liver and joints [1]. Course of anti-fungi medication

were prolonged and outcomes were poor.

Candida albicans is considered an opportunistic

pathogen. Whether people become ill or not depends on the

immunity and the defense of the host, as well as the viru-

lence of the pathogen. In normal conditions, candida albi-

cans in the body is yeast-like and non-pathogenic.

However, when the immunity and defense of the host de-

creases, candida albicans proliferates and transforms to an

invasive, multicellular filamentous form (also called

pseudohyphae) to infect the host tissue, thus people will

become ill and clinical manifestations arise. candida albi-

cans has several known virulence factors contributing to its

pathogenicity: adherence to epithelial and endothelial cells:

virulence is parallel with adherence and candida albicans

adheres most strongly to epithelial cells among the genus

candida. Pseudohyphae formation: When infection occurs,

candida albicans is in the multicellular filamentous form,

which is of greater virulence than the yeast-like morph.

Toxin: the polycose toxin on the surface and another kind

called ‘candida toxin’ may be the pathogenic factors. The

components of the cell wall; extracellular membrane-dam-

aging enzymes: candida albicans can excrete some species

of enzymes like lysophospholipase, phospholipase, acid

protease, etc, among which extracellular acid protease is

the most important, which can hydrolyze not only protein,

but also keratin and collagen, leading to the promotion of

the ability of adherence of candida albicans.

The process of the candida albicans infection is as fol-

lows: The fungus adheres to the epithelial cells and forms in-

fectious focus with the help of the aforementioned

pathogenic factors. The process of adherence is accom-

plished by the combination of collagen and adherence ac-

ceptors, which are located on the surface of the candida

albicans and the host cells respectively. The collagen widely

distributes in vascular walls, inflammation and trauma, mak-

ing the candida albicans adhere and invade the host’s tis-

sues much more easily. Compared to other candida species,

candida albicans demonstrates increased adherence and pen-

etration of vascular endothelium, possibly accounting for its

higher incidence as a cause of IFI. Since the kidney, ocular

fundus and central nervous system are abundant in blood

vessels, which are the destination of candida albicans’ ad-

herence, these organs are prone to be involved.

What are the clinical features of preterm end-organ dis-

semination of candida albicans infection? The authors

demonstrate the clinical data of the eight cases infected with

candida albicans, with the involvement of central nervous

system (CNS), kidney, choroidal and/or retina as follows.

CNS candida infection may involve disseminated minor

abscesses (diameter < three mm), meningitis, ventriculi-

tis, cerebral infarction, mycotic aneurysm, and subarach-

noid hemorrhage [2]. In the present study, six of eight


cases had CNS infection, with the clinical manifestations

of fever, decreased responsiveness, and apnea in all, con-

vulsion in only one case, CSF changes in three cases of in-

creased of protein, and white blood cells and negative

culture, and multiple minor abscesses in all the CNS in-

volved cases’ MRI except for one who could not undergo

the examination because of the severity of the disease.

Thus, the CNS candida albicans infection cannot be ex-

cluded even the cerebral spinal fluid (CSF) is normal, and

the infants with the clinical manifestations of IFI should

routinely accept cerebral MRI screening. The present ob-

servations that foci of abscesses, numerous and relatively

small, disseminate widely and coordinate well with

Mueller’s study [3]. After the administration of flucona-

zole for four to six weeks, multiple cerebral abscesses dis-

appeared after one to two months. Among the cases are a

couple of twins who are nine-month-old now and normally

developed their CNS, left with no sequelae.

Five cases during the study developed candida albicans

infection in the urinary system, with positive urine culture

in all the five cases, the same with the blood culture. Other

auxiliary examinations included urine routine test, renal

Doppler ultrasonography, and renal CT. White blood cells

increased in the urine. With ultrasonography, multiple

parenchymal echoless areas and hyperechonic areas were

detected respectively in parenchyma and renal pelvis bilat-

erally in several cases. Corresponding with CT, the renal

abscesses appeared as parenchymal oval low-density le-

sions. Also, high-density masses appeared in the renal

pelvis and upper renal duct. One case with renal abscesses

developed renal dysfunction, and recovered after peritoneal

dialysis, urinary tract flushing and anti-fungal medication.

Candida albicans adheres easily to epithelial cells of vessels

and other tracts because of the ability of adherence. Since

the glomerulus and nephric tubules are abundant in vessels,

candida albicans infection easily involves urinary system

and forms abscess, which are difficult to eradicate. The

clinical symptoms of fungal infection in urinary tract are

always insidious, so it should be routine for the patient with

candidemia to accept the urine test, urine culture, and image

examination to clear whether the patient has fungal urinary

infection [4-6]. It should also be noted that central venous

catheters create a unique surface for proliferation of can-

dida albicans, so the catheters should be removed for any

preterm infant with candidemia. As for management, med-

icine-like fluconazole that has a high concentration in the

urinary system should be administrated. In case of recur-

rence, the course should be prolonged [7-8]. In the present

study, the five cases accepted fluconazole for two to three

weeks until the urinary culture turned negative. However,

two of them relapsed after the drug withdrawal. The short

course may account for the recurrence. So in case of recur-

rence, the course of urinary tract fungal infection should

last for at least four to six weeks until the several negative

urine culture results.

Three cases caused fungal retino-choroiditis with the

white fluffy balls in the fundus examination. According to

the reference, candida albicans infection, the main part of

the endogenous endophthalmitis, may occur at any age,

have no gender difference, and 70% of the patients develop

the disease in binoculus [9-11]. Fungal retino-choroiditis

has the following characteristics: the infective process de-

velops gradually. The posterior segment lesions are mainly

caused by invasion via the choriocapillaries, crossing the

pigment epithelium affecting the retina. If the organism pen-

etrates the internal limiting membrane of retina, the lesions

break free and disseminate to form ‘satellite foci’. If the fun-

gus gains access to the vitreous cavity, multiple clumps may

form within the vitreous. The multiple clumps in the vitre-

ous are often connected by thread-like strands, thus their as-

pect is referred to as having ‘string of pearls appearance

[12]. The posterior hyaloid fixed by inflammatory foci,

around which granulation and organization form, results in

the severe sequel of hemorrhage or traction retinal detach-

ment [13]. The course of the disease can be divided into two

phases [14]: retino-choroiditis phase and endophthalmitis

phase involving vitreous and sometimes anterior uvea. Med-

ical treatment varies according to the tissues involved in the

candida albicans infection: systemic administrations through

the venous route of antifungal agents like fluconazole or am-

photericin B for retino-choroiditis; as for the endoph-

thalmitis, injection of amphotericin B in the vitreous cavity

or vitrectomy is performed, and the simultaneous adminis-

tration of antifungal agents helps. Because of the insidious

clinical symptoms and the severe sequel-like retinal necro-

sis, traction retinal detachment, bulbus oculi atrophy, and

visual loss of the fungal retino-choroiditis [15-16], infants

who are suspected to have fungal infection especially IFI,

should accept routine screening through indirect ophthal-

moscope after mydriasis [17-18]. Since the fungal infection

can be detected in the retinal phase, endophthalmitis and the

severe results may be prevented under proper and prompt

treatment. The three cases were administrated with flu-

conazole for two to four weeks, resulting in the gradual dis-

appearance of the white dots. No visual loss was detected

during the follow-up.

Preterm infants, especially smaller and more immuno-

compromised ones, are susceptible to fungal infection

[19]. In the present study, fungal end-organ infection of

cerebral abscess, urinary infection, and retino-choroiditis

in the eight preterm infants with IFI have obvious and spe-

cific signs detected through imaging examination. Can-

dida species can also cause fungal arthritis, dermatitis,

cardiac valvulitis, and fungal abscesses may form in skin

and liver, etc [20]. When the neonates develop candida al-

bicans invasive infection, they should accept the auxiliary

examination to identify whether they are complicated with

end-organ infection in CNS, kidney, fundus, skin and

joints, which are necessary for the determination of the

management and the prediction of the prognosis.

Cerebral and renal abscess and retino-choroiditis secondary to candida albicans in preterm infants: eight case retrospective study 523

Acknowledgement

The study was supported by Jilin Provincial Science and

Technology Department (Grant No. 20110922) and Jilin

Provincial Administration of traditional Chinese Medicine

(Grant No. 2011-JS20)

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YU-MEI LI, M.D.

Department of PICU,

First Hospital of Jilin University,

Changchun 130021 (China)


Introduction

Endometriosis is a chronic, estrogen-dependent disorder,

characterized by the presence of endometrial glands and

stroma in an ectopic site. It is clinically associated with

chronic pelvic pain, dyspareunia, dysmenorrhea, and infer-

tility. Endometriosis has a high socio-economic impact

given the large number of affected women in reproductive

age (10% - 15%); its symptomatology undermines normal

family and social life and it interferes with the patient’s

ability to work. The disorder is frequently associated with

infertility. The partial understanding of the pathogenesis,

its multifactorial nature, and the low specificity of its symp-

toms render the diagnosis of endometriosis difficult and late

in the evolution of the disorder [1,2].

The scientific literature of recent years has shown a

growing interest in the research on biomarkers and sets of

biomarkers that could be useful in making an early and

non-invasive diagnosis of endometriosis and in following-

up treated patients and identifying relapses in their earliest

stages.

The goal of the present study was to highlight all the bio-

markers (plasma, serum, urinary, peritoneal, and endome-

trial biomarkers) proposed in the international scientific

literature of the last 28 years and, through a meta-analytic

reprocessing of the data, assess their clinical value (based

on sensitivity and specificity) in making a non-invasive di-

agnosis of endometriosis.


The present work was divided into three stages: computer

search throughout the scientific literature on this issue from Jan-

uary 1984 to January 2012, definition of the inclusion and exclu-

sion criteria, analysis of the sensitivity (S), and specificity (Sp) of

individual biomarkers and panels of biomarkers proposed by the

authors.

The computer search envisaged the use of some online medical

search engines (PUBMED, EMBASE, MEDLINE, CINHAL) and

of the following keywords: endometriosis, plasma-serum-blood-

urine-biological-tissue-endometrial biomarkers, cells, diagnosis,

non invasive, and mass screening. Only publications in English

that met the inclusion and exclusion criteria (Table 1) were taken

into account. A further selection was then made using the Quality

Assessment of Diagnostic Accuracy Studies (QUADAS) criteria

in the version modified by Whiting in 2003 (Table 2). Finally

through the statistical processing of the data, the best potential

biomarkers or panels of biomarkers (greater specificity and sen-

sitivity) for a non-invasive diagnosis of endometriosis were iden-

tified.

Results

The computer search produced 11,665 total results; of

these 11,488 were eliminated after evaluating the title, con-

tent of the abstract, and compliance with the Quality As-

sessment of Diagnostic Accuracy Studies inclusion and

exclusion criteria” and with the “QUADAS criteria”. In this

way, a final number of 177 articles remained whose analy-

sis highlighted many potential biomarkers and panels of

biomarkers, that are listed below:

Cytokines Interleukin 6 (IL-6): Six studies show a relationship be-

tween increased IL-6 serum levels and endometriosis [3-

7]. In particular, in the study by Martinez et al. [7] high

levels of IL-6 were found above all in women with a Stage

I-II disease. With a threshold value of 25.75 pg/ml, a 75%

sensitivity, and an 83.3% specificity were obtained. Be-

daiwy et al. showed a sensitivity and specificity respec-

tively of 90% and 67% with a threshold of two pg/ml [4].

On the contrary, other studies did not report a significant

increase in IL-6 [8-12].

524

New horizons in the non-invasive diagnosis of endometriosis

F. Patacchiola1, A. D’Alfonso2, A. Di Fonso2, G. Di Febbo2, S. Di Giovanni3, A. Carta4, G. Carta2

1Department of Health Sciences, University of L’Aquila 2Department of Surgical Sciences, University of L’Aquila, L’Aquila3Department of Gynecology and Obstetrics, University of Chieti, Chieti 4University of Medicine “Tor Vergata”, Rome (Italy)

Summary

Endometriosis is a chronic disorder, clinically associated with chronic pelvic pain, dyspareunia, dysmenorrhea, and infertility. Its

socio-economic impact is extensive, given the large number of affected women in reproductive age, its symptomatology (that interferes

with normal social life and the patient’s ability to work), and its frequent association with infertility. Nonetheless, the diagnosis of en-

dometriosis is still difficult and late in the evolution of the disorder. The authors have used the Quality Assessment of Diagnostic Ac-

curacy Studies (QUADAS) criteria to make a systematic review of the literature of the last 28 years, seeking to identify potential

biomarkers useful for a non-invasive diagnosis of endometriosis. The authors have highlighted more than 50 biomarkers in the studies

included in the present report, but they have not succeeded in identifying a clinically useful non-invasive diagnostic biomarker or panel

of biomarkers. More studies are needed before biomarkers can be introduced in clinical practice.

Key words: Endometriosis; Infertility; Peripheral biomarkers; Early diagnosis.

Revised manuscript accepted for publication March 28, 2013


XXXIX, n. 2, 2012

F. Patacchiola, A. D’Alfonso, A. Di Fonso, G. Di Febbo, S. Di Giovanni, A. Carta, G. Carta 525

Interleukin 8 (IL-8): A study of 2003 showed increased

serum levels especially for Stages I and II [13].

TNF-α: Various authors report particularly high serum

and peritoneal levels in women with endometriosis in

Stages III and IV [5, 13-18]. In the study by Bedaiwy et al.,with a threshold of 15 pg/ml, a sensitivity and specificity of

100%, and 89% [4], respectively, are achieved when the

cytokine assay was performed on the peritoneal fluid of af-

fected women.

Monocyte chemotactic protein 1 (MCP-1): by using a

threshold value of 100 pg/ml, a 65% sensitivity and a 61%

specificity are obtained [19].

Interferon-gamma (IFNγ): In 2003, Darai et al. found an

increase in the serum levels of IFNγ in women with en-

dometriosis [6].

Other cytokines: Other interesting findings are the high

levels of interleukin 1α (IL-1α) in the serum [20] and high

levels of IL-12 and IL-18 in the peritoneum fluid of af-

fected women [21-23].

Inflammatory markersC-reactive protein and high-sensitivity C-reactive pro-

tein (CRP and hs-CRP): The study carried out by Lermann

shows higher CRP (3.54 mg/l) and higher hs-CRP (3.61

mg/l) average values in the group of patients with en-

dometriosis (E-group), as compared to healthy controls

(non-E group) (CRP = 2.88 mg/l; hs-CRP = 2.48 mg/l)

[24]. Although there is a real difference in the concentration

of molecules between the two study groups, the difference

is not statistically significant. Hence, CRP and hs-CRP can-

not be potential biomarkers.

Antibodies (Ab) Anti-endometrium antibodies: These have an 86% sensi-

tivity and a 76% specificity in the diagnosis of en-

dometriosis [25]. Sensitivity and specificity increase

considerably, up to 87%, if used for the diagnosis in women

with infertility, dysmenorrhea, and chronic pelvic pain [26].

IgG antibodies are those that appear to correlate most with

endometriosis [27,28]. A recent study identified eight new

antibodies against some endometrial antigens such as:

tropomyosin 3 (TPM3), stomatin-like protein 2, (SLP2),

and tropomodulin-3 (TMOD3). The following are respec-

tively, the sensitivity and specificity of these antibodies in

the early stages of the disease: Ac anti-TPM3a (61%, 93%),

Ac anti-TPM3c (44%, 93%), Ac anti-TMP3d (78%, 89%),

Ac anti-SLP2a (50%, 96%), Ac anti-SLP2c (61%, 93%),

Ac anti-TMOD 3b (61%, 96%), Ac anti-TMOD3c

(78%,93%), Ac anti-TMOD3d (78%, 96%) [29].

Anti-carbonic anhydrase Ab: Kiechle et al. have shown

a sensitivity of 13% for type I and of 24% for type II [30].

Anti-transferrin and anti-α2-HS glycoprotein Ab: these

present maximum sensitivity and specificity if assayed

using the ELISA technique, reach values of 95% [31, 32].

Ab against oxidative stress markers: women with en-

dometriosis present increased levels of Ac anti-lipid per-

oxide modified rabbit serum albumin, Ac anti-copper

oxidized low-density lipoprotein, and Ac anti-malondi-

aldehyde-modified low density lipoprotein [33].

Anti-laminin Ab: some authors have found high concen-

trations of these autoantibodies in patients with infertility

(the cut-off of one U/ml has a sensitivity of 43% and a

specificity of 89%) [34, 35].

Anti-α enolase Ab: have a sensitivity and specificity

comparable with that of CA125 [36].

Anti-PDIK1L (PD-interacting kinase 1 like) Ab: PDIK1L

is abundantly expressed by endometriotic cells. With a cut-

off of 300 U/ml, the test provides a sensitivity of 59.4%

and a specificity of 84.1%. Anti-PDIK1L autoantibodies

are expressed in larger amounts in Stage I-II, therefore they

could be of assistance in the early diagnosis of the disease

[36].

Anti-syntaxin 5 Ab: at a cut-off of 400 U/ml shows a sen-

sitivity of 53.6% and a specificity of 87.8% in a Stage II

endometriosis [37].

Anti-IGFII mRNA-binding protein1 (IMP1) and Anti-cy-clin B1 Ab: Yi et al. have reported for IMP1 a sensitivity of

85.7% and a specificity of 63.3% in women with en-

Table 2. — Inclusion and exclusion criteria of the study.Modified version of the QUADAS criteria (Whiting et al., 2003)

• Were the patients and controls recruited from women with

symptoms suggestive of endometriosis?

• Were the selection criteria described clearly?

• Was the time between diagnosis and the assay of the

biomarkers sufficiently short to avoid variations in the stage

of the disease?

• Was the absence of disease among the controls checked

surgically?

• Was a sufficient description made of the method?

• Were the results interpreted using a blinded fashion model?• Was the diagnosis of endometriosis made without knowing

the outcome of the test on the biomarkers?

• Were intermediate or non-interpretable results reported?

• Was the decision, if any, to drop out of the study declared?

• Were the samples collected during an adequate phase of the

menstrual cycle or were the results correct for the phase of

the cycle?

• Were the samples collected from women with a specific

stage of the disease or were the results correct for the stage

of the disease?

Table 1. — Inclusion and exclusion criteria of the study.Inclusion criteria Exclusion criteria

• Biomarkers assayed from

serum, plasma, urine,

peritoneal fluid;

• Visual and/or histologic

confirmation of

endometriosis during

laparoscopic exploration

• Biomarkers obtained using

invasive procedures

• Studies that did not include

healthy controls

• Studies on CA125 before

the meta-analysis by Mol

et al. (1998);

• Studies with male

individuals among the

controls;

• Studies that required

extended cell cultures (>

24h) to show differences in

the expression of the

biomarkers

New horizons in the non-invasive diagnosis of endometriosis526

dometriomas. In combination with cyclin B2, it presents

lower sensitivity (83.9%) but greater specificity (72.7%)

[38].

Glycoproteins Cancer antigen-125 (CA-125): This is the glycoprotein

of great interest for endometriosis. Some recent studies

show that CA125 is the most reliable glycoprotein in diag-

nosing Stage III-IV endometriosis [39, 40]. Xavier et al.show that the cut-off that provides the greatest sensitivity

and specificity (86% and 89% respectively) is lower (22.6

IU/ml) than that reported in most of the literature (35

IU/ml) [41]. Various studies have established that the serum

concentration of CA125 correlates with the severity of the

disease [42] and tends to be higher in women with ovarian

endometriosis (with a threshold of 30 IU/ml the sensitivity

is 79% in women with endometrioma and drops to 44% for

other sites) [43]. Finally, O’ Brien et al., have demonstrated

that the technique used to assay CA- 125 considerably in-

fluences its efficacy as clinical biomarker of endometriosis

[44].

Cancer antigen-19-9 (CA-19-9): The threshold value of

5.4 IU/ml gives the best diagnostic performance [45, 46].

Cancer antigen-15-3 (CA-15-3) and Cancer antigen-72(CA-72): Various authors have studied these glycoproteins

but have obtained contrasting results [47-49].

Haptoglobine: Typically produced by endometriosis le-

sions. A selective increase in serum levels of the β isoform

in the follicular phase of the menstrual cycle has been found

[50].

Follistatin: The serum concentrations of follistatin are

raised in women with endometriomas compared to healthy

controls [51].

Gremlin-1: This glycoprotein is hyperexpressed in the

endometrial stroma of affected women. Its serum concen-

tration is found to be increased exclusively in the prolifer-

ating stage [52, 53].

Cell populationsThe patients with endometriosis present alterations in the

normal lymphocyte count and in the monocyte-macrophage

line. In particular the following is observed: increase in T

suppressor lymphocytes (CD8+, CD11+) and in activated

T lymphocytes (CD3+ ed HLA-DR+) [54,55], reduction in

the circulating NK cells [56,57], and increase in the neu-

trophil/lymphocyte ratio (NLR) (consequence of the in-

crease in circulating neutrophils) [58].

Other immunological biomarkersEndometriosis is associated with an increase in the serum

concentrations of the C3 and C4 complement fractions [59]

and in the soluble forms of CD4 and CD23 [60-62]. A re-

cent paper has shown the presence of high levels of pep-

tides known as human neutrophil peptides 1, 2, 3 (HNP 1-3)

in the peritoneal fluid of affected women [63].

Adhesion molecules From the studies, the present authors have examined that

it can be inferred that endometriosis is associated with an

increase in the serum concentrations of the following ad-

hesion molecules: ICAM-1 (particularly high in Stages I-II

of the disease [64, 65], VCAM [66], E-cadherin (that does

not present any particular correlation with the stage of the

disease) [67], and finally, osteopontin [68].

Growth factorsA study has shown an increase in the serum levels of

IGF-1 exclusively in Stages III-IV [69].

Circulating cell-free DNA (ccf-DNA)Through real time PCR, it was possible to demonstrate a

ccf-n DNA plasma concentration that was significantly

greater in patients with endometriosis compared to controls;

the test presents a sensitivity of 70% and a specificity of

87% [70].

HormonesProlactin (PRL): The association of hyperprolactinemia,

galactorrhea with endometriosis, has been known for more

than 30 years. Recent studies have shown the presence of

hyperprolactinemia (PRL > 20 ng/ml) in 30% of women

with endometriosis and infertility, whereas none of the fer-

tile women with endometriosis and none of the controls

presented raised levels of this hormone [71].

Luteinizing hormone (LH), testosterone, cortisol: Vari-

ous studies have shown increased serum levels of this hor-

mone in women with endometriosis; testosterone seems to

be selectively associated with ovarian endometriosis and

cortisol with advanced stage endometriosis (III-IV) [71,

72].

Leptin and adiponectin: Their serum levels are respec-

tively increased and reduced in patients with endometriosis

compared to controls [73-75].

Angiogenetic factorsVarious studies have demonstrated the increase, in the

advanced stages of this disorder, in serum concentrations

of VEGF, and in one of its soluble receptors (sFlt-1) pres-

ent in the serum and in the urine [18, 19, 76], Angiogenin

[77], in FGF-2 [78] and finally in HGF [79].

Proteomic markersThe analysis of protein expression profiles in the serum

and in the endometrium of women with the disorder is one

of the most promising areas of research on potential bio-

markers: the presence, absence, hypo- or hyper-expression

of peculiar isoforms in the blood and/or endometrial tissue,

could indicate new useful biomarkers. The protein peaks

found, indeed, could be used to construct a diagnostic pro-

tein pattern in patients with endometriosis. The most im-

portant proteomic studies carried out so far are the

following: Wang et al. [80] who have identified a pattern

consisting of five protein peaks endowed with a sensitivity

and specificity equal to 92% and 90%, respectively; the

study by Kyama et al. have used two proteomic panels :

the first, that examined endometriosis of Stages I-II, pre-

sented a sensitivity and specificity of 100%, and the sec-

ond panel showed a sensitivity of 80% and a specificity of


70%. Furthermore, this latter study developed a protein

panel suited to the diagnosis of endometriosis irrespective

of the stage of the disorder that consists of five protein

bands and presents a sensitivity of 89.5% and a specificity

of 90% [81].

Other potential biomarkersSerum urocortin: it presents considerably increased val-

ues in the ovaries of women with endometriosis; it is there-

fore useful in making a differential diagnosis of the ovarian

mass Sensitivity is 88%, and specificity is 90% [82]. In ac-

tual fact, a more recent study showed lower values: 72.6%

sensitivity and 45.7% specificity [83].

Protein PP14: high especially in advanced stages [84];

Tumor associated trypsin inhibitor (TATI): sensitivity

34% and specificity 85% [85];

Amyloid A: increases in Stages III-IV;

Paroxonase 1 (PON-1): antioxidant glycoprotein. Its sen-

sitivity is 98% and its specificity is 83% [86];

Matrix metalloproteinase 9 and 2 (MMP-9, MMP-2) andphosphatase of regenerating liver 3 (PRL-3): reach a sen-

sitivity of 87.5% in Stages III-IV [87,88].

Urinary vitamin D-binding protein (VDBP): sensitivity

58%, specificity 76% [89].

Urinary cytokeratin-19 (CK-19): initial studies have es-

tablished a sensitivity and a specificity of 100% [90].

PanelsFrom the statistical analysis of the panels of biomarkers

proposed in the literature of the last 28 years, those with

greater diagnostic efficacy are:

IL-6, IL-8, TNFα, hs-CRP, CA-125, CA19-9 (sensitivity

= 92.2% specificity = 82%) [91];

CA-125, NLR: (sensitivity > 86% specificity > 89%)

[58];

PGP9, VIP, substance P (sensitivity = 95% e specificity

= 100%) [92];

CCR1 m RNA, MCP1, CA-125 (sensitivity = 92.2%

specificity = 82%) [93].

CA-125, CA19-9, survivin: (sensitivity = 87%) [94].

Discussion

The numerous difficulties encountered in pursuing the

present objective are linked to various factors. First of all,

a negative impact was due to the inherent characteristics of

endometriosis such as: its multifactorial nature and the het-

erogeneity in terms of stage, site, and aspect of the lesions.

Moreover, specific characteristics found in the various stud-

ies have proven to be important such as: inadequate patient

sample (insufficient number, lack of confirmation of the di-

agnosis of endometriosis through laparoscopic exploration,

lack of definition of recruitment criteria), and/or inade-

quacy of the group of healthy controls (limited number, not

well-defined recruitment criteria, presence of co-morbidi-

ties); poor specificity of most of the biomarkers taken into

account; the frequent disagreement among the data pro-

vided by various studies on the same biomarker (attribut-

able to: method used, threshold value, timing of the

sampling of the biological samples, adjustment of data to

menstrual phase), and the lack of publication of studies

with negative or irrelevant outcomes that could have pro-

vided useful insight [95].

With regards to the biomarkers, some of them, albeit

presenting high sensitivity, do not have an adequate level

of specificity, since they are implied also in physiologi-

cal processes (cytokines) or in various pathologies. Some

examples of biomarkers having low specificity are: CA-

125 glycoproteins CA-19-9 [96], urinary IGF [97], VEFG

and anti-cardiolipin antibodies [98], urocortin [99]. The

diagnostic efficacy of biomarkers is considerably in-

creased by the phases of the menstrual cycle, by the stage

of the disease, and by the site of the lesions: elements that

can cause conspicuous variations in terms of sensitivity

and specificity of the values. The design of the studies the

present authors selected is an important factor in evaluat-

ing the reliability of the results obtained. Indeed, even

though rigid inclusion criteria were used, many works

concerning the same biomarker often provided diverging

results because of the wide variability in the threshold

value taken into account, in the method used for the assay

of the biomarkers, in the origin of the biological sample,

in the method, timing of sampling and storage of the bio-

logical sample, in the selection criteria of the group of pa-

tients and controls and the breadth and scope of the

results, and finally the statistical instrument used for pro-

cessing the results.

The threshold selected significantly affects the diagnos-

tic accuracy of the biomarkers; this is the case of CA-125

whose sensitivity ranges from 27% to 79% depending on

the cut-off that was adopted [41-44], and of IL-6 with a sen-

sitivity varying between 71% and 90% and a specificity

ranging from 51% to 89% [4,7,8,12]. Of considerable im-

portance is also the biological sample, as regards the type

of sample and the sampling and storage techniques. TNF-

α [5] has a sensitivity and specificity of about 95% when

serum assays are performed, and a sensitivity of 100% and

specificity of about 89% when assays are performed on the

peritoneal fluid. An adequate selection of the group of pa-

tients and controls is indispensable for the quality of the

study. In many studies the control group was not adequately

selected:

Indeed a fundamental factor is the heterogeneity of the

control groups that should include healthy individuals as

well as women with symptoms suggestive of en-

dometriosis in whom however the disease has not been

excluded with a laparoscopic test. At the same time, with

reference to the studies that included among the controls

women with benign gynaecological disorders, one cannot

exclude that the pathologic condition of some women may

have affected the outcome of the study. The handling dif-

ficulties instead are a limit to the application of the prom-

ising proteomic tests in clinical practice. Indeed it would

be a good thing to be able to purify and identify protein

molecules corresponding to the protein peaks, so as to in-

troduce immunological tests that assay these proteins in

the laboratory without necessarily having to use the

SELDI-TOF-MS techniques.


Conclusion

At this point in time, endometriosis is a disorder with a

high socio-economic impact whose diagnosis is made dif-

ficult by the poor knowledge of its etiopathogenesis, by the

non-specificity of its symptoms, and by the lack of an ef-

fective non-invasive test. The aim of this study was to

search for a biomarker or a panel of biomarkers with sen-

sitivity, specificity, and ease of use suited to make a non-in-

vasive diagnosis of endometriosis. Unfortunately, the

present research data were not sufficient to identify a to-

tally reliable non-invasive diagnostic protocol that could

be immediately introduced into clinical practice, especially

for the lack of very high quality studies, for the large dis-

crepancy between the results of different studies carried out

on the same biomarker, for the absence at the present time

of a molecule or a panel of molecules that are exclusively

correlated to the endometriotic disorder, and finally, for the

difficult handling and/or costs of some tests.

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F. PATACCHIOLA, M.D.

Department of Health Sciences,

University of L’Aquila

Via Tedeschini 7

02100 Rieti (Italy)


531

Introduction

Polycystic ovarian syndrome (PCOS) has been shown

to be identified by oligomenorrhea or amenorrhea as men-

struation disorders, hyperandrogenism, and small multiple

cystic follicles in the ovary on ultrasonography, and is usu-

ally found as a complex and heterogenous endocrine dis-

order [1]. It occurs in about ten percent of women around

reproductive age. In addition, it is associated with obesity

in approximately 16% to 80% with PCOS. Recent work

has identified that PCOS is often complicated with insulin

resistance (IR) accompanied by compensatory hyperinsu-

linemia [2]. IR is suggested to be enhanced by the inter-

action between obesity and this syndrome [3].

These facts that both lean and obese PCOS patients

show reduced insulin sensitivity and resultant hyperinsu-

linemia to some degree [4], suggest that hyperinsulinemia

caused an increase in androgen biosynthesis [5] and a de-

crease in the levels of sex hormone-binding globulin

(SHBG) [6]. These findings could possibly indicate the

pathogenesis of hyperandrogenism. In addition to repro-

ductive disorder, IR and hyperinsulinemia are recognized

to increase the risk of long-term metabolic diseases, not

only impaired glucose tolerance and type 2 diabetes [7],

but also as cardiovascular disease [8].

Several studies have been reported to measure the circulat-

ing levels of adiponectin because of the importance of IR and

obesity in PCOS [9, 10]. In recent years, it has been shown

that adipocytes are secretorycells which produce various pro-

teins with hormonal-type functions called adipocytokines. It

is demonstrated that adiponectin is a 244-amino-acid protein,

which is produced exclusively by adipose cells, andmay have

a role in preventing or counteracting the development of in-

sulin resistance [11, 12]. In contrast to other adipocytokines,

such as leptin, the production of adiponectin is decreased in

obese subjects [12, 13].

The aim of this study was to clarify the determinants of

adiponectin levels and to investigate the potential role of

adiponectin in IR in women with PCOS. Furthermore, an-

other objective of this study was also to clarify whether

adiponectin is a marker of some degree in PCOS patients.


Twenty-seven consecutive reproductive-aged, amenorrheic

women with PCOS were recruited at the Infertility and

Endocrinology Clinic, Oita University Hospital, between January

2002 and December 2004. Exclusion criteria were excess alcohol

consumption (n = 1), cigarette smoking (n = 2), previous or

current oral contraceptive use (n = 3), and endurance physical

training (n = 1).

Criteria for PCOS were chronic anovulation (fewer than six

cycles in 12 months) or amenorrhea, elevated serum levels of

luteinizing hormone (LH), with normal follicle-stimulating

hormone (FSH), and LH/FSH of at least 1.5, and polycystic

appearance of the ovaries on ultrasound, defined by ten or more

follicles two to eight mm in diameter, with a tendency toward

peripheral distribution and bright echodense stroma. Baseline

characteristics included age, height, weight, body mass index

(BMI), and hirsutism status. BMI was calculated as weight (kg)

divided by height squared (m2). Subjects with Ferriman-Gallwey

scores exceeding ten were defined as hirsute [14]. None of the

PCOS patients had evidence of an androgen-secreting neoplasm,

pituitary adenoma, homozygous adrenal hyperplasia,

The role of serum adiponectin levels in women with

polycystic ovarian syndrome

H. Itoh, Y. Kawano, Y. Furukawa, H. Matsumoto, A. Yuge, H. Narahara

Department of Obstetrics and Gynecology, Faculty of Medicine, Oita University, Yufu, Oita (Japan)

Summary

Purpose of investigation: The aim of this study was to measure serum adiponectin concentrations in women with polycystic ovarian

syndrome (PCOS) and to assess possible correlations between adiponectin and the hormonal or metabolic parameters of this syndrome.

Materials and Methods: Serum adiponectin levels were evaluated in 20 women with PCOS and 22 women without PCOS whose age

and body mass index (BMI) matched the patients. The levels of fasting blood glucose, fasting insulin, gonadotropin, and sex steroid hor-

mones were evaluated in both groups. The homeostasis model assessment (HOMA) score was also calculated. The serum adiponectin

levels were assayed by enzyme-linked immunoabsorbent assay (ELISA). Results: Serum adiponectin levels were significantly lower in

obese women than in normal-weight women, and they were also significantly lower in PCOS patients with HOMA scores greater than

1.7 compared with those with HOMA scores lower than 1.7. When the subjects were divided in two groups based on serum adiponectin

levels (> 40 µg/ml, < 40 µg/ml), 65% of patients with PCOS were included in the lower adiponectin group (p < 0.05). In addition, go-

nadotropin levels were increased, dependent on the adiponectin levels in women with PCOS. Conclusion: Adiponectin is regarded as

a possible link between adiposity and insulin resistance (IR). From this data, the secretions of gonadotropin are implicated in the lev-

els of adiponectin in women with PCOS. It is suggested that adiponectin may play an important role in the pathogenesis of PCOS.

Key words: PCOS; Adiponectin; Insulin resistance; Obesity.



XXXIX, n. 2, 2012

acromegaly, or Cushing syndrome in accordance with National

Institutes of Health criteria. None of the subjects were taking any

medication likely to affect muscle size, muscle strength, or body

fat distribution. All women in the control group had normal ovu-

lating cycles and no signs of hyperandrogenism.

In all women, the basal serum levels of serum gonadotropin

(FSH, LH), estradiol 17β, testosterone, dehydroepiandrosterone

sulfate (DHEAS), and androstenedione were measured using

commercially available radioimmunoassays (RIAs). Serum levels

of prolactin (PRL), glucose, and insulin were also measured.

Serum adiponectin was measured using a commercially avail-

able enzyme linked immunosorbent assay (ELISA). The intra-

assay and inter-assay coefficients of variation for these RIAs and

ELISA were 3%-5% and 8% to l0%, respectively.

IR in the fasting state was evaluated by using homeostasis

model assessment (HOMA) and was calculated with the follow-

ing formula: fasting plasma glucose (mg/dl)×fasting serum

insulin (µU/ml) divided by 405. High HOMA scores denote IR

[15]. The subjects were allocated to four groups on the basis of

the adiponectin value and a diagnosis of PCOS. Hence, group 1

(n = 35) women had PCOS + adiponectin < 40 µg/ml; group 2

(n = 35) had PCOS + adiponectin > 40 µg/ml; group 3 (controls;

n = 15) were ovulating without PCOS + adiponectin < 40 µg/ml;

and group 4 (controls; n = 15) were ovulating without PCOS +

adiponectin > 40 µg/ml.

Informed consent was obtained from each subject, and the

study was approved by the Institutional Review Board, and was

conducted in accordance with institutional guidelines and the

Declaration of Helsinki.

Statistical analysisData are presented as means ± SD, and were analyzed using

the Mann-Whitney U test, chi-square (χ2) test, and Bonfer-

roni/Dunn test for multiple comparisons. A p value < 0.05 was

considered to be statistically significant.

H. Itoh, Y. Kawano, Y. Furukawa, H. Matsumoto, A. Yuge, H. Narahara532

Table 1. — Clinical and endocrine features of PCOS patientsand controls.

PCOS Controls

No. of patients 20 22

Age 31.3 ± 4.7 30.3 ± 4.8

Height (cm) 157.5 ± 5.5 157.6 ± 4.4

Weight (kg) 56.6 ± 11.0 55.8 ± 10.0

BMI (kg/m2) 22.9 ± 4.8 22.5 ± 4.3

LH (mIU/ml) 9.3 ± 5.8* 4.7 ± 1.6

FSH (mIU/ml) 5.7 ± 1.5** 7.2 ± 1.5

LH/FSH 1.7 ± 0.8* 0.7 ± 0.2

E2 (pg/ml) 43.0 ± 24.0 36.6 ± 21.8

PRL (ng/ml) 11.0 ± 6.1 12.4 ± 9.2

T (ng/ml) 34.2 ± 21.3 32.2 ± 13.7

FBS (mg/dl) 93.0 ± 7.6 92.5 ± 7.2

IRI (pmol/l) 13.2 ± 12.1 7.9 ± 5.6

HOMA-IR 3.1 ± 3.0 1.9 ± 1.5

BMI = body mass index; LH = luteinizing hormone; FSH = follicle-

stimulating hormone; E2 = estradiol; PRL = prolactin; T = testosterone; FBS

= fasting blood glucose; IRI = insulin resistance index; HOMA-IR =

homeostasis model assessment-insulin resistance; *p < 0.01, **p < 0.05 for

differences between PCOS and controls by the Mann-Whitney U test. Data

represent mean ± SD.

Table 2. — The number of subjects on the basis of adiponectinlevels in PCOS and controls.

Adiponectin (µg/ml)

< 40 ≥ 40

PCOS (n = 20) 13 (65%) 7 (35%)*

Controls (n = 22) 6 (27%) 16 (73%)*

*p < 0.05 for differences between PCOS with lower adiponectin levels and

controls with higher adiponectin levels by the χ2-test.

Figure 1. — The concentrations of serum adiponectin levels in PCOS patients and controls, with classification based on body weight.

The figures below the X-axis indicate the number of subjects, in each subgroup. A statistically significant interaction between PCOS

and body weight was observed.

* p < 0.05 vs controls. The data are expressed as means ± SD.

Figure 2. — The concentrations of serum adiponectin levels in PCOS patients and controls, with classification based on the degree

of insulin resistance (HOMA-IR). The figures below the X-axis indicate the number of subjects, in each subgroup. A statistically sig-

nificant interaction between PCOS and the degree of HOMA-IR was observed.

* p < 0.05 vs controls. The data are expressed as means ± SD.

The role of serum adiponectin levels in women with polycystic ovarian syndrome 533

Results

Patients and controls were equally distributed according to

age, BMI, and degree of obesity (Table 1). LH and LH/FSH

ratio were significantly higher in patients with PCOS com-

pared with controls. However, no significant differences were

observed between the BMI-matched groups.

The results of the univariate analysis of the effects of

PCOS or of control status and of the degree of obesity are

shown in Figure 1. Serum adiponectin levels were signifi-

cantly lower in the ≥ 25 kg/m2 BMI group than among nor-

mal-weight (BMI < 25 kg/m2) women among PCOS

patients; however, these levels were not affected by obe-

sity in controls.

These levels were also significantly lower in women with

a HOMA score greater than 1.7, compared with those with

an HOMA score less than 1.7 among PCOS patients. No

difference was found in adiponectin levels among controls

as shown in Figure 2.

Women with PCOS (subjects) were classified according

to serum adiponectin levels as described in Materials and

Methods. When PCOS patients and controls were divided

into two groups by serum adiponectin level (< 40 µg/ml, >

40 µg/ml), 65% of patients with PCOS were included in the

lower adiponectin group (Table 2). LH and LH/FSH ratio

were significantly increased in lower adiponectin group

(group 1) compared with higher adiponectin group (group 2)

among PCOS patients shown in Figure 3. By contrast, there

were no significant differences between two groups in other

hormone levels (Table 3).

Table 3. — Baseline characteristcs and hormonal features inPCOS and controls.

1 2 3 4

PCOS PCOS Controls Controls

Adiponectin < 40 µg/ml ≥ 40 µg/ml < 40 µg/ml ≥ 40 µg/ml

No. of patients 13 7 6 16

Age 29.4 ± 4.8d 33.9 ± 3.3 30.0 ± 4.6 30.5 ± 5.1

BMI (kg/m2) 24.1 ± 5.5a,d 20.3 ± 1.7 26.7 ± 3.5b,d 21.0 ± 3.3

HOMA-IR 3.0 ± 2.3a 3.0 ± 4.2 3.4 ± 2.1 1.3 ± 0.6

PRL (ng/ml) 9.5 ± 6.5 12.3 ± 5.4 11.6 ± 8.0 12.7 ± 9.9

E2 (pg/ml) 43.5 ± 20.9 47.0 ± 31.3 23.8 ± 5.8 41.4 ± 23.7

T (pg/ml) 40.4 ± 49.5 22.7 ± 19.2 36.2 ± 8.2 30.7 ± 15.3

BMI = body mass index; HOMA-IR = homeostasis model assessment; PRL =

prolactin; E2 = estradiol; T = testosterone.

PCOS patients and controls were classified according to serum diponectin levels

as described in Methods. ap < 0.05 vs group 4 bp < 0.01 vs group 4 cp < 0.001

vs group 4 dp < 0.05 vs group 2 ep < 0.01 vs group 3 for differencies between

four groups by Bonferroni-Dunn test. Data represent mean ± SD.

Figure 3. — The concentrations of serum LH and FSH levels in PCOS patients and controls, with classification based on serum

adiponectin levels. The figures below the X-axis indicate the number of each subgroup. * a p < 0.05 between groups 1 and 4 in FSH

levels, ** b p < 0.01 between groups 2 and 4 in FSH levels, † c p < 0.001 between groups 1 and 4 in LH levels and LH/FSH ratio,†† d p < 0.05 between groups 1 and 2 in LH levels and LH/FSH ratio, ‡ e p < 0.01 between groups 1 and 3 in LH levels, and LH/FSH

ratio. The data are expressed as means ± SD.

Discussion

In the present study, the authors investigated the rela-

tionship between endocrine parameters and adiponectin

levels in PCOS patients. Adiponectin is thought to be al-

most exclusively produced in adipose tissue. It was demon-

strated that obesity, IR, and type 2 diabetes were associated

with low plasma adiponectin levels in previous study [13].

In this data, obese women (BMI ≥ 25 kg/m2) showed sig-

nificantly decreased fasting serum concentrations of

adiponectin as compared with those of matched lean

women (BMI < 25 kg/m2) with PCOS.

It has been reported that serum adiponectin levels are

decreased in PCOS patients [10, 16, 17]. Thus, this result

may be particularly important in the context of the con-

currence of obesity (9), IR [18, 19] and/or impaired glu-

cose tolerance [20] in these women. It is well-recognized

that IR is frequently observed and has been linked to the

clinical and endocrine alterations, such as hyperandro-

genism and reproductive disorders in PCOS patients [21,

22]. Likewise, hyperinsulinaemia associated with IR might

be physiological roles of not only impaired glucose toler-

ance and type 2 diabetes mellitus, but also atherosclerosis

and cardiovascular disease observed in women with PCOS

[7, 23].

Overall, these findings are based on the previous studies,

in which significant lower adiponectin levels were evident,

in obese women with PCOS [15]. On the other hand, lean

women with PCOS did not show significant decreases in

adiponectin levels as compared with the corresponding lean

women in control group.

It is demonstrated that adiponectin is highly-expressed

in white adipose tissue, and is by far the most abundant

circulating specific protein derived from adipose tissues in

humans [13]. The evidence that adiponectin has the po-

tential to enhance insulin sensitivity and to improve glu-

cose metabolism [11, 12, 24, 25] has been demonstrated

in vitro and in vivo studies using rodents as a model. The

mechanisms of improvement of IR and glucose metabo-

lism by adiponectin are currently under investigation, al-

though it is well-recognized that the effects of

insulin-sensitizing agents have been implicated both in

the liver and muscle [24].

Consistent with findings in a rodents’ model, the

adiponectin levels were involved in obesity, type 2 diabetes

mellitus, and cardiovascular disease [12, 26]. In this way,

circulating low adiponectin levels in PCOS may not only

determine the degree of IR, but could also provide a link to

a higher risk of type 2 diabetes mellitus and cardiovascular

disease [21].

The decreasing of adiponectin levels may contribute to

IR in women with PCOS, because adiponectin is consid-

ered to reduce the triglyceride content of muscle, enhanc-

ing insulin signaling, and activates peroxisomal

proliferator-activated receptor alpha (PPARα), resulting

to increase energy combustion. Adiponectin also up-reg-

ulates fat oxidation and transport of muscle and inhibits

the expression of enzymes with gluconeogenesis, reduc-

ing hepatic glucose production by phosphorylation of

AMP-activated protein kinase [27].

Overall, one interesting point that arises from these re-

sults is that serum adiponectin levels are observed in hor-

monal differences (elevated LH and LH/FSH ratio) in

PCOS, but not observed in controls. The fact that go-

nadotropin secretion is associated with adiponectin con-

centrations suggests that it may represent the role of

adiponectin on the endocrine condition directly or indi-

rectly in women with PCOS.

In conclusion, these data have shown that compared with

controlsof similar body weight, PCOS patients have altered

adiponectin secretion. These differences may be caused by

the result of altered adipose tissue function. Likewise, al-

tered adiponectin secretion may still be involved in the

characteristic IRof PCOS. Further studies will be needed to

elucidate this issue.

Acknowledgement

This research was supported in part by Grants-in-Aid

22591829 (Y. Kawano) for Specific Research from the Ministry

of Education, Science, and Culture of Japan.

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[19] Sepilian V., Nagamani M.: “Adiponectin levels in women with poly-

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Endocr. Rev., 2005, 26, 439.


Y. KAWANO, M.D., Ph.D.


Faculty of Medicine

Oita University, Yufu, Oita (Japan)


Introduction

Stress urinary incontinence (SUI) is defined as inconti-

nence secondary to increased abdominal pressure such as

coughing, sneezing, and heavy lifting [1]. It affects

approximately 30% of adult women. In the 20th century,

more than 100 surgical techniques for the treatment of

urinary incontinence were developed. The tension-free

vaginal tape (TVT) procedure, initially described by

Ulmsten et al. in 1996, was the first minimally invasive

mid-urethral sling procedure with 84% cure and eight

percent significant improvement rates at two years follow-

up [2]. The complication rates are low for TVT and

mainly include bladder injury, hematomas, and transient

retention of urine with bladder injury being the most

common and occurring in three to nine percent of cases

[3-6]. There have been rare reports of bowel and vascular

injury with TVT [7]. In order to overcome the bladder,

bowel, and vascular injuries related to TVT, transobtura-

tor approach (TOT) was developed by Delorme, main-

taining the efficacy of TVT and reducing or even elimi-

nating the complications related to the penetration of the

retropubic space [8]. In 2003, de Leval described the

inside-out technique of transobturator approach (TVT-O)

for better control of the vaginal passage [9].

Various studies have been conducted comparing the

efficacy and complication rates of these two methods;

however, literature lacks sufficient amount of reports con-

cerning the effect of these methods on urodynamics and

relationship with the success of these methods. In this

study, the authors evaluated the effects of TVT and TVT-

O operations on urodynamics and compared the two

methods according to patient satisfaction and objective

measures of success.


Thirty-six patients admitted to the present institution with the

complaint of SUI or mixed urinary incontinence and operated

were included in this prospective study. Informed consent was

obtained from all patients. Ethics approval was obtained from

the local ethics committee. The patients were randomly assigned

and 19 patients underwent TVT-O and the remaining 17 under-

went TVT operation.

Preoperative and postoperative evaluations included urinaly-

sis, urine culture, urogynecologic symptom assessment and

gynecologic examination, one-hour pad test, four-day bladder

diary, stress test, Q-tip test, and urodynamics were performed.

Pelvic organ prolapse was evaluated using Baden-Walker

Halfway System. The Bristol Female Lower Urinary Tract

Symptoms Questionnaire-Scored form (BFLUTS) was used to

evaluate the effect of SUI on the patient’s everyday life and for

the quantification of the lower urinary tract symptoms [10]. Uro-

dynamic studies (MMS UD-2000) included uroflowmetry, mul-

tichannel cystometry, and urethral pressure profile. In cases of

grade 3 and more pelvic organ prolapse, normal anatomy was

restored using a pessary or a vaginal tampon during the tests.

The same surgeon performed all of the surgical procedures.

The operations were performed with spinal or general anesthe-

sia according to patient preference in accordance with original

techniques described by Ulmsten and De Leval. For TVT oper-

536

Does tension-free vaginal tape and tension-free vaginal

tape-obturator affect urodynamics?

Comparison of the two techniques

F. Gungor Ugurlucan, H. Ayyildiz Erkan, C. Yasa, O. Yalcin

Istanbul University, Medical Faculty, Department of Obstetrics and Gynecology, Istanbul (Turkey)

Summary

Aim: To evaluate the effects of tension-free vaginal tape (TVT) and tension-free vaginal tape-obturator (TVT-O) operations on uro-

dynamics and subjective and objective outcomes. Materials and Methods: Thirty-six patients with stress or mixed urinary incontinence

underwent TVT or TVT-O. Bristol Female Lower Urinary Tract Symptoms (BFLUTS) Questionnaire-Scored Form, one-hour pad test,

Q-tip test, perineometer, and urodynamics were performed before and after the operations. Blaivas-nomogram was used for assessment

of postoperative voiding difficulty. Results: Nineteen patients underwent TVT-O and 17 patients underwent TVT. Mean follow-up was

18.4 ± 6.8 months. There was no difference between two groups regarding demographic variables, degree of prolapse, type of inconti-

nence, perineometer, Q-tip test, pad test, and urodynamics. There was a significant increase in the maximum urethral closure pressure

(MUCP) and residual volume in TVT-O group. According to Blaivas-nomogram, five patients had mild, one had medium obstruction

in the TVT-O group, whereas one had mild and three had medium obstruction in TVT group. Two bladder perforations occurred dur-

ing TVT. One patient developed groin pain after TVT-O. Conclusions: TVT-O may lead to an increase in MUCP and residual urine vol-

ume. TVT-O is as efficient as TVT and leads to milder obstruction when compared to TVT.

Key words: Stress urinary incontinence; Urinary incontinence; Midurethral sling; Tension-free vaginal tape; Transobturator tape; Uro-

dynamics.

Revised manuscript accepted for publication January 17, 2013


XXXIX, n. 2, 2012

ations Gynecare TVT, for TVT-O operations Gynecare TVT

Obturator System tension- free support for incontinence was

used. Cystoscopy was routinely performed in all of the TVT pro-

cedures and in suspected cases during TVT-O operations.

Foley catheter was introduced during all of the operations and

kept for 24 hours in cases of isolated midurethral sling opera-

tions, and kept for three days if anterior colporrhaphy was

included. The residual urine volume was measured after the

Foley catheter was removed and the patients were discharged

when the residual urine volume was < 100 ml. In case of urinary

retention, the catheter was inserted and kept in place for an addi-

tional 24 hours. Perioperative and postoperative complications

were noted in all of the cases.

Patients were re-evaluated at three to 12 months after surgery.

Groups were compared according to demographic variables,

urinary leakage, pad usage, voiding problems, Q-tip test, stress

test, pad test, uroflowmetry, cystometry, and urethral pressure

profile. For the determination of postoperative bladder outlet

obstruction, Blaivas nomogram was used [11].

Statistical analysisStatistical analysis was performed with the computer program

Statistical Package for the Social Sciences (SPSS) 11.0 for

Windows by a professional statistician. Data are expressed as

mean ± standard deviation.

All univariate comparisons were performed using Student's t-

test in cases where the data were normally distributed. Normal-

ity assumption was performed and Mann Whitney U test,

Wilcoxon signed rank test, Spearman correlation, chi-square

test, and McNemar chi-square test were used for abnormally dis-

tributing data. All outcome comparisons were one-sided to

compare the methods used in each group to assess the improved

outcomes. Comparisons of patient characteristics were two-

sided. A p value less than 0.05 was considered statistically sig-

nificant.

Results

Thirty-six patients were included in the study. TVT-O

was performed in 19 patients and 17 patients underwent

TVT. The demographic variables of patients are summa-

rized in Table 1. There was no statistically significant dif-

ference between the groups for age, body mass index,

menopausal state, hormone treatment, and surgical

history. One patient in the TVT-O group had a history of

periurethral injection, which was unsuccessful.

Five patients (26%) in the TVT-O group and four patients

(24%) in the TVT group had genuine SUI. Fourteen

patients (74%) in the TVT-O group and 13 patients (76%)

in the TVT group suffered from mixed urinary inconti-

nence. Eighteen (96%) of the patients in the TVT-O group

and all of the patients in the TVT group had a cystocele,

two patients in the TVT-O group, and three patients in the

TVT group had a rectocele, nine patients in the TVT-O

group, and eight patients in the TVT group had uterine pro-

lapse. The types of the operations performed are summa-

rized in Table 2. Four patients in the TVT-O group and

three patients in the TVT group did not have pelvic organ

prolapse and underwent sling operation only.

No significant difference was observed between the TVT

and TVT-O groups in terms of preoperative pad test, Q-tip

test, perineometer results, and bladder diaries. All of the

patients had urethral mobility before the operation. Only

five patients in the TVT-O group and two patients in the

TVT group had negative pad test results before the opera-

F. Gungor Ugurlucan, H. Ayyildiz Erkan, C. Yasa, O. Yalcin 537

Table 1. — Demographic variables of the two groups.TVT-O (n = 19) TVT (n = 17) p

Age 51.1 ± 9.3 50.6 ± 8.0 > 0.05*

Body mass index (kg/m2) 30.9 ± 4.9 30.4 ± 4.3 > 0.05*

Parity 3.58 ± 1.54 3.06 ± 1.30 > 0.05†

Menopause 9 (47%) 9 (52%) > 0.05°

Hormone replacement

treatment 3 (16%) 3 (17%) > 0.05°

Previous anti-incontinence

surgery 1 (0.05%)^ 0 > 0.05°

Previous hysterectomy 2 (10.5%) 3 (17.6%) > 0.05°

Previous prolapse surgery 2 (10.5%) 1 (5.8%) > 0.05°

*Student-t test; †Mann-Whitney U-test; °Fischer chi-square test.

Table 2. — Operations performed in the two groups. Operation TVT-O TVT

(n = 19) (n = 17)

Sling operation only 4 3

Prolapse operation included 15 14

Vaginal hysterectomy +

colporraphy anterior + posterior 6 5

Colporrhaphy anterior 1 0

Colporrhaphy posterior 3 0

Colporrhaphy anterior + posterior 1 3

Manchester operation 1 0

Vaginal hysterectomy 2 1

Total abdominal hysterectomy 1 3

Vaginal hysterectomy + colporrhaphy anterior 0 2

Chi square test, p > 0.05.

Table 3. — One-hour pad test, Q- tip Test, and perineometerresults of the two groups before and after surgery.

TVT-O (n = 19) TVT (n = 17) pPreoperative Postoperative Preoperative Postoperative

One-hour pad 16.1 ± 26.8 0 29.1 ± 28.4 6.46 ± 19.32 > 0.05*

test (gr) (5.0) (0-85) (0-70)

(0-100)

Q-tip Test (°) 62.5 ± 17.5 45.0 ± 20.4 59.1 ± 18.0 48.5 ± 19.3 > 0.05*

(35-90) (20-90) (35-85) (15-80)

Perineometer 24.4 ± 13.4 25.4 ± 13.5 20.1 ± 10.7 25.0 ± 14.0 > 0.05*

(cm H2O) (4-51) (3.0-45.0) (4-44) (6-49)

*Mann-Whitney U test.

Table 4. — Comparison of the preoperative and postoperativebladder diaries.

TVT-O (n = 19) TVT (n = 17) pPreoperative Postoperative Preoperative Postoperative

Mean amount 1793 ± 494 1808 ± 594 2181 ± 658 1975 ± 612 0.05

of fluid intake/ (600-2800) (600-2566) (837-3219) (925-2887)

day (ml)

Mean daytime 8.5 ± 2.6 6.5 ± 2.4 9.3 ± 3.4 7.6 ± 2.4 0.05

number of (5-14) (4-12.5) (4-17) (4-11)

micturition

Mean number of 4.6 ± 4.7 1.8 ± 4.4 3.6 ± 4.2 1.1 ± 1.8 0.05

urgency episodes/ (0-15) (0-14) (0-16) (0-5)

day

Mean number of 2.2 ± 2.7 0.5 ± 0.9 2.5 ± 3.5 0.8 ± 1.8 0.05

leakage/day (0-8.5) (0-2.5) (0-14) (0-6)

Does tension-free vaginal tape and tension-free vaginal tape-obturator affect urodynamics? Comparison of the two techniques538

tion. Stress test was positive in five patients in the TVT-O

group and four patients in the TVT group (Tables 3 and 4).

There was no significant difference in the preoperative

urodynamic parameters between the two groups. Six

patients (32%) with mixed urinary incontinence and two

patients (10%) with SUI in the TVT-O group, and five

patients (30%) with mixed urinary incontinence in the TVT

group had detrusor overactivity during cystometry. SUI was

observed in eight patients (42%) in the TVT-O and seven

patients (41%) in the TVT group. There was no difference

in the mean abdominal leak point pressure between the two

groups. The results are summarized in Table 5.

The mean follow-up period was 18.4 ± 6.8 months. Cure

was accomplished in 89.5% of the TVT-O group, 65% of

the TVT group and 10.5% of the TVT-O group, and 35% of

the TVT group improved (p = 0.002). Stress test was neg-

ative in all of the patients. Only one patient in the TVT

group and one patient in the TVT-O group did not have ure-

thral mobility in the postoperative evaluation (Table 3).

None of the patients who underwent TVT-O complained of

SUI in the postoperative period, but two patients (10.5%)

suffered from urge urinary incontinence. One had mixed

urinary incontinence before the operation, and the other one

developed de novo. One patient (5.8%) in the TVT group

suffered from SUI, four patients (23.5%) had urge urinary

incontinence, and one patient (5.8%) had mixed urinary in-

continence. There was a significant difference between the

two groups in total number of incontinent patients. When

the postoperative pad test results were compared, none of

the patients in the TVT-O group and only two patients in the

TVT group had a positive pad test (p > 0.05).

BFLUTS results revealed no significant difference in the

symptoms of obstructed voiding between the two groups,

but in both groups, postoperative voiding dysfunction in-

creased; 41% of the TVT group and 42% of the TVT-O

group noted changing in the voiding pattern and hesitancy

during voiding. Frequency of micturition and pad usage de-

creased (Table 6).

When the postoperative urodynamic parameters were

compared, there was no significant difference in

maximum flow rate, the time to reach maximum flow,

micturition volume, residual urine volume, compliance,

maximum detrusor pressure, abdominal leak point pres-

Table 6. — Comparison of the symptoms of voiding difficulty ofthe two groups before and after surgery.

TVT-O TVT pPreoperative Postoperative Preoperative Postoperative

Slow stream 6 (31%) 11 (58%) 6 (35%) 11 (65%) > 0.05

Straining for voiding 5 (26%) 11 (58%) 6 (35%) 9 (53%)

De novo: 7 De novo: 4

(37%) (23.5%)

Difficult voiding 3 (16%) 11 (58%)+ 6 (35%) 13 (76%)+ > 0.05

De novo: 8 De novo: 7

(42%) (41%)

Pad usage 14 0+ 13 5+ > 0.05

Frequency 11 (58%) 1 (5%)+ 9 (53%) 5 (29%) > 0.05

De novo: 2

(12%)

*McNemar Chi square test; ^Chi square test; +p for TVT-O < 0.05; p for TVT < 0.05.

Table 5. — Comparison of uroflowmetry, cystometry, and urethral pressure profile before and after surgery. TVT-O (n = 19) TVT (n = 17)

Preoperative Postoperative p Preoperative Postoperative p p

UroflowmetryMaximum flow rate (ml/s) 28.3 ± 8.3 (13-43) 17.8 ± 6.1 (11-42) > 0.05* 28.9 ± 10.8 (17-60) 23.5 ± 9.1 (10-45) > 0.05* > 0.05*

Time to maximum flow (s) 8.6 ± 8.2 (2-33.6) 8.9 ± 3.9 (4-15) > 0.05* 11.6 ± 8.9 (2.4-31.2) 9.9 ± 9.4 (2.4-40) > 0.05* > 0.05*

Residual urine volume (ml) 20.6 ± 21.4 (0-80) 38.9 ± 52.4 (0-90) = 0.047* 19.7 ± 23.9 (0-70) 23.1 ± 24.6 (0-80) > 0.05* > 0.05*

Micturition time (sn) 30.5 ± 11.6 (14-55) 42.0 ± 24.5 (18-96) > 0.05* 39.1 ± 17.1 (12.8-73) 38.5 ± 11.8 (20-61) > 0.05* > 0.05*

CystometryFirst sensation of urine (ml) 187 ± 57 (125-319) 175 ± 45 (121-391) > 0.05* 191 ± 75 (83-351) 154 ± 77 (40-326) > 0.05* > 0.05*

Strong sensation of urine (ml) 323 ± 256 (no-699) 496 ± 131 (251-658) > 0.05* 516 ± 119 (227-660) 504 ± 131 (316-709) > 0.05* > 0.05*

Maximum bladder capacity (ml) 595 ± 177 (184-720) 609 ± 153 (317-717) > 0.05* 629 ± 141 (354-717) 589 ± 135 (337-725) > 0.05* > 0.05*

Compliance (ml/cmH2O) 75.9 ± 56.6 (13-210) 124 ± 156 (13-450) > 0.05* 73.9 ± 44.1 (13-150) 92.7 ± 56.5 (15-159) > 0.05* > 0.05*

Maximum detrusor pressure

(cm H2O) 10.3 ± 8.5 (3-36) 14.5 ± 10.6 (3-85) = 0.021* 10.3 ± 6.5 (2-25) 25.0 ± 28.6 (3- 87) > 0.05* > 0.05*

Abdominal leak point pressure

(cm H2O) 78.8 ± 29.3 (40-131) – 85.2 ± 41.5 (22-141) 92.7 ± 42.5 (47-131) > 0.05*

Detrusor leak pressure (cm H2O) 27.0 ± 11.9 (15-47) 25.0 ± 7.3 (15-31) > 0.05* 30.6 ± 14.8 (13-52) 30.3 ± 16.5 (20- 54) > 0.05* > 0.05*

Detrusor pressure at micturition

(cm H2O) 35.7 ± 23.5 (5-85) 25.0 ± 7.5 (12-33) > 0.05* 27.4 ± 12.2 (10-48) 33.5 ± 18.7 (2- 64) > 0.05* > 0.05*

UPPMaximum urethral pressure

(cm H2O) 48.7 ± 25.8 (25-115) 68.1 ± 34.0 (23-131) > 0.05* 63.7 ± 33.6 (8-117) 44.9 ± 18.4 (13- 46) > 0.05* >0.05*

Maximum urethral closure pressure

(cm H2O) 43.4 ± 30.8 (0-115) 63.1 ± 25.8 (23-107) = 0.031* 57.7 ± 31.2 (8-116) 45.1 ± 18.4 (11- 86) > 0.05* = 0.01*

Functional urethral length (cm) 3.1 ± 0.5 (2.2-3.9) 2.9 ± 0.6 (1.5-3.7) > 0.05* 2.9 ± 0.5 (1.7-3.8) 2.8 ± 0.7 (1.4- 4.0) > 0.05* > 0.05*

* Mann-Whitney U test; Wilcoxon signed rank test.

Table 7. — Comparison of the complications encounteredduring or after TVT-O and TVT procedures. Complications TOT TVT p

(n = 19) (n = 17)

Urinary retention 2 2 > 0.05*

Bladder perforation 0 2 > 0.05*

Postoperative pain 1 0 > 0.05*

De novo UI 1 0 > 0.05*

Fever 2 2 > 0.05*

Chi square test, p > 0.05.

sure, detrusor pressure at micturition, maximum urethral

pressure, and functional urethral length. The results are

summarized in Table 5. The mean maximum urethral

closure pressure was 63.1 ± 25.8 cm H2O (23-107 cm

H2O) in the TVT-O group and 45.1 ± 18.4 cm H2O (11-

86 cm H2O) in the TVT group. There was a significant

increase in the maximum urethral closure pressure and

residual urine volume in patients who underwent TVT-O

operation (Table 4).

As shown in Figure 1, none of the patients in the TVT-

O group had severe obstruction according to Blaivas

nomogram. One patient (5.2%) was in the moderate and

five patients (26%) were in the mild obstruction group. In

the TVT group, three patients (17%) were in the moder-

ate obstruction group and one patient (26%) was in the

mild obstruction group.

Intraoperative and postoperative complications are

summarized in Table 7. Postoperative urinary retention

developed in two patients in both groups, but resolved

completely shortly after. Groin pain developed in one

patient in the TVT-O group. De novo urge incontinence

was seen in one patient in the TVT-O group. Bladder per-

foration occurred in two patients in the TVT group.

Discussion

In this study, the effect on urodynamics and subjective

and objective outcomes of TVT and TVT-O procedures

have been evaluated. Subjective and objective criteria

including urodynamics were used to compare the TVT and

TVT-O operations. There was no difference between the

two groups regarding age, parity, menopausal state, and the

prevalence of mixed urinary incontinence; therefore the

two groups were suitable for comparison in this study.

There was a significant difference in patient satisfac-

tion and cure rates in the two groups with more patients

cured in the TVT-O group. In this study, cure was defined

as no leakage episodes after surgery. In another study

regarding the success rate of TVT operation from the

present institution with mean follow-up period of 11

months (1-24 months), the cure rate was 90% and 10% of

the patients had improved [12]. The mean age of the pop-

ulation studied and the inclusion of other vaginal surgical

procedures were similar to the present study group.

Various other reports presented 90% cure-rate in the first

year after surgery using TVT with reduction in the

success rate when cases with intrinsic sphincter defi-

ciency and pelvic organ prolapse were included [13-15].

In most of the studies evaluating the success rate of TVT

operations, patients with pelvic organ prolapse and pelvic

reconstruction surgery and previous anti-incontinence

surgery have been excluded. Tsivian et al. [16] reported

that when these cases are included, the cure rate declines

to 78.9%. In a recent systematic review, retropubic pro-

cedures have shown greater objective success, but no dif-

ference in subjective outcomes [17]. The current authors

did not accept the patients as cured when there were still

symptoms (loss, urge, high residual urine volume), even

if they had a negative pad test and stress test result and

no leakage in uroydnamics. However, this study demon-

strates that TVT-O is as successful as TVT operation and

the rate of complications is very low. In a study evaluat-

ing the patient perceptions of success after TOT and TVT,

65.5% of the patients in the TVT group and 63.4% of the

TOT group reported no stress incontinence [18]. Simi-

larly, in a recent multicenter randomized controlled trial

using both objective and subjective outcomes, the

success rate for TVT was 80.8% and for TOT was 77%

[19] However, for subjective outcomes, success rates

were 62.6% and 55.5% for TVT and TOT, respectively.

These two operations do not aim at correcting the ure-

thral hypermobility. On the contrary, the persistence of

urethral hypermobility after surgery is important for the

dynamic movement of the urethra during increases in

intra-abdominal pressure [20]. It was shown that urethral

mobility was not affected after TVT [21, 22]. The conti-

nence mechanisms of TVT and TOT and TVT-O are

similar. Fellipi showed the persistence of urethral mobil-

ity after TOT operation using cystography [23]. In

another study using a Q-tip test, no effect of TOT on ure-

thral mobility was found [24]. According to the present

study, neither TVT nor TVT-O affected the urethral

mobility in the postoperative period.

One of the major complications of both procedures is

voiding difficulty, which may be observed after inconti-

nence procedures. Significant portion of the patients

began to suffer from hesitancy and voiding difficulty

after the operations in both groups. Porena et al. reported

voiding difficulty in 44% and 24% following TVT and

TOT, respectively [24]. However, in other studies lower

rates of voiding dysfunction were reported. Definitions of

voiding difficulty vary between studies, so it is difficult

to draw conclusions.


Figure 1. — Blaivas nomogram a) for TVT-O; b) for TVT.

Maxim

al

detr

ussor

pre

ssure

(cm

H2O

)

Severe obstruction

Moderate

obstruction

Mild obstruction

Maximal flow rate (ml/sec)

No obstruction

Does tension-free vaginal tape and tension-free vaginal tape-obturator affect urodynamics? Comparison of the two techniques540

Persistence of urge incontinence or de novo urge incon-

tinence may occur following the aforementioned proce-

dures. In the present cohort, urge incontinence and de

novo urge incontinence was not observed in the TVT

group. One patient suffered from de novo urge inconti-

nence in the TVT-O group. Thirteen patients in the TVT

group had mixed urinary incontinence symptoms before

surgery and this was reduced to five patients after

surgery. Similarly, 14 patients had mixed urinary inconti-

nence symptoms before the operation and only one

patient after surgery had mixed symptoms in the TVT-O

group. Segal et al. [25] studied the effect of TVT on urge

urinary incontinence and detrusor overactivity. In this

study, urge incontinence symptoms disappeared in 63.1%

of the mixed urinary incontinence cases in the TVT group

and 57.7% could stop their anticholinergic drugs. The

present findings are in parallel. Similarly TVT-O leads to

a reduction in urge incontinence symptoms in patients

with mixed urinary incontinence.

Both TVT and TVT-O have high rates of success in

the treatment of SUI and one would anticipate changes

in the urodynamic parameters after these procedures.

However; there was no significant difference in the uro-

dynamics between TVT and TVT-O. There was a sig-

nificant increase in the maximum urethral closure pres-

sure in the postoperative evaluation in the TVT-O

group. According to the present study, TVT-O might as

well be effective in the treatment of intrinsic sphincter

deficiency together with urethral hypermobility in

patients. There was also a slight increase in the residual

urine volume and micturition time. In the Blaivas nomo-

gram, which shows voiding difficulty based on

maximum detrusor pressure and maximum flow rate,

there was no significant difference between the two

groups. None of the patients in the TVT-O group had

severe obstruction. Higher rates of voiding difficulty

have been reported with TVT compared with TOT oper-

ation [16], possibly because it is more obstructive; but

this was not seen in the study by Richter et al. (2.7% for

TVT and 0% for TOT) [19].

The other complications following both techniques

include bladder perforation, vascular injuries, hematomas,

vaginal perforations, and groin pain [3-7]. In this study,

there was a low rate of complications (Table 7). Two

bladder perforations developed in the TVT group during

the operations and the inserted needle was removed and

re-inserted. No bladder perforations, vaginal sulcus

injury or vascular injury developed in the TVT-O group,

but one patient suffered from groin pain.

Conclusion

This study demonstrates that TVT and TVT-O proce-

dures have high success rates with minimal effect on

bladder storage and voiding functions. Both work well in

patients with mixed urinary incontinence and pelvic

organ prolapse. However, TVT-O procedure resulted in a

higher cure rate with a significant increase in maximum

urethral closure pressure than did the TVT procedure.

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[1] Abrams P., Cardozo L., Fall M., Griffiths D., Rosier P., Ulmsten U.

et al.: “The standardisation of terminology of lower urinary tract

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167.

[2] Ulmsten U., Henriksson L., Johnson P., Varhos G.: “An ambulatory

surgical procedure under local anesthesia for treatment of female

urinary incontinence”. Int. Urogynecol. J., 1996, 7, 81.

[3] Enzelsberger H., Schaluphy J., Heider R., Mayer G.: “TVT versus

TOT-A prospective randomized study for the treatment of female

stress urinary incontinence at a follow-up of 1 year”. GeburtshilfeFrauenheilkd, 2005, 65, 506.

[4] Kim Y.-W., Na Y.-G., Sul C.-K.: “Randomized prospective study

between pubovaginal sling using SPARC sling system and

MONARC sling system for the treatment of female stress urinary

incontinence: short term results”. Korean J. Urol., 2005, 46, 1078.

[5] David-Montefiore E., Frobert J.L., Grisard-Anaf M., Leinhart J.,

Bonnet K., Poncelet C. et al.: “Peri-operative complications and

pain after the suburethral sling procedure for urinary stress incon-

tinence: a French prospective randomized multicentre study com-

paring the retropubic and transobturator routes”. Eur. Urol., 2006,

49, 133.

[6] Wang A.C., Lin Y.H., Tseng L.H., Chih S.Y., Lee C.J.: “Prospective

randomized comparison of transobturator suburethral sling (Monarc)

vs. suprapubic arc (Sparc) sling procedures for female urodynamic

stress incontinence”. Int. Urogynecol. J., 2006, 17, 439.

[7] Palanca A.B., Perez F.C., Meseguer J.F.B., Zaragoza J.A.Q., Clara-

munt J.E., Sepere F.P.: “Estudio comparativo de diferentes procedi-

mientos de sling suburetral para el tratamiento de la incontinencia

urinaria de esfuerzo”. Actas Urol. Esp., 2005, 29, 757.

[8] Delorme E., Droupy S., de Tayrac R., Delmas V.: “Transobturator

tape (Uratape): a new minimally invasive procedure to treat female

urinary incontinence”. Eur. Urol., 2004, 45, 203.

[9] de Leval J.: “Novel surgical technique for the treatment of female

stress urinary incontinence: transobturator vaginal tape inside-out”.

Eur. Urol., 2003, 44, 724.

[10] Brookes S.T., Donovan J.L., Wright M., Jackson S., Abrams P.: “A

scored form of the Bristol Female Lower Urinary Tract Symptoms

questionnaire: Data from a randomized controlled trial of surgery

for women with stress incontinence”. Am. J. Obstet. Gynecol.,2004, 191, 73.

[11] Blaivas J.G., Groutz A.: “Bladder outlet obstruction nomogram for

women with lower urinary tract symptomatology”. Neurourol.Urodynam., 2000, 19, 553.

[12] Yalcin O., Isikoglu M., Beji N.K.: “Results of TVT operations

alone and combined with other vaginal surgical procedures”. Arch.Gynecol. Obstet., 2004, 269, 96.

[13] Deffieux X., Daher N., Mansoor A., Debodinance P., Muhlstein J.,

Fernandez H.: “Transobturator TVT-O versus retropubic TVT:

results of a multicenter randomized controlled trial at 24 months

follow-up”. Int. Urogynecol. J., 2010, 21, 1337.

[14] Paick J.S., Ku J.H., Shin J.W., Son H., Oh S.J., Kim S.W.:

“Tension-free vaginal tape procedure for urinary incontinence with

low valsalva leak point pressure”. J. Urol., 2004, 172, 1370.

[15] Liapis A., Bakas P, Salamalekis E. Botsis D, Creatsas G.: “Tension-

free vaginal tape in women with low urethral closure pressure”.

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[16] Tsivian A., Mogutin B., Kessler O., Korczak D., Levin S., Sidi

A.A.: “Tension-free vaginal tape procedure for the treatment of

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[17] Novara G., Artibani W., Barber M.D., Chapple C.R., Costantini E.,

Ficarra V. et al.: “Updated systematic review and metaanalysis of

the comparative data on colposuspensions, pubovaginal slings, and

midurethral tapes in the surgical treatment of female stress urinary

incontinence”. Eur. Urol., 2010, 58, 218.

[18] Freeman R., Holmes D., Hillard T., Smith P., James M., Sultan A.

et al.: “What patients think: patient-reported outcomes of retropu-

bic versus trans-obturator mid-urethral slings for urodynamic stress

incontinence-a multi-centre randomised controlled trial”. Int. Urog-ynecol. J., 2011, 22, 279.


[19] Richter H.E., Albo M.E., Zyczynski H.M.D., Kenton K., Norto

P.A., Sirls L.T.: “Retropubic versus transobturator midurethral

slings for stress incontinence”. N. Engl. J. Med., 2010, 362, 2066.

[20] Lo T.S., Wang A., Horng S.G., Liang C.C., Soong Y.K.: “Ultra-

sonographic and urodynamic evaluation after tension-free vaginal

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[21] Atherton M., Stanton S.: “A comparison of bladder neck movement

and elevation after tension-free vaginal tape and colposuspension”.

Br. J. Obstet. Gynecol., 2000, 107, 1366.

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cedure: correction of stress incontinence with minimal alteration in

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of transobturator tape procedure on proximal urethral mobility”.

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[24] Porena M., Costantini E., Frea B., Giannantoni A., Ranzoni S.,

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[25] Segal J., Vasallo B., Kleeman S., Silva W.A., Karram M.M.:

“Prevalance of persistent and de novo overactive bladder symp-

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104, 1263.


F. GUNGOR UGURLUCAN, M.D.

Atakoy 9 Kisim, B6 Blok

Daire 40, Atakoy, Istanbul (Turkey)


Introduction

Menopause is mainly connected to the gradual and mas-

sive reduction of the estrogen levels in women. This hor-

monal condition has different effect on various target

organs such as the uterus, vaginal mucosa, skin, and en-

dothelium. The protective role of estrogens on the en-

dothelium has been proven by multiple studies and so

menopause can induce endothelial dysfunction and lead to

metabolic syndrome and cardiovascular disease (CVD), the

first cause of death in women during the postmenopausal

period [1, 2]. Several biochemical substances in the blood

serum have been studied and used at present as valuable

risk markers for CVD such as total cholesterol (TC), low-

density lipoprotein (LDL), high-density lipoprotein (HDL),

triglycerides (Tg), high-sensitivity C-reactive protein

(hsCRP), homocysteine (Hcy), endothelin-1 (ET-1), and

many others both in men and women, mainly addressed to

the endothelial function.

Hormone replacement therapy (HRT) in postmenopausal

women had been welcomed with enthusiasm at the begin-

ning, both by patients and clinicians due to the relief of the

postmenopausal symptoms and the proven positive effect

on the evolving osteoporosis during menopause and the

positive effect on the prevention of CVD [3]. On the con-

trary the results of randomized-controlled studies showed

that HRT has adverse effects on the cardiovascular system

[4]. Further studies in the past decade has given more clar-

ity in the safe length of HRT regimes and made patients

less reluctant to the use of it [5].

Tibolone is a synthetic steroid with tissue-specific es-

trogenic, androgenic, and progestogenic properties. It

mainly acts as an agonist at all Type I steroid hormone

receptors [6]. It was primarily used against osteoporosis

but nowadays is also used as an alternative to HRT for

relief of menopausal symptoms. Though, acting as an es-

trogen, data suggest that tibolone may have cardio-pro-

tective role by acting positively on biochemical risk

factors for CVD, when used in postmenopausal women

[7]. The results among relevant studies on the topic are

still conflicting.


Fifty-two Caucasian healthy postmenopausal women were en-

rolled in a prospective, randomized, case-controlled outpatient trial.

All women presented at the Menopause Outpatient Clinic of the

present university teaching hospital after referral for post-

menopausal symptoms. After consultation the patients were ran-

domized in two groups. Group 1 (n = 26) received 2.5 mg/d tibolone

for six months, while Group 2 (n = 26) received no treatment.

Randomization was carried out by using sealed envelopes con-

taining computer-generated randomization numbers. Informed con-

sent was obtained from all women and the study was approved by

the regional ethical committee.

542

Effect of short-term tibolone treatment on risk markers

for cardiovascular disease in healthy postmenopausal women:

a randomized controlled study

A. Traianos1, D. Vavilis1, A. Makedos1, A. Karkanaki2, K. Ravanos2, N. Prapas2, B.C. Tarlatzis1

1First Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, “Papageorghiou” General Hospital of Thessaloniki, Thessaloniki

2Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, “Ippokrateio” General Hospital of Thessaloniki,Thessaloniki (Greece)

Summary

Objective: The aim of this prospective randomized controlled cross sectional study was to evaluate the effect of a six month tibolone

treatment in healthy postmenopausal women on biochemical CVD markers by calculating the changes of the blood serum levels of

total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (Tg), high-sensitivity C-reactive

protein (hsCRP), homocysteine (Hcy), and endothelin-1 (ET-1) at the beginning of the treatment and after six months. Materials andMethods: Fifty-two healthy postmenopausal women were enrolled in a prospective, randomized, case-controlled outpatient trial. Group

1 (n = 26) received 2,5 mg/d tibolone for six months, while Group 2 (n = 26) received no treatment. Serum levels of TC, LDL, HDL,

Tg, hsCRP, Hcy, and ET-1 were evaluated at baseline and after six months. Results: The two groups did not statistically differ at base-

line characteristics. In Group 1 tibolone treatment decreased significantly TC (p = 0.01), HDL (p < 0.001), and Tg (p < 0.001) serum

levels while a significant increase of hsCRP (p < 0.001) was observed. Finally no changes were noticed on LDL, Hcy, and ET-1 serum

levels. Regarding Group 2, no changes were observed. Conclusion: Short-term tibolone treatment in healthy postmenopausal women

exerts a mixed action, acting beneficially in some markers (TC, LDL, Tg, Hcy, and ET-1) where as detrimentally in others (HDL,

hsCRP).

Key words: Tibolone, cardiovascular disease; Risk markers; Postmenopausal women.



XXXIX, n. 2, 2012

A. Traianos, D. Vavilis, A. Makedos, A. Karkanaki, K. Ravanos, N. Prapas, B.C. Tarlatzis 543

Inclusion criteria in the study were: the time interval since the

last menstrual bleeding (MSM) more than 12 months; for surgi-

cal menopause time interval ≥ four months, and the body mass

index (BMI) < 30 kg/m2. In all patients follicular stimulating

hormone (FSH) was > 40 IU/l. Moreover all patients were:

healthy without taking any medication. Exclusion criteria were:

medical history of thrombophilia, arterial hypertension, CVD,

hepatic or kidney disease, thyroid disease, diabetes mellitus, use

of HRT more than six months prior to the study, and any type of

neoplasia. All women were requested to avoid any diet and

lifestyle modifications or commence any long-term medication

during the trial.

During the first visit in the clinic, medical history was taken

and also clinical examination, transvaginal ultrasound (TVUS) of

the internal genital organs, and smear test collection were per-

formed. Further bone densitometry (DEXA) of the hip was or-

dered and performed by the radiology department of this hospital.

At the same day blood sampling was performed after 12 hours of

fasting for the evaluation of serum levels of TC, LDL, HDL, Tg,

hsCRP, Hcy, and ET-1. Six months later, another blood sampling

was performed under the same conditions for the evaluation of

the same markers.

AssaysET-1 serum levels were measured using ET-1 ELISA kits . The

sensitivity of the kit is 0.064 pg/ml. ET-1 concentrations were

found to be in the range 0.401-2.83 pg/ml. HsCRP serum levels

were measured using Cardiphase hsCRP ELISA kits. Expected val-

ues for healthy individuals are typically ≤ 3 mg/l. The sensitivity

of the method is 0.175 mg/l. Serum Hcy levels were measured by

fluorescence polarization immunoassay. Within-assay and be-

tween-assay CV were 1.4 – 2.2% and 2.9 – 4.8%, respectively. TC

serum levels were measured by enzymatic method. Expected val-

ues for normal individuals were < 200 mg/dl. Within-assay and be-

tween-assay CV were 0.8% and 1.7%, respectively. LDL serum

levels were measured by enzymatic method. Expected values for

normal individuals were < 100 mg/dl. Within-assay and between-

assay CV were 0.71-0.81% and 1.16-1.2%, respectively. HDL


ues for normal individuals were ≥ 55 mg/dl. Within-assay and be-

tween-assay CV were 0.58-0.9% and 1.3-1.85%, respectively. Tg


ues for normal individuals were < 130 mg/dl. Within-assay and be-

tween-assay CV were 1.5% and 1.8%, respectively.

StatisticsStatistical analysis was conducted with the use of SPSS 17.0

and STATISTICA 8.0. The Kolmogorov-Smirnov test was used

to check normality assumptions. All data are expressed as mean

± standard error of mean (SEM). Differences regarding measure-

ments among groups were evaluated with t-test or Mann-Whit-

ney U-test, where appropriate. A repeated measures ANOVA was

used for the assessment of group differences over time. Fisher’s

post-hoc test was employed. All tests were performed at level a =

0.05. All values are expressed as mean ± SEM and statistical sig-

nificance was set for confidence interval (CI) 95% (p < 0.05). In

cases of p > 0.05, it was characterized as non-significant (NS).

Results

There was no statistical significant differences at the

basic characteristics between the two groups (Group 1 vs

Group 2) regarding the age (50.46 ± 0.52 vs 51.84 ± 0.54),

BMI (25.44 ± 0.26 vs 24.84 ± 0.32), and MSM (16.8 ± 1.59

vs 18.81 ± 1.75) (Table 1).

At baseline, no statistical significant difference was

found between the two groups (Group 1 vs Group 2) re-

garding TC (204.38 ± 4.33 vs 210.57 ± 6.2 mg/dl), LDL

(130.80 ± 4.33 vs 134.46 ± 6.75 mg/dl), HDL (52.65 ± 2.39

vs 51.42 ± 2.38 mg/dl), Tg (106.8 ± 6.61 vs 115.15 ± 5.06

mg/dl), hsCRP (1.22 ± 0.15 vs 1.23 ± 0.13 mg/l), Hcy

(10.26 ± 0.52 vs 9.98 ± 0.41 mmol/l), and ET-1 (1.29 ± 0.11

vs 1.03 ± 0.07 pg/ml).

Within groups after six months treatment with tibolone,

significant statistical decrease was found in TC (194.8 ±

4.33 mg/dl, p = 0.01), HDL (49.07 ± 2.03 mg/dl, p <0.001), Tg (84.26 ± 5.06 mg/dl, p < 0.001), and significant

increase in hsCRP (2.01 ± 0.16 mg/dl, p < 0.001) serum

levels, while no change was noted in LDL (128.07 ± 5.06

mg/dl), Hcy (10.15 ± 0.48 mmol/l), and ET-1 (1.20 ± 0.11

Table 1. — Baseline characteristics of the two groups. Dataare given as mean ± SEM.

Group 1 Group 2 pn = 26 n = 26

Age (years) 50.46 ± 0.52 51.84 ± 0.54 NS

BMI (kg/m2) 25.44 ± 0.26 24.84 ± 0.32 NS

MSM (months) 16.8 ± 1.59 18.61 ± 1.75 NS

Table 2. — Serum levels of TC, LDL, HDL, Tg, CRP, Hcy, andET-1 in groups 1 and 2 at baseline, and at six months.

Group 1 Group 2

n = 26 n = 26

TC (mg/dl)

Baseline 204.38 ± 4.33 210.57 ± 6.2

Six months 194.8 ± 4.58 206.34 ± 5.45

p 0.01 NS

LDL (mg/dl)

Baseline 130.8 ± 4.33 134.46 ± 6.75

Six months 128.07 ± 5.06 132.61 ± 5.8

p NS NS

HDL (mg/dl)

Baseline 52.65 ± 2.39 51.42 ± 2.38

Six months 49.07 ± 2.03 50.53 ± 2.3

p < 0.001 NS

Tg (mg/dl)

Baseline 106.08 ± 6.61 115.15 ± 5.06

Six months 84.26 ± 5.06 113.04 ± 5.72

p < 0.001 NS

hsCRP (mg/l)

Baseline 1.22 ± 0.15 1.23 ± 0.13

Six months 2.01 ± 0.16 1.08 ± 0.13

p < 0.001 NS

Hcy (mmol/l)

Baseline 10.26 ± 0.52 9.98 ± 0.41

Six months 10.15 ± 0.48 10.16 ± 0.4

p NS NS

ET-1 (pg/ml)

Baseline 1.29 ± 0.11 1.03 ± 0.07

Six months 1.20 ± 0.11 0.98 ± 0.08

p NS NS

Data are given as mean ± SEM. p < 0.05 = statistically significant.

Effect of short-term tibolone treatment on risk markers for cardiovascular disease in healthy postmenopausal women: etc.544

pg/ml) levels. In the group of women who did not receive

tibolone serum levels of TC (206.34 ± 5.45 mg/dl), LDL

(132.61 ± 5.8 mg/dl), HDL (50.53 ± 2.3 mg/dl), Tg (113.04

± 5.72 mg/dl), hsCRP (1.08 ± 0.13 mg/dl), Hcy (10.16 ±

0.4 mmol/l), and ET-1 (0.98 ± 0.08 pg/ml) remained un-

changed (Table 2).

Regarding the menopausal symptoms, all patients re-

ported improvement during the six month use of tibolone

without mentioning any side-effects.

Discussion

The systematic study of the endothelial function through

biochemistry has established several markers in the serum

of the blood that can diagnose dysfunction and possible ten-

dency for evolving CVD in these patients. There are many

studies including women as patients that examine the short-

term effect of different regimes such as oral contraceptives,

HRT, tibolone, and others on these markers. In these stud-

ies, though that use the same medication, there is an obvi-

ous difference in the number of patients participating, the

number of markers included, and the length of the study.

In the present study the authors examined the effect of ti-

bolone for a six months period on the most important CVD

markers in postmenopausal women. While patients were

asked not to change any dietary habits, the results show that

tibolone significantly decreased TC, Tg, and HDL serum

levels, which is a finding in the majority of the related stud-

ies [8-12]. Very few studies did not show any effect on

these markers [11, 13], but definitely did not prove that ti-

bolone can cause an increase in a similar period of time.

HsCRP is an acute-phase protein and also a valuable

marker of inflammation, but in low levels and without any

symptomatic pathology, can be a marker of low-grade

chronic inflammation, endothelial dysfunction, and an es-

tablished CVD marker. In most of the studies where ti-

bolone was used, there was a significant increase of hsCRP

serum levels [14-18] and very few studies showed that

serum levels remained unchanged during similar time in-

terval [19, 20]. From the present results, the authors agree

that tibolone may increase hsCRP serum levels in post-

menopausal women during a six-month period course, but

not above the physiological range.

The non-significant impact of tibolone on LDL, Hcy, and

ET-1 is at least favorable for the endothelial function of

postmenopausal women and these results come into agree-

ment with the existing literature regarding LDL [8, 12, 21]

and Hcy [15, 22, 23]. Concerning ET-1, tibolone is known

to lower the ET-1 levels from the limited existing literature

[24, 25].

Limitations of the study can be considered the short-term

interval of tibolone use (six months) and also the inclusion

of both women with surgical and natural menopause, with

different time-interval since the last menstrual period, tak-

ing though into consideration that it is still unclear if the

CVD risk factors are age or estrogen-related [26]. The au-

thors believe that similar studies only with patients shortly

after surgical menopause will give stronger evidence on the

subject.

Conclusion

The results of the present study suggest that the use of ti-

bolone in postmenopausal women for six months may have

a favorable effect on the endothelial function or at least not

negatively affect other CVD markers, excluding HDL and

hsCRP. After the safe length of tibolone is established, it

would be valuable that more studies with further follow-

up of these specific patients be announced in the future, with

further biochemical and clinical follow-up and definitely, as

in all clinical trials, a proper meta-analysis with adequate

number of studies that will further clarify the effect of ti-

bolone on CVD markers in postmenopausal women.

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endothelin-1, vascular cell adhesion molecule-1, and E-selectin in

surgically menopausal monkeys”. Menopause, 2002, 9, 411.

[25] Haenggi W., Bersinger N.A., Mueller M.D., Birkhaeuser M.H.: “De-

crease of serum endothelin levels with postmenopausal hormone re-

placement therapy or tibolone”. Gynecol. Endocrinol., 1999, 13, 202.

[26] Antonicelli R., Olivieri F., Morichi V., Urbani E., Mais V.: “Preven-

tion of cardiovascular events in early menopause: possible role for

hormone replacement therapy”. Int. J. Cardiol., 2008, 130, 140.


A. MAKEDOS, M.D.

3 Patriarchou Ioakim street

546 22 Thessaloniki (Greece)


Introduction

Cesarean scar pregnancy (CSP) is rare type of ectopic

pregnancy and belongs to long-term complications of low

segment cesarean sectioning. With the increase in ce-

sarean rates worldwide, the incidence of CSP gradually

increased over the years. If not diagnosed and treated,

CSP is potentially life-threatening and may lead to severe

complications, such as uncontrolled hemorrhage and even

hysterectomy [1-3].


From September 2011 to January 2012, transvaginal removal of ec-

topic pregnancy tissue and repair of a uterine defect were performed

in 17 CSP patients which were diagnosed with transvaginal sonogram

in this hospital. Regarding the surgical technique, the uterus, (Figure

1) low segment was exposed through the anterior vaginal wall and the

peritoneum incision was folded back. The uterine defect was an ob-

vious sag in the lower segment. Ectopic pregnancy tissue was removed

after a low-segment incision was made to the uterus (Figure 2). The

uterine defect and vaginal wall were then both sutured (Figure 3).

546

Transvaginal removal of ectopic pregnancy tissue

and repair of uterine defect for cesarean scar pregnancy

Z. Wang, L. Shan, H. Xiong

Department of Gynecology, Nanshan Affiliated Hospital of Guangdong Medical College, Shenzhen (China)

Summary

Purpose: This work aimed to introduce a new surgical operation for cesarean scar pregnancy (CSP). Materials and Methods: Tran-

svaginal removal of ectopic pregnancy tissue and repair of a uterine defect were performed in 17 CSP patients. Results: The new sur-

gical operation was performed successfully in all cases. Conclusions: The new surgery operation is safe, effective, and minimally

invasive in CSP patients.

Key words: Cesarean scar pregnancy; Transvaginal operation.

Figure 1. — Exposing of lower uterine segment.

Figure 2. — Transvaginal removal of ectopic pregnancy tissue.

Figure 3. — Repair of lower uterine segment.

1 2 3



XXXIX, n. 2, 2012

Z. Wang, L. Shan, H. Xiong 547

Results

In all cases, transvaginal surgery was successfully per-

formed. The average operation time was 40 minutes and

average bleeding was 20 ml. Serum beta-human chori-

onic gonadotropin (β-hCG) levels declined to normal lev-

els within a month after surgery.

Discussion

Transvaginal removal of ectopic pregnancy tissue and re-

pair of a uterine defect is a novel surgical operation and it in-

cludes several advantages. Firstly, repair of the uterine defect

can prevent secondary CSP, secondly, after transvaginal oper-

ation, patients have minimal trauma and a rapid recovery time.

Lastly, it may save admission costs because the patients re-

main hospitalized for only three to four days. Overall, based on

this observation of 17 treated cases, the transvaginal removal

of ectopic pregnancy tissue and repair of the uterine defect is

safe, effective, and minimally invasive in patients with CSP.

References

[1] Wang J.H., Xu K.H., Lin J., Xu J.Y., Wu R.J.: “Methotrexate ther-

apy for cesarean section scar pregnancy with and without section

curettage”. Fertil. Steril., 2009, 92, 1208. doi:

10.1016/j.fertnstert.2008.07.1780. Epub 2008 Oct 30.

[2] Deans R., Abbot J.: “Hysteroscopic management of cesarean scar ec-

topic pregnancy”. Fertil. Steril., 2010, 93, 1735. doi:

10.1016/j.fertnstert.2008.12.099. Epub 2009 Apr 1.

[3] Lee J.H., Kim S.H., Cho S.H., Kim S.R.: “Laparoscopic surgery of ec-

topic gestational sac implanted in the cesarean section scar”. Surg.Laparosc. Endosc. Percutan. Tech., 2008, 18, 479. doi:

10.1097/SLE.0b013e318180F696.


Z. WANG, M.D.

Department of Gynecology

Nanshan Affiliated Hospital of

Guangdong Medical College

Shenzhen 518000 (China)


548

Introduction

Vaginal bleeding during the first trimester of pregnancy

occurs in approximately 25% of women and about half of

these pregnancies terminate in abortion [1]. The main rea-

sons for vaginal bleeding are retrochorial hemorrhage and

retrochorial hematoma (RCH) [2].

RCH may be detected sonographically in the first

trimester by the presence of a crescent-shaped echo-free

area outlining the intact gestational sac [3].

Its etiology is unknown [4]. The risk of abortion in early

pregnancies complicated by RCH remains controversial. Ben-

nett et al [5] concluded that fetal outcome depends on the size

of the hematoma, wheares Pedersen and Mantoni [6] claimed

that even large hematomas do not pose a serious threat. Tower

and Regan and Mandruzzato et al. [7,8] concluded that mis-

carriage occurred in 17.7 % patients with a RCH.

Jouppila [3] in a broadly cited study concluded that there

are no therapeutic options, and Ben-Haroush et al. [9]

doubted the benefit of bed-rest. The aim of the present

study was to determine the frequency of a RCH in the

group of threatened miscarriages and to examine the pos-

sible relationship of parity, previous miscarriages,

hematoma size and localization, and duration of vaginal

bleeding to pregnancy outcome.


The present study included 852 women referred for ultrasound

examination because of vaginal bleeding in the first trimester of

pregnancy from 2010.-2011 in the present Center.

The study group consisted of 45 women of 852 (5.2 %) who

were found to have a RCH in the presence of a singleton live em-

bryo. The control group consisted of 807 women with vaginal

bleeding in the first trimester of pregnancy, which were not found

to have a RCH in the presence of a singleton live embryo. The

sonographic criterion for RCH in the first trimester was a cres-

cent-shaped echo-free area outlining the intact gestational sac.

All patients were clinically followed at seven-day intervals, in-

cluding bimanual and sonographic examination until the bleed-

ing ceased, the RCH disappeared or abortion occurred.

All sonographic examinations were performed by experts. The

women were followed prospectively from the time of the first

bleeding episode and data were collected on gestational age at

onset of vaginal bleeding, parity, previous miscarriage, duration

and frequency of bleeding, size and localization of the RCH, and

pregnancy outcome (spontaneous abortion, preterm or term de-

livery). The intensity and course of bleeding were monitored daily

and the therapy was dosed accordingly, with the ultimate goal to

stop bleeding. None of the patients suffered from: diabetes melli-

tus (laboratory analysis confirmed regular glucoregulation), hy-

pertension or autoimmune diseases. The time of bleeding and the

time of coagulation were within the limits of referential values in

all the patients with a RCH. The number of thrombocytes was in

the range of 150,000 - 400,000.

Categorical data were analyzed statistically with Chi-square,

Fisher´s exact test, and Student t-test, as appropriate A p value

less than 0.05 was considered statistically significant.

Threatened miscarriage in the first trimester and retrochorial

hematomas: sonographic evaluation and significance

V. Soldo, N. Cutura, M. Zamurovic

Faculty of Medicine, University Clinic for Obstetrics and Gynecology “Narodni Front”, Belgrade (Serbia)

Summary

Background: Vaginal bleeding during the first half of pregnancy occurs in approximately

25% of women and about half of these pregnancies terminate in abortion. In many instances a retrochorial hematoma (RCH) is sono-

graphically found. Objective: The aim of the present study was to determine the frequency of a RCH in the group of threatened mis-

carriages and to examine the possible relationship of parity, previous miscarriages, hematoma size and localization, and duration of

vaginal bleeding to pregnancy outcome. Materials and Methods: The study group consisted of 45 women of 852 (5.2 %) referred for

ultrasound examination due to vaginal bleeding in the first trimester of pregnancy, who were found to have a RCH in the presence of a

singleton live embryo. The control group consisted of 807 women with the same gestational age, with vaginal bleeding, and vital sin-

gleton pregnancy without sonographically proven RCH. All were followed with repeated sonograms at seven days intervals until bleed-

ing ceased, the RCH disappeared or abortion occurred. The authors have examined the possible relationship of duration of vaginal

bleeding, hematoma size and localization, parity, and previous miscarriages to pregnancy outcome (spontaneous abortion, term or

preterm delivery). Results: The researches have shown that the previous miscarriages and deliveries do not affect the occurrence of

RCH. In the group with a RCH on the back wall of uterus, as well as repeated bleedings affect higher frequency of spontaneous mis-

carriages. Hematoma size itself does not affect higher frequency of spontaneous miscarriage. Conclusion: Ultrasound is the method of

choice for diagnosing the existence of aRCH. The frequency of RCH in the group of threatened spontaneous miscarriages is 5.2 %. A

RCH on the back wall and repeated bleedings affect higher frequency of spontaneous miscarriages.

Therapy procedure is based on strict bed rest and administration of: pregnyl, gestagenic drugs, progesterone, antihistamines, and

sedatives.

Key words: Retrochorial hematoma; Spontaneous miscarriage; Ultrasound; Therapy.

Revised manuscript accepted for publication February, 26, 2013


XXXIX, n. 2, 2012

V. Soldo, N. Cutura, M. Zamurovic 549

Results

In relation to parity the patients in the present study were

almost equally proportioned: primiparas 53% and multi-

paras 47%. The percentage of patients bleeding in the pe-

riod to eight weeks of gestation was 24.4%, and of the

percentage of patients bleeding after eight weeks of gesta-

tion was 75.6 %. Only five of the patients (11.1%) had one

previous spontaneous miscarriage. The authors’ research

has shown that previous deliveries and miscarriages do not

affect the occurrence of a RCH, which is statistically con-

firmed (p > 0.05).

Eight pregnancies (17.7%) in the group with RCH

ended in abortion, and 247 (30.6%) in the control group.

In none of them did the weekly ultrasonographic or clin-

ical follow-up reveal any signs of cervical incompetence.

The present study has shown that a RCH does not increase

the risk of spontaneous miscarriage. By observing the

varying sizes of hematomas in the present study, miscar-

riage occurred with large but also with very small

hematomas, which leads to the conclusion that the

hematoma size in itself is not an initiating factor for the

occurrence of miscarriage. The critical factor is the posi-

tion of hematoma, as miscarriage was more frequent with

localization on the back wall (62.5 %), which might be

explained by poorer circulation in the spiral arteries on

the back wall of uterus (Table 1).The initiating factor for

occurrence of miscarriage is bleeding. Miscarriages oc-

curred in the patients with a RCH who bled twice heavily

or several times mildly, although they were on an ade-

quate therapy (Table 2). In the patients that bled once and

in which bleeding stopped with the prescribed therapy ex-

perienced hematoma regression.

Discussion

In view of the presented results as well as the results of

other authors‘ studies [10,11], the present authors believe

that an ultrasound examination is the method of choice for

diagnosing the existence of a RCH in patients with signs

of threatened miscarriage. In the present study, RCH was

found in 5.2 % of patients with clinical signs of threatened

abortion, which is similar to the results of Stabile et al.[10]. Miscarriage occurred in 17.7% of the presented pa-

tients with RCH (mostly due to repeated bleeding), which

complies with the results of other authors [7,8]. In the con-

trol group (without RCH), miscarriage occurred in 30.6%

women. The present study has shown that RCH does not

increase the risk of spontaneous miscarriage by itself. Abu-

Yousef et al. [1] claim that the poor outcome of pregnancy

with a RCH is in connection with the intensity of vaginal

bleeding and increase of hematoma volume accompanied

with pain. All the patients in this study that had miscar-

riage bled twice heavily or several times mildly, although

they were on adequate therapy. In the patients that bled

once and in which bleeding stopped with the prescribed

therapy experienced hematoma regression. Other authors

[3,5,12,13] reported similar results in their researches,

whereas Ben Haroush et al. [9] claimed that there was no

association of pregnancy outcome with duration of vaginal

bleeding. In the present study, miscarriage occurred in

large but also in very small hematomas, which leads to the

conclusion that the hematoma size itself is not an initiating

factor for the occurrence of miscarriage. The initiating fac-

tor is bleeding, especially repeated bleeding. The study has

shown that the critical factor for miscarriage is the position

and not the size of the hematoma. Miscarriage occurred

more frequently with hematomas localized on the back

wall (62.5%), which might be explained by poorer circu-

lation in the spiral arteries on the back wall and perhaps

by more difficult discharge of hematoma due to its posi-

tion. The important indication is the course of hematoma

therapy is much bed rest throughout the duration of bleed-

ing. Women who rested during vaginal bleeding had lower

percentage of spontaneous miscarriages (9.9%) in relation

to those that did not rest (23.3%), as claimed by Ben-

Haroush et al. [9]. With the present study, the authors did

not succeed in assessing the importance of bed rest in re-

ducing the percentage of miscarriage, because severe cases

were admitted to the clinic with signs of threatened mis-

carriage, so that the lowest percentage of miscarriages was

in the group of two patients lying more than 20 days (0 %)

and less than ten days (6.6 %) of bed rest, and the highest

was in the group of the women with to to 20 days (46%)

of bed rest. However, if the average of miscarriages is

taken, regardless of the duration of bed rest, which is 17%,

it complies with the results of Ben-Haroush et al. [9]. All

the present patients with a RCH were monitored until the

final outcome of pregnancy, which was: spontaneous mis-

carriage (17.7%), or delivery (82.3%) premature or on

term. All patients had a vaginal delivery. Newborns had

somewhat lighter weight, but without the need for a long

term intensive care.

Table 1. — Localization of hematoma and miscarriage.Miscarriage IZNAD Back wall Front wall Fundus Total

UN. UŠĆA

Yes 3 5 0 0 8

No 16 13 6 2 37

total 19 18 6 2 45

Table 2. — Hemorrhage and miscarriages in the examinedgroup.Hemorrhage Miscarriage No miscarriage Total

Once 0 37 37

Twice 5 0 5

More than twice 3 0 3

Total 8 37 45

Threatened miscarriage in the first trimester and retrochorial hematomas: sonographic evaluation and significance550

Conclusion

Currently, an ultrasound is the method of choice for di-

agnosing the existence of a RCH in patients with signs of

threatened miscarriage. The frequency of RCH in the group

of patients with the signs of threatened miscarriage is 5.2%.

RCH in this study group did not experience an increased

risk of spontaneous miscarriages (17.7% vs. 30.6%). Parity

and previous miscarriage did not cause a more frequent oc-

currence of a RCH. The size of a hematoma did not sub-

stantially affect the final outcome of pregnancy. A RCH

localized on the back wall and repeated bleedings caused

higher frequency of spontaneous miscarriages. Therapy

procedure is based on strict bed rest and administration of:

pregnyl, gestagenic drugs, progesterone, antihistamines,

and sedatives.

References

[1] Abu-Yousef M.M., Bleider J.J., Williamson R.A., Weiner C.P.: “Sub-

chorionic hemorrhage: Sonographic diagnosis and clinical signifi-

cance“. Am. J. Roentgeol., 1987, 149, 737.

[2] Saurbrei E.E., Pham D.H.: “Placental abruption and subchorionic

hemorrhage in the first half of pregnancy: US appearance and clini-

cal outcome“. Radiology, 1986, 160, 109.

[3] Jouppila P.: “Clinical consequences after ultrasonic diagnosis of in-

trauterine hematoma in threatened abortion“. J. Clin. Ultrasound,

1985, 13, 107.

[4] Kaufman A.L., Fleischer A.C., Thiema G.A., Shah D.M., James A.G.

Jr.: “Separated chorioamnion and elevated chorion: sonographic fea-

tures and clinical significance“. J. Ultrasound Med., 1985, 4, 119.

[5] Bennett G.L., Bromley B., Lieberman E., Benacerraf B.R.: “Sub-

chorionic hemorrhage in first-trimester pregnancies: prediction of

pregnancy outcome with sonography“. Radiology, 1996, 200, 803.

[6] Pedersen J.G., Mantoni M.: “Large intrauterine hematoma in threat-

ened miscarriage. Frequency and clinical consequences“. Br. J. Ob-stet. Gynecol., 1990, 97, 75.

[7] Tower C.L., Regan L: “Intrauterine hematomas in a recurrent mis-

carriage population“. Hum. Reprod., 2001, 16, 2005.

[8] Mandruzzato G.P., D`Ottavio G., Rustico M.A., Fontana A., Bogatti

P.: “The intrauterine hematoma: diagnostic and clinical aspects“. J.Clin. Ultrasound, 1989, 17, 503.

[9] Ben-Haroush A., Yogev Y., Mashiach R., Meizner I.: “Pregnancy

outcome of threatened abortion with subchorion hematoma: possible

benefit of bed-rest?“ Isr. Med. Assoc. J., 2003, 5, 422.

[10] Stabile I., Campbell S., Gruzdinskas J.G.: “Threatened miscarriage

and intrauterine hematomas. Sonographic and biochemical studies“.

J. Ultrasound Med., 1989, 8, 289.

[11] Nagy S., Bush M., Stone J., Lapinski R.H., Gardo S.: “Clinical sig-

nificance of subchorionic and retroplacental hematoma detected in

the first trimester of pregnancy“. Obstet. Gynecol., 2003, 102, 94.

[12] Bloch C., Altchek A., Levy-Ravetch M.: “Sonography in early preg-

nancy: the significance of subchorionic hemorrhage“. Mt. Sinai J.,Med., 1989, 56, 290.

[13] Glavind K., Nohr S., Nielsen P.H., Ipsen L.: “Intrauterine hematoma

in pregnancy“. Eur. J. Obstet. Gynecol. Reprod. Biol., 1991, 40, 7.


V. SOLDO, M.D., PhD

University Clinic for Obstetrics and Gynecology

“Narodni Front”

62, Kraljice Natalije Street

Belgrade 11000 (Serbia)


551

Introduction

For the induction of pneumoperitoneum, the pressures

required to provide adequate intra-abdominal operational

space (10-15 mmHg) during the laparoscopic surgery are

usually higher than the normal physiological portal

system circulation pressure (7-10 mmHg). This causes a

decrease in micro- and macro-circulation of the abdomi-

nal organs and tissues, leading to hypoxia-anoxia espe-

cially in splanchnic organs, including the small intestine,

liver, and kidneys [1]. In addition to this ischemic-

hypoxic period, following deflation, which restores vis-

ceral perfusion of organs with oxygenated blood, the gen-

eration of reactive oxygen free radicals causes a

second-hit to the cell, leading to cell death by both apop-

tosis and necrosis [1, 2]. As a consequence, laparoscopic

surgery may cause ischemia-reperfusion (I/R) injury in

the abdominal organs and tissues in a time- and pressure-

dependent manner [3].

Hence, during the initial ischemic period, cells may die,

which is known as necrosis; after that, following reperfu-

sion of blood, apoptotic loss of cells will take place,

requiring energy substituted from the blood stream [4].

Subsequently, cells undergo specific changes in enzyme

activities, mitochondrial function, cytoskeletal structure,

membrane transport, and antioxidant defenses in response

to hypoxia, which then collectively predispose them to

reoxygenation injury [5]. A number of mitochondrial

enzymes decrease in activity, and expression of the multi-

subunit cytochrome oxidase, and cytoskeletal changes

could likely alter endothelial and epithelial permeability

that can be observed as damaged ultrastructure [5]. All of

these structural and morphological changes, owing to

oxidative stress and inflammation, can only be correctly

ascertained by a transmission electron microscope and not

by a light microscope in the early stage, as in the present

study. The light microscopic histologic findings are

regarded as late stage [6].

To date, no study has investigated the effect of carbon

dioxide (CO2) pneumoperitoneum and different intraperi-

toneal pressures on the ovarian surface epithelium, cili-

ated fallopian tube epithelium, and ovarian endothelium.

Moreover, studies investigating the effect of capnoperi-

toneum on the ultrastructure of parietal and visceral peri-

toneum were evaluated by scanning electron microscope

(SEM) only and not by transmission electron microscope

[7-11]. Intracellular organelles and DNA cannot be evalu-

ated with SEM. Therefore, the ovarian surface epithelium

(being a part of the peritoneum), ovarian endothelium as

a surrogate of ovarian microcirculation, and ciliated

epithelium of the fallopian tube were evaluated according

to the structural configuration.

The aim of the experimental study was to analyze ultra-

structural alterations to the integrity of the ovarian surface

and fallopian tube epithelium generated by increased

intra- abdominal pressure due to capnoperitoneum.

Does carbon dioxide pneumoperitoneum altering

pressure levels lead to ultrastructural damage

of fallopian tube and ovary?

K. Beyhan1, O. Gogsen1, C. Gulumser1, M. Barıs1, Z. Hulusi1, K. Gulten2, K. Esra1

1Baskent University, Obstetrics and Gynecology, Ankara; 2Baskent University, Histology, Ankara (Turkey)

Summary

Aim: To assess carbon dioxide pneumoperitoneum and its different pressure levels related to cellular injury on ovarian surface epithe-

lium, endothelium, and fallopian tube ciliated epithelium in laparoscopic rat model. Materials and Methods: Twenty-four Wistar-Albino

female rats were randomized into three groups. Laparotomy was applied for Group 1 (control). Groups 2 and 3 had laparoscopy with pneu-

moperitoneum pressures at 10 mmHg and 15 mmHg, respectively. After 150 minutes (last 30 minutes was after desufflation for Group 2

and 3) in all groups, bilateral ovariectomy and salpingectomy were performed. The ultrastructures of ovarian surface epithelium, ovarian

endothelium, and fallopian tube ciliated epithelium were evaluated by transmission electron microscope. Ovarian surface epithelium changes

were divided into three groups, apical surface changes, lateral surface chances, and organelle modification/damage. Results: No apical or

lateral surface changes or organelle modifications in ovarian surface epithelium were observed in the control group. Apical ovarian surface

epithelium changes were statistically significant in Groups 2 and 3 in comparison to the control group. No significant differences were ob-

served with regards to lateral surface changes in all groups. The organelle modification was only significant in Group 3 compared to the

control group. The authors revealed that the ultrastructures of the ovarian endothelium and fallopian tube epithelium were not affected by

pneumoperitoneum. Conclusions: Pneumoperitoneum may cause ischemia-reperfusion damage in ovarian cortex correlated with the amount

of pressure.

Key words: Pneumoperitoneum; Laparoscopy; Transmission electrone microscope; Rat; Fallopian tubes; Ovaries.



XXXIX, n. 2, 2012

K. Beyhan, O. Gogsen, C. Gulumser, M. Barıs, Z. Hulusi, K. Gulten, K. Esra552


Animals: This study was performed at the Experimental

Research Center of Baskent University. The Ethical Committee

approval was obtained. Twenty-four mature (four months old)

female, non-pregnant Wistar Albino rats weighing between 170

and 304 g were used as an experimental model. All rats were

provided by Animal Laboratory of Baskent University. They

were caged in a controlled environment of 22°C with 12 h

light/dark cycles. Standard rat feed and reverse-osmosis-

purified water were provided ad libitum. All rats were allowed

to have one week of acclimation to this environment before the

experiment. Female Wistar rats were fasted overnight with free

access to water containing 20% glucose.

The rats were randomized into three groups each one consist-

ing of total of eight rats: Group 1 (control) had laparotomy and

were left for 150 minutes after the incision. Groups 2 and 3 had

laparoscopy and were left for 120 minutes under at 10 mmHg

and at 15 mmHg of pressure, respectively. Thirty minutes after

desufflation, laparotomy was also performed in Groups 2 and 3.

In all groups, bilateral ovariectomy and salpingectomy were per-

formed. The ultrastructures of the ovarian surface epithelium,

ovarian endothelium, and fallopian tube ciliated epithelium were

evaluated by transmission electron microscope.

The Baskent University Committee on the Use and Care of

Animals approved the experiments, and all investigations com-

plied with the 1996 National Academy of Science’s Guide for

Care and Use of Laboratory Animals.

Surgical procedures: All the rats were anesthetized with an

intraperitoneal administration of 50 mg kg-1 ketamine hydrochlo-

ric acid and five mg kg-1 xylazine hydrochloric acid. They were

immobilized on a standard rat surgery board. Before surgery, the

abdominal skin was shaved and antisepsis was achieved with

10% povidone iodine solution. All the animals were kept on a

warming mat. Five cm ventral vertical incision was made and

covered with a sterile sponge soaked with saline and left for 150

min ın Group l. Groups 2 and 3 were insufflated with CO2 under

a pressure of 10 mmHg and 15 mmHg, respectively using a

CO2-pneu-Automat 2245 laparoscopic insufflator via an 18-

gauge arterial catheter inserted into the peritoneal cavity

through the right lower abdominal wall. The pneumoperitoneum

was maintained for 120 min. The rats were left for 30 min for

the occurrence of the ischemia-reperfusion injury. Then five-cm

ventral vertical incision was made to expose the reproductive

organs. The ovaries and tuba uterine of each rat in all the groups

were removed after the 150 minutes. Specimens were fixed in

10% formalin and 2.5% glutaraldehyde for transmission electron

microscopy examination. Two surgeons blinded to the groups

performed all the operations and measurements.

Histologic examination: The specimens were fixed in 2.5%

glutaraldehyde in 0.1l of phosphate buffer, pH 7.3, for six hours.

The fixative was washed out in buffer for two x 15 min, post-

fixed in one percent osmium tetroxide (OsO4) in the same buffer

for 120 min, washed twice in buffer for two x 15 min, and dehy-

drated in a graded series of ethanol concentrations (25%, 50%,

75%, and 95% absolute alcohol) embedded with araldite 2-dode-

cenyl succinic anhydride (CY 212, DDSA ), benzyldimethyl

amine (BDMA), and dibutyl phthalate. They were polymerized

for 48 h at 56°C in an incubator. Uranyl acetate and lead-citrate

dyed ultrathin sections were studied in a transmission electron

microscope (LEO 906E EM).Analysis of transmission electron microscopy: In accordance

with literature, the normal findings of ultrastructural evaluation

of the Ovarian Surface Epithelium (OSE) are described as

follows: OSE is heterogeneous and shows deep invagination,

and serous-villous like papillary projections. Usually OSE is

composed of a single layer of cubic epithelium covered with

short uniform villi and differentiated from each other by signif-

icant intercellular borders. Golgi apparatus, endoplasmic reticu-

lum at apical cytoplasm, scattered polysomes in the perinuclear

cytoplasm, and various numbers of mitochondria are located in

the basal and apical zones of cells. Intercellular lateral connec-

tions are formed as interdigitation, and in some areas large,

asymmetric, irregular gaps are observed. These gaps fill with a

pale amorphous substance (intracellular liquid?).

The ultrastructural evaluation of the OSE was categorized into

three main groups: apical surface specializations, lateral surface

specializations, and organelle modifications. All results were

recorded as positive or absent.

Staging the damage in ovary epithelial cells by means of

transmission electron microscopy:

Stage 0: Normal cells, no damage. Ovary epithelial cells (ger-

minal epithelium) usually consist of a single line of cuboidal

cells (simple cuboidal epithelium) separated from each other by

clear intercellular borders and covered with short, uniform

microvilli (M). The lateral face junctions between cells are

observed to be in the form of interdigitation. There is a terminal

bar in the apical section. A large number of mitochondria are

located in apical and basal. The nucleus is covered with double-

membrane nucleolemma and has made indentation in some cells.

It has a clear nucleolus. The cells are located on the basement

membrane.

Stage 1: Deterioration of lateral face junctions, disordered

microvilli distribution, no microvilli observed in the apical

surface (M), deletion of mitochondria cristae (cristolysis) in 25%

of the cells, swelling in the mitochondria, and vacuolization (V)

formation inside the cell.

Stage 2: Cristolysis of mitochondria cristae, presence of resid-

ual bodies (R) in the cell, V formation in the cell, and observa-

tion of changes as presence of lipid droplets in more than 50%

of the cells.

Stage 3: Cristolysis of mitochondria cristae, swollen mito-

chondria, presence of R bodies in the cell, V formation in the

cell, and observation of changes like presence of lipid droplets

in more than 50% of the cells.

Stage 4: No remnants of amorphous bodies between the cells,

separation of large cytoplasmic bodies from the cell, formation

of projections and blebs (B), and complete separation of the cells

from the basement membrane.

Statistical analysisThe categorical data was evaluated by Chi-Square test.

Because the case number for each cell was not sufficient, p value

could not be given. Therefore the groups were compared in

doubles. Each time point was evaluated separately, and p values

less than 0.05/3 = 0.017 was considered significant. SPSS (Sta-

tistical Package for the Social Sciences, version 11.0) was used

for all analysis.

Results

No apical or lateral surface changes or organelle modi-

fications in ovarian surface epithelium were observed in

the control group (Figure 1). Apical ovarian surface

epithelium changes were statistically significant (p <0.001) in Groups 2 and 3 in comparison to the control

Group (Figures 2-4), but no significant difference was

found between Groups 2 and 3 according to the apical

Does carbon dioxide pneumoperitoneum altering pressure levels lead to ultrastructural damage of fallopian tube and ovary? 553

surface changes. In terms of lateral surface changes in

ovarian surface epithelium, no statistically significant dif-

ferences were observed among the groups. The organelle

modification was only significant (p < 0.001) in Group 3

compared to the control group (Figure 5). The ultrastruc-

ture of the endothelium under the surface epithelium of

the ovaries and the isthmus epithelium of the fallopian

tube were not affected by pneumoperitoneum (Figure 6).

Discussion

In literature, studies shows that CO2 pneumoperi-

toneum and increasing the intra-abdominal pressure lead

to ischemia and reperfusion damage and some dysfunc-

tions of the organs. However ovarian surface epithelium,

ovarian endothelium, and tubal sillier epithelium were not

examined in such studies. In this study, the authors have

shown that CO2 pneumoperitoneum leads to alterations in

Figure 1. — Control group. Ovarian epithelial cells (germinal

epithelium) usually consist of a single line of cuboidal cells

(simple cuboidal epithelium) separated from each other by clear

intercellular borders (small arrow) and covered with short,

uniform microvilli (M, dark arrow). The lateral face junctions

between cells are observed to be in the form of interdigitation

(IS). There is a terminal bar in the apical section. A large number

of mitochondria are located in apical and basal. The nucleus (N) is covered with double-membrane nucleolemma (No) and has made

indentation(ID) in some cells. It has a clear nucleolus. The cells are located on the basement membrane (BM). [x2,784]

Figure 2. — Group 1 (10 mmHg). Disordered microvilli distribution (dark arrow), deterioration of apical border (small arrow) of

lateral face junctions(IS). [x2,784]

Figure 3. — Group 1 (10 mmHg). Disordered and decreased microvilli distribution (arrows), gathered microvilli at the apical surface.

[x3,597]

Figure 4. — Group 1 (10 mmHg). No microvilli observed in the apical surface. [x2,784]

Fig. 1 Fig. 2

Fig. 3

Fig. 4

ovarian surface epithelium’s ultrastructure, the degree of

which is well-dependent on intra-abdominal pressure. In

pneumoperitoneum models where insufflations pressures

were compared to each other although the intra-abdomi-

nal pressure was above 7 mmHg, fairly “lower” (i.e. 10

mmHg) and “higher” (i.e. 15 mmHg) intra-abdominal

pressures were used. The general finding of these studies

is that when high intra-abdominal pressure is used, there

is increased tissue-organ hypo-perfusion and damage,

increased metabolic effects, and increased formation of

free oxygen radicals.

The response of each tissue to ischemia and the entry

into irreversible phase differs. Characteristically, it is

noted that there are two phenomena which show that irre-

versible points are reached: mitochondria and plasma

membrane damage. At this point, plasma membrane

damage is central factor in pathogenesis. One of the

important biochemical mechanisms having a role in mem-

brane damage is a reactive oxygen particle, which causes

ischemia and reperfusion damage. While reactive oxygen

particles can be formed in the post-ischemic mitochondria

by the insufficient reduction of oxygen or by the synthe-

sis of superoxide ion by the ksantin oxidase on the vascu-

lar endothelium, it is in fact secreted by polymorphonu-

clear leukocytes. As a result of all these, there is calcium

charge into the cell and the cells move towards the irre-

versible point [28].

If ischemia continues, there will be irreversible damage

in the cell. The transition from irreversible status to cell

death is not biochemically clear. While the degeneration

of the membranes in the cell may result, intracellular

calcium flow into the mitochondria may be observed as

well. This will result in the vascularization of the mito-

chondria and the formation of mitochondrial density

residual items. The calcium charge to the cell will increase

especially if the ischemic area is reperfused. There will be

constant outflow of enzymes, proteins, metabolites, etc.

from the cell. At this point, lysosomal enzymes will be

secreted in the cell and cell death occurs [28].

In the present study, while both in the 10 mmHg and 15

mmHg groups apical surface changes and membrane

damage in the ovarian surface epithelium were observed,

in the entire 15 mmHg group, in addition to the above,

mitochondrial degeneration was also observed. It is

logical that while ischemia occurred during pneumoperi-

toneum, it initially damages the plasma membrane and

apical modifications in the cell, when the intra-abdominal

pressure increases organelles, from which mitochondria is

initially damaged. Because, after ischemia, oxidative

phosphorylation in the mitochondria and the energy

carrier of the cell, ATP decreases, which stops the activi-

ties associated with aerobic circulation. The sodium pump

does not work; intracellular ion and water balance become

disrupted. Furthermore, there will be calcium charge into

the cell and potassium discharge of the cell. As a result,

the cell swells, microvilli and cell skeleton disrupts, pro-

trusions on the cell membrane are formed, mitochondria

swells and expands, myelin figures are formed within and

outside the cell [28].

Although statistically non-significant, especially in

Group 2 (15 mmHg), higher trend for changes in lateral

surface modifications and widening of the intercellular

junctions were found. However it is not clear whether

these changes are either attributable to an inherent prop-

erty of CO2 per se [12], leading to local acidosis or a

direct pressure effect, leading to the temporary stretching

and expansion of the peritoneal surface area by the pneu-

moperitoneum [13].


Figure 5. — Group 2 (15 mmHg). Separation of large cytoplas-

mic bodies from the cell (**), formation of projections, and blebs

(arrow)), decreased microvilli (small arrow), and swollen mito-

chondria (MD). [x3,597]

Figure 6. — Group 2 (15 mmHg). The preserved isthmus epithe-

lium of the fallopian tube. [x1,670].

Fig. 5 Fig. 6

Does carbon dioxide pneumoperitoneum altering pressure levels lead to ultrastructural damage of fallopian tube and ovary? 555

The other interesting finding was the mitochondrial

degeneration that was found strikingly in high and in

partly low pressures of pneumoperitoneum. In contrast to

the above-mentioned findings, the degenerative changes

in mitochondria were most likely related to post-ischemic

reperfusion damage-second hit effect (surrogate of irre-

versible cell damage) leading to influx of calcium and

H2O, and affecting the cell skeleton [14-16].

The final deleterious effect that resulted from either

local acidosis or the direct compression is disturbed

microcirculation and hypoxemia [8]. Hypoxic tolerance of

various cell types differs, depending on the metabolic rate

and intrinsic adaptive mechanisms of the tissue. The dete-

rioration of blood flow during pneumoperitoneum was

more prominent in solid organs, such as the liver, pan-

creas, spleen, and kidneys, compared to that in hollow

viscus organs such as the intestine, while it was non-sig-

nificant in the stomach [17]. This discrepancy suggests a

potentially varying degree of sensitivity to ischemic insult

among different tissues. Although in literature various

splanchnic organs have been tested for pneumoperi-

toneum-associated ischemia and reperfusion injury, only

one study evaluated the ovarian tissue [18-21].

Fallopian tube ciliated epithelial cells are extremely sen-

sitive to hormones, in rat estrous cycle, such that their mor-

phology can completely change in a 24-hour period. Con-

stant change of morphology, especially ciliary movement

after ovulation requires high energy and mitochondria

activity. Hence, in the initial stages of study, they were

assumed to be effected by ischemia and reperfusion

damage and were included in the study. However, the

response of the cells to damage depends on the type, dura-

tion, and intensity of the damage. Furthermore, the types

of cells and their general condition are also important in

this response. Each cell has a different response to

ischemia and a different period of entry into the irre-

versible period. While this period is one to two hours for

liver cells, it is three to five minutes for neurons. This may

be the reason for the difference observed in the fallopian

tube ciliated epithelial cells received from the isthmus,

which is relatively inactive compared to ampulla. Another

reason may be the observation of the internal epithelia,

which is protected from the direct mechanical effect of the

increased intra-abdominal pressure, contrary to the exter-

nal fallopian tube epithelia. Furthermore, in contrast to

ovarian surface epithelium, as these cells were not in direct

contact with CO2, intercellular hypercapni and acidosis

may have occurred. If this experiment was conducted in

the ampulla where ciliated cells are the most active, they

may have less exposure to ischemic reperfusion damage

(provided all subjects are in the estrus phase). The present

authors revealed that in all groups ciliated tube epithelium

was unaffected. Another explanations for these results may

be avoiding exposure to direct CO2 and stable intra-tubal

pressure. Although SEM may be considered principally as

an appropriate means for evaluating peritoneal surface

changes, microvilli and organelles cannot easily be used

for comparison because their number and appearance may

vary greatly [23]. Hence transmission electron microscopy

is more suitable for the evaluation of microvilli and intra-

cellular organelles.

Although no standard CO2 pneumoperitoneal pressures

were identified in experimental studies, various studies

used working pressure as low as four mmHg and as high

as 20 mmHg [24-26]. In accordance with this finding, the

present authors preferred to use high and low pressures in

this study. In literature, nonetheless some studies pro-

posed that pressures above eight to 10 mmHg in a rat

model do not correlate well with working pressures in

humans. Thus, the findings may not be applicable for

humans. However, there were some methodological prob-

lems with the above mentioned recent study [26]. In this

study, there was some variability in the end-tidal CO2baseline levels between the different pressure groups. This

variability is the largest flaw of this study. The other crit-

icism for this study is not measuring the central venous

pressure, consequently lacking of close hemodynamic

monitoring.

There are some limitations in the current study that

must be acknowledged. There is a disadvantage in extrap-

olating data across species, as the immunologic properties

of species are different. Additionally, rats were not

mechanically ventilated due to technical constraints, as

well as blood gas follow-up and close hemodynamic mon-

itoring, especially in experiments in which a high intra-

abdominal pressure model is used, in order to reduce eval-

uation errors that could result from differences in the

insufflations system, and the intra-abdominal volume of

the subject. Since the authors did not perform intubation

and mechanical ventilation and did not follow up blood

gases during the experiment, they cannot state whether

hypercapnia or elevated intra-abdominal pressure influ-

enced the results. Under full intubation, especially tissue

perfusion being potentially different and effecting the

results, comparison of low and high intra-abdominal pres-

sure with regard to the present transmission electron find-

ings are so significant that could not be disregarded even

with such limitations.

A suggestion for a follow-up study and further analysis

would be to examine the histological changes in ovaries

under the same experimental conditions but one week

later, to determine whether the changes are as significant

and/or permanent.

The present authors found hazardous effects particularly

ultrastructural damage on ovarian surface epithelium

when the intra-abdominal pressure was set at 10 mmHg or

15 mmHg. They therefore planned a further study with

lower intra-abdominal pressure (five mmHg) and different

cytoprotective agents [27].

In literature, up until the period during which this study

was conducted, no model on alternation of ovarian vascu-

larization, the thin structure of the endothelium of the

ovarian mucosa, due to increased pneumoperitoneum or

intra-abdominal pressure, have been found; for this

reason, it is not known how the ovarian microcirculation

is affected from increased intra-abdominal pressure.

This experimental study demonstrated the depressed

tissue blood flow and also prominent evidence of oxida-


tive stress injury in the ovaries during CO2 pneumoperi-

toneum and proposed that the ovaries were also highly

sensitive to ischemia. It was suggested that this hypoper-

fusion period may cause significant detrimental effects on

the ovaries especially in critical conditions related to the

ovary, such as unexplained infertility, in which subtle

changes in follicle development, ovulation, and the luteal

phase may be important etiologic factors [22]. The post-

operative fertility studies should be undertaken to deter-

mine any long-term fertility effects. The clinical signifi-

cance of the findings regarding humans has yet to be

established. For this purpose, similar studies on the human

ovary are imperative [22].

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C. GULUMSER, M.D.

Baskent University School of Medicine,


Kubilay Sokak No: 36,

06570 Maltepe, Ankara (Turkey)


557

Introduction

Delayed cord clamping has proven useful for newborn in-

fants in the perinatal period and in the first year of life [1].

Delayed cord clamping provides neonates with an adequate

blood volume and iron reserve [1]. Moreover, evidence from

the literature suggests better adaptation for preterm babies

and higher red blood cell flow to vital organs during the first

few days of life for all babies [2-4]; additionally, behavioural

benefits of delayed cord clamping may be helpful for foster-

ing early breastfeeding [2].

Two pivotal concepts should be drawn from the afore-

mentioned evidence. Firstly: one should wait a reasonable

time to clamp cord to allow the transfusion of an adequate

blood volume from cord and placenta to the neonate. Sec-

ondly: one should consider at least two minutes as the ad-

equate time for clamping cord, as considered in randomized

trials [5, 6]. The aforementioned concepts are however not

congruent. Indeed, flow is a function of volume and time,

and is a continuous variable. Therefore, the volume of

blood transfused is in continuous relation with the time

elapsed from birth to cord clamping. Mathematically, when

the time from birth to cord clamping is infinite (if one does

not clamp the cord), the flow from placenta and cord to

neonate is infinite, since the blood volume in cord and pla-

centa is not null.

Some authors [1] consider it useful to delay cord clamping

by two to three minutes because cord pulse stops within the

same minutes, suggesting that placental flow has stopped.

The authors do not agree with this concept: cord flow is di-

rected from the left fetal heart to the placenta through the

umbilical arteries, and from the placenta to right fetal heart

through the umbilical vein. With breathing movements, the

newborn infant induces a depression in the chest and shifts

the direction of blood flow to the lungs from the placenta,

through the umbilical vein, and right heart atrium and ven-

tricle [7]. Moreover, intrauterine pressure after birth is higher

than before delivery [8-10]. As explained by Laplace’s rule,

the pressure within a sphere is inversely related to the sphere

radius. Therefore, when the infant has been delivered, the

uterine volume and, therefore, the uterine radius are reduced,

leading to a rise in intrauterine pressure. The higher in-

trauterine pressure encounters blood pressure in the fetal um-

bilical arteries and favours flow through the uterine vein to

the neonate lungs, for as long as the placenta is still within the

uterine cavity. Therefore, there may be a time lapse in which

umbilical arterial flow has stopped while umbilical vein flow

is still present, with the effect of transferring the whole blood

volume content in cord and placenta from the cord and pla-

centa to the newborn infant.

As a logical consequence, one should consider the time

from birth to cord clamping as a continuous variable that,

along with time elapsed from birth to first breathing move-

ments, may influence neonate well-being in a continuous way.

Behaviour of lab parameters and neonatal weight loss

in relation to neonatal breathing movements

and cord clamping time

U. Indraccolo1, R. Santafata2, P.L. Palazzetti2, 3, R. Di Iorio2, S.R. Indraccolo2

1Complex Operative Unit of Gynecology and Obstetrics of Civitanova Marche, Hospital of Civitanova Marche, Civitanova Marche2Department of Gynecological, Obstetrical, and Urological Sciences, “La Sapienza” University of Rome, Rome

3Complex Operative Unit of Gynecology and Obstetrics, G.B. Grassi Hospital of Ostia, Ostia (Italy)

Summary

Background: To date, delaying cord clamping two to three minutes after birth is considered effective for newborn well-being. This time

does not consider the newborn’s breathing movements, which may also condition neonate well-being. Aim: To investigate the behaviour

of neonatal weight loss and of some umbilical vein lab parameters, in relation to timing of newborn breathing and cord clamping. Mate-rials and Methods: Time from birth to cord clamping and time from birth to first cry of the newborn were collected in 87 full-term healthy

women. First cry is a sign of effective breathing. Birth weight loss at the first, second, and third day from birth and lab parameters were as-

sessed in relation to: time from birth to cord clamping, time from birth to first cry, and cord clamping before or after the first cry. Results:Partial pressure of carbon dioxide (pCO2) decreased if cord clamping was performed after first cry and increased if first cry occurred after

cord clamping, independently from the time elapsed from birth to first cry (p = 0.012). Calcium (Ca2+) concentration decreased if cord clamp-

ing was performed after the first cry and increased if first cry of the baby after birth was delayed (p = 0.021). Each second of delay from

birth to cord clamping resulted in an increase in Cl_ concentration (p < 0.001). Each second of delay in cord clamping resulted in a reduc-

tion in the percentage of weight loss at the first day (p = 0.024), at the second day (p = 0.007), and at the third day (p = 0.028) after birth.

Conclusions: Neonate breathing after birth should induce umbilical vein flow from placenta to lungs, conditioning the reduction of birth

weight loss after birth and umbilical lab parameters modifications.

Key words: Delayed cord clamping; Neonatal breathing; Neonatal circulation.



XXXIX, n. 2, 2012

U. Indraccolo, R. Santafata, P.L. Palazzetti, R. Di Iorio, S.R. Indraccolo558

The following study will quantitatively investigate the

behaviour of neonatal weight loss and of some umbilical

vein lab parameters in relation to timing of newborn breath-

ing and cord clamping.


A sample of 87 full-term healthy women who delivered vagi-

nally was enrolled from March 2011 to November 2011 at the

G.B. Grassi hospital of Ostia (Italy). Immediately after delivery,

time from birth and cord clamping was collected by stopwatch

and expressed in seconds. The time from birth to the first cry was

collected in the same way. Crying is considered an objective sign

of at least an appropriate breathing movement. The midwife was

free to decide the time of cord clamping after birth and did not

know the aim of the study. Therefore the study is observational

and does not modify the current practice of the facility. Immedi-

ately after cord clamping, a blood sample from the umbilical vein

was collected to instantly assess the following lab parameters: par-

tial pressure of oxygen (pO2), partial pressure of carbon dioxide

(pCO2), pH, bases excess (BE), sodium (Na+), potassium (K+),

calcium (Ca2+), chlorine (Cl_), hematocrit. An analyser was used

for specific assessment of such parameters. Capillary bilirubin

and glucose levels were assessed on the first day after delivery, as

routine screening tests of newborn infants. Birth weight was col-

lected at birth and on days one, two, and three after birth. Weight

loss on the same days was expressed using a percentage scale.

Each of those variables was considered as dependent variables in

regression models. The independent variables considered in each

multivariable regression model were: time from birth to cord

clamping (seconds), time from birth to first cry (seconds), cry after

cord clamping (yes/no).

Moreover, to check the interdependence among dependent vari-

ables, a three-component, rotated, factor analysis was built, in

order to aggregate the associated variables. By checking the in-

terdependence among the dependent variables, it is possible to de-

termine which dependent variables are linked and, therefore,

which ones vary together, according to trends found in regression

models.

SPSS 16.0 package was used for statistical calculations and p< 0.05 was set as minimum significance.

Results

Mean time from birth to cord clamping was 95.6 seconds

(± 66.6). Mean time from birth to first cry was 38 seconds

(± 29.4). Fourteen (16.1%) patients underwent cord clamp-

ing before the baby’s first cry, and 73 (83.9%) patients un-

derwent cord clamping after first cry. Table 1 reports the

mean values with standard deviations of lab parameters as-

sessed in umbilical vein samples and the mean values with

standard deviations of the first, second, and third day of

weight loss.

Regression models found significant relationships for

pCO2, Ca2+, Cl—, and for weight loss at first, second, and

third day after birth (Table 2). pCO2 decreased if cord

clamping was done after first cry and increased if first cry

occurred after cord clamping, independently from time

elapsed from birth to first cry (partial regression coeffi-

cients (B) = -5.951, 95% confidence intervals (CI) -10.580

- -1.323) (p = 0.012). Moreover, each second of delay from

birth to cord clamping increased pCO2 (B = 0.039, CI 95%

0.013 - 0.065) (p = 0.003). Ca2+ concentration decreased if

cord clamping was performed after the first cry and in-

creased if first cry of the baby after birth was delayed (B =

-1.081, 95% CI -1.996 - -0.165) (p = 0.021). Each second

of delay from birth to cord clamping resulted in an increase

in Ca2+ concentration (B = -0.01, 95% CI -0.005, - -0.015)

(p < 0.001) and an increase in Cl—

concentration (B = -

0.022, 95% CI 0.011 - 0.033) (p < 0.001).

Table 1. — Descriptive statistics including mean values withstandard deviations of continuous variables.

Means Standard deviations

pH 7.31 ± 0.08

p02 34.4 mmHg ± 13.6 mmHg

pC02 39.7 mmHg ± 7.6 mmHg

Bases excess -5 mmol/l ± 1.9 mmol/l

Na+ 134 mmol/l ± 3.6 mmol/l

K+ 5 mmol/l ± 0.9 mmol/l

Ca2+ 5.08 mg/dl ± 1.54 mg/dl

Cl_ 107.5 mmol/ml ± 3.72 mmol/ml

Bilirubin 1.87 mg/dl ± 0.49 mg/dl

Glucose 90.1 mg/dl ± 20.5 mg/dl

Hematocrit 53% ± 11%

1st day percentage of weight loss 3.5% ± 1.68%

2nd day percentage of weight loss 5.7% ± 2.03%

3rd day percentage of weight loss 5% ± 3.48%

Table 2. — Regression analyses and factor analysis. Time inseconds between birth and cord clamping between birth andfirst cry of the baby and the effects on lab tests and neonatalweight loss.

Cry after Time from Time from Variables

cord birth to birth to cord interdependence

clamping first cry clamping

ph N.S. N.S. N.S. ┐2

p02 N.S. N.S. N.S. ┤2

pC02 -5.951 N.S. 0.039 ┐2 ┤2

p = 0.012 p = 0.003 │2 │2

Bases excess N.S. N.S. N.S. ┤2 ┤2

Na+ N.S. N.S. N.S. ┤2 ┤2

K+ N.S. N.S. N.S. ┤2 │3

Ca2+ -1.081 N.S. 0.01 ┤2 │2

p = 0.021 p < 0.001 │2 │2

Cl—

N.S. N.S. 0.022 ┘2 │2

p < 0.001 │2

Bilirubin N.S. N.S. N.S. ┤2

Glucose N.S. N.S. N.S. │2

Hematocrit N.S. N.S. N.S. ┘2

1st day percentage

of weight loss N.S. N.S -0.216 ┐2

p = 0.024 │2

2nd day percentage

of weight loss N.S. N.S. -0.328 │p = 0.007 ┤1 2

3rd day percentage

of weight loss N.S. N.S. -0.441 ┘2

p = 0.028

Behaviour of lab parameters and neonatal weight loss in relation to neonatal breathing movements and cord clamping time 559

Each second of delay in cord clamping resulted in a re-

duction in the percentage of weight loss at the first day (B

= 0.216, 95% confidence interval (CI) -0.403 - -0.029; p =

0.024), at the second day (B = -0.328, 95% CI -0.564 - -

0.092; p = 0.007), and at the third day (B = -0.441, 95% CI

-0.832 - -0.050; p = 0.028) after birth.

The three-component rotated factor analysis highlights

interdependence among variables (Bartlett’s test of spheric-

ity: p < 0.001). The interdependence is strong with weight

loss variables (marked with 1 on Table 2, right-hand col-

umn). Interdependence is less strong for pCO2, BE, Na+,

K+, Ca2+, Cl—

(marked with two in Table 2, right-hand col-

umn). Additionally, pO2, pH, pCO2, BE, Na+, bilirubin,

and hematocrit depict a scanty interdependence (marked

with three in Table 2, right-hand column).

Discussion

This study aimed to assess if time lapse from birth to cord

clamping can independently influence neonate well-being,

as measured by neonatal weight loss, and if it is related to

breathing.

Interestingly, pCO2 rises if the sample is taken before a

breathing movement and when cord clamping is delayed. A

pCO2 behaviour similar to the one reported has been re-

ported by Wiberg et al. [11]. These authors found an in-

crease in pCO2 levels both in the artery and vein most

markedly at 45 minutes after birth. Interestingly, De Paco

et al. [12] did not find an increase in pCO2 at two minutes

from birth, but pO2 increased after more than two minutes

from birth. Taken together, those data suggest that pCO2 in

the umbilical vein is strongly related to breathing move-

ments, which usually occur some seconds after birth.

Therefore, when the umbilical vein cord clamp is per-

formed two minutes after birth, a healthy neonate will have

already taken a breath in at least the majority of the cases.

A logical conclusion drawn from this pCO2 behaviour, is

that lung function is needed for the ventilation of CO2 in

newborn infants after birth, and that the placenta is not

needed to ensure respiratory function during the few min-

utes after birth, because pO2 increases in umbilical blood

vein if cord clamping is delayed [12].

Ca2+ behaviour would suggest that pCO2 modifications

in the umbilical cord vein are linked with umbilical vein

flow. Ca2+ concentration in peripheral venous blood in-

creases due to blood stasis [13]. Ca2+ increases in the um-

bilical vein may be linked to blood stasis as well: if the

neonate cries (denoting breathing), the Ca2+ concentrations

decrease. Therefore, breathing movements induce blood

flow through the umbilical vein, and are able to induce CO2ventilation through the lungs.

Cl–

concentration changes follow the Ca2+ and the pCO2modifications. This is demonstrated by the second cluster

of interdependence found by factor analysis (the one

marked with two in the right-hand column of Table 2). Such

interdependence could be explained by anionic gap behav-

iour in the very special condition of the umbilical vein of

the newborn infant some seconds after birth. It was reported

by Wiberg et al. [11] that lactate increases 45 and 90 sec-

onds after birth in the umbilical vein. Even if the increase

of lactic acid was not assessed in the present study, it does

indeed occur. Usually, the rise in lactates does alter the an-

ionic gap in an adult, reducing the Cl–

concentration, and is

buffered by bicarbonates [14], producing CO2 and H2O.

In the umbilical vein, however, due to blood stasis, the au-

thors found that Ca2+ increases, thereby explaining the rise in

Cl—

in order to maintain electrical neutrality. Therefore the

excess of anions could be neutralized by the rise in Ca2+ con-

centrations.

Another weak interdependence (marked as 3 in the right-

hand column of Table 2) was found among pO2, pH, pCO2,

BE, Na+, bilirubin, and hematocrit. Nelle et al. [15] re-

ported that delayed cord clamping leads to a rise in hema-

tocrit value. This behaviour may influence some metabolic

and respiratory parameters in a pathophysiological rela-

tionship, as depicted by the interdependence found in the

present study. Interestingly, the blood volume of neonates

is higher in the case of delayed cord clamping, rising by

about 32% when cord clamp is delayed by at least three

minutes [15]. The interdependence relationships found by

the present authors and results from Nelle et al. [15, 16]

lead to consider that delaying cord clamping supplies both

blood cells and water to the newborn infant. This idea im-

pacts neonatal well-being, since neonatal weight loss at first

day after birth is reduced. Consequently, this supply of

water impacts weight loss at second and third days after

birth too, as proven by the strongest interdependence (one

on the right-hand column of Table 2).

Caution should be used in interpreting the percentage of

reduction of weight loss from partial regression coefficients

(B). As suggested by large intervals of confidence for each

coefficient of regression, the percentage of weight loss varies

very much for each newborn, and it may be explained by

other variables not considered in the multivariable regres-

sion models (such as, breastfeeding or milk formula supple-

ments). Therefore the authors judged that the reduction of

the weight loss percentage predicted by timing of cord

clamping may be overestimated.

In summary, the authors depict the following evolution of

cord flow after birth. Umbilical arteries restore the placen-

tal bed until cord pulsation stops. Then, placental and cord

blood volume halts until the first breathing movements

occur, accumulating CO2, lactate, O2, and Ca2+. This could

be due to oxygenation in the placenta and to the anaerobic

metabolism of red blood cells in the cord, producing lactic

acid, buffered by bicarbonates. Vein stasis leads to in-

creased Ca2+ ions that neutralize anions. With breathing, a

quantity of blood volume stored in the placental vascular

bed and umbilical vein is shifted to lungs, supplying blood

cells, iron, and water to the newborn infant. Each second of

delaying cord clamping supplies the neonate with blood

volume for perfusing lungs and removing CO2. The supply

of water prevents newborn weight loss in the days after

birth.

An intriguing speculation suggests that blood flow

through the umbilical vein may exist until blood volume in

the placenta is detectable (five days after birth, according

to Nelle et al. results [16]). This blood volume could be

helpful for avoiding neonatal weight loss, substantiating

U. Indraccolo, R. Santafata, P.L. Palazzetti, R. Di Iorio, S.R. Indraccolo560

the lotus birth practice [17]. The topic will require appro-

priate investigations that quantify the blood volume trans-

fusion through the umbilical vein in relation to neonatal

breathing movements and time elapsed from birth.

Conclusion

Delaying cord clamping reduces newborn weight loss

during the first days after birth. The hypothesis that umbil-

ical vein flow after birth would not stop with artery pulse

seems to be supported by data variations of lab parameters

in relationship with breathing. Therefore, it is useful to

clamp cord after the initial newborn breathing movements,

and breathing movements are needed for perfusing lung

vascular bed.

References

[1] Chaparro C.M., Lutter C.K.: “Incorporating nutrition into delivery

care: delivery care practices that affect child nutrition and maternal

health”. Matern. Child. Nutr., 2009, 5, 322.

[2] Mercer J.S.: “Current best evidence: a review of the literature on um-

bilical cord clamping”. J. Midwifery Womens Health, 2001, 46, 402.

[3] No Authors Listed. Cord blood banking for potential future trans-

plantation: subject review. Work Group on Cord Blood. Banking.

Pediatrics, 1999, 104, 116.

[4] Wardrop C.A., Holland B.M.: “The roles and vital importance of pla-

cental blood to the newborn infant”. J. Perinat. Med., 1995, 23, 139.

[5] Hutton E.K., Hassan E.S.: “Late vs early clamping of the umbilical

cord in full-term neonates. Systematic review and meta-analysis of

controlled trials”. JAMA, 2007, 297, 1241.

[6] Neilson J.P., Cochrane Update: “Effect of timing of umbilical cord

clamping at birth of term infants on mother and baby outcomes”.

Obstet. Gynecol., 2008, 112, 177.

[7] Gao Y., Raj J.U.: “Regulation of the pulmonary circulation in the

fetus and newborn”. Physiol. Rev. 2010, 90, 1291.

[8] Schorn M.N.: “Uterine activity during the third stage of labour”. J.Midwifery Womens Health, 2012, 57, 151.

[9] Cowan D.B., van Middelkoop A., Philpott R.H.: “Intrauterine-pres-

sure studies in African nulliparae: normal labour progress”. Br. J.Obstet. Gynaecol., 1982, 89, 364.

[10] Buhimshi C.S., Buhimshi I.A., Malinow A.M., Weiner C.P.: “In-

trauterine pressure during the second stage of labor in obese

women”. Obstet. Gynecol., 2004, 103, 225.

[11] Wiberg N., Källén K., Olofsson P.: “Delayed umbilical cord clamp-

ing at birth has effects on arterial and venous blood gases and lactate

concentrations”. BJOG, 2008, 115, 697.

[12] De Paco C., Florido J., Garrido M.C., Prados S., Navarrete L.: “Um-

bilical cord blood acid-base and gas analysis after early versus de-

layed cord clamping in neonates at term”. Arch. Gynecol. Obstet.,2011, 283, 1011.

[13] Lippi G., Salvagno G.L., Montagnana M., Brocco G., Guidi G.C.:

“Influence of short-term venous stasis on clinical chemistry testing”.

Clin. Chem. Lab. Med., 2005, 43, 869.

[14] Bartlett D.: “Understanding the anion and osmolal gaps laboratory

values: what they are and how to use them”. J. Emerg. Nurs., 2005,31, 109.

[15] Nelle M., Zilow E.P., Kraus M., Bastert G., Linderkamp O.: “The

effect of Leboyer delivery on blood viscosity and other hemorheo-

logic parameters in term neonates”. Am. J. Obstet. Gynecol., 1993,

169, 189.

[16] Nelle M., Zilow E.P., Bastert G., Linderkamp O.: “Effect of Leboyer

childbirth on cardiac output, cerebral and gastrointestinal blood flow

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[17] Crowther S.: “Lotus birth: leaving the cord alone”. Pract. Midwife,2006, 9, 12.


U. INDRACCOLO, M.D.

Via Montagnano 16,

62032 Camerino (MC) (Italy)


561

Introduction

Twin-to-twin transfusion syndrome (TTTS) refers to

obvious hemodynamics differences between twins and a

series of pathological and physiological changes

caused, due to placental vascular anastomoses during

twin pregnancy [1]. Perinatal mortality rate is extremely

high. If treatment is not conducted, its mortality rate can

reach 80% to 90% [2]. At present, fetoscopic laser

occlusion of chorioangiopagous vessels (FLOC) is the

internationally-preferred method for TTTS treatment.

According to domestic reports, TTTS incidence rate is

low, and such operation is conducted in only a few hos-

pitals. However, fetoscopic laser surgery also causes

many psychological reactions to pregnant women. It is

reported that the surgically treated pregnant women

with TTTS have obvious psychological stress reactions

or mental disorders [3], and surgery itself can induce

some reactions such as agrypnia, anxiety, and depres-

sion that inevitably influence the life quality of patients

[4]. As pregnant women cannot understand and accept

its damages to fetuses, they are bound to not accept

surgery as an option. The present summarizes the treat-

ment results of ten cases of patients with TTTS receiv-

ing FLOC and the psychological intervention from 2007

to assist pregnant women to actively respond to the

intervention, relieve anxiety extent of pregnant women

intraoperatively, and enhance compliance in order to

provide a reference for smooth implementation of treat-

ment and postoperative rehabilitation of pregnant

women with TTTS.


General dataTen cases of pregnant women diagnosed TTTS from January

2007 to December 2009 receiving surgical treatment in the

present hospital were selected. Their average age was 28.3 years,

and gestational weeks ranged from 16 to 29 weeks. They had no

history of disease of vital organs and no medication and radia-

tion exposure history during pregnancy. Among them, one case

was in stage I pregnancy, one case was in stage II pregnancy,

four cases were in stage III pregnancy, and four cases were in

stage IV pregnancy.

This study was conducted in accordance with the Declaration

of Helsinki and with approval from the Ethics Committee of the

Affiliated Hospital of Hangzhou Normal University. Written

informed consent was also obtained from all participants

Surgical methodsFLOC: after various routine examinations of pregnant women

were completed, local anesthesia was conducted at uterine

fundus or anterior uterine wall rather than placental attachment

skins under the location of B ultrasound. Trocar punctured the

skin to enter the amniotic cavity. After amniotic fluid outflowed,

a fetoscope was positioned to seek the transportation vascular

branch near amnion at placenta bottom. In the handle hole, 365.0

µm laser transmission optical fiber was inserted to aim at the

vessels. Subsequently, energy and frequency were set (1.0 - 2.0

J/10Hz). Laser was used to cauterize and occlude vessels. Intra-

operatively, several vessels were respectively cauterized. After

surgery was completed, partial amniotic fluids were slowly

released until the deepest amniotic fluid area was five to six cm.

The surgical process was strictly monitored by B ultrasound and

fetal heart and fetal movement of two fetuses were normal.

Finally, amniotic fluid index and umbilical artery’s pulsatility

index (PI), resistance index (RI), and systolic/diastolic (S/D)

values were measured.

Role of psychological intervention in fetoscopic laser surgery

of twin-to-twin transfusion syndrome

L.X. Li, Y. Gao, S.L. Xu

The Affiliated Hospital of Hangzhou Normal University, Hangzhou (China)

Summary

Objective: This study aims to investigate the influence of application of psychological intervention in fetoscopic laser surgery of

twin-to-twin transfusion syndrome (TTTS) on perinatal outcome. Materials and Methods: A total of ten cases of pregnant women di-

agnosed with TTTS from January 2007 to December 2009 in the present hospital were selected. Their gestational weeks ranged from

16 to 29 weeks. Under the location of B ultrasound, the method of intra-amniotic fetoscopic laser occlusion of chorioangiopagous ves-

sels (FLOC) plus amnioreduction was conducted for treatment. Contemporarily, psychological intervention was also carried out. Re-sults: Preoperative, intraoperative, and postoperative behavior controls of all pregnant women were good, and all operations were

successfully completed to achieve the desired purpose of rehabilitation discharge. Conclusion: Fetoscopic laser surgery is an effective

treatment for TTTS and competent psychological intervention is one of important measures for successful operation and pregnant

woman rehabilitation discharge.

Key words: Twin-to-twin transfusion syndrome; Laser; Psychological Intervention.



XXXIX, n. 2, 2012

L.X. Li, Y. Gao, S.L. Xu562

Psychological intervention methodPsychological problems and requirements of pregnant

women were understood by the specialized intervention team,

which was composed of a primary nurse, head nurse, and

obstetrician that evaluated the psychological changes of the

pregnant women, and appropriate measures were promptly

taken preoperatively, intraoperatively, and postoperatively [5]

Preoperative psychological intervention: 1) provide infor-

mation. As fetoscopic laser surgery used for TTTS was a

newer treatment technique, information acquisition routes of

pregnant women and families were fewer and there were more

worries. Therefore, it was necessary for doctors to provide the

actual information of FLOC used for TTTS to pregnant

women and their families before surgery, including both sub-

jective and objective information. The subjective information

provided intraoperative impressions, intraoperative potential

problems, and coordinating measures regarding FLOC to

pregnant women. The objective information was to introduce

details of FLOC, existent achievements of FLOC, possible

complications and precautions to patients and their families

before surgery. 2) General supportive psychotherapy. It was

very important to understand whether emotions of pregnant

women were stable to conduct psychological intervention. In

the preoperative discussion with pregnant women, doctors

avoided using medical nomenclature and allowed pregnant

women and their families to set forth as many problems as

possible and explain the fetoscopic laser surgery process by

use of a graphic method to eliminate some wrong concepts

and unrealistic ideas. Among the ten cases, one case overcame

psychological concerns and finally signed the surgical cogni-

tive consent at after six hours of repeated psychological coun-

seling. 3) Strengthening the doctor-patient communication.

The operating nurse strengthened ward communications of

medical care staffs with pregnant women and their families,

visited pregnant women and their families before surgery to

introduce anesthesia method, surgical process, surgical room

environment, etc. and provided timely feedback of the prob-

lems and needs of the patients and their families to medical

care staff within the ward. The medical care staff timely

resolved the problems of pregnant women and their families.

Therefore, it greatly relieved the tension of both the patients

and their families and reduced various interferences of fami-

lies towards surgery. 4) Teaching the physical and mental

relaxation methods to allow patients [6] to learn self-adjust-

ment. The physical and mental relaxation method attempted to

eliminate patient distractions and calm mind and body through

self-training. Specific method: the nurse guided pregnant

women to naturally sit up, with eye closure and two palms

placed on both knees. Also, their attentions focused on their

two foot arches. They uniformly and slowly breathed for three

to four minutes to relax each group of muscles for extending

to systemic relaxation. Subsequently, they slowly opened their

eyes. In this fashion, relaxation was carried out once daily for

less than 30 minutes.

Intraoperative psychological intervention: fetoscopic laser

surgery of TTTS was conducted under B ultrasound location

and local anesthesia, and surgery continued for about 60

minutes. The pregnant women were always in the waking state

of consciousness. The authors observed that the patients often

intraoperatively guessed and imagined the surgical process.

In order to avoid undue psychological distress of the patients,

unrelated conversations and communications were minimized

as much as possible, and professional terms were used in the

communications [7]. While doctors conducted surgery, they

offered comfort and explained the surgical progress to the

patients, while nurses offered encouraging words at head side

of the patients, such as “you are good!”, “you are fantastic!”.

In the interim, they closely observed vital signs and psychic

reactions and dispersed attentions of pregnant women. For

some particularly-nervous patients, the nurses constantly com-

municated with them (talking about some families or friends,

work, and other unrelated matters) to disperse their attentions

and timely updated the surgical progress to offer psychologi-

cal support to them. As a result, ten cases were completed

without any complications.

Postoperative psychological intervention: if the patients

presented anxiety, dysphoria, and other symptoms due to

wound pain or discomfort and other reasons within 24 hours

after FLOC, the medical care staffs strengthened tour inspec-

tions to carefully observe systemic symptoms, monitor vital

signs, monitor fetus situations, abdominal incision to confirm

whether there were threatened premature delivery symptoms,

and timely treated uncomfortable situations of pregnant

women, foreseeing resolved requirements of pregnant women

and enhanced the trust of the patients towards medical staff.

Twenty-four hours postoperatively, the conditions of pregnant

women were relatively stable. At this time, a majority of preg-

nant women expressed concern regarding fetal state and its

survival. Therefore, medical care staffs actively communi-

cated with pregnant women to highlight rest importance. At

the postoperative third day, the patients had absolute bed rest.

The nurses timely explained fetal monitoring situations, illus-

trated the monitoring of the fetuses to the patients, and

attempted to obtain comprehensive care for meeting the

patients’ requirements while winning their active cooperation.

Individual patients became irritable, and the nurses guided

these to use the attention dispersing method. According to

habits, hobbies, and cultural literacy of pregnant women, the

excessive concern of pregnant women to fetal prognosis was

transferred. Relaxing and soothing music or video materials

were selected to transfer pregnant women’ mood and disperse

their attention [8, 9], and better results were obtained.

Results

All patients with TTTS had different extents of psycho-

logical problems in the perioperative period. Among

them, 70% had an operative contradictory psychology

before surgery and worried about threatening fetal life and

unsuccessful surgery. In the perioperative period, the

number of pregnant women confident to successful

surgery greatly increased after implementation of psycho-

logical intervention, and ten cases underwent surgery in a

healthy mood. As a result, preoperative, intraoperative,

and postoperative moods of the cases were well con-

trolled.

Ten cases were compliant with medical care staffs to

complete surgery. Postoperative vital signs of pregnant

women were stable, and postoperative B ultrasound re-

examination showed that except for biparietal diameter,

femur length, scalp edema, and pyoperitoneum of two

fetuses, umbilical artery blood flow indices PI value, RI

value, S/D value of the remaining were normal [10]. No

complications occurred and the desired treatment purpose

was achieved. On average, the patients were discharged

after seven days of hospitalization.

Role of psychological intervention in fetoscopic laser surgery of twin-to-twin transfusion syndrome 563

Discussion

In China, fetoscopic laser surgery used for TTTS is a

novel technique. The Affiliated Hospital of Hangzhou

Normal University is one of the first hospitals to conduct

such treatment and better results have been obtained. The

success of this treatment is not only related to doctors’

experience, but also closely related to the psychological

intervention of medical staff.

For patients with TTTS and gestational weeks less than

26 weeks, FLOC is the preferred treatment method. Rossi

[11] summarized 611 cases of TTTS cases and drew a

conclusion that fetuses receiving laser therapy more easily

survived than fetus receiving amnioreduction. Especially

in stages III and IV, advantages of laser therapy are more

obvious [12]. Compared with continuous amnioreduction,

FLOC can increase the survival rate of perinatal period

and reduce the incidence rate of nervous system [13].

Abroad, FLOC treatment is more consolidated. It is

reported at home that TTTS incidence rate is low, and

such an operation is carried out only in a few hospitals.

Fetoscopic laser surgery used for TTTS is a new tech-

nique. As there are a fewer reports on disease conditions

and treatment information of TTTS, pregnant women and

their families obtain with difficulty the relevant knowl-

edge. Some studies [14] suggested that if patients did not

know the disease condition in detail, they easily generated

doubt, fear, and random guess psychologies. These are

unfavourable for psychological health and disease treat-

ment, while effective communications and common

investigations on disease-related knowledge and treatment

schemes are useful for the treatment and rehabilitation of

patients. According to this phenomenon, the authors

provide the information in the form of images and words

for pregnant women and their families, allowing them to

understand the disease conditions and surgical process,

allowing them to better home internal supports during

hospitalization. Therefore, confidence and courage of

pregnant women to surgical treatment are enhanced and

treatment compliance is increased [15, 16].

Due to the initial experience to this traumatic opera-

tion, a majority of pregnant women will exaggerate the

fetal surgical risk, which causes them to generate larger

psychological changes and generate anxiety and fear.

Many studies confirm that in case of high anxiety level,

muscle tension increases, while pain threshold decreases.

Therefore, it increases the pain experience of patients

during surgery and renders it more difficultly for them to

cooperate, whereas cooperation extent influences diagno-

sis and treatment efficiency. Therefore further psycho-

logical support is provided [17] and guidance and encour-

agement of both patients and their families to express

their feelings by use of one-to-one support expression

method. According to the psychological requirements

and existent problems of pregnant women, explanation,

encouragement, and comfort are timely given. In addi-

tion, pregnant women generate fear reaction towards

surgery and generate anxiety due to excessive concerns

regarding fetal safety. Studies suggest that people only

focus on a matter at a time. If the attention or accompa-

nied bad mood is transferred to the interest task or work

attracting the attention, the link between the conditioned

stimulus and response can be prevented. Therefore, dis-

persing attention through communication can act as a

way of relieving psychological stress reaction towards

surgery [18, 19]. The attention dispersing method used by

medical staff is simple and convenient and it can inde-

pendently provide auxiliary measures of relieving psy-

chological stress reaction.

A number of practices [20] prove that relaxation train-

ing can offset negative influences of physiological and

psychological stresses to restore the balance and coordi-

nation of human body, psychology, and spirit. It not only

can apparently relieve general mental tension and nerve

disorder, but also can treat stress-induced psychosomatic

reactions. The physical and mental relaxation method

adopted by the authors is a more utilized behavior method

for the relaxation before obstetric operation [21]. As a

result of operability, safety, and convenience of relaxation

training, a majority of pregnant women are willing to

accept such a method and obtain better effectiveness of

relieving psychological perplexity from it.

The results of this study show that fetoscopic laser

surgery used for treatment of women with TTTS has dif-

ferent extents of negative psychological problems and the

psychological intervention used during the perioperative

period can improve the psychological status resulting in

the smooth operative implementation and satisfactory

postoperative rehabilitation. As limited researched

samples, it is necessary to carry out verifications and

researches on a larger range. At the same time, after the

post-discharge psychological intervention of pregnant

women is combined, it will improve post-discharge

quality of life of the patients.

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intervention2. Holist. Nurs. Pract., 2000, 14, 30.

[21] Yao Z.L., Xin Z.F.: “Effect of psychological intervention during

perioperative period on women receiving caesarean birth”. Chin.Mental Health J., 2008, 22, 137.


Y. GAO, M.D.

Department of Obstetrics and Gynecology,

The Affiliated Hospital of Hangzhou Normal

University,

Hangzhou 310015 (China)


565

Introduction

Endometriosis, affecting about 10% of women of repro-

ductive age, is often associated with pelvic pain and/or in-

fertility. Pain symptoms can be severe particularly in the

presence of deep invasive endometriosis and can affect the

quality of life of these patients [1]. According to the litera-

ture, the number of cases and the severity of the disease are

increasing and the actual incidence of the disease may be

higher, owing to the requirement of surgical visualization

for diagnosis [2, 3]. Moreover, the disease tends to recur

even if the recurrence risk factors are not well clarify. Nev-

ertheless, adhesions and previous surgery seem to have a

role [4]. The etiology of endometriosis is unclear, but it is

probably multifactorial involving hormonal, genetic, im-

munologic, and environmental factors [5]. The possibility

that exposure to environmental chemicals is a contributing

factor to the development of endometriosis has been a mat-

ter of scientific debate for 20 years.

Review

A compound, which has been of great concern, is 2,3,7,8-

tetrachlorodibenzo-p-dioxin (TCDD), an undesired by-

product of many combustion processes. It is the prototype

of a group of substances which have similar chemical char-

acteristics and spectrum of effects and are both persistent

and bioaccumulative. Chemicals belonging to this group

are polyhalogenated aromatic hydrocarbons (PHAHs) and

they may contain multiple chlorine and/or bromine atoms

at three or more lateral positions on the multiaromatic ring

structure [6]. They include polyhalogenated dibenzo-p-

dioxins (PCDDs and PBDDs), dibenzofurans (PCDFs and

PBDFs), biphenyls (PCBs and PBBs), and naphthalenes

(PCNs and PBNs). Polychlorobiphenyls (PCBs) include

209 different congeners which are divided into ‘dioxin-like’

(DL-PCBs) and ‘non dioxin-like’ according to their struc-

ture. Dioxin-like congeners have no or only one chlorine

in the ortho position while non-dioxin-like PCBs are char-

acterized by two or more chlorines in the ortho position.

PCBs, polychlorodibenzodioxins and polychlorodibenzo-

furans (PCDDs and PCDFs, commonly referred to as ‘diox-

ins’) are resistant to degradation and they bioaccumulate at

higher levels in the food chain due to their lipophilicity.

Food is thus the most important source of exposure to these

pollutants [7]. Humans and animals are exposed to com-

plex combinations of such chemicals; however, most stud-

ies focus only on single toxicants.

Some dioxin-like and non-dioxin-like PCBs and

organochlorinated pesticides (such as p,p’-DDE, a metabo-

lite of DDT) seem to interfere with the endocrine (as en-

docrine-disruptor) and the immune systems, causing

reproductive disorders such as endometriosis. Endocrine

disruptors (EDCs) are compounds that may interfere with

the endocrine system and produce adverse developmental,

reproductive, neurological, and immune effects in both hu-

mans and wildlife. They can mimic, reduce, and in some

cases, completely block the effects of endogenous hor-

mones.

The hypothesis that exposure to environmental pollutants

could play a role in disease etiology was first suggested by

Rier et al. [8]. The study conducted in monkeys, which

were chronically exposed to TCDD, found a dose-depen-

dent increase in the incidence and severity of spontaneous

endometriosis. Although strongly criticized by some sci-

entists [9, 10], this paper opened new ways for further re-

search investigating the relationship between endometriosis

and environmental pollutants.

The effects of TCDD, dioxins, and PCBs have been stud-

ied by numerous investigators and yielded contrasting re-

sults [3, 5, 11-14]. In 2002, Eskenazi et al. [15] evaluated

the role of TCDD in the development of endometriosis inRevised manuscript accepted for publication December 17, 2012

Role of environmental organochlorinated pollutants

in the development of endometriosis

M.G. Porpora, S. Resta, E. Fugetta, P. Storelli, F. Megiorni, L. Manganaro, E. De Felip

Department of Obstetrics-Gynecology and Urology, “Sapienza” University of Rome, Rome (Italy)

Summary

Endometriosis is a gynecological disease, which involves the growth of endometrial tissue outside the uterine cavity, commonly in

the pelvic region. The etiology of the disease is unclear, but multiple factors may contribute to its pathogenesis. Environmental

organochlorinated pollutants, particularly dioxins and polychlorinated biphenyls (PCBs), are thought to play a role in the development

of this disease; however, the results of clinical trials are discordant, and it is not clear how the effect of exposure to these compounds is

linked to endometriosis. Their effects on cytokines, immune system, hormones, and growth factors are thought to increase the risk of

endometriosis. The purpose of this review is to provide an overview of epidemiological studies, which have evaluated the relationship

between endometriosis and exposure to persistent organochlorinated pollutants.

Key words: Endometriosis, TCDD; PCB; Persistent organic pollutants; Organochlorinated pesticides; Dioxin-like compounds.


XXXIX, n. 2, 2012

M.G. Porpora, S. Resta, E. Fugetta, P. Storelli, F. Megiorni, L. Manganaro, E. De Felip566

women exposed to a great amount of this toxicant. The

study subjects were those who lived in Seveso, Italy, in July

1976, when a chemical explosion dispersed large quanti-

ties of TCDD into the atmosphere. The researchers did not

find a significant association between endometriosis and

TCDD concentrations in serum, but only a trend.

Many studies have investigated the relation between en-

dometriosis and exposure to dioxins and DL-PCBs. All

these compounds bind to the aryl hydrocarbon receptor

(AhR), expressed in both the endometrium and immune

cells, eliciting the same spectrum of toxicological activi-

ties. The binding affinity and the toxic potency of each con-

gener is expressed in relation to the most toxic compound

of the group (the TCDD), termed as the toxicity equiva-

lency factor (TEF). The concentration of a mixture of con-

geners is therefore expressed in toxicity equivalents

(TEQs), multiplying the analytical concentration of each

congener by its TEF. TEQs for each single congener, are

then summed to obtain the total TEQ, which characterizes

the overall toxicity of the mixture [12].

Heilier et al. [13] provided epidemiological evidence

linking endometriosis with increased concentrations of

dioxin and dioxin-like compounds. This study conducted

in women with peritoneal and/or deep infiltrating en-

dometriosis found that they had higher serum TEQ levels

than controls. Tsukino et al. [14] did not confirm this asso-

ciation, finding lower TEQ levels in patients with en-

dometriosis than controls. However, Tsukino et al. included

in the control group patients with Stage I endometriosis and

infertile women, whereas in the study of Heilier et al., the

control group was constituted only by healthy women with

no infertility or endometriosis [13]. These differences in

the selection of control groups probably contributed to the

differing results.

The mechanisms involved in the deleterious effects of

such compounds on reproduction are still under evaluation.

AhR mediates most of the toxic effects of “dioxins” on cell

functions, and activates several genes including cy-

tochrome P450. Exposure to AhR agonists may influence

an inflammatory-like process, triggering endometrial men-

struation [16]. Bruner-Tran et al. [12, 17] demonstrated that

TCDD triggers an inflammatory-like pattern of cell-cell in-

teraction in the human endometrium, which interferes with

progesterone’s ability to suppress matrix metalloproteinases

(MMPs) expression in both epithelial and stromal cells.

Progesterone exposure during the secretory phase of the

menstrual cycle serves to down-regulate the endometrial

MMP system, so that endometrial breakdown does not

occur before menstruation. Under normal circumstances

endometrial tissue, which has reached the peritoneum due

to retrograde flow of menstruation, is eliminated by the in-

nate immune system. Several studies show that inflamma-

tory-like processes caused by dioxin-like toxicants can

interfere with the normal physiology of the endometrium

and the immune system. This condition may permit the per-

sistence and the development of endometrial tissue within

the peritoneal cavity [12, 17].

Exposure to PCBs may be linked to an altered endocrine

status in humans, which may cause development of repro-

ductive tract dysfunctions and diseases. Some studies sug-

gest that endometriosis is linked to exposure to certain

PCBs [3, 5, 13], while other studies do not confirm such a

link [14, 18, 19].

In our studies we found a significant association between

increased levels of some PCBs and endometriosis, but did

not find any difference in blood concentrations of dioxin-

like chemicals (PCDDs, PCDFs, and the 12 dioxin-like

PCBs) in women with different stages of the disease [3, 5].

We also examined the immunological functions of patients

with endometriosis and serum level of PCBs and p, p’-DDE

to verify the impact of these environmental contaminants

on the dysregulation of immune functions and they ob-

served that increased concentrations of these compounds

were associated with altered natural killer (NK) immune

responses [20].

The different results obtained in the published studies

may be influenced by differences in control groups, meth-

ods used for compound analysis, type of congeners inves-

tigated, and the statistical tests employed.

Selection of the control group is a possible source of error

in an epidemiological study investigating the association

between PCBs and endometriosis. Women living in the

same area as the test subjects should be recruited as con-

trols, so that both the groups are likely to have been simi-

larly exposed to organochlorines. The development of

endometriosis as a co-morbidity factor in infertile women

may confound the interpretation of studies enrolling infer-

tile subjects without the disease as controls [14].

Another potential bias is the method used to exclude the

presence of endometriosis in controls, as laparoscopic ex-

amination remains the only reliable diagnostic tool to assess

the presence or the absence of the disease.

In two studies that confirmed a link between exposure to

PCBs and endometriosis, laparoscopy was performed in

both cases and controls to confirm or exclude the presence

of the disease [5, 21].

Lactation is an important PCB excretory route, which

leads to a significant decrease in the body burden of

organochlorine compounds. To avoid the confounding fac-

tor of breast-feeding, only nulliparous or non-nulliparous

women, who have never breastfed should be enrolled [5,

22].

Furthermore, the type of endometriosis may also influ-

ence the results. Heilier et al. [13] found that concentra-

tions of PCBs and dioxin-like compounds in the serum

were associated with a significantly increased risk of de-

veloping deep endometriotic nodules of the recto-vaginal

septum, although the risk of developing peritoneal en-

dometriosis was not statistically significant. The authors

also suggested that organochlorines might mainly cause de-

velopment of deep endometriosis. Future studies should

consider peritoneal endometriosis and deep endometriotic

nodules as distinct entities, in order to assess the possible

etiological contribution of organochlorines.

Genetic predisposition and environmental factors have

been suggested to concur to the onset and progression of

endometriosis. Genetic susceptibility was explored by

studying mutations in genes responsible for detoxifica-

Role of environmental organochlorinated pollutants in the development of endometriosis 567

tion, such as glutathione transferase (GST), as a possible

risk factor to endometriosis per se and in association with

exposure to PCBs. Vichi S et al. [23] showed that the

GSTs polymorphisms per se do not increase per se the risk

of developing endometriosis. However, a gene-environ-

ment interaction was observed for GSTP1 and GSTM1

null genotypes, modulating the effect of total PCBs on

disease risk.

Research should also focus on the risk of developing en-

dometriosis by exposure to environmental chemicals in the

womb, during early childhood, puberty, and adulthood.

In conclusion, accumulated evidence supports the hy-

pothesis that exposure to organochlorine pollutants may in-

duce endometriosis. The mechanisms involved are still

unclear. They may act as immune toxicants and/or en-

docrine disruptors, enhancing estrogen synthesis and dis-

ruption of progesterone-dependent remodeling responses,

which under normal circumstances prevent development of

endometriosis. Additional standardizing studies in humans

and animals are needed to better investigate the link be-

tween exposure to these toxicants and development of en-

dometriosis and to identify the mechanisms involved.

References

[1] Porpora M.G., Koninckx P.R., Piazze J. Natili M., Colagrande S.,

Cosmi E.V.: “Correlation between endometriosis and pelvic pain”. J.Am. Assoc. Gynecol. Laparosc., 1999, 6, 429.

[2] Giudice L.C., Kao L.C.: “Endometriosis”. Lancet, 2004, 364, 1789.

[3] Porpora M.G., Ingelido A.M., di Domenico A., Ferro A., Crobu M.,

Pallante D., et al.: “Increased levels of polychlorobiphenyls in Ital-

ian women with endometriosis”. Chemosphere, 2006, 63, 1361.

[4] Porpora M.G., Pallante D., Ferro A., Crisafi B., Bellati F., Benedetti

Panici P.: “Pain and ovarian endometrioma recurrence after laparo-

scopic treatment of endometriosis: a long-term prospective study”.

Fertil. Steril., 2010, 93, 716.

[5] Porpora M.G., Medda E., Abballe A., Bolli S., De Angelis I., di Do-

menico A., et al.: “Endometriosis and Organochlorinated Environ-

mental Pollutants: a case-control study on italian women of

reproductive age”. Environ. Health Perspect., 2009, 117, 1070.

[6] Birnbaum L.S., Cummings A.M: “Dioxins and endometriosis: a

plausible hypothesis”. Environ. Health Perspect., 2002, 110, 15.

[7] Rier S., Foster W.G.: “Environmental dioxins and endometriosis”.

Semin. Reprod. Med., 2003, 21, 145.

[8] Rier S.E., Martin D.C., Bowman R.E., Dmowski W.P., Becker J.L.:

“Endometriosis in rhesus monkeys (Macacamulatta) following

chronic exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin”. Fundam.Appl. Toxicol., 1993, 21, 433.

[9] Guo S.W.: “The link between exposure to dioxin and endometrio-

sis: a critical reappraisal of primate data”. Gynecol. Obstet. Invest.,2004, 57, 157.

[10] Hitchin D.: “Re: concerns about statistical methods”. Fundam. Appl.Toxicol., 1994, 23, 141.

[11] Jacobson-Dickman E., Lee M.M.: “The influence of endocrine dis-

ruptors on pubertal timing”. Curr. Opin. Endocrinol. Diabetes Obes.,2009, 16, 25.

[12] Bruner-Tran K.L., Yeaman G.R., Crispens M.A., Igarashi T.M., Os-

teen K.G.: “Dioxin may promote inflammation-related development

of endometriosis”. Fertil. Steril., 2008, 89 (5 Suppl), 1287.

[13] Heilier J.F., Nackers F., Verougstraete V.: “Increased dioxin-like com-

pounds in the serum of women with peritoneal endometriosis and deep

endometriotic (adenomyotic) nodules”. Fertil. Steril., 2005, 84, 305.

[14] Tsukino H., Hanaoka T., Sasaki H., Motoyama H., Hiroshima M.,

Tanaka T., et al.: “Associations between serum levels of selected

organochlorine compounds and endometriosis in infertile Japanese

women”. Environ. Res., 2005, 99, 118.

[15] Eskenazi B., Mocarelli P., Warner M., Samuels S., Vercellini P., Olive

D., et al.: “Serum dioxin concentrations and endometriosis: a cohort

study in Seveso, Italy”. Environ. Health Perspect., 2002, 110, 629.

[16] Rier S.: “The potential role of exposure to environmental toxicants

in the pathophysiology of endometriosis”. Ann. N. Y. Acad. Sci.,2002, 955, 201.

[17] Bruner-Tran K.L., Osteen K.: “Dioxin-like PCBs and endometrio-

sis”. Syst. Biol. Reprod. Med., 2010, 56, 132.

[18] Fierens S., Mairesse H., Heilier J.F., De Burbure C., Focant J.F.,

Eppe G., et al.: “Dioxin/polychlorinated biphenyl body burden, di-

abetes and endometriosis: findings in a population-based study in

Belgium”. Biomarkers, 2003, 8, 529.

[19] Niskar A.S., Needham L.L., Rubin C., Turner W.E., Martin C.A.,

Patterson D.G. Jr., et al.: “Serum dioxins, polychlorinated biphenyls,

and endometriosis: a case-control study in Atlanta”. Chemosphere,

2009, 74, 944.

[20] Quaranta M.G., Porpora M.G., Mattioli B., Giordani L., Libri I., In-

gelido A.M. et al.: “Impaired NK-cell-mediated cytotoxic activity

and cytokine production in patients with endometriosis: a possible

role for PCBs and DDE”. Life Sci., 2006, 79, 491.

[21] Reddy B.S., Rozati R., Reddy S., Kodampur S., Reddy P., Reddy R.:

“High plasma concentrations of polychlorinated biphenyls and ph-

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[22] De Felip E., Porpora M.G., Di Domenico A., Ingelido A.M,, Car-

delli M,, Cosmi E.V., Donnez J.: “Dioxin-like compounds and en-

dometriosis: a study on Italian and Belgian women of reproductive

age”. Toxicol. Lett., 2004, 150, 203.

[23] Vichi S., Medda E., Ingelido A.M., Ferro A., Resta S., Porpora M.G.,

et al.: “Glutathione transferase polymorphisms and risk of en-

dometriosis associated with polychlorinated biphenyls exposure in

Italian women: a gene-environment interaction”. Fertil. Steril., 2012,

97, 1143.


E. FUGGETTA, M.D.

Department of Obstetrics-Gynaecology and Urology,

“Sapienza” University of Rome,

Viale del Policlinico 155, 00161 Rome (Italy)


Introduction

Human pregnancy is maintained by a complex endocrine

balance involving autocrine and paracrine signaling [1].

Although the precise mechanisms that control the onset of

labor have not as yet been fully explained, accumulating

data suggest that progesterone and corticotropin-releasing

hormone (CRH) play substantial roles.

Progesterone (P) maintains pregnancy by promoting

myometrial relaxation and quiescence [2]. It is thought to

actively block myometrial contractility and its withdrawal

converts the myometrium to the laboring state. Mean-

while, maternal plasma CRH is closely linked to the

timing of parturition in human pregnancies [3]. Placental

CRH is synthesized by human trophoblast, amnion,

chorion, and decidual cells [4] and is secreted in maternal

and fetal plasma [5]. It plays a key role in the initiation of

parturition and in regulating the cascade of events

involved in the birthing process [4, 6]. In addition, CRH

may interact with the declining P levels which leads to the

onset of labor [7], although this has not as yet been

studied in detail.

The authors aimed to examine the relationship between

maternal plasma P and CRH levels and the onset and pro-

gression of labor. Hypothesizing that the onset of labor is

associated with a rise in CRH accompanied by a drop in

P levels, P and CRH maternal serum levels were com-

pared in the latent phase, active labor, and postpartal

period spontaneously laboring women at term. Addition-

ally, serum P from third-trimester non-laboring women

was measured as baseline. Studies undertaking further

examination of the fluctuation occurring in the plasma

levels of CRH and P during labor and postpartum will

shed additional light on the mechanisms of normal labor,

while the conclusions of this study could be applied in the

ongoing research of preterm labor.


Fourteen women at term were included in the study: nine of

them presented in spontaneous early labor and delivered vagi-

nally and the remaining five were admitted for an elective

cesarean section by maternal request. None of the subjects was

on any medications or had any documented medical or antena-

tal problems. None of the women who delivered vaginally

received epidural anesthesia. Blood samples were taken from all

subjects in the latent phase of labor (n = 9), in the active phase

of labor (n = 9), and prior to the elective cesarean section (n =

5), and postpartum. Gestational age was confirmed by a first-

trimester dating ultrasound. All subjects gave informed consent

for participation in the study. The study was approved by the

Ethics Review Board of the hospital.

Collection of blood samplesTen milliliters of venous blood was collected from each par-

ticipant by venipuncture of the antecubital vein. Blood samples

were centrifuged at 1,600 rpm for 15 min at 0°C. Plasma was

collected in duplicate aliquots. Plasma was frozen at -80°C and

each aliquot was thawed on the day of the assay quantification.

Radioimmunoassay assessment of hormone levelsPlasma was extracted and processed for radioimmunoassay

(RIA) by using a conventional RIA Kit according to the manu-

facturer’s instructions. CRH was extracted from three ml of

plasma with Sep-Pak C-18 cartridges and eluted with Buffer B

(60% acetonitrile, 1% TFA, and 39% distilled water). The extracts

568

Corticotropin-releasing hormone and progesterone plasma

levels association with the onset and progression of labor

F. Stamatelou1, E. Deligeoroglou2, N. Vrachnis2, S. Iliodromiti2, Z. Iliodromiti2, S. Sifakis3,

G. Farmakides1, G. Creatsas2

1Sixth Department of Obstetrics and Gynecology, Elena Venizelou Maternity Hospital, Athens2Second Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieion Hospital, Athens

3Department of Obstetrics and Gynaecology, University Hospital of Heraklion, Heraklio, Crete (Greece)

Summary

Purpose of Investigation: To examine the relationship between maternal plasma progesterone along with corticotropin- releasing hor-

mone (CRH) plasma levels and the progression of labor. Materials and Methods: Maternal serum CRH and progesterone were meas-

ured during the latent phase of labor, active labor, and 24 hours postpartum in women who went into spontaneous labor and delivered

vaginally at term. Progesterone (P) levels in women delivered by an elective cesarean section at term were also measured as baseline.

Results: Mean maternal plasma P was 18% higher in the active phase than in the latent phase of labor (p < 0.01), and declined signifi-

cantly by 24 hours postpartum (p < 0.001). Mean level of serum CRH was 24% higher in the active phase than in the latent phase of

labor (p < 0.01), and subsequently declined significantly by 24 hours postpartum (p < 0.001). Conclusions: As labor progresses, P and

CRH increase and subsequently decrease precipitously in the immediate postpartal period. P levels tend to drop in women who are in

early labor compared with non-laboring full-term women.

Key words: CRH; Progesterone; Phases of labor; Term labor; Latent phase of labor; Active labor; Postpartum.



XXXIX, n. 2, 2012

F. Stamatelou, E. Deligeoroglou, N. Vrachnis, S. Iliodromiti, Z. Iliodromiti, S. Sifakis, G. Farmakides, G. Creatsas 569

were evaporated, reconstituted in assay buffer, and assayed for

CRH immunoreactivity. The RIA kit had a detection rate ranging

from 0.1 to 67 pg/tube. A CRH-specific rabbit antiserum was used

as the probe. CRH iodinated with I125 served as the tracer. Serum

P was similarly assayed by a conventional RIA kit.

Statistical analysisData were distributed normally and are presented as means ±

standard deviation. Mean maternal plasma P and CRH concen-

trations in the latent phase of labor (cervical dilation < four cm),

in the active phase of labor (cervical dilation ≥ four cm), and 24

hours postpartum were compared in the women (n = 9) who

delivered vaginally at term (over 37 weeks of gestation) by two-

way analysis of variance (ANOVA). The sources of difference

underlying effects revealed by ANOVA were detected by

Fisher’s post hoc analysis. Mean plasma concentrations of P

during the latent phase of labor in the above women were com-

pared with the levels of P in the women (n = 5) who were deliv-

ered by an elective cesarean section at term by student t-test. A

p < 0.05 was considered as level of statistical significance.

Results

P and CRH level changes during progression of laborTable 1 and Figure 1A demonstrate a significant effect of

labor phase (latent, active, postpartum) on P levels (p <0.001). Specifically, the mean maternal plasma concentra-

tion during active labor was 18% higher than the mean level

during the latent phase of labor (p < 0.01). A steep decline

in P levels was observed following delivery: mean maternal

plasma P concentration at 24 hours postpartum was signifi-

cantly lower than active labor mean level (p < 0.001).

Likewise, there was a significant effect of labor phase

(latent, active, postpartum) on CRH level (Table 1 and

Figure 1B). Mean maternal plasma CRH concentration

during active labor was 24% higher than that during the

latent phase of labor (p < 0.01). Similarly to the pattern

observed in P levels, there was a precipitous decline in

CRH levels following delivery. Mean maternal plasma

CRH concentration 24 hours postpartum was roughly

1/34th of active labor mean level (p < 0.001).

P levels elevated with spontaneous occurrence of laborTable 2 illustrates that mean P concentrations in women

who were at term and in early labor differed from those

who were full term but not in labor (p < 0.10). Although

this does not reach statistically significant levels, there is

a trend showing that the mean maternal plasma concen-

tration of P in the non-laboring group was higher than in

the latent phase laboring group, a determination likely to

be further confirmed with a larger number of participants.

Discussion

The fluctuation of maternal CRH and P levels during

different stages of labor was examined in this study. P

levels were lower in full-term pregnant women who

labored spontaneously compared to gestation-matched

women who did not labor, suggesting that a drop in P levels

is linked to the initiation of labor. In addition, there was a

parallel increase in P and CRH levels as women progressed

from the latent to the active phase of labor. Both hormones

subsequently dropped rapidly to non-pregnant levels as

compared to standard laboratory values of non-pregnant

women by day one after delivery (Figure 1).

The observed pattern in P levels complements the find-

ings of Winkler et al. [8] who assessed P receptor (PR) con-

centrations in the human lower uterine segment at different

stages of cervical dilatation during parturition at term. They

found that PR concentration diminished significantly as

women progressed from two to four cm cervical dilatation

to four to six cm cervical dilatation and then increased to >

six cm cervical dilation.

The finding of the increase in CRH levels as women

progressed from latent to active labor followed by a pre-

cipitous postpartal decline accords with data from other

studies [9, 10]. Beyond the characteristic rise of CRH in

the third trimester [11], CRH rises dramatically during the

active phase of labor [9] and declines rapidly towards the

non-pregnant levels by the first day postpartum [10]. It is

interesting to note that the rapid drop in CRH and subse-

quently in CRH-induced cortisol in the immediate post-

natal period is likely to be responsible for the ‘baby-blues’

commonly observed at postpartum.

CRH, the primary regulator of stress via its manage-

ment of the hypothalamic-pituitary-adrenal axis (HPA),

acts on the fetal pituitary-adrenal axis as well as on the

uterus. This multi-sited action possibly maintains a posi-

tive feed-back loop between the fetal pituitary-adrenal

axis and the placenta, which leads to an up-regulation of

fetal secretion of cortisol [12] and dehydroepiandros-

terone-sulfate (DHEA-S) [13]. Fetal cortisol, which is

essential for the maturation of the fetal lungs [14], sequen-

tially stimulates CRH release from the placenta [8, 11].

Meanwhile, DHEA-S stimulates placental estrogen pro-

duction, which is also hypothesized to play a major role

in the initiation of parturition [15]. CRH receptors exist in

the myometrium [16, 17], fetal membranes [18], and pla-

centa [19], indicating that CRH has multiple targets. In

addition, placental and fetal membrane secretion of

Table 1. — Progesterone (ng/ml) and CRH (pg/ml) levels(mean ± SD) in full term mothers during latent labor, activelabor and post delivery.

Latent Active Post F-test Effect

phase phase delivery of time

Progesterone 103.2 ± 17.6 121.8 ± 11.3a 12.2 ± 8.2b 221.2 p < 0.001

CRH 778.9 ± 226.6 968.9 ± 240.3a 28.5 ± 16.3b 118.1 p < 0.001

ap < 0.01 vs latent phase, bp < 0.001 vs active phase.

Table 2. — Progesterone (ng/ml) levels (mean ± SD) in fullterm women in latent phase of labor (n = 9) compared with fullterm women not in labor (n = 5).

Latent labor Not in labor t-test Statistical

significance

Progesterone 103.2 ± 17.6 123.2 ± 19.4 1,965t p < 0.10

(Prob = 0.073)

Corticotropin-releasing hormone and progesterone plasma levels association with the onset and progression of labor570

prostaglandins E2 and F2a is up-regulated in response to

CRH [20, 21]. The ability of CRH to potentiate the action

of oxytocin may also contribute to the onset of labor both

at term and prematurely [22, 23]. Similarly, the CRH

binding protein, which is thought to delay CRH-con-

trolled pituitary-adrenal stimulation by binding and elim-

inating the free potent CRH, falls rapidly around 20 days

prior to spontaneous labor, while placental CRH secretion

continues to rise as labor approaches [24].

It becomes apparent that initiation of labor involves

complex mechanisms that initiate autonomic and central

functions which coordinate myometrial contractility and

cervical dilatation. In addition, CRH and its related

peptide urocortin 1 increase local metalloproteinase-9

(MMP-9) activity in placenta and fetal membranes, which

may trigger the initiation of labor [25]. Studies in second-

trimester amniotic fluid from pregnancies that went on to

preterm labor revealed raised levels of ADAM-8, a met-

alloproteinase, and cortisol [26]. This finding further sup-

ports the theory of the existence of a ‘CRH placental

clock’ which determines the length of the pregnancy from

an early stage [24]. Furthermore, there are accumulating

data strongly indicating that CRH and P initiate a cascade

of immune responses in the myometrium also contribut-

ing to synchronization of the onset of labor [27].

P has an inhibitory effect [7] on the secretion of CRH

from the placenta [28], presumably by prohibiting the ini-

tiation of a positive feedback loop between CRH, adreno-

corticotropic hormone and cortisol [29]. It has been sug-

gested that the inhibitory effect of P is exerted by its

binding to glucocorticoid receptors (GRs) on trophoblast

cells [30]. At term, CRH-induced high levels of cortisol

displace GR-bound P [31], whereby the action of cortisol

is initiated. Based on the above, the parallel drop and

increase in CRH and P levels and in particular the rise of

P levels while labor advances (Figure 1), which was

shown in this study, seems a paradoxical finding. A pos-

sible explanation for this is that a sequential effect of

prostaglandins may take place during labor. Mesiano [32]

concluded that functional P withdrawal is mediated by an

increase in the myometrial PR-A/PR-B expression ratio.

The PR-A isoform opposes P actions mediated by its

counterpart, the PR-B isoform. Hence, women with a

higher PR-A/PR-B ratio are more likely to deliver earlier

than those with lower values. Prostaglandin E2 (PGE2)

increases both PR-A and PR-B isoforms without changing

the PR-A/PR-B ratio; on the other hand, prostaglandin

F2α (PGF2a) selectively induces the expression of PR-A,

thereby increasing the PR-A/PR-B ratio [32]. In the

present study, the initial diminishing levels of P in women

experiencing spontaneous early labor may be a result of a

primary PGF2α-mediated increase in the PR-A/PR-B

ratio, followed by an increase in PGE2, which does not

affect the PR-A/PR-B ratio and may enable the subse-

quent rise of P levels while labor progresses. Further

studies are needed to elucidate the sequential effect of P

on the expression and action of various prostaglandins.

The authors conclude that the onset of spontaneous

labor is associated with a drop in P levels, which is fol-

lowed by a parallel rise in the levels of CRH and P while

labor progresses. Both hormones decrease rapidly, almost

to the pre-pregnancy levels, in the immediate postnatal

period. By enhancing an understanding of the mecha-

nisms related to the onset and progression of labor at term,

the same principles in preterm labor, one of the main

causes of perinatal mortality, and in which area little

improvement has been achieved over the last few decades,

can be assessed.

Figure 1. — Progesterone (1A, ng/ml) and CRH (1B, pg/ml) levels

in a group of women who delivered vaginally at term during the

latent phase of labor, active phase of labor, and 24 hours postpar-

tum. ap < 0.01 vs latent labor, bp < 0.001 vs active labor.

F. Stamatelou, E. Deligeoroglou, N. Vrachnis, S. Iliodromiti, Z. Iliodromiti, S. Sifakis, G. Farmakides, G. Creatsas 571

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[6] Robinson B.G., Emanual R.L., Frim D.M., Majzoub J.A.: “Gluco-

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gene in human placenta”. Proc. Natl. Acad. Sci. USA, 1988, 85, 5244.

[7] Petraglia F., Sutton S., Vale W.: “Neurotransmitters and peptides

modulate the release of immunoreactive corticotropin-releasing

factor from cultured human placental cells”. Am. J. Obstet.Gynecol., 1989, 160, 247.

[8] Gibb W., Challis J.R.G.: “Mechanisms of term and preterm birth”.

J. Obstet. Gynaecol. Can., 2002, 24, 874.

[9] Winkler M., Zlantinsi S., Kemp B., Neulen J., Rath W.: “Concen-

tration of estrogen and progesterone receptors in the lower uterine

segment at term labor”. Z. Geburtshilfe Neonatol., 2002, 204, 74.

[10] Grammatopoulos D.K., Hillhouse E.W.: “Role of corticotropin

releasing hormone in onset of labor”. Lancet, 1999, 354, 1546.

[11] Petraglia F., Florio P., Nappi C., Genazzani A.R.: “Peptide signal-

ing in human placenta and membranes: autocrine, paracrine and

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[13] Smith R., Mesiano S., Chan E.C., Brown S., Jaffe R.B.: “Corti-

cotropin releasing hormone directly and preferentially stimulates

dehydroepiandrosterone sulphate secretion by human fetal adrenal

cortical cells”. J. Clin. Endocrinol. Metab., 1998, 83, 2916.

[14] Muglia L., Jacobson L., Dikkes P., Majzoub J.A.: “Corticotropin

releasing hormone deficiency reveals major fetal but not adult glu-

cocorticoid need”. Nature, 1995, 373, 427.

[15] Mecenas C.A., Giussani D.A., Owiny J.R., Jenkins S.L., Wu W.X.,

Honnebier B.O. et al.: “Production of premature delivery in preg-

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[16] Hillhouse E.W., Grammatopoulos D., Milton N.G.N., Quartero

H.W.P.: “The identification of a human myometrial corticotpophin

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control of human parturition”. J. Soc. Gynecol. Investig., 2004, 11,193.


N. VRACHNIS, M.D.

Second University, Department of

Obstetrics and Gynecology

University of Athens Medical School

Aretaieion Hospital

124B Vasilisis Sofias Av.

11526 Athens (Greece)


Introduction

Hysteroscopy is a significant method commonly used in

the evaluation of the vagina, cervix, and endometrium [1].

Currently, it has become the gold standard as it is minimally

invasive and can be performed on an outpatient basis. Al-

though it is widely used for quite a large group of indica-

tions, some restrictive factors may occasionally limit its

use. One of these factors is virginity.

As virginity refers to the intactness of the hymen and

sexual integrity in many cultures, it is directly related to

female social life. It is of great importance in China and

Mediterranean cultures, as well as in Muslim communi-

ties [2, 3]. Therefore, interventions through the vaginal

route are found unacceptable in these cultures. It is obvi-

ous that there is a need to develop virginity-preserving

methods.

The present study aims to specify the details of a new

technique developed to preserve virginity.


In the present study, retrospective records of five cases were

examined in whom hymen-preserving hysteroscopic technique

through the vaginal route was performed. All of the patients

and their parents were informed about the technique in detail,

and written consents were obtained. The procedure was con-

ducted under intravenous sedo-analgesia. The technique is per-

formed in patients with annular hymenal morphology. Briefly,

in a lithotomy position, an office hysteroscope was inserted

through the hymenal opening and vaginoscopy was conducted

without using a vaginal speculum. A panoramic image of the

cervix was obtained and external cervical orifice was rendered

more visible. Then, with the visual guidance of office hys-

teroscopy, a tenaculum was inserted through hymenal orifice

and the upper cervical lip was grasped. The cervix was then

pulled down through the vagina as close as possible to the

proximity of the hymenal orifice (Figure 1). After adequate

traction, the cervix was dilated by Hegar dilators through hy-

menal orifice up to nine mm and an operative hysteroscope

was introduced into the endometrial cavity. The cervix was

firmly held in traction throughout the procedure. The rest of

the procedure was conducted in line with routine operative

hysteroscopy.

Results

In this study, the aforementioned technique was per-

formed in five cases. All the cases were virgins and had

annular hymens. All the cases had a complaint of abnor-

mal uterine bleeding which did not respond to medical

treatment. Two of the patients had submucous leiomy-

omas and three had endometrial polyps. Mean operation

time was 16 ± 3 minutes. Fluid deficit was 340 ± 80 ml.

None of the patients had intraoperative or postoperative

complications. Hymenal integrity was preserved in all

patients.

Discussion

The findings of the present study have shown that op-

erative hysteroscopy can be safely performed when hy-

menal integrity is a concern. There are only few studies

about virginity-preserving gynecological interventions.

Most of them are small case series that have reported the

use of office hysteroscopy mainly in cervical pathologies

[4, 5]. All the cases in the present study had intrauterine

pathologies, and in this respect it is the first of its kind in

the literature. The described method has some restric-

tions. Social, cultural, and religious values of the patients

are the main obstacle to the vaginal approach [2]. This

situation seems to be the most common limitation which

572

Operative hysteroscopy preserving virginity:

a new technique

C. Yalcinkaya, H. Kalayci, E. Simsek, C.T. Iskender, H.A. Parlakgumus

Baskent University, Medical School, Department of Obstetrics and Gynecology, Adana (Turkey)

Summary

Objective: To present a new technique of virginity-preserving operative hysteroscopy in the treatment of intrauterine pathologies. Ma-terials and Methods: The details of operative hysteroscopy in which the hymenal orifice was left intact to preserve virginity are presented.

The technique briefly involved the following steps: holding the cervix with a tenaculum and its traction to the immediate posterior hymenal

opening with use of office hysteroscopy, which was then followed by operative conventional hysteroscopy. Results: The technique was

performed successfully in all patients with an annular hymenal morphology. The technique enabled complete resection of intrauterine

pathologies in all cases. There was no case of inadvertent hymenal injury during the procedure. Conclusion: The presented technique,

makes it possible to easily treat intrauterine pathologies while preserving the hymen. It can be preferred in groups of patients in whom it

is necessary to preserve virginity.

Key words: Operative hysteroscopy; Vaginoscopy; Virginity.



XXXIX, n. 2, 2012

C. Yalcinkaya, H. Kalayci, E. Simsek, C.T. Iskender, H.A. Parlakgumus 573

can be overcome by adequate information. Variations in

hymenal morphology, size, and shape of hymenal orifice

are also significant intrinsic factors that can limit the use

of this operative hysteroscopy. This present method can-

not be used in septate or cribriform hymenal structures.

However, this type of hymenal morphology is found in

about three percent of patients, therefore this is a limited

concern [6]. Another potentially limiting factor is the in-

ability to provide adequate cervical traction. As stated

above, traction of the cervix is the essential step of the

method. Conditions like endometriosis, pelvic infections,

and nulliparity may compromise the amount of descensus

provided.

The approach proved that operative hysteroscopy is a

viable option in virgin patients whose main concern is

preservation of hymenal integrity. The method was suc-

cessfully applied in all five cases. However applicability

of this technique in all virgin patients still remains to be

answered due to the aforementioned limitations.

In conclusion, the technique the authors have described

may enable the treatment of intrauterine pathologies re-

quiring operative hysteroscopy while preserving hymenal

integrity.

References

[1] Fernandez H.: “Update on the management of menometrorrhagia:

new surgical approaches”. Gynecol. Endocrinol., 2011, 27, 1131.

[2] van Moorst B.R., van Lunsen R.H., van Dijken D.K., Salvatore C.M.:

“Backgrounds of women applying for hymen reconstruction, the ef-

fects of counselling on myths and misunderstandings about virginity,

and the results of hymen reconstruction”. Eur. J. Contracept. Reprod.Health Care, 2012, 17, 93.

[3] Studd J.: “A comparison of 19th century and current attitudes to fe-

male sexuality”. Gynecol. Endocrinol., 2007, 23, 673.

[4] Küçük T.: “When virginity does matter: rigid hysteroscopy for diag-

nostic and operative vaginoscopy-a series of 26 cases”. J. Minim. In-vasive Gynecol., 2007, 14, 651.

[5] Ou K.Y., Chen Y.C., Hsu S.C., Tsai E.M.: “Hysteroscopic manage-

ment of lower genital tract lesions in females with limited vaginal ac-

cess”. Fertil. Steril., 2009, 91, 293.

[6] Heger A.H., Ticson L., Guerra L., Lister J., Zaragoza T., McConnell

G., Morahan M.: “Appearance of the genitalia in girls selected for

nonabuse: review of hymenal morphology and nonspecific findings”.

J. Pediatr. Adolesc. Gynecol., 2002, 15, 27.


C. YALCINKAYA, M.D.

Baskent University, Medical School


Seyhan Research Hospital

01110 Seyhan, Adana (Turkey)


Figure 1. — Grasping of cervix during vaginoscopy.

Introduction

Pain due to delivery is a normal physiological phenom-

enon, but severe persistence causes primiparas to experi-

ence fear along with pain, but it is also a neuroendocrine

reaction induced by this stress that causes adverse effects

in puerperant delivery process and fetuses [1]. Due to fear

of delivery pain, partial primiparas will select cesarean

section to avoid it. As a result, cesarean section rate of

China with dominant primiparas constantly increases, and

short- and long-term complications are increasingly ap-

parent, which has become a serious public social problem

[2]. With the progress of society, development of medi-

cine, and change of obstetrics service, a safe, effective,

and pain-relieving delivery has become an urgent need for

gravidas, and it is an important issue in clinical re-

searches. In recent years, although the delivery analgesia

technology is increasingly effective, its popularity rate is

still low in China: less than ten percent. So far, there is

still no satisfactory, safe, simple, economical, and popu-

lar delivery analgesic method and drug suitable for the na-

tional conditions of China. In addition, it is always

contestable whether it will delay labor and increase ce-

sarean section, postpartum hemorrhage, and neonatal as-

phyxia rates [3].

Therefore, the authors use the delivery analgesia method

with spinal epidural anesthesia plus a psycological Doula

support in a prospective study in order to investigate its

analgesic effect and its influences on mother and baby in

providing a reference for promoting natural delivery and

reducing cesarean section rate.


Clinical data The primiparas laboring in the present hospital from May 2010

to May 2012 were selected, and their ages ranged from 20 to 34

years. For all primiparas, pregnancy months were adequate. Also,

each primipara only delivered one fetus through cephalic presen-

tation. In addition, there was no cephalopelvic disproportion, ob-

stetric or internal medicine complications, and epidural anesthesia

contraindications. During labor, 200 primiparas voluntarily se-

lected to deliver with analgesia (observation group). At the same

time, 200 primiparas delivered without analgesia (control group).

For age, gestational week, and fetal size, there was no significant

difference between the two groups. This study was conducted in

accordance with the Declaration of Helsinki, and with the ap-

proval of the Ethics Committee of Beijing Tongren Hospital of

Capital Medical University. Written informed consent was also

obtained from all participants.

Doula and anesthesia analgesiaIn the observation group, from initial labouring to two hours

postpartum, each primipara was accompanied with one Doula

midwife. During the delivery accompanying process, Doula

midwife conducted psychological, physiological, and physical

care, and explained delivery-related concepts to primiparas and

their families and provided mental and spiritual support. When

uterine orifice of the primiparas was dilated by about two to

574

Investigation on delivery analgesia effect of combined spinal

epidural anesthesia plus Doula and safety of mother

and baby

Bi-Bo. Feng, Lei Wang, Jian-Jun Zhai

Department of Obstetrics and Gynecology, Beijing Tongren Hospital of Capital Medical University, Beijing (China)

Summary

Objective: To explore the effect of patient-controlled lumbar epidural combined anesthesia with Doula for labor analgesia with ropi-

vacaine and sufentanil, and its influence on the progress of labor, and outcomes of mother and infant. Materials and Methods: Two hun-

dred parturients that requested labor analgesia were randomly selected by patient-controlled lumbar epidural combined anesthesia with

Doula as the observation group, meanwhile another 200 parturients were selected as the control group without any analgesic measure-

ments. Labor pain score, labor duration, blood gas analysis results, the incidence of cesarean section, neonatal asphyxia, and postpar-

tum hemorrhage were compared between the two groups. Results: Compared with the control group, labor analgesic effect was

remarkable, the cesarean section rate was significantly reduced in observation group, and the difference was statistically significant (p< 0.05), but with respect to the duration of labor, maternal, postpartum hemorrhage, and neonatal asphyxia, there was no statistical sig-

nificance between the two groups (p > 0.5). In the observation group regarding maternal and neonatal blood gas analysis results, PO2was higher and PCO2 was lower than those in the control group. The differences were statistically significant (p < 0.05). Conclusion:Labor analgesia by patient-controlled lumbar epidural combined anesthesia accompanied with Doula with ropivacaine and sufentanil

is effective, safe, reliable, has no adverse effects, and reduces cesarean section rate.

Key words: Lumbar epidural combined anesthesia; Labor analgesia; Doula; Effects; Outcomes.



XXXIX, n. 2, 2012

three cm, a catheter was positioned for spinal analgesia. A first

dose of anesthetic solution (ropivacaine 2.5 mg plus sufentanil

2.5 µg) was infused in the subarachnoid space. Subsequently, a

solution of 0.1% ropivacaine plus one µg/ml sufentanil was in-

fused into epidural cavity via the epidural catheter using a micro

self-controlled pump at a rate of five to six ml/h for maintaining

analgesia until uterine orifice was completely opened and dur-

ing episiorrhaphy oxytocin intension and amniotomy were per-

formed to maintain satisfactory uterine contraction frequency

and intensity. If the labor was complicated with fetal distress,

abnormal fetal position, and protracted labor without resolution,

cesarean section was performed.

Analgesic effectPain indicator: the visual analogy scoring method (VAS, 0-10

scores) was used [4], 0: no pain; below 3 scores: slight pain, tol-

erable; 4 to 6 scores: pain affected sleep, tolerable; 7 to 9 scores:

intolerable; 10 scores: sharp pain. According to the scores, pain

situations of two groups of primiparas in the latent period, the ac-

tive phase, and the second and third stages of labor were evalu-

ated.

Blood gas analysisAs it was confirmed that primiparas were in the second stage of

labor, one-ml radial artery blood specimen was acquired, sealed,

and immediately sent for testing. After a fetus was delivered and

before crying, one-ml of umbilical artery blood specimen was im-

mediately acquired, sealed, and sent for testing.

Recording clinical dataVital signs, labor times, visual analogy scores, amniotomies,

oxytocin applications, delivery modes, neonatal asphyxia, and

postpartum hemorrhage were recorded.

Statistical analysisSPSS10.0 software was used for t-test and chi-square (χ2) test.

If p < 0.05, a significant difference could be observed.

Results

Comparison of pain situations between two groups ofprimiparas

During labor, there were respectively, 20 and 38 cases re-

ceiving cesarean section due to fetus, delivery force, and

other factors in the observation and control groups, and

pain scoring was not conducted in them. For VAS score of

pain before analgesia, there was no significant difference

between two groups (p > 0.05). After analgesia, the pain of

the observation group was significantly relieved. Between

two groups, there was a significant difference for VAS

score of pain (p < 0.05) (Table 1).

Comparisons of labor time and medical interventionmeasures between two groups

For the active phase time, the time of the second and third

stages of labor, amniotomy intervention rate, and oxytocin

application rate, there was no significant difference be-

tween two groups (p > 0.05) (Table 2). In addition, two

groups of primiparas receiving cesarean section were ex-

cluded from the statistics.

Comparisons of delivery mode and delivery outcomebetween two groups

Although the assisted vaginal delivery rate of the obser-

vation group was higher than that of the control group, the

cesarean section rate was low and there was a significant

difference between two groups (p < 0.05). However, there

was no significant difference for neonatal asphyxia and

postpartum hemorrhage rates between two groups (p >

0.05) (Table 3).

Comparisons of blood gas analysis results of primiparasand their neonates between two groups

For comparison of blood gas analyses, results of primi-

paras and their neonates, there was no significant differ-

ence between two groups (p > 0.05) (Table 4). In addition,

two groups of primiparas receiving cesarean section were

excluded from the statistics.

Discussion

The ideal delivery analgesia should cause minor psyco-

logical impact to mother and baby and it should be easily

administered. Furthermore, it should satisfy all the opera-

tive requirements of delivery analgesia and avoid compli-

cations [5]. According to this analysis, the delivery

analgesia method of self-controlled combined spinal

epidural anesthesia of low-concentration ropivacaine and

low-dose sufentanil analgesia plus Doula, is a method with

satisfactory effectiveness.

In the delivery process, drastic uterine contraction pain

cause primiparas to feel anxious, frightened, and nervous.

Primiparas hope to receive treatment from healthcare

providers to relieve psychological tension. Doula delivery

Bi-Bo Feng, Lei Wang, Jian-Jun Zhai 575

Table 1. — Comparison of pain VAS scores at different timesbetween the two groups (x

_± s).

Groups Cases Latent Active Second stage Third stage

period phase of labor of labor

Observation 180 8.1 ± 1.3 3.6 ± 1.1# 3.2 ± 1.1# 2.6 ± 1.4#

Control 162 8.3 ± 1.7 8.8 ± 1.0# 9.1 ± 0.6# 5.4 ± 1.6#

For comparison between two groups, #p < 0.05.

Table 2. — Comparison of labor time and medical interventionmeasures between the two group (x

_± s) n (%).

Group Case Active Second stage Third stage Amniotomy Oxytocin

phase (h) of labor of labor n (%) n (%)

(min) (min)

Observation 180 6.1 ± 2.1 86.6 ± 20.1 11.2 ± 3.1 61 (33.9) 38 (21.1)

Control 162 5.8 ± 1.7 82.6 ± 29.2 10.1 ± 1.6 54 (33.3) 35 (21.6)

Table 3. — Comparison of delivery mode and delivery outcomebetween the two groups [n (%)].Group Case Natural Assisted Cesarean Neonatal Postpartum

delivery vaginal section asphyxia hemorrhage

delivery

Observation 200 145 (72.5) 35 (17.5)# 20 (10.0)# 9 (4.5) 13 (6.6)

Control 200 141 (70.5) 21 (10.5)# 38 (19.0)# 11 (5.5) 11 (5.5)

For comparison between two groups, #p < 0.05.

[6] provides a one-to-one new delivery care service mode

for primiparas. It not only relieves emotional tension of

primiparas and provides a spiritual pillar, but personalizes

the assistance throughout the delivery process. This

methodology was applied to the observation group. There-

fore, the whole labor process was conducted under the ac-

tive management and close cooperation of anesthetist,

obstetrician, and midwife. In addition, the drug effect ap-

parently mitigated or entirely relieved pain sensation of

primiparas. This kind of delivery also appears to mitigate

tension and anxiety of primiparas that can better cooperate

with the obstetrical team enabling the delivery progression.

Application time, type, and dose of analgesic drugs, ex-

tension of analgesia, and blocking range determine the re-

sults of delivery anesthesia [7]. Local anesthetic is a most

widely-used painless delivery of epidural anesthesia. Gor-

mar et al. [8] reported that the action of this method was

slow, not always satisfactory, and it could block motor

nerves. In the two groups, during labor, a pain VAS scoring

was conducted. Pain VAS scores of the observation group

in various stages were respectively, 8.1 ± 1.3, 3.6 ± 1.1, 3.2

± 1.1, and 2.6 ± 1.4, and pain VAS scores of the control

group were respectively, 8.3 ± 1.7, 8.8 ± 1.0, 9.1 ± 0.6, and

5.4 ± 1.6. Based on the pain VAS score, no significant dif-

ference before analgesia was found between two groups (p> 0.05) (Table 1). After analgesia, the pain of in the obser-

vation group was mitigated, with a sustainable self-control

and with a low pain VAS score. The difference between the

two groups has a statistical significance. Yaakov et al. [9]

suggested that ropivacaine is a novel long-acting amide

local anesthetic. It has lesser cardiac toxicity and has no ap-

parent influence on uterine and placental blood flow. Also,

it has a high-degree of blocking and dissociation of sensory

and motor nerves, and it can effectively relieve pain. In ad-

dition, there are fewer microvessels in subarachnoid space,

and drug absorption is slower, which makes local anesthetic

ropivacaine play a role for a lengthy period of time with

only minimal motor blocking. Its subsequent effect lies in

its synergy with epidural medication and generates a

stronger analgesic effect. Therefore, it not only avoids

shortcomings of slow-action of simple epidural anesthesia

and analgesic imperfection and reduces the dosage, but also

avoids some side-effects, such as nausea, emesia, and blood

pressure drop caused by simple subarachnoid space anes-

thesia and headache after anesthesia. After infusion is ter-

minated, muscle function is rapidly restored. The addition

of sufentanil into local anesthetic does not only reduce the

concentration and dosage of local anesthetics, but can also

enhance the analgesic effect, mitigate motor blocking, and

generate apparent motion sensory dissociation isolation to

achieve the purpose of rapid action and long analgesic time

[10]. It is generally thought that as anesthesic level is con-

trolled below T1, it does not affect uterine contraction, but

causes obstetric canal relaxation, which is in favor of fetal

head drop and expansion of uterine orifice [11]. After anes-

thesic analgesia, a self-controlled pump is used to adjust

medication according to the situations. In the condition

without uterine contraction pain, primiparas can conduct

activity, feeding, and micturition. In the second stage of

labor, they can freely use abdominal pressure to actively

participate in the delivery process. Therefore, uterine iner-

tia, postpartum hemorrhage, and other complications can

be avoided.

Some authors [12] believe that painless delivery would

not delay labor, while others [13] believe that painless de-

livery would not delay the second stage of labor and that

it could be useful for natural delivery. The key reason for

controversy is possibly related to the type and dose of anal-

gesic drugs, level of anesthesia, control of blocking range,

and other factors. Some studies [14] suggest that if anes-

thetic dose was higher, anesthetic could block pelvic floor

muscle and rectal sensory nerves, reducing motility and

could inhibit uterine contraction and thus weaken delivery

force, delay labor, and increase the possibility of cesarean

section and assisted vaginal delivery. The solution is to

mainly add opioid drugs such as sufentanil, to reduce the

dosage of local anesthetic. In this study, the delivery anal-

gesic method of self-controlled combined spinal epidural

anesthesia of ropivacaine and low-dose sufentanil was

used to observe the time of the active phase, and the sec-

ond and third stages of labor. The time of various stages of

the observation group was respectively, 6.1 ± 2.1 h, 86.6 ±

20.1 min and 11.2 ± 3.1 min, and the time of various stages

of the control group was respectively, 5.8 ± 1.7 h, 82.6 ±

29.2 min, and 10.1 ± 1.6 min. Between the two groups,

there was no significant difference for the time of various

stages of labor. In addition, some studies [15] showed that

painless delivery increased the artificial amniotomy and

oxytocin intervention rates during labor. This study reports

that the artificial amniotomy and oxytocin intervention

rates of the observation group were respectively, 33.9%

and 21.1%, and those of the control group were respec-

tively, 33.3% and 21.6%. For the oxytocin intervention

rate during labor, there was no significant difference be-

tween the two groups. According to the aforementioned

results, it can be suggested that painless delivery does not

affect labor progression and does not increase artificial am-

niotomy and oxytocin intervention rates. For the influence

of painless delivery on delivery mode, one study [16] re-

ports that painless delivery obviously increased the rates of

assisted vaginal delivery and cesarean section. This group

of data show that assisted vaginal delivery rate and ce-

Investigation on delivery analgesia effect of combined spinal epidural anesthesia plus Doula and safety of mother and baby576

Table 4. — Comparison of blood gas analysis results of primiparas and their neonates between the two groups.Group Case pH value Neonates PO2 (mmHg) Neonates # PCO2 (mmHg) Neonates #

Primiparas Primiparas # Primiparas #

Observation 180 7.41 ± 0.02 7.25 ± 0.03 105.32 ± 13.45 25.48 ± 3.51 30.45 ± 3.51 43.32 ± 2.51

Control 162 7.39 ± 0.07 7.23 ± 0.04 102.38 ± 12.51 24.31 ± 4.53 36.37 ± 3.35 46.21 ± 4.82

For comparison between two groups, #p < 0.05

Bi-Bo Feng, Lei Wang, Jian-Jun Zhai 577

sarean section rate of the observation group are respec-

tively, 17.5% and 10.0%, and those of the control group

are respectively, 10.5% and 19.0%. Although painless de-

livery of the observation group increases the assisted vagi-

nal delivery rate to a certain extent, its cesarean section

rate is significantly lower than that of the control group;

there is a significant difference between the two groups. It

is indicted that this delivery analgesic method cannot ob-

viously influence labor progression, but can reduce ce-

sarean section rate and promote vaginal delivery. The

present analysis results are possibly related to the applica-

tions of novel local anesthetic ropivacaine and low-dose

opioid sufentanil and the control of implementation and

closing time of analgesia. Under the premise of good anal-

gesic effect, the combination of sufentanil and low-con-

centration ropivacaine reduces ropivacaine concentration

and thus mitigates blocking of motor nerves. Delivery

analgesia begins in the latent period in cases of uterine ori-

fice of two to three cm, and primiparas justly feel obvious

pain; at this time, it is best to conduct analgesia. Primi-

paras keep quiet and can actively cooperate. As uterine ori-

fice is nearly fully open, analgesia pump is timely closed.

At the second stage of labor, the relaxation effect of anal-

gesia on vagina and perineum fades away incompletely.

Therefore, it reduces the resistance to birth canal and mit-

igates the inhibition of analgesic to abdominal muscle and

levator ani muscle. At this time, primiparas have accumu-

lated their energy, which helps them to hold force in case

of uterine contraction and is useful for smooth progress of

labor. In addition, the authors believe that even if painless

delivery increases a certain cesarean section rate, its in-

fluence is minor when compared with cesarean section rate

caused by other factors, such as the ratio of primiparas

fearing pain that require cesarean section (16.69%), as re-

ported by the literature [17]. High cesarean section rate

caused by this kind of social factor has an important sig-

nificance especially in China. Primiparas in China are nu-

merous, and fear and anxiety towards delivery increase

cesarean section rate to a larger extent. Painless delivery

updates the concept that delivery is certainly pained and it

reduces unnecessary cesarean section. In this sense, it un-

doubtedly reduces cesarean section rate.

Neonatal asphyxia and postpartum hemorrhage inci-

dence rates are the objective indicators of directly evalu-

ating influences of delivery analgesia on mother and baby.

For the influence of spinal analgesia on fetal heart rhythm,

it is always contestable. Lee et al. [18] thought that the in-

fusion of opioid drugs into subarachnoid space used for

delivery analgesia could increase the risks of slow fetal

heartbeat and postpartum hemorrhage, but it could not in-

crease cesarean section rate. The study of Grondin et al.[19] showed that epidural low-concentration sufentanil in-

fusion had no inhibition to neonate breathing. Ropivacaine

used in this study is a novel long-acting local anesthetic.

After the delivery analgesic method of self-controlled

combined spinal epidural anesthesia with low-concentra-

tion ropivacaine and low-dose sufentanil analgesia plus

Doula, the results showed that neonatal asphyxia and post-

partum hemorrhage rates of the observation group were

respectively, 4.5% and 6.6%, and those of the control

group were respectively, 5.5% and 5.5%; between two

groups, there was no significant difference. It is suggested

that this delivery analgesic method is effective and exact

and it has no influence on postpartum hemorrhage and

neonatal asphyxia incidence rates and its safety is also

high. Sufentanil belongs to opioid drugs, and its applica-

tion in small amounts can reduce ropivacaine dosage in

order to achieve the purpose of minimal motor block and

no influence on uterine contraction and labor progress.

During delivery, mother and baby are treated as a single

entity. Fetal oxygenation status is not only influenced by

the fetus’ own metabolism, but is also related to maternal

acid-base status and uteroplacental blood flow. Therefore,

blood gas results of mother and baby can accurately reflect

maternal acid-base status and fetal intrauterine anoxia in-

hibition extent. In this study, blood gas analysis result

showed that PO2 of primiparas and neonates in the obser-

vation group were respectively, 105.32 ± 13.45 mmHg and

25.48 ± 3.51 mmHg, and PO2 of primiparas and neonates

in the control group were respectively, 102.38 ± 12.51

mmHg and 24.31 ± 4.53 mmHg; blood gas analysis result

showed that PCO2 of primiparas and neonates in the ob-

servation group were respectively, 30.45 ± 3.51 mmHg and

43.32 ± 2.51 mmHg, and PCO2 of primiparas and

neonates in the control group were respectively, 36.37 ±

3.35 mmHg and 46.21 ± 4.82 mmHg. According to the

aforementioned results, partial pressures of oxygen of

primiparas and neonates of the observation group are

higher than those of the control group, while partial pres-

sures of carbon dioxide primiparas and neonates are lower

than those of the control group. Between the two groups,

there are significant differences. It is suggested that deliv-

ery analgesia cannot only relieve pain, but can also in-

crease vital capacity, improve lung function, and facilitate

fetal oxygen supply. Simultaneously, it can mitigate stress

reaction, avoid neonatal hypoxemia, and acidosis caused

by apnea of gravidas in case of uterine contraction, im-

prove uterine blood flow, and increase PO2 of umbilical

arterial blood, which is useful for both mother and baby.

Bolukbasi et al. [20] also found that self-controlled

epidural delivery analgesia could decrease the stress reac-

tion and oxygen consumption of primiparas and reduce

fetal acidosis incidence rate, by detecting plasma adrena-

line and noradrenaline, blood sugar, and blood gas of um-

bilical arterial blood of primiparas; it is in line with the

viewpoint of this study.

In conclusion, the delivery analgesia method of self-con-

trolled combined spinal epidural anesthesia applying the

mixture solution of low-concentration and low-dose ropi-

vacaine and trace sufentanil plus Doula has a rapid action

and an exact analgesic effect, and it is also easily adminis-

tered. It can meet the analgesic requirements of the entire

labor process, and greatly mitigate related delivery pain. In

addition, its influence on mother and baby is small, and its

safety is high, therefore, it is easy for primiparas to accept

it. As a result, it reduces the cesarean section rate caused

due to the “social factor” fear to pain, saves medical costs,

and avoids medical risks.

References

[1] Sharma S.K., McIntire D.D., Wiley J., Leveno K.J.: “Labor analge-

sia and cesarean delivery”. Anesthesiology, 2004, 100, 142.

[2] Lumbiganon P., Laopaiboon M., Gulmezoglu A.M., Souza J.P., Ta-

neepanichskul S., Ruyan P. et al.: “Method of delivery and preg-

nancy outcomes in Asia: the WHO global survey on maternal and

perinatal health 2007-08”. Lancet, 2010, 375, 490.

[3] Zi T.F., Xue L.G., Hui X.Y.: “Popularizing labor analgesia in China”.

Int. J. Gynecol. Obstet., 2007, 98, 205.

[4] Patrick D.W., Ronald M.: “Textbook of Pain”. New York: Chruchill

Livingstone, 1985, 377.

[5] Leong W.L., Sng B.L., Sia A.T.: “A comparison between remifen-

tanil and meperidine for labor analgesia: a systematic review”.

Anesth. Analg., 2011, 13, 818.

[6] Capogna G., Camorcia M., Stirparo S.: “Expectant fathers’ experi-

ence during labor with or without epidural analgesia”. Int. J. Obstet.Anesth., 2007, 16, 110.

[7] Cynthia A., Wong M.D.: “Labor analgesia: is there an ideal tech-

nique?”. Anesth. Analg., 2009, 109, 296.

[8] Gormar C., Fernandez C.: “Epidural analgesia-anaesthesia in ob-

stetrics”. Eur. J. Anaesth., 2000, 17, 542.

[9] Yaakov B., Stephen H.: “Ropivacaine versus bupivacaine for

epidural labor analgesia”. Anesth. Analg., 2010, 111, 482.

[10] Atie M.C., Palanca J.M., Torres F., Borràs R., Gil S., Esteve I.: “A

randomized comparison of levobupivacaine, bupivacaine and ropi-

vacaine with fentanyl for labor analgesia”. Int. J. Obstet. Anesth.,2008, 17, 106.

[11] Cappiello E., O’Rourke N., Segal S., Tsen L.C.: “A randomized trial of

dural puncture epidural technique compared with the standard epidural

technique for labor analgesia”. Anesth. Analg., 2008, 107, 1646.

[12] Wong C.A., Scavone B.M., Slavenas J.P., Vidovich M.I., Peaceman

A.M., Ganchiff J.N.: “Efficacy and side effect profile of varying

doses of intrathecal fentanyl added to bupivacaine for labor analge-

sia”. Int. J. Obstet. Anesth., 2004, 13, 19.

[13] Zhang J., Yancey M.K., Klebanoff M.A., Schwarz J., Schweitzer D.:

“Does epidural analgesia prolong labor and increase risk of cesarean de-

livery? A natural experiment”. Am. J. Obstet. Gynecol., 2001, 185, 128.

[14] Halpern S.H., Breen T.W., Campbell D.C., Muir H.A., Kronberg J.,

Nunn R. et al.: “A Multicenter, randomized, controlled trial com-

paring bupivacaine with ropivacaine for labor analgesia”. Anesthe-siology, 2003, 98, 1431.

[15] Wong C.A., Ratliff J.T., Sullivan J.T., Scavone B.M., Toledo P., Mc-

Carthy R.J.: “A randomized comparison of programmed intermittent

epidural bolus with continuous epidural infusion for labor analge-

sia”. Anesth. Analg., 2006, 102, 904.

[16] Calimaran A.L., Strauss-Hoder T.P., Wang W.Y., McCarthy R.J.,

Wong C.A.: “The effect of epidural test dose on motor function after

a combined spinal-epidural technique for labor analgesia”. Anesth.Analg., 2003, 96, 1167.

[17] Handelzalts J.E., Fisher S., Lurie S., Shalev A., Golan A., Sadan O.:

“Personality, fear of childbirth and cesarean delivery on demand”.

Acta Obstet. Gynecol. Scandinavica, 2012, 91, 16.

[18] Lee B.B., Ngan Kee W.D., Ng F.F., Lau T.K., Wong E.L.: “Epidural

infusions of ropivacaine and bupivacaine for labor analgesia: a ran-

domized, double-blind study of obstetric outcome”. Anesth. Analg.,

2004, 98, 1145.

[19] Grondin L.S., Nelson K., Ross V., Aponte O., Lee S., Pan P.H.: “Suc-

cess of spinal and epidural labor analgesia”. Anesthesiology, 2009,

111, 165.

[20] Bolukbasi D., Sener E.B., Sarihasan B., Kocamanoglu S., Tur A.:

“Comparison of maternal and neonatal outcomes with epidural bupi-

vacaine plus fentanyl and ropivacaine plus fentanyl for labor anal-

gesia”. Int. J. Obstet. Anesth., 2005, 14, 288.


B.B. FENG, M.D.


Beijing Tongren Hospital of

Capital Medical University

Beijing 100730 (China)


Investigation on delivery analgesia effect of combined spinal epidural anesthesia plus Doula and safety of mother and baby578

579

Introduction

Vaginal packing with gauze is commonly used in

vaginal surgery for different conditions. This type of tam-

ponade is performed with the aim to stop venous bleeding

of the dissected vaginal tissue and to avoid subsequent

bleeding and haematomas formation. In most cases, the

tamponade is removed after 24 hours [1-3].

However, the long gauze used for this procedure may

absorb blood and conceal considerable blood loss. More-

over retaining and removal of vaginal gauze is not com-

fortable for the patient.

The authors describe their experience with balloon tam-

ponade after vaginal surgery in 85 consecutive cases using

a new tamponade system, Vagistop, a balloon specifically

created for vaginal distension and inspection (Figure 1).

This preliminary experience has encouraged the authors to

use Vagistop for severe vaginal obstetric haemorrhages

[4].


Vaginal balloon tamponade with Vagistop was used at the end

of vaginal surgery in 80 consecutive cases of planned vaginal

surgery and in five cases of emergency vaginal surgery (Table

1), from January 2011 to June 2012. The 80 planned cases

underwent vaginal surgery for prolapse, in most cases with asso-

ciated hysterectomy.

At the end of surgical procedure, Vagistop was applied. The

device is made of a flexible tube with a balloon tip, connected

to a syringe through a valve that allows inflating the balloon

continuously, without pulling out the syringe. The balloon is

inserted until the posterior vaginal fornix or cuff. After insertion

the balloon is inflated with air using a 20-ml syringe connected

to the inflation tube through the valve (Figure 1) until the whole

vaginal space is occupied (Figure 2); at this point the balloon

internal pressure is about 50 mmHg, greater than the venous pres-

sure in the pelvis. The material of the surface of the balloon is a

polymer that allows the device to adhere to the vaginal walls. The

total capacity of the balloon is 250 ml. The air volume used

ranged from 180 to 40 ml, with an average of 90 ml.

Results

The balloon was deflated and removed 24 hours later.

In ten cases Vagistop was expelled spontaneously between

two and six hours after surgery. Expulsion occurred in all

cases with severe postoperative vomiting.

In all cases the nurse easily removed Vagistop. None of

the patients complained of discomfort (VAS score 0/10).

No bleeding occurred in any of the cases.

Discussion

Vaginal tamponade with gauze is a commonly used pro-

cedure at the end of different vaginal surgical procedures

[1-3]. The aim is to avoid bleeding and haematomas

caused by venous bleeding of the dissected vaginal tissue.

Gauze packing is however a matter of discomfort for the

woman and may absorb a lot of blood before evidence of

persisting bleeding is recognized.

As far as the authors know, only one case of balloon

tamponade for vaginal hemorrhage in gynecology has

been published [5]. The authors’ previous positive experi-

ence in obstetrics with vaginal balloon tamponade with

Vagistop [4] led them to apply Vagistop in substitution of

gauze packing in vaginal surgery. Simple and rapid appli-

cation and removal, both in planned and in emergency

surgeries (without use of anaesthesia), compliance of the

patients, as well as optimal adhesion to vaginal walls, are

the main advantages of Vagistop in comparison with

gauze packing.

Balloon tamponade for prevention and treatment

of vaginal hemorrhages in gynecology

G. Ghirardini, C. Alboni

Obstetrics and Gynecology Unit, New Civil Hospital, Sassuolo (MO) (Italy)

Summary

The preliminary experience of balloon tamponade in planned vaginal surgery and in emergency vaginal bleeding using a new device

(Vagistop) is reported. The results shows the advantages of the system in comparison with vaginal gauze packing.

Key words: Vaginal surgery; Vaginal balloon tamponade; Vagistop.

Table 1. — Cases with emergency vaginal balloon tamponade.Case Type of problem Volume Time in Result

no. used place (hours)

1 Laparotomy for retroperitoneal mass 180 24 good

2 Bleeding after Bartholin’s cyst removal 140 24 good

3 Bleeding after vaginal cyst removal 140 24 good

4 Hemorrhage 3 days after vaginal cyst removal 140 24 good

5 Hemorrhage 2 days after conization 140 24 good



XXXIX, n. 2, 2012

Conclusions

The results obtained in this preliminary case justify the

use of vaginal balloon tamponade to prevent and treat

vaginal bleeding and haematomas in vaginal surgery, as

well as in an emergency setting.

References

[1] Rock J.A., Jones H.W. III (eds.): Te Linde’s operative gynecology,

10th ed., Philadelphia, Lippincott, 2008.

[2] Reiffenstuhl G., Platzer W., Knapstein P.: “Die vaginalen Operatio-

nen: chirurgische Anatomie und Operationslehre”. Urban

Schwarzenberg, München, 1994.

[3] Webb M.J. (ed.): Mayo Clinic Manual of Pelvic Surgery, 2nd ed.

Philadelphia, Lippincott, 2000.

[4] Ghirardini G., Alboni C., Mabrouk M.: “Use of balloon tamponade

in management severe postpartum hemorrhage and vaginal

hematoma: a case series”. Gynecol. Obstet, Invest., 2012, 74, 320.

doi: 10.1159/000339931. Epub 2012 Aug 16.

[5] Schlicher N.R.: “Balloon compression as treatment for refractory

vaginal hemorrhage”. Ann. Emerg. Med., 2008, 52, 148.


G. GHIRARDINI, M.D.

New Civil Hospital

Via Ruini 2, I

41047 Sassuolo, MO (Italy)


G. Ghirardini, C. Alboni580

Figure 1. — Vagistop.

Figure 2. — Vagistop after application.

Fig. 1 Fig. 2

581

Introduction

Pregnancy and the transition to parenthood involve

major biological and psychosocial changes [1]. These

changes have been linked to an increase in anxiety symp-

toms (AS), depression symptoms (DS), worry, and stress

[2]. World Health Organization (WHO) estimates that

depressive disorders will be the second leading cause of

global disease burden by 2020 [3]. Postnatal depression

shares similar prevalence ratings to those of depression in

the general population, ranging from 12%-20%, with a

commonly-reported estimate of 13% [4]. Although many

studies have examined the prevalence and risk factors of

postnatal depression, only a few studies have explored the

prevalence of DS, and even fewer studies have addressed

the prevalence of AS in pregnancy. A meta-analysis of 21

studies on depression during pregnancy indicated that the

prevalence of antenatal depression (AD) was approxi-

mately 10.7%, ranging from 7.4% in the first trimester to

12.8% in the second trimester [5]. However, the rate of

AD in individual studies ranges from 4.8% up to 40% [4,

6-12]. Moreover, the incidence rate of anxiety during

pregnancy has been reported to range between 6.8% and

59.5% [4, 6, 9, 12, 13]. It is noteworthy that the estima-

tion of the incidence of stress and worries during preg-

nancy has been a relatively neglected area of research.

Anxiety, depression, and other stressful feelings during

prenatal period can easily lead to more severe diseases,

which may be harmful to the mother, fetus, and the expec-

tant newborn’s health [6]. Anxiety and depression during

pregnancy have been associated with prematurity, low

birth weight, and fetal growth retardation [14-16], obstet-

ric complications, increased nausea and vomiting, planned

cesarean delivery [17], postpartum depression [4], and may

have a negative impact on child development [18]. There-

fore, it is essential to investigate the prevalence of anxiety,

stress, and depression of the pregnant women in order to

implement interventions to reduce adverse pregnancy out-

comes. The current literature suggests that low income and

unemployment are major risk factors of antenatal anxiety

and depression [4, 9, 10]. Therefore, the prevalence of ante-

natal anxiety, stress, and depression in a country with a

major financial crisis and high unemployment rates as in

Greece would be worthy of attention.


Sample and data collectionThe study was conducted in one of the largest hospitals in

Athens, Greece to achieve a representative database. The ques-

tionnaire was administered to a sample of 163 pregnant women

with a gestational age of between 11 and 26 weeks, who were

booked for antenatal screening in the antenatal clinic of a public

hospital of Athens. Following ultrasound scanning, a midwife of

this research team contacted the eligible women. The pregnant

women were informed of the study aim and protocol, and once

they voluntarily agreed to participate, they were given an enve-

lope containing the questionnaires and an informed consent

form. The completed questionnaires and the signed consent form

were returned directly or by mail to the researcher (within two

to three weeks).

Study instrumentsWorries during pregnancy were measured with the Cambridge

Worry Scale (CWS) developed by Green et al., in 2003 [19]. The

CWS contains items concerning worries during pregnancy, such

as the baby's health, financial issues, and giving birth. Each item

is scored on a six-point Likert-type scale ranging from not aworry (0) to major worry (5). The CWS scale can be used

throughout pregnancy. Depending on the pregnancy week, addi-

tional context-specific items can be added or removed as appro-

Prevalence of women’s worries, anxiety, and depression

during pregnancy in a public hospital setting in Greece

K. Gourounti1, F. Anagnostopoulos2, K. Lykeridou1, F. Griva2, G. Vaslamatzis3

1Department of Midwifery, TEI of Athens, Athens; 2Department of Psychology, Panteion University, Athens3Department of Psychiatry, Athens University, Medical School, Eginitio Hospital, Athens (Greece)

Summary

Many studies have examined the prevalence and risk factors of postnatal depression. However, only a few studies have explored the

prevalence of anxiety and depressive symptoms in pregnancy. The aim of this study was to investigate the prevalence of worries, ante-

natal anxiety (AA), and antenatal depression (AD). The sample of this study consisted of 163 pregnant women with gestational age from

11 to 26 weeks. Worries were measured with Cambridge Worry Scale (CWS), anxiety was measured with State-Trait Anxiety Inven-

tory (STAI), and depression was measured with Center for Epidemiologic Studies-Depression scale (CES-D). Depressive symptoms were

found in 32.7% of the participants and 44.4% had STAI scores indicating anxiety symptoms of clinical significance. The mean score

for total CWS was 26 (SD = 12.3). It is noteworthy that the most important worries in the study sample were “the possibility of some-

thing going wrong with the baby”, “giving birth”, and “financial problems”. The prevalence of antenatal anxiety and depression iden-

tified in this study is of concern. Screening for antenatal anxiety and depressive symptoms with validated instruments is crucial.

Key words: Anxiety; Depression; Worries; Pregnancy; Prevalence.



XXXIX, n. 2, 2012

priate. The CWS used in this study comprised of 16 items, which

allowed a total sum score that ranged from 0 to 80 to be calcu-

lated. According to the instrument developers and the Greek val-

idation outcome, the CWS has a four-factor structure: (1) socio-

medical aspects of having a baby: giving birth, going to hospital,

internal examinations, and coping with the new baby, (2) socio-

economic issues: money, employment problems, housing, and

the law, (3) health of mother and baby: miscarriage, something

going wrong with the baby, and own health, and (4) relationships

with partner, family, and friends. A higher score reflects higher

worries. The CWS was adapted to the Greek language and has

been found to have satisfactory psychometric properties (e.g.,

construct validity).

State and trait anxiety was measured with the State Trait

Anxiety Inventory (STAI) [20]. State anxiety is defined as an

unpleasant emotional condition that emerges in case of threaten-

ing demands or dangers. Therefore, it should be low in non-stress-

ful situations and high if circumstances are perceived to be threat-

ening or dangerous. The state scale consists of 20 items that ask

people to describe how they feel at a particular moment in time,

rated on a four-point scale ranging from not at all (1) to very much

so (4). The trait scale consists of 20 items and asks people to

describe how they generally feel (e.g., confident), rated on a four-

point frequency scale ranging from (1) almost never to (4) almostalways. Total scores for state and trait anxiety range from 20 to

80. The STAI was adapted to the Greek language and has been

found to have satisfactory psychometric properties [21]. A cut-off

score of 43 or was used in this study as a point indicating high-

state anxiety [22]. Cronbach’s alpha of 0.84 (state) and 0.87 (trait)

were obtained in the present study.

The Center for Epidemiologic Studies-Depression scale

(CES-D) was used to assess depression symptoms of the study

population [23]. CES-D is a self-reporting 20-item scale that

covers affective, behavioural, and somatic symptoms experi-

enced during the past week. Responses to item statements are

graded from 0 (rarely or none of the time) to 3 (most or all of

the time). Four items are reverse-scored items. Scores for each

item in the CES-D scale are summed to obtain an overall score.

The overall score ranges from 0 to 60, where the higher the

score, the more frequent the depressive symptoms. A cut-off

score of 16 or higher was used in this study as that point indica-

tive of significant or mild depressive symptomatology in many

studies addressing depression during pregnancy [24, 25]. The

CES-D was adapted to the Greek language and has been found

to have satisfactory psychometric properties [26]. A Cronbach’s

alpha of 0.86 was obtained in this study.

Basic demographic and medical information included: age,

gestational age, parity, previous miscarriages, previous deliv-

eries, complications during previous pregnancy and labour,

previous infertility problems, marital status, educational level,

economic level, and employment status. The educational level

was categorized as low (up through elementary school),

medium (high school certificate) or high (university degree).

The annual income level was categorized as low (€ 9,600-

17,999 or USD 13.300-25.000), medium (€ 18,000-35,999 or

USD 25.001-50.170) or high (> € 36,000 or > USD 50.171)

[27].

Statistical analysisStatistical analysis was performed using SPSS version 17.0.

Descriptive statistics, such as means, standard deviations, and fre-

quencies, were used to represent the demographic characteristics

of the participants. Mean values and standard deviations of the

total sum scores of the CWS, STAI, and CES-D, were also calcu-

lated; p values less than 0.05 were considered significant.

EthicsThe Research and Ethics Committee of the Elena Benizelou hos-

pital, approved this study protocol. All participants in this study

were informed about the scope and the purpose of the study. Eligi-

ble women were also assured that the collected data would be used

only for the purpose of the study, and that their decision to withdraw

would not compromise the standard of the received care. A signed

informed consent was obtained from all study participants.

Results

Characteristics of participantsThe mean age of participants was 31.2 years (SD 4.2

and range 22-44). Sixty-two percent had education

beyond high school and 37% had high school, and one

percent had less than a high school education. Eighty

percent of women participated in the work-force and 96%

were married. For 46% of the sample, this was their first

pregnancy, 36% had already a child, 22% of the women

had experienced previous miscarriages, and 12% of the

participants had experienced a complication during previ-

ous pregnancy or previous labour.

Prevalence of antepartum anxiety and depressive symptomsThe means for STAI-state and trait scores were 41.5

(SD = 8.4) and 39.7 (SD = 8.3), respectively. The mean

score for CES-D was 13.4 (SD = 9.2). Of the 163 partic-

ipants assessed at the first and second trimesters of the

pregnancy, 32.7% had CES-D scores ≥ 16, indicating

depressive symptoms, and 44.4% had state anxiety scores

≥ 43, indicating anxiety symptoms. Specifically, 34.4% of

participants with gestational age between 11 and 14 weeks

had a CES-D score ≥ 16 and 46.9% of participants with

gestational age between 11 and 14 weeks had STAI-state

score ≥ 43. Moreover, 32.3% of participants with gesta-

tional age between 15 and 26 weeks had a CES-D score ≥

16 and 43.8% of participants with gestational age between

15 and 26 weeks had STAI-state score ≥ 43.

Prevalence of antepartum worries The mean score for total CWS was 26 (SD = 12.3). It is

noteworthy that the most important worries in the sample

were the “possibility of something going wrong with the

baby”, “giving birth”, and “financial problems”.

Discussion

According to the authors’ knowledge, this is the first

study that reports on the incidence of anxiety, depression,

and worries in a sample of pregnant women admitted to a

Greek public hospital. The main findings of this study

suggest that AD occurs in one-third of pregnant women

and AA in almost half of pregnant women. The rate of

anxiety is in agreement with previous reports from both

high-income [4, 12] and low-income countries [13]. Nev-

ertheless, the rate of depression in this study was higher

than those reported in countries such as USA [28], Sweden

[27], Australia [4], Hungary [9], and China [6]. The high

prevalence of depressive symptomatology in this study

could be attributed to special socio-economic circum-

K. Gourounti, F. Anagnostopoulos, K. Lykeridou, F. Griva, G. Vaslamatzis582

Prevalence of women’s worries, anxiety, and depression during pregnancy in a public hospital setting in Greece 583

stances, such as financial crisis and high rates of unem-

ployment. In addition to that, the direct association

between poverty and depression is well-documented in

high-income countries [4, 9]. Moreover, the worries

related to the financial problems, ranked third in this study,

whereas in previous relevant studies it did not rank top

[29-31]. Therefore, financial issues may have caused sig-

nificant worries among Greek pregnant women.

Conclusion

According to the findings of this study, about 50% of

pregnant women experience anxiety symptoms and 30%

experience antenatal depression, that not only had delete-

rious effects on the woman but also on her baby. The

prevalence of antenatal anxiety and depression identified

in this study is of concern. Midwives and healthcare pro-

fessionals, who recognise the signs and symptoms of ante-

natal depression and anxiety, and the risk factors associ-

ated with these disorders, can help to identify and prevent

them. The signs and symptoms of depression in pregnancy

do not differ from depression at any other time. However,

antenatal depression may go undiagnosed because the

depressive symptoms could be considered complaints of

pregnancy and could be attributed to the physical and hor-

monal changes associated with pregnancy [32]. Therefore,

screening for antenatal anxiety and depressive symptoms

with validated instruments is crucial.

Acknowledgment

This study was partly funded by the Hellenic Institute for Mental

Health and the Therapy and Research of Personality Disorders.

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tal depression and parenting stress”. BMC Psychiatry, 2008, 8, 24.

[5] Bennett H.A., Einarson A., Taddio A., Koren G., Einarson T.R.:

“Prevalence of depression during pregnancy: systematic review”.

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[6] Qiao Y.X., Wang J., Ablat A.: “The prevalence and related risk factors

of anxiety and depression symptoms among Chinese pregnant women

in Shanghai”. Austr. New Zeal J. Obstet. Gynaecol., 2009, 49, 185.

[7] Melville J., Gavin A., Guo Y., Fan M.Y., Katon W.: “Depressive

disorders during pregnancy: prevalence and risk factors in a large

urban sample”. Obstet. Gynecol., 2010, 116, 1064.

[8] Mohammad K., Gamble J., Creedy D.: “Prevalence and factors

associated with the development of antenatal and postnatal depres-

sion among Jordanian women”. Midwifery, 2011, 27, 238.

[9] Bodecs T., Horvath B., Kovacs L., Diffelne Nemeth M., Sandor J.:

“Prevalence of depression and anxiety on a population based Hun-

garian sample”. Orv. Hetil., 2009, 150, 1888.

[10] Faisal-Cury A., Savoia M., Menezes P.: “Coping style and depres-

sive symptomatology during pregnancy in a private setting

sample”. Span. J. Psychol., 2012, 15, 295.

[11] Kaaya S., Mbwambo J., Kilonzo G., Van Den Borne H., Leshabari M.,

Fawzi M., Schaalma H.: “Socio-economic and partner relationship factors

associated with antenatal depressive morbidity among pregnant women in

Dar es Salaam, Tanzania”. Tanzan J. Health Res., 2010, 12, 23.

[12] Lee A.M., Chong C.S.Y., Chiu H.W., Lam S.K., Fong D.Y.T.:

“Prevalence, course, and risk factors for antenatal anxiety and

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[13] Faisal-Cury A., Menezes R.: “Prevalence of anxiety and depression

during pregnancy in a private setting sample”. Arch. Womens MentHealth, 2007, 10, 25.

[14] Rondó P.H., Ferreira R.F., Nogueira F., Ribeiro M.C., Lobert H.,

Artes R.: “Maternal psychological stress and distress as predictors

of low birth weight, prematurity and intrauterine growth retarda-

tion”. Eur. J. Clin. Nutr., 2003, 57, 266.

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Kuhn C., Gonzalez-Quintero V.: “Prenatal depression effects on the

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[17] Anderson L., Sundstrom-Poromma I., Wuff M., Astrom M., Bixo

M.: “Implications of antenatal depression and anxiety for obstetric

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[18] Huizink A.C., Mulder E.J.H., Robels de Medina P., Visser G.,

Buitelaar J.: “Is pregnancy anxiety a distinctive syndrome?”. EarlyHum. Dev., 2004, 79, 81.

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[22] Anagnostopoulou T., Kioseoglou G.: “Spielberger anxiety ques-

tionnaire (state-trait anxiety inventory)”. In: Stalikas A., Triliva S.,

Roussi P. (Ed) The psychometric tools in Greece. Greek Letters

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[23] Radloff L.: “The CES-D Scale: a self report depression scale for rese-arch

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Phillips D. et al.: “Length of gestation and depressive symptoms at

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[27] Hellenic Statistical Authority. 2006, Annual income for Greek popula-

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SJO46_TB_4Y_00_2006_03_F_GR.pdf

[28] Josefsson A., Berg G., Nordin C., Sydsjö G.: “Prevalence of

depressive symptoms in late pregnancy and postpartum”. ActaObstet. Gynecol. Scand., 2001, 80, 251.

[29] Georgsson Öhman S., Grunewald C., Waldenstrom U.: “Women’s

worries during pregnancy: testing the Cambridge Worry Scale on

200 Swedish women”. Scand. J. Caring. Sci., 2003, 17, 148.

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of the Cambridge Worry Scale”. BMC Public Health, 2009, 9, 490.

[31] Carmona Monge F., Penacoda-Puente C., Morales Martin D., Abellan

Carretero I.: “Factor structure, validity and reliability of the Spanish

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[32] Bowen A., Muhajarine N.: “Antenatal depression”. Can Nurse,2006, 102, 26.


K. GOUROUNTI, PhD.

Department of Midwifery, TEI of Athens,

Agnoston Martiron 33-37

Nea Smirni, 17123 Athens (Greece)


Introduction

Newborn clavicle fracture is a typical kind of birth injury

in obstetrics [1]. The injuries cause severe psychological

pressure on the parents and midwives of the newborns al-

though it includes simple therapy and good prognosis. It is

critical to reduce the incidence and carry out early diagno-

sis and treatment [2]. Six patients in 4,456 infants born

through vaginal delivery were found clavicle-fractured in

our hospital from October 2002 to October 2011.


A total of 4,456 fetuses weighing from 1,900 g to 4,350 g

underwent vaginal delivery from October 2002 to October 2011

in our department, including 422 cases of multipara, 4,034 cases

of primipara, 367 cases by forceps delivery, 248 cases with

shoulder dystocia, and 61 cases with nuchal cord around neck.

Six fetuses suffered from neonatal clavicular fractures at gesta-

tional age of 38-40 weeks, weighing from 3,450 g to 3,850 g,

total laboring time four to 19 hours, and second stage of labor

time 30 min to 1.5 hours. Out of these six, three had shoulder

dystocia and three cases had forceps application together with

Kristeller maneuver, while in five cases the fracture was in the

distal third of the clavicle.

The injured babies cried, especially when the affected upper arm

was moved. The injured upper arm was limited in movement, had

local swelling, extravasated blood, bony crepitus, and reduced or

disappeared embrace reflex in the ipsilateral clavicle. The earliest

fracture time in one case was at delivery (fractural sound heard at

shoulder delivery during labor). Other five cases were found at

routine clavicle palpation within 24 hours and confirmed by X-ray.

The confirmed injured babies were set in supine position with

chest expanded to mitigate the affected upper limb movements. In

one case, an eight-style bandage was used for fracture dislocation.

The fractured site was X-rayed and was well-reduced after the

bandage was removed after two weeks. The remaining patients

were not specially fixed. All patients were discharged together

with their mothers.

Results

Callus growth was found in the fractured ends through

X-ray examination at three weeks postpartum and all had

healed at six weeks postpartum as confirmed during the

normally scheduled follow-up visits. All patients were

discharged with their mothers at the same time. Before

leaving the hospital, individualized breastfeeding,

bathing, and nursing education were performed. The

follow-up contact cards were established to contact

patients and encourage them for re-examination in the

hospital. The follow-up visits were scheduled in four to

six weeks in order to assess the healing conditions of the

fractured limbs.

Discussion

Neonatal clavicular fracture is associated to the laboring

manner, vaginal dystocia, fetal weight, and midwifery tech-

nique [3]. The fracture rate over vaginal dystocia is signif-

icantly higher than vaginal delivery and cesarean operation

[4]. Five cases of this group occurred over vaginal dystocia.

Therefore, dystocia is a fundamental factor in birth trauma

that is elicited by mechanical factors. Midwifery maneu-

vers are thus one of the vital causes for the injuries [5]. Pro-

viding that the posterior shoulder is raised prematurely

when the anterior shoulder is not adequately delivered, the

clavicle of the anterior shoulder is bound to press below the

pubic arch causing the clavicle to fracture due to excessive

forces [6]. Persistent occipitotransverse position or occipi-

toposterior position, fetal excessive weight (> 3,500 g),

oversized fetal shoulder circumference, and premature up-

lift of posterior shoulder when the anterior shoulder is not

adequately delivered, will lead to fracture through exces-

sive pressure of anterior shoulder on the clavicle [7].

It is critical to avoid and prevent neonatal clavicular frac-

ture by controlling the delivery for cephalic presentation

and abnormal fetal position, properly treating shoulder dys-

tocia against violent traction, and constantly improving the

584



XXXIX, n. 2, 2012

Preventive nursing of neonatal clavicular fracture in

midwifery: a report of six cases and review of the literature

Y. Xiang1, D. Luo2, P. Mao1

1Department of Obstetrics and Gynecology, the Third Xiangya Hospital, Central South University, Changsha2School of Public Health, Central South University, Changsha (China)

Summary

Purpose: To summarize and analyze the obstetric factors and medical care for neonatal clavicle fracture during delivery. Materialsand Methods: In 4,456 vaginal deliveries, only six newborns were found with a clavicle fracture in our hospital from October 2002 to

October 2011. Results: Clinical findings showed that dystocia and improper midwifery manoeuvres are the two major reasons which

lead to newborn clavicular fractures. Conclusion: More attention should be paid to non-violent traction and proper treatment of shoul-

der dystocia.

Key words: Midwifery; Newborn; Clavicle fracture; Nursing.

Y. Xiang, D. Luo, P. Mao 585

childbirth technique [8]. In the event of shoulder dystocia,

the McRobert method is immediately adopted. Three cases

of neonatal clavicular fracture associated to improper mid-

wifery way occurred in 74 cases of shoulder dystocia. Ob-

stetricians should keep vigilant over this [9].

It is important to timely identify the neonatal clavicular

fracture through careful examination. In the event of neona-

tal clavicular fracture, psychological care and health edu-

cation should be enhanced for parents in order to establish

a good nurse-patient relationship, to reduce or prevent com-

plications, as well as to avoid medical disputes [10]. Five

cases in the group with neonatal clavicular fractures were

found by the nurses through conventional clavicle palpa-

tion within 24 hours after childbirth, and they underwent

X-rays, orthopedic consultation, and immediate care. The

affected limb was immobilized to ensure healing during

breastfeeding and bathing. A good social supportive sys-

tem is created to allow the parents to care for the newborns

with scientific approaches, to benefit the affected limb re-

covery, shorten the disease course, and reduce or protect

the complications. Detailed discharge guidance and regular

follow-up visits are conducive to the healing of the fracture

and improve the doctor-patient relationship to reduce med-

ical disputes.

Conclusion

Generally bone remodelling will complete within six to

12 months in good condition and even recover its normal

aspect, along with the stress change in limb in severe short-

ened angular deformed callus without any future sequelae

or repercussions.

References

[1] Parker L.A.: “Part 2: Birth trauma: injuries to the intraabdominal or-

gans, peripheral nerves, and skeletal system”. Adv. Neonatal Care,2006, 6, 7.

[2] Mavrogenis A.F., Mitsiokapa E.A., Kanellopoulos A.D., Ruggieri P.,

Papagelopoulos P.J.: “Birth fracture of the clavicle”. Adv. NeonatalCare, 2011, 11 328.

[3] Gilbert W.M., Tchabo J.G.: “Fractured clavicle in newborns”. Int.Surg., 1988, 73, 123.

[4] Jeray K.J.: “Acute midshaft clavicular fracture”. J. Am. Acad. Or-thop. Surg., 2007, 15, 239. Review. Erratum in: J. Am. Acad. Orthop.Surg., 2007, 15, 26A.

[5] Shannon E.G., Hart E.S., Grottkau B.E.: “Clavicle fractures in chil-

dren: the essentials”. Orthop. Nurs., 2009, 28, 210.

[6] Hsu T.Y., Hung F.C., Lu Y.J., Ou C.Y., Roan C.J., Kung F.T. et al.:“Neonatal clavicular fracture: clinical analysis of incidence, predis-

posing factors, diagnosis, and outcome”. Am. J. Perinatol., 2002, 19,17.

[7] Kuo Y.H.: “Reappraisal of neonatal clavicular fracture: relationship

between infant size and neonatal mortality”. Obstet. Gynecol. 2003,

101, 202.

[8] Nield L.S., Kamat D.: “Refracture of the clavicle in an infant: case

report and review of clavicle fractures in children”. Clin. Pediatr.(Phila), 2005, 44, 77.

[9] Camune B., Brucker M.C.: “An overview of shoulder dystocia: the

nurse’s role”. Nurs. Womens Health., 2007, 11, 488.

[10] Lam M.H., Wong G.Y., Lao T.T.: “Reappraisal of neonatal clavicu-

lar fracture: relationship between infant size and neonatal morbid-

ity”. Obstet. Gynecol., 2002, 100, 115.


P. MAO, M.D.


Third Xiangya Hospital

Central South University

Changsha, 410013 Hunan (China)


Introduction

Uterine prolapse is one of the most common types in

pelvic organ prolapse (POP), and its exact etiology is still

unknown. The researches showed that the abnormal colla-

gen metabolism in pelvic floor fascia connective tissue was

the key of uterine prolapse; matrix metalloproteinases

(MMPs) was involved in the occurrence and development

of POP through regulating the collagen catabolism [1-6].

Recent researches showed that transforming growth factor-

β1 (TGF-β1)-connective tissue growth factor (CTGF) path-

way regulated the collagen metabolism; however, the

function in uterine prolapse is still unknown [7-10].

Multiple studies have shown that superoxide dismutase

(SOD), glutathione peroxidase (GPx), and catalase (CAT)

constitute the antioxidation defense system of organisms,

the decrease of the antioxygenic enzymes activity up-reg-

ulate the oxidative stress in cells, then affect the activity

of collagen metabolism enzymes, such as MMPs and tis-

sue inhibitor of metalloproteinases (TIMPs). One study

found that the concentration of selenium and GPx was

lower in camel with uterine prolapse than in normal camel

[11]. Choy et al. found that the level of isoprostane in-

creased in the cardinal ligament and urine of patients with

POP, which suggested that oxidative stress might be one

etiology of POP [12]. In addition, research findings re-

ported that the level of plasma selenium and GPx was

lower in camel with uterine prolapse than that in the nor-

mal camel.

So, the authors hypothesized that the decrease of GPx ac-

tivity in pelvic floor fascia tissue would reduce the an-

tioxygen stress ability. It may be the important reason why

the oxidative stress increases in pelvic floor tissue and GPx

activity was closely related with TGF-β1-CTGF regulating

pathway.


Materials included: rabbit anti-human GPx1 polyclonal anti-

body, rabbit anti-human TGF-β1, CTGF polyclonal antibody,

horseradish peroxidase labelled goat anti-rabbit polyclonal anti-

body, DBA, and an SP Kit.

Samples: approximately 100 mg of tissue sample was

obtained with a sample intraoperatively from the pubocervical

fascia tissue from each patient.

Methods: samples of the cervical fascia tissue were collected

from 50 women undergoing vaginal hysterectomy at the present

hospital from September 2010 to June 2011. Thirty of the

patients with POP studied were placed into Group 1 (n = 10),

Group 2 (n = 10), and Group 3 (n = 10), according to Pelvic

Organ Prolapse Quantification (POP-Q). POP-Q II is group 1,

POP-Q III is group 2, and POP-Q IV is group 3. Twenty cases

with other benign gynecological disease were selected as the

control group.

Control and prolapse subjects who were smokers or had con-

comitant malignant pelvic diseases or had been receiving local

or systemic hormone replacement therapy, under anti-inflamma-

586

The expression of glutathione peroxidase-1 and the anabolism

of collagen regulation pathway transforming growth factor-

β1-connective tissue growth factor in women with uterine

prolapse and the clinic significance

B.S. Li, L. Hong, J. Min, D.B. Wu, M. Hu, W.J. Guo

Department of Obstetrics and Gynecology, Renmin Hospital, Wuhan University, Wuhan (China)

Summary

Objectives: To investigate the expression of the anabolism of collagen regulation pathways connective tissue growth factor (CTGF) -

transforming growth factor-beta1 (TGF-β1) and glutathione peroxidase-1 (GPx1) in women with uterine prolapse and a study of the

clinic significance. Materials and Methods: The expression of TGF-β1, CTGF, and GPx1 was detected by immunohistochemical stain-

ing in pubocervical fascia tissue of 30 women with uterine prolapse, including ten cases of POP-QII, ten cases of POP-QΙΙΙ, ten cases of

POP-QIV, and 20 cases were control group with non-prolapse and non-malignant lesions. Results: There was a negative correlation be-

tween the POP-Q and expression of TGF-β1. With the increase of POP-Q degree, the expression degree of TGF-β1 decreased corre-

spondingly, which also applied to CTGF and GPx1. On the other hand, there was a positive correlation between TGF-β1 and CTGF. The

synergistic change trend was found between TGF-β1 and CTGF. It could also be seen between CTGF and GPx1 and betweenTGF-β1 and

GPx1. Conclusion: The expression of the antioxidase GPx1 in pelvic support structure of POP women was decreased, which resulted in

the antioxidation reduced. It could break the balance of oxidation and antioxidation in pelvic support structure, and may induce an increase

of ROS level and the down-regulation of TGF-β1-CTGF pathway. It could inhibit the anabolism of collagen and injury the pelvic sup-

port structure, thus promoting the occurrence and development of POP.

Key words: Uterine prolapse; TGF-β1; CTGF; GPx1.



XXXIX, n. 2, 2012

B.S. Li, L. Hong, J. Min, D.B. Wu, M. Hu, W.J. Guo 587

tory or steroid medications, were excluded from the study. All

patients were matched to exclude possible influencing factors

such as age, parity, and body mass index. Informed consents

were obtained from all participating subjects and the Ethics

Committee approval was obtained.

Immunohistochemical staining for GPx1 was performed to

determine the presence and distribution of this protein in the

pubocervical fascia tissue of POP patients. Semi-quantitative

score was used to analyze the staining result. Two investigators

who had no idea of the patients’ clinical information independ-

ently assessed the staining intensity. Preimmune sera was used

as a negative control.

The data were analyzed by Chi-square test and Spearman rank

correlation analysis. Significance was accepted at p < 0.05.

Results

Expression of TGF-β1, CTGF and GPx1The positive granules of TGF-β1 and CTGF appeared

dark brown or filemot, which presented a diffuse or focal

distribution throughout the cytoplasm (Figures 1A-1D).

TGF-β1 expression showed significant decrease, χ2

=

27.242, p < 0.05 (Table 1). CTGF expression also showed

significant decrease, χ2

= 23.958, p < 0.05 (Table 2).

The positive granules of GPx1 appeared dark brown or

filemot, which presented a focal or diffuse distribution

throughout the cytoplasm (Figures 2A-2B). GPx1 expres-

sion also showed significant decrease, χ2

= 9.545, p < 0.05

(Table 3).

Correlation between the expression of TGF-β1 and thePOP-Q, CTGF and the POP-Q or GPx1 and the POP-Q

As the ordered category variables, there was a negative

correlation between the POP-Q and expressions of TGF-

β1. With the degree of POP-Q increasing,, the expression

of TGF-β1 decreased correspondingly (Table 1). It also

could be seen between POP-Q and expression of CTGF

(Table 2), and between POP-Q and expression of GPx1

(Table 3).

The correlation analysis between the expression of TGF-β1 and CTGF, CTGF and GPx1 or TGF-β1 and GPx1

As the ordered category variables, there was a positive

correlation between TGF-β1 and CTGF. The synergistic

change trend was found between TGF-β1 and CTGF (Table

4) It also could be seen in CTGF and GPx1 (Table 5) and

between TGF-β1 and GPx1 (Table 6).

Discussion

It is generally considered that pregnancy and vaginal

childbirth are associated with POP, but the exact etiology is

still unknown. Female pelvic tissues were in a complex bio-

mechanical environment with pregnancy, childbirth, high

abdominal pressure (chronic cough, constipation, and obe-

sity) etc. In the pathogenesis of POP, some researchers fo-

cused on the changes of extracellular matrix components,

such as collagen-I, collagen-III, MMP, TIMP, and elastin

in connective tissues. So, the decrease of mechanical prop-

Table 1. — The expression of TGFβ1 in pubocervical fascia offour groups.Groups Expression of TGFβ1

– + ++ +++ %

POP-QII 30.00 (3/10) 70.00 (7/10) 0 0 70.00 (7/10)

POP-QIII 50.00 (5/10) 50.00 (5/10) 0 0 50.00 (5/10)

POP-QIV 80.00 (8/10) 20.00 (2/10) 0 0 20.00 (2/10)

Total POP 53.33 (16/30) 46.67 (14/30) 0 0 46.67 (14/30)*

Control 10.00 (2/20) 25.00 (5/20) 45.00 (9/20) 20.00 (4/20) 90.00 (18/20)

*The comparison between total POP and control, the χ2 = 27.242, p < 0.05. The correlation coefficient

between TGFβ1 and POP-Q was –0.409, p < 0.05.

Table 2. — Expression of CTGF in pubocervical fascia of fourgroups.Groups Expression of CTGF

– + ++ +++ %

POP-QII 20.00 (2/10) 80.00 (8/10) 0 0 80.00 (8/10)

POP-QIII 40.00 (4/10) 60.00 (6/10) 0 0 60.00 (6/10)

POP-QIV 90.00 (9/10) 10.00 (1/10) 0 0 10.00 (1/10)

Total POP 50.00 (15/30) 50.00 (15/30) 0 0 50.00 (15/30)*

Control 15.00 (3/20) 25.00 (5/20) 35.00 (7/20) 25.00 (5/20) 85.00 (17/20)

*The comparison between total POP and control, the χ2 = 23.958, p < 0.05. The correlation coefficient

between CTGF and POP-Q was –0.572, p < 0.05.

Table 3. — Comparison of expression of GPx1 protein inpubocervical fascia among four groups.Groups Samples Expression of GPx1 [% (n/n)] Total positive

(n) – + ++ +++ rate

POP-QII 10 40.00 (4/10) 50.00 (5/10) 10.00 (1/10) 0 60.00 (6/10)

POP-QIII 10 80.00 (8/10) 20.00 (2/10) 0 0 20.00 (2/10)

POP-QIV 10 100.00 (10/10) 0 0 0 0

POP Group 30 73.33 (22/30) 23.33 (7/30) 3.33 (1/30) 0 26.67 (8/30)

Control 20 20.00 (4/20) 40.00 (8/20) 30.00 (6/20) 10.00 (2/20) 80.00 (16/20)

* The comparison with the control, χ2 = 9.545, p < 0.05. The correlation coefficient between GPx1 and POP-Q

was –0.660, p < 0.05.

Table 4. — Correlation of expression of TGF-β1 and CTGF inthe POP patients.TGF-β1 CTGF Total

– + ++ +++

– 11 5 0 0 16

+ 4 10 0 0 14

++ 0 0 0 0 0

+++ 0 0 0 0 0

Total 15 15 0 0 30

r = 0.401, p = 0.028.

Table 5. — Correlation of expression of GPx1 and CTGF in thePOP patients.CTGF Gpx1 Total

– + ++ +++

– 14 1 0 0 15

+ 8 6 1 0 15

++ 0 0 0 0 0

+++ 0 0 0 0 0

Total 22 7 1 0 30

r = 0.455, p = 0.012.

Table 6. — Correlation of expression of GPx1 and TGFβ1 inthe POP patients.TGFβ1 Gpx1 Total

– + ++ +++

– 16 0 0 0 16

+ 6 7 1 0 14

++ 0 0 0 0 0

+++ 0 0 0 0 0

Total 22 7 1 0 30

r = 0.641, p < 0.001.

erty induced by matrix remodeling was the key to the oc-

currence of POP [13].

Collagen is the main component in ligament and fascia,

which determines the toughness of connective tissue. The

connective tissue in pelvic floor mainly contained colla-

gen-I and collagen-III [14-17]. The metabolic balance be-

tween collagen synthesis and collagen catabolism was

broken, which led to pelvic floor tissue becoming weak and

lax. It would ultimately result in the occurrence of POP [18,

19].

Under normal physiological conditions, the oxidation-

antioxidation system maintains dynamic balance, which not

only guarantees the physiological function of the normal

oxidative stress reaction, but also prevents the injury of

ROS. Only with the ROS overload or insufficient expres-

sion of antioxidation enzymes, the dysequilibrium of oxi-

dation-antioxidation system would injure cells and tissues.

The oxidation-antioxidation system is the basic of the

health.

GPx is an important selenium protein in organism. Sele-

nium is the active center of the enzyme, and its activity can

reflect the level of selenium. GPx1 is one of the isozymes,

and is widely distributed in the cytoplasms and mitochon-

dria of every tissue cells. The expression of GPx1 reflects

the level of selenium in tissue, and also is closely related to

the ability of antioxidant. Some studies found that oxidative

stress interferes with collagen metabolism in fibroblast cells

[20-21].

Other factors such as pregnancy, childbirth, chronic con-

stipation, and chronic cough, which increase intra-abdom-

The expression of glutathione peroxidase-1 and the anabolism of collagen regulation pathway transforming growth factor-β1- etc.588

Figure 1. — TGFβ1 and CTGF expression in pubocervical fascia (two-step staining) (×400).

1A and 1C show the expression of TGFβ1 in pubocervical fascia in experimental and control group, respectively. 1B and 1D show

the expression of CTGF in pubocervical fascia in experimental and control group, respectively.

Fig. 1A

Fig. 1C

Fig. 1B

Fig. 1D

B.S. Li, L. Hong, J. Min, D.B. Wu, M. Hu, W.J. Guo 589

inal pressure, also are the important causes of POP. Dan

found that mechanical strain changes the fibroblast cell

morphology in uterosacral ligament and regulates the ex-

pression of collagen-I, collagen-III, and MMP-1 [22]. Ex-

cessive mechanical strain increases the level of ROS in

cells, and then up-regulates the activity of MMPs to fasten

the degradation of collagen [23-25]. Therefore, pregnancy,

childbirth, chronic constipation, and chronic cough may re-

sult in the occurrence and development of POP by inducing

the oxidative stress.

In this study, it was first found that the expression of

GPx1, an antioxidase, decreased significantly in the pelvic

floor fascia tissue of patients with POP, which negatively

correlated with the degree of POP-Q. This study suggests

that the increasing of mechanical strain or the decreasing

expression of GPx1 could break the oxidation-antioxida-

tion system balance of fibroblast cells in pelvic floor sup-

porting tissue, and up-regulate ROS to disturb the

metabolic balance of collagen synthesis, which was the key

to the occurrence of POP.

In addition, the authors also found that the TGF-β1-

CTGF regulating pathway was decreased in the pelvic floor

fascia tissue of patients with POP, and negatively correlated

with the degree of POP-Q and positively correlated with

GPx1. It could confirm that the expression of GPx1 de-

creased, which would make the antioxidation weak, in-

crease ROS level in cells, down-regulate TGF-β1-CTGF

pathway, and inhibit the collagen synthesis. The increase

of ROS in cells would up-regulate the activity of enzymes

such as MMPs and fasten the collagen decomposition.

Conclusion

The expression of the antioxidase GPx1 in pelvic support

structure of POP women decreased, which resulted in the

antioxidation reduced. It could break the balance of oxida-

tion and antioxidation in pelvic support structure, and may

induce the increase of ROS level and the down-regulation

of TGF-β1-CTGF pathway. It could inhibit the anabolism

of collagen and injure the pelvic support structure, thus pro-

moting the occurrence and development of POP. In con-

clusion, the authors provide the hypothesis that the

mechanism of POP may be the oxidation-antioxidation sys-

tem disequilibrium. So, how to regulate the balance is the

key to prevent and cure POP.

Acknowledgment

The authors are grateful to the National Nature Science Foun-

dation of China (Project no. 81270684) for its financial support.

References

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L. HONG, M.D.


Renmin Hospital

Medical College of Wuhan University

Wuhan 430060 (China)


[email protected]

The expression of glutathione peroxidase-1 and the anabolism of collagen regulation pathway transforming growth factor-β1- etc.590

591

Introduction

Steroid cell tumors of the ovary are rare and account for

approximately 0.1% of all ovarian tumors. These are classi-

fied into three subtypes: stromal luteomas, Leydig cell tu-

mors, and steroid cell tumors, not otherwise specified (NOS),

which account for approximately 60% of all steroid cell tu-

mors [1]. Steroid cell tumors-NOS produce virilization in

56%-77%, hyperestrogenism in 6%-23%, and Cushing’s

syndrome in 6%-10% of cases [2, 3]. Steroid cell tumors-

NOS may produce the full range of steroid hormones seen in

the other types. As menstrual abnormalities are common,

pregnancies in the setting of this tumor are very rare. Only

one case of maternal virilization by a steroid tumor NOS in

pregnancy with a male fetus has been reported in the litera-

ture [4], and this case was not associated with fetal female

pseudohermaphroditism. Herein, the authors report a case of

maternal virilization and female pseudohermaphroditism

caused by steroid cell tumor-NOS, along with the clinical

course, histopathological features, and the literature review.

Case Report

A 36-year-old primigravida woman was admitted to this hospi-

tal with preterm rupture of membranes and the onset of labor at 22

weeks of gestation. She had a history of an exploratory laparotomy

five years prior for bilateral solid ovarian tumors, which were ini-

tially suspected to be malignant. A left salpingo-oophorectomy was

performed, and the tumor was thought to be benign on intraopera-

tive gross inspection. The right ovarian tumor was not removed so

as to not compromise fertility. The left ovarian tumor was initially

diagnosed as a leiomyoma. The original tissue blocks were not

available at the time this case report was drafted. The patient had ir-

regular menstrual cycles since menarche at age 11. She was treated

for infertility for four years and eventually became pregnant fol-

lowing ICSI (intracytoplasmic sperm injection). Magnetic reso-

nance imaging (MRI) performed at 15 weeks of gestation, prior to

referral showed a 75 x 80 mm solid tumor in the right pelvis, with

heterogeneous low to intermediate signal intensity on T2-weighted

imaging without contrast enhancement (Figure 1a).

On admission, her height was 160 cm, weight 51 kg, and her

blood pressure was 118/70 mmHg. She presented with virilization

manifested by increased facial, abdominal, and lower extremity

hair, worsening acne, and a slightly enlarged clitoris. Virilization of

the patient was not noticed in previous hospital during treatment

for infertility. On ultrasonography, a 76 x 71 x 80 mm solid tumor

was detected in the pouch of Douglas; Doppler evaluation of the

tumor demonstrated hypovascularity. There was no morphological

abnormality in the maternal adrenal gland. The fetus measured ap-

propriate for gestational age and had normal anatomy and appeared

to have male genitalia; however, the structure of the scrotum was

obscure. The levels of follicle-stimulating hormone (FSH), luteiniz-

ing hormone (LH), thyroid-stimulating hormone (TSH), and free-

T3 or T4 were all within the normal range. The serum testosterone

level was markedly elevated (32 ng/ml, normal range; 0.1~0.7

ng/ml). The levels of serum tumor markers, carcinoembryonic anti-

gen (CEA), CA19-9 were normal; however, the CA125 was slightly

elevated (73 U/ml). A right ovarian sex-cord stromal tumor that pro-

duced testosterone was suspected, based on the physical, labora-

tory, and radiological findings. The patient was treated for preterm

labor after admission to this hospital; however, she eventually de-

veloped chorioamnionitis and entered into active labor at 29 weeks

of gestation. She delivered by cesarean section and underwent a

right ovarian cystectomy at the same time. There was no evidence

of extra-ovarian tumor or metastatic disease. A small amount of as-

cites was seen in the cul de sac.

The tumor measured seven by eight cm in diameter and was a

well-circumscribed, grayish-yellow mass without apparent area of

necrosis or degeneration (Figure 1b). The tumor was easily sepa-

rated from the grossly normal-appearing ovarian tissue. Cytologi-

cal examination of ascites was negative for malignancy.

Histological examination of the tumor demonstrated an encapsu-

lated, non-infiltrative pattern. The tumor included areas in which

cuboidal or polygonal cells with oval to polygonal nuclei, small dis-

Female pseudohermaphroditism associated with maternal

steroid cell tumor, not otherwise specified of the ovary:

a case report and literature review

K. Hasegawa1, Y. Minami1, H. Inuzuka1, S. Oe1, R. Kato1, K. Tsukada1, Y. Udagawa1, M. Kuroda2

1Department of Obstetrics and Gynecology, and 2Department of Pathology, Fujita Health University School of Medicine, Toyoake, Aichi (Japan)

Summary

Maternal virilization in pregnancy with or without fetal female pseudohermaphroditism has several etiologies. Of these, pregnancy lu-

teoma is the most common cause of maternal virilization during pregnancy, and approximately 20 cases have been reported in recent years.

Moreover, four cases of pregnancy luteomas with female pseudohermaphroditism have been reported. However, the extremely rare steroid

cell tumor, not otherwise specified (NOS), has been reported only once as a cause for maternal virilization. Herein, the authors report the

first case of maternal virilization with female pseudohermaphroditism associated with steroid cell tumor-NOS along with the clinical course,

pathological features, and a review of the literature.

Key words: Female pseudohermaphroditism; Maternal virilization; Steroid cell tumor; Not otherwise specified; testosterone; Patho-

logical diagnosis.

Case Reports



XXXIX, n. 2, 2012

tinct nucleoli, and abundant eosinophilic cytoplasm were arranged

in a diffuse pattern of columns or nests. These columns were sur-

rounded by spindle cells with central, small, round-to-oval nuclei

with small nucleoli. These cells lacked typical Reinke’s crystals

commonly seen in Leydig cell tumors. Only a few microscopic

areas of necrosis were identified. The cellular atypia was scant and

mitotic figures were found in less than two per ten high-power fields

(Figure 2a, 2b). Both cell types were focally positive for fat stains

by oil red and Sudan III.

Immunohistochemical staining was performed for AE1/AE3

(anion exchange protein) (1: 100 dilution), CAM 5.2 (1: 40 dilu-

tion), alpha-smooth muscle actin (SMA) (clone 1A4, 1: 200 dilu-

tion), vimentin (clone V9, 1: 400 dilution), desmin (clone DE-R-11,

1: 200 dilution), inhibin-alpha (clone R1, 1: 50 dilution), estrogen

receptor (clone SP1, 1: 2 dilution), progesterone receptor (clone

1E2, 1: 2 dilution), testosterone (1: 50 dilution), and Ki-67 (clone

MIB-1, 1:100 dilution) using the streptavidin-biotin-peroxidase

complex method. Consequently, immunohistochemical staining of

the two-component cell types was negative for cytokeratin

(CAM5.2 and AE1/AE3), estrogen receptor, and progesterone re-

ceptor, and positive for inhibin-alpha and vimentin. Only the spin-

dle cells were positive for smooth muscle actin SMA and desmin.

Importantly, testosterone staining was positive in both components

(Figure 2c~2f). The Ki-67 labelling index was 2.5% throughout the

specimen. The final pathological diagnosis was a steroid cell tumor-

NOS of the ovary.

The maternal serum testosterone level immediately normalized

following tumor resection and her hirsutism slowly decreased. She

has had no evidence of recurrence for five years, and her serum

testosterone level has remained normal.

The neonate weighed 1,280 g at birth, and had Apgar scores of 9

at one minute and 9 at five minutes. The neonate was admitted to

the neonatal intensive care unit. The neonate had ambiguous geni-

talia with a small penis without an obvious scrotum or palpable

testis in the inguinal or genital region. Cytogenetic investigation on

blood lymphocytes of the baby revealed a normal female karyotype

46, XX and was negative for the SRY gene. The neonate exhibited

complete masculinization of the external genitalia with the external

urethral meatus opening at the apex of the penis and complete labial

fusion (Prader type V) [5] (Figure 3a). MRI findings revealed a

small uterus; the uterine corpus and the cervix were not distin-

guishable, and the vagina was closed just beneath the labia (Figure

3b). While the neonate initially grew normally, she developed hy-

drocephalus secondary to a cerebellar tumor. The tumor was re-

sected and was consistent with a medulloblastoma with extensive

nodularity and advanced neuronal differentiation. The tumor re-

curred and the infant died of disease progression at one year of age.

Discussion

The differential diagnosis of maternal virilization in preg-

nancy is divided into adrenal, ovarian, and iatrogenic causes.

Ovarian tumors or tumor-like lesions which produce andro-

gens include pregnancy luteoma, hyperreactio luteinalis,

granulosa cell tumor, thecoma, Sertoli-Leydig cell tumor,

steroid cell tumors including pure Leydig cell tumor, stro-

mal luteoma and steroid cell tumor-NOS, stromal hyperthe-

cosis, and ovarian tumors with functioning stroma including

cystadenoma, cystadenocarcinoma, Brenner tumor, dermoid

cyst, and Krukenberg (metastatic) tumor [6].

Pregnancy luteoma is the most common cause of maternal

virilization during pregnancy, and approximately 20 cases

have been reported in recent years [7]. Moreover, four cases

of pregnancy luteomas with female pseudohermaphroditism

have been reported in the English literature [6, 8-10]. This le-

sion is characterized by spontaneous disappearance of the tu-

mors and normalization of the androgen levels after delivery.

Imprudent surgical intervention should be withheld except

for ovarian torsion or obstructed labour. However, three of

four cases with female pseudohermaphroditism underwent

surgery to obtain the accurate pathological findings at the

same time of cesarean section or puerperium. Wang et al. re-

ported a case of a nulligravida woman suffering from bilat-

eral hydronephrosis and recurrent pyelonephritis caused by

K. Hasegawa, Y. Minami, H. Inuzuka, S. Oe, R. Kato, K. Tsukada, Y. Udagawa, M. Kuroda592

Table 1. — Cases of female pseudohermaphroditism.Authors Mat. Gravida Gestat. Tumor size Radiological Histological Maternal Prader Maternal Maternal Fetal

age and para weeks at at diagnosis findings or clinical testosterone class therapy outcome outcome

diagnosis (mm) diagnosis level

Massa V. [8] 34 nulligravida 13 R: 50 US; small hypo- bilateral T: 2,000 ng/ml V cesarean section improvement feminizing

echoic and pregnancy (normal range: with bil-tumorectomy of hirsutism genitoplasty

hyperechoic area luteoma 50-300 ng/ml) at 39 weeks gestation

ADS: 6,500 ng/ml

(normal range:

100-250 ng/ml)

Wang Y.C. [9] 27 nulligravida 35 R: 70x60x50 MRI; solid mass bilateral T: 11,539 ng/ml NS vaginal delivery bilateral ovaries NS

L: 90x64x50 and multiple pregnancy (normal range: (I?) at 36 weeks normalized and

nodules luteoma 20-86 ng/ml) improvement

of hirsutism

Spitzer R.F. [6] 36 nulligravida post- R: 73x74x47 MRI; r-pregnancy T: 10.6 nmol/l II- vaginal delivery improvement considering

partum heterogeneously; luteoma (normal range: III at 36 weeks and of hirsutism urogenital

predominantly < 2.9 ng/ml) RSO and OMT on sinus repair

solid the 18th postpartum

Ugaki H. [10] 33 nulligravida 35 L: 60 NS l-pregnancy T: 6.11 ng/ml NS cesarean section improvement feminizing

luteoma (normal range: (III?) with LSO at 35 of hirsutism genitoplasty

0.85 ± 0.28 ng/ml) weeks gestation

Current case 36 nulligravida 15 R: 75x80 heterogeneous r-SCT-NOS T: 32 ng/ml V cesarean section improvement died of

low to interme- (normal range: with right-ovarian of hirsutism cerebellar

diate signal inten- 0.1-0.7 ng/ml) tumorectomy at 29 tumor

sity on T2-wighted weeks gestation

imaging

R: right, L: left, T: Testosterone, ADS: Androstenedione, NS: not specified, RSO: right salpingo-oophorectomy, OMT: omentectomy, LSO: left salpingo-oophorectomy.

Female pseudohermaphroditism associated with maternal steroid cell tumor, not otherwise specified of the ovary: a case report etc. 593

Figure 1. — a) MRI showing a 75 x 80 mm solid tumor in the right

pelvis, with heterogeneous low to intermediate signal intensity on

T2-weighted imaging without contrast enhancement (arrow indi-

cates the tumor). b) Macroscopic findings. The tumor measured 7 x

8 cm in diameter and was a well-circumscribed, grayish-yellow mass

without apparent area of necrosis or degeneration.

Figure 2. — a), b) Pathological examination. The tumor includes areas in which cuboidal or polygonal cells with oval to polygo-

nal nuclei, small distinct nucleoli, and abundant eosinophilic cytoplasm are arranged in a diffuse pattern of columns or nests. These

columns are surrounded by spindle cells with central, small, round-to-oval nuclei with small nucleoli. These cells lack typical

Reinke’s crystals. Only a few microscopic areas of necrosis are identified. The cellular atypia are scant and mitotic figures are

found in less than two per ten high-power fields. [a) hematoxylin and eosin (H&E), original magnification x100, b) H&E, x400]

c), d), e), and f) Immunohistochemical study. c) inhibin-alpha (original magnification x 200), d) SMA (x100), e) vimentin (x200),

f) testosterone (x 200).

The two-component cell types are positive for inhibin-alpha, vimentin, and testosterone. Only the spindle cells are positive for

SMA.

bilateral solid ovarian tumors presented maternal virilization

[9]. The unique MRI imaging features of this case were re-

ported by Kao et al. as follows; intermediate high signal and

contrast enhanced on T1, and low signal on T2-weighed im-

ages [11]. Based on the clinical and MRI imaging, bilateral

ovarian tumors of this case were diagnosed as pregnancy lu-

teoma, and this case was subsequently avoided from surgi-

cal intervention at pre- or post-partum [9, 11]. Moreover, this

woman conceived her second pregnancy with a female fetus

of 46, XX karyotype. Her pregnancy was terminated at 14

weeks gestation because of suffering from pregnancy lu-

teoma repeatedly (maternal serous testosterone level; 751

ng/ml), and fetal ambiguous external genitalia with clitoral

hypertrophy was confirmed [12]. She conceived a third preg-

nancy with a male by Y-bearing spermatozoa for intrauterine

insemination as a male preselection. A healthy boy was born

without disorder of sex development at 35 weeks gestation

by cesarean section with bilateral pregnancy luteoma en-

larged up to ten cm in diameter and elevated serum testos-

terone; 12,400 ng/ml [12].

However, the almost androgen-producing ovarian tumors,

except for pregnancy luteoma, do not regress spontaneously

after delivery, so the differential diagnosis of an ovarian

tumor during pregnancy is important and essential for fur-

ther management.

There has, however, been only one report of maternal

virilization caused by a steroid cell tumor-NOS during

pregnancy [4]. Vulink et al. reported a 37-year-old preg-

nant woman who showed progressive hair growth on her

face, arms, and legs, deepening of the voice, and slight

enlargement of the clitoris. A solid, homogenous tumor of

the left ovary was detected by ultrasonography at 12

weeks of gestation along with elevated serum testos-

terone. She underwent an exploratory laparotomy with

left salpingo-oophorectomy at 16 weeks of gestation, and

the histopathological findings were consistent with a be-

nign ovarian steroid cell tumor-NOS. As the fetus was

male, there were no visible effects of testosterone expo-

sure. To the best of the authors’ knowledge, the present

case is the first to report female pseudohermaphroditism

associated with maternal steroid cell tumor-NOS of ovary.

Differentiation of the female external genitalia occurs be-

tween the seventh and 12th week of gestation. Increased ex-

posure to androgens during this critical period results in

labial fusion. After the 12th week of gestation, labia and cli-

toral hypertrophy may be induced [13, 14]. Almost all pre-

viously reported cases of female pseudohermaphroditism

caused by pregnancy luteoma have been Prader type I to III

(Table 1) [7]. However, Mazza et al. reported a case with

Prader type V fetal masculinization [6]. They identified the

duration and timing of embryo-fetal androgen exposure, a

deficit of protective factors, and fetal organ sensitivity as in-

fluencing the degree of fetal masculinization. The duration

of embryo-fetal androgen exposure in the present case with

maternal steroid cell tumors-NOS was longer than in those

of cases with a pregnancy luteoma and likely explains the

complete female masculinization.

Steroid cell tumors typically are solid and well-circum-

scribed and are rarely lobulated [15]. These tumors are bi-

lateral in six percent of cases [2]. Steroid cell tumors-NOS

occur at any age with average age of diagnosis of 43 years

[2]. These tumors are larger than the other steroid cell tu-

mors; with cases ranging from 1.2 to 45 cm in diameter [2,

16]. Histopathologically, steroid cell tumors-NOS can be

K. Hasegawa, Y. Minami, H. Inuzuka, S. Oe, R. Kato, K. Tsukada, Y. Udagawa, M. Kuroda594

Figure 3. — a) External genitalia of the neonate. The neonate exhibited complete masculinization of the external genitalia with the

external urethral meatus opening at the apex of the penis and complete labial fusion (Prader type V). (arrow indicates the external

urethral meatus ). b) MRI findings revealing a small uterus; the uterine corpus and the cervix are not distinguishable, and the vagina

is closed just beneath the labia (arrow indicates the uterus).

Female pseudohermaphroditism associated with maternal steroid cell tumor, not otherwise specified of the ovary: a case report etc. 595

differentiated from stromal luteomas, which are confined

within ovarian stroma and commonly associated with stro-

mal hyperthecosis. They are also distinguishable from Ley-

dig cell tumors which contain cytoplasmic Reinke crystals

[1]. Steroid cell tumors-NOS are composed of two types of

cells: cells with abundant eosinophilic, slightly granular cy-

toplasm, and cells with vacuolated cytoplasm [2]. These

cells are most commonly arranged in a diffuse pattern but

are occasionally seen in nests and columns. The stroma is

sparse, consisting of delicate connective tissue supporting a

rich vascular network, and is occasionally fibrous or hyalin-

ized [2]. These tumors are commonly positive for inhibin-

alpha and vimentin, and negative for cytokeratin. They have

recently been shown to be positive for calretinin and Melan

A [17, 18]. In the present case, the histopathological findings

were not typical for a steroid cell tumor-NOS. The tumor

consisted of large cells with abundant pale or eosinophilic

cytoplasm, as well as spindle cells. The former cells were

consistent with those found in a steroid cell tumors-NOS.

Inhibin-alpha and vimentin were positive and cytokeratin

was negative for both cell types, whereas SMA and desmin

were positive only in the spindle cells. These spindle cells

were thought to be differentiating to smooth muscle cells,

which may have been what prompted the diagnosis of

leiomyoma for the previously resected left ovarian tumor in

this patient.

The majority of steroid cell tumors-NOS are benign. De-

spite the majority being low-grade, approximately 25%-

43% of these tumors are malignant in adults [2, 19]. In a

review of 63 cases, the pathological features associated with

malignant behavior are: two or more mitotic figures per ten

high-power fields (92% malignant); necrosis (86% malig-

nant); tumor diameter of more than seven cm (78% malig-

nant); hemorrhage (77% malignant); and grade 2-3 nuclear

atypia (64% malignant) [2]. The average age of patients with

malignant steroid cell tumors-NOS is higher than that of pa-

tients with benign tumors, of 54 and 38 years, respectively

[2]. The tumor in the present case showed benign patholog-

ical features with the exception of the tumor measuring

seven by eight cm. Since the patient was treated with a cys-

tectomy, she has been followed closely with monitoring of

the serum testosterone level and has shown no evidence of

recurrence.

Two of four masculinized females caused by pregnancy

luteoma underwent feminizing genitoplasty, and one case

was considering urogenital sinus repair at appropriate age

in the literature (Table 1). As for the present case, the

neonate died of her cerebellar tumor before the planning of

postnatal medical care, gender assignment, and the timing of

feminizing genitoplasty. The association between the cere-

bellar tumor and maternal testosterone excess is uncertain.

Steroid cell tumors-NOS produce the full spectrum of

hormonal perturbations seen with other steroid cell tu-

mors. Therefore, they frequently result in primary or sec-

ondary infertility. The present patient became pregnant by

ICSI after a four-year history of infertility treatment. The

serum testosterone level during infertility treatment of the

present case was not available without the awareness of

virilization in previous hospital. While the infertility was

circumvented, the effects on the fetus remained. The pres-

ent case also illustrates a potential pitfall of artificial re-

productive technology.

References

[1] Young R.H., Scully R.E.: “Sex cord-stromal and steroid cell ovarian

tumors”. Kurman R.J., Blaustein’s Pathology of the Female Genital

Tract. 5th ed. Pp 905, Springer-Verlag, New York, 2001.

[2] Hayes M.C., Scully R.E.: “Ovarian steroid cell tumors (not otherwise

specified). A clinicopathological analysis of 63 cases”. Am. J. Surg.Pathol., 1987, 11, 835.

[3] Reedy B., Richards W.E., Ueland F., Uy K., Lee E.Y., Bryant C., van

Nagell J.R. Jr.: “Ovarian steroid cell tumours, not otherwise specified:

a case report and literature review”. Gynecol. Oncol., 1999, 75, 293.

[4] Vulink A.J.E., Vermes I., Kuijper P., ten Cate L.N., Schutter E.M.:

“Steroid cell tumour not otherwise specified during pregnancy: a case

report and diagnostic work-up for virilisation in a pregnant patient”.

Eur. J. Obstet. Gyecol., 2004, 112, 221.

[5] Prader A.: “Disorders of sexual differentiation (Intersexuality)”. In:

Labhart A. (ed.) Clinical Endocrinology Theory and Practice, Springer

Verlag, 1986, 715.

[6] Spitzer R.F., Wherrett D., Chitayat D., Colgan T., Dodge J.E., Salle

J.L., Allen L.: “Maternal luteoma of pregnancy presenting with viril-

ization of the female infant”. J. Obstet. Gynecol. Can., 2007, 29, 835.

[7] Masarie K., Katz V., Balderston K.: “Pregnancy luteomas- Clinical

presentation and management strategies”. Obstet. Gynecol. Surv.,2010, 65, 575.

[8] Mazza V., Di Monte I., Ceccerelli P.L., Rivasi F., Falcinelli C., Fora-

bosco A., Volpe A.: “Prenatal diagnosis of female pseudohermaphro-

ditism associated with bilateral luteoma of pregnancy”. Hum. Reprod.,

2002, 17, 821.

[9] Wang Y.C., Su H.Y., Liu J.Y, Chang F.W., Chen C.H.: “Maternal and

female fetal virilization caused by pregnancy luteomas”. Fertil. Steril.,2005, 84, 509. e15.

[10] Ugaki H., Enomoto T., Tokugawa Y., Kimura T.: “Luteoma-induced

fetal virilization”. J. Obstet. Gynecol. Res., 2009, 35, 991.

[11] Kao H.W., Wu C.J., Chung K.T., Wang S.R., Chen C.Y.: “MD1MR

imaging of pregnancy luteoma: a case report and correlation with the

clinical features”. Korean J. Radiol., 2005, 6, 44.

[12] Chen C.H., Chen I.C., Wang Y..C, Liu J.Y., Wu G.J., Tzeng C.R.: “Boy

born after gender preselection following successive gestational an-

drogen excess of maternal luteoma and female disorders of sex de-

velopment”. Fertil. Steril., 2009, 91, 2732. e5.

[13] Manganiello P.D., Adams L.V., Harris D., Ornvold K.: “Virilisation

during pregnancy with spontaneous resolution postpartum: a case re-

port and review of English literature”. Obstet. Gynecol., 1995, 50, 404.

[14] McClamrock H.D., Adashi E.Y.: “Gestational hyperandrogenism”.

Fertil. Steril., 1992, 57, 257.

[15] Wang P.H., Chao H.T., Lee R.C., Lai C.R., Lee W.L., Kwok C.F.:

“Steroid cell tumors of the ovary: clinical, ultrasonic, and MRI diag-

nosis- a case report”. Eur. J. Radiol., 1998, 26, 269.

[16] Mok J.E., Shon W.S.: “Surgical management of steroid cell tumors of

the ovary”. CME J Obstet Oncol., 2003, 8, 173.

[17] Varras M., Vasilakaki T., Skafida E., Akrivis C.: “Clinical, ultrasono-

graphic, computed tomography and histopathological manifestation

of ovarian steroid cell tumor, not otherwise specified: our experience

of a rare case with female virilisation and review of the literature”.

Gynecol. Endocrinol., 2011, 27, 412.

[18] Deavers M.T., Malpica A., Ordonez N.G. et al.: “Ovarian steroid cell

tumors: an immunohistochemical study including a comparison of cal-

retinin with inhibin”. Int. J. Gynecol. Pathol., 2003, 22, 162.

[19] Taylor H.B., Norris H.J.: “Lipoid cell tumors of the ovary”. Cancer,1967, 20, 1953.


K. HASEGAWA, M.D.


Fujita Health University School of Medicine

1-98 Dengakugakubo, Kutsukake-cho Toyoake,

Aichi, 470-1192 (Japan)


Introduction

The reported maternal mortality for morbidly adherent

placenta ranges from seven to ten percent worldwide. The

incidence of morbidly adherent placenta has increased over

the past 50 years, mirroring the increase in the rate of ce-

sarean delivery [1]. Damage to the decidua basalis second-

ary to previous uterine injury, such as cesarean section,

myomectomy, traumatic uterine curettage, and intrauterine

sepsis has been implicated. Significant maternal morbidity

may occur because of massive postpartum hemorrhage and

its sequelae, which include loss of fertility, multiple blood

transfusions, transfusion-associated acute lung injury, co-

agulopathy, sepsis, multiorgan failure, and even death..

Many women experience psychologic effects owing to loss

of fertility secondary to peripartum hysterectomy. Addi-

tional complications include damage to the urinary bladder,

bowel, or ureters including fistulae or incontinence [2, 3]. A

15-year analysis of peripartum hysterectomy reported that

the procedure was associated with a maternal mortality rate

of 12.5% and a urinary tract injury rate of 7.5% [4]. Sepa-

ration of the placenta from its highly vascular bed is likely

to cause massive obstetric hemorrhage. It is mostly diag-

nosed after delivery when manual removal of the retained

placenta fails. The conventional treatment is hysterectomy.

Case Report

A primigravida 28-year-old patient, presented at 38 weeks plus

five days amenorrhea with a premature rupture of membranes

(PROM). After few hours of labor, she vaginally delivered a

healthy female baby, followed by retained placenta. She under-

went two unsuccessful attempts of manual removal with surgical

curettages. She was conscious, cooperative, weighing 68 kilo-

grams, with moderate pallor, regular pulse rate of 90 beats per

minute, blood pressure recording of 120/75 mm of mercury,

afebrile, no cyanosis with clear chest, and nothing abnormal on

circulatory system examination. On abdominal examination, her

uterus was 22 weeks in size, well-contracted but with an irregu-

lar surface for the presence of a bulky node myoma. The pelvic

examination showed scarce amount of bleeding per vaginum. She

was hemodynamically stable and her hemoglobin was 12.4 mg/dl.

She was blood group B, Rh positive, with normal readings of rou-

tine urine analysis, platelet count, coagulation profile, and hepatic

and renal function tests. Vaginal swab was sent for culture which

later reported sterile. Transabdominal and vaginal sonography re-

vealed uterus to be of postpartum size with endometrial cavity

showing an echogenic mass of dimensions 8.11 cm x 7.0 cm, sug-

gestive of placenta, with vascularity on colour Doppler confirm-

ing it to be adherent to the uterine wall (placenta accreta), but with

no definite invasion, and a solid, inhomogeneous, poorly vascu-

larized mass in the lower part of the anterior wall of the uterus

showing typical features of an intramural fibroid measuring ap-

proximately ten cm. Supportive measures, like broad-spectrum

antibiotics, were initiated. Considering the desire of the patient

for retaining her uterus for future fertility, conservative manage-

ment was planned. Modality adopted was: placenta left in situ and

performance of a prophylactic selective right uterine artery em-

bolization to reduce vaginal discharge, an injection of methotrex-

ate given intramuscularly in the schedule of one mg/kg, using the

multidose regimen that involves the administration of methotrex-

ate calculated according to body weight, alternated with 0.1 mg/kg

of leucovorin calcium per os after 30 hours in four doses, based

on continuous monitoring of the dimensions and vascularity of

the mass (representing adherent placenta) with serial sonographic

and colour Doppler studies which regularly showed the reducing

trend. Leucocyte counts were routinely performed on a daily basis

which remained within limits. Size of the placenta decreased re-

markably with a concomitant reduction by 30% in uterine myoma

volume. With this conservative strategy, vaginal bleeding never

became alarming and vaginal discharge never purulent. Patient

was discharged, not breastfeeding, in a satisfactory condition, ful-

filling her initial desire of conserving the uterus, after 12 days of

hospitalization. On subsequent follow-ups, every seven days, pa-

tient remained afebrile with no history or evidence of infection.

After two months she experienced her first period after childbirth.

Vaginal sonography revealed uterus to be entirely occupied by the

detached placenta, whose release was hampered by the myoma

node. Thus, in agreement with the patient, it was decided to per-

form a myomectomy with concomitant removal of the placenta.

She was discharged in a satisfactory condition after four days of

hospitalization and the subsequent follow-up showed perfect clin-

ical conditions of the patient.

596

Placenta accreta: conservative approach

G. Di Luigi1, F. Patacchiola1, L. Di Stefano1, A. D’Alfonso1, A. Carta2, G. Carta1

1Department of Obstetrics and Gynecology, University of L’Aquila, L’Aquila2Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Rome (Italy)

Summary

Placenta accreta refers to any abnormally invasive placental implantation. Diagnosis is suspected postpartum with failed delivery of

a retained placenta. Massive obstetrical hemorrhage is a known complication, often requiring peripartum hysterectomy. The authors re-

port a case of placenta accreta in a primiparous patient with multinodular leiofibromyomatosis of the uterus following failed manual re-

movals of a retained placenta. They describe a conservative management in a stable patient desiring future fertility with a unilateral

prophylactic uterine artery embolization, a multidose regimen of methotrexate, and a subsequent abdominal myomectomy.

Key words: Placenta accreta; Methotrexate; MTX; Multidose methotrexate; Conservative treatment.

Revised manuscript accepted for publication February 26, 2013


XXXIX, n. 2, 2012

G. Di Luigi, F. Patacchiola, L. Di Stefano, A. D’Alfonso, A. Carta, G. Carta 597

Discussion

Placenta accreta is a severe obstetric complication in-

volving an abnormally deep attachment of the placenta,

through the endometrium and into the myometrium. There

are three forms of placenta accreta, distinguishable by the

depth of penetration: accreta, increta, and percreta. Placenta

accreta is the invasion of the myometrium which does not

penetrate the entire thickness of the muscle. This form of

the condition accounts for around 75% of all cases. The pla-

centa usually detaches from the uterine wall relatively eas-

ily, but women who encounter placenta accreta during

childbirth are at great risk of hemorrhage during its re-

moval. This commonly requires surgery to stem the bleed-

ing and fully remove the placenta, and in severe forms can

often lead to a hysterectomy or be fatal.

One of the potentially catastrophic obstetric complica-

tions, placenta accreta is alarmingly on the rise in the de-

veloped as well as developing world given the current trend

towards elective repeat cesarean sections [5]. The incidence

of placenta accreta is considered between one in 7,000 to as

high as one in 540 pregnancies [6]. It is a life threatening

condition associated with high maternal morbidity and

mortality rate reaching as high as seven percent [7]. The

risk factors for placenta accreta are previous uterine sur-

gery (myomectomy or cesarean sections, multiple cesare-

ans are present in over 60% of placenta accreta cases),

previous dilation and curettage (which is used for many in-

dications including miscarriage, termination, and postpar-

tum hemorrhaging), placenta previa (placenta accreta

affects around ten percent of cases of placenta previa), ad-

vanced maternal age, multiparity, smoking, Asherman’s

syndrome, and presence of fibroids [8, 9, 10]. A thin de-

cidua can also be a contributing factor to such trophoblas-

tic invasion. Some studies suggest that the rate of incidence

is higher when the fetus is female [11].

It is important to make an early and accurate diagnosis for

appropriate management and reduction of associated mor-

bidity, thereof, and prenatal diagnosis may be established

by ultrasound, colour Doppler, and magnetic resonance im-

aging [7]. Premature delivery and subsequent complications

are the primary concerns for the baby. Bleeding during the

third trimester may be a warning sign that placenta accreta

exists, and when placenta accreta occurs, it commonly re-

sults in a premature delivery. The placenta usually has dif-

ficulty separating from the uterine wall. The primary

concern for the mother is hemorrhaging during manual at-

tempts to detach the placenta. Severe hemorrhaging can be

life threatening. Other concerns involve damage to the

uterus or other organs (percreta) during removal of the pla-

centa. Hysterectomy is a common therapeutic intervention,

but the results involve the loss of the uterus and the ability

to conceive. There is nothing a woman can do to prevent

placenta accreta, and there is little that can be done for treat-

ment once placenta accreta has been diagnosed. The safest

treatment is a planned cesarean section and abdominal hys-

terectomy if placenta accreta is diagnosed before birth [12,

13]. Conservative treatment can also be uterus sparing but

may not be as successful and has a higher risk of complica-

tions [13]. Though traditional management of this entity has

centered upon hysterectomy, but there has been a gradual

shift towards its management which involves uterine con-

servation and leaving the adherent placenta in situ with ei-

ther a) adjuvant treatment with methotrexate [14] or b) by

simply awaiting its spontaneous resorption [8], with the pos-

sibility to perform a complementary uterine artery em-

bolization [15]. Percutaneous embolization was initially

performed to control traumatic [16] or tumor bleeding [17,

18]. The first reported use of transcatheter arterial em-

bolization of postpartum hemorrhage was described by

Brown et al. [19] in 1979. The use of methotrexate in the

conservative treatment of the placenta accreta left in situ

was described for the first time by Arulkumaran in 1986:

oral methotrexate allowed the expulsion of the placenta at a

distance of 11 days after its administration [20]. Tong et al.[21] pioneered the conservative method by administering

systemic methotrexate. The outcome varies widely ranging

from expulsion at seven days to progressive resorption in

roughly six months [22]. Courbiere et al. [15] conducted a

study on conservative management in which placenta acc-

reta was always left in situ with one of the following asso-

ciated treatments: bilateral hypogastric artery ligation,

medical treatment with methotrexate or uterine artery em-

bolisation. Placental resorption occurred in the majority of

their cases with no report of maternal mortality.

Conclusion

Conservative management appears to be a safe alterna-

tive to the extirpative management and is a logical option

in well-selected hemodynamically stable patients with ad-

herent placenta. Antepartum diagnosis should be improved

among patients with a high risk profile for placenta accreta

in order to optimize conservative strategy. Conservative

treatment for placenta accreta can assist women to avoid

hysterectomy and involves a low rate of severe maternal

morbidity in centers with adequate equipment and re-

sources.

References

[1] Wu S., Kocherginsky M., Hibbard J.U.: “Abnormal placentation:

twenty-year analysis”. Am. J. Obstet. Gynecol., 2005, 192, 1458.

[2] Khong T.Y., Robertson W.B.: “Placenta creta and placenta praevia

creta”. Placenta, 1987, 8, 399.

[3] Wright J.D., Devine P., Shah M., Gaddipati S., Lewin S.N., Simpson

L.L. et al.: “Morbidity and mortality of peripartum hysterectomy”.

Obstet. Gynecol., 2010, 115, 1187.

[4] Okogbenin S.A., Gharoro E.P., Otoide V.O., Okonta P.: “Obstetric

hysterectomy: fifteen years’ experience in a Nigerian tertiary cen-

tre”. J. Obstet. Gynaecol., 2003, 23, 356.

[5] Khong T.Y.: “The pathology of Placenta accreta – a worldwide epi-

demic”. J. Clin. Pathol., 2008, 61, 1243.

[6] Wu S., Kocherginsky M., Hibbard J.U.: “Abnormal placentation:

twenty-year analysis”. Am. J. Obstet. Gynecol., 2005, 192, 1458.

[7] Resnik R.: “Diagnosis and management of placenta accreta”. ACOGClin. Rev., 1999, 4, 8.

[8] Fergal M.: “Placenta accreta percreta”. Contemporary Obstet. Gy-necol., 2002, 4, 116.

[9] Capella-Allouc S., Morsad F., Rongières-Bertrand C., Taylor S., Fer-

nandez H.: “Hysteroscopic treatment of severe Asherman's syndrome

and subsequent fertility”. Hum. Reprod., 1999, 14, 1230.

[10] Al-Serehi A., Mhoyan A., Brown M., Benirschke K., Hull A., Pre-

torius D.H.: “Placenta accreta: An association with fibroids and Ash-

erman syndrome”. J. Ultrasound Med., 2008, 27, 1623.

[11] American Pregnancy Association (January 2004) 'Placenta Accreta'.

[12] Johnston T.A., Paterson-Brown S.: “Placenta praevia, placenta prae-

via accreta and vasa praevia: diagnosis and management”. Green-

top Guideline No. 27. Royal College of Obstetricians and

Gynecologists (January 2011).

[13] Oyelese, Yinka; Smulian, John C.: “Placenta Previa, placenta acc-

reta, and vasa previa”. Obstet. Gynecol., 2006, 107, 927.

[14] Flama F., Karlstom P.O., Bjourn C., Lena G.: “Methotrexate treat-

ment for retained placental tissue”. Eur. J. Obstet. Reprod. Biol.,1999, 83, 127.

[15] Courbiere B., Bretelle F., Porcu G., Gamerre M., Blanc B.: “Con-

servative treatment of placenta accreta”. J. Gynecol. Obstet. Biol.Reprod. (Paris), 2003, 32, 549.

[16] Margolies M.N., Ring E.J., Waltman A.C., Kerr W.S. Jr., Baum S.:

“Arteriography in the management of hemorrhage from pelvic frac-

tures”. N. Engl. J. Med., 1972, 287, 317.

[17] Rosch J., Dotter C.T., Brown M.J.: “Selective arterial embolization:

a new method for control of acute gastrointestinal bleeding”. Radi-ology, 1972, 102, 303.

[18] Goldstein H.M., Medellin H., Ben-Menachem Y., Wallace S.: “Tran-

scatheter arterial embolization in the management of bleeding in the

cancer patient”. Radiology, 1975, 115, 603.

[19] Brown B.J., Heaston D.K., Poulson A.M., Gabert H.A., Mineau

D.E., Miller F.J. Jr.: “Uncontrollable postpartum bleeding: a new ap-

proach to hemostasis through angiographic arterial embolization”.

Obstet. Gynecol., 1979, 54, 361.

[20] Arulkumaran S., Ng C.S., Ingemarsson I., Ratnam S.S.: “Medical

treatment of placenta accreta with methotrexate”. Acta Obstet. Gy-necol. Scand., 1986, 65, 285.

[21] Tong S.Y.P., Tay K.H., Kwek Y.C.K.: “Conservative man-agement of

placenta accreta: Review of three cases”. Singapore Med. J., 2008,

49, 156.

[22] Gupta D., Sinha R.: “Management of placenta accrete with oral

methotrexate”. Int. J. Gynaecol. Obstet., 1998, 60, 171.


G. DI LUIGI, M.D.



U.O. Ginecologia ed Ostetricia DU

Ospedale Civile “San Salvatore”

67100 Coppito, L’Aquila (Italy)


Placenta accreta: conservative approach598

599

Introduction

Endometriosis is the existence of endometrial glands and

stroma outside the uterine cavity. Ectopic endometrial tissue

is commonly found at pelvic region, but it can be found any-

where in the body [1]. It can be found in the extrapelvic

areas such as the eyes, kidneys, adrenal glands, lungs, in-

testines, umbilicus, diaphragm, gall bladder, heart, liver,

bones, and central and peripheral nervous systems [2]. There

are several theories about the etiology of endometrial tissue

outside the uterine cavity. These include metaplasia, retro-

grade menstruation, venous and lymphatic metastases, and

mechanical implantation. Endometrioma is a well-defined

form of endometriosis. Incisional endometriosis (IE) gen-

erally occurs after hysterectomy, cesarean section, epi-

siotomy, tubal ligation, and trocar entry during laparoscopy

and amniocentesis [3].

The authors present a case of endometrioma in the ab-

dominal wall, which was treated with local excision.

Case Report

A 33-year-old woman had a cesarean section five years ago.

She was admitted to this clinic complaining of left lower quad-

rant abdominal pain and swelling which was more severe during

menstruation. A painful firm mass was palpated at the middle of

the cesarean incision scar during a physical exam. Ultrasono-

graphic examination showed a 23 x 20 mm hypoechoic solid le-

sion with irregular contours. Magnetic resonance imaging (MRI)

was performed to delineate the relationship between the mass and

other intra-abdominal organs. MRI showed a fibrous soft tissue

component in the rectus abdominal muscle which was not related

to the intra-abdominal organs and indistinguishable from muscle

contours (Figure 1). Subsequently, surgical excision was per-

formed and the mass was widely excised, forming a three-cm de-

fect in the abdominal wall (Figure 2).

Microscopic examination revealed endometrial gland structures

with endometrial stroma in adipose tissue in sections of specimens,

indicative of endometriosis. During the pathological examination,

the fibroadipose tissue was found with the neighboring hemor-

rhagic areas. The lumen of histiocytes and neutrophils in a single-

row that contained the structure of the endometrial glands were

lined by endometrial epithelium. Around the areas of hemorrhage

showing an endometrial stromal structure in a single-row colum-

nar epithelium lined by endometrial gland structures was observed

(Figure 3). The patient recovered uneventfully and did not report

any symptoms of recurrence without any medical treatment four

months after surgery.

Discussion

Abdominal wall endometriosis is the most common form

of extrapelvic endometriosis. It is seen most frequently in

women 20-40 years of age, and generally detected two to

five years after cesarean section [1]. In the present case, the

patient was 33-years-old, and became symptomatic five

years after the cesarean section. In a study of post-cesarean

cases, 0.2% of the cases developed incisional endometrioma

after two years or more [4]. Pathogenesis is thought to be

due to implantation, direct invasion, and vascular/lymphatic

invasion. The diagnosis of scar endometriosis can be diffi-

cult despite specific symptoms, such as pain and swelling

during menstruation. Less frequently, it can be seen as a

mass unrelated to menstrual cycles [5]. The differential di-

agnosis of IE includes hernia, hematoma, lymphadenopa-

thy, lymphoma, lipoma, abscess, subcutaneous cyst, suture

granuloma, neuroma, soft tissue sarcoma, and metastatic

cancer [5]. Fine-needle aspiration biopsy, ultrasound, com-

puted tomography (CT), and MRI are valuable for the pre-

operative diagnosis [6, 7]. In this case, the patient had pain

and swelling during menstruation. Her work-up included

imaging by ultrasound and MRI, and she underwent sur-

gery after the determination of the differential diagnosis.

During the surgical excision for the treatment of IE, the

mass must be removed with a ten-mm margin of healthy tis-

sue, and without rupturing and leaving behind endometri-

oma tissue. Recurrence after resection is seen in 4.3% of

cases and the possibility of malignancy should be considered

if the mass grows rapidly or recurs [5]. Mesh or tissue graft

Rectus abdominal muscle endometriosis in a patient with

cesarian scar: case report

L. Şahin1, O. Dinçel2, B. Aydın Türk3

1Department of Obstetrics and Gynecology, Academia Hospital, Sanliurfa; 2Department of Surgery, Gölbaşı State Hospital, Adiyaman3Department of Pathology, Adiyaman Training and Research Hospital, Adiyaman (Turkey)

Summary

Endometriosis is the existence of endometrial tissue out of the intrauterine cavity. Abdominal wall endometrioma is a well-defined

mass composed of endometrial glands and stroma that may develop after gynecologic and obstetrical surgeries . A cyclic painful mass

at the site of a cesarean section scar is most likely due to an endometrioma, and wide local excision is the advisable treatment. The au-

thors present a case of endometrioma in the abdominal wall, which was treated with local excision.

Key words: Endometriosis; Scar; Cesarean section.



XXXIX, n. 2, 2012

may be utilized in order to repair the defect that may occur

after the excision of IE [8]. In this case, the mass was ex-

cised with one-cm margins of healthy tissue. As the fascial

defect was small and tension free, it was primarily repaired.

Rarely, IE can be multifocal. Since the most common site of

an incision lesion is at an end, to prevent direct inoculation,

Evsen et al. suggested that while suturing the fascia at the

end of the incision, the surgeon or assistant must use clean

surgical equipment instead of their fingers to retract the sub-

cutaneous tissue in the incision [9].

Conclusions

In order to make the preoperative diagnosis of incisional

endometrioma, a detailed history should be taken, and a

physical examination should be performed. Additionally,

radiological investigation and fine-needle aspiration

biopsy should also be performe d. Endometrioma should

be the top differential diagnosis in patients who have pain

and swelling occurring every menstrual cycle on the scar

following gynaecological surgeries.

References

[1] Horton J.D., DeZee K.J., Ahnfeldt E.P., Wagner M.: “Abdominal wall

endometriosis: A surgeon’s perspective and review of 445 cases”. Am.J. Surgery, 2008, 196, 207.

[2] Rehman J., Yildirim G., Khan S.A., Chughtai B., Nezhat F.: “A case

of successful laparoscopic resection of adrenal gland endometrio-

sis”. Fertil. Steril., 2008, 90, 2015.

[3] Francia G., Giardiello C., Angelone G., Cristiano S., Finelli L., Tra-

montano G.: “Abdominal wall endometrioma near caserean delivery

scars”. J. Ultrasound Med., 2003, 22, 1041.

[4] Gaunt A., Heard G., McKain E.S., Stephenson B.M.: “Caesarean scar

endometrioma”. Lancet, 2004, 364, 368.

[5] Teng C.C., Yang H.M., Chen K.F., Yang C.J., Chen L.S., Kuo C.L.:

“Abdominal wall endometriosis:an overlooked but possibly prevent-

able complication”. Taiwan J. Obstet. Gynecol., 2008, 47, 42.

[6] Balleyguier C., Chapron C., Chopin N., Hélénon O., Menu Y.: “Ab-

dominal wall and surgical scar endometriosis:result of magnetic res-

onance imaging”. Gynecol. Obstet. Invest., 2003, 55, 220.

[7] Simsir A., Thorner K., Waisman J., Cangiarella J.: “Endometriosis in

abdominal scars: a report of three cases diagnosed by fine-needle as-

piration biopsy”. Am. Surg., 2001, 67, 984.

[8] Patterson G.K., Winburn G.B.: “Abdominal wall endometriomas: re-

port of eight cases”. Am. Surg., 1999, 65, 36.

[9] Evsen M.S., Sak M.E., Yalinkaya A., Firat U., Caca F.N.: “A case of

bifocal endometriosis involving a pfannenstiel incision”. Ginekol.Pol. 2011, 82, 71.


L. SAHIN, M.D.


Academia Hospital, Sanliurfa (Turkey)


L. Şahin, O. Dinçel, B. Aydın Türk600

Figure 1. — MRI scan of the mass at the level of the rectus

abdominal muscle.

Figure 2. — Extensive excision of the mass.

Figure 3. — Areas of hemorrhage showing endometrial stromal

structure in a single-row columnar epithelium lined by endome-

trial gland structures (H&E stain, X200).

Fig. 1 Fig. 2

Fig. 3

601

Introduction

Uterine leiomyomas are common, benign smooth muscle

tumours of the uterus. They are found in nearly half of

women over the age of 40 years and infrequently cause

complications. Uterine leiomyomas, also colloquially

known as fibroids, tend to grow under the influence of es-

trogen, and regress when estrogen levels are reduced. Thus,

growth frequently occurs during pregnancy, followed by

regression after delivery. Most uterine fibroids are asymp-

tomatic, but some women develop heavy menstrual flow

(menorrhagia), which often cause anemia, bleeding be-

tween periods, pain, infertility or subinfertility, pelvic pres-

sure, stress urinary incontinence, and ureteral obstruction.

The diagnosis of uterine leiomyoma is usually based on the

clinical findings of an enlarged, irregularly shaped, firm

uterus, which may or may not be tender. Sometimes the di-

agnosis is unclear, and diagnostic tests are used to delin-

eate fibroids and exclude other problems. Diagnostic

techniques include ultrasound, magnetic resonance imaging

(MRI), and computed tomography (CT) scanning, la-

paroscopy, and histological examination.

A variety of degenerative changes may occur in leiomy-

omas. The larger the leiomyoma, the more likely it will be

that a degenerative component will be present. Several

mechanisms are likely to contribute to this phenomenon,

including ischemia and hormonal effects. More than one

pattern of degeneration may be observed in the same

leiomyoma. These changes include hyaline, cystic, red, cal-

cific, and fatty degenerations. The most common of these

is hyaline degeneration, whereby expanded septa lose their

fibrillary structures and assume a uniform, pale,

eosinophilic, translucent appearance resembling ground-

glass. Degenerative changes may be localized or affect ex-

tensive areas of the tumour, and occasionally even its en-

tirety. Surviving muscle cells may orient themselves into

lacework patterns that accompany degenerative changes in

leiomyomas.

The terms mucoid and myxoid degeneration are used to

describe changes that are similar to hyaline changes, with

or without cystic formation. In mucoid degeneration, the

matrix typically appears to be mucinous in nature. There is

no difference in practical terms between mucoid and myx-

oid forms of degeneration, thus the two terms are often used

interchangeably. However, extensive mucoid degeneration

is rare among these changes. Here, the authors report a case

of uterine multiple leiomyomas that were complicated by

mucoid degeneration.

Case Report

A 37-year-old Han woman, gravida 2, para 1, with a history of

one cesarean section in 1996, was admitted after presenting with

lumbosacral swelling and pain for more than two months. These

symptoms had worsened over the previous week. Gynaecologi-

cal examination revealed a non-tender anteverted uterus, which

was enlarged to the size of a two-month pregnancy, with moder-

ate texture and mobility. A mass that was four cm in diameter was

discovered in the left adnexal area, and another mass, six cm in di-

ameter, was discovered in the right adnexal area. The two masses

were moderate in texture with no clear borders but had infiltrated

the uterus.

B-mode ultrasound examination revealed an anteverted uterus

that measured 6.4 × 4.6 × 5.0 cm, with a regular morphology. An

intrauterine device was observed in the correct location. One en-

hanced echo image showed a mass that measured 4.8 × 3.1 cm in

the left adnexal area, without a clear border separating it from the

left ovary. One cystic dark area, measuring 6.0 × 4.6 cm, was de-

tected in the right adnexal region. The wall of this cyst appeared

Uterine multiple leiomyomas complicated by extensive

mucoid degeneration: case report

L. Yu, N. Yin, J. Guo

Department of Obstetrics and Gynaecology, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing (P.R. China)

Summary

Uterine leiomyomas are the most common form of gynaecological tumours, and are exclusively benign. Only a few are associated with

sarcomatous change. It is therefore important for the radiologist to be familiar with their range of appearances on magnetic resonance im-

aging (MRI) scans to distinguish them from other significant uterine pathologies, such as ovarian neoplasms, that require different man-

agement strategies. Here, the authors present the case of a 37-year-old Han woman, gravida 2, para 1 (cesarian section in 1996), who

presented with a two-month history of lumbosacral swelling and pain. Physical examination revealed a pelvic mass and she was admit-

ted with the presumptive diagnosis of an ovarian neoplasm. Laparotomy revealed multiple degenerated neoplasms that were benign in

appearance, which was pathologically confirmed. A literature review was conducted to explore the natural history of uterine leiomyomas

and their underlying etiopathogenesis. The optimal imaging modalities are also defined in the report, which enable the correct preopera-

tive diagnosis to be made in order to optimize the care of women by multiple uterine leiomyomas.

Key words: Uterine leiomyomas; Gynaecological tumour; Aetiopathogenesis.



XXXIX, n. 2, 2012

to be thick and ill-defined, and a dense reflection to the right could

be detected from the cystic wall. A fluid dark area, measuring 1.1

cm in diameter, was observed in the pouch of Douglas. The re-

sults of the following examinations and tests were within the nor-

mal range: routine blood tests; coagulation function; hepatic and

renal functions; blood biochemistry; blood glucose; carcinoma

antigen 125 (CA 125); alpha fetal protein (AFP); carcinoma em-

bryonic antigen (CEA); and electrocardiography. No positive find-

ings were detected with an ultrasound examination of the liver,

gallbladder, pancreas or spleen. A barium enema check also

yielded negative results.

The patient was admitted to hospital with the presumptive di-

agnosis of an ovarian neoplasm in November 2009. A laparotomy

was performed under general anaesthesia. At laparotomy, the

uterus was found to be slightly enlarged, and two soft masses,

measuring three cm in diameter, were found in the bilateral uter-

ine horns (Figure 1). There were multiple dark red bubbles, rang-

ing in size from one to three cm, attached to the anterior uterine

wall. A four-cm cyst was found in the left mesosalpinx, and an-

other six-cm cyst was found in the right mesosalpinx. Both were

soft in texture and were composed of multiple cysts with gelati-

nous contents. Similar neoplasms were also detected in the bilat-

eral broad ligaments of the uterus. The neoplasm in the left

mesosalpinx was stripped and sent for frozen section examina-

tion. The findings suggested the diagnosis of a benign soft tissue

neoplasm. Both ovaries appeared to be normal in both morphol-

ogy and size.

When the masses from the uterine horns were incised, soft and

gelatinous tissue with indistinct boundaries was observed. Patho-

logical examination suggested the diagnosis of an endometrial

mesenchymal neoplasm, which was likely to be benign (Figure 2).

Consequently, a total hysterectomy and bilateral salpingectomy

were performed, and the neoplasms in the bilateral broad ligaments

were stripped using blunt dissection. The features of these neo-

plasms were the same as those from the mesosalpinx. There was no

obvious abnormality in the endometrium upon dissection. Gelati-

nous tissue with no observable envelope was scattered within the

muscular layer of the uterus. Examination of the pathology of

paraffin-embedded sections yielded a diagnosis of multiple uterine

leiomyomas with conspicuous mucoid degeneration. The patient

was discharged from hospital after rehabilitation. No recurrence

was observed after a 12-month follow-up period.

Discussion

Molecular biologists have begun to probe the etiology

of uterine leiomyomas, exploiting DNA methylation dif-

ferences between polymorphic loci on both active and in-

active X chromosomes to confirm that each leiomyoma is

derived from a single transformation event [1]. Most im-

portantly, these studies also suggest that each tumour is a

distinct clone, which reinforces the notion that smooth

muscle tumourigenesis is exceedingly common. The ge-

netic mechanisms that initiate and promote the growth of

leiomyomas must occur frequently, but are not fully un-

derstood. However, cytogenetic analysis of these benign

smooth muscle tumours has already revealed some impor-

tant clues. Almost half of leiomyomas have chromosomal

rearrangements that are large enough to be seen in G-

banded karyotypes. These chromosomal rearrangements

are generally simple, which is in sharp contrast to the aber-

rations seen in leiomyosarcomas. To date, recurrent aber-

rations have allowed the definition of seven cytogenetic

subgroups: t(12;14)(q14-15;q23-24); del(7)(q22q32); re-

arrangements of 6p21 and 10q22; trisomy 12; and dele-

tions of 3q and 1p. Of these, the translocation between

chromosomes 12 and 14 and the rearrangements involv-

ing chromosome 6 are perhaps best understood. Both re-

arrangements involve genes for two closely related

non-histone chromatin proteins: HMGA1 at 6p21 and

HMGA2 at 12q15 [2, 3]. There are few reports that de-

scribe the various mechanisms by which uterine leiomy-

omas degenerate.

In the present patient, the degeneration of multiple uter-

ine leiomyomas led to the formation of variously-sized,

L. Yu, N. Yin, J. Guo602

Figure 1. — Macroscopic appearance of the lesion showing the longitudinal section of the uterus. The tissue samples show scattered

intramural myoma tissue without a capsule, as well as myomas in the adnexa bilaterally, and the broad ligament.

Figure 2. — Microscopic features of the degenerated leiomyoma: a) mucoid degeneration; b) myoma tissue; and c) normal myome-

trial tissue. There is a clear boundary between the tumour cells and the normal myometrial tissue. The spindle-shaped tumour cells

are arranged in a staggered pattern, and the mucoid degeneration is obvious. The atypia of the tumour cells is not remarkable.

Fig. 1 Fig. 2

Uterine multiple leiomyomas complicated by extensive mucoid degeneration: case report 603

hollow masses filled with neoplastic tissue, which were liq-

uefied due to the lack of a blood supply. The mucoid con-

tents in the cavities modified the texture of the leiomyomas

to soft masses. Given the soft texture of the tissue, malig-

nant ovarian tumour and/or malignant uterine tumours had

to be considered in the differential diagnosis. Intraopera-

tive pathologic diagnosis was very helpful in the differen-

tial diagnosis.

Degenerated leiomyomas, especially those with larger

volumes, often bring difficulties in differential diagnosis

and corresponding clinical decision-making. A MRI scan

is the most accurate technique for detecting and localizing

leiomyomas. Degenerated leiomyomas have variable ap-

pearances on T2-weighted images and contrast-enhanced

images. The common types of degeneration are hyaline (>

60% of cases), cystic (approximately four percent), myx-

oid, and red. Edema is not a phenomenon of degeneration,

but is a common histopathological finding (approximately

50% of cases). Hemorrhage, necrosis, and calcification

(approximately four percent of cases) may also be ob-

served. Specific types of unusual leiomyomas include

lipoleiomyoma and myxoid leiomyoma, which may have

MRI features that are sufficiently characteristic to allow

differentiation from other gynaecological and non-gynae-

cological diseases. Intravenous leiomyomatosis, metasta-

tic leiomyoma, diffuse leiomyomatosis, and peritoneal

disseminated leiomyomatosis represent unusual growth

patterns. Other unusual growth patterns are retroperitoneal

growth, parasitic growth, and a pattern that may occur in

cervical leiomyoma [4].

On T2-weighted MRI images, non-degenerated leiomy-

omas appear as well-circumscribed masses of decreased sig-

nal intensity; however, cellular leiomyomas can have

relatively higher signal intensities on T2-weighted images

and demonstrate enhancement on contrast material-enhanced

images. The differential diagnosis of leiomyomas includes

adenomyosis, solid adnexal mass, focal myometrial con-

traction, and uterine leiomyosarcoma [5]. For patients who

are symptomatic, medical or surgical treatment may be indi-

cated. MRI also has a role in treatment of leiomyomas by as-

sisting in surgical planning and monitoring response to

medical therapy. The use of 18F-FDG positron emission to-

mography/CT (PET/CT) may also play a role in the diagno-

sis of uterine leiomyoma and can sometimes be helpful in

the evaluation of related degeneration [6].

As leiomyomas are the most common gynaecological tu-

mours, and are almost exclusively benign, it is important

to be familiar with the variety of MRI appearances of uter-

ine leiomyomas in order to distinguish them from other sig-

nificant diseases.

Acknowledgement

This work was supported by a grant (No. 8107050) from

the National Natural Science Foundation of China.

References

[1] Hashimoto K., Azuma C., Kamiura S., Kimura T., Nobunaga T., Kanai

T. et al.: “Clonal determination of uterine leiomyomas by analyzing

differential inactivation of the X-chromosome-linked phosphoglyc-

erokinase gene”. Gynecol. Obstet. Invest., 1995, 40, 204.

[2] Hennig Y., Wanschura S., Deichert U., Bartnitzke S., Bullerdiek J.:

“Rearrangements of the high mobility group protein family genes and

the molecular genetic origin of uterine leiomyomas and endometrial

polyps”. Mol. Hum. Reprod., 1996, 2, 277.

[3] Williams A.J., Powell W.L., Collins T., Morton C.C.: “HMGI(Y) ex-

pression in human uterine leiomyomata. Involvement of another high-

mobility group architectural factor in a benign neoplasm”. Am. J.Pathol., 1997, 150, 911.

[4] Ueda H., Togashi K., Konishi L., Kataoka M.L., Koyama T.: “Un-

usual appearances of uterine leiomyomas: MR imaging findings and

their histopathologic background”. Radiographics, 1999, 19, S131.

[5] Murase E., Siegelman E.S., Outwater E.K., Perez-Jaffe L.A., Tureck

R.W.: “Uterine leiomyomas: histopathologic features, MR imaging

findings, differential diagnosis, and treatment”. Radiographics, 1999,

19, 179.

[6] Kitajima K., Murakami K., Yamasaki E., Kaji Y., Sugimura K.: “Stan-

dardized uptake values of uterine leiomyoma with 18F-FDG PET/CT:

variation with age, size, degeneration, and contrast enhancement on

MRI”. Ann. Nucl. Med., 2008, 22, 505.


J. GUO, M.D.


Daping hospital, 10 Changjiang Zhilu

Chongqing 400042 (P.R. China)


Introduction

Ovarian pregnancy (OP) is a rare form of ectopic preg-

nancy, constituting approximately three percent of all ec-

topic pregnancies [1]. Assisted reproductive technologies

have been associated with an increased incidence of ectopic

pregnancy. In cases of ectopic pregnancy following in vitro

fertilization-embryo transfer (IVF-ET), the prevalence of

OP has been reported to be six percent [2]. Early diagnosis

of OP is mandatory to ensure the success of life-saving la-

paroscopic conservative surgery.

Several reports of unruptured OP in IVF-ET patients at-

tributed successful treatment by laparoscopic surgery to

early ultrasonography diagnosis, close follow-up, and

awareness of the high-incidence of ectopic pregnancy, in-

cluding OP, compared with natural pregnancy [3]. Diag-

nosing OP in the case of natural conception is difficult,

especially when the date of conception is not known. Al-

though a low serum human chorionic gonadotropin (HCG)

level facilitates early recognition of abnormal implantation

[3], repeat measurement is usually needed.

Transvaginal ultrasonography (TVUS) is an important

tool for early detection of OP. Comstock et al reported that

an echolucent ovarian area with a wide echogenic ring was

a diagnostic sonographic finding of OP [4]. Here, the au-

thors present a case where a lesion with this typical ring

appearance compressed an adjacent echolucent sol of a cor-

pus luteum cyst in the ovary.

Case Report

A 31-year-old nulligravida woman presented to the present hos-

pital with amenorrhea and transient vaginal bleeding. She was un-

dergoing prednisolone therapy (three mg, daily) for treatment of

rheumatoid arthritis but had no history of pelvic inflammation, sur-

gery, or infertility. The chief complaint was a scant brownish vagi-

nal discharge; there were no other symptoms. A rapid urine preg-

nant test yielded positive results, and the HCG level on the following

day was 400 mIU/ml. The menstrual age was eight 4/7 weeks. Vagi-

nal ultrasonography showed no intrauterine gestational sac (GS) and

a normal left ovary without a lutein cyst (Figure 1a). There was no

evidence of cul-de-sac fluid or pelvic adhesions. The right ovary was

slightly enlarged, with a maximum diameter of 47 mm, and the pa-

tient complained of slight tenderness when it was pushed by the ul-

trasonography probe. In the right ovary, there was a echolucent area

(diameter, 20 mm) surrounded by an echogenic ring. The ring was

more echogenic than the ovarian stroma or adjacent corpus luteum,

an appearance consistent with GS. No fetal cardiac activity or yolk

sac was evident. A 25-mm corpus luteum cyst was compressed by

the adjacent ovarian mass (Figure 1b). The findings suggested a pro-

visional diagnosis of OP, and the patient elected surgical treatment.

During laparoscopy, the uterus and both fallopian tubes appeared

normal (Figure 2a), and no ascites or adhesions were seen. The right

ovary was enlarged because of a lutein cyst and a dark bluish mass

with a smooth external surface (Figure 2b). Wedge resection was

performed with monopolar electroscissors (Figure 2c), and the mass

was removed through a ten-mm trocar using a retrieval bag. The re-

sected tissue was cut in half (Figure 2d). Macroscopic examination

revealed chorionic villi within the mass and negative tissue mar-

gins. The lutein cyst was confirmed by cutting the surface. The re-

maining right ovary was not oversewn. Uterine curettage showed

no chorionic villi in the endometrium. The operative time was 80

minutes, and intraoperative blood loss was minimal. The patient

had an uneventful recovery and was discharged on postoperative

day five. Subsequent pathological diagnosis confirmed the diag-

nosis of OP. She became pregnant four months later and has ex-

perienced no complications.

Discussion

Spiegelberg published the first report describing the di-

agnostic criteria of OP. He stated that the fallopian tube on

the affected side must be intact and separate from the ovary,

the gestational sac must occupy the position of the ovary,

the ovary must be connected to the uterus by the utero-ovar-

604

Detection of unruptured ovarian pregnancy subsequently

successfully treated by conservative laparoscopic surgery:

a case report and review of the literature

H. Tsubamoto, Y. Wakimoto, R. Wada, R. Takeyama, Y. Ito, K. Harada

Department of Obstetrics and Gynecology, Hyogo College of Medicine, Hyogo (Japan)

Summary

Early detection of ovarian pregnancy (OP) is essential for successful laparoscopic conservative surgery. However, early preopera-

tive ultrasonography-based diagnosis is often difficult when fetal cardiac activity or the yolk sac is absent. The authors report a case

of OP diagnosed at eight weeks gestational age in a natural pregnancy. The patient presented with amenorrhea and transient vaginal

bleeding, and slight tenderness in the right ovary was noted during vaginal ultrasonography. Furthermore, ultrasonography showed a

gestational sac (GS) without fetal cardiac activity or yolk sac, consistent with OP, and an adjacent compressible lutein cyst. The uterus,

fallopian tubes, and left ovary were normal, and no cul-de-sac blood or ascites were found. Laparoscopy showed a two-cm mass par-

tially covering the right ovary, which contained an unruptured GS. Subsequently, the mass was removed, and OP was histologically

confirmed.

Key words: Laparoscopic surgery; Ovarian pregnancy; Ultrasonography.



XXXIX, n. 2, 2012

H. Tsubamoto, Y. Wakimoto, R. Wada, R. Takeyama, Y. Ito, K. Harada 605

ian ligament, and that ovarian tissue must be found in the

gestational sac wall [5]. The risk factors for OP include his-

tory of prior gynecologic surgery, use of intrauterine con-

traceptive devices, assisted reproduction, or endometriosis

[6]. The present case did not have known risk factors. Mar-

cus and Brinsden suggested that implantation in the ovary

occurs after reverse migration of the fertilized egg [3]. Ac-

cording to this theory, the fertilized egg may have adhered

to the ruptured follicle and thus remained in the ovary. La-

paroscopic resection of the GS and preservation of remain-

Figure 2. — Photograph of the right ovarian pregnancy during laparoscopic surgery. (a) Normal right fallopian tube. No adhesions

were seen. In this view, the right ovary appears normal. (b) Right ovary (reverse side), showing the GS (arrowhead) and lutein cyst

(arrow). (c) Wedge resection of GS. Cut surface, confirming lutein cyst. (d) Clos-eup view of chorionic villi within the resected GS.

Figure 1. — Transvaginal ultrasonography scan. (a) Normal uterus with an empty endometrial cavity. (b) Coexisting well-defined GS

(arrowhead) and lutein cyst (arrow); GS compressed an adjacent lutein cyst.

ing ovarian tissue is the preferred treatment for ovarian

pregnancy [7-15].

Early diagnosis of OP is vital to prevent emergency inva-

sive procedures, serious complications, or death. Raziel etal. reported that OP was diagnosed after laparoscopic exam-

ination or direct laparotomy in 20 patients from 1971 to 1989

[1]. Odejinmi et al and Choi et al. reported that 75% and 16%

cases of OP, respectively, were diagnosed before surgery [6,

7]. These findings are summarized in Table 1.

Technical advances in ultrasonography and the development

of more sensitive methods for HCG detection facilitate earlier

and more accurate non-invasive diagnosis of ovarian preg-

nancies. The finding of a round echogenic ovarian mass on ul-

trasonography in a pregnant patient suggests the diagnosis of

OP [4, 7]. However, once rupture occurs, the GS may resem-

ble a hemorrhagic corpus luteum sonographically and even

macroscopically at surgery. In this present case, the coexis-

tence within the ovary of an unruptured GS without fetal car-

diac activity or yolk sac and of a lutein cyst made the

ultrasonography-based diagnosis relatively easy. The coexis-

tence of GS and a lutein cyst within the ovary suggested OP.

Compressibility also helped to distinguish between a GS and

lutein cyst. The authors believe that the “coexistence and com-

pression” sign might be useful for the early diagnosis of OP.

This conservative procedure avoids excessive removal of

healthy ovarian tissue and allows young patients to maintain

their reproductive capability. In the present patient, laparo-

scopic surgery was successfully conducted before rupture of

OP. To avoid misdiagnosis, frozen section analysis of spec-

imens obtained at the time of surgery is advisable [16] in

order to detect chorionic villi in the surgical specimen.

Methotrexate is an effective therapeutic option for the

medical management of unruptured ectopic pregnancy.

However, in cases where diagnostic laparoscopy is neces-

sary, definitive surgical management is easily performed at

the same time [17-19]. Therefore, surgery is currently the

mainstay for management of OP.

References

[1] Raziel A., Golan A., Pansky M., Ron-El R., Bukovsky I., Caspi E.:

“Ovarian pregnancy: A report of twenty cases in one institution”. Am.J. Obstet. Gynecol., 1990, 163, 1182.

[2] Marcus S.F., Brinsden P.R.: “Analysis of the incidence and risk factors

associated with ectopic pregnancy following in-vitro fertilization and

embryo transfer”. Hum. Reprod., 1995, 10, 199.

[3] Marcus S.F., Brinsden P.R.: “Primary ovarian pregnancy after in vitro

fertilization and embryo transfer: Report of seven cases”. Fertil. Steril.,1993, 60, 167.

[4] Comstock C., Huston K., Lee W.: “The ultrasonographic appearance

of ovarian ectopic pregnancies”. Obstet. Gynecol., 2005, 105, 42.

[5] Spiegelberg O.: “Casuistry in ovarian pregnancy”. Arch. Gynaekol.,1878, 13, 73.

[6] Choi H.J., Im K.S., Jung H.J., Lim K.T., Mok J.E., Kwon Y.S.: “Clin-

ical analysis of ovarian pregnancy: A report of 49 cases”. Eur. J. Ob-stet. Gynecol. Reprod. Biol., 2011, 158, 87.

[7] Odejinmi F., Rizzuto M.I., Macrae R., Olowu O., Hussain M.: “Diag-

nosis and laparoscopic management of 12 consecutive cases of ovar-

ian pregnancy and review of literature”. J. Minim. Invasive Gynecol.,2009, 16, 354.

[8] Einenkel J., Baier D., Horn L.C., Alexander H.: “Laparoscopic therapy

of an intact primary ovarian pregnancy with ovarian hyperstimulation

syndrome”. Hum. Reprod., 2000, 15, 2037.

[9] Gavrilova-Jordan L., Tatpati L., Famuyide A.: “Primary ovarian preg-

nancy after donor embryo transfer: early diagnosis and laparoscopic

treatment”. JSLS, 2006, 10, 70.

[10] Var T., Tonguc E.A., Akan E., Batioglu S., Akbay S.: “Laparoscopic

conservative approach to ovarian pregnancies: two cases”. Arch. Gy-necol. Obstet., 2009, 280, 123.

[11] Priya S., Kamala S., Gunjan S.: “Two interesting cases of ovarian preg-

nancy after in vitro fertilization-embryo transfer and its successful laparo-

scopic management”. Fertil. Steril., 2009, 92, 394.e17. Epub 2009 April 28.

[12] Tobiume T., Shiota M., Umemoto M., Shimaoka M., Kotani Y.,

Hoshiai H.: “Ovarian pregnancy: a report of 3 cases diagnosed and

treated laparoscopically”. Acta Med. Kinki Univ., 2010, 35, 109.

[13] Koo Y.J., Choi H.J., Im K.S., Jung H.J., Kwon Y.S.: “Pregnancy out-

comes after surgical treatment of ovarian pregnancy”. Int. J. Gynaecol.Obstet., 2011, 114, 97.

[14] Dhorepatil B., Rapol A.: “A rare case of unruptured viable secondary

ovarian pregnancy after IVF/ICSI treated by conservative laparoscopic

surgery”. J. Hum. Reprod. Sci., 2012, 5, 61.

[15] Kashima K., Yahata T., Yamaguchi M., Fujita K., Tanaka K.: “Ovar-

ian pregnancy resulting from cryopreserved blastocyst transfer”. J.Obstet. Gynaecol. Res., 2012, DOI: 10.1111/j.1447.

[16] Chelmow D., Gates E., Penzias A.S.: “Laparoscopic diagnosis and

methotrexate treatment of an ovarian pregnancy: a case report”. Fer-til. Steril., 1994, 62, 879.

[17] Kudo M., Tanaka T., Fujimoto S.: “A successful treatment of left ovar-

ian pregnancy with methotrexate”. Nihon Sanka Fujinka GakkaiZasshi, 1988, 40, 811.

[18] Mittal S., Dadhwal V., Baurasi P.: “Successful medical management of

ovarian pregnancy”. Int. J. Gynaecol. Obstet., 2003; 80, 309.

[19] Kiran G., Guven A.M., Köstü B.: “Systemic medical management of

ovarian pregnancy”. Int. J. Gynaecol. Obstet., 2005, 9, 177.


H. TSUBAMOTO, M.D.


Hyogo College of Medicine,

Mukogawa 1-1 Nishinomiya, Hyogo 663-8501 (Japan)


Detection of unruptured ovarian pregnancy subsequently successfully treated by conservative laparoscopic surgery etc.606

Table 1. — Summary of findings in reports of OP. Studies published since 2000, excluding single case reports. Data reported byChoi and Koo for patients in the same institute during the same period. n, number of patients; IUD, intrauterine contraceptivedevice; OP, ovarian pregnancy; US, ultrasonography; NA, not available.

Risk factors Before surgery At surgery

Authors n Study period IUD usePrior surgery Post IVF No OP diagnosed Embryo or yolk Un- Wedge

or endometriosis follow-up symptom by US sac detected by US ruptured resection

Comstock et al. [4] 6 1990-2003 0 NA 0 0 NA 2 (33%) 4 (67%) NA

Odejinmi et al. [7] 12 2003-2008 2 (17%) NA NA NA 9 (75%) NA 0 11 (92%)

Var et al. [10] 2 NA 0 0 0 0 1 1 2 2

Priya et al. [11] 2 2001-2005 0 0 2 1 2 2 0 1

Tobiume et al. [12] 3 NA 0 1 0 0 0 0 0 3

Choi et al. [6] 49 1996-2009 2 (4%) NA 5 (10%) 9 (18%) 8 (16%) NA NA 39 (80%)

Koo et al. [13] 28 1996-2009 2 (7%) 18 (64%) 5 (18%) 3 (11%) NA 17 (61%) NA 26 (93%)

607

Introduction

Reversible posterior leukoencephalopathy syndrome

(RPLS) or posterior reversible encephalopathy syndrome

(PRES) was first described by Hinchey in 1996 [1].

The syndrome is acute with diverse clinical presenta-

tions and characteristic computed tomography (CT) scan

or magnetic resonance imaging (MRI) features.

This clinico-neuroradiological entity is a complication

of multiple clinical conditions: hypertension, pre-eclamp-

sia and eclampsia, renal failure, therapy with immuno-

suppressant or high dose of cytotoxic medications

(cyclosporin A and tacrolimus) for autoimmune disease,

and allogeneic bone marrow or organ transplantation.

Other clinical conditions are characterized by uraemia and

porphyria [2]. The association of PRES with toxemia of

pregnancy is established [3].

The clinical hallmarks of this syndrome are: headache,

altered mental functioning, seizures, and loss of vision

associated with white matter changes. This changes are

suggestive of edema mainly in the posterior regions of

the cerebral hemispheres, but also involving the brain-

stem, cerebellum, and other cerebral areas [4]. The find-

ings on neuroimaging in PRES include non-enhancing

white matter abnormalities that appear as areas of low

attenuation on CT scan and appear hypointense on T1-

weighted imaging and hyperintense on T2-weighted

MRI. The lesions are mainly seen in the posterior

regions of the cerebral hemispheres. These abnormali-

ties partially or completely resolve on follow-up scan-

ning, thereby, suggesting subcortical edema without

infarction [5].

The white matter is composed of myelinated-fiber tracts

in a cellular matrix of glial cells, arterioles, and capillar-

ies that makes it susceptible to the accumulation of fluid

in the extracellular spaces [4]. It is suggested that verte-

bro-basilar territory, owing to its relatively sparse sympa-

thetic innervation, may experience preferential disruption

of autoregulatory mechanisms, leading to increased per-

fusion and edema [6].

Case Report

A 22-year-old woman, 36-week pregnant, weighing 63 kg,

gravida 1, presented to the present department after she experi-

enced headache, blurring of vision, and acute onset of general-

ized seizure.

The results of her general examination were unremarkable.

Blood pressure was 140/90 mmHg with a heart rate of 95 beats

per minute. Respiratory rate was 17 breaths per minute with an

O2 saturation of 99%. Body temperature was 36.3°C. Electro-

cardiogram was normal.

Her investigations included: haemochrome, serum elec-

trolytes, serum calcium, serum magnesium, liver function tests,

and coagulation profile were within normal limits. Biochemical

values were: Hgb 11.7 g/dl, Htc 37.2%, WBC 13,130/mm³; PLT

220,000/mm3, AST 29 U/l, ALT 32 U/l, amylase 26 U/l, LDH

450 U/l; her coagulation parameters were: prothrombin time

(PT): 113%, activated prothrombin time (APTT): 26 sec, INR

0,97. serum level of sodium was 138 mmol/l, potassium 3.6

mmol/l, and calcium 9.0 mmol/l. Renal function test and urine

analysis were normal.

A diagnosis of eclampsia was made and the patient was trans-

ferred to the operating room where the patient underwent an

emergency lower segment cesarian section under spinal anaes-

thesia. She gave birth to a healthy baby with a five- minute

Apgar score of 9. Postoperatively she was transferred to the

medical intensive care unit.

She underwent an invasive monitoring of vital parameters,

assisted ventilation, neurological counselling, brain and thorax

CT scans, and spinal tap. At the time, she was treated with nife-

pidine and fenobarbital.

Neurological examination, lumbar puncture, and thorax CT

was normal. Brain CT showed extensive, bilateral white matter

Reversible posterior leukoencephalopathy syndrome

in pregnancy: a case report

F. Patacchiola1, V. Franchi1, G. Di Febbo1, A. Carta2, G. Carta1

1Department of Life, Health, and Environmental Sciences, University of L’Aquila, L’Aquila2University of Medicine “Tor Vergata”, Rome (Italy)

Summary

Posterior reversible encephalopathy syndrome (PRES), is an acute, neurotoxic state. It is a very rare clinico-neuroradiological entity,

and it is a complication of multiple clinical conditions. The association of PRES with toxemia in pregnancy is established. In this arti-

cle, the authors discuss the case of a 22-year-old woman, gravida 1, 36-week pregnant, with extensive, bilateral white matter hypoden-

sity, predominantly involving the parieto-occipital lobes region. These changes were highly suggestive of posterior reversible

encephalopathy. This case report demonstrates that early treatment with control of blood pressure seizures can reverse this condition and

also prevent progression to an irreversible damage, thus emphasizing the need for early diagnosis and treatment.

Key words: Reversible posterior leukoencephalopathy syndrome; Hypertension in pregnancy; Eclampsia; Brain edema.

Revised manuscript accepted for publication March 28, 2013


XXXIX, n. 2, 2012

hypodensity, predominantly involving the parieto-occipital lobes

region. These changes were highly suggestive of posterior

reversible leukoencephalopathy. However atypical imaging find-

ings can at times be misleading. On follow-up examination,

patient showed marked clinical improvement with control of

hypertension and was discharged in stable condition, as also

confirmed by imaging . She was discharged from hospital on the

nine post-operative day. At one month follow-up, the CT was

completely normal.

Discussion

PRES is a very rare clinical entity. The differential diag-

nosis for seizures in pregnancy period includes: eclamp-

sia, subarachnoid haemorrhage, intracerebral haemor-

rhage, thrombotic phenomena, intracranial neoplasm,

head trauma, idiopathic epilepsy, infection (meningo-

encephalitis), and amniotic fluid embolism. PRES is still

an under-recognised and untreated condition and the

clinic-radiological hallmarks are to be established. There

are no consensual guidelines to validate diagnosis of

PRES [8].

Two theories have been proposed to explain the patho-

physiology. The more popular theory suggests that hyper-

tension leads to failure of autoregulation, subsequent

hyper-perfusion, and vasogenic edema. The other theory

suggests that vasoconstriction and hypoperfusion leads to

brain ischemia and subsequent vasogenic edema [7].

PRES is a clinico-radiological entity. The combination

of suggestive clinical manifestation and radiological crite-

ria establishes the diagnosis of PRES.

PRES is reversible after appropriate treatment, which

makes it important to recognize and treat the etiology to

prevent its progression to irreversible damage.

This case report demonstrates that early treatment with

control of blood pressure seizures can reverse this condi-

tion and also prevent progression to irreversible damage,

thus emphasizing the need for early diagnosis and treat-

ment [9, 10].

References

[1] Hinchey J., Chaves C., Appignani B. et al.: “A reversible posterior

leukoencephalopathy syndrome”. N. Engl. J. Med., 1996, 334, 494.

[2] Hagemann G., Ugur T., Witte O.W., Fitzek C.: “Recurrent posterior

reversible encephalopathy syndrome”. J. Hum. Hypert., 2004, 18,287.

[3] Bartynski W.S.: “Posterior reversible encephalopathy syndrome, part

1: fundamental imaging and clinical features”. AJNR, 2008, 29, 1036.

[4] Pedraza R., Marik P.E., Varon J.: “Posterior reversible encephalopa-

thy syndrome: a review”. Crit. Care & Shock, 2009, 12, 135.

[5] Abdelfatah S., Burud S., Anies S., Ali J.I., Tarek D.: “Reversible

posterior leukoencephalopathy syndrome: a case report”. Pak J.Med. Sci., 2005, 2, 213.

[6] Lee, Wijdicks et al.: “Clinical spectrum of reversible posterior

leukoencephalopathy syndrome”. Arch. Neurol., 2008, 65, 205.

[7] Bartynski W.S.: “Posterior reversible encephalopathy syndrome,

part 2: Controversies surrounding pathophysiology of vasogenic

edema”. AJNR, 2008, 29, 1043.

[8] Wagner S.J. et al.: “Posterior reversible encephalopathy syndrome

and eclampsia: pressing the case for more aggressive blood pres-

sure control”. Mayo Clin. Proc., 2011, 86, 851.

[9] Demirel I. et al.: “Anesthesia and intensive care management in a

pregnant woman with PRES: a case report”. Case Rep. Anesthe-siol., 2012, 2012, 745939

[10] Achar et al.: “Posterior reversible encephalopathy syndrome at

term pregnancy”. Indian J. Anaesth., 2011, 55, 399.


F. PATACCHIOLA, M.D.

Department of Health Sciences,


Via Tedeschini 7

02100 Rieti (Italy)


F. Patacchiola, V. Franchi, G. Di Febbo, A. Carta, G. Carta608

609

Introduction

The incidence of polycystic ovarian syndrome (PCOS)

is reported to be six to ten percent of the female population

[1]. The disorder is characterized by polycystic ovaries, hy-

perandrogenemia, and menstrual irregularity. Oral contra-

ceptives that contain both estrogen and progestin constitute

the most common form of therapy for adolescents with

PCOS-related amenorrhea. Women with ovulatory dys-

function are treated with clomiphene or gonadotropin to in-

duce ovulation [2]. Recently, ovarian hyperstimulation

syndrome (OHSS) has been reported to be complicated by

ovarian torsion [2, 3]. Thus, women with PCOS, who are

undergoing ovulation induction, are at high-risk for OHSS.

Hence, the cycle of ovulation induction should be carefully

monitored to prevent the onset of OHSS. However, in gen-

eral, adnexal torsion is a rare complication following ovar-

ian enlargement due to hyperstimulation [3]. The authors

recently treated a PCOS patient who had right ovarian tor-

sion and had not undergone ovulation induction. The case

has been presented here, together with a review of some of

the literature regarding this subject.

Case Report

A 21-year-old nulliparous woman who complained of right,

lower abdominal pain had been prescribed estrogen and proges-

terone to treat PCOS. She had stopped taking the medication with-

out consulting her physician, two months before visiting this

hospital. The physician considered that the patient’s abdominal

pain was not caused by a digestive disorder. Ultrasonography (US)

examination showed an enlarged right ovary, and the patient ex-

perienced pain in this region during the procedure. The patient was

diagnosed with ovarian hemorrhage and underwent a gynecologic

examination at this outpatient clinic.

The patient’s height was 145 cm and her body weight was 44

kg. Physical examination showed mild tenderness in her right

lower abdomen. US examination showed normal uterine find-

ings. However, her right ovary measured 66.2 × 41.5 × 51.4 mm

and her left ovary measured 37.8 × 20.9 × 28.2 mm; she showed

US features characteristics of PCOS. The patient’s blood tests

showed a normal hemoglobin level of 13.8 g/dl, a serum CA125

level of 10.1 U/ml (normal range, 0 - 35 U/ml), a luteinizing

hormone (LH) level of 12.62 mIU/ml, a follicle-stimulating hor-

mone (FSH) level of 5.75 mIU/ml, and an estradiol (E2) level of

22 pg/ml. Magnetic resonance imaging (MRI) showed ischemic

edema of the right ovary and a polycystic left ovary (Figures

1A, B). An emergency laparoscopy showed a necrotic right

ovary that was purplish-black in color and had undergone a 540°

torsion around the utero-ovarian ligament (Figures 1C).

Consequently, a right salpingo-oophorectomy (SO) was per-

formed, and the diagnosis of PCOS with torsion was confirmed

by the presence of edema and hemorrhagic foci. Signs of

necrosis were visible during the subsequent histological ex-

amination.

One month after the operation, another US examination

showed that the endometrium of the uterus exhibited the typi-

cal secretory changes accompanying spontaneous ovulation, as

well as findings typical of menstrual cycle progression after

ovulation (Figure 1D). During this examination, the left ovary

was found to measure 40.4 × 31.5 × 36.1 mm. The LH level

was 2.33 mIU/ml, FSH level was 0.73 mIU/ml, and E2 level

was 230 pg/ml. Spontaneous ovulation was confirmed at six

months after the operation.

Discussion

The PCOS criteria defined by the Japanese Society of

Obstetrics and Gynecology (JSOG) consist of the presence

of all of the following factors: chronic anovulation, LH hy-

persecretion and/or hyperandrogenism, and the presence of

polycystic ovaries [4]. Moreover, an elevated LH level and

an elevated LH/FSH ratio are typical findings in the ma-

Ovarian torsion associated with cessation of hormonal

treatment for polycystic ovarian syndrome: a case report

M. Murakami1, E. Takiguchi2, S. Hayashi2, Y. Nakagawa2, T. Iwasa3

1Department of Obstetrics and Gynecology, Kagawa National Children’s Hospital, Kagawa; 2Department of Obstetrics and Gynecology, Social Insurance Kinan Hospital, Wakayama; 3Department of Obstetrics and Gynecology,

Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima (Japan)

Summary

Torsion of an ovary or fallopian tube (adnexal torsion) usually occurs in ovaries with tumors or functional cysts. In polycystic ovar-

ian syndrome (PCOS), the ovaries are bilaterally enlarged, but these enlarged ovaries rarely twist. Recently, the authors encountered a

PCOS patient with ovarian torsion after the cessation of Kaufmann treatment. The etiological factors were unclear, but the authors sug-

gest that the increase in ovarian volume was due to transient hypergonadotropic feedback. Thus, more attention should be paid to ad-

nexal torsion that may arise subsequent to transient hypergonadtropic states, in relation to the cessation of hormonal treatment, and

enlarged ovaries in PCOS patients.

Key words: Polycystic ovarian syndrome; Contraception; Ovarian torsion; Ovarian hyperstimulation syndrome; Ovarian cysts.



XXXIX, n. 2, 2012

jority of patients with PCOS [1]. However, poor repro-

ducibility of the elevated LH levels or LH/FSH ratios have

been reported in PCOS patients. In addition, US images

have shown that oral contraceptives suppress LH secretion

and lead to a decrease in ovarian androgen production [5].

In this case, the patient met the diagnostic criteria; how-

ever, she had also discontinued her hormonal treatment.

Hence, the authors thought that the effect of the hormonal

treatment would have disappeared. The FSH and LH lev-

els might have increased as part of the feedback interrup-

tion caused by the cessation of hormonal treatment. This

concept was considered on the basis of the MRI finding of

an enlarged right ovary; the right ovary was thought to

have been enlarged to the same degree before the ovarian

torsion. The mobility of the left ovary might have been

limited by the sigmoid colon, allowing only the right ovary

to twist in this case.

Torsion of the ovary or fallopian tube usually occurs in

ovaries with tumors, functional cysts, or paraovarian

cysts. Here, the authors have described a PCOS patient

who had right ovarian torsion and underwent unilateral

oophrectomy (UO). A beneficial side-effect of UO treat-

ment was the development of spontaneous ovulation.

PCOS patients have been reported to have good fecun-

dity and have an ovarian reserve that is possibly superior

to women with normal ovaries [6]. UO is a fertility-spar-

ing procedure that allows the preservation of the func-

tional ovary.

Conclusion

The authors recommend that PCOS patients should be

carefully monitored for adnexal torsion after cessation of

hormonal treatment.

M. Murakami, E. Takiguchi, S. Hayashi, Y. Nakagawa, T. Iwasa610

Figure 1. — A) Unenhanced axial T2-weighted image clearly showing multiple small peripheral cysts, central stroma, and increased

volume of the right ovary. B) Contrast-enhanced axial T1 image showing contrast enhancement of the left ovary and does not show

hyperintense appearance of the right ovary. C) Laparoscopic approach showing a purplish-black right ovary that had undergone a

540° torsion around the utero-ovarian ligament. D) Ultrasonography image showing the endometrium in the luteal phase.

Ovarian torsion associated with cessation of hormonal treatment for polycystic ovarian syndrome: a case report 611

References

[1] Mashiach R., Melamed N., Gilad N., Ben-Shitrit G., Meizner I.:

“Sonographic diagnosis of ovarian torsion: accuracy and predictive

factors”. J. Ultrasound Med., 2011, 30, 1205.

[2] Fauser B.C., Tarlatzis B.C., Rebar R.W., Legro R.S., Balen A.H.,

Lobo R. et al.: “Consensus on women’s health aspects of polycys-

tic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Spon-

sored 3rd PCOS Consensus Workshop Group”. Fertil. Steril., 2012,

97, 28.

[3] Shiau C.S., Huang Y.H., Chang M.Y., Lo L.M., Hsieh T.T., Hsieh C.L.:

“Adnexal torsion in a woman undergoing ovarian hyperstimulation

with clomiphene citrate therapy: a case report and review of the liter-

ature”. Arch. Gynecol. Obstet., 2012, 285, 271.

[4] Iwasa T., Matsuzaki T., Murakami M., Shimizu F., Kuwahara A., Yasui

T. et al.: “Reproducibility of luteinizing hormone hypersecretion in

different phases of the menstrual cycle in polycystic ovary syndrome”.

J. Obstet. Gynaecol. Res., 2009, 35, 514.

[5] Kaaijk E.M., Hamerlynck J.V., Beek J.F., van der Veen F.: “Clinical

outcome after unilateral oophorectomy in patients with polycystic

ovary syndrome”. Hum. Reprod., 1999, 14, 889.

[6] Hudecova M., Holte J., Olovsson M., Sundström Poromaa I.: “Long-

term follow-up of patients with polycystic ovary syndrome: repro-

ductive outcome and ovarian reserve”. Hum. Reprod., 2009, 24, 1176.


M. MURAKAMI, M.D.

Division of Maternal Fetal Medicine

Center for Maternal, Fetal and Neonatal Medicine

Kagawa National Children’s Hospital Zentsuji 2603,

Zentsuji City

Kagawa 765-8501 (Japan)


EDITORIAL ARTICLE

The interrelationship of sleep, biologic clocks, neurotransmitters, gonadotropins and pubertal development - J.H.

Check

ORIGINAL ARTICLES

Reproductive Biology SectionIsolating sperm by selecting those with normal nuclear morphology prior to intracytoplasmic sperm injection (ICSI)does not provide better pregnancy rates compared to conventional ICSI in women with repeated conception failurewith in vitro fertilization - J.H. Check, A. Bollendorf, D. Summers-Chase, W. Yuan, D. Horwath . . . . . . . . . . . . . .

Intracytoplasmic sperm injection allows normal pregnancy rates for males ≥ 40 with low hypoosmotic swellingtest scores even when complicated by very low motility percentage - J.H. Check, A. Tubman, C. Wilson . . . . . .

Pregnancy rates following the exclusive transfer of twice frozen twice thawed embryos using a modified slow coolcryopreservation technique - J.H. Check, D. Summers-Chase, W. Yuan, D. Horwath, M.C. Garberi-Levito . . . .

Embryo apoptosis may be a significant contributing factor in addition to aneuploidy inhibiting live deliveriesonce a woman reaches age 45 - J.H. Check, S. Burgos, B. Slovis, C. Wilson . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adding luteinizing hormone to follicle stimulating hormone from day 3-5 improves pregnancy outcome in normalbut not poor responders using gonadotropin releasing hormone antagonists - T. Levi, J.H. Check, C. Wilson, J.

Mitchell-Williams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The effect of diminished oocyte reserve in younger women (age ≤ 37) on pregnancy rates in natural cycles - J.H.

Check, J. Liss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Younger women with diminished oocyte reserve are not more prone to meiosis errors leading to spontaneousabortion than their age peers with with normal oocyte reserve - B.H. Slovis, J.H. Check . . . . . . . . . . . . . . . . . . .

Intrauterine insemination (IUI) does not improve pregnancy rates in infertile couples where semen parameters arenormal and postcoital tests are adequate - J.H. Check, J. Liss, A. Bollendorf . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Low hypo-osmotic swelling tests correlate with low percent motility and age of the male - A. Tubman, J.H. Check,

A. Bollendorf, C. Wilson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Effect of triple line vs isoechogenic endometrial texture on pregnancy outcome following embryo transferaccording to use of controlled ovarian stimulation (COH) or estrogen/progesterone replacement - J.H. Check, C.

Dietterich, J.K. Choe, R. Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General SectionFrequency of endometriosis and adenomyosis in patients with leiomyomas, gynecologic premalignant, andmalignant neoplasias - R.S. Nomelini, F.A. Ferreira, R.C. Borges, S.J. Adad, E.F.C. Murta . . . . . . . . . . . . . . . . .

Placental apoptosis in preeclampsia, intrauterine growth retardation and HELLP syndrome: Animmunohistochemical study with caspase-3 and bcl-2 - U. Cali, S. Cavkaytar, L. Sirvan, N. Danisman . . . . . . . .

Obstetric outcome in adolescence: a single centre experience over seven years - D. Kellartzis, D. Tsolakidis, T.

Mikos, D. Vavilis, V. Tzevelekis, G. Tampakoudis, B. Tarlatzis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The impact of socio-economic, lifestyle habits, and obesity in developing of pregnancy-induced hypertension infast-growing country: global comparisons - A. Bener, N.M. Saleh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arterial hypertension and female sexual dysfunction in postmenopausal women - P. De Franciscis, G. Mainini,

E.M. Messalli, C. Trotta, A. Luisi, E. Laudando, G. Marino, G. Della Puca, F.V. Cerreto, M. Torella . . . . . . . . . .


OBSTETRICS & GYNECOLOGYEditors-in-Chief: M. Marchetti - Montréal (CND), J.H. Check - Canden, NJ (USA)

General index - Volume XL, 2013

No. 1, January-February-March

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Contents - Volume XL, 2013 613

Gestational hypertension risk evaluation based on epidemiological, biochemical, and hemodynamic factors - L.

Yang, W. Zhang, L. Zhang, S. Zhang, Y. Yang, Q. Wang, J. Shao, G. Chen, Y. Wang . . . . . . . . . . . . . . . . . . . . . .

Relevance of anti-Mu llerian hormone on in vitro fertilization outcome - E. Celik, E. Bastu, O. Dural, C. Yasa, F.

Buyru . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Doppler parameters of maternal renal blood flow in normal pregnancy - V. Mandic Markovic, Z. Mikovic, M.

Djukic, S. Simic Ogrizovic, M. Vasiljevic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison of transvaginal 3D sonohysterography with outpatient hysteroscopy in the evaluation of abnormaluterine bleeding - C. Katsetos, S. Radhakrishnan, A. Koumousidis, M. Kontoyannis, V. Sanoulis, D. Spaliaras, S.

Kouvelas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Factors affecting completion of laparoscopic myomectomy - E.H. Yoo, S.K. Lee . . . . . . . . . . . . . . . . . . . . . . . . .

How to prevent the complications caused by the changes of pelvic anatomical relationship after gynecologicalsurgery? - Xu Tianmin, Chang Weiqin, Cui Manhua, Si Lihui, Wei Tianshu . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bilateral hypogastric artery ligation in emergency setting for intractable postpartum hemorrhage: a secondarycare center experience - F.K. Boynukalin, H. Boyar, H. Gormus, A.I. Aral, N. Boyar . . . . . . . . . . . . . . . . . . . . . .

Loss of heterozygosity in the fragile histidine triad (FHIT) locus and expression analysis of FHIT protein inpatients with breast disorders - R.A. Souza Rabelo, L.M. Greggi Antunes, R.M. Etchebehere, R.S. Nomelini,

G.A. Nogueira Nascentes, E.F.C. Murta, A.L. Pedrosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The value of negative chlamydia trachomatis antibody in prediction of normal tubes in infertile women - Z. Raoofi,

M. Barchinegad, L. Haghighi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Evaluation of low-dose letrozole addition to ovulation induction in IVF - C. Yasa, E. Bastu, O. Dural, E. Celik,

B. Ergun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Lentivirus vectors mediated eGFP transfected into rat ovary in vivo - W. Jidong, L. Shuang, P. Hongjuan, Y.

Zhenwei, M. Xiaohui . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Practical biometric ratios of first-trimester screening - R.N. Ergin, M. Yayla, A.S. Ergin . . . . . . . . . . . . . . . . . .

Immunohistochemical study of Inhibin A and B expression in placentas from normal and pathological gestations- A. Kondi-Pafiti, C. Grigoriadis, D. Samiotaki, A. Filippidou-Giannopoulou, C. Kleanthis, D. Hassiakos . . . . .

Ultrasound parameters and L/S ratio in prediction of perinatal outcome in term-growth restricted newborns - I.Babovic, Z. Radojicic, S. Plesinac, S. Aksam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Symptomatic Shigella sonnei urinary tract infection in pregnancy - S. Baka, A. Spathi, I. Tsouma, E. Kouskouni . . .

Single dose epidural morphine instead of patient-controlled epidural analgesia in the second day of Cesareansection; an easy method for the pain relief of a new mother - A. Bilir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The efficacy of intrauterine versus oral progestin for the treatment of endometrial hyperplasia. A prospectiverandomized comparative study - K. Dolapcioglu, A. Boz, A. Baloglu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ondansetrone or metoclopromide? Which is more effective in severe nausea and vomiting of pregnancy? Arandomized trial double-blind study - M. Kashifard, Z. Basirat, M. Kashifard, M. Golsorkhtabaramiri, A.

Moghaddamnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Liquid based cytology and HPV DNA testing in a Greek population compared to colposcopy and histology - S.

Diamantopoulou, A. Spathis, A. Chranioti, D. Anninos, M. Stamataki, C. Chrelias, A. Pappas, I. Panayiotides, P.

Karakitsos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The role of mini laparotomy in patients with uterine myomas - D. Zygouris, G. Androutsopoulos, C. Grigoriadis,

E. Terzakis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ankaferd blood stopper in episiotomy repair - E.G. Yapar Eyi, Y. Engin-Üstün, M. Kaba, L. Mollamahmutog˘lu . . .

Type of delivery and self-reported postpartum symptoms among Iranian women - M. Nikpour, M.A. Delavar, Z.

Abedian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison of HbA1c levels in obese and non-obese polycystic ovarian patients - A.N. Unluer, R.B. Findik, N.

Sevinc, J. Karakaya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Administration of lopinavir/ritonavir association during rat pregnancy: maternal and fetal effects - L. Kulay Jr.,

C.C. Hagemann, M.U. Nakamura, R.S. Simões, A. Moreira de Carvalho, R.M. Oliveira-Filho, S. Espiridião . . . . .

CASE REPORTS

Surgical repair of a complicated urethro-vaginal fistula: case report and review of the literature - C. Grigoriadis,

P. Bakas, A. Liapis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Misoprostol for labor induction in the second trimester in a woman with previous three cesarean deliveries andan intrauterine death of an anencephaly - A.A. Rouzi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contents - Volume XL, 2013614

Repeated term pregnancies in a young patient with pelvic organ prolapse - S. Özyer, Ö. Uzunlar, A. Payaslı, C.

Toğrul, M. Beşli, N. Danışman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ultrasound diagnosis of recurring Jeune’s syndrome: a case report - E.N. Kontomanolis, E. Markopoulou, P.

Pinidis, A. Georgiadis, S. Kokkoris, V. Limperis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Benign pelvic metastatic leiomyoma: case report - H. Wei, Y. Liu, H. Sun, F. Qian, G. Li . . . . . . . . . . . . . . . . . .

Pyomyoma after dilatation and curettage for missed abortion - F.G. Ugurlucan, A.C. Iyibozkurt, S. Sen, O. Kuru,

S. Berkman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The management of fusion of the labia minora pudendi in adult women using a radiosurgical knife - M. Prorocic,

M. Vasiljevic, L. Tasic, O. Džatić, S. Brankovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Spontaneous rupture of uterine varices in third trimester pregnancy: an unexpected cause of hemoperitoneum. Acase report and literature review - K.L.P. Nguessan, D.B. Mian, G.A. Aissi, C. Oussou, S. Boni . . . . . . . . . . . . .

Laparoscopic myomectomy of a giant myoma - A. Kavallaris, D. Zygouris, N. Chalvatzas, E. Terzakis . . . . . . . .

No. 2, April-May-June

ORIGINAL ARTICLES

Reproductive Biology SectionA study to determine the efficacy of controlled ovarian hyperstimulation regimen using a gonadotropin releasinghormone agonist versus antagonist in women of advanced reproductive age with varying degrees of oocytereserve on outcome following in vitro fertilization-embryo transfer - J.H. Check, J.K. Choe, D. Brasile, R.

Cohen, C. Wilson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Defective oocytes are not a common cause of unexplained infertility as determined by evaluation of sharingoocytes between infertile donors and recipients - B. Katsoff, J.H. Check, J. Mitchell-Williams . . . . . . . . . . . . . .

A comparison of clinical pregnancy rates and multiple gestation rates with 2 vs 3 embryos transferred with pairsmatched for embryo quality - E. Borman, J.H. Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General SectionPlacental and umbilical cord macroscopic changes associated with fetal and maternal events in the hypertensivedisorders of pregnancy - A.K. Marques Salge, R. Maioni Xavier, W.S. Ramalho, É. Lopes Rocha1, A.S.F. Coelho,

J.V. Guimarães, K.M. Siqueira, D.R. Abdalla, M. Antoniazi Michelin, E.F.C. Murta . . . . . . . . . . . . . . . . . . . . . .

Experience improves performance of hysterosalpingo-contrast sonography (HyCoSy): a comprehensive and well-tolerated screening modality for the subfertile patient - R.D. Saunders, S.T. Nakajima, J. Myers . . . . . . . . . . . . .

Evaluation of adhesions after laparoscopic myomectomy using the Harmonic Ace and the autocrosslinkedhyaluronan gel vs Ringer’s lactate solution - P. Litta, N. Pluchino, L. Freschi, S. Borgato, S. Angioni . . . . . . . . .

Relevance of thrombophilia and impact of office hysteroscopy on recurrent in vitro fertilization failures: a caseseries - O. Dural, E. Bastu, C. Yasa, E. Celik, F. Gungor Ugurlucan, F. Buyru . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dihydrotestosterone may contribute to the development of migraine headaches - J.H. Check, R. Cohen . . . . . . .

Colostrum in menopause effects on vaginal cytology/symptoms - S. Tucci, R. Mancini, C. De Vitis, A. Noto, E.

Marra, A. Lukic, M.R. Giovagnoli, M. Moscarini . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Superselective uterine arterial embolization combined with transcatheter intra-arterial methotrexate infusion in40 cases with fallopian tube ectopic pregnancy - H. Ren, W. Gong, C. Han, Y. Li, X. Li, Z. Wu . . . . . . . . . . . . .

Sympathomimetic amines effectively control pain for interstitial cystitis that had not responded to other therapies- J.H. Check, G. Cohen, R. Cohen, J. Dipietro, B. Steinberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dyslipidemia is a persistent problem in puerperium with or without preeclampsia - H. Mendieta-Zerón, O. Huerta-

Coyote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Low-dose estrogen and drospirenone combination: effects on metabolism and endothelial function inpostmenopausal women with metabolic syndrome - P. De Franciscis, G. Mainini, D. Labriola, S. Leo, F.

Santangelo, A. Luisi, C. Russo, F.V. Cerreto, D. Ambrosio, M. Torella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maternal mortality in Serbia - M. Petronijevic, S. Vrzic-Petronijevic, I. Ivanovic, M. Krstic, D. Bratic . . . . . . . .

Operative treatment of gynaecologic diseases in puberty: seven years of experience - D. Kellartzis, D. Vavilis, T.

Mikos, S. Papadopoulos, V. Tzevelekis, D. Tsolakidis, B. Tarlatzis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Eclampsia with neurological complications: a five-year experience of a tertiary centre - Z. Kurdoglu, G. Ay, R.

Sayin, M. Kurdoglu, M. Kamaci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Accuracy of the cytopathology, bacterioscopy, and vaginal flora culture - P.Q. Almeida, M.A.P. Pereira, F.S.

Palomo, C. Okazaki, M.A. Schimidt, N.M.G. Speck, J.C.L. Ribalta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison of hysterosonography and hysteroscopy for diagnosing perimenopausal bleeding - D. Dimitrijevic,

M. Vasiljevic, R. Anicic, S. Brankovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diagnosis value of hysteroscopy for chronic endometritis - G.L. Guo, S.Y. Chen, W. Zhang, C. Zhang, L. He

- Shiyan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The prevalence of phenotypic subgroups in Greek women with polycystic ovarian syndrome - V. Vaggopoulos, E.

Trakakis, P. Panagopoulos, G. Basios, I. Salloum, C. Christodoulaki, C. Chrelias . . . . . . . . . . . . . . . . . . . . . . . . .

Does Kruger’s strict criteria have prognostic value in predicting ICSI clinical results? - B. Sariibrahim, E.

Cogendez, S. Kayatas, M.R. Asoglu, I. Koleli, L. Bakir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maternal adiponectin and visfatin concentrations in normal and complicated pregnancies - B. Cetinkaya Demır,

M.A. Atalay, K. Ozerkan, Y. Doster, G. Ocakoglu, S. Kucukkomurcu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

261 Platelet count as a predictive factor of neonatal outcome in twin pregnancy with fetal demise - S. Plešinac,

B. Kastratović Kotlica, S. Akšam, I. Babović, I. Pilić . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Effects of flavonoids from semen cuscutae on the hippocampal-hypothalamic-pituitary-ovarian sex hormonereceptors in female rats exposed to psychological stress - J. Ke, R. Duan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Clinical features and treatment of lactational mastitis: the experience from a binational study - G. Iatrakis, S.

Zervoudis, I. Ceausu, P. Peitsidis, I. Tomara, K. Bakalianou, D. Hudita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Perinatal outcome of singleton pregnancies following in vitro fertilization - J. Stojnic, N. Radunovic, K. Jeremic,

B. Kastratovic Kotlica, M. Mitrovic, I. Tulic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASE REPORTS

The use of sympathomimetic amines for the treatment of severe constipation refractory to conventional therapy -case report - J.H. Check, B. Katsoff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vanishing twins in diamniotic dichorionic in vitro fertilization gestation in mid-second trimester - P. Pinidis, E.N.

Kontomanolis, T. Mylonas, A. Georgiadis, S. Kokkoris, G. Galazios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Management of a late-presenting complex - an unclassified uterine anomaly in the presence of large leiomyomas- K. Marques, J.E. deVente, T. Hall, L. Gavrilova-Jordan, D. Ansah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Herlyn-Werner-Wunderlich syndrome - a case report - L. Nejkovic, D. Stanojevic . . . . . . . . . . . . . . . . . . . . . . . .

Gonadotropinoma presenting as a case of pseudo-ovarian failure changing to macroprolactinoma - J.H. Check . . .

Pregnancy with 15 live fetuses and severe ovarian hyperstimulation syndrome after ovulation induction andintrauterine insemination - S.M. Abbas, A.A. Rouzi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The significance of 3D power Doppler in prenatal diagnosis and the evaluation of the anatomical structure of veinof Galen aneurysmatic malformation: case report - A. Dobrosavljevic, B. Dobrosavljevic, S.J. Raznatovic, B.

Vranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cesarean section scar pregnancy treatment - case report - L. Nejkovic´, V. Pazˇin, D. Filimonović . . . . . . . . . .

Successful pregnancy after pulmonary embolism and heparin-induced thrombocytopenia - case report - S.

Plešinac, I. Babovi , V. Plešinac Karapandžić . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No. 3, July-August-September

ORIGINAL ARTICLES

Reproductive Biology SectionEffect of poor motility on pregnancy outcome following intracytoplasmic sperm injection in couples whose malepartners have subnormal hypo-osmotic swelling test scores - A. Tubman, J.H. Check, A. Bollendorf, C. Wilson . . . .

A comparison of three types of therapies for three different ovulation disorders in establishing pregnancies andevaluation of laboratory parameters that could influence the outcome - J.H. Check, D, J. Liss, R. Cohen . . . . . .

Effects of early-cleavage embryo transfer on in vitro fertilization-embryo transfer pregnancy outcomes - W.L.

Lian, Z.M. Xin, H.X. Jin, W.Y. Song, Z.F. Peng, Y.P. Sun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General SectionSingle curettage endometrial biopsy injury in the proliferative phase improves reproductive outcome of subsequentin vitro fertilization-embryo transfer cycle in infertile patients with repeated embryo implantation failure - T.

Hayashi, K. Kitaya, Y. Tada, S. Taguchi, M. Funabiki, Y. Nakamura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Idiopathic premature ovarian failure: what is the most suitable ovarian stimulation protocol? - J. Awwad, C.

Farra, A. Hannoun, M. Abou-Abdallah, K. Isaacson, G. Ghazeeri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Lipid peroxidation and antioxidant status in vagina microenvironment of patients with several common vaginitis- H.Y. Guo, X.M. Hu, D.D. Han, Z.P. Wang, L. Meng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nonhormonal management of postmenopausal women: effects of a red clover based isoflavones supplementationon climacteric syndrome and cardiovascular risk serum profile - G. Mainini, M. Torella, M.C. Di Donna, E.

Esposito, S. Ercolano, R. Correa, G. Cucinella, L. Stradella, A. Luisi, A. Basso, F.V. Cerreto, R. Cicatiello, M.

Matteo, P. De Franciscis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Outcome in single and twin pregnancies at 20 to 24 weeks gestation: ten years experience in one perinatal center- F. Louwen, I. Antwerpen, T. Ernst, L. Reichenbach, A. Reitter, E. Herrmann, J. Yuan, J. Reinhard . . . . . . . . . .

Effects of combined zidovudine/lopinavir/ritonavir therapy during rat pregnancy: morphological aspects - L.P.

Fogarolli de Carvalho, R.S. Simões, A. Wagner, J.S. Tavella Jr., R.M. Oliveira-Filho, L. Kulay Jr., M. Uchiyama

Nakamurau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

De novo symptoms and their impact on life quality in patients following transvaginal reconstructive pelvic surgerywith polypropylene mesh - Y.H. Zhang, Y.X. Lu, W.J. Shen, Y. Zhao, K. Niu, W.Y. Wang . . . . . . . . . . . . . . . . . .

Which factors may influence the duration of misoprostol-induced abortion in the second trimester? - M.E. Sak,

H.E. Soydinc, M.S. Evsen, S. Sak, T. Gul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pre-pregnancy counseling in Lagos: a report on the first 1,000 cases - G.O. Ajayi, A.T. Popoola, T. Dina, N.

Okorie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A suppository for treating cervical erosion and its preparation method - T. Zhu, Z. Chen, Q. Xia, S. Jiang, Q. Jin,

M.R.D. Farahani, L. Cai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maternal and umbilical cord oxygen content and acid-base balance in relation to general, epidural orsubarachnoid anesthesia for term elective cesarean section - C. Staikou, A. Tsaroucha, P. Vakas, N. Salakos, D.

Hasiakos, K. Panoulis, G. Petropoulos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The expression and role of oxidative stress markers in the serum and follicular fluid of patients with endometriosis- F. Liu, L. He, Y. Liu, Y. Shi, H. Du . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Surgical treatment outcomes of serious chronic tubo-ovarian abscess: a single-center series of 20 cases - K.

Nakayama, M. Ishikawa, H. Katagiri, A. Katagiri, T. Ishibashi, K. Iida,N. Nakayama, K. Miyazaki . . . . . . . . . .

The determination of high-risk pregnancy: the use of antenatal scoring system - A. Kuru, N. Sogukpinar, L.

Akman, M. Kazandi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Investigation on maternal physiological and psychological factors of cheilopalatognathus - J. Ma, W. Zhao, R.M.

Ma, X.J. Li, Z.H. Wen, X.F. Liu, W.D. Hu, C.B. Zhang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The effects of hormone therapy on ischemia modified albumin and soluble CD40 ligand levels in obese surgicalmenopausal women - M.A. Osmanağaoğlu, S.C. Karahan, T. Aran, S. Güven, A. Cora, M. Kopuz, H. Bozkaya . . . .

Reference charts and equations of fetal biometry for normal singleton pregnant women in Shaanxi, China - X.

Jiang, Y.H. Zhang, Y. Li, X. Ma, Y.S.H. Zhu, L. Shang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Association between periodontal disease and adverse pregnancy outcomes in a cohort of pregnant women inJordan - H.A. Alchalabi, R. Al Habashneh, O. Al Jabali, Y.S. Khader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anesthesia management for open fetal intrauterine surgery - J. Liu, Y. Ye, Z. Dong, Y. Liu, R. Ni, L. Zheng . . .

Prevalence of genital warts in reproductive-aged Turkish women presenting at gynecology outpatient clinics for anyreason - M.F. Kose, L. Akin, K. Yuce, Turkish Society for Colposcopy and Cervical Pathology Study Group . . . . . .

Sperm pooling and intrauterine tuboperitoneal insemination for mild male factor infertility - E. Mamas, F. Romiou,

E. Nikitos, L. Mamas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Is laparoscopic surgery safe in patients with an elevated shock index due to ruptured ectopic pregnancy? - H.

Cengiz, C. Kaya, M. Ekin, S. Karakaş, L. Yasar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A comparison of the effect of levonorgestrel IUD with oral medroxyprogesterone acetate on abnormal uterinebleeding with simple endometrial hyperplasia and fertility preservation - M. Karimi-Zarchi, R. Dehghani-

Firoozabadi, A. Tabatabaie, Z. Dehghani-Firoozabadi, S. Teimoori, Z. Chiti, A. Dehghani . . . . . . . . . . . . . . . . . .

CD34 expression of chorionic villous in pre-eclamptic placenta: an immunohistochemical and ultrastructuralstudy - S. Kalkanli, E. Deveci, M.E. Sak, M.S. Evsen, Ö. Baran, S. Özekinci, D. Yavuz . . . . . . . . . . . . . . . . . . . .

Association between mean platelet volume and different phases of menstrual cycle in primary dysmenorrhea - H.E.

Soydinc, M.S. Evsen, M.E. Sak, A. Ozler, A. Turgut, T. Gul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

327

331

337

342

345

350

356

359

361

367

372

377

381

384

389

393

399

403

407

415

418

421

425

429


CASE REPORTS

Mild increases in serum FSH in late follicular phase increases the risk of the luteinized unruptured follice: casereport - J.H. Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

An autopsy case of acute aortic dissection during postpartum period - S. Ichigo, M. Sugiyama, T. Murase, T.

Ikeda, A. Imai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Immature malignant sacrococcygeal teratoma: case report and review of the literature - I. Grammatikopoulou,

E.N. Kontomanolis, E. Chatzaki, E. Chouridou, P. Pavlidis, E.M. Papadopoulos, M. Lambropoulou . . . . . . . . . .

Laparoscopic surgery for ectopic pregnancy within a cesarean scar - S. Jiang, S. Zhao . . . . . . . . . . . . . . . . . . . .

Heterotopic pregnancy diagnosed before the onset of severe symptoms: case report - R. Yamamoto, H. Murakoshi,

Y. Yamashita, Y. Ejima, S. Yoshida, S. Motoyama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Second-trimester miscarriage and umbilical cord knot. Case report and review of the literature - P. Bakas, E.

Papadakis, D. Hassiakos, A. Liapis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urethral sex in a woman with previously undiagnosed Mayer-Rokitansky-Küster-Hauser syndrome - A.A. Rouzi . .

Antepartum embolization in managementof labor induction in placenta previa - L.L. Huang, H. Tang, R. Awale,

Z.S. Zeng, F.R. Li, Y. Chen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Simultaneous dermoid cyst and endometriosis in the same ovary: a case report - M. Prorocic, L. Tasic, M.

Vasiljevic, A. Jurisic, O.D. Smiljkovic, S. Raznatovic, M. Saranovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Congenital disorder of true cyclopia with polydactylia: case report and review of the literature - T.E. Deftereou,

V. Tsoulopoulos, G. Alexiadis, E. Papadopoulos, E. Chouridou, M. Katotomichelakis, M. Lambropoulou . . . . .

No. 4, October-November-December

ORIGINAL ARTICLES

Reproductive Biology SectionPrevention of first-trimester miscarriage with dextroamphetamine sulfate treatment in women with recurrentmiscarriage following embryo transfer - case report - J.H. Check, R. Chern, B. Katsoff . . . . . . . . . . . . . . . . . . .

Secondary amenorrhea despite normal endometrial development with secretory changes and absence of uterinesynechiae – a second case of the endometrial compaction – apoptosis syndrome - J.H. Check, R. Cohen . . . . . .

Human spermatozoa antigens in unexplained infertility - L. Karakoc Sokmensuer, B. Demir, D. Zeybek, E. Asan,

S. Gunalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The practical role of anti-Müllerian hormone in assisted reproduction - C. Siristatidis, M. Trivella, C. Chrelias,

N. Vrachnis, A. Drakeley, D. Kassanos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General SectionRole of exclusive breastfeeding in energy balance and weight loss during the first six months postpartum - A.

Antonakou, D. Papoutsis, I. Panou, A. Chiou, A.L. Matalas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Association of serum levels of vascular endothelial growth factor and early ectopic pregnancy - M.O. Fernandes

da Silva, J. Elito Jr., S. Daher, L. Camano, A. Fernandes Moron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chronic pelvic pain: evaluation of the epidemiology, baseline demographics, and clinical variables via aprospective and multidisciplinary approach - A.B. Hooker, B.R. van Moorst, E.P. van Haarst, N.A.M. van

Ootegehem, D.K.E. van Dijken, M.H.B. Heres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison of the classic TVT and TVT-Secur - H.S.O. Abduljabbar, H.M.A. Al-Shamrany, S.F. Al-Basri, H.H.

Abduljabar, D.A. Tawati, S.P. Owidhah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Expression of regulatory T and helper T cells in peripheral blood of patients with pregnancy-induced hypertension- X. Cao, L.L. Wang, X. Luo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Semi-automatic Sono T measurement of nuchal translucency - F. Bonilla-Musoles, F. Raga, F. Bonilla Jr., J.C.

Castillo, N.G. Osborne, O. Caballero . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

mtDNA4977 deletion is not a common feature in patients with premature ovarian failure and primary infertility- A. Bojarska-Junak, A. Semczuk, E. Grywalska, J. Roliński, L. Putowski . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unmet needs and knowledge of postpartum contraception in Italian women - C. Bastianelli, M. Farris, G.

Benagiano, G. D’Andrea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cerebral and renal abscess and retino-choroiditis secondary to candida albicans in preterm infants: eight caseretrospective study - G.H. Wang, C.L. Dai, Y.F. Liu, Y.M. Li . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

433

435

437

440

445

448

452

454

457

460

471

473

475

482

485

489

492

499

502

505

510

514

519


New horizons in the non-invasive diagnosis of endometriosis - F. Patacchiola, A. D’Alfonso, A. Di Fonso, G. Di

Febbo, S. Di Giovanni, A. Carta, G. Carta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The role of serum adiponectin levels in women with polycystic ovarian syndrome - H. Itoh, Y. Kawano, Y.

Furukawa, H. Matsumoto, A. Yuge, H. Narahara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Does tension-free vaginal tape and tension-free vaginal tape-obturator affect urodynamics? Comparison of thetwo techniques - F. Gungor Ugurlucan, H. Ayyildiz Erkan, C. Yasa, O. Yalcin . . . . . . . . . . . . . . . . . . . . . . . . . . .

Effect of short-term tibolone treatment on risk markers for cardiovascular disease in healthy postmenopausalwomen: a randomized controlled study - A. Traianos, D. Vavilis, A. Makedos, A. Karkanaki, K. Ravanos, N.

Prapas, B.C. Tarlatzis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Transvaginal removal of ectopic pregnancy tissue and repair of uterine defect for cesarean scar pregnancy - Z.

Wang, L. Shan, H. Xiong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Threatened miscarriage in the first trimester and retrochorial hematomas: sonographic evaluation andsignificance - V. Soldo, N. Cutura, M. Zamurovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Does carbon dioxide pneumoperitoneum altering pressure levels lead to ultrastructural damage of fallopian tubeand ovary? - K. Beyhan, O. Gogsen, C. Gulumser, M. Barıs, Z. Hulusi, K. Gulten, K. Esra . . . . . . . . . . . . . . . . .

Behaviour of lab parameters and neonatal weight loss in relation to neonatal breathing movements and cordclamping time - U. Indraccolo, R. Santafata, P.L. Palazzetti, R. Di Iorio, S.R. Indraccolo . . . . . . . . . . . . . . . . . . .

Role of psychological intervention in fetoscopic laser surgery of twin-to-twin transfusion syndrome - L.X. Li, Y.

Gao, S.L. Xu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Role of environmental organochlorinated pollutants in the development of endometriosis - M.G. Porpora, S. Resta,

E. Fugetta, P. Storelli, F. Megiorni, L. Manganaro, E. De Felip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Corticotropin-releasing hormone and progesterone plasma levels association with the onset and progression oflabor - F. Stamatelou, E. Deligeoroglou, N. Vrachnis, S. Iliodromiti, Z. Iliodromiti, S. Sifakis, G. Farmakides, G.

Creatsas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Operative hysteroscopy preserving virginity: a new technique - C. Yalcinkaya, H. Kalayci, E. Simsek, C.T.

Iskender, H.A. Parlakgumus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Investigation on delivery analgesia effect of combined spinal epidural anesthesia plus Doula and safety of motherand baby - Bi-Bo. Feng, Lei Wang, Jian-Jun Zhai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Balloon tamponade for prevention and treatment of vaginal hemorrhages in gynecology - G. Ghirardini, C. Alboni

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevalence of women’s worries, anxiety, and depression during pregnancy in a public hospital setting in Greece- K. Gourounti, F. Anagnostopoulos, K. Lykeridou, F. Griva, G. Vaslamatzis . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Preventive nursing of neonatal clavicular fracture in midwifery: a report of six cases and review of the literature- Y. Xiang, D. Luo, P. Mao . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The expression of glutathione peroxidase-1 and the anabolism of collagen regulation pathway transforming growthfactor-β1-connective tissue growth factor in women with uterine prolapse and the clinic significance - B.S. Li, L.

Hong, J. Min, D.B. Wu, M. Hu, W.J. Guo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CASE REPORTS

Female pseudohermaphroditism associated with maternal steroid cell tumor, not otherwise specified of the ovary:a case report and literature review - K. Hasegawa, Y. Minami, H. Inuzuka, S. Oe, R. Kato, K. Tsukada, Y.

Udagawa, M. Kuroda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Placenta accreta: conservative approach - G. Di Luigi, F. Patacchiola, L. Di Stefano, A. D’Alfonso, A. Carta, G.

Carta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rectus abdominal muscle endometriosis in a patient with cesarian scar: case report - L. Şahin, O. Dinçel, B.

Aydın Türk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Uterine multiple leiomyomas complicated by extensive mucoid degeneration: case report - L. Yu, N. Yin, J. Guo . . .

Detection of unruptured ovarian pregnancy subsequently successfully treated by conservative laparoscopicsurgery: a case report and review of the literature - H. Tsubamoto, Y. Wakimoto, R. Wada, R. Takeyama, Y. Ito,

K. Harada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reversible posterior leukoencephalopathy syndrome in pregnancy: a case report - F. Patacchiola, V. Franchi, G.

Di Febbo, A. Carta, G. Carta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ovarian torsion associated with cessation of hormonal treatment for polycystic ovarian syndrome: a case report- M. Murakami, E. Takiguchi, S. Hayashi, Y. Nakagawa, T. Iwasa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

524

531

536

542

546

548

551

557

561

565

568

572

574

579

581

584

586

591

596

599

601

604

607

609

619

Abbas S.M., 297

Abdalla D.R., 198

Abduljabar H.H., 499

Abduljabbar H.S.O., 499

Abedian Z., 144

Abou-Abdallah M., 327

Adad S.J., 40

Aissi G.A., 175

Ajayi G.O., 359

Akin L., 407

Akman L., 381

Aksam S., 113, 268

Al Habashneh R., 399

Al Jabali O., 399

Al-Basri S.F., 499

Al-Shamrany H.M.A., 499

Alboni C., 579

Alchalabi H.A., 399

Alexiadis G., 460

Almeida P.Q., 243

Ambrosio D., 233

Anagnostopoulos F., 581

Androutsopoulos G., 137

Angioni S., 210

Anicic R., 246

Anninos D., 131

Ansah D., 289

Antonakou A., 485

Antoniazi Michelin M., 198

Antwerpen I., 342

Aral A.I., 85

Aran T., 389

Asan E., 475

Asoglu M.R., 257

Atalay M.A., 261

Awale R., 454

Awwad J., 327

Ay G., 240

Aydın Türk B., 599

Ayyildiz Erkan H., 536

Babovi I., 307

Babovic I., 113, 268

Baka S., 116

Bakalianou K., 275

Bakas P., 155, 448

Bakir L., 257

Baloglu A., 122

Baran Ö., 425

Barchinegad M., 95

Barıs M., 551

Basios G., 253

Basirat Z., 127

Basso A., 337

Bastianelli C., 514

Bastu E., 66, 98, 215

Benagiano G., 514

Bener A., 52

Berkman S., 168

Beşli M., 159

Beyhan K., 551

Bilir A., 118Bojarska-Junak A., 510

Bollendorf A., 15, 33, 35, 315

Boni S., 175

Bonilla Jr. F., 505

Bonilla-Musoles F., 505

Borgato S., 210

Borges R.C., 40

Borman E., 196

Boyar H., 85

Boyar N., 85

Boynukalin F.K., 85

Boz A., 122

Bozkaya H., 389

Brankovic S., 170, 246

Brasile D., 191

Bratic D., 236

Burgos S., 22

Buyru F., 66, 215

Caballero O., 505

Cai L., 361

Cali U., 45

Camano L., 489

Cao X., 502

Carta A., 524, 596, 607

Carta G., 524, 596, 607

Castillo J.C., 505

Cavkaytar S., 45

Ceausu I., 275

Celik E., 66, 98, 215

Cengiz H., 418

Cerreto F.V., 58, 233, 337,

Cetinkaya Demır B., 261

Chalvatzas N., 178

Chatzaki E., 437

Check J.H., 7, 15, 18, 20, 22, 24,

27, 29, 33, 35, 37, 191,193,

196, 217, 227, 284, 295, 315,

317, 433, 471, 473

Chen G., 61

Chen S.Y., 250

Chen Y., 454

Chen Z., 361

Chern R., 471

Chiou A., 485

Chiti Z., 421

Choe J.K., 37, 191

Chouridou E., 437, 460

Chranioti A., 131

Chrelias C., 131, 253, 482

Christodoulaki C., 253

Cicatiello R., 337

Coelho A.S.F., 198

Cogendez E., 257

Cohen G., 227

Cohen R., 37, 191, 217, 227,

317, 473

Cora A., 389

Correa R., 337

Cucinella G., 337

Cutura N., 548

D’Alfonso A., 524, 596

D’Andrea G., 514

Daher S., 489

Dai C.L., 519

Danışman N., 45, 159

De Felip E., 565

De Franciscis P., 58, 233, 337

De Vitis C., 219

Deftereou T.E., 460

Dehghani A., 421

Dehghani-Firoozabadi R., 421

Dehghani-Firoozabadi Z., 421

Delavar M.A., 144

Deligeoroglou E., 568

Della Puca G., 58

Demir B., 475

Deveci E., 425

deVente J.E., 289

Di Donna M.C., 337

Di Febbo G., 524, 607

Di Fonso A., 524

Di Giovanni S., 524

Di Iorio R., 557

Di Luigi G., 596

Di Stefano L., 596

Diamantopoulou S., 131

Dietterich C., 37

Dimitrijevic D., 246

Dina T., 359

Dinçel O., 599

Dipietro J., 227

Djukic M., 70

Dobrosavljevic A., 300

Dobrosavljevic B., 300

Dolapcioglu K., 122

Dong Z., 403

Doster Y., 261

Drakeley A., 482

Du H., 372

Duan R., 271

Dural O., 66, 98, 215

Džatić O., 170

Ejima Y., 445

Ekin M., 418

Elito Jr. J., 489

Engin-Üstün Y., 141

Ercolano S., 337

Ergin A.S., 106

Ergin R.N., 106

Ergun B., 98

Ernst T., 342

Espiridião S., 151

Esposito E., 337

Esra K., 551

Etchebehere R.M., 89

Evsen M.S., 356, 425, 429

F.A. Ferreira F.A., 40

Farahani M.R.D., 361

Farmakides G., 568

Farra C., 327

Farris M., 514

Feng Bi-Bo, 574

Fernandes da Silva M.O., 489

Fernandes Moron A., 489

Filimonović D., 304

Filippidou-Giannopoulou A., 109

Findik R.B., 148

Fogarolli de Carvalho L.P., 345

Franchi V., 607

Freschi L., 210

Fugetta E., 565

Funabiki M., 323

Furukawa Y., 531

Galazios G., 286

Gao Y., 561

Garberi-Levito M.C., 20

Gavrilova-Jordan L., 289

Georgiadis A., 162, 286

Ghazeeri G., 327

Ghirardini G., 579

Giovagnoli M.R., 219

Gogsen O., 551

Golsorkhtabaramiri M., 127

Gong W., 222

Gormus H., 85

Gourounti K., 581

Grammatikopoulou I., 437

Greggi Antunes L.M., 89

Grigoriadis C., 109, 137, 155

Griva F., 581

Grywalska E., 510

Guimarães J.V.,198

Gul T., 356, 429

Gulten K., 551

Gulumser C., 551

Gunalp S., 475

Gungor Ugurlucan F., 215,

536

Guo G.L., 250

Guo H.Y., 331

Guo J., 601

Guo W.J., 586

Güven S., 389

Hagemann C.C., 151

Haghighi, L. 95

Hall T., 289

Han C., 222

Han D.D., 331

Hannoun A., 327

Harada K., 604

Hasegawa K., 591

Hasiakos D., 367

Hassiakos D., 109, 448

Hayashi S., 609

Hayashi T., 323

He L., 250, 372

Heres M.H.B., 492

Herrmann E., 342

Hong L., 586

Hongjuan P., 101

Hooker A.B., 492

Horwath D., 15, 20

Hu M., 586

Hu W.D., 384

Hu X.M,, 331

Huang L.L., 454

Hudita D., 275

Huerta-Coyote O., 229

Index of Authors in alphabetical order

620

Hulusi Z., 551

Iatrakis G., 275

Ichigo S., 435

Iida K., 377

Ikeda T., 435

Iliodromiti S., 568

Iliodromiti Z., 568

Imai A., 435

Indraccolo S.R., 557

Indraccolo U., 557

Inuzuka H., 591

Isaacson K., 327

Ishibashi T., 377

Ishikawa M., 377

Iskender C.T., 572

Ito Y., 604

Itoh H., 531

Ivanovic I., 236

Iwasa T., 609

Iyibozkurt A.C., 168

Jeremic K., 277

Jiang S., 361, 440

Jiang X., 393

Jidong W., 101

Jin H.X., 319

Jin Q., 361

Jurisic A., 457

Kaba M., 141

Kalayci H., 572

Kalkanli S., 425

Kamaci M., 240

Karahan S.C., 389

Karakaş S., 418

Karakaya J., 148

Karakitsos P., 131

Karakoc Sokmensuer L., 475

Karimi-Zarchi M., 421

Karkanaki A., 542

Kashifard M., 127

Kassanos D., 482

Kastratović Kotlica B, 277, 268

Katagiri A., 377

Katagiri H., 377

Kato R., 591

Katotomichelakis M., 460

Katsetos C., 74

Katsoff B., 193, 284, 471

Kavallaris A., 178

Kawano Y., 531

Kaya C., 418

Kayatas S., 257

Kazandi M., 381

Ke J., 271

Kellartzis D., 49, 238

Khader Y.S., 399

Kitaya K., 323

Kleanthis C., 109

Kokkoris S., 162, 286

Koleli I., 257

Kondi-Pafiti A., 109

Kontomanolis E.N., 162, 286,

437

Kontoyannis M., 74

Kopuz M., 389

Kose M.F., 407

Koumousidis A., 74

Kouskouni E., 116

Kouvelas S., 74

Krstic M., 236

Kucukkomurcu S., 261

Kulay L. Jr., 151, 345

Kurdoglu M., 240

Kurdoglu Z., 240

Kuroda M., 591

Kuru A., 381

Kuru O., 168

Labriola D., 233

Lambropoulou M., 437, 460

Laudando E., 58

Lee S.K., 78

Leo S., 233

Levi T., 24

Li F.R., 454

Li G., 165

Li L.X., 561

Li X., 222

Li X.J., 384

Li Y., 222, 393

Li Y.M., 519

Lian W.L., 319

Liapis A., 155, 448

Lihui Si, 81

Limperis V., 162

Liss D.J., 317

Liss J., 27, 33

Litta P., 210

Liu F., 372

Liu J., 403

Liu X.F., 384

Liu Y., 165, 372, 403

Liu Y.F., 519

Lopes Rocha É., 198

Louwen F., 342

Lu Y.X., 350

Luisi A., 58, 233, 337

Lukic A., 219

Luo D., 584

Luo X., 502

Lykeridou K., 581

Ma J., 384

Ma R.M., 384

Ma X., 393

Mainini G., 58, 233, 337

Maioni Xavier R., 198

Makedos A., 542

Mamas E., 415

Mamas L., 415

Mancini R., 219

Mandic Markovic V., 70

Manganaro L., 565

Manhua Cui, 81

Mao P., 584

Marino G., 58

Markopoulou E., 162

Marques K., 289

Marques Salge A.K., 198

Marra E., 219

Matalas A.L., 485

Matsumoto H., 531

Matteo M., 337

Megiorni F., 565

Mendieta-Zerón H., 229

Meng L., 331

Messalli E.M., 58

Mian D.B., 175

Mikos T., 49, 238

Mikovic Z., 70

Min J., 586

Minami Y., 591

Mitchell-Williams J., 24, 193

Mitrovic M., 277

Miyazaki K., 377

Moghaddamnia A., 127

Mollamahmutoğlu L., 141

Moreira de Carvalho A., 151

Moscarini M., 219

Motoyama S., 445

Murakami M., 609

Murakoshi H., 445

Murase T., 435

Murta E.F.C., 40, 89, 198

Myers J., 203

Mylonas T., 286

Nakagawa Y., 609

Nakajima S.T., 203

Nakamura M.U., 151

Nakamura Y., 323

Nakayama K., 377

Nakayama N., 377

Narahara H., 531

Nejković L., 291, 304

Nguessan K.L.P., 175

Ni R., 403

Nikitos E., 415

Nikpour M., 144

Niu K., 350

Nogueira Nascentes G.A., 89

Nomelini R.S., 40, 89

Noto A., 219

Ocakoglu G., 261

Oe S., 591

Okazaki C., 243

Okorie N., 359

Oliveira-Filho R.M., 151, 345

Osborne N.G.., 505

Osmanağaoğlu M.A., 389

Oussou C., 175

Owidhah S.P., 499

Özekinci S., 425

Ozerkan K., 261

Ozler A., 429

Özyer Ş., 159

Palazzetti P.L., 557

Palomo F.S., 243

Panagopoulos P., 253

Panayiotides I., 131

Panou I., 485

Panoulis K., 367

Papadakis E., 448

Papadopoulos E., 460

Papadopoulos E.M., 437

Papadopoulos S., 238

Papoutsis D., 485

Pappas A, 131

Parlakgumus H.A., 572

Patacchiola F., 524, 596, 607

Pavlidis P., 437

Payaslı A., 159

Pažin V., 304

Pedrosa A.L., 89

Peitsidis P., 275

Peng Z.F., 319

Pereira M.A.P., 243

Petronijevic M., 236

Petropoulos G., 367

Pilić I.,268

Pinidis P., 162, 286

Plešinac Karapandžić V., 307

Plesinac S., 113, 268, 307

Pluchino N., 210

Popoola A.T., 359

Porpora M.G., 565

Prapas N., 542

Prorocic M., 170, 457

Putowski L., 510

Qian F., 165

Radhakrishnan S., 74

Radojicic Z., 113

Radunovic N., 277

Raga F., 505

Ramalho W.S., 198

Raoofi Z., 95

Ravanos K., 542

Raznatovic S., 457

Raznatovic S.J., 300

Reichenbach L., 342

Reinhard J., 342

Reitter A., 342

Ren H., 222

Resta S., 565

Ribalta J.C.L., 243

Roliński J., 510

Romiou F., 415

Rouzi A.A., 157, 297, 452

Russo C., 233

Şahin L., 599

Sak M.E., 356, 425, 429

Sak S., 356

Salakos N., 367

Saleh N.M., 52

Salloum I., 253

Samiotaki D., 109

Sanoulis V., 74

Santafata R., 557

Santangelo F., 233

Saranovic M., 457

Sariibrahim B., 257

Saunders R.D., 203

Sayin R., 240

Schimidt M.A., 243

Semczuk A., 510

Sen S., 168

Sevinc N., 148

Shan L., 546

Shang L., 393

Shao J., 61

Shen W.J., 350

Shi Y., 372

Shuang L., 101

Sifakis S., 568

Simic Ogrizovic S., 70

Simões R.S., 151, 345

Simsek E., 572

Siqueira K.M., 198

Siristatidis C., 482

621

Sirvan L., 45

Slovis B.H., 22, 29

Smiljkovic O.D., 457

Sogukpinar N., 381

Soldo V., 548

Song W.Y., 319

Souza Rabelo R.A., 89

Soydinc H.E., 356, 429

Spaliaras D., 74

Spathi A., 116

Spathis A., 131

Speck N.M.G., 243

Staikou C., 367

Stamataki M., 131

Stamatelou F., 568

Stanojevic D., 291

Steinberg B., 227

Stojnic J., 277

Storelli P., 565

Stradella L., 337

Sugiyama M., 435

Summers-Chase D., 15, 20

Sun H., 165

Sun Y.P., 319

Tabatabaie A., 421

Tada Y., 323

Taguchi S., 323

Takeyama R., 604

Takiguchi E., 609

Tampakoudis G., 49

Tang H., 454

Tarlatzis, B., 49, 238

Tarlatzis B.C., 542

Tasic L., 170, 457

Tavella Jr. J.S., 345

Tawati D.A., 499

Teimoori S., 421

Terzakis E., 137, 178

Tianmin Xu, 81

Tianshu Wei, 81

Toğrul C., 159

Tomara I., 275

Torella M., 58, 233, 337

Traianos A., 542

Trakakis E., 253

Trivella M., 482

Trotta C., 58

Tsaroucha A., 367

Tsolakidis D., 49, 238

Tsoulopoulos V., 460

Tsouma I., 116

Tsubamoto H., 604

Tsukada K., 591

Tubman A., 18, 35, 315

Tucci S., 219

Tulic I., 277

Turgut A., 429

Turkish Society for Colposcopy

and Cervical Pathology Study

Group, 407

Tzevelekis V., 49, 238

Uchiyama Nakamurau M., 345

Udagawa Y., 591

Ugurlucan F.G., 168

Unluer A.N., 148

Uzunlar Ö., 159

Vaggopoulos V., 253

Vakas P., 367

van Dijken D.K.E., 492

van Haarst E.P., 492

van Moorst B.R., 492

van Ootegehem N.A.M., 492

Vasiljevic M., 70, 170, 246, 457

Vaslamatzis G., 581

Vavilis D., 49, 238, 542

Vrachnis N., 482, 568

Vranes B., 300

Vrzic-Petronijevic S., 236

Wada R., 604

Wagner A., 345

Wakimoto Y., 604

Wang G.H., 519

Wang L.L., 502

Wang Lei, 574

Wang Q., 61

Wang W.Y., 350

Wang Y., 61

Wang Z., 546

Wang Z.P., 331

Wei H., 165

Weiqin Chang, 81

Wen Z.H., 384

Wilson C,, 18, 22, 24, 35, 191,

315

Wu D.B., 586

Wu Z., 222

Xia Q., 361

Xiang Y., 584

Xiaohui M., 101

Xin Z.M., 319

Xiong H., 546

Xu S.L., 561

Yalcin O., 536

Yalcinkaya C., 572

Yamamoto R., 445

Yamashita Y., 445

Yang L., 61

Yang Y., 61

Yapar Eyi E.G., 141

Yasa C., 66, 98, 215, 536

Yasar L., 418

Yavuz D., 425

Yayla M., 106

Ye Y., 403

Yin N., 601

Yoo E.H., 78

Yoshida S., 445

Yu L., 601

Yuan J., 342

Yuan W., 15, 20

Yuce K., 407

Yuge A., 531

Zamurovic M., 548

Zeng Z.S., 454

Zervoudis S., 275

Zeybek D., 475

Zhai Jian-Jun, 574

Zhang C., 250

Zhang C.B., 384

Zhang L., 61

Zhang S., 61

Zhang W., 61

Zhang W., 250

Zhang Y.H., 350, 393

Zhao S., 440

Zhao W., 384

Zhao Y., 350

Zheng L., 403

Zhenwei Y., 101

Zhu T., 361

Zhu Y.S.H., 393

Zygouris D., 137, 178


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OBSTETRICS & GYNECOLOGY

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