What to do when it is breech? A state-of-the-art review on management of breech presentation

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.

Primary peritoneal hemangioendothelioma simulating an ovarian cyst: A case report and review of literature

BACKGROUND

Epithelioid hemangioendothelioma (EHE) is an extremely rare tumor with a prevalence of one in a million and a very heterogenous spectrum of disease that varies from an indolent to a metastasizing aggressive disease, with the liver, lung and bone being the primarily involved organs. Peritoneal forms of EHE are even rare, and only 12 cases have been reported to date in the literature.

CASE SUMMARY

A 66-year-old female came to our attention complaining low abdominal and perineal pain. Magnetic resonance imaging examination showed a 52 mm × 58 mm × 32 mm cystic mass with some smooth septa, simulating an ovarian cyst. Explorative laparoscopy demonstrated the presence of a peritoneal mass of augmented consistency connected with a sigmoid epiploic appendix in the right side of the Pouch of Douglas, that was surgically removed. Histological exa-mination revealed a primitive peritoneafl hemangioendothelioma. The patient easily recovered from surgery with no residual pain or discomfort. She is regularly attending a 3-years follow-up that is negative for local recurrence of disease or distant metastases.

CONCLUSION

Peritoneal form of EHE often simulates masses of other nature, as in our case. Given its unspecific clinical and radiological presentation, patients are often forced to a large series of tests and examinations before reaching a definitive diagnosis, that can only histologically made. The possibility of EHE should always be considered in case of unexplained chronic abdominal pain associated to a non-specific mass.

Prevalence and factors associated with non-adherence to therapy among partners of pregnant women with syphilis in a city of northeastern Brazil

BACKGROUND

One of the main difficulties faced in the prevention of the vertical transmission of syphilis is the inadequate treatment of pregnant women and their partners. The disease causes serious repercussions in infected newborns.

AIM

To evaluate the prevalence and factors associated with the therapeutic adhesion among partners of pregnant women with syphilis in a county in Northeastern Brazil.

METHODS

This is a descriptive, analytic, quantitative, cross-sectional study that was carried out through interviews with 46 pregnant women diagnosed with syphilis between 2017 and 2018 as well as with their partners. The interviews aimed at collecting data regarding sociodemographic characteristics, obstetric variables and information about syphilis, and partners’ related variables.

RESULTS

Our results showed that 73.91% of the partners did not undergo appropriate treatments, and obtaining negative results in syphilis tests was the main reason for the absence of therapies. The following factors were significantly associated with the lack of treatment among partners: Being a partner that is not the current mate of the pregnant woman, having a level of schooling inferior to 8 years [odds ratio (OR) = 10.28], and the pregnant woman undergoing up to two syphilis tests during the prenatal care (OR = 8.6). The study found a higher odds of absent treatment among partners if the pregnant woman is not white (OR = 13.88) or if the partner has less than 8 years of schooling (OR = 21.00) or has a monthly income of less than half the minimum wage (OR = 13.93).

CONCLUSION

The findings of this study show a high prevalence of partners that are not adequately treated for syphilis, a phenomenon that is strongly associated with socioeconomic factors.

Therapeutic challenges in metastatic follicular thyroid cancer occurring in pregnancy: A case report

BACKGROUND

Hormones could play a role in the evolution of follicular thyroid cancer (FTC) for which we discuss an unusual presentation of FTC occurring during pregnancy.

CASE SUMMARY

A pregnant woman was admitted with FTC metastasis resulting in a gluteal mass. Preoperative abdominal computed tomography revealed liver metastasis for which the patient underwent total thyroidectomy and liver resection, oral radioiodine therapy and radiotherapy, followed by embolization of the pelvic mass. The patient died of cerebral hemorrhage 16 mo after the initial diagnosis.

CONCLUSION

Human chorionic gonadotropin and estrogen stimulation might have a role in cancer growth, especially during pregnancy. FTC management aims to stop disease progression and overcome hormonal imbalances after thyroidectomy thus reducing fetal complications. It is still under debate whether it is possible to combine optimal timing for treatment to ensure the best possible outcome with reduction of fetal complications and risk of cancer growth.

Self-monitoring of blood glucose in gestational diabetes mellitus patients during the COVID-19 pandemic in low- and middle-income countries

Self-monitoring of blood glucose (SMBG) is critical for gestational diabetes mellitus (GDM) care. However, there are several hurdles to its practice during the coronavirus disease 2019 (COVID-19) pandemic in GDM patients in low- and middle-income countries when GDM care recommendations emphasize telemedicine-based care. Based on available knowledge, this letter proposes the following barriers to SMBG in these GDM patients during the ongoing COVID-19 pandemic: Poor internet connectivity, affordability of SMBG and digital applications to connect with healthcare providers, government-imposed social mobility restriction, psychological stress, and mental health conditions. Nevertheless, definitive evidence will only be acquired from rigorous research.

Microglandular hyperplasia-like mucinous adenocarcinoma of the endometrium: A rare case report

BACKGROUND

Microglandular hyperplasia (MGH) is a proliferation of endocervical glands, related to estrogen stimulation, mainly occurring in the reproductive age group. The differential diagnosis includes endometrial adenocarcinoma with MGH-like pattern (MGA), a distinction that may be particularly problematic in curettage specimen.

CASE SUMMARY

A 57-year-old, postmenopausal woman was admitted in our hospital for surgical treatment. She had been diagnosed with a uterine leiomyoma, after complaints of irregular vaginal bleeding. She underwent dilatation and curettage (D&C) and subsequent total abdominal hysterectomy with bilateral salpingo-oophorectomy. D&C were compatible with MGA. Histologically, a proliferation of small glands, without intervening stroma, with mucin production, accumulation of neutrophils in the gland lumen and stroma, mild nuclear atypia and rare mitoses, were seen. In the hysterectomy specimen, the endometrium was thickened, but without apparent tumor formation. On microscopic examination, a residual similar adenocarcinoma was seen in the isthmus and more conventional-of endometrioid and mucinous type, in the rest of the endometrium.

CONCLUSION

MGH-like proliferation with mild cytologic atypia, detected in the endometrial curettage specimen of a postmenopausal woman, should alert pathologists for MGA of the endometrium. VIM, p16, PAX-2, CD10 and CD34 may help in the differential diagnosis.

Mental fitness during transition to fatherhood

Transition into fatherhood is often marked by a period of adjustment, uncertainty and psychological distress and challenges for many men, along with social isolation and relationship problems. Risk factors for paternal mental health issues are maternal depression, marital distress, parenting stress, gender role stress, mismatched expectations for pregnancy and after childbirth, poor physical health, inadequate self-care behaviours, avoiding seeking help for mental health issues, and having a child with sleeping, feeding and temperament problems. Paternal depression, anxiety and post-traumatic stress disorder can have negative impacts on the social and emotional wellbeing of fathers, their partners and their children. Nevertheless, these issues are not widely acknowledged, recognised or treated. Men’s mental health illness is a silent crisis. They often fail to seek help due to their feeling of shame, stigma for a lack of emotional control, distress or anxiety related to utilising mental health support services, and underrating the severity of their symptoms. These necessitate the need for timely attention, psychological support and proper education to minimise their risk of mental health issues. Although research has indicated fathers’ inclination toward being included in practices such as the mental health assessment, perinatal education and postnatal educational approaches need to be inclusive of fathers and encourage them to seek support for their paternal mental health issues and parenting difficulties.

Teenage pregnancy and the sociodemographic attributes as a major contributor: Findings from an urban referral center in Nepal

BACKGROUND

Teenage pregnancy is a challenging issue worldwide. Yet, despite the increased health risk and socioeconomic impact of teenage pregnancy, the numbers remain high in Nepal.

AIM

To determine the prevalence and sociodemographic factors associated with teenage pregnancy in Nepal.

METHODS

A hospital-based cross-sectional study was conducted in the Paropakar Maternity and Women’s Hospital from April to August 2017. A total of 1359 mothers were assessed and interviewed regarding their reproductive history and sociodemographic attributes. Ethical approval from the Nepal Health Research Council, permission from the concerned hospital, and consent from study subjects were obtained.

RESULTS

Of the 5526 deliveries, 679 (12.3%) were teenage pregnancy deliveries. The majority (85.1%) of mothers (out of 1359) were married at < 20 years of age, with a mean age of marriage of 17.57 years (± 1.994, range: 12-25 years). Marriage age was a significant determinant of teenage pregnancy (odds ratio [OR] 2.423 [2.262-2.596]; P < 0.001). Likewise, a love marriage (OR: 2.018 [1.585-2.570]; P < 0.001) and first teenage pregnancy (OR: 3.622 [3.265-4.017]; P < 0.001) were significant determinants for subsequent teen pregnancies. Knowledge of family planning methods (OR: 0.474; 0.288-0.779; P = 0.003) and use of any methods of family planning utilization (OR: 0.345; 0.248-0.479; P = 0.000) significantly lowered the chance of teenage pregnancy.

CONCLUSION

Teenage pregnancy occupies a substantial proportion of total deliveries in the Nepalese maternity hospital. In addition, early pregnancy was significantly associated with age and type of marriage, education level, knowledge, and practice of contraceptive methods.

Relationship between Mollicutes and spontaneous abortion: An epidemiological analysis

BACKGROUND

Abortion is of great importance in public health, as it is among the main causes of maternal morbidity and mortality. In addition to sociodemographic- and lifestyle-related factors, studies have associated infections of the genital tract with higher rates of abortion. Therefore, the exacerbated presence and rise of Mollicutes in the genitourinary tract may be related to higher rates of abortion.

AIM

To perform an epidemiological analysis of women who had spontaneous abor-tions and placental colonization by Mollicutes in a maternity hospital.

METHODS

This cross-sectional study involved the collection of data and biological material from women hospitalized due to spontaneous abortion or term delivery. The sample consisted of 89 women who miscarried and 20 women who had full term pregnancy. Data collection was carried out in three stages: (1) Conducting research on the information and clinical data in medical records of patients hospitalized due to abortion; (2) Application of a semi-structured questionnaire to identify the patient's epidemiological profile and (3) Collection of placental tissue. Placental samples were collected after the curettage procedure (abortion) and after placental expulsion (delivery), both performed by an obstetrician. Microbial identification in the fragments was performed by real-time polymerase chain reaction. In this study, the following explanatory variables were considered: (1) Sociodemographic variables; (2) Variables related to access to health services; (3) Variables related to lifestyle; and (4) Variables related to sexual and reproductive health, all of which were used to perform descriptive, univariate and multivariate analyses.

RESULTS

In the final model, placental colonization by Mollicutes was independently associated with the variables age [odds ratio (OR) = 7.55; CI: 2.37-24.03] and menarche (OR = 3.43; CI: 1.03-11.44). In this investigation, the prevalence of Mollicutes colonization by at least one of the following three species: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum in women who had spontaneous abortion was 73.0%. When comparing colonization between the two groups of participating women, there was an 8.12-fold risk of placental colonization by at least one Mollicutes species in the women who had an abortion, compared to those who completed pregnancy. The final multivariate analysis model revealed a statistically significant association between placental colonization by Mollicutes in abortion with the following variables: age, as women up to 29 years old had a 7.55-fold risk of spontaneous abortion, compared to those who were older than 29 years; menarche, where women who had menarche up to 13 years old had a 3.43-fold risk of miscarriage compared to those who had menarche over 13 years old; and a change in eating habits, after the discovery of pregnancy, was a protective factor (OR = 0.16).

CONCLUSION

These findings revealed a positive association between spontaneous abortion and placental colonization by Mollicutes. This indicates the need for further investigation of this issue, to guide decision-making for the prevention of abortion.

Myasthenia gravis and pregnancy

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular junction that has higher incidence in younger women than men, which could be related to differences in sex hormones physiology and immune system functioning between males and females. MG can first present during pregnancy and variably affect pregnancy, labor, and postpartum period. In this paper, we had an updated overview on our understanding about MG presentation and its effect on pregnancy and vice versa, therapeutic options for MG pregnant women, management of pregnancy or labor complications in MG patients, and finally fetal and neonatal considerations in MG pregnant women. A multidisciplinary approach, involving obstetricians/gynecologists, neurologists, and anes-thesiologists, plays a pivotal role in improving the clinical outcomes in both MG mothers and their infants during pregnancy, delivery and postpartum.

Streptococcus agalactiae: Sensitivity profile in pregnant women attending health units in northeastern Brazil

BACKGROUND

Group B Streptococcus agalactiae (GBS) is the main etiologic agent associated with early-onset neonatal sepsis, and of all newborns of parturients colonized by GBS, approximately 1%-2% develop invasive, early-onset disease. The risk of infection increases to 15.2% in premature neonates, to 10.7% when the parturient has chorioamnionitis or premature rupture of membranes for more than 24 h and to 9.7% if the mother has postpartum bacteremia. In addition to causing perinatal, neonatal and postnatal deaths, neonatal hospital infection is associated with high costs, as hospitalization is three times longer than in uninfected children. The identification of pregnant women colonized by GBS, through universal screening, associated with the adoption of appropriate antibiotics at the time of delivery are the most successful preventive measures.

AIM

To evaluate the sensitivity profile of GBS isolated from pregnant women attending Vitória da Conquista-BA.

METHODS

This is a cross-sectional study with a quantitative approach carried out in the municipality of Vitória da Conquista-Bahia between February 2017 and March 2018. The study population was composed of 210 pregnant women, with a gestational age of 32 to 40 wk, who were aged 18 years or older living in the urban area of the municipality of Vitória da Conquista. After a brief explanation about the research and obtaining a signed an informed consent form, data and vaginorectal swabs were collected from the women for GBS research. Examination of the samples in order to identify the presence of GBS was by culture on sheep blood agar and chromogenic agar for GBS and then, seeded on plates containing streptococcal culture medium and incubated for 18 h to 24 h at 35°C. The antimicrobial sensitivity profile of positive GBS samples was determined by the disk diffusion technique, according to the Clinical and Laboratory Standards Institute manual (2017). The data obtained were stored in a database using Microsoft Office Excel spreadsheets and a descriptive analysis was performed with the aid of the EPI-INFO statistical package (version 3.5.2).

RESULTS

Among the 210 pregnant women participating in the study, 38 (18.1%) had a positive GBS culture. All strains isolated from GBS were sensitive to 10 U penicillin, 10 µg ampicillin, 30 µg cefotaxime and 30 µg vancomycin. Seven strains (18.4%) resistant to clindamycin 2 µg and eight (21.1%) resistant to erythromycin 15 µg were found. Of these, six were concomitantly resistant to erythromycin and clindamycin, two resistant only to erythromycin and one resistant only to clindamycin. All nine GBS isolates that showed resistance to erythromycin and/or clindamycin showed negative results on the D-test. Two thirds of the isolates showed cMLSB phenotype and resistance only to erythromycin in specimens in this study (02), refers to strains with phenotype M and resistance to clindamycin (01) only with phenotype L.

CONCLUSION

Chemoprophylaxis for GBS in pregnant women, especially for those allergic to penicillin, should be guided by an antimicrobial susceptibility test as resistant GBS strains were reported in this study.

Primary extragenital mixed malignant Mullerian tumour presenting as a painful splenic mass: A case report and review of the literature

BACKGROUND

Mixed malignant Mullerian tumours (MMMTs) are highly aggressive cancers that present at a late stage and are associated with a poor long-term prognosis. They are characterised by the presence of both epithelial and sarcomatous tissue types on histological examination and hence are known as biphasic tumours or carcinosarcomas. MMMTs almost always arise in the female genital tract (most commonly the uterus) but extragenital sites are also possible. Treatment options are limited and usually consists of surgery and adjuvant chemotherapy.

CASE SUMMARY

A 74-year-old woman presented with a 1-wk history of worsening left upper quadrant abdominal pain and a perisplenic mass on computed tomography (CT) scan. Features on imaging raised the possibility of a malignant process but were not diagnostic. Splenectomy was performed and histology confirmed the presence of a mixed malignant Mullerian tumour. A subsequent pelvic ultrasound identified another heterogenous cystic mass in the Pouch of Douglas without evidence of primary pathology in the uterus or adnexa. A second operation was performed for this with curative intent but previously-unknown widespread metastases were encountered at laparotomy. A biopsy of the pelvic mass confirmed it was also a MMMT with identical histological features to the perisplenic mass. There was no clinical or histological evidence of the MMMT having arisen primarily from the female genital tract. The patient subsequently suffered multi-organ failure and was palliated, succumbing to death on the 19^th post-operative day.

CONCLUSION

Primary extragenital MMMT arising from the spleen or peritoneum represents an atypical form of an already rare gynaecological tumour.

Assessing quality of life using the brief cancer-related worry inventory for gynecological surgery

BACKGROUND

The mental status of gynecologic patients has an important influence on their quality of life (QOL). Although high-quality QOL studies into breast cancer patients have been performed internationally, few QOL studies have examined patients with gynecological cancer.

AIM

To investigate the brief cancer-related worry inventory (BCWI) could evaluate the mental status of gynecological patients.

METHODS

Between July 2018 and December 2018, 19 consecutive gynecological cancer patients were prospectively recruited for this study. The BCWI is a 15-item self-reported questionnaire that assesses cancer-related worries on a numeric scale (0–100).

RESULTS

The high BCWI group was significantly younger than the low BCWI group. Regarding social status, the absence of a spouse and children was significantly more common in the high BCWI group than in the low BCWI group. The operation time was longer in the worsening BCWI group than in the stable BCWI group (305.3 ± 140.5 min vs 171.1 ± 97.2 min; P = 0.026).

CONCLUSION

Being young, having no family, and a long operation time were found to be risk factors for increased anxiety. Therefore, gynecological cancer patients should be assessed using the BCWI, and specific perioperative mental care should be considered for highly anxious patients.

Endorphins, oxytocin, sexuality and romantic relationships: An understudied area

Endorphins are the body’s natural opioids that are created and released by the central nervous system, hypothalamus and pituitary gland. Endorphins have a reputation for pain reduction, enhancing excitement or satisfaction, boosting confidence, enabling control of emotions and generating feelings of euphoria, and are involved in the natural reward cycle. There is also evidence in the literature suggesting the role of endorphins in sexuality (including sexual function and sexual behaviours), as they may regulate the release of sex hormones, prolactin and growth hormone, which are involved in sexual function and love. Endogenous oxytocin is another intrinsic hormone whose role in inducing labour contractions, the delivery of the baby and stimulating lactation has been well studied. However, the potential impact of endorphins and oxytocin on sexuality and romantic relationships is not well understood. This article reviews the research on endorphins and endogenous oxytocin and how they relate to human sexuality and romantic relationships. Some animal studies report the effect of endorphin and oxytocin on sex hormones and mating behaviours, but these findings have not been supported by research into human behaviour, indicating many gaps in knowledge relating to the association between these hormones and human sexuality.

Hypothyroidism during pregnancy: Controversy over screening and intervention

Thyroid hormones are critical for foetal neurological development and maternal health. Maternal hypothyroidism during pregnancy is associated with adverse impact on health of the mother as well as the progeny. Reduced thyroid hormone levels predispose the child to develop mental retardation and cognitive delay in early life. In the mother, hypothyroidism during pregnancy is associated with spontaneous abortion, placental abruption, preterm delivery and hypertensive disorders. Therefore, screening and therapeutic intervention is justified to prevent foetal as well as maternal co-morbidities. In view of impact of such a large-scale screening and intervention program on limited healthcare resources, it is debatable if a targeted rather than universal screening program will result in comparable outcomes. In addition, there is an ongoing debate regarding best evidence-based practice for the management of isolated hypothyroxinaemia, subclinical hypothyroidism and euthyroid women with autoimmune hypothyroidism. We have carried out a review of the literature; firstly, to determine whether universal screening for asymptomatic women in early pregnancy would be cost-effective. Secondly, we have retrospectively reviewed the literature to analyse the evidence regarding the impact of therapeutic intervention in women with subclinical hypothyroidism.

Is nitric oxide level affected in postmenopausal women with hypothyroidism?

AIM

To analyze serum levels of nitric oxide (NO), an indicator of cardiovascular health, in post-menopausal females with and without hypothyroidism.

METHODS

NO was analyzed colorimetrically in 30 newly diagnosed hypothyroid postmenopausal females and 30 postmenopausal females with normal thyroid profile. Results were compared and subjected to appropriate statistical analysis.

RESULTS

The levels of serum NO were found to be significantly decreased in postmenopausal females with hypothyroidism as compared to the levels in those with normal thyroid profile (P value < 0.05). A negative correlation of NO was observed with thyroid stimulating hormone whereas a positive correlation of NO was observed with free T3 (FT3), free T4 (FT4), T3 and T4 though it was statistically significant only for FT4 among postmenopausal females with hypothyroidism.

CONCLUSION

Postmenopausal hypothyroid females may be at a risk of compromised cardiovascular health as indicated by low NO levels. Regular monitoring and risk assessment is essential for timely intervention.

Observed prevalence and risk factors of birth defects in Shanghai, China

AIM

To investigate the prevalence and related risk factors of birth defects in Shanghai.

METHODS

This report describes a population-based study of all births at the Obstetrics and Gynecology Hospital of Fudan University in Shanghai, China from January 2008 to December 2014. A logistic regression analysis was used to identify the parameters that are independently associated with birth defects.

RESULTS

A total of 82814 births, including 824 cases of birth defects, were recorded. The rate of birth defects was 0.995 per 100 births. In the multivariable regression analysis, neonatal birth defects were likely to be associated with higher gravidity [odds ratio (OR), 1.099, 95%CI: 1.024-1.178], premature birth (OR = 1.905, 95%CI: 1.501-2.418), low birth weight (OR = 3.844, 95%CI: 3.004-4.919), twin births or higher order multiple pregnancies (OR = 1.477, 95%CI: 1.107-1.969), cesarean delivery (OR = 1.184, 95%CI: 1.016-1.380) and registration as part of a migrant population (OR = 1.380, 95%CI: 1.167-1.632). Female infants were less likely to have birth defects than male infants (OR = 0.710, 95%CI: 0.616-0.818).

CONCLUSION

Higher gravidity, premature birth, lower birth weight, twin births or higher order multiple pregnancies, and registration as part of a migrant population are independent predictors of birth defects.

Birth experience of fathers in the setting of teenage pregnancy: Are they prepared?

AIM

To explore the birth experiences of teenage fathers and determine the extent to which they are prepared for childbirth.

METHODS

A mixed methods observational study was undertaken comparing the birth experience of 50 fathers in the setting of teenage pregnancy (teenage) compared to a group of 50 older fathers. Fathers were recruited in the antenatal period and completed structured questionnaires following the birth of their child. Quantitative and qualitative analysis was undertaken.

RESULTS

Teenage fathers were younger, less educated and less likely to attend prenatal childbirth education classes (P < 0.0001). During birth, they were less prepared and consulted by attending staff (both P < 0.05). They reported limited roles in intrapartum decision-making (< 20%). In multivariate analysis being a father in the setting of teenage pregnancy remained significantly associated with feeling unprepared for birth. The major themes in qualitative analysis were feeling unprepared, shock, fear, a sense of detachment, happiness, pride, love of the baby and satisfaction with fertility.

CONCLUSION

Teenage fathers are less prepared for the birth of their child and this results in shock, fear and detachment that may impact on the early father-infant relationship.

Screening and diagnosis of endometrial cancer in Lynch syndrome

Lynch syndrome (LS) is an autosomal dominant inherited cancer predisposition syndrome caused by a mismatch of DNA repair (MMR system). Lifetime risk of developing endometrial and ovarian cancer in LS is higher than in the general population and gynecologic screening appears interesting. Screening is based on several tests: pelvic ultrasound, endometrial biopsy and hysteroscopy for endometrial cancer, pelvic ultrasound and CA125 for ovarian cancer. Those tests appear efficient for the diagnosis of gynecologic cancers in LS. Nevertheless, screening tests have not proved clinical benefit until now, and potential problems of compliance, risk of false negative cases, and interval cancer associated with screening do justify offering prophylactic surgery to patients. Women with LS should be informed of the potential benefits and risks of screening and the importance of evaluation in case of gynecologic symptoms or abnormal bleeding. Chemoprevention by progestin-containing oral contraceptives and the treatment of premalignant lesion are available options for reducing the risk of endometrial cancer in LS population.

Laparoscopic Burch urethropexy at time of mesh sling removal: A cohort study evaluating functional outcomes and quality of life

AIM: To theorize that performing a laparoscopic Burch urethropexy at time of sling removal would significantly decrease subjective symptoms of stress urinary incontinence (SUI) and improve patient satisfaction.

METHODS: Women who underwent a combined sling removal and laparoscopic Burch procedure between 2009 and 2014 were matched via age and sling-type in a 1:2 ratio to women who only underwent a sling removal. Those who underwent surgery within 6 mo of data collection were excluded from the study, as were women who underwent multi-stage surgery. Preoperative assessment for both groups included a focused clinical exam with or without functional testing and questionnaires including urogenital distress inventory-6 (UDI-6) and incontinence impact questionnaire-7 (IIQ-7) per the standard clinical practice. All non-exempt women were sent a questionnaire that included UDI-6 and IIQ-7 in addition to standard follow-up questions. Research staff contacted participants via email, mail, and telephone using the same questionnaire template and script. Data was analyzed by using χ² test for categorical data, and Student’s t test and Wilcoxon Rank Sum test for continuous data. The measure of effect was determined by logistic regression analysis.

RESULTS: A total of 48 women out of 146 selected patients were successfully recruited with n = 22 in the Burch cohort and n = 26 in the control cohort. The mean age was 54.7 ± 7.8 years and mean body mass index was 22.0 ± 13.9 kg/m². The majority of patients were Caucasian (73.3%), postmenopausal (91.1%), nonsmokers (57.9%), with a history of hysterectomy (81.4%). Six nineteen point six percent of women presented after at least 2 years from placement, which was significantly more common in the Burch cohort. Pain was the most common chief complaint (64.4%) in both groups at the time of initial presentation, and 78.9% of women reported concomitant urinary incontinence. There was no significant difference in pre-operative UDI-6 and IIQ-7 scores between the two cohorts. However, the change in UDI-6 score postoperatively was significantly improved in the Burch cohort with an average drop in score of 28.41 points compared to a decrease of 4.01 points in the control group (P = 0.02, 95%CI: 3.84 to 44.97). Although not statistically significant, the Burch cohort was 58% more likely to show an overall improvement in their score after surgery and 40% more likely to meet the minimal important difference of 11 points (RR = 1.58, 95%CI: 0.97 to 2.57; RR 1.40, 95%CI: 0.79 to 2.46). The difference in IIQ scores was nonsignificant. There was no significant difference in blood loss, complications, or postoperative pain or dyspareunia.

CONCLUSION: Performing a Burch urethropexy during sling removal does not increase complication rates and results in a significant change in validated symptom-related quality of life scores.

Care of survivors of gynecologic cancers

The number of cancer survivors is increasing and most healthcare providers will manage patients who have completed therapy for malignancy at some point. The care of survivors of gynecologic malignancies may seem daunting in a busy general gynecology practice. This paper intends to review the literature and suggest management of these women for the general gynecologist.

Cancer stem cells and early stage basal-like breast cancer

Ductal carcinoma in situ (DCIS) is a category of early stage, non-invasive breast tumor defined by the intraductal proliferation of malignant breast epithelial cells. DCIS is a heterogeneous disease composed of multiple molecular subtypes including luminal, HER2 and basal-like types, which are characterized by immunohistochemical analyses and gene expression profiling. Following surgical and radiation therapies, patients with luminal-type, estrogen receptor-positive DCIS breast tumors can benefit from adjuvant endocrine-based treatment. However, there are no available targeted therapies for patients with basal-like DCIS (BL-DCIS) tumors due to their frequent lack of endocrine receptors and HER2 amplification, rendering them potentially susceptible to recurrence. Moreover, multiple lines of evidence suggest that DCIS is a non-obligate precursor of invasive breast carcinoma. This raises the possibility that targeting precursor BL-DCIS is a promising strategy to prevent BL-DCIS patients from the development of invasive basal-like breast cancer. An accumulating body of evidence demonstrates the existence of cancer stem-like cells (CSCs) in BL-DCIS, which potentially determine the features of BL-DCIS and their ability to progress into invasive cancer. This review encompasses the current knowledge in regard to the characteristics of BL-DCIS, identification of CSCs, and their biological properties in BL-DCIS. We summarize recently discovered relevant molecular signaling alterations that promote the generation of CSCs in BL-DCIS and the progression of BL-DCIS to invasive breast cancer, as well as the influence of the tissue microenvironment on CSCs and the invasive transition. Finally, we discuss the translational implications of these findings for the prognosis and prevention of BL-DCIS relapse and progression.

Urinary incontinence following obstetric fistula repair

Prolonged and/or obstructed labour is the most common cause of genital tract fistula world-wide, in particular, sub-Saharan Africa and parts of Asia where emergency obstetric services are unavailable or suboptimal to afford timely delivery of the baby. This results in pressure necrosis by the fetal presenting part at the level of the obstruction in the maternal pelvis. Other reasons for obstetric fistula include trauma from vaginal deliveries (spontaneous or instrumental) and iatrogenic from cesarean section/hysterectomy. The majority of women develop the fistula during their first labour and most babies are stillborn. Women with a fistula suffer from leakage of urine and/or faeces from the vagina and surgery is the treatment for an established fistula. Long-term complications of fistulas include recurrent fistula, urinary incontinence, reproductive dysfunction, sexual dysfunction, mental health dysfunction, social isolation and orthopaedic complications such as footdrop. Ongoing urinary symptoms are not uncommon after successful fistula closure. There are various reasons for residual urinary incontinence following obstetric fistula repair including urinary stress incontinence, overactive bladder, mixed urinary incontinence and voiding dysfunction. Urinary incontinence after fistula repair requires careful evaluation prior to further surgery, as in some diagnoses, continence surgery is unlikely to treat and may worsen the condition. Initial results from educational and physiotherapy programs demonstrated a positive impact on post-fistula incontinence.

Gynecologic oncologists involvement on ovarian cancer standard of care receipt and survival

AIM

To examine the influence of gynecologic oncologists (GO) in the United States on surgical/chemotherapeutic standard of care (SOC), and how this translates into improved survival among women with ovarian cancer (OC).

METHODS

Surveillance, Epidemiology, and End Result (SEER)-Medicare data were used to identify 11688 OC patients (1992–2006). Only Medicare recipients with an initial surgical procedure code (n = 6714) were included. Physician specialty was identified by linking SEER-Medicare to the American Medical Association Masterfile. SOC was defined by a panel of GOs. Multivariate logistic regression was used to determine predictors of receiving surgical/chemotherapeutic SOC and proportional hazards modeling to estimate the effect of SOC treatment and physician specialty on survival.

RESULTS

About 34% received surgery from a GO and 25% received the overall SOC. One-third of women had a GO involved sometime during their care. Women receiving surgery from a GO vs non-GO had 2.35 times the odds of receiving the surgical SOC and 1.25 times the odds of receiving chemotherapeutic SOC (P < 0.01). Risk of mortality was greater among women not receiving surgical SOC compared to those who did [hazard ratio = 1.22 (95%CI: 1.12–1.33), P < 0.01], and also was higher among women seen by non-GOs vs GOs (for surgical treatment) after adjusting for covariates. Median survival time was 14 mo longer for women receiving combined SOC.

CONCLUSION

A survival advantage associated with receiving surgical SOC and overall treatment by a GO is supported. Persistent survival differences, particularly among those not receiving the SOC, require further investigation.

Laparoscopic surgery in pregnancy

Each year, roughly 2% of pregnant women will undergo non-obstetrical abdominal surgery. Appendicitis, symptomatic cholelithiasis and adnexal masses are some of the common diagnoses encountered. Pregnancy poses challenges in the diagnosis and surgical management of these conditions for several reasons. Since the 1990’s, laparoscopic surgery has gained popularity and in the past few years has become the standard of care for pregnant women with surgical pathologies. The advantages of laparoscopic surgery include shorter hospital stay, lower rates of wound infection, and decreased time to bowel function. This brief review discusses key points in laparoscopic surgery during pregnancy and highlights studies comparing laparoscopic and open approaches in common surgical conditions during pregnancy.

Single incision slings: Are they ready for real life?

AIM: To review of the efficacy and safety outcomes of different single incision slings (SIS) systems, also in comparison with traditional slings.

METHODS: A literature search was conducted in PubMed/MEDLINE database. The research was restricted to randomized and/or prospective trials and retrospective studies, published after 2006, with at least 20 patients with non-neurogenic stress urinary incontinence (SUI). The studies had to assess efficacy and/or safety of the SIS with a minimum follow-up of 12 mo. All the paper assessing the performance of tension free vaginal tape secur were excluded from this review. The final selection included 19 papers fulfilling the aforementioned criteria. Two authors independently reviewed the selected papers.

RESULTS: Four different SIS systems were analysed: Ajust^®, Ophira^®, Altis^® and MiniArc^®. The average objective cure rate was 88%. Overall no statistically significant differences were found between SIS and traditional mid-urethral slings (MUS) in terms of objective cure (all P > 0.005). Only one paper showed a statistically lower success rate in MiniArc^®vs Advantage^® slings (40% vs 90%) and higher rates of failure in the SIS group. Since there was a great variability in terms of tests performed, it was not possible to compare subjective cure between studies. The vast part of the studies showed no major complications after SIS surgery. We also observed very low reported pain rates in SIS patients. The RCTs on Ajust^® and MiniArc^®, showed better outcomes in terms of post-operative pain compared to MUS. None of the patients reported long- term pain complains.

CONCLUSION: SIS showed similar efficacy to that of traditional slings but lower short-term pain, complication and failure rates.

Risks and guidelines for the consumption of alcohol during pregnancy

Daily average intake of alcohol during pregnancy has consistently been associated with short term adverse outcomes such as miscarriage, preterm birth and intrauterine growth restriction, a large variety of malformations, as well as long term adverse outcomes such as foetal alcohol syndrome, mental retardation and general impairment of cognitive functions including intelligence, attention, learning abilities as well as social and behavioural functions. Weekly average consumption and alcohol binge drinking (usually defined as ≥ 5 drinks on a single occasion) independently of high daily average intake has not been consistently associated with short and long term adverse outcomes. Health authorities in most countries recommend that pregnant women completely abstain from alcohol. Even so, many health professionals including doctors, midwives and nurses do not provide information to pregnant women in accordance with the official recommendations, although a large proportion of women of child bearing age and pregnant women drink alcohol, especially before recognition of pregnancy. The discrepancy between guidelines and the information practice of health personnel is likely to continue to exist because guidelines of abstinence are not clearly evidence-based and not in line with current focus on autonomy and informed choice for patients, and because guidelines do not consider the everyday clinical communication situation.

Review of the current surgical management of vulval cancer

Currently in the United Kingdom, 1200 cases of vulval cancer are diagnosed per annum accounting for 6% of female genital cancers. Although classically a condition that affects older women and associated with lichen sclerosus, there has been a greater incidence of vulval squamous tumours in young women due to the increasing prevalence of promoting human papillomavirus (HPV). The advent of a vaccination programme against HPV 16 and 18, the main aetiological causes of vulval intraepithelial neoplasia and cervical intraepithelial neoplasia, may reduce the incidence in future generations. Primary surgery is the current gold standard treatment and although mortality rates have reduced by 40% since the 1970s, radical vulval resections are associated with significant morbidity such as wound breakdown, infection, lymphoedema and psychosexual consequences. Over the past decade there has been a move to less mutilating procedures in women diagnosed with early vulval cancer. This is in combination with the introduction of new surgical methods such as sentinel lymph node testing, more directed radiotherapy and chemotherapy options. These treatment methods are being assessed in clinical trials to determine their associated recurrence rates, survival rates and morbidity. Most vulval cancers are squamous cell in origin but, there are other histological subtypes including Paget’s disease and vulval melanoma which can require different management approaches. The objective of this paper is to review the current literature on the management of vulval cancer, summarise the new treatments which are being developed and the associated evidence.

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.

Human papilloma virus vaccination: Review article and an update

Human papilloma virus (HPV) is sexually transmitted and associated with uterine cervix, vaginal, and vulvar cancers in females, oropharyngeal and anal cancer in both genders, and penile cancer in males. Moreover, genital warts are benign tumors which are HPV-related and can occur in both genders. This is a review of HPV structure, HPV infection transmission, the global impact of HPV and its associated diseases, HPV vaccines and their efficacy and safety, public acceptance of HPV vaccines, the obstacles for its acceptance and strategies to address the barriers. Cervarix (a bivalent vaccine with protection against HPV types 16 and 18) and Gardasil (a quadrivalent vaccine with protection against HPV types 6, 11, 16 and 18) are 2 recommended vaccines. The longest follow up of 9.4 years has shown efficacy and protection of the vaccine against HPV types 16 and 18. The adverse effects have been minimal and the vaccine is considered safe. Numerous studies are conducted to follow the vaccinated individuals to better understand the effect of HPV vaccine on incidence of HPV-related cancers and precancerous lesions.

Pathobiological role of MUC16 mucin (CA125) in ovarian cancer: Much more than a tumor biomarker

MUC16 (CA125) has remained the mainstay for ovarian cancer assessment and management since the early 1980’s. With the exception of HE4, it is the only reliable serum biomarker for ovarian cancer. MUC16 belongs to a family of high-molecular weight glycoproteins known as mucins. The mucin family is comprised of large secreted transmembrane proteins that includes MUC1, MUC4 and MUC16. These mucins are often overexpressed in a variety of malignancies. MUC1 and MUC4 have been shown to contribute to breast and pancreatic tumorigenesis. Recent studies have uncovered unique biological functions for MUC16 that go beyond its role as a biomarker for ovarian cancer. Here, we provide an overview of the literature to highlight the importance of MUC16 in ovarian cancer tumorigenesis. We focus on the growing literature describing the role of MUC16 in proliferation, migration, metastasis, tumorigenesis and drug resistance. Accumulating experimental evidence suggest that the C-terminal domain of MUC16 is critical to mediate theses effects. The importance of MUC16 in the pathogenesis of ovarian cancer emphasizes the need to fully understand the signaling capabilities of MUC16 C-terminal domain to develop more efficient strategies for the successful treatment of ovarian cancer.

Variation in use of menopausal hormone treatment on risk of health outcomes

AIM: To determine the relative risk of selected serious outcomes with variations in use of menopausal hormone treatment (MHT).

METHODS: A cohort of 489 women, randomly recruited at age 40-79 years, from a longitudinal study of urbanised population was a study group and was followed for 14 years. Four selected outcomes (coronary artery disease, stroke, peripheral artery disease, breast cancer) were tested. Each woman on entry to the study was interviewed by a dedicated medical practitioner, and data on menstrual and menopausal history and health status were obtained. Outcome information was ascertained by questionnaire and medical reports from attending medical practitioners. In case of death, cause of death was checked with the Registry of Births, Deaths, Marriages and Divorce. This information was available for all women. An ever-user of MHT was defined as use for 6 mo or more at any time during the study. A late start of MHT was defined as 3 years or more from onset of menopause. The generalised linear statistical package was used to examine the data; univariate logistic regression models were used to describe the relationship between patient characteristics and a disease outcome, followed by stepwise multi variate analysis, controlling for age, lifestyle factors and co-morbidities.

RESULTS: The risk of ever-use of MHT was significantly increased only for peripheral artery disease (RR = 2.16; 0.99, 4.71; P = 0.05), and not for coronary artery disease, stroke and breast cancer. A late start of MHT (three years or more from onset of menopause) was associated with significantly increased risks for coronary artery disease (RR = 2.56; 1.15, 5.72; P = 0.02) and peripheral artery disease (RR = 4.42; 1.55, 12.64; P = 0.005), and use after age 60 years with significantly increased risks for coronary artery disease (RR = 4.98; 2.19, 11.55; P < 0.001), stroke (RR = 2.99; 1.11, 8.08; P = 0.03) and peripheral artery disease (RR = 4.18; 1.24, 14.14; P = 0.02). Use up to 10 years was not associated with significant risk for all outcomes. These risks were confirmed by stepwise multi variate analysis, adjusting for age at recruitment, body mass index, smoking, physical activity and alcohol use, and existing diabetes, mellitus, hypertension and hypercholesterolaemia. Regardless of variations in use, risk for breast cancer was not found.

CONCLUSION: The study confirms ever-use of MHT affected only risk of peripheral artery disease; but some use variations could have adverse effects.

Implications of multigene testing for hereditary breast cancer in primary care

Approximately 1 in 8 women will develop breast cancer during their lifetime and the risk factors include age, family history, and reproductive factors. In women with a family history of breast cancer, there is a proportion in which a gene mutation can be the cause of the predisposition for breast cancer. A careful assessment of family and clinical history should be performed in these women in order to determine if a genetic counseling referral is indicated. In cases of hereditary breast cancer, genetic testing with a multigene panel can identify specific genetic mutations in over 100 genes. The most common genes mutated in hereditary breast cancer are the high-penetrance BRCA1 and BRCA2 genes. In addition, other mutations in high-penetrance genes in familial cancer syndromes and mutations in DNA repair genes can cause hereditary breast cancer. Mutations in low-penetrance genes and variants of uncertain significance may play a role in breast cancer development, but the magnitude and scope of risk in these cases remain unclear, thus the clinical utility of testing for these mutations is uncertain. In women with high-penetrance genetic mutations or lifetime risk of breast cancer > 20%, risk-reducing interventions, such as intensive screening, surgery, and chemoprevention, can decrease the incidence and mortality of breast cancer.

Imperative for improvements and international convergence of intrapartum fetal monitoring: A bird’s eye view

Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography (CTG) has been a major driver for litigation for neonatal neurological injury. This analytical review tries to explore why extensive clinical studies and trials over 50 years have failed to demonstrate or bring about significant improvement in intrapartum fetal monitoring. There seems a need for significant reform. International congruence on most aspects of CTG interpretation [definitions of fetal heart rate (FHR) parameters, CTG recording speed, 3-tier systems, etc.] is highly desirable to facilitate future meaningful clinical studies, evaluation and progress in this field. The FHR changes are non-specific and poor surrogate for fetal well-being. As a compromise for maintaining low false-negative results for fetal acidemia, a high false-positive value may have to be accepted. The need for redefining the place of adjuvant tests of fetal well-being like fetal blood sampling or fetal electrocardiography (ECG) is discussed. The FHR decelerations are often deterministic (center-stage) in CTG interpretation and 3-tier categorization. It is discussed if their scientific and physiological classification (avoiding framing and confirmation biases) may be best based on time relationship to uterine contractions alone. This may provide a more sound foundation which could improve the reliability and further evolution of 3-tier systems. Results of several trials of fetal ECG (STAN) have been inconclusive and a need for a fresh approach or strategy is considered. It is hoped that the long anticipated Computer-aided analysis of CTG will be more objective and reliable (overcome human factors) and will offer valuable support or may eventually replace visual CTG interpretation. In any case, the recording and archiving all CTGs digitally and testing cord blood gases routinely in every delivery would be highly desirable for future research. This would facilitate well designed retrospective studies which can be very informative especially when prospective randomised controlled trials are often difficult and resource-intensive.

Alpha1B adrenoceptor expression is a marker of reduced survival and increased tumor recurrence in patients with endometrioid ovarian cancer

AIM: To investigate the expression patterns of different adrenoceptor isoforms in ovarian cancer and their association with survival and tumor recurrence.

METHODS: The protein expression levels of α1B, α2C and β2 adrenoceptor were assessed in unselected ovarian cancer using immunohistochemistry on microarrayed archival tissue samples. A database containing clinical and pathology parameters and follow-up was used to investigate the association between adrenoceptor isoform expression with ovarian specific survival and tumor recurrence, using univariate and multivariate statistical analysis.

RESULTS: Expression of α1B showed an association with reduced ovarian specific survival (P = 0.05; CI: 1.00-1.49) and increased tumor recurrence (P = 0.021, CI: 1.04-1.69) in the whole patient group. On sub-analysis the expression of α1B in endometrioid cancers (χ² = 5.867, P = 0.015) was found to predict reduced ovarian specific survival and increased tumor recurrence independently of tumor grade, clinical stage and chemotherapy. An association with clinical outcome was not seen for α2C or β2 AR.

CONCLUSION: Alpha1B adrenoceptor protein was found to predict increased risk of tumor recurrence and reduced mortality in patients with endometrioid type ovarian cancer and should be investigated as a biomarker for identifying patients at increased risk of disease progression. Furthermore, α adrenergic receptor antagonists with α1B selectivity should be investigated as a possible adjuvant therapy for treating patients with endometrioid cancer. Proof of principle could be tested in a retrospective population study.

Clinical applicability of immunotherapy of cervical intraepithelial neoplasia

Immunotherapy for cervical intraepithelial neoplasia (CIN) has not yet reached clinical applicability, but seems sensible and shows promising preliminary results. One of the most promising forms of immunotherapy for CIN may currently be imiquimod, because of its established role in other human papillomavirus (HPV)-induced genital conditions, its promising treatment efficacy in high-grade CIN, and its off-label availability. Although imiquimod cannot yet replace the current gold standard treatment for CIN [i.e., large loop excision of the transformation zone (LLETZ)] in all patients, it may be considered in subgroups of patients; for example, young women who may wish to become pregnant in the future, or patients with recurrent CIN lesions in whom a second LLETZ is to be avoided. Immunotherapy of CIN could be extended to post-treatment vaccination, in order to prevent new HPV infections and disease recurrence.

Apoptosis and endometrial receptivity: Relationship with in vitro fertilization treatment outcome

Apoptosis is an important process in the reconstruction of endometrium within the menstrual cycle. The balance between cell proliferation and apoptosis regulates the periodic repair and shedding of endometrial cells and leads to the menstruation or prepare the mucosal layer of endometrium for the implantation of the embryo. Many factors with pro- and antiapoptotic action, such as B cell lymphoma/leukemia-2 and inhibitors apoptosis proteins families, caspases, tumor necrosis factor receptors, phosphatase and tensin homolog, proliferator-activated receptor gamma, microRNAs and others are differently expressed in the endometrial tissue at phases of menstrual cycle. Receptivity of the endometrium at the period of “window of implantation” is associated with the significant increase of apoptosis in endometrium to allow the embryo to be successfully implanted. The impairment of apoptosis regulation in the endometrium at this period often is observed in infertile women with endometriosis, tubal factor, polycystic ovary syndrome, etc.. In many cases the impairment of apoptosis regulation in the endometrium is the main cause of in vitro fertilization (IVF) treatment failure in these patients. As of today, the exact mechanisms and factors mediating the apoptotic process in normal endometrium and in infertile women are not fully understood. Herein, the literature data concerning the endometrial apoptosis regulation in general, and in light of the influence of apoptosis upon IVF treatment outcome are reviewed. The possibility to use some parameters of endometrial apoptosis for prediction of the successful pregnancy achievement in women participating in IVF protocols also is discussed.

Evaluation of sentinel lymph nodes in vulvar, endometrial and cervical cancers

Sentinel lymph node (SLN) biopsies are a sensitive tool in evaluating lymph nodes for multiple cancers, and in some diseases they decrease morbidity in both the short- and long-term. SLN detection in gynecologic malignancies has been studied extensively over the past decade. We review the current literature on SLN dissection in vulvar, endometrial and cervical cancers. Large, well-designed trials in each of the three types of cancer have demonstrated high sensitivity and low false-negative rates when SLN biopsy is performed in the correct patients and with an appropriate technical approach. In all of these cases the addition of ultra-staging to conventional pathology yields increased detection of micrometastatic disease. Biopsy of the sentinel nodes is feasible and safe in early vulvar malignancies, with multiple studies describing low recurrence rates in those women who have with negative SLNs. There does not appear to be a survival benefit to lymphadenectomy over SLN biopsy and quality of life is improved in women undergoing SLN biopsy. Optimal treatment strategies for women with positive nodal biopsies, particularly in cases with micrometastatic disease, remain unclear. Multiple large studies investigating the utility of SLN biopsy in endometrial malignancy have found that sentinel nodal status is a reliable predictor of metastases in women with low-risk disease. Prospective studies are ongoing and suggest sentinel nodal detection may soon become widely accepted as an alternative standard of care for select cases of endometrial cancer. In cervical cancer, SLN biopsy is accurate for diagnosing metastatic disease in early stage tumors (≤ 2 cm diameter or stage ≤ IB2) where the risk of metastasis is low. It is unknown if women who undergo SLN biopsy alone will have different survival outcomes than women who undergo complete lymphadenectomy in these cases. In a specific population of women with vulvar cancer, SLN dissection is an effective and safe alternative to complete dissection. It can be offered as an alternative management strategy in these women. In women who do undergo SLN biopsy, it is associated with improved quality of life. Promising evidence supporting the utility of SLN dissection in endometrial and cervical cancer continues to emerge, and it may soon become a reasonable option for select patients. However, continued research and refinement of appropriate patient selection and long-term follow-up are necessary.

Update on human papillomavirus vaccination: Where are we now?

Infection with human papillomavirus (HPV) is the major cause of pre-invasive and invasive lesions of the urogenital tract, resulting in morbidity and mortality worldwide. HPV-related infection is responsible for most cases of cervical cancer, a leading cause of cancer death in women worldwide. Developed countries have screening programs in place to detect precancerous lesions at early stages; in resource-limited settings however, HPV related diseases are often identified in advanced stages. This is due to limitations in the availability and roll out of effective screening programs. The relatively recent availability of the HPV vaccine has provided a new public health opportunity to decrease the incidence of HPV-related disease. The high mortality rates seen in developing countries could be reduced through effective implementation of HPV vaccination programs. Large trials have proven the efficacy of bivalent, quadrivalent vaccine and most recently 9-valent vaccine. Uptake in vaccination remains low due to multiple barriers including lack of education, lack of access, and costs. New strategies are being assessed to increase access, increase knowledge and reduce costs that may result in feasible vaccination programs worldwide. The goal of this article is to review the effectiveness and safety of the current HPV vaccines available, vaccine delivery strategies, cost effectiveness, and efforts to improve the acceptability. A literature search was conducted through PubMed using the terms “HPV vaccination, and safety, and males, and acceptability and strategies, and cost effectiveness,”focusing on articles published between 2006 and 2015. The most relevant and larger scale trials were evaluated for discussion.

Amniocentesis: A contemporary review

Amniocentesis is an essential tool in obstetrics. Invasive testing remains the only modality for diagnostic genetic testing and the only way to provide comprehensive testing for chromosomal abnormalities. Despite increasing use of cell free fetal deoxyribonucleic acid (DNA) testing, amniocentesis should still be offered to all women who desire more complete and accurate genetic testing. Counseling patients on the limitations of screening tests is of the upmost importance and amniocentesis should continue to be recommended to confirm positive results from cell free fetal DNA testing or in the case of failed cell free fetal DNA test. As cell free fetal DNA screening has not adequately been studied in multiple gestations, its use is not recommended in this population and invasive testing should be offered. Amniocentesis is also very useful in providing additional information in settings other than genetic testing the second and third trimester. If intraamniotic infection is suspected, but the clinical findings are not enough to guide management, amniocentesis can provide testing that can both immediately clarify the picture (interleukin-6, gram stain, glucose levels) and finally confirm the presence of infection (culture). It can also be used to detect the presence of intrauterine viral infections. Additionally, amniocentesis may be used to test for markers of fetal lung maturity. The American Congress of Obstetricians and Gynecologists recommends that amniocentesis for this indication not be used in cases where late preterm delivery is indicated. It may be useful in guiding decision-making, however, when late preterm delivery is indicated, but when exact timing is unclear. Regardless of the indication, amniocentesis appears to be a relatively low risk procedure with minimal risk to the patient. Additional randomized controlled trials are not likely, as they are not feasible to due extremely high number of participants that would be needed to detect a difference in loss rates. Based on current literature, however, the risk of pregnancy loss from second trimester amniocentesis is low in both singleton and twin gestations. We counsel patients that technique has changed since the original studies in the 1970s and feel comfortable quoting a loss rate of 1/500-1/1000 based on contemporary data.

Overview of embryonal rhabdomyosarcoma of cervix in women over 40-year-old

The literature on cervical embryonal rhabdomyosarcoma (RMS) is reviewed here to identify management guidelines for middle-aged women diagnosed with this rare type of gynecologic cancer. Specifically, the PubMed, Web of Science and Google Scholar databases, were searched to find published case series on cervical embryonal RMS reporting on four or more patients, of whom at least one was > 40-year-old. The χ² test was used to assess heterogeneity. Five articles published between 1986 and 2013 were identified, reporting on a total of 47 patients, of whom 22 (46.8%) were older and 25 (53.2%) younger than 40-year-old. Although the two age groups did not differ significantly by stage of disease or radiotherapy treatment, the older age group received less chemotherapy (55% vs 90%, P = 0.008) and had more hysterectomy (86% vs 43%, P = 0.009). Follow-up data was missing for 18/47 (38.3%) patients. Among the 29 patients with follow-up data, survival was shorter in the older group, with 8/12 (67%) alive and 3 with disease at a median follow-up of 2.6 years, as compared with the younger group that had 15/17 (88%) alive and none with disease at a median follow-up of 3.5 years. The longest survivals among the older women were observed in those who received radiotherapy, including one case with a resected lung metastasis. A prospective multi-institutional collaboration and better follow-up are needed to determine the optimal management of cervical embryonal RMS. Long-term survival appears feasible if management is accompanied by chemotherapy and radiotherapy.

Thyroid disease in pregnancy: A review of diagnosis, complications and management

Malfunction of the thyroid gland is the second most common endocrine disorder encountered during pregnancy. It is well known that overt disease of the thyroid gland, either hyper or hypo can adversely affect pregnancy outcome. There is also an ongoing debate surrounding the issue of subclinical hypothyroidism and its effect on the cognitive development of the unborn child. The goal of this paper is to present a systematic review of the literature and the current recommendations for diagnosis and treatment of thyroid disease in pregnancy and postpartum.

Postpartum intrauterine device contraception: A review

AIM: To review the safety (infection, perforation) and efficacy (expulsion, continuation rates, pregnancy) of intrauterine device (IUD) insertion in the postpartum period.

METHODS: MEDLINE, PubMed and Google Scholar were searched for randomized controlled trials and prospective cohort studies of IUD insertions at different times during the postpartum period. Time of insertion during the postpartum period was documented specifically, immediate post placenta period (within 10 min), early post placenta period (10 min to 72 h), and delayed/interval period (greater than 6 wk). Other study variables included mode of delivery, vaginal vs cesarean, manual vs use of ring forceps to insert the IUD.

RESULTS: IUD insertion in the immediate postpartum (within 10 min of placental delivery), early postpartum (10 min up to 72 h) and Interval/Delayed (6 wk onward) were found to be safe and efficacious. Expulsion rates were found to be highest in the immediate postpartum groups ranging from 14% to 27%. Immediate post placental insertion found to have expulsion rates that ranged from 3.6% to 16.2%. Expulsion rate was significantly higher after insertion following vaginal vs cesarean delivery. The rates of infection, perforation and unplanned pregnancy following postpartum IUD insertion are low. Method of insertion such as with ring forceps, by hand, or another placement method unique to the type of IUD did not show any significant difference in expulsion rates. Uterine perforations are highest in the delayed/interval IUD insertion groups.Breastfeeding duration and infant development are not affected by delayed/interval insertion of the non-hormonal (copper) IUD or the Levonorgestrel IUD. Timing of the Levonorgestrel IUD insertion may affect breastfeeding.

CONCLUSION: IUD insertion is safe and efficacious during the immediate postpartum, early postpartum and delayed postpartum periods. Expulsion rates are highest after vaginal delivery and when inserted during the immediate postpartum period. IUD associated infection rates were not increased by insertion during the postpartum period over interval insertion rates. There is no evidence that breastfeeding is negatively affected by postpartum insertion of copper or hormone-secreting IUD. Although perforation rates were higher when inserted after lactation was initiated. Randomized controlled trials are needed to further elucidate the consequence of lactation on postpartum insertion. Despite the concerns regarding expulsion, perforation and breastfeeding, current evidence indicates that a favorable risk benefit ratio in support of postpartum IUD insertion. This may be particularly relevant for women for whom barriers exist in achieving desired pregnancy spacing.

MicroRNAs: New players in endometriosis

Endometriosis is an estrogen-dependent inflammatory disorder that limits the quality of life of affected women. This pathology affects 10% of reproductive-age women, although the prevalence in those patients experiencing pain, infertility or both is as high as 35%-50%. Endometriosis is characterized by endometrial-like tissue outside the uterus, primarily on the pelvic peritoneum, ovaries and the pouch of Douglas. Despite extensive research endeavours, a unifying theory regarding the exact etiopathogenic mechanism of this high prevalent and incapacitating condition is still lacking, although it has been suggested that epigenetics could be involved. MicroRNAs (miRNAs), one of the epigenetic players, are small non-coding RNAs that can act as post-transcriptional regulators of gene expression, reducing the expression of their target mRNAs either inhibiting its translation or promoting its degradation. MiRNA expression profiles are specific of tissue and cell type. Abnormal miRNA expression has been described in different pathological conditions, such as a myriad of oncological, cardiovascular and inflammatory diseases and gynecological pathologies. In endometriosis, miRNA expression patterns of eutopic endometrium from patients and control women and from different endometriotic lesions have been described. These small non-coding molecules have become attractive candidates as novel biomarkers for an early non-invasive diagnosis of the disease, which could suppose a valuable benefit to the patients in terms of improvement of prognosis and reduction of the ratio of recurrence. In this systematic review we will focus on the role of miRNAs in the pathophisiology of endometriosis.

Preeclampsia - What is to blame? The placenta, maternal cardiovascular system or both?

Preeclampsia (PE) is a pregnancy-specific syndrome, complicating 2%-8% of pregnancies. PE is a major cause of maternal mortality throughout the world with 60000 maternal deaths attributed to hypertensive disorders of pregnancy. PE also results in fetal morbidity due to prematurity and fetal growth restriction. The precise aetiology of PE remains an enigma with multiple theories including a combination of environmental, immunological and genetic factors. The conventional and leading hypotheses for the initial insult in PE is inadequate trophoblast invasion which is thought to result in incomplete remodelling of uterine spiral arteries leading to placental ischaemia, hypoxia and thus oxidative stress. The significant heterogeneity observed in pre-eclampsia cannot be solely explained by the placental model alone. Herein we critically evaluate the clinical (risk factors, placental blood flow and biomarkers) and pathological (genetic, molecular, histological) correlates for PE. Furthermore, we discuss the role played by the (dysfunctional) maternal cardiovascular system in the aetiology of PE. We review the evidence that demonstrates a role for both the placenta and the cardiovascular system in early- and late-onset PE and highlight some of the key differences between these two distinct disease entities.

Use of hyaluronic acid for sperm immobilisation and selection before intracytoplasmic sperm injection: A systematic review and meta-analysis

AIM: To appraise critically the published randomised controlled trials (RCTs) reporting on the effectiveness of using hyaluronic acid (HA) for sperm immobilisation and selection before intracytoplasmic sperm injection (ICSI).

METHODS: Two authors used the PICO Method in order to perform a comprehensive literature search of the standard medical databases in June 2015. Data from the included studies was extracted independently by two authors using a predefined pro-forma. Review Manager (RevMan) was used to calculate the combined outcomes where multiple studies contributed with their results. Risk ratio (RR) with a 95%CI using the Mantel-Haenszel method was calculated for binary data variables. Heterogeneity was measured using the χ² test and quantified using I². In case of substantial heterogeneity (P < 0.10 for χ² test or I² > 50%) the combined outcome was calculated using the random effects model. The results from the meta-analysis were displayed as forest plots. The guideline of the Cochrane Collaboration was used to assess the risk of bias and it was illustrated as a risk of bias graph.

RESULTS: The systematic literature search identified 166 different studies related to sperm immobilisation and selection for ICSI. Eleven RCTs involving 13719 oocyte intracytoplasmatic injections with sperm immobilised and selected using HA or polyvinylpyrrolidone (PVP) were included in this systematic review and meta-analysis. There was low heterogeneity among the included trials (χ² = 16.86, df = 11, P = 0.11; I² = 35%). There was no statistical difference between HA and PVP groups in terms of fertilisation rate (RR = 1.01; 95%CI: 0.99-1.03; z = 0.75; P = 0.45), good embryos rate (RR = 1.01; 95%CI: 0.96-1.06; z = 0.30; P = 0.76), live birth rate (RR = 1.15; 95%CI: 0.86-1.54; z = 0.92; P = 0.36), clinical pregnancy rate (RR = 1.04; 95%CI: 0.92-1.17; z = 0.62; P = 0.53) and implantation rate (RR = 1.17; 95%CI: 0.94-1.46; z = 0.40; P = 0.16). The quality of most of the included studies was moderate to poor because of unclear randomisation technique, inadequate allocation concealment and blinding.

CONCLUSION: This systematic review and meta-analysis provides evidence of similar efficiency between using HA or PVP for sperm immobilisation and selection before ICSI.

Emergency contraception: What is new?

Unintended pregnancy rates remain high throughout the World and increase the risk of poor maternal and infant outcomes. Most of unintended pregnancies occur in women who were not using contraception or who became pregnant despite the reported use of contraception. Women who have had recent unprotected intercourse including those who have had another form of contraception fail are potential candidates for this intervention. Currently used emergency contraceptive methods are pills that contain combined estrogen-progesterone, only progestin, antiprogestins and copper intrauterine devices. The most common form of this type of contraception is oral progestin-only pills (levonorgestrel). The most effective method is copper intrauterine devices followed by anti-progestins and oral progestin-only pills. The major pathogenesis of oral emergency contraceptives is the prevention or delay of ovulation. Although conception is possible on only a few days of the cycle, emergency contraception is offered when indicated without regard to the timing of the menstrual cycle because of uncertainty in the timing of the ovulation. Levonorgestrel and E/P regimes are most effective as soon as possible after unprotected sexual intercourse. A linear relationship has been shown between effectiveness and the time of dose. The effectiveness continues for 120 h, but it is recommended to be used within 72 h after intercourse. Intrauterine devices may prevent pregnancy when 5 d after ovulation.

Universal screening for hemoglobinopathies in today's multi-ethnic societies: How and when

Increasing multi-ethnicity in countries endemic or non-endemic for hemoglobinopathies has brought fundamental changes to the screening strategies for these traits. While in the past pre-screening on microcytosis was a reasonable method to economize upon follow up analysis, selecting low mean corpuscular volume means today missing all those normocytic carriers of common traits associated with severe conditions. Therefore, blood count should not be considered as a pre-selection tool but as additional information to be used for the interpretation of the provisional results, obtained by routine high throughput separation and measurement of the hemoglobin (Hb) fractions. Moreover, the moment of screening should be well planned depending on the social and cultural situation. Screening for genetic diseases in a modern multi-ethnic society should be offered to couples seeking progeny when both partners are more likely to be equally concerned with the good health of their children. In several societies screening before marriage and changing partner choice is culturally accepted. However, new generations are bound to disagree with these more or less imposed conditions and may decide not to renounce the choice of their partner asking for other preventive methods. In addition, a carrier state during pre-marital screening may in some cultures stigmatize the carrier, mostly the female with adverse social consequences. Therefore, screening for hemoglobinopathies early in pregnancy is the most sensible alternative in modern countries. Adding hemoglobinopathies to the routine rhesus screening using a simple separation of the Hb fractions on dedicated devices (high performance liquid chromatography or capillary electrophoresis) will virtually identify all female carriers of all common traits responsible for the severe conditions mainly sickle cell disease and thalassemia major in time for partner analysis, counseling and primary prevention.

Infertility and ovarian failure in celiac disease

Unexplained infertility in females may be a devastating event for the reproductive-aged female. However, infertility may be due to ovarian failure associated with celiac disease, an immune-mediated disorder that may have few or no symptoms and can be successfully treated. In some prospective serologically-based studies, over 4% of infertile females may prove to have celiac disease. Serological screening for celiac disease is relatively inexpensive and involves testing for antibodies to tissue transglutaminase. If positive, a small intestinal biopsy should be done to confirm the diagnosis. The initial treatment for this disorder is a gluten-free diet. To date, a number of reports have indicated that this treatment for celiac disease may result in successful pregnancy, in spite of prolonged periods of infertility. Celiac disease, when untreated, may also lead to several adverse events following pregnancy including increased risk of recurrent abortions, low birthweight and impaired fetal growth. Recent molecular and pathological studies from different laboratories suggest that altered placental function may be due to binding to cells in the trophoblast by tissue transglutaminase antibodies impairing embryo implantation and leading to failure of early pregnancy or retarded intrauterine growth.