Spontaneous uterine rupture at a non-cesarean section scar site caused by placenta percreta in the early second trimester of gestation: A case report

OBJECTIVES

Risk factors for placenta percreta are placenta previa and prior cesarean delivery. Placenta percreta-induced ruptures at non-cesarean sites are very rare, particularly in the early second trimester.

CASE REPORT

A 30-year-old woman with a prior cesarean delivery was brought to our emergency department at 17 weeks' gestation for sudden-onset consciousness loss and generalized convulsions. Hypovolemic shock was identified. Computed tomography scans suggested uterine rupture and massive ascites, r/o hemoperitoneum. Emergency exploratory laparotomy revealed a ruptured hole over the left uterine fundus with protruding placental tissue; placenta percreta was impressed. An intact intrauterine sac was dissected and removed. The placenta was removed and hysterorrhaphy was completed.

CONCLUSION

Placenta percreta is dangerous and is rarely seen in the early second trimester. Uterine rupture should always be kept in mind in pregnant woman with acute abdomen associated with hypovolemic shock, even in those of early pregnancy without scarred uterus. Routine sonographic examination of placentation, even in early second trimester, should be emphasized.

Ovarian cancer detection by DNA methylation in cervical scrapings

Background

Ovarian cancer (OC) is the most lethal gynecological cancer, worldwide, largely due to its vague and nonspecific early stage symptoms, resulting in most tumors being found at advanced stages. Moreover, due to its relative rarity, there are currently no satisfactory methods for OC screening, which remains a controversial and cost-prohibitive issue. Here, we demonstrate that Papanicolaou test (Pap test) cervical scrapings, instead of blood, can reveal genetic/epigenetic information for OC detection, using specific and sensitive DNA methylation biomarkers.

Results

We analyzed the methylomes of tissues (50 OC tissues versus 6 normal ovarian epithelia) and cervical scrapings (5 OC patients versus 10 normal controls), and integrated public methylomic datasets, including 79 OC tissues and 6 normal tubal epithelia. Differentially methylated genes were further classified by unsupervised hierarchical clustering, and each candidate biomarker gene was verified in both OC tissues and cervical scrapings by either quantitative methylation-specific polymerase chain reaction (qMSP) or bisulfite pyrosequencing. A risk-score by logistic regression was generated for clinical application.

One hundred fifty-one genes were classified into four clusters, and nine candidate hypermethylated genes from these four clusters were selected. Among these, four genes fulfilled our selection criteria and were validated in training and testing set, respectively. The OC detection accuracy was demonstrated by area under the receiver operating characteristic curves (AUCs) in 0.80–0.83 of AMPD3, 0.79–0.85 of AOX1, 0.78–0.88 of NRN1, and 0.82–0.85 of TBX15. From this, we found OC-risk score, equation generated by logistic regression in training set and validated an OC-associated panel comprising AMPD3, NRN1, and TBX15, reaching a sensitivity of 81%, specificity of 84%, and OC detection accuracy of 0.91 (95% CI, 0.82–1) in testing set.

Conclusions

Ovarian cancer detection from cervical scrapings is feasible, using particularly promising epigenetic biomarkers such as AMPD3/NRN1/TBX15. Further validation is warranted.

Gestational Thrombocytopenia Complicated with Macrosomia, Failure to Progress in Active Labor, and Postpartum Hemorrhage

OBJECTIVE

Gestational thrombocytopenia is a rare event, and the etiology is unknown. Generally, there is no need for intervention because of the absence of coagulopathy. However, when complicated with other obstetric conditions, care should be taken to prevent a dangerous cascade. Here, we present a patient with severe gestational thrombocytopenia complicated with macrosomia, failure to progress in active labor, and severe postpartum hemorrhage after cesarean section.

CASE REPORT

A 25-year-old, gravida 4, para 0, patient from our antenatal clinic developed thrombocytopenia with advancing gestation. Severe thrombocytopenia (platelets, 53 x 109/L) and suspected macrosomia were noted at 39 3/7 weeks of gestation. Induction of labor was conducted for a planned vaginal delivery, but the active labor failed to progress. A cesarean section was performed instead, resulting in immediate postpartum hemorrhage due to uterine atony. Uterine massage, direct compression, and 10 IU of oxytocin (Piton-S, 10 IU/mL; PT Organon, Indonesia) improved uterine contraction only temporarily. Misoprostol was administered rectally. The patient was given a transfusion of packed red blood cells and single-donor platelets. Her condition stabilized after intensive intervention.

CONCLUSION

Gestational thrombocytopenia does not usually require treatment if there is no bleeding tendency. However, when other bleeding complications are present, it may exacerbate coagulopathy and exhaust the platelet reserve, thereby worsening the condition. If surgical intervention cannot be avoided, blood and platelet transfusion before a cesarean delivery is highly recommended in severe gestational thrombocytopenia.

Laparoscopy-assisted Robotic Myomectomy Using the DA Vinci System

OBJECTIVE

To report a case of a woman with a large uterine myoma who underwent laparoscopy-assisted robotic myomectomy using the da Vinci system.

CASE REPORT

A 38-year-old, gravida 2, para 2, female patient presented to our office with a chief complaint of lower abdominal pressure and pain. A pelvic sonogram disclosed a subserosal myoma with a broad base, measuring approximately 9 x 8 x 7 cm, which was located at the anterior uterine wall. The patient insisted on preserving her uterus and was concerned with the cosmetic results after the surgery. She showed willingness to undergo myomectomy using the newly developed laparoscopy-assisted robotic system (da Vinci) and signed the consent form. The operation time was about 3 hours, with an estimated blood loss of 150 mL. The patient passed flatus and resumed oral intake on the following day.

CONCLUSION

Minimally invasive surgery is the trend of the future. Robot-assisted laparoscopic surgery is a new technique for myomectomy. This robotic system provides a three-dimensional operative field and an easy-to-use control panel, which may be of great help when applying the suturing techniques and may shorten the learning curve. More experience with and long-term follow-up of robotic surgery may be warranted to further validate the role the robot-assisted approach in gynecologic surgery.

Activation of noradrenergic mechanism attenuates glutamate-induced vasopressor responses in the pons and medulla of cats in vivo

1. Using anesthetized cats, the authors examined the noradrenergic modulation of the glutamate induced pressor and depressor responses in various brainstem areas, including pontine gigantocellular tegmental field (FTG), dorsomedial medulla (DM), rostral ventrolateral medulla (RVLM), and caudal ventrolateral medulla (CVLM). 2. Unilateral microinjection of L-glutamate (Glu, 3 nmol in 30 nL saline) into FTG, DM and RVLM produced an increase in systemic arterial pressure (SAP) and a decrease in heart rate (HR), while into CVLM produced decreases of SAP and HR. 3. Application of norepinephrine (NE) into the pressor areas (0.05 to 5 nmol) did not alter the resting SAP and HR, but significantly attenuated the Glu-induced pressor response with an order of potency: FTG > DM > RVLM. In the depressor CVLM, NE alone produced a dose-dependent decrease of resting SAP and HR, but did not affect the Glu-induced depressor responses. 4. The involvement of different adrenoceptor subtypes was further investigated by application of selective adrenoceptor agonists including phenylephrine (alpha1), clonidine (alpha2), and isoproterenol (beta). Responses to these agonists are similar to those elicited by NE, except that only alpha-adrenoceptor agonists could antagonize the Glu-induced pressor responses of the RVLM. 5. Our observations indicate that NE not only inhibits the pressor mechanisms in various brainstem areas but also elicits a direct depressor response in CVLM. These findings also suggest that NE acts more likely a neurotransmitter, rather than a modulator, in the CVLM.

Role of nitric oxide on pressor mechanisms within the dorsomedial and rostral ventrolateral medulla in anaesthetized cats

1. The role of nitric oxide (NO) in central cardiovascular regulation and the correlation between NO and glutamate-induced mechanisms is not clear. Microinjection of glutamate (3 nmol/30 nL) into dorsomedial medulla (DM) and rostral ventrolateral medulla (RVLM) increased arterial blood pressure (BP) and sympathetic vertebral nerve activity (VNA). Thus, in the present study, we examined the modulation by NO of glutamate-induced pressor responses in the DM and RVLM of cats. 2. Histochemical methods using nicotinamide adenine dinucleotide phosphate diaphorase (NADPHd) as a marker to stain neurons containing NO synthase (NOS), showed positive findings of NOS in both the DM and RVLM. 3. Microinjection of N(G)-nitro-L-arginine methyl ester (L-NAME), a NOS inhibitor, into the DM or RVLM did not alter resting BP and VNA, but it did cause a dose-dependent attenuation of glutamate-induced pressor responses. Interestingly, the increase in NO levels that resulted from pretreatment with L-arginine (L-Arg) or sodium nitroprusside (SNP) did not alter resting BP and VNA, but still inhibited glutamate-induced pressor responses in the DM and RVLM in a dose-dependent manner. 4. We also examined whether NO modulated the pressor responses induced by activation of different excitatory amino acid receptors. N-Methyl-D-aspartate (NMDA) and alpha-amino-3-hydroxy-5-methyl-4-isoxazole proprionic acid (AMPA) were used. Consistent with the results from the initial glutamate studies, we observed that not only L-NAME, but also L-Arg and SNP attenuated pressor responses induced by NMDA and AMPA. No difference was found between the effects of NO on NMDA- and AMPA-induced pressor responses. 5. To investigate the possibility of a loss of agonist selectivity, the effects of D-2-amino-5-phosphonovalerate (D-AP5) and 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) on AMPA and NMDA responses in the DM were examined. The results showed that CNQX did not alter NMDA-induced pressor responses, while D-AP5 failed to alter AMPA-induced responses. 6. Our results suggest that activation of the glutamate-induced pressor mechanism is regulated by changes in NO levels in the DM and RVLM. This implies that NO may play a permissive role to allow operation of the glutamate-activation mechanism.

Prolonged exposure to hyperbaric oxygen induces neuronal damage in primary rat cortical cultures

While seizure attack is one of the serious complications during the hyperbaric oxygen (HBO) therapy, there is still no direct evidence showing that HBO can induce neuronal damage in the brain. The objective of this study was first to investigate whether HBO would lead to neurotoxicity in the primary rat cortical culture. Second, since alterations in neurotransmitters have been suggested in the pathophysiology of central nervous system (CNS) oxygen toxicity, the protective effects of the N-methyl-D-aspartate (NMDA) receptor antagonism and nitric oxide (NO) synthase inhibition on the HBO-induced neuronal damage were examined. The results showed that HBO exposure to 6 atmosphere absolute pressure (ATA) for 30, 60, and 90 min increased the lactate dehydrogenase (LDH) activity in the culture medium in a time-dependent manner. Accordingly, the cell survival, measured by the 3,(4,5-dimethyl-2-thiazolyl)2, 5-diphenyl-tetrazolium bromide (MTT) assay, was decreased after HBO exposure. Pretreatment with the NMDA antagonist MK-801 protected the cells against the HBO-induced damage. The protective effect was also noted in the cells pretreated with L-N(G)-nitro-arginine methyl ester, an NO synthase inhibitor. Thus, our results suggest that activation of NMDA receptors and production of NO play a role in the neurotoxicity produced by hyperbaric oxygen exposure.

Systemic administration of D-amphetamine induced a delayed production of nitric oxide in the striatum of rats

Nitric oxide (NO) is a free-radical gas with a role in various signal transduction processes. In the CNS, NO acts as an important central nervous messenger, but in excess it may be neurotoxic. Chronic or high dose administration of D-amphetamine (AMPH) has been shown to induce striatal neurotoxicity in rodents and primates. In this study, we studied whether AMPH given systemically elicits NO formation in the striatum of rats and determined the relationship between NO formation and striatal DAergic terminal damage. Our results demonstrated that a single large dose administration of AMPH with desipramine elicited a delayed production of NO and concomitant long-term DA loss in the striatum. These phenomena were blocked by treatment with either the nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME) or the glutamate N-methyl-D-aspartate antagonist MK-801. It appears that AMPH-induced NO formation is critical for development of long-lasting DAergic terminal toxicity in the striatum of rats.

Precollicular decerebration reduces the pressor responses evoked by stimulation of rostral pons but not medulla in cats

In 30 cats under chloralose (40 mg/kg) and urethane (400 mg/kg) anesthesia, the ponto-medullary region involved in cardiovascular integration were stimulated by rectangular pulses (0.5 ms, 80 or 5 Hz, 100 to 200 microA) and/or by microinjection of sodium glutamate (Glu, 0.25-0.5 M, 70-200 nl). Changes of systemic arterial blood pressure (SAP) and renal sympathetic nerve activity (RNA) following stimulation were compared before and after precollicular decerebration. Precollicular decerebration itself resulted in an immediate but brief (5 to 15 min) hypotension with a decrease in SAP ranging from 40 to 100 mmHg. Stimulation of the lateral tegmental field (FTL) produced depressor responses. After precollicular decerebration, the stimulation induced depressor responses were either abolished or converted to mild pressor responses. Stimulation of the dorsal gigantocellular tegmental field-periventricular grey (dFTG-PVG) produced pressor responses. These responses were abolished after precollicular decerebration without exception. On the other hand, precollicular decerebration did not reduce pressor responses produced by stimulation of the ventrolateral medulla (VLM) and the dorsal medulla (DM). In 7 additional cats killed with an overdose of pentobarbital, the brain stem were processed for dopamine beta-hydroxylase (DBH). The pressor areas of the VLM and DM were DBH positive, indicating the presence of norepinephrine, while the dFTG-PVG and FTL were not. These findings suggest that the depressor mechanism of the FTL and the pressor mechanism of the dFTG, but not of the VLM or DM depend on actions of the brain structures rostral to superior colliculi.

Protozoan and helminth parasites of humans in mainland China

To date, 30 species of protozoa, 12 species of cestodes, 26 species of trematodes, 23 species of nematodes, two species of gordius and one acanthocephalan species hae been reported as parasites of man in mainland China.

Comparison of morphology, pathogenicity and drug response among three isolates of Schistosoma japonicum in the mainland of China

Geographic differences among isolates of Schistosoma japonicum from Anhui Province (A) in the east, Guangxi Autonomous Region (G) in the south and Yunnan Province (Y) in the southwest of mainland of China were studied. C57BL mice were used to compare these isolates. Morphologically, both male and female worms of isolate Y were shorter than those of isolates A and G, and the ovary of female worm of isolate G was the smallest. In isolate A, the percentage of male worms bearing 7 testes was 87%, while 64% of isolate Y and 75% of isolate G were with 7 testes. As to the volume of hepatic egg granuloma which was used as a parameter of pathogenicity in our experiment, that of isolate G was the smallest. The sensitivity to praziquantel of isolates was estimated by parasite reduction rate at ED50 (230 mg/kg) level. It was found that isolate Y's response was significantly higher than that of isolates A and G, and the latter two were similar in drug response. The results indicate significant differences among the three isolates studied.

Schistosomiasis control in the people's Republic of China

Evidence exists that schitosomiasis japonica has been present in China for more than 2,200 years. The first parasitologically confirmed clinical case was reported in 1905. Fragmentary surveys before 1949 suggested that there were 5 million schistosomiasis patients distributed in 138 hsiens (counties); however, a more systematic survey after the founding of the People's Republic showed that these figures represented only 50% of patients and 40% of infected hsiens. Based on the epidemiological pattern and ecological characteristics of the snail intermediate host, endemic areas have been divided into three strata: plain region, mountainous and hill region, and marshland and lake region. Following comprehensive control measures, with stress on applied research and integrating technical work with involvement of the population, in 204 hsiens the snail control programs are now considered to be relatively consolidated and the number of patients needing treatment is relatively few. In the marshland and lake region and mountainous region eradication of schistosomiasis remains a difficult problem.