Clinical Efficacy of Calcium Gluconate Combined With Ergometrine Maleate in the Prevention of Uterine Atony-Induced Postpartum Hemorrhage and Their Effects on Coagulation Function

This study aims to explore the clinical efficacy of calcium gluconate combined with ergometrine maleate in preventing and treating uterine atony-induced postpartum hemorrhage (PPH) and its impacts on coagulation function. Ninety-six postpartum women with uterine atony were randomly assigned into a study group and a control group (48 cases each) using a double-blind method. The control group received calcium gluconate, while the study group received calcium gluconate combined with ergometrine maleate. Postpartum blood loss at 2 and 24 h, hemostasis time, hemoglobin levels, red blood cell (RBC) count, coagulation indices (PT, TT, APTT, D-D, FIB), inflammatory markers (CRP, IL-6, PCT), labor duration, hospital stay, menstruation recovery, stress-related indicators, and blood viscosity were compared. The study group had significantly lower postpartum blood loss, shorter labor stages, and higher hemoglobin levels and RBC counts at 24 h (p < 0.05). Postpartum, PT, TT, APTT, D-D, inflammatory markers, and stress indicators were lower, while FIB was higher in the study group (p < 0.05). The combination of ergometrine maleate and calcium gluconate effectively reduces PPH, improves stress-related inflammation, and shortens hemostasis time, demonstrating significant clinical benefits.

The Impact of the COVID-19 Pandemic on Women’s Health: A Review

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During any crisis, whether it is health, economic, or environmental, people are more likely to experience stress, anxiety, and other psychological issues that jeopardize their general well-being. The Coronavirus, or COVID-19, is considered a global pandemic that affects millions of persons. Many people of different ages have significantly suffered from mental illness as a result of COVID-19, especially women affected vulnerable. As per the report, the death rates of men have doubled in comparison with women; this epidemic shows a bigger influence on the health of women than men. Even quarantine impacts make the females afraid, bewildered, and feel alone, which is terrible for them, as it also disturbs their health, such as pregnancy, sexual life, postpartum depression, etc. This review article reveals the COVID-19 impact on the health of women and finds a way to prevent and manage the health implications in women at various periods throughout their lives.

Treatments for cesarean scar pregnancy: a systematic review and meta-analysis

OBJECTIVE

To report the outcome of cesarean scar pregnancy (CSP) undergoing treatment.

METHODS

MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications.All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR).

RESULTS

176 studies (13431 women with CSP undergoing treatment) were included.Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3-89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3-89.3) with local MTX, 83.9% (95% CI 66.7-95.6) with interventional radiology, 90.42% (95% CI 82.9-96.0) with hysteroscopy, 96.1% (95% CI (92.3-98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2-99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7-6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8-15.1) with local MTX or KCl, 1.2% (95% CI 0.1-3.5) with interventional radiology, 1.4% (95% CI 0.4-2.9) with hysteroscopy, 5.5% (95% CI 0.4-25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage.When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0-95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8-93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3-95.2) with local MTX and curettage, 96.2% (95% CI 92.3-98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9-99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4-97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8-99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9-97.5) with curettage and hysteroscopy.When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment.

CONCLUSIONS

A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications.

Rational Design of Nanomedicine for Placental Disorders: Birthing a New Era in Women's Reproductive Health

The placenta is a transient organ that forms during pregnancy and acts as a biological barrier, mediating exchange between maternal and fetal circulation. Placental disorders, such as preeclampsia, fetal growth restriction, placenta accreta spectrum, and gestational trophoblastic disease, originate in dysfunctional placental development during pregnancy and can lead to severe complications for both the mother and fetus. Unfortunately, treatment options for these disorders are severely lacking. Challenges in designing therapeutics for use during pregnancy involve selectively delivering payloads to the placenta while protecting the fetus from potential toxic side effects. Nanomedicine holds great promise in overcoming these barriers; the versatile and modular nature of nanocarriers, including prolonged circulation times, intracellular delivery, and organ-specific targeting, can control how therapeutics interact with the placenta. In this review, nanomedicine strategies are discussed to treat and diagnose placental disorders with an emphasis on understanding the unique pathophysiology behind each of these diseases. Finally, prior study of the pathophysiologic mechanisms underlying these placental disorders has revealed novel disease targets. These targets are highlighted here to motivate the rational design of precision nanocarriers to improve therapeutic options for placental disorders.

Urinary protein and coagulation-fibrinolysis indicators in preeclampsia: Expression and significance

This study investigates the expression and significance of urinary protein and coagulation-fibrinolysis indicators in preeclampsia, categorized into mild preeclampsia (109 cases) and severe preeclampsia (97 cases) based on disease severity. Additionally, 110 patients with gestational hypertension (gestational hypertension group) were included for comparative analysis. General information, laboratory indicators, urinary protein, and coagulation-fibrinolysis indicator levels were collected for each group. Significant differences were observed in blood pressure among groups (P < .05), while uric acid, serum creatinine, aspartate transaminase, alanine transaminase, and triglycerides showed no significant differences (P > .05). Total cholesterol, triglycerides, and low-density Lipoprotein levels in severe preeclampsia were higher than those in mild preeclampsia and gestational hypertension groups, whereas high-density lipoprotein, albumin, and platelet levels were lower in severe preeclampsia. No significant differences were observed in prothrombin time or D-dimer levels among groups (P > .05). Urinary protein, urinary protein quantification, activated partial thromboplastin time, thrombin time, and fibrinogen were identified as influencing factors for adverse maternal and infant outcomes in severe preeclampsia patients. The study concludes that urinary protein and coagulation-fibrinolysis indicators are elevated in preeclampsia, particularly in severe preeclampsia cases, suggesting their potential use as diagnostic influencing factors for severe preeclampsia.

Effectiveness of mindful self-compassion therapy on psychopathology symptoms, psychological distress and life expectancy in infertile women treated with in vitro fertilization: a two-arm double-blind parallel randomized controlled trial

OBJECTIVES

Infertility is a prominent problem affecting millions of couples worldwide. Recently, there has been a hightened emphasis on elucidating the subtle linkages between infertility treatment leveraging assisted reproductive technology and the complex realm of psychological challenges, as well as efforts in implementation of psychological interventions.The Mindful Self-Compassion (MSC) program seeks to improve self-compassion, compassion for others, mindfulness, and life satisfaction while reducing depression, anxiety, and stress. In the current study, an MSC intervention was performed on infertile women (IW) undergoing in vitro fertilization (IVF) to assess the effectiveness of this intervention in reducing psychological distress and psychopathological symptoms and enhancing life expectancy.

METHODS

Fifty-seven IW undergoing IVF were randomly allocated to two groups: MSC (n = 29) or treatment as usual (TAU; n = 28). Participants in MSC met once a week for two hours for eight weeks and attended a half-day meditation retreat. The Synder's Hope questionnaire and the Revised 90-Symptom Checklist (SCL-90-R) were used as the primary outcome measures. Data were obtained before the intervention, immediately after the intervention, and two months post-intervention. Repeated measures of ANCOVA and paired t-tests in all assessment points were used to compare the MSC and the TAU groups in outcomes.

RESULTS

In the MSC group, hopelessness, anger-hostility, anxiety, interpersonal sensitivity difficulties, and depression were significantly reduced compared with the TAU group, and those improvements persisted at the two-month follow-up. Reliable change index revealed that the MSC group's gains were both clinically significant and durable.

CONCLUSIONS

MSC can facilitate higher life satisfaction and mental well-being for IW undergoing IVF by reducing psychological distress, psychopathological symptoms, and hopelessness. These encouraging findings call for more research into the effectiveness of mindfulness-based therapies in addressing psychological problems among IW undergoing IVF.

Treatment suspension due to the coronavirus pandemic and mental health of infertile patients: a systematic review and meta-analysis of observational studies

BACKGROUND

Access to fertility treatments is considered a reproductive right, but because of the quarantine due to the coronavirus pandemic most infertility treatments were suspended, which might affect the psychological and emotional health of infertile patients. Therefore, this study was conducted to review the mental health of infertile patients facing treatment suspension due to the coronavirus pandemic.

METHODS

This study was conducted based on the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guideline. The Web of Science, PubMed, Embase, Scopus, and Cochrane library databases were searched by two independent researchers, without time limitation until 31 December 2022. All observational studies regarding the mental health of infertile patients facing treatment suspension including anxiety, depression, and stress were included in the study. Qualitative studies, editorials, brief communications, commentaries, conference papers, guidelines, and studies with no full text were excluded. Quality assessment was carried out using Newcastle-Ottawa Scale by two researchers, independently. The random effects model was used to estimate the pooled prevalence of mental health problems. Meta-regression and subgroup analysis were used to confirm the sources of heterogeneity.

RESULTS

Out of 681 studies, 21 studies with 5901 infertile patients were systematically reviewed, from which 16 studies were included in the meta-analysis. The results of all pooled studies showed that the prevalence of anxiety, depression, and stress in female patients was 48.4% (95% CI 34.8-62.3), 42% (95% CI 26.7-59.4), and 55% (95% CI 45.4-65), respectively. Additionally, 64.4% (95% CI 50.7-76.1) of patients wished to resume their treatments despite the coronavirus pandemic.

CONCLUSION

Treatment suspension due to the coronavirus pandemic negatively affected the mental health of infertile patients. It is important to maintain the continuity of fertility care, with special attention paid to mental health of infertile patients, through all the possible measures even during a public health crisis.

A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section

BACKGROUND

Intractable postpartum hemorrhage (PPH) during cesarean section has been a significant concern for obstetricians. We aimed to explore the effectiveness and safety of a new type of uterine compression suture, the step-wise surgical technique of knapsack-like sutures for treating intractable PPH caused by uterine atony and placenta factors in cesarean section.

METHODS

The step-wise surgical technique of knapsack-like sutures was established on the basis of the artful combination of vertical strap-like sutures and an annular suture-ligation technique. This novel surgical technique was applied to 34 patients diagnosed with PPH during cesarean section due to severe uterine atony and placental factors in our department. The hemostatic effects, clinical outcomes and follow-up visit results were all reviewed and analyzed.

RESULTS

This new uterine compression suture successfully stopped bleeding in 33 patients, and the effective rate was 97.06%. Only 1 patient failed and was changed to use bilateral uterine arterial embolization and internal iliac artery embolization. The follow-up visits indicated that 33 patients restored menstruation except for 1 who was diagnosed with amenorrhea. The gynecological ultrasound tests of all the patients suggested good uterine involutions, and they had no obvious complaints such as hypogastralgia.

CONCLUSIONS

This step-wise surgical technique of knapsack-like uterine compression sutures can compress the uterus completely. It is a technique that can conserve the uterus and fertility function without special equipment in caesarean section for PPH, with the characteristics of being safe, simple and stable (3 S) with rapid surgery, reliable hemostasis and resident doctor to operation (3R).

Caesarean scar ectopic pregnancy: A case series

Caesarean scar ectopic pregnancy (CSEP) is a uncommon presentation of pregnancy with incidence of nearly 1 in 2000 pregnancies. We present this case series of scar pregnancy with a objective to help obstetricians in early diagnosis and appropriate management to prevent its catastrophic complications.

Femoral and obturator neuropathies

The femoral and obturator nerves both arise from the L2, L3, and L4 spinal nerve roots and descend into the pelvis before emerging in the lower limbs. The femoral nerve's primary function is knee extension and hip flexion, along with some sensory innervation to the leg. The obturator nerve's primary function is thigh adduction and sensory innervation to a small area of the medial thigh. Each may be injured by a variety of potential causes, many of them iatrogenic. Here, we review the anatomy of the femoral and obturator nerves and the clinical features and potential etiologies of femoral and obturator neuropathies. Their necessary investigations, including electrodiagnostic studies and imaging, their prognosis, and potential treatments, are discussed in this chapter.

Novel concepts and improvisation for treating postpartum haemorrhage: a narrative review of emerging techniques

BACKGROUND

Most treatments for postpartum haemorrhage (PPH) lack evidence of effectiveness. New innovations are ubiquitous but have not been synthesized for ready access.

NARRATIVE REVIEW

Pubmed 2020 to 2021 was searched on 'postpartum haemorrhage treatment', and novel reports among 755 citations were catalogued. New health care strategies included early diagnosis with a bundled first response and home-based treatment of PPH. A calibrated postpartum blood monitoring tray has been described. Oxytocin is more effective than misoprostol; addition of misoprostol to oxytocin does not improve treatment. Heat stable carbetocin has not been assessed for treatment. A thermostable microneedle oxytocin patch has been developed. Intravenous tranexamic acid reduces mortality but deaths have been reported from inadvertent intrathecal injection. New transvaginal uterine artery clamps have been described. Novel approaches to uterine balloon tamponade include improvised and purpose-designed free-flow (as opposed to fixed volume) devices and vaginal balloon tamponade. Uterine suction tamponade methods include purpose-designed and improvised devices. Restrictive fluid resuscitation, massive transfusion protocols, fibrinogen use, early cryopreciptate transfusion and point-of-care viscoelastic haemostatic assay-guided blood product transfusion have been reported. Pelvic artery embolization and endovascular balloon occlusion of the aorta and pelvic arteries are used where available. External aortic compression and direct compression of the aorta during laparotomy or aortic clamping (such as with the Paily clamp) are alternatives. Transvaginal haemostatic ligation and compression sutures, placental site sutures and a variety of novel compression sutures have been reported. These include Esike's technique, three vertical compression sutures, vertical plus horizontal compression sutures, parallel loop binding compression sutures, uterine isthmus vertical compression sutures, isthmic circumferential suture, circumferential compression sutures with intrauterine balloon, King's combined uterine suture and removable retropubic uterine compression suture. Innovative measures for placenta accreta spectrum include a lower uterine folding suture, a modified cervical inversion technique, bilateral uterine artery ligation with myometrial excision of the adherent placenta and cervico-isthmic sutures or a T-shaped lower segment repair. Technological advances include cell salvage, high frequency focussed ultrasound for placenta increta and extra-corporeal membrane oxygenation.

CONCLUSIONS

Knowledge of innovative methods can equip clinicians with last-resort options when faced with haemorrhage unresponsive to conventional methods.

Investigation of CD56, ADAM17 and FGF21 Expressions in the Placentas of Preeclampsia Cases

Objective: In the present study, we investigated the expression of CD56, ADAM17 and FGF21 antibodies (Ab), which we think have an effect on the pathophysiology of preeclampsia (PE), in pregnant patients with healthy placentas and placentas with PE. The expression of these antibodies has been investigated in a limited amount of former research, but their role in PE has not yet been clarified. With this study, we aimed to contribute to the elucidation of the pathophysiology of PE and the detection of new target molecules for treatment. Materials and Methods: Parturients with singleton pregnancy at 32 weeks or above without any maternal or fetal pathology who were admitted to the Department of Obstetrics and Gynecology, Zonguldak Bülent Ecevit University Practice and Research Hospital between 11 January 2020 and 7 January 2022 were included in the present study. Pregnant women with coexisting disease or a pathology related to the placenta (ablation placenta, vasa previa, hemangioma, etc.) were excluded. CD56, ADAM17 and FGF21 antibodies were histopathologically and immunohistochemically detected in 60 placentas with PE (study group) and 43 healthy placentas (control group). Results: CD56, ADAM17 and FGF21 proteins were all more intensely expressed in preeclamptic placentas and a statistically significant difference was found between the two groups for all three antibodies (p < 0.001). Deciduitis, perivillous fibrin deposition, intervillous fibrin, intervillous hemorrhage, infarct, calcification, laminar necrosis and syncytial node were found to be significantly more common in the study group (p < 0.001). Conclusions: We observed that CD56, ADAM17 and FGF21 expressions increased in preeclamptic placentas. These Ab may be responsible for the pathogenesis of PE, which can be illuminated with further studies.

Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies

BACKGROUND

Obturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND).

OBJECTIVE

To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers.

SURGICAL PROCEDURE

ONI was identified during PLND and managed according to the type of nerve injury.

RESULTS AND LIMITATIONS

The management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction.

CONCLUSIONS

ONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae.

PATIENT SUMMARY

We describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer - Demonstration of a successful repairing procedure

OBJECTIVE

In order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis.

DESIGN

Stepwise demonstration of the technique with narrated video footage.

SETTING

A 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™.

INTERVENTIONS

A careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5-0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh.

CONCLUSION

It is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

A systematic review of nerve grafting, end-to-end repair, and nerve transfer for obturator nerve injuries

OBJECTIVE

Obturator nerve injury can occur as a complication of gynecologic surgeries, occurring most frequently in patients with endometriosis and genitourinary malignancies. The resulting injury causes paresthesia and major weakness in adduction and atrophy of the adductor group of lower extremity muscles. The objective of this study was to conduct a systematic review and meta-analysis of the effectiveness of end-to-end repair, nerve grafting, and nerve transfer in improving motor function in patients with obturator nerve injury.

METHODS

PubMed, Cochrane, Medline, and Embase libraries were searched from May 1994 to August 2020 according to the PRISMA guidelines for articles that present functional outcomes after obturator nerve injury in patients treated with nerve grafting, end-to-end repair, or nerve transfer.

RESULTS

A total of 25 patients from 22 studies were included in the study, 15 of whom were treated with end-to-end repair (60%), nine with nerve grafting (36%), and one with nerve transfer (4%). Of the 15 patients with transection data, two had incomplete (13%) and 13 had complete (87%) nerve transections. The patients underwent pelvic lymphadenectomy (n=24) and radical cystectomy (n=1) operations. The mean Medical Research Council (MRC) score was 2.95±1.7 immediately after treatment and 4.77±0.6 at the final follow-up. All patients achieved good outcomes (MRC ≥3) at the final follow-up. The mean MRC score for end-to-end repair (n=15), nerve grafting (n=9), and nerve transfer (n=1) was 4.8±0.6, 4.7±0.8, and 5, respectively. Patients with end-to-end repair had higher immediate post-operative strength than those treated with nerve grafting (p=0.03) and tended to achieve full functional recovery after shorter periods of time (rho=-0.65, p=0.049). Other parameters did not correlate with MRC.

CONCLUSION

End-to-end repair, nerve grafting, and nerve transfer are equally effective in restoring function in patients with obturator nerve injury. However, patients treated with end-to-end repair had higher immediate post-operative strength than those treated with nerve grafting.

Surgical Interventions for Lumbosacral Plexus Injuries: A Systematic Review

Background:

Nerve reconstruction techniques for lumbosacral plexus (LSP) injuries vary. There are no clear treatment guidelines available, and summative evaluations of the literature discussing these surgeries are lacking. For these reasons, this investigation aimed to systematically review and consolidate all available literature discussing surgical interventions for LSP injuries and cohesively present patient-reported and objective postoperative outcomes.

Methods:

The authors conducted a systematic review using PubMed, Embase, Web of Science, ProQuest Dissertations and Theses Global (via Proquest.com), and ClinicalTrials.gov databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After title and abstract screening, identified articles were read in full and selected for inclusion based on prespecified criteria.

Results:

Our literature search identified 8683 potential citations, and after duplicate removal, abstract screening, and full-text review, 62 studies remained meeting inclusion and exclusion criteria. Outcomes were extracted according to the location of injury and type of surgical repair. Injuries were classified into isolated femoral nerve injuries, isolated obturator nerve injuries, isolated sciatic nerve injuries, and multilevel LSP injuries. Surgical treatment was further classified into exploration with neurolysis, direct repair, nerve grafting, and nerve transfer surgery.

Conclusions:

Although results vary based on the location of the injury and the surgical technique used, nerve grafts and transfers demonstrated reasonable success in improving functional and pain outcomes. Overall, isolated femoral and obturator nerve injuries had the best outcomes reported with surgical treatment. Furthermore, incomplete sciatic nerve and multilevel LSP injuries had more reported surgical options and better outcomes than complete sciatic nerve injuries.

How to dissect the pelvic nerves: from microanatomy to surgical rules. An evidence-based clinical review

Background: Advanced gynaecological procedures often include extensive pelvic dissections, with the nervous structures involved in the disease. Nerve-sparing and preservation is a key factor in reducing postoperative morbidity. Objectives: The goal of this review is to describe in detail the structure of the pelvic nerves and to gather information from other surgical specialties to give recommendations for safe nerve dissection applied in different gynaecological subspecialties. Materials and methods: An extensive literature review was carried out in PubMed and Google Scholar. The search included articles concerning peripheral nerve anatomy, mechanisms of injury and different dissection techniques, with the most exhaustive being analysed for the review. Articles from different fields of medicine like orthopaedics, plastic surgery, maxillofacial surgery dealing with peripheral nerve injuries and repair have been reviewed. Results: The following review demonstrates the in-depth anatomy and mechanism of injury of the peripheral nerves, describes the different techniques for neurolysis and proposes some directions for safe nerve dissection. Conclusion: When performing complex gynaecological surgeries, the surgeon should avoid unnecessary nerve handling, apply nerve-sparing techniques whenever possible and use the new devices to preserve the nervous structures. Advanced gynaecological surgeries should be performed in specialised centres by expert surgeons with comprehensive knowledge in neuropelveology. What is new? To our knowledge, this is the first article focused on peripheral nerves that collects data from such a wide range of specialties in order to propose the most comprehensive recommendations that could be applied in pelvic surgery.

Diabetes associated with cervical carcinoma among high-risk HPV-infected patients with cytologically diagnosed high grade squamous intraepithelial lesion

BACKGROUND

Diabetes causes metabolic disorders and immune changes that may be potential triggers of cervical cancer. Therefore, diabetes is not a "bystander" to cervical cancer. However, the conclusion that diabetes promotes cervical cancer lacks clinical epidemiological evidence, and the reported potential association between diabetes and cervical cancer is controversial.

METHODS

We conducted an explorative cross-sectional study of 791 women with cytological HGSIL and HR-HPV, who attended the cervical clinic of the largest academic women's hospital in China from May 2019 to March 2022. After cervical screening, patients who were requiring colposcopy were tested for HbA1c. HbA1c level of 6.5% or higher defines diabetes and HbA1c level of 5.7%-6.4% was defined as prediabetes. The relationship between diabetes and cervical cancer was observed by a dose-response graph. Subgroup analysis and multivariate logistic regression analysis were conducted to estimate the associations between diabetes and cervical cancer.

RESULTS

Among HGSIL patients with high-risk HPV infection, compared with women with HbA1c &lt;5.7%, the odds ratio for women with prediabetes was 1.72 (95% CI: 0.87-3.41) and the odds ratio for women with diabetes was 3.29 (95% CI: 1.10-9.80) for cervical cancer. Sensitivity analysis showed that diabetes was significantly associated with cervical cancer in different age groups and different HPV variant. E-value analysis showed robustness to unmeasured confounding.

CONCLUSIONS

In patients with HR-HPV combined with HGSIL, diabetes and prediabetes are associated with cervical cancer.

Diabetes associated with HPV infection in women aged over 50 years: A cross-sectional study from China's largest academic woman's hospital

BACKGROUND

Metabolic disturbances and immune alterations caused by diabetes are not just bystanders of HPV infection, but the conclusion that diabetes increases the risk of HPV infection requires more clinical epidemiological evidence to confirm. Our aim was to evaluate the association of diabetes with HPV infection risk in female patients aged over 50 years in the cervical clinic.

METHODS

We conducted a cross-sectional study of 6402 women aged over 50 years in the cervical clinic between May 2019 and March 2022 from China's largest academic woman's hospital. The quantitative-effect relationship between diabetes and HPV infection was observed by dose-response graph. Segmented multivariate logistic regression analysis was conducted to estimate the relative risk of HPV infection in diabetes patients. Multivariable predicted marginal proportions from logistic regression models were used to compute adjusted risk ratios.

RESULTS

There is a nonlinear relationship between HbA1c and the risk of HPV infection. When the HbA1c exceeds 5.7%, there is a saturation effect. After adjustment for confounders, the risk ratio for HPV infection in women with prediabetes was 1.09 (95% CI: 1.00-1.18) compared with women with HbA1c <5.7%, and the risk ratio for HPV infection in women with diabetes was 1.18 (95%). CI: 1.04-1.33). Sensitivity analysis showed that the risk ratio for HPV infection was 1.47 (95% CL: 1.07-1.91) when diabetes was associated with vaginitis. E-value analysis suggested robustness to unmeasured confounding.

CONCLUSIONS

Diabetes and prediabetes are at increased risk of coinfection with HPV in female patients aged over 50 years in the cervical clinic.

Sensitive Tumor Cell Line for Annonaceous Acetogenins and High Therapeutic Efficacy at a Low Dose for Choriocarcinoma Therapy

Annonaceous acetogenins (ACGs) have attracted much attention because of excellent antitumor activity. However, the lack of selectivity and the accompanying serious toxicity have eventually prevented ACGs from entering clinical application. To decrease the side effects of ACGs, the cytotoxicity of ACGs on 10 types of tumor cell lines was investigated by the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) test to identify one that was very sensitive to ACGs. Meanwhile, ACGs nanoparticles (ACGs-NPs) were prepared using poloxamer 188 (P188) as an excipient so as to solve the problem of poor solubility and the in vivo delivery of ACGs. ACG-NPs were 163.9±2.5 nm in diameter, negatively charged, and spherical with a high drug loading content (DLC) of 44.9±1.2%. MTS assays demonstrated that ACGs had strong cytotoxicity against JEG-3, HeLa, SiHa, MCF-7, A375, A2058, A875, U-118MG, LN- 229, and A431 cells, among which JEG-3 cell line was extremely sensitive to ACGs with a 50% inhibitory concentration (IC50) value of 0.26 ng/mL, a very encouraging discovery. ACGs-NPs demonstrated very good dose-dependent antitumor efficacy in a broad range of 45?1200 μg/kg on JEG-3 tumor-bearing mice. At a very low dose (1200 μg/kg), ACGs-NPs achieved a high tumor inhibition rate (TIR) of 77.6% through oral administration, displaying a significant advantage over paclitaxel (PTX) injections that are currently used as first-line anti-choriocarcinoma drugs. In the acute toxicity study, the half lethal dose (LD50) of ACGs-NPs was 135.5 mg/kg, which was over 100 times as of the effective antitumor dose, indicating good safety of ACGs-NPs. ACGs-NPs show promise as a new type of and potent anti-choriocarcinoma drug in the future.

24 h urinary creatinine excretion during pregnancy and its application in appropriate estimation of 24 h urinary iodine excretion

BACKGROUND

Urinary creatinine can be used to adjust urinary iodine to evaluate iodine nutritional status during pregnancy. However, the reference intervals and impact factors of urinary creatinine are unknown.

METHODS

24 h urine creatinine concentration (24 hUCr) and spot UCr at four different time periods of the day of pregnant women from Part 1 (n = 743) were measured. Linear regression analysis was performed to identify the impact factors of 24 h urinary creatinine excretion (24 hUCrE) and obtain the estimated 24 h urinary creatinine excretion (24 hUCrE_est). Then measured urinary iodine concentration (UIC) of 24 h and at fasting of pregnant women from Part 2 (n = 325), used spot urinary iodine to creatinine concentration ratio (UIC/UCr) and 24 hUCrE_est to calculate the estimated 24 h urinary iodine excretion (24 hUIE_est), finally checked the consistency and correlation of 24 hUIE_est and 24 h urinary iodine excretion (24 hUIE).

RESULTS

In Part 1, the median 24 hUCrE was 1.24(IQR0.98-1.76)g, and the reference interval was 0.61-2.93 g. The median 24 hUCr was 0.76 (IQR0.57-1.01)g/L, and the reference interval was 0.36-1.88 g/L. Multiple linear regression results showed that pregnancy weight was an influencing factor to 24 hUCrE after adjusting by gestational weeks, age, pre-pregnancy BMI, and percentage of body fat (F = 45.029, p＜0.001). In Part 2, there was no statistically significant difference between 24 hUIE_est and 24 hUIE (Z =-0.767, p = 0.443). Using 24hUIE as the gold standard, the relative average difference in 24hUIE_est was 4.2 %, the relative average differences for UIC and UIC/UCr were 32.4 % and 37.2 %. The reference interval of 24 hUIE and 24 hUIE_est were 88.43-585.90 μg and 50.97-700.39 μg, respectively.

CONCLUSIONS

The reference intervals of 24 hUCrE, spot UCr, 24 hUIE, and 24 hUIE_est during pregnancy were established. 24 hUCrE has important application value in iodine nutrition evaluation to gain more lead time for pregnant women with iodine nutrition-related diseases.

Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis

OBJECTIVE

The association between the most severe types of placenta accreta spectrum disorders and caesarean scar pregnancy (CSP) poses the question of whether early diagnosis may impact the clinical outcome of these anomalies. The aim of this study is to report the outcome of cesarean scar pregnancy (CSP) diagnosed in the early (≤9 weeks) versus late (>9 weeks) first trimester of pregnancy.

STUDY DESIGN

Medline, Embase and Clinicaltrail.gov databases were searched. Studies including cases of CSP with an early (≤9 weeks of gestation) compared to a late (>9 weeks) first trimester diagnosis of CSP, followed by immediate treatment, were included in this systematic review. The primary outcome was a composite measure of severe maternal morbidity including either severe first trimester bleeding, need for blood transfusion, uterine rupture or emergency hysterectomy. The secondary outcomes were the individual components of the primary outcome. Random-effect meta-analyses were used to combine data.

RESULTS

Thirty-six studies (724 women with CSP) were included. Overall, composite adverse outcome complicated 5.9 % (95 % CI 3.5-9.0) of CSP diagnosed ≤9 weeks and 32.4 % (95 % CI 15.7-51.8) of those diagnosed >9 weeks. Massive hemorrhage occurred in 4.3 % (95 % CI 2.3-7.0) of women with early and in 28.0 % (95 % CI 14.1-44.5) of those with late first trimester diagnosis of CSP, while the corresponding figures for the need for blood transfusion were 1.5 % (95 % CI 0.6-2.8) and 15.8 % (95 % CI 5.5-30.2) respectively. Uterine rupture occurred in 2.5 % (95 % CI 1.2-4.1) of women with a prenatal diagnosis of CSP ≤ 9 weeks and in 7.5 % (95 % CI 2.5-14.9) of those with CSP > 9 weeks, while an emergency intervention involving hysterectomy was required in 3.7 % (95 % CI 2.2-5.4) and 16.3 % (95 % CI5.9-30.6) respectively. When computing the risk, early diagnosis of CSP was associated with a significantly lower risk of composite adverse outcome, (OR: 0.14; 95 % CI 0.1-0.4 p < 0.001).

CONCLUSIONS

Early first trimester diagnosis of CSP is associated with a significantly lower risk of maternal complications, thus supporting a policy of universal screening for these anomalies in women with a prior cesarean delivery although the cost-effectiveness of such policy should be tested in future studies.

The use of intra-operative ultrasound in gynecological surgery: a review

Ultrasound is a readily available, safe and portable imaging modality that is widely applied in gynecology. However, there is limited guidance for its use intra-operatively especially with complex gynecological procedures. This narrative review examines the existing literature published on the use of intraoperative ultrasound (IOUS) in benign gynecology and in gynecological oncology. We searched for the following terms: ‘intraoperative,’ ‘ultrasonography,’ ‘gynecology’ and ‘oncology’ using Pubmed/Medline. IOUS can minimize complications and facilitate difficult benign gynecological procedures. There is also a role for its use in gynecological oncology surgery and fertility-sparing surgery. The use of IOUS in gynecological surgery is an emerging field which improves visualization in the surgical field and aids completion of minimally invasive techniques.

Ultrasound (US) is a portable and safe imaging method that uses high frequency sound waves to visualize structures within the body. While most US examinations are done outside the body there is an emerging field which uses US devices within the body during surgery to aid complex procedures. This review examines the published literature on this technique in benign gynecology and in gynecological oncology. This review demonstrates the use of intraoperative US improves visualization and minimizes surgical complications.

Obturator nerve injury in a chemo and radio-resistant patient with a locally-advanced cervical cancer after two previous uterine artery embolizations for severe vaginal bleeding: Case report and review of literature

Chemo and radiotherapy are actually the gold standard of treatment for locally-advanced cervical cancer. We report a case report showing a repaired (video 1) right obturator nerve after an incidental injury during a right internal iliac artery closure with 10 mm titanium clip for severe pelvic bleeding in a patient with locally-advanced cervical cancer. A 52 year-old postmenopausal woman with a chemo and radio-resistant locally-advanced squamous cervical cancer was admitted at our department for severe vaginal bleeding after two previous uterine artery embolizations. As a consequence of the increasing vaginal bleeding, and after a MRI-scan, an open surgical treatment was decided with a type C radical hysterectomy with bilateral salpingo-oophorectomy. During dissection of obturator, paravescical and pararectal spaces and removal of metastatic pelvic lymphnodes, a severe blood loss that required a right internal iliac artery closure with 10 mm titanium clip was observed. A right obturator nerve incidental injury during this time occurred. After an immediate grasping of the two sides of the lesion, the obturator nerve was succesfully repaired using 4-0 Prolene interrupted sutures (Ethicon, Johnson & Johnson, New Jersey, USA). The patient was regularly discharged four days after the surgical procedure without neurological deficit, paresthesia or side effects. In conclusion obturator nerve repair is an emergency procedure for treatment of patients with advanced cervical cancer, but it should be reserved for oncologic surgeons trained in extensive oncological procedures and repair of nerve and vascular injuries potentially associated with high mortality rate.

Assessment of the necessity of uterine artery embolization during suction and curettage for caesarean scar pregnancy: a prospective cohort study

Background

Uterine artery embolization (UAE) followed by suction and curettage is a common conservative treatment for caesarean scar pregnancy (CSP), but the advantages of suction and curettage alone are underestimated due to the lack of standards for selecting appropriate cases for which this approach would be applicable. We sought to identify indicators with which to assess the need for UAE during suction and curettage.

Methods

The prospective cohort consisted of 105 women diagnosed with CSP in Peking Union Medical College Hospital between January 2016 and September 2018 who were followed up until 60 days after surgery. The main outcome was the therapy used, and secondary outcomes included recovery, bleeding, surgery time, length of hospital stay, and total cost.

Results

We found that β-human chorionic gonadotropin (β-hCG) levels were significantly lower (P < 0.05), foetal cardiac activity was significantly lower (P < 0.05), the myometrial layer was significantly thicker (P < 0.05), expenditures were lower and lengths of hospital stay were shorter in patients who received suction and curettage alone (the non-UAE group) than in those who received UAE followed by suction and curettage (the UAE+ group). In addition, for CSP patients, UAE might be less necessary when the myometrial thickness is ≥2 mm and the gestational sacmeasures ≤5 cm, and suction and curettage alone may be safer for these patients.

Conclusion

Suction and curettage alone is a more suitable option than UAE followed by suction and curettage because the former carries a lower cost, shorter length of hospital stay, and lower risk of adverse events. Regarding risk factors, patients with a lower uterine segment thickness ≥ 2 mm and a gestational mass diameter ≤ 5 cm have an increased probability of being successfully treated with suction and curettage alone.

Hydatidiform mole in a scar on the uterus: A case report

BACKGROUND

Cesarean scar molar pregnancy is extremely rare, but the incidence has been rising due to the continuous increase in the rate of cesarean section. The presence of a hydatidiform mole in the scar left on the uterus by the procedure may lead to severe complications. We performed a literature review and found only seven reported cases of cesarean scar molar pregnancy. Accurate diagnosis and appropriate treatment are extremely important for the patients’ prognosis.

CASE SUMMARY

A 35-year-old woman, gravida 4, para 1, complained of vaginal bleeding lasting more than 1 mo and amenorrhea lasting more than 2 mo. The patient’s serum human chorionic gonadotropin was 4287800 IU/L. Ultrasound showed a 11.5 cm × 7.5 cm mass at the anterior lower wall of the uterus. The patient underwent suction evacuation, and partial grape-like tissue mixed with blood clots was removed. Uterine arterial embolization was performed to control intraoperative and postoperative bleeding. Histological examination confirmed the presence of a hydatidiform mole in uterine scar. After surgery, there was still a mass with heterogeneous intensity near the isthmus of the uterus on magnetic resonance imaging. The patient then underwent chemotherapy. During the 6-mo follow-up period, the mass disappeared and the serum human chorionic gonadotropin level gradually decreased to normal level.

CONCLUSION

We report a case of cesarean scar molar pregnancy successfully cured by comprehensive treatment. We found that cesarean scar molar pregnancy was subject to intraoperative bleeding, and uterine arterial embolization before surgery may be helpful.

Cesarean section scar ectopic pregnancy - a management conundrum: a case report

BACKGROUND

Cesarean section scar ectopic pregnancies are a rare complication of pregnancy that may follow previous hysterotomy for any cause, uterine manipulation, and in vitro fertilization. It has become more common with the increasing number of cesarean sections worldwide. Fortunately, the use of first-trimester ultrasound imaging has led to a significant number of these pregnancies being diagnosed and managed early.

CASE PRESENTATION

We report a case of a 36-year-old black African patient who had two previous cesarean sections and one previous surgical evacuation. She presented with a type 2 cesarean section scar ectopic pregnancy that was suspected on the basis of transvaginal ultrasound imaging, but not at laparoscopy/hysteroscopy. A bladder adherent to the upper segment of the anterior uterine wall obscured the gestational mass at laparoscopy. There were extensive intracavitary adhesions that interfered with hysteroscopic visualization. This resulted in the original operative procedure being postponed until magnetic resonance imaging confirmed the ectopic location of the pregnancy. The ectopic gestation was subsequently excised, and the uterus was repaired via laparotomy.

CONCLUSIONS

It is important for clinicians and radiologists managing women with risk factors for a scar ectopic pregnancy to maintain a high index of suspicion during follow-up. Failure to diagnose and initiate prompt management may lead to uterine rupture, massive hemorrhage, and maternal death.

Delayed diagnosis of a cesarean scar pregnancy: a case report

Background

Cesarean scar pregnancy is rare but may be related to early uterine rupture and may result in massive hemorrhage. Nowadays, most cesarean scar pregnancies are diagnosed early and can be managed properly. However, diagnoses of cesarean scar pregnancies that develop in the obstetrical area are sometimes delayed.

Case presentation

A 28-year-old Asian woman visited our institution because of suspected cesarean scar pregnancy. Ultrasonography and computed tomography confirmed a cesarean scar pregnancy with a live fetus with a crown-rump length of 4.83 cm, corresponding to 11 weeks 6 days of gestation. Initially, we injected 50 mg of methotrexate in the amniotic sac under transabdominal ultrasonographic guidance. However, fetal cardiac activity was still observed 2 days later. We decided to perform open laparotomy because of the possibility of massive bleeding. The gestational sac was removed, as well as most of the trophoblastic tissues that were adherent and invading the wall of the lower uterine segment. She was discharged in good condition 5 days after the operation.

Conclusions

Despite the popular use of ultrasonography in prenatal care, diagnosis of cesarean scar pregnancy is still delayed. Surgical treatment with local methotrexate injection could be an option for the management of advanced cesarean scar pregnancy.

Correction of iatrogenic injury of the obturator nerve during pelvic laparoscopic lymphadenectomy by the use of sural nerve grafts

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Intraoperative injury of the obturator nerve is not an infrequent complication of gynecological surgeries.

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This injury can occur in association with pelvic lymphadenectomy for uterine or cervical cancer.

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This manuscript demonstrates an alternative technique for the obturator nerve repair, when primary end to end anastomosis is not possible.