Uterine Perforation as a Complication of the Intrauterine Procedures Causing Omentum Incarceration: A Review

OBJECTIVE

Omentum involvement resulting from uterine perforation is a rare complication following intrauterine procedures that might require immediate intervention due to severe ischemic consequences. This review examines the prevalence of this complication, risk factors, the mode and timing of diagnosis, the proper management and the outcome.

METHODS

A systematic literature search was conducted on PubMed, PubMed Central and Scopus using uterine perforation, D&C, abortion and omentum as keywords. The exclusion criteria included the presence of the uterus or placenta's malignancy and uterine perforation following delivery or caused by an intrauterine device.

RESULTS

The review included 11 articles from 133 screened papers. We identified 12 cases that three evaluators further analysed. We also present the case of a 32-year-old woman diagnosed with uterine perforation and omentum involvement. The patient underwent a hysteroscopic procedure with resectioning the protruding omentum into the uterine cavity, followed by intrauterine device insertion.

CONCLUSION

This paper highlights the importance of a comprehensive gynaecological evaluation following a D&C procedure that includes a thorough clinical examination and a detailed ultrasound assessment. Healthcare providers should not overlook the diagnosis of omentum involvement in the presence of a history of intrauterine procedures.

Histological and immunohistochemical study of brain damage in traumatic brain injuries in children, depending on the survival period

Numerous studies showed that, at present, traumatic brain injury (TBI) is one of the main causes of death in young adults, but also a main cause of disabilities at all ages. For these reasons, TBI are continuously investigated. In our study, we evaluated the histopathological (HP) and immunohistochemical (IHC) changes that occurred in the brain in underage patients after a severe TBI depending on the survival period. We histopathologically and immunohistochemically analyzed a number of 22 cases of children, deceased in Dolj County, Romania, following some severe TBI, undergoing autopsy within the Institute of Forensic Medicine in Craiova between 2015-2020. Patients were divided into three groups depending on the survival period, namely: (i) patients who died during the first 24 hours of the accident; (ii) patients who died after seven days of survival; (iii) patients who died after 15 days of survival. Microscopic examinations of the brain fragments, collected during the necropsy examination, showed that the traumatic agent caused primary injuries in all brain structures (cerebral parenchyma, meninges, blood vessels). However, HP injuries ranged in size and intensity from one area to another of the brain. In patients with a longer survival period, there was observed the presence of smaller primary injuries and larger secondary injuries. There was also observed a growth in the number of meningo-cerebral microscopic injuries, depending on the increase of the survival period.

Virtual autopsy and confirmation of normal fetal heart anatomy in the first trimester using three-dimensional (3D) reconstruction of histological sections

OBJECTIVE

In this pilot study, we tested the feasibility of cardiac structures reconstruction from histological sections in 12-13 weeks normal fetuses. Conventional autopsy is hampered at this gestational age because of the small size of the heart anatomical structures, while alternative non-invasive methods for pathology examination of the fetus are expensive, rarely available and lack accuracy data regarding the confirmation of first trimester heart defects suspected by early prenatal ultrasound (US) scans.

MATERIALS AND METHODS

Normal hearts from fetuses aged 12-13 gestational weeks (GW) were harvested for histological preparation, virtual reconstruction, and cardiac structures analysis. The normalcy of heart structures was confirmed before pregnancy termination, using a detailed US scan protocol. The fetal heart was routinely processed for formalin fixation and paraffin embedding (FFPE) and 10 μm seriate sections have been cut until finishing the specimen. All sections have been scanned and a three-dimensional (3D) reconstruction of the whole organ has been rendered, based on computer-aided manual tracing. Using the 3D navigation software, the main cardiac structures were searched for a proper and confident visualization.

RESULTS

Five cases were investigated. Visualization of the normal heart cavities, including atrioventricular septum was very good in all fetuses. The entire course of right and left ventricle outflow tracts was confidently confirmed, along the branching pattern of aorta and pulmonary artery trunk. Regarding the veno-atrial connections, it was easy to identify the entrance of the inferior and superior caval veins into the right atrium, but a detailed review of the histological sections was necessary for the visualization of the left atrium venous openings. The inherent morphological deformation following heart block sectioning resulted in a lower resolution or quality of the "reconstructed" planes, but these distortions did not represent a significant impediment in any of the cases. The resources involved ordinary histology and information technology (IT) equipment. To further decrease the time involved by the protocol, many steps may be automated: cutting, coloring, and scanning.

CONCLUSIONS

The results indicate that this method can be implemented to routine clinical practice. The use of 3D reconstruction of fetal heart histological sections in first trimester may serve as an important audit to confirm the normalcy of heart structures. Also, the histological and postprocessed information is retained, and this volume can be stored, reanalyzed, or sent online for a second opinion. The method involves relatively undemanding resources, i.e., hardware, software, competences, and time. The procedure could also benefit from refinements used in other imaging techniques to limit human-computer interactions, such as sections distortion.

Complications related to breast reconstruction after mastectomy using multiple surgical techniques - a national and international comparative analysis

The present paper describes and analyzes complications related to alloplastic breast reconstruction, as well as those associated with surgical techniques involving myocutaneous flaps. The article also contains a comparative analysis of the results obtained with the data in the international specialized literature. The statistical analysis is primary based on data obtained from patients included in the National Breast Reconstruction Program developed within the "Bagdasar-Arseni" Emergency Clinical Hospital, Bucharest, Romania, between 2015 and 2019. In order to highlight and present a thorough comparison between the possible long-term complications associated with multiple reconstructive techniques, the paper also includes data related to patients who have undergone such surgical interventions in the aforementioned Health Unit, but which were not included in the national program, resulting a total of 73 reconstructive surgical interventions. The research results show that the overall rate of complications was 43.83%, skin necrosis, superficial infection and seroma being in this order the main complications that were identified. In the authors' opinion, risks of complications are moderated in relation with breast reconstruction surgery. However, the complication rate significantly varies depending on the chosen technique. The lowest risk levels registered in this study were associated with the breast reconstruction using the two-stage expander-implant technique. The analysis compares the achieved results with data provided by international studies, the main differences being caused by the status of the medical infrastructure, as well as the moment of hospital admission that is primarily determined by the level of medical education.

The performance of hyperadherence markers in anterior placenta praevia overlying the Caesarean scar

OBJECTIVES

To assess the ultrasound (US) impact in diagnosing placenta accreta (PA) in patients with anterior placenta praevia localization, overlying a Caesarean scar.

PATIENTS, MATERIALS AND METHODS

This is a prospective study between January 2016 and December 2017 that included patients with Caesarean scar and placenta praevia in the third trimester of pregnancy. By means of two-dimensional (2D) grayscale and color Doppler, we investigated the presence of the following US markers for placental invasion: intraplacental lacunae, abnormal blood vessels at the myometrium-bladder interface, thinning of the hyperechogenic uterine serosa-bladder wall interface, loss of normal hypoechoic retroplacental myometrial space. Definitive diagnosis was made at delivery. The US findings were correlated with intraoperative and histopathological (HP) evaluations.

RESULTS

We found 46 cases with anterior placenta praevia overlying a Caesarean scar. Twelve patients presented US criteria for PA. The confirmation was obtained (by means of intraoperative and/or HP features) in 11 of them. The US evaluation with all markers yields a sensitivity of 100% for PA detection. Among the US markers, the association of abnormal blood vessels at the myometrium-bladder interface and the intraplacental lacunae had the highest statistical correlation in the antenatal diagnosis of PA.

CONCLUSIONS

Our study suggests that the antenatal US is a useful tool in predicting PA in high-risk patients. Special attention should be given to the presence of intraplacental lacunae and abnormal myometrial vessels in cases where the placental insertion overlaps a uterine scar for best identification of PA high-risk cases.

Evaluation of brain injuries in children deceased due to head trauma

Traumatic brain injuries (TBIs) present an ever-growing prevalence, especially in the developing countries. Although 80-95% are mild to average injuries, they determine multiple severe neurological sequelae and disabilities. Most of these injuries are caused by traffic accidents. We studied a number of 29 cases of severe TBIs, in children who deceased immediately or after a few days of survival. Most of them (over 68%) were caused by traffic accidents. The incidence of traumas increased by age, most cases being recorded in the age group 10-15 years old. The TBIs were complex ones. In 86.21% of the cases, the forensic examination highlighted the presence of cranial fractures; in 93% of the cases, there were highlighted complex meningo-cerebral injuries: leptomeningeal hemorrhage associated with brain contusion injuries and with intraventricular blood flood, as well as destructive lesions of brain dilaceration; only in 7% of the cases there were highlighted meningeal lesions, with no brain lesions. The severity of the brain injuries was quite varied, according to the force of the cause agent. The histopathological and immunohistochemical examinations showed that the severity of TBIs increased according to the survival time, by adding secondary lesions caused by brain ischemia and local inflammatory reaction.

Stillbirth in dichorionic twins discordant for major and minor anomaly, followed by asynchronous delivery - a rare occurrence. Case presentation

The single stillbirth long-term intrauterine retention in dichorionic twin pregnancy is rarely reported. Also, the birth of a fetus is followed in most cases by immediate expulsion of the second twin. We hereby present an unusual case of asynchronous delivery of dichorionic twins, associating discordance for major and minor anomaly. The intrauterine death of the twin A, presenting a large sacrococcygeal tumor, occurred in the second trimester. The deceased twin A was born at 29 weeks' gestational age (GA). The twin B was extracted by Caesarean section at 31 weeks and had a good outcome. We performed a close follow-up of the high-risk pregnancy and we used tocolytic and antibiotic drugs for prolonging it. Corticoid therapy was administered for the lung maturation of the second twin. The expectant management in the single twin stillbirth dichorionic pregnancy and the asynchronous delivery had a significant impact on the newborn outcome.

EGFR, HER2÷neu and Ki67 immunoexpression in serous ovarian tumors

In this study, we analyzed EGFR, HER2/neu and Ki67 immunoexpression for 26 benign, borderline and malignant serous ovarian tumors. EGFR and HER2/neu immunoreactions were present in some benign/borderline tumors with high/low intensity of immunostain. In poorly differentiated adenocarcinomas, the EGFR/HER2/neu reaction was intense compared to well-differentiated ones. The Ki67 medium proliferation index was 2.1% for benign tumors, 6% in the borderline and 47.7% in malignant tumors. EGFR, HER2/neu and Ki67 can be used to identify benign/borderline tumors with progression potential and the malignant aggressive tumors.

The study of p53 and p16 immunoexpression in serous borderline and malignant ovarian tumors

The study assessed p53 and p16 immunoexpression in 20 cases of ovarian serous carcinomas and four cases of serous borderline tumors, the results being statistically analyzed in relation to clinicopathological data of the cases. The p53 immunoreaction was observed in 85% of cases, the medium percentage of positivity being 15% for borderline tumors, 45% for low-grade carcinomas and 60% for high-grade carcinomas. The p16 immunoreaction was observed in 75% of cases, the medium percentage of positivity being 30% for borderline tumors, 25% for low-grade carcinomas and 62% for high-grade carcinomas. The p53 and p16 reaction was also identified at the tubal epithelium in cases of invasive carcinomas. Statistical analysis indicated significant differences in p53 expression depending on tumor type and for p53 and p16 expression compared to the degree of tumor differentiation. The study indicated a diffuse immunostain for p53 and p16 in high-grade serous ovarian carcinomas. The presence of "p53 signature" and areas with variable tumor differentiation and reactivity, in the case of high-grade carcinomas, supporting the existence of multiple mechanisms of their occurrence and progression.