Osseous metastases of uterine leiomyosarcoma: Analysis of survival & surgical management

BACKGROUND

Uterine leiomyosarcoma represents a seldom-encountered subset within the spectrum of uterine malignancies. Occurrences of appendicular skeletal metastases in uterine leiomyosarcomas are infrequent. In this study, we examined patient surveys to elucidate the clinical characteristics and outcomes of individuals with uterine leiomyosarcoma exhibiting metastatic dissemination to these anatomical regions. We hypothesized that palliative surgical treatment would have no effect on survival in patients diagnosed with uterine leimyosarcoma with appendicular bone metastases.

METHODS

One hundred fourteen patients diagnosed with uterine leiomyosarcoma and treated at the Department of Oncologic Orthopedics at XXX hospital from 2004 to 2021 met the criteria for inclusion in this retrospective cohort study. The study specifically encompassed patients with histopathologically confirmed appendicular bone metastases secondary to uterine leiomyosarcoma, who underwent either surgical intervention or conservative treatment. Exclusion criteria involved patients with exclusive vertebral bone metastases, as well as those lacking essential examination and follow-up data. Notably, the study included nine follow-up patients with at least 2 years of follow-up who developed appendicular skeletal metastases during the follow-up period.

RESULTS

Of the 9 patients, 3 had humeral metastases, 2 had femoral metastases, 1 had femoral and diffuse pelvic metastases, and the other 3 had pelvic metastases. Bone metastases occurred at a mean of 33.3 ± 32.4 months (range 3 - 108) after the diagnosis. After bone metastasis, 6 patients died after an average of 40.3 ± 26.7 months (range 12-84 months). One patient with a pathologic fracture in the proximal humerus underwent resection arthroplasty, 1 patient with metastases in the proximal femur underwent resection arthroplasty, 2 patients with metastases to the femoral shaft underwent curettage-cementation (C&C) and intramedullary nailing, and 1 patient with persistent pelvic pain underwent C&C. No surgery was performed in the other patients.

CONCLUSION

In patients diagnosed with uterine leiomyosarcomas, survival did not differ between palliative surgery and conservative treatment after appendicular bone metastases. Patient assessment should be individualized, and overall health should be evaluated before palliative surgery is performed.

LEVEL OF EVIDENCE

IV.

Post-operative outcomes associated with anterior mesh location after laparoscopic sacrocolpopexy

OBJECTIVE

To investigate the relationship between the anatomical position of the anterior arm of the mesh, measured by ultrasound through the bladder neck-mesh distance technique and the surgical outcomes after laparoscopic sacrocolpopexy (SCP) for apical prolapse.

STUDY DESIGN

It was a retrospective analysis of prospectively collected data in a tertiary care hospital. Between January 2019 and September 2019, 63 women who underwent laparoscopic SCP due to apical prolapse were included. Bladder neck-mesh distance was measured immediately after surgery. The pelvic floor was evaluated using the Pelvic Organ Prolapse Quantification (POP-Q) System before, 1 month, and 2.7 years (mid-term) after the surgery. Post-operative stress urinary incontinence (SUI) and Patient Global Impression of Improvement (PGI-I) scores were also assessed. The correlation between bladder neck-mesh distance and the post-operative outcomes was investigated using the Spearman rank correlation coefficient.

RESULTS

At mid-term follow-up visit, bladder neck-mesh distance was inversely correlated with the correction of apical prolapse and post-operative SUI. No correlation was detected with the anterior compartment prolapse correction. PGI-I scores were high in all patients at mid-term follow-up, irrespective of bladder neck-mesh distance values.

CONCLUSION

The shorter the bladder neck-mesh distance, the better the outcome for apical compartment repair. Bladder neck-mesh distance had no correlation with the anterior anatomical correction. Shorter bladder neck-mesh distance values were positively correlated to better PGI-I scores and a higher risk of SUI.

An illustrated review on herbal medicine used for the treatment of female infertility

Infertility is one of the significant global issues that affects approximately 15-17 % of couples worldwide, with around 50 % of cases being attributed to female infertility factors. The exploration of herbal extracts and their effects on female infertility has been limited, particularly regarding the underlying mechanisms beyond hormonal and oxidative stress influences. In this study, the herbal medicines with potential effects such as antioxidative properties, enhancement of insulin sensitivity, and modulation of the hypothalamic-pituitary-gonadal axis have been reviewed. Several herbal extracts were found to exhibit significant antioxidant properties and demonstrate phytoestrogenic effects on reproductive factors and hormonal levels. Antioxidants are essential in mitigating oxidative stress by neutralizing free radicals, which in turn helps to lower insulin resistance, total cholesterol, fat accumulation, and the proliferation of cancerous cells. Furthermore, this review highlights that certain parts of specific plants are rich in polyphenolic compounds, including isoflavones and flavonoids, along with other advantageous substances that support women's reproductive health. These compounds not only modulate female endocrine systems but also alleviate menopausal symptoms and effectively address a range of reproductive disorders, such as polycystic ovary syndrome (PCOS), premature ovarian failure (POF), endometriosis, hyperprolactinemia, and hypothalamic dysfunction. Turning to the other side, the plants and herbal extracts with suppressive effects on female fertility have been reviewed. These findings indicated that herbal extracts could be exploited to develop natural products as supplements for supporting the female reproductive system.

Cardio-Metabolic Risk Profile of Women With Endometriosis: A Population-Based Study

AIMS

Endometriosis (EM) and metabolic disorders are frequent health problems among reproductive-aged women worldwide. Cardio-metabolic risk profile of women with EM is not well understood. We aimed to investigate the cardio-metabolic risk profile of Iranian reproductive-aged women with EM.

METHODS

This study included 976 female participants aged 20-45 years of Tehran Lipid and Glucose Study. Endometriosis was diagnosed based on the participants' self-reported previous diagnosis of EM, which was confirmed by reviewing the relevant medical documentation. All biochemical measures (low-density lipoprotein cholesterol [LDL], high-density lipoprotein cholesterol [HDL], triglycerides [TG], and fasting blood glucose concentrations [FBG]) and measurement of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and anthropometric parameters were performed according to the standard protocol of TLGS. Logistic regression analysis was performed to estimate the odds ratio of cardio-metabolic disease.

RESULTS

Of the 976 study participants, 161 individuals (16.5%) had a confirmed diagnosis of endometriosis. There were no significant differences in the median of metabolic parameters among women with and without endometriosis (p > 0.05). The prevalence of metabolic syndrome was significantly higher in women with EM group compared to the non-EM group (21.9% vs. 14.9%). The presence of endometriosis was associated with an increased odds of metabolic syndrome (adjusted odds ratio 1.99 [95% CI 1.20-3.30]; p = 0.007). And endometriosis significantly increased odds of low HDL by 2.07 (1.02-4.20); after adjustment, it still remained significant (p = 0.03). Endometriosis also increased odds of high waist circumstance significantly (1.58 [1.06-2.37]; p = 0.02).

CONCLUSIONS

Women with endometriosis may be at an increased risk of developing metabolic syndrome, high waist circumstance and low HDL compared to their counterparts without the condition. Given the potential cardio-metabolic implications, healthcare providers should consider assessing the metabolic profile of women diagnosed with endometriosis.

Association of maximum uterine diameter with postoperative complications in laparoscopic supracervical hysterectomy: A retrospective cohort study

OBJECTIVE

To determine the maximum uterine diameter threshold associated with an elevated risk of complications following laparoscopic supracervical hysterectomy (LSH).

METHODS

This was a retrospective cohort study from a single tertiary referral center. We enrolled patients who underwent LSH for benign indications at our hospital between January 2013 and June 2023. The primary outcome was the occurrence of surgical complications within the 30-day timeframe of hysterectomy. The covariate included the year of the procedure, patient age, body mass index, parity, American Society of Anesthesiologists classification, comorbidities, history of previous abdominal and pelvic surgery, and preoperative anemia, blood loss, surgical time, hospital stay and pathology. The exclusion criteria comprised those who underwent hysterectomy for malignancy, individuals who underwent total vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy, and those with missing data on uterine maximum diameter, study outcomes, or covariates.

RESULTS

We included a final sample of 120 patients, revealing a median uterine diameter of 9.12 cm, with 9.2% experiencing complications. The median uterine weight among 40 patients was 275 g. Receiver operating characteristic (ROC) curve analysis suggested a potential cutoff of 11.55 cm for predicting complications, with an area under the ROC curve of 0.67. Multivariate logistic regression confirmed a significant association between uterine diameter exceeding the cutoff and increased complication risk (OR 33.925, 95% CI: 2.294-501.690, P = 0.0103). A correlation (r = 0.762, P < 0.001) between uterine weight and diameter indicated the latter's suitability for preoperative assessment of uterine weight.

CONCLUSION

The maximum uterine diameter with an optimal cutoff of 11.55 cm was associated with increased complication risk.

A systematic literature review on patient-reported outcome domains and measures in nonsurgical efficacy trials related to chronic pain associated with endometriosis: an urgent call to action

ABSTRACT

Endometriosis, a common cause for chronic pelvic pain, significantly affects quality of life, fertility, and overall productivity of those affected. Therapeutic options remain limited, and collating evidence on treatment efficacy is complicated. One reason could be the heterogeneity of assessed outcomes in nonsurgical clinical trials, impeding meaningful result comparisons. This systematic literature review examines outcome domains and patient-reported outcome measures (PROMs) used in clinical trials. Through comprehensive search of Embase, MEDLINE, and CENTRAL up until July 2022, we screened 1286 records, of which 191 were included in our analyses. Methodological quality (GRADE criteria), information about publication, patient population, and intervention were assessed, and domains as well as PROMs were extracted and analyzed. In accordance with IMMPACT domain framework, the domain pain was assessed in almost all studies (98.4%), followed by adverse events (73.8%). By contrast, assessment of physical functioning (29.8%), improvement and satisfaction (14.1%), and emotional functioning (6.8%) occurred less frequently. Studies of a better methodological quality tended to use more different domains. Nevertheless, combinations of more than 2 domains were rare, failing to comprehensively capture the bio-psycho-social aspects of endometriosis-associated pain. The PROMs used showed an even broader heterogeneity across all studies. Our findings underscore the large heterogeneity of assessed domains and PROMs in clinical pain-related endometriosis trials. This highlights the urgent need for a standardized approach to both, assessed domains and high-quality PROMs ideally realized through development and implementation of a core outcome set, encompassing the most pivotal domains and PROMs for both, stakeholders and patients.

Oncological outcomes and risk factors for recurrence of mucinous borderline ovarian tumors: A 15-year experience at a tertiary center

BACKGROUND

The most common subtype of borderline ovarian tumors in Asia is mucinous borderline ovarian tumors (mBOTs). Intraoperative distinction from mucinous carcinoma can be difficult. Despite the indolent behavior of mBOTs, recurrence or metastases may occur. The objectives of this study were to determine the oncological outcomes of mBOTs and the risk factors for their recurrence.

RESULTS

This retrospective study enrolled patients with mBOTs treated or referred to our institution between January 2005 and December 2019. Histological reviews of the recurrent cases (primary and recurrent or metastatic tumors) were performed. Patients with other tumor subtypes, pseudomyxoma peritonei, or no in-house operation were excluded. Two hundred thirty-two patients were diagnosed with mBOTs. The median follow-up was 52 months. Six patients (2.58%) had tumor recurrence or metastasis. The risk factors for recurrence were a ruptured tumor, residual tumor after an operation, high serum CA19-9 level, and stage of the disease. The recurrence rates of fertility-sparing and radical surgery were not significantly different. Detailed surgical staging, intraepithelial carcinoma, and microinvasion were also not associated with disease recurrence.

CONCLUSIONS

mBOTs have an excellent prognosis. Currently, fertility-sparing surgery is the standard treatment, showing no significant difference in oncological outcomes compared to radical surgery. Patients with risk factors should be closely monitored.

Prenatal diagnosis of 9q34.3 microdeletion-associated Kleefstra syndrome in a pregnancy complicated by polyhydramnios: A case report and literature review

OBJECTIVE

Kleefstra Syndrome (KS) is a rare genetic disorder caused by a deletion at 9q34.3. Studies showed that various heart defects are observed in 41-43% of patients and abnormal features on brain imaging in 58-63%. To date, the prenatal phenotype in KS has yet to be defined.

CASE REPORT

We present the first prenatal diagnosis and chromosomal microarray analysis (CMA) of a case of 9q34.3 microdeletion in a fetus with increased amniotic fluid, supported by abnormal prenatal ultrasound findings, and confirmed via autopsy. CMA revealed a 2.1 Mb 9q34.3 microdeletion encompassing an OMIM gene of EHMT1, which is consistent with the diagnosis of Kleefstra syndrome and 9q subtelomeric deletion syndrome.

CONCLUSION

When a fetus with normal karyotype presents with polyhydramnios or abnormalities noted during second-trimester prenatal ultrasound screening, CMA analysis can be considered as the next step to rule out or confirm the diagnosis of chromosomal or other genetic aberrations.

Ultra-low-impact laparoscopy: a new concept for a minimally invasive surgery

INTRODUCTION

Minimally invasive surgery is considered the gold standard for the treatment of gynecological diseases. Our study aims to assess the effectiveness of the new concept of ultra-low-impact laparoscopy as a combination of low-impact laparoscopy, consisting in the use of miniaturized instruments through 3-5mm ports and low-pressure pneumoperitoneum, with regional anesthesia to evaluate the perioperative outcomes.

METHODS

A cross-sectional study was performed from May 2023 to December 2023, to enroll 26 women affected by benign gynecological disease and threated by mini-invasive surgical approach. The surgical procedures were performed following the low-impact laparoscopy protocol and the regional anesthesia protocol. The postoperative pain, nausea, and vomiting and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were analyzed.

RESULTS

Operative time was within 90 min (41.1 ± 17.1 mean ± standard deviation (SD)) and no conversion to laparotomy or general anesthesia was required. According to VAS score, the postoperative pain during the whole observation time was less than 3 (mean). Faster resumption of bowel motility (6.5 ± 2.1 mean ± SD) and women's mobilization (3.1 ± 0.7 mean ± SD) were observed as well as low incidence of post-operative nausea and vomit. Early discharge and patient's approval were recorded. Intraoperatively pain score was assessed on Likert scale during all stages.

CONCLUSION

Ultra-low-impact laparoscopy showed to provide a satisfying recovery experience for patients in terms of short hospital stays, cosmetic result, and pain relief, without compromising surgical outcomes. The encouraging results lead us to recruit a greater number of patients to validate our technique as a future well-established produce.

Lobular carcinoma metastasis to endometrial polyps: Insights from a case report and literature analysis

INTRODUCTION AND IMPORTANCE

Endometrial polyps are rare sites of metastatic breast carcinoma. Such cases have mainly been reported in tamoxifen-related polyps.

CASE PRESENTATION

We describe the case of a 56-year-old woman with invasive lobular carcinoma who was experiencing vaginal bleeding. She underwent hysteroscopy with biopsy. Microscopic examination revealed an endometrial polyp with foci of adenocarcinoma. The morphological features of the tumor matched those of the original breast carcinoma.

CLINICAL DISCUSSION

Neoplasms originating from extra-genital sites frequently spread to the female genital organs. However, these metastases are mainly concentrated in the ovaries and vagina, while those affecting the uterus are rare. Among non-genital malignant tumors, mammary carcinoma - particularly the lobular type - is the most common to affect the uterus, followed by digestive and pulmonary tumors. Metastases within an endometrial polyp are particularly unusual.

CONCLUSIONS

It is crucial to consider metastatic tumors when assessing vaginal bleeding in patients with breast carcinoma. Because of the possibility of endometrial polyps being affected by metastasis, pathologists must examine them rigorously and thoroughly.

What Should I Use? Impact of Adhesion Barriers on Postoperative Abdominal Complications: A Systematic Review

BACKGROUND

Adhesions are a feared complication of abdominal surgery. There have been many new adhesion barriers developed and tested; however, there is no recent systematic review analyzing all the published literature. To address this, we aimed to analyze the different types of adhesion barriers, and determine their effects on postoperative outcomes in patients.

METHODS

A total of 14,038 articles utilizing adhesion barriers in abdominal surgery were retrieved from the PubMed, EMBASE, and Scopus databases. Inclusion criteria were: patients undergoing abdominal surgery, patients receiving an adhesion barrier, and reported postoperative outcomes. Two reviewers independently screened titles/abstracts and full-text articles using Covidence. The ROBINS-I tool was used to assess the quality of the included studies. Study protocol: Prospero CRD42023458230.

RESULTS

A total of 20 studies, with no overall high risk of bias, with 171,792 patients were included. Most studies showed an equivocal benefit for adhesion barriers, with no singular adhesion barrier type that had definitive superior outcomes compared to the others. Bioresorbable barriers emerged as the most extensively researched adhesion barrier type, exhibiting promising results in colorectal surgery. Starch-based adhesion barriers also exhibited a reduction in overall postoperative bowel obstructions and may be beneficial for stoma sites and port closures. On the other hand, many studies raised concerns regarding complications, including risk of abscess formation, fistula development, peritonitis, and anastomotic leakage.

CONCLUSIONS

Adhesion barriers should be considered on a case-by-case basis, however, they should not be utilized prophylactically in all abdominal surgeries due to their risk of complications.

Association between urinary cotinine level and hypertensive disorders of pregnancy in women with uterine myoma: findings from the Japan Environment and Children's Study

The effect of smoking on hypertensive disorders of pregnancy is a public concern. Recent evidence suggests that the risk of hypertensive disorders of pregnancy is influenced by the presence of uterine fibroids. We explored the association between maternal smoking exposure and the risk of hypertensive disorders of pregnancy in relation to the presence of uterine fibroids using data from Japan's largest birth cohort study. This study focused on first-time mothers, and the study population comprised 2752 and 35,294 first-time mothers with and without uterine fibroids, respectively. Hypertensive disorders of pregnancy was categorized as early-onset (before 34 weeks) and late-onset (after 34 weeks). Maternal smoking exposure was assessed by measuring the urinary cotinine concentration during the mid-trimester. Participants were classified into four quartiles based on their urinary cotinine levels as follows: Q1 (low concentration) to Q4 (high concentration). Multivariate analysis adjusted for potential confounders revealed that in women without uterine fibroids, the Q3 urinary cotinine level was associated with a modified risk of early-onset hypertensive disorders of pregnancy (adjusted odds ratio: 0.63, 95% confidence interval: 0.44-0.89). Conversely, for women with uterine fibroids, Q4 urinary cotinine level was associated with an increased risk of hypertensive disorders of pregnancy (adjusted odds ratio: 1.68, 95% confidence interval: 1.05-2.72). In conclusion, this study indicated that the impact of maternal smoking exposure varied based on the presence of uterine fibroids, underscoring the importance of personalized preconception care.

Biomarkers to inform the management of polycystic ovary syndrome: A review of systematic reviews

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is the commonest endocrine condition affecting reproductive age women. Many biomarkers may aid assessment and management, however evidence is limited on their utility in clinical practice. We conducted a review of systematic reviews to identify the most useful biomarkers in the clinical management of PCOS.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and HTA until August 2023 for reviews evaluating biomarkers in PCOS women compared to healthy controls. Methodological quality was assessed using the AMSTAR2 tool. We reported pooled evidence for each biomarker with 95% confidence intervals from the most recent, up-to-date, and best quality review.

RESULTS

From 3360 citations, we included 75 systematic reviews (88 biomarkers, 191,792 women). Most reviews (50/75, 67%) were moderate quality, but reported high heterogeneity (66/75, 88%). We identified 63 abnormal biomarkers in women with PCOS versus healthy controls. Of these, 22 core biomarkers could help evaluate the multisystemic impact of PCOS and inform patient management and surveillance: dehydroepiandrosterone, prolactin, sex hormone-binding globulin, total and free testosterone, anti-Mullerian hormone, systolic and diastolic blood pressure, c-reactive protein, fibrinogen, oral glucose tolerance test, homoeostatic model assessment-insulin resistance index, fasting insulin, total cholesterol, triglycerides, lipoprotein(a), HDL, LDL, non-HDL-cholesterol, ferritin, iron, and 25-hydroxy-vitamin D.

CONCLUSION

We identified 22 core biomarkers assessing the multisystemic impact of PCOS and inform its clinical management. Future research is required to establish validated healthcare pathways.

Extremely rare mucinous adenocarcinoma of the small bowel causing bilateral metastatic Kukenberg tumors of the ovaries: A case report

RATIONALE

Small bowel adenocarcinoma (SBA) is an extremely rare tumor that is not fully understood, SBA accounts for less than 5% of gastrointestinal cancers, Krukenberg tumors account for a lower proportion of all ovarian tumors, close to 2%. Stomach is the most common primary site of Krukenberg tumor. The phenomenon of bilateral ovarian Kukenberg tumor caused by implantation and metastasis of small bowel cancer is extremely rare, with few literature reports and limited clinical diagnosis and treatment data. We present a case of a 55-year-old woman with bilateral Kukenberg's tumor caused by small bowel cancer implantation and share our views on the diagnosis and treatment of this case.

PATIENT CONCERNS

A 55-year-old woman presented with vaginal bleeding and persistent lower abdominal pain after fatigue 10 days ago. Pelvic ultrasound at a local hospital revealed 2 solid masses in her pelvis, and she came to our hospital for further diagnosis and treatment. The results of colonofiberscope examination and histopathological examination confirmed intramucosal adenocarcinoma in the small intestine.

DIAGNOSES

The results of colonofiberscope examination and histopathological examination confirmed intramucosal adenocarcinoma in the small intestine. Contrast-enhanced computed tomography showed multiple cystic space-occupying lesions in the pelvic cavity, and the possibility of ovarian tumor was considered.

INTERVENTIONS

Radical treatment of right half colon cancer and pelvic mass resection were performed under general anesthesia. Combined with intraoperative and postoperative pathological examination, the diagnosis was mucinous adenocarcinoma of the small intestine stage IV (pT4N1M1). Bilateral ovarian metastasis, metastatic cancer (3/19): lymph nodes around the small intestine (3/12), lymph nodes around the colon (0/7).

OUTCOMES

He is currently receiving chemotherapy, the chemotherapy regimen is XELOX regimen. The specific drugs were oxaliplatin and capecitabine.

LESSONS

SBA is often difficult to diagnose due to few specific symptoms and is usually detected at stage IV. Bilateral ovarian Kukenberg tumor caused by small bowel cancer implantation metastases is extremely rare, and clinicians must be vigilant for women with fewer specific symptoms of gastrointestinal discomfort and conduct further diagnostic studies to avoid delayed diagnosis and treatment.

A multi-biomarker panel for predicting Tocilizumab response in Rheumatoid arthritis patients

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by inflammation in the synovial lining of the joints. Key inflammatory cytokines such as interleukin-6 (IL-6), TNF-α, and others play a critical role in the activation of local synovial leukocytes and the induction of chronic inflammation. Tocilizumab (TCZ), a humanized anti-IL-6 receptor monoclonal antibody, has demonstrated significant clinical efficacy in treating RA patients. However, similar to other inflammatory cytokine blockers, such as TNF-alpha inhibitors, Interleukin-1 inhibitors, or CD20 inhibitors, some patients do not respond to treatment. To address this challenge, our study employed a high-precision proteomics approach to identify protein biomarkers capable of predicting clinical responses to Tocilizumab in RA patients. Through the use of data-independent acquisition (DIA) mass spectrometry, we analyzed serum samples from both TCZ responders and non-responders to discover potential biomarker candidates. These candidates were subsequently validated using individual serum samples from two independent cohorts: a training set (N = 70) and a test set (N = 18), allowing for the development of a robust multi-biomarker panel. The constructed multi-biomarker panel demonstrated an average discriminative power of 86 % between response and non-response groups, with a high area under the curve (AUC) value of 0.84. Additionally, the panel exhibited 100 % sensitivity and 60 % specificity. Collectively, our multi-biomarker panel holds promise as a diagnostic tool to predict non-responders to TCZ treatment in RA patients.

New online dynamic nomograms to predict recurrence-free and overall survival after resection of endometrial cancer: a single-institution retrospective cohort study

PURPOSE

The significant global burden of endometrial cancer (EC) and the challenges associated with predicting EC recurrence indicate the need for a dynamic prediction model. This study aimed to propose nomograms based on clinicopathological variables to predict recurrence-free survival (RFS) and overall survival (OS) after surgical resection for EC.

METHODS

This single-institution retrospective cohort study included patients who underwent surgical resection for EC. Web-based nomograms were developed to predict RFS and OS following resection for EC, and their discriminative and calibration abilities were assessed.

RESULTS

This study included 289 patients (median age, 56 years). At a median follow-up of 51.1 (range, 4.1-128.3) months, 13.5% (39/289) of patients showed relapse or died, and 10.7% (31/289) had non-endometrioid tumors (median size: 2.8 cm). Positive peritoneal cytology result (hazard ratio [HR], 35.06; 95% confidence interval [CI], 1.12-1095.64; P = 0.0428), age-adjusted Charlson comorbidity index (AACCI) (HR, 52.08; 95% CI, 12.35-219.61; P < 0.001), and FIGO (Federation of Gynecology and Obstetrics) stage IV (HR, 138.33; 95% CI, 17.38-1101.05; P < 0.001) were predictors of RFS. Similarly, depth of myometrial invasion ≥ 1/2 (HR, 1; 95% CI, 0.46-2.19; P = 0.995), AACCI (HR, 93.63; 95% CI, 14.87-589.44; P < 0.001), and FIGO stage IV (HR, 608.26; 95% CI, 73.41-5039.66; P < 0.001) were predictors of OS. The nomograms showed good predictive capability, positive discriminative ability, and calibration (RFS: 0.895 and OS: 0.891).

CONCLUSION

The nomograms performed well in internal validation when patients were stratified into prognostic groups, offering a personalized approach for risk stratification and treatment decision-making.

Preterm birth in singleton pregnancies conceived by in vitro fertilization or intracytoplasmic sperm injection: an overview of systematic reviews

BACKGROUND

The rate of preterm birth of singletons conceived through in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) is increased, being as high as 15% to 16% across Europe and the United States. However, the underlying etiology, phenotype, and mechanisms initiating preterm birth (PTB) are poorly understood.

OBJECTIVE

To quantify the PTB risk and examine supposed etiology in IVF/ICSI singleton pregnancies compared to naturally conceived.

STUDY DESIGN

Overview of reviews including all available systematic reviews with meta-analysis comparing PTB risk in IVF/ICSI and naturally conceived singletons. A comprehensive search of PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases was performed up to December 31, 2023. Information available on etiology, phenotype, initiation of PTB, and relevant moderators was retrieved and employed for subgroup analyses. Random-effects meta-analysis models were used for pooling effect measures. Estimates were presented as odds ratios (ORs) with 95% confidence intervals (CIs). The extent of overlap in the original studies was measured using the corrected covered area assessment. The quality of the included reviews was evaluated with the AMSTAR 2 tool. The Grading of Recommendations Assessment, Development and Evaluation approach was applied to rate evidence certainty. The protocol was registered on PROspective Register of Systematic Reviews (CRD42023411418).

RESULTS

Twelve meta-analyses (16,522,917 pregnancies; ˃433,330 IVF/ICSI) were included. IVF/ICSI singletons showed a significantly higher PTB risk compared to natural conception (PTB ˂37 weeks: OR: 1.72, 95% CI: 1.57-1.89; PTB<32 weeks: OR: 2.19, 95% CI: 1.82-2.64). Influential analysis reinforced the strength of this association. Subgroup analyses investigating supposed etiology revealed a comparable risk magnitude for spontaneous PTB (OR: 1.79, 95% CI: 1.56-2.04) and a greater risk for iatrogenic PTB (OR: 2.28, 95% CI: 1.72-3.02). PTB risk was consistent in the subgroup of conventional IVF (OR: 1.95, 95% CI: 1.76-2.15) and higher in the subgroup of fresh only (OR: 1.79, 95% CI: 1.55-2.07) vs frozen-thawed embryo transfers (OR: 1.39, 95% CI: 1.34-1.43). There was minimal study overlap (13%). The certainty of the evidence was graded as low to very low.

CONCLUSION

Singletons conceived through IVF/ICSI have a 2-fold increased risk of PTB compared to natural conception, despite the low certainty of the evidence. There is paucity of available data on PTB etiology, phenotype, or initiation. The greater risk increase is observed in fresh embryo transfers and involves iatrogenic PTB and PTB ˂32 weeks, likely attributable to placental etiology. Future studies should collect data on PTB etiology, phenotype, and initiation. IVF/ICSI pregnancies should undertake specialistic care with early screening for placental disorders, cervical length, and growth abnormalities, allowing appropriate timely follow-up, preventive measures, and therapeutic interventions strategies.

Dynamic changes in gene expression of growing nonhuman primate antral follicles

The growth of the ovarian antral follicle is a complex process that is difficult to study, especially in human and nonhuman primates. Understanding the antral stage of development is key to new approaches to regulating reproduction. This study analyzed cohorts of three sizes of developing antral follicles obtained from adult rhesus macaque females using RNA sequencing of oocytes and cumulus and granulosa cells. The overall objective of this study was to identify key developmental changes in gene expression in oocytes, granulosa, and cumulus cells, as nonhuman primate antral stage follicles transition through progressively larger sizes in the absence of exogenous hormonal stimulation. Only a relatively small number of genes displayed altered mRNA expression levels in any of the three cell types during this period. Most of the identified differentially expressed genes (DEGs) decreased in the granulosa cells or increased in the cumulus cells. Although the number of DEGs observed was small, these DEGs indicate predicted effects on distinct upstream regulators in the cumulus and granulosa cells. This study is particularly important because it shows for the first time the gene expression changes during antral follicle growth in a medically relevant model.NEW & NOTEWORTHY Changes in gene expression in oocytes, granulosa, and cumulus cells were determined in nonhuman primate antral stage ovarian follicles transitioning through progressively larger sizes without exogenous hormonal stimulation. Only a small number of genes displayed altered mRNA expression levels in any of the three cell types. Most of the differentially expressed genes (DEGs) decreased in granulosa cells or increased in cumulus cells. These results identified upstream regulators of antral follicle development.

[Pregnancy after intrauterine insemination following hysterosalpingo-foam-sonography or hysterosalpingography]

OBJECTIVE

To compare clinical pregnancy rates following intrauterine insemination performed after hysterosalpingography (HSG) or hysterosalpingo-foam-sonography (HyFoSy).

MATERIAL AND METHODS

This is a retrospective study including 242 intrauterine insemination (IUI) performed between 2015 and 2020 at the fertility center of the Reunion Island. Among these inseminations, 121 with previous HSG and 121 with previous HyFoSy were matched. The main outcome of interest was clinical pregnancy rate. Secondary outcomes were birth rate and time to pregnancy after tubal patency test.

RESULTS

The pregnancy rate after insemination was 9.9% for the HSG group and 11.6% for the HyFoSy group, with no statistically significant difference between the groups (P=0.66). The live birth rate was similar in the two groups (7.4% for HSG and 10.7% for HyFoSy; P=0.37). Over half (57.1%) of the pregnancies occurred within 6 months after HyFoSy, whereas only 8.3% after HSG.

CONCLUSION

IUI results are not influenced by HyFoSy compared to HSG with regard to the pregnancy rates. Use of HyFoSy in infertility assessment allows global evaluation and more rapid adapted management. This approach could optimize management of patients undergoing IUI.

Predictive and Diagnostic Value of the Angiogenic Proteins in Patients With Chronic Kidney Disease

BACKGROUND

Our objective was to investigate the predictive and diagnostic accuracy of the angiogenic proteins sFlt-1 (soluble fms-like tyrosine kinase-1) and PlGF (placental growth factor) for preterm preeclampsia and explore the relationship between renal function and these proteins.

METHODS

We completed a blinded, prospective, longitudinal, observational study of patients with chronic kidney disease followed at a tertiary center (2018-2023). Serum samples were obtained at 3 time points along gestation (planned sampling): 12-16, 18-22, and 28-32 weeks. In addition, samples were obtained whenever preeclampsia was suspected (indicated sampling). sFlt-1 and PlGF levels remained concealed until the study ended. The primary outcome was preterm preeclampsia. The planned and indicated samples were used to estimate the predictive and diagnostic accuracy of the angiogenic proteins, respectively.

RESULTS

Of the 97 participants, 21 (21.6%) experienced preterm preeclampsia. In asymptomatic patients with chronic kidney disease, the angiogenic proteins were predictive of preterm preeclampsia only when sampled in the third trimester, in which case the sFlt-1/PlGF ratio (false positive rate of 37% for a detection rate of 80%) was more predictive than either sFlt-1 or PlGF in isolation. In patients with suspected preeclampsia, the diagnostic accuracy of the sFlt-1/PlGF ratio (false positive rate of 26% for a detection rate of 80%) was higher than that of sFlt-1 and PlGF in isolation. Diminished renal function was associated with increased levels of PlGF.

CONCLUSIONS

sFlt-1 and PlGF can effectively predict and improve the diagnostic accuracy for preterm preeclampsia among patients with chronic kidney disease. The optimal sFlt-1/PlGF ratio cutoff to rule out preeclampsia may need to be lower in patients with impaired renal function.

Value of pelvic examination in women with pelvic organ prolapse: A systematic review

BACKGROUND

Recent recommendations from the French High Authority of Health on pelvic organ prolapse (POP) management underline the value of a pelvic examination.

OBJECTIVES

The aim of this paper was to analyze the literature and identify the best evidence available regarding pelvic examination for women presenting prolapse-associated symptoms in terms of diagnosis and predictability of treatment success.

SEARCH STRATEGY

The databases were queried similarly using Medical Subject Headings (MeSH) and non-MeSH terms broadly related to pelvic examination and POP management.

SELECTION CRITERIA

We included studies assessing the diagnostic contribution of pelvic examination (correlation with symptoms) and its value for assessing the risk of pessary failure or recurrence after reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We assessed peer-reviewed articles on PubMed, Embase, and Cochrane database up to May 2023. The methodological quality of all the included studies was assessed using the ROBINS-E or RoB2 tools.

MAIN RESULTS

In all, 67 studies were retained for the review. Prolapse-associated symptoms are poorly correlated with POP diagnosis. The symptom that is best correlated with the POP stage is the presence of a vaginal bulge (moderate to good correlation). The factors most strongly associated with the risk of recurrence after surgery or pessary failure are clinical: essentially a higher POP stage before surgery, levator ani muscle avulsion, and vaginal and genital measurements.

CONCLUSIONS

In women complaining of prolapse-associated symptoms, a pelvic examination (vaginal speculum and digital vaginal examination) can confirm the presence of POP and identify risk factors for treatment failure or recurrence after surgical management or pessary placement. A higher stage of POP and levator ani muscle avulsion-discernible on pelvic examination-are major risk factors for POP recurrence or treatment failure. These features must be taken into account in the treatment choice and discussed with the patient.

Guillain-Barré syndrome in pregnancy: a case report and review of the literature

Guillain-Barré syndrome represents a heterogeneous group of immune-mediated peripheral neuropathies that are characterized by various clinical manifestations. Reporting this clinical case emphasizes the rarity of Guillain-Barré syndrome, the diagnostic challenges faced by healthcare providers, and the risk of delayed diagnosis for both the mother and fetus. A 34-year-old pregnant woman at 33 weeks of gestation presented to the inpatient ward complaining of paresthesia in the lower and upper limbs, muscle pain, balance disturbances, moderate headache, nausea and vertigo, general weakness, and pronounced fatigue. The patient had experienced an acute viral respiratory infection 4 weeks before presenting to the hospital. The patient was admitted to the intensive care unit with a preliminary diagnosis of acute viral respiratory infection and nasopharyngitis. The patient's condition worsened dynamically, manifesting bulbar syndrome (swallowing problems), paresthesia of the anterior abdominal wall, reduced perception of fetal movements, numbness of the tongue, and low fever (37.2°C). A diagnosis of acute inflammatory demyelinating polyradiculopathy (Guillain-Barré syndrome) was established. Despite treatment, the neurologic symptoms worsened. The paravertebral radicular type pains were difficult to manage with administered analgesic therapy, and there was a progression of the bulbar syndrome. Treatment with intravenous immunoglobulin was initiated. Consequently, it was recommended by the multidisciplinary council to perform an emergency cesarean delivery, in the interest of the mother and fetus. Guillain-Barré syndrome is a rare condition that occurs during pregnancy and requires thorough evaluation, prompt multidisciplinary assessment, and individualized management of delivery to improve maternal and fetal prognosis.

A meta-analysis of the effect of pelvic and para-aortic lymph node dissection on the prognosis of patients with endometrial cancer

Endometrial cancer (EC) is the second most common malignant tumor of the female reproductive system, and it occurs in the peri- and post-menopausal periods. The metastasis routes of EC include direct spread, hematogenous metastasis and lymph node metastasis. Symptoms such as vaginal discharge or irregular vaginal bleeding may occur in the early stage. The pathological stage of the patients treated at this time is mostly in the early stage, and comprehensive treatment such as surgery, radiotherapy and chemotherapy can improve the prognosis. This article investigates whether endometrial cancer requires pelvic and para-aortic lymph node dissection. The clinical data of 228 patients with endometrial cancer who underwent pelvic lymphadenectomy in our hospital from July 2020 to September 2021 were retrospectively analyzed. All patients underwent preoperative clinical staging and postoperative pathological staging. This paper compared lymph node spread rates of endometrial carcinoma in different stages, depth of muscle invasion, and pathological characteristics to analyze lymph node metastasis risk factors. Results showed metastasis rates of 7.5% in 228 cases of endometrial cancer, increasing with deeper myometrial invasion. Different clinicopathological factors had varying lymph node spread rates. Different clinicopathological factors have different pelvic lymph node spread rates in surgical patients. The lymph node spread rate of differentially differentiated carcinoma is higher than that of well-differentiated carcinoma. The lymph node spread rate of serous carcinoma is 100%, but there is no difference between the lymph node metastasis rate of special type carcinoma and adenocarcinoma. Statistical significance (P > 0.05).

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a strategy for postpartum haemorrhage management: A narrative review

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality worldwide, with a significant impact on global health. Optimal management of PPH involves distinct steps executed simultaneously by a multidisciplinary approach, with anesthesiologists playing a key role in hemodynamic control and patient resuscitation. In this context, an aortic blood flow interruption through an internal balloon should be considered a rescue option among the various opportunities, to treat or prevent abdominal hemorrhages. Given this perspective, there is increasing interest in the role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), originally used in trauma and military medicine, which has emerged as a novel strategy for managing PPH. Indeed, this technique has shown promise in managing severe cases of PPH, especially where traditional measures are insufficient. It also offers potential as a prophylactic measure in pregnancies with high risk for PPH, such as in the case of placenta accrete spectrum. This review aims to examine the efficacy, safety, and potential applications of REBOA in PPH management and prevention. At the same time, challenges such as the need for skilled operators, potential complications, costs, and the consideration of fetal safety were also discussed. REBOA presents as a promising tool against PPH, with efficacy in reducing blood loss, preserving fertility, and potentially decreasing maternal mortality and improving outcomes. However, its implementation requires careful consideration, training, and further research to establish clear guidelines for its use in obstetric care.

Different minimally invasive surgical methods to hysterectomy for benign gynecological disease: A systematic review and network meta-analysis

Background and Aims

This network meta-analysis aimed to compare the perioperative efficacy of various minimally invasive hysterectomy procedures for treating benign gynecological diseases and to assess whether vaginal natural orifice transluminal endoscopic hysterectomy (VNOTEH), a recently emerging procedure, is inferior to traditional laparoscopy.

Methods

We searched PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), Wanfang Data, and China VIP Database from inception to August 2022 and updated in June 2023. We included randomized controlled trials (RCTs) comparing different minimally invasive hysterectomy techniques in patients with benign gynecological conditions. The intervention measures included nine minimally invasive hysterectomies. The two researchers used the Cochrane risk-of-bias assessment tool for study appraisal. All statistical analyses and drawings were performed using STATA 17.0 and R 4.4.1. A network meta-analysis (NMA) was conducted to compare the effectiveness of minimally invasive hysterectomy and rank its relative impact probabilistically.

Results

A total of 78 RCTs involving 7640 patients and nine minimally invasive hysterectomy methods with 16 intervention combinations were included in this study. Among these, 2, 63, and 13 studies were deemed to have a low, medium, and high risk of bias, respectively. Based on the Surface Under the Cumulative Ranking (SUCRA) probability ranking results of NMA, laparoendoscopic single-site surgery-laparoscopic-assisted vaginal hysterectomy (LESS-LAVH) demonstrated superior outcomes in terms of complications, infections, and 24-h postoperative pain scores. LAVH exhibited better performance in injuries and hospital stays, total laparoscopic hysterectomy showed the least blood loss, and vaginal hysterectomy had the shortest operation time.

Conclusion

LESS-LAVH and LAVH are recommended options, if feasible. Meanwhile, VNOTEH can achieve comparable results to traditional laparoscopy but requires careful attention to the risk of injury and infection. Future research should aim to broaden the search scope by including high-quality, large-scale, multicenter RCTs.

Use of a sperm-Hyaluronan binding assay for evaluation of sperm quality in dromedary camels

The objective of this study was to assess the ability of camel spermatozoa to bind in the Hyaluronan Binding Assay (HBA), to determine if conventional sperm quality parameters, in vitro fertilization capacity, and precursor of A-Kinase Anchoring Protein 4 (proAKAP4) values correlate with HBA results. The potential to predict post-thaw fertilization performance from HBA for fresh dromedary camel sperm was also evaluated. Semen samples were collected and assessed both fresh and post thawing, at 0 h and 1.5 h. Conventional semen analysis, HBA, and a proAKAP4 biomarker-test were used to validate sperm quality. A heterologous sperm penetration assay using zona pellucida-free goat oocytes was used to assess in vitro sperm fertilizing capacity. The results showed that dromedary camel spermatozoa bound to hyaluronan with no correlation between results from fresh samples and after thawing. Furthermore, the proAKAP4 test results showed a negative correlation with HBA at 0 h after thawing (r = - 0.62; P = 0.03). In the conventional analysis, only progressive motility (r = 0.65; P = 0.02) and straightness correlated with HBA for fresh semen (r = 0.69; P = 0.01). In the sperm penetration assay, a moderate but non-significant correlation was identified between fresh sperm HBA and penetration (r = 0.52; P = 0.07). In conclusion, results suggested that HBA can be used to assess camel sperm properties, but further investigation is needed to understand its correlation with other sperm quality parameters. The HBA score from fresh dromedary camel sperm was unable to predict post-thaw fertilization performance.

A simple and practical approach to elective egg freezing to control costs and expand access to care

Social elective egg freezing (EEF) is now widely used globally but in many countries is unaffordable to many women because of high costs and lacking insurance coverage. Efforts to reduce costs, therefore, are of importance. Surprisingly, a simple, well-defined and practical approach ensuring optimal outcomes for EEF has, however, so-far not been published. We, therefore, conducted a narrative review of the literature for relevant articles regarding the different steps of ovarian stimulation (OS) in the EEF process, in order to define such a standard protocol. This review revealed that in order to maximize oocyte yields with minimal number of OS cycles - while ensuring patient safety - a multiple-dose GnRH antagonist protocol with a daily gonadotropin dose of 300 IU appears best, unless patients demonstrate a polycystic ovarian phenotype, suggestive of likely high responses. The initial gonadotropin should be recFSH, while LH supplementation should be co-administered with the addition of GnRH antagonist. Final follicular maturation should be triggered by GnRH agonist trigger, with a dual trigger (1000-1500 IU hCG) considered for suboptimal responders to GnRH agonist trigger, optionally with Cabergoline to mitigate ovarian hyperstimulation syndrome (OHSS) in high responders.

Minimal important difference of Berg Balance Scale, performance-oriented mobility assessment and dynamic gait index in chronic stroke survivors

OBJECTIVE

The Berg Balance Scale (BBS), Performance-Oriented Mobility Assessment (POMA), and Dynamic Gait Index (DGI) are crucial standard tools used to evaluate functional balance. However, their minimal important difference (MID) threshold is yet to be established. The objective of this research was to explore the MID for BBS, POMA, and DGI in people suffering from chronic stroke.

METHODS

A total of 130 chronic stroke patients were assessed using BBS, POMA and DGI before and after undergoing interventions. The treatment procedures included a series of task-oriented exercises focusing on motor re-learning. In anchor-based approach, the Clinical Global Impression of Improvement scale served as the anchor. The Receiver Operating Characteristic (ROC) curve was employed to identify the best MID cut-off point for BBS, POMA, and DGI. In the distribution-based approach, one-third standard deviation (SD), half SD, one standard error of measurement (SEM), and the total score of BBS, POMA and DGI were used to determine the MID.

RESULTS

The MID from the ROC curve was greater than 2 points for BBS, greater than 1 point for POMA and DGI. For the distribution-based approach, the MIDs corresponding to one-third of the SD, half of the SD, and one SEM for BBS were 1.92, 3.20, and 0.90; for POMA were 1.47, 2.45, and 1.96; for DGI were 1.48, 2.47, and 1.16 points, respectively.

CONCLUSION

BBS, POMA and DGI are suitable instruments for assessing functional balance in individuals with chronic stroke, with demonstrable MID. Additionally, the results indicated that DGI has higher sensitivity and specificity than the other examined scales for distinguishing between groups without change and those with minimal balance improvement after receiving interventions.

Associations between the time interval from myomectomy to subsequent pregnancy and the obstetric outcomes: A population-based cohort study

OBJECTIVE

To investigate the associations between time interval from myomectomy to pregnancy (TIMP) and subsequent pregnancy and obstetric complications, and to explore whether these associations vary according to maternal age at birth.

METHODS

A retrospective population-based cohort study was conducted from 2008 to 2017. Data were extracted from the National Health Insurance Research Database and the Taiwan Maternal and Child Health Database, comprising 2024 379 births from 1 391 856 pregnancies. Eligible cases were identified using diagnostic and procedure codes; 4006 first singleton births in 4006 women after their first laparotomic myomectomy were identified. We estimated the risks of pregnancy and obstetric outcomes according to TIMP (<6, 6-11, and ≥12 months). Subgroup analysis was performed by further dividing according to maternal age at birth (18-34 vs ≥35 years old).

RESULTS

We observed higher risks of gestational hypertensive disorders (adjusted odds ratio [aOR] 1.97, 95% confidence interval [CI] 1.22-3.18, P = 0.005) and neonatal death (aOR 4.59, 95% CI 1.49-14.18, P = 0.008) for TIMP of <6 months versus TIMP of 6-11 months. Likewise, a TIMP ≥12 months was associated with increased risks of gestational hypertensive disorders (aOR 1.72, 95% CI 1.14-2.58, P = 0.010), and neonatal death (aOR 3.27, 95% CI 1.16-9.24, P = 0.025) versus a TIMP of 6-11 months. In subgroup analysis, women over 35 years old still had higher risks of gestational hypertensive disorders when TIMP was <6 months (aOR 2.26, 95% CI 1.17-4.37, P = 0.015) or ≥12 months (aOR 2.04, 95% CI 1.17-3.54, P = 0.012), and a higher risk of neonatal death when TIMP was <6 months (aOR 4.05, 95% CI 1.06-15.53, P = 0.041); whereas women aged 18-34 years old did not.

CONCLUSIONS

This study suggests that a TIMP between 6 and 11 months is associated with lower risks of gestational hypertensive disorders and neonatal death compared with a TIMP <6 months or ≥12 months, especially for women over 35 years old.

Stone Babies: A Pictorial Essay With Insights From 25 Museal Lithopaedions

BACKGROUND

Lithopaedion, or "stone baby," represents an exceptionally rare clinical phenomenon with fewer than 350 documented cases existing in the medical literature. This condition arises when an advanced extrauterine pregnancy ceases its developmental trajectory and undergoes a lithification process, potentially resulting in a calcified mass with fetal-like morphology. Typically, lithopaedions remain asymptomatic for decades, but may occasionally elicit acute symptoms necessitating medical intervention. However, predominantly, these entities are incidental findings discovered during radiological examinations or autopsies.

RESULTS

In this article, we present a comprehensive overview of 25 lithopaedion cases, including unreported cases from several European medical museums. When feasible, additional radiological imaging was conducted to enhance diagnostic clarity. Furthermore, this article situates lithopaedions within a broader historical perspective and a detailed etiopathogenetic framework, elucidating the physiological and pathological mechanisms contributing to their formation. The phenomenon of lithopaedion is a testimony to the complex and often enigmatic nature of the human body.

CONCLUSIONS

By compiling and scrutinizing a substantial number of cases, this review offers valuable insights into the clinical implications of lithopaedions. Furthermore, it highlights the necessity for ongoing research and meticulous documentation of rare medical conditions like this, in order to contribute to a deeper understanding of extraordinary phenomena.

Transvaginal Posterior Levatorplasty Combined with Perineoplasty: An Effective Surgical Method for Vaginal Rejuvenation

BACKGROUND

Gynecologic cosmetic surgery and rejuvenation surgery have become increasingly popular, with growing demand for vaginal surgery to address vaginal laxity. Follow-up data on the effectiveness of these procedures remain limited. The authors conducted a retrospective study to investigate the effects of transvaginal posterior levatorplasty combined with perineoplasty on vaginal rejuvenation.

METHODS

The study included 45 patients who underwent transvaginal posterior levatorplasty combined with perineoplasty between July of 2020 and May of 2022. Patient characteristics before operation, at baseline, and 3, 6, and 12 months postoperatively, and questionnaires on patient symptoms, quality of life, and sexual function, including the Vaginal Laxity Questionnaire and Female Sexual Function Index, were evaluated. Pelvic ultrasound imaging was performed preoperatively and 3 months postoperatively.

RESULTS

Mean vaginal capacity index and vaginal laxity scores were different at baseline and 6 and 12 months postoperatively ( P < 0.01). Female sexual function, including libido, sexual arousal, lubrication, orgasm, sexual satisfaction, and pain levels, were significantly improved (preoperative, 21.68 ± 4.15; 6 months postoperatively, 26.88 ± 2.44; 1 year postoperatively, 29.97 ± 2.10; P < 0.01). Symptoms of stress urinary incontinence and recurrent vaginitis were improved in 78.6% and 90.5% of patients, respectively. On pelvic floor ultrasound, retrovesical angle, urethral rotation angle, levator hiatus, and bladder neck distance were significantly different preoperatively and 3 months postoperatively ( P < 0.01). Overall satisfaction was 93.3% at 12 months postoperatively.

CONCLUSIONS

Transvaginal posterior levatorplasty combined with perineoplasty is effective for the improvement of patient symptoms, quality of life, sexual function, stress urinary incontinence, and postnatal constipation. Further research on the underlying mechanisms is required.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Activatable Fluorescence and Bio/Chemiluminescence Probes for Aminopeptidases: From Design to Biomedical Applications

Aminopeptidases are exopeptidases that catalyze the cleavage of amino acid residues from the N-terminal fragment of protein or peptide substrates. Owing to their function, they play important roles in protein maturation, signal transduction, cell-cycle control, and various disease mechanisms, notably in cancer pathology. To gain better insights into their function, molecular imaging assisted by fluorescence and bio/chemiluminescence probes has become an indispensable method to their superiorities, including excellent sensitivity, selectivity, and real-time and noninvasive imaging. Numerous efforts are made to develop activatable probes that can effectively enhance efficiency and accuracy as well as minimize the side effects. This review is classified according to the type of aminopeptidases, summarizing some recent works on the design, work mechanism, and sensing, imaging, and theranostic performance of their activatable probe. Finally, the current challenges are outlined in developing activatable probes for aminopeptidases and provide possible solutions for future advancements.

Vascular Ehlers-Danlos syndrome and pregnancy: A systematic review

BACKGROUND

Vascular Ehlers-Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge.

OBJECTIVES

To systematically review the literature data on the complications in pregnancy associated with vEDS.

SEARCH STRATEGY

We searched the Pubmed Medline and Embase databases for articles using the following terms "vascular Ehlers-Danlos syndrome" or "vEDS" AND "pregnancy".

SELECTION CRITERIA

Women with vEDS.

DATA COLLECTION AND ANALYSIS

We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS.

MAIN RESULTS

A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%.

CONCLUSIONS

Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation.

Fear of childbirth among pregnant women: A concept analysis

AIM

To clarify the concept of fear of childbirth among pregnant women and to examine its current measure tools.

BACKGROUND

Fear of childbirth is a psychological symptom, prevalent among pregnant women, which negatively impacts women's health and well-being. It has become an increasingly concerning issue in perinatal mental health. However, due to its poor conceptualization, it presents difficulty in conducting reliable assessments and identifying risk factors.

METHODS

The Walker and Avant approach to concept analysis guided this review. Six bibliographic databases were systematically searched for published research from their inception date to May 2023. Additional records were identified by manually searching the reference lists of relevant studies. Quantitative and qualitative studies investigating fear of childbirth in pregnant women were included.

RESULTS

Three critical attributes have been identified: cognitive impairments, affective disorders and somatic symptoms. Antecedents include perceived a real or anticipated threat of pregnancy or its outcomes, low perceived self-coping ability and unmet social support needs. Consequences include processing and avoiding behaviours. This study also identified the dimensions of fear of childbirth, including 6 primary categories and 14 subcategories. The content of five scales was analysed and none covered all domains.

CONCLUSIONS

The current analysis provides healthcare providers with a more comprehensive framework to assess and identify fear of childbirth. Further research is needed to develop a suitable instrument that covers all the attributes and dimensions of this concept and assesses its severity.

IMPACT

This conceptual analysis provides a comprehensive insight into the phenomenon of fear of childbirth. This will help family members, healthcare providers and policymakers to identify the psychological needs of pregnant women and improve the quality of antenatal care.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable as no new data were generated.

Narrow-band imaging offers a shorter menstrual bleeding time and a longer remission for hysteroscopic surgery in symptomatic post-cesarean scar diverticulum compared to white light

BACKGROUND

Narrow-band imaging (NBI) is a novel endoscopic imaging technology that improves the visibility of capillaries. The aim of this study was to evaluate the efficacy of NBI hysteroscopic excision in symptomatic post-cesarean scar diverticulum (PCSD) patients compared to conventional white light (WL) hysteroscopy.

METHOD

A total of 73 patients with symptomatic PCSD between January 2014 and December 2018 were enrolled. The enrolled patients were stratified into NBI and WL groups according to whether they received NBI or WL hysteroscopy. Postoperative menstrual patterns at one, six, and 12 months after the operation were collected and compared between the NBI and WL groups.

RESULTS

A total of 32 patients underwent NBI hysteroscopy (NBI group), while 41 patients received WL hysteroscopy (WL group). The symptom-free remission rates in the NBI group were significantly higher than in the WL group at six months and 12 months post-hysteroscopy. At the final follow-up, the menstrual bleeding duration in the NBI group was significantly shorter than in the WL group.

CONCLUSION

The use of NBI hysteroscopy in treating symptomatic PCSD resulted in shorter menstrual bleeding days and longer symptomatic remission compared to conventional WL hysteroscopy.

A heterozygous SPRY4 variant identified in female infertility characterized by reduced oocyte potential and early embryonic arrest

STUDY QUESTION

Can novel genetic factors contributing to early embryonic arrest in infertile patients be identified, along with the underlying mechanisms of the pathogenic variant?

SUMMARY ANSWER

We identified a heterozygous variant in the SPRY4 (sprouty RTK signaling antagonist 4) in infertile patients and conducted in vitro and in vivo studies to investigate the effects of the variant/deletion, highlighting its critical role in female reproductive health.

WHAT IS KNOWN ALREADY

SPRY4 acts as a negative regulator of receptor tyrosine kinases (RTKs) and functions as a tumor suppressor. Its abnormal expression can lead to recurrent miscarriage by affecting trophoblast function. In mice, Spry4 knockout (KO) leads to craniofacial anomalies and growth defects. A human study links the SPRY4 variant to a male patient with isolated hypogonadotropic hypogonadism (IHH), hypothetically impacting gonadotropin-releasing hormone (GnRH) neurons, and causing reproductive dysfunctions. SPRY4 is thus potentially integral in regulating endocrine homeostasis and reproductive function. To date, no study has reported SPRY4 variants associated with female fertility, and a causal relationship has not been established with functional evidence.

STUDY DESIGN, SIZE, DURATION

Whole-exome sequencing (WES) was performed in 392 infertile women who suffered from primary infertility of unknown reason, and the heterozygous SPRY4 variant were identified in one independent family. The infertile patients presenting were recruited from July 2017 to November 2023.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women diagnosed with primary infertility were recruited from the Reproduction Center of Zhongshan Hospital, Fudan University. Genomic DNA was extracted from peripheral blood for WES analysis. The SPRY4 variant were identified through WES, in silico analysis, and variant screening. All variants were confirmed by Sanger sequencing. The effects of the variants were investigated in human embryonic kidney (HEK) 293T (HEK293T) cells via western blotting, and in mouse oocytes and embryos through complementary RNA (cRNA) injection, RNA sequencing, fluorescence, absorbance, and RT-qPCR assays. Gene function was further examined in Spry4 KO mice via histology, western blotting, ELISA, and RT-qPCR assays.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified a missense heterozygous pathogenic variant in SPRY4 (GRCh38, GenBank: NM_030964.5, c.157C>T p.(Arg53Trp), rs200531302) that reduces SPRY4 protein levels in HEK293T cells and disrupts the redox system and mitochondrial function in mouse oocyte, and perturbs developmental potential in mouse embryos. These phenotypes could be partially reversed by the exogenous addition of Nrf1 cRNA. Additionally, Spry4-/- mice exhibit ovarian oxidative stress and decreased ovarian function.

LIMITATIONS, REASONS FOR CAUTION

Due to the limited WES data and population, we identified only one family with a SPRY4 mutation. The deeper mechanism and therapeutic strategy should be further investigated through mutant mice and recovery experiment.

WIDER IMPLICATIONS OF THE FINDINGS

Our study has identified a pathogenic variant in SPRY4 associated with early embryonic arrest in humans. These findings enhance our understanding of the role of SPRY4 in early embryonic development and present a new genetic marker for female infertility.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (82071643 and 82171655) and Natural Science Foundation of Shanghai (22ZR1456200). None of the authors have any competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Placental lesions in systemic lupus erythematosus pregnancies associated with small for gestational age infants

OBJECTIVES

Up to a quarter of pregnant individuals with SLE have small for gestational age (SGA) infants. We aimed to characterize placental pathology associated with SGA infants in SLE.

METHODS

We retrospectively analysed SLE deliveries with placental analysis at UCSD from November 2018 to October 2023, comparing SLE pregnancies resulting in SGA to those that did not, and additionally, to matched pregnancies with SGA but without SLE.

RESULTS

Placental analysis was available only for 28/70 (40%) SLE deliveries, which had high rates of adverse outcomes (75%). All exhibited at least one histopathologic abnormality. Key findings distinguishing 12 SLE placentas resulting in SGA infants (vs.16 without) included small placental disc for gestational age (100% vs 56%, P = 0.01), placental disc infarct (50% vs 6%, P = 0.02) and increased perivillous fibrin deposition (PVFD, 58% vs 0%, P = 0.001). All seven SLE placentas with increased PVFD resulted in SGA infants. Compared with matched non-SLE pregnancies with SGA (n = 36), the only distinguishing placental lesion was a higher prevalence of increased PVFD in SLE-associated SGA (58% vs 22%, P = 0.03).

CONCLUSION

The higher prevalence of increased PVFD in placentas of SLE-associated SGA may indicate a specific mechanism of placental injury leading to SGA in this context. Thus, its presence, particularly in context of SGA, should prompt providers to screen for an underlying autoimmune disease, including SLE. Systematic placental examination in context of SLE and associated autoimmune diseases could help evaluate responses to existing therapies, comparative studies of novel therapies and correlation to adverse outcomes.

Risk of Postpartum Hemorrhage in Hypertensive Disorders of Pregnancy: Stratified by Severity

OBJECTIVE

 We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH.

STUDY DESIGN

 Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic-ischemic encephalopathy, or neonatal death.

RESULTS

 Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] = 1.11, 95% CI: 1.01-1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR = 1.52, 95% CI: 1.32-1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR = 1.49, 95% CI: 1.06-2.09).

CONCLUSION

 CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage.

KEY POINTS

· Individuals with HDP had an 11% higher likelihood of CMHO.. · After stratification, increased CMHO was limited to those with preeclampsia with severe features.. · There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH..

Regulators of placental antibody transfer through a modeling lens

Infants are vulnerable to infections owing to a limited ability to mount a humoral immune response and their tolerogenic immune phenotype, which has impeded the success of newborn vaccination. Transplacental transfer of IgG from mother to fetus provides crucial protection in the first weeks of life, and maternal immunization has recently been implemented as a public health strategy to protect newborns against serious infections. Despite their early success, current maternal vaccines do not provide comparable protection across pregnancies with varying gestational lengths and placental and maternal immune features, and they do not account for the dynamic interplay between the maternal immune response and placental transfer. Moreover, progress toward the rational design of maternal vaccines has been hindered by inadequacies of existing experimental models and safety challenges of investigating longitudinal dynamics of IgG transfer in pregnant humans. Alternatively, in silico mechanistic models are a logical framework to disentangle the processes regulating placental antibody transfer. This Review synthesizes current literature through a mechanistic modeling lens to identify placental and maternal regulators of antibody transfer, their clinical covariates, and knowledge gaps to guide future research. We also describe opportunities to use integrated modeling and experimental approaches toward the rational design of vaccines against existing and emerging neonatal pathogen threats.

Sexual hormones changes in burning mouth syndrome: A systematic review

BACKGROUND

Burning mouth syndrome (BMS) is a chronic pain condition affecting the oral cavity. This condition mostly affects peri- or postmenopausal women; for this reason, sexual hormonal changes have been implicated in BMS pathogenesis.

METHODS

A systematic review was performed in MEDLINE/PubMed, Scopus, Web of Science, Cochrane Library and EMBASE without restriction for language or year. Eligibility criteria were controlled studies addressing the PICO question: (P) patients with BMS; (I) detection of the sex hormones; (C) patients without BMS; (O) changes on sexual hormones as a risk factor for BMS severity. Risk of bias was performed with Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Four studies were included. Salivary levels were evaluated in three studies and serum blood was used in one. Three studies analysed oestradiol and/or dehydroepiandrosterone (DHEA), two assessed progesterone and one evaluated follicle-stimulating hormone (FSH). Oestradiol results were contradictory, with two studies reporting lower levels in BMS patients compared to controls and one finding the opposite. DHEA was statistically lower in the BMS group in one study. Progesterone showed opposite results in two studies, although none with statistical significance. FSH was statistically higher in the BMS group compared to controls. Correlation of hormones with quality of life was performed in three studies and there was no significant correlation with self-perceived symptoms severity.

CONCLUSION

Sexual hormones can be altered in BMS, especially oestradiol. Despite these changes, we did not find correlation between hormone fluctuation and BMS symptoms intensity affecting quality of life. These findings suggested the need for further investigation on hormonal alterations, which may be a promising target on BMS management.

Multivariable prediction models for fetal macrosomia and large for gestational age: A systematic review

BACKGROUND

The identification of large for gestational age (LGA) and macrosomic fetuses is essential for counselling and managing these pregnancies.

OBJECTIVES

To systematically review the literature for multivariable prediction models for LGA and macrosomia, assessing the performance, quality and applicability of the included model in clinical practice.

SEARCH STRATEGY

MEDLINE, EMBASE and Cochrane Library were searched until June 2022.

SELECTION CRITERIA

We included observational and experimental studies reporting the development and/or validation of any multivariable prediction model for fetal macrosomia and/or LGA. We excluded studies that used a single variable or did not evaluate model performance.

DATA COLLECTION AND ANALYSIS

Data were extracted using the Checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies checklist. The model performance measures discrimination, calibration and validation were extracted. The quality and completion of reporting within each study was assessed by its adherence to the TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) checklist. The risk of bias and applicability were measured using PROBAST (Prediction model Risk Of Bias Assessment Tool).

MAIN RESULTS

A total of 8442 citations were identified, with 58 included in the analysis: 32/58 (55.2%) developed, 21/58 (36.2%) developed and internally validated and 2/58 (3.4%) developed and externally validated a model. Only three studies externally validated pre-existing models. Macrosomia and LGA were differentially defined by many studies. In total, 111 multivariable prediction models were developed using 112 different variables. Model discrimination was wide ranging area under the receiver operating characteristics curve (AUROC 0.56-0.96) and few studies reported calibration (11/58, 19.0%). Only 5/58 (8.6%) studies had a low risk of bias.

CONCLUSIONS

There are currently no multivariable prediction models for macrosomia/LGA that are ready for clinical implementation.

Use of intravenous immunoglobulin in antiphospholipid antibody positive patients with high risk of miscarriage: a systematic review and meta-analysis

Objective

The purpose of the present study was to evaluate whether intravenous immunoglobulin (IVIG) increases live birth rates and improves neonatal results in patients with antiphospholipid antibodies (aPL) at high-risk for miscarriage.

Background

Positivity of aPL in pregnant women is a high-risk factor for miscarriage, and IVIG treatment has emerged as a potential intervention.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was employed to search multiple electronic databases for articles published until August 20, 2023, including PubMed, Web of Science, Embase, Scopus and Medline. The inclusion criteria encompassed studies assessing the efficacy of IVIG in aPL-positive patients with a high risk of miscarriage. Relevant articles were assessed for the quality and data were extracted for analysis. Two independent reviewers performed study selection, data extraction, and quality assessments. The risk of bias was evaluated according to the Cochrane risk of bias tool. All analyses were conducted using Review Manager 5.3.

Results

This systematic review included nine randomized controlled trials, with 366 aPL-positive women at high risk of miscarriage. These studies included in this review were randomized controlled trials. The primary outcome measures were successful pregnancy outcomes and live birth rates. The secondary outcomes included obstetric complications, and neonatal outcomes (such as birth weight and live-birth rate). The comparison between the intervention and control groups revealed no significant differences in terms of obstetric complications and neonatal outcomes. The group receiving IVIG treatment had a higher prevalence of preterm deliveries than controls (OR = 2.05, I2 = 46%, 95% CI [0.58-5.24]), but also exhibited a partial improvement in live birth rates (OR = 2.86, I2 = 52%, 95% CI [1.04-7.90]), because it reduced the number of miscarriages (OR = 0.35, I2 = 52%, 95% CI [0.13-0.96]).

Conclusion

Based on the available evidence, IVIG intervention appears to be a potentially effective approach for managing of aPL-positive pregnant women with high risk of miscarriage. While IVIG shows significant potential in tripling the chances of having a live-born child, further large-scale randomized controlled trials are necessary, preferably comparing IVIG with hydroxychloroquine or lifestyle and dietary interventions, to refine treatment protocols and ensure the most effective application.

Adverse perinatal outcomes related to pregestational obesity or excessive weight gain in pregnancy

OBJECTIVES

To evaluate outcomes related to pregestational obesity and excessive weight gain during pregnancy.

METHODS

This retrospective cohort was conducted from August to December 2020. Participants were divided into four groups: non-obese with non-excessive weight gain (n=765, 45.9 %), obese with non-excessive weight gain (n=190, 11.4 %), non-obese with excessive weight gain (n=532, 31.9 %), and obese with excessive weight gain (n=179, 10.7 %). The outcomes were evaluated for gestational diabetes (GDM), pregnancy-induced hypertension (PIH), newborn large for gestational age (LGA) and cesarean delivery. A p-value of <0.05 was considered significant.

RESULTS

The odds of GDM were significant in groups 2 (CR, 3.6; 95 %CI, 2.5-5.2) and 4 (CR,1.9; 95 %CI, 1.3-2.9). The odds of PIH in groups 3 (CR, 1.7; 95 %CI, 1-2.6) and 4 (CR,3.1; 95 %CI, 1.9-5.2) and those of LGA newborns in groups 2 (CR, 2.0; 95 %CI, 1.2-3.3), 3 (CR, 2.6; 95 %CI, 1.9-3.7), and 4 (CR, 3.2; 95 %CI, 2-5) were high.

CONCLUSIONS

The odds of GDM were higher in participants with pregestational obesity, while the odds of PIH were higher in participants with excessive weight gain. All groups analyzed, except the reference group, had greater chances of LGA newborns. the form of delivery was not affected.

Proteomic analysis of plasma total exosomes and placenta-derived exosomes in patients with gestational diabetes mellitus in the first and second trimesters

Gestational diabetes mellitus (GDM) is the first spontaneous hyperglycemia during pregnancy. Early diagnosis and intervention are important for the management of the disease. This study compared and analyzed the proteins of total plasma exosomes (T-EXO) and placental-derived exosomes (PLAP-EXO) in pregnant women who subsequently developed GDM (12-16 weeks), GDM patients (24-28 weeks) and their corresponding controls to investigate the pathogenesis and biomarkers of GDM associated with exosomes. The exosomal proteins were extracted and studied by proteomics approach, then bioinformatics analysis was applied to the differentially expressed proteins (DEPs) between the groups. At 12-16 and 24-28 weeks of gestation, 36 and 21 DEPs were identified in T-EXO, while 34 and 20 DEPs were identified in PLAP-EXO between GDM and controls, respectively. These proteins are mainly involved in complement pathways, immunity, inflammation, coagulation and other pathways, most of them have been previously reported as blood or exosomal proteins associated with GDM. The findings suggest that the development of GDM is a progressive process and that early changes promote the development of the disease. Maternal and placental factors play a key role in the pathogenesis of GDM. These proteins especially Hub proteins have the potential to become predictive and diagnostic biomarkers for GDM.

Maternal and newborn outcomes in pregnancies complicated by Guillain-Barré syndrome

OBJECTIVES

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. The purpose of our study was to evaluate maternal and fetal/neonatal outcomes among pregnancies complicated by GBS.

METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project - National Inpatient Sample from the United States. ICD-9 codes were used to identify all pregnant women who delivered between 1999 and 2015 and had a diagnosis of GBS. The remaining women without GBS who delivered during that time period constituted the comparison group. The associations between maternal GBS and obstetrical and fetal/neonatal outcomes were evaluated using multivariate logistic regression, while adjusting for the confounding effects of maternal characteristics.

RESULTS

Of 13,792,544 births included in our study, 291 were to women with GBS, for an overall incidence of 2.1/100,000 births. A steady increase in maternal GBS was observed over the study period (from 1.26 to 3.8/100,000 births, p=0.02). Further, women with GBS were more likely to have pregnancies complicated by preeclampsia, OR 1.69 (95 % CI 1.06-2.69), sepsis, 9.30 (2.33-37.17), postpartum hemorrhage, 1.83 (1.07-3.14), and to require a transfusion, 4.39 (2.39-8.05). They were also at greater risk of caesarean delivery, 2.07 (1.58-2.72) and increased length of hospital stay, 4.48 (3.00-6.69). Newborns of women with GBS were more likely to be growth restricted, 2.50 (1.48-4.23).

CONCLUSIONS

GBS in pregnancy is associated with maternal and newborn adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy and in the postpartum period.

Causality of immune cells and endometriosis: a bidirectional mendelian randomization study

BACKGROUND

Endometriosis, a prevalent chronic condition, afflicts approximately 10% of women in their reproductive years. Emerging evidence implicates immune cells in the pathogenesis of endometriosis, particularly in angiogenesis, tissue proliferation, and lesion invasion. This investigation employs two-sample Mendelian Randomization (MR) to dissect the bidirectional causal relationships between immune cell profiles and endometriosis.

METHODS

We leveraged publicly available genome-wide association study (GWAS) data to elucidate the causal interplay between immune cell traits and endometriosis. Utilizing GWAS summary statistics ranging from accession numbers GCST90001391 to GCST90002121 and endometriosis data from the FinnGen study GWAS (8,288 endometriosis cases and 68,969 controls), we adopted stringent criteria for instrumental variable selection. We applied MR-Egger, weighted median, inverse variance weighted (IVW), and weighted mode methods to derive causal estimates. To address potential heterogeneity and pleiotropy, Cochran's Q test, MR-Egger intercept, and leave-one-out analyses were executed. Reverse-direction MR and bidirectional MR analyses evaluated potential reciprocal causation and the influence of endometriosis on immune cell composition.

RESULTS

Our analysis identified five immune phenotypes inversely associated with endometriosis risk. These phenotypes comprise: a percentage of CD11c + HLA-DR + + monocytes, CD25 expression on CD39 + CD4 + T cells, elevated CD25 on CD45RA + CD4 + non-regulatory T cells, HLA-DR intensity on HLA-DR + CD8 bright (CD8br) T cells, and the proportion of naïve double-negative (CD4 - CD8- %DN) T cells. In contrast, eleven phenotypes were positively correlated with endometriosis risk, including: CD127 expression on T cells, the proportion of CD24 + CD27 + B cells within lymphocytes, CD25 expression on CD28 + CD4 + T cells, CD28 expression on CD39 + activated regulatory T cells (activated Tregs), the frequency of bright CD33 HLA-DR + CD14 - cells within the CD33br HLA-DR + compartment, CD45 expression on lymphocytes and natural killer (NK) cells, activation status of central memory CD8 bright (CM CD8br) T cells, CX3CR1 expression on monocytes, and the percentage of HLA-DR + NK cells within the NK cell subset. Sensitivity assessments that excluded significant heterogeneity and pleiotropy confirmed the stability of these associations, thereby reinforcing the validity of our findings.

CONCLUSION

This study provides novel evidence of the potential causal impact of specific immune cells on the risk of developing endometriosis. These findings enhance our understanding of endometriosis pathophysiology and may inform innovative approaches for its diagnosis and management. While our findings provide novel insights, limitations such as potential horizontal pleiotropy and reliance on European ancestry data should be considered. Future research should expand to diverse populations and incorporate individual-level data to refine these findings.

Transforming growth factor-β micro-environment mediated immune cell functions in cervical cancer

Propensity to develop cervical cancer (CC) in human papilloma virus (HPV) infected individual could potentially involve the impaired immune functioning. Several stages of HPV surveillance by immune cells in tumor micro-environment (TME) is regulated mainly by transforming growth factor-beta (TGF-β) and is crucial for the establishment of CC. The role of TGF-β in the initiation and progression of CC is very complex and involve different suppressor of mothers against decapentaplegic homolog (SMAD) dependent and SMAD independent signaling mechanism(s). This review summarizes the handling of HPV by immune cells such as T lymphocytes, B lymphocytes, natural killer cells (NK), dendritic cells (DC), monocytes, macrophages, myeloid derived suppressor cells (MDSC) and their regulation by TGF-β. The hijack mechanisms adapted by HPV to evade this surveillance process is discussed. Biomarkers indicating the stages of CC and immune checkpoints that can be targeted for improved outcome are included for immune-based theragnostics. This review also addresses the direct actions of TGF-β on CC cells and tumor/immune cell interactions. Therapies focused on targeting TGF-β using small molecule inhibitors, monoclonal antibodies and TGF-β chimeric antigen receptor (CAR)T cells are collated to understand the current strategies related to TGF-β in the management of CC.

Metformin in gestational diabetes: physiological actions and clinical applications

Metformin is an effective oral hypoglycaemic agent used in the treatment of type 2 diabetes mellitus; however, its use in pregnancy for the treatment of gestational diabetes mellitus (GDM) remains controversial owing to concerns around safety and efficacy. This comprehensive review outlines the physiological metabolic functions of metformin and synthesizes existing literature and key knowledge gaps pertaining to the use of metformin in pregnancy across various end points in women with GDM. On the basis of current evidence, metformin reduces gestational weight gain, neonatal hypoglycaemia and macrosomia and increases insulin sensitivity. However, considerable heterogeneity between existing studies and the grouping of aggregate and often inharmonious data within meta-analyses has led to disparate findings regarding the efficacy of metformin in treating hyperglycaemia in GDM. Innovative analytical approaches with stratification by individual-level characteristics (for example, obesity, ethnicity, GDM severity and so on) and treatment regimens (diagnostic criteria, treatment timing and follow-up duration) are needed to establish efficacy across a range of end points and to identify which, if any, subgroups might benefit from metformin treatment during pregnancy.

A systematic catalog of studies on fetal heart rate pattern and neonatal outcome variables

OBJECTIVES

To study the methodology and results of studies assessing the relationship between fetal heart rate and specified neonatal outcomes including, heart rate, infection, necrotizing enterocolitis, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, and seizure.

METHODS

Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and CINAHL were searched from inception to October 5, 2023.

RESULTS

Forty-two studies were included, encompassing 57,232 cases that underwent fetal monitoring and were evaluated for neonatal outcome. Heterogeneity was observed in the timing and duration of fetal heart rate assessment, classification guidelines used, number of assessors, and definition and timing of neonatal outcome assessment. Nonreassuring fetal heart rate was linked to lower neonatal heart rate variability. A significant increase in abnormal fetal heart rate patterns were reported in neonates with hypoxic-ischemic encephalopathy, but the predictive ability was found to be limited. Conflicting results were reported regarding sepsis, seizure and intraventricular hemorrhage. No association was found between necrotizing enterocolitis rate and fetal heart rate.

CONCLUSIONS

There is great heterogeneity in the methodology used in studies evaluating the association between fetal heart rate and aforementioned neonatal outcomes. Hypoxic-ischemic encephalopathy was associated with increased abnormal fetal heart rate patterns, although the predictive ability was low. Further research on developing and evaluating an automated early warning system that integrates computerized cardiotocography with a perinatal health parameter database to provide objective alerts for patients at-risk is recommended.