Retroperitoneal 'uterus-like mass' of cervical origin

We report a rare case of a retroperitoneal uterus-like mass communicating with the endocervix, which presented as abdominal pain and bloating associated with severe irregular vaginal and postcoital bleeding. Our patient did not have any structural abnormalities of the urogenital system or otherwise, which makes a müllerian defect unlikely in our case. Based on the diagnostic criteria for the choristoma, that theory would be excluded here as the mass communicated with the endocervix. This strengthens the theory of metaplasia, under the effect of oestrogen and accelerated by the hyperoestrogenic state of pregnancy as the most likely postulate for our patient. Although the uterus-like mass is not commonly reported, it should be considered as a possible differential for pelvic masses.

Utero-vaginal anastomosis in cases of cervical malformations: long-term follow-up and fertility challenges

PURPOSE

To study the long-term results of utero-vaginal anastomosis in cases of cervical malformations.

METHODS

This is a retrospective cohort study. Nine patients presented with cryptomenorrhea due to cervical malformations (5 patients with cervical agenesis and vaginal aplasia, 2 patients with cervical agenesis and upper vaginal aplasia, and two patients with cervical dysgenesis in form of cervical obstruction). Five patients had utero-vaginal anastomosis (UVA) with McIndoe vaginoplasty. Four patients had UVA without vaginoplasty. Follow-up was done by transabdominal and/or transvaginal ultrasound monthly for the first 3 months then every 6 months thereafter for a duration that ranged from 15 to 82 months. The main outcome measures are achieving menstruation, dysmenorrhea, pelvic inflammatory disease (PID), needed interventions after primary surgery, infertility, and pregnancy rate.

RESULTS

Nine (100%) patients achieved menstruation, one (12%) experienced severe dysmenorrhea, two (22%) had PID, seven (78%) needed dilatation of the anastomosis site, three (33%) needed reoperation, nine (100%) had primary infertility, two (28.5%) achieved clinical pregnancy, and only one (14%) ended by live birth.

CONCLUSION

Conservative surgery for cervical malformation is a promising choice for relieving the obstructive symptoms. Regular dilatation is recommended. Pregnancy is a remote hope that is hindered by many challenges.

Antibody microarray analysis of amniotic fluid proteomes in women with cervical insufficiency and short cervix, and their association with pregnancy latency length

Introduction

This study aimed to investigate amniotic fluid (AF) proteins that were differentially expressed between patients with cervical insufficiency (CI) and asymptomatic short cervix (SCX, ≤ 25 mm), and whether these proteins could be predictive of spontaneous preterm birth (SPTB) in these patients.

Method

This was a retrospective cohort study of 129 singleton pregnant women with CI (n = 80) or SCX (n = 49) at 17 to 26 weeks who underwent amniocentesis. An antibody microarray was used to perform comparative proteomic profiling of AF from matched CI (n = 20) and SCX (n = 20) pregnancies. In the total cohort, an ELISA validation study was performed for 15 candidate proteins of interest. Subgroup analyses of patients with CI and SCX were conducted to evaluate the association between the 15 proteins and SPTB at < 32 weeks of gestation.

Results

Eighty-six proteins showed intergroup differences. ELISA validation confirmed significantly higher levels of AF EN-RAGE, IL-8, lipocalin-2, MMP-9, S100A8/A9, thrombospondin-2, and TNFR2 in patients with CI than in those with SCX. Multivariable analysis showed that increased AF levels of EN-RAGE, S100A8/A9, and uPA were independently associated with SPTB at < 32 weeks in patients with CI; whereas in patients with SCX, high AF levels of APRIL, EN-RAGE, LBP, and TNFR2 were independently associated with SPTB at < 32 weeks.

Conclusions

Multiple AF proteins show altered expression in patients with CI compared with SCX controls. Moreover, several novel mediators involved in inflammation were identified as potential biomarkers for predicting SPTB after the diagnosis of CI and SCX. These results provide new insights into target-specific molecules for targeted therapies to prevent SPTB in patients with CI/SCX.

Primary Amenorrhea Due to Anatomical Abnormalities of the Reproductive Tract: Molecular Insight

Congenital anomalies of the female reproductive tract that present with primary amenorrhea involve Müllerian aplasia, also known as Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), and cervical and vaginal anomalies that completely obstruct the reproductive tract. Karyotype abnormalities do not exclude the diagnosis of MRKHS. Familial cases of Müllerian anomalies and associated malformations of the urinary and skeletal systems strongly suggest a complex genetic etiology, but so far, the molecular mechanism in the vast majority of cases remains unknown. Primary amenorrhea may also be the first presentation of complete androgen insensitivity syndrome, steroid 5α-reductase type 2 deficiency, 17β-hydroxysteroid dehydrogenase type 3 deficiency, and Leydig cells hypoplasia type 1; therefore, these disorders should be considered in the differential diagnosis of the congenital absence of the uterus and vagina. The molecular diagnosis in the majority of these cases can be established.

Vaginal Atresia with Cervical Agenesis, a Rare Congenital Malformation

Congenital vaginal atresia and cervical agenesis is a rare congenital abnormality of the female genital tract. Here we report a case of 15-year old girl with primary amenorrhea with hematometra, presented with lower abdominal mass. She was symptomatic since 5 months and visited local hospital after 4 months of onset of her symptoms when it became severe, where diagnostic laparotomy was performed for suspected Adnexal mass. Intraoperatively adnexal mass was adhered with and extended up to the uterus with 16 weeks size of uterus. Abdomen was closed without any further intervention and was referred to higher center for needful. When she presented to Kathmandu Model Hospital, she was asymptomatic on her 5th post-operative day of laparotomy. We planned for surgical intervention after examination and investigation. Drainage with vaginoplasty with amnion graft with placement of mould was done.

Three degrees of separation: complete uterine and cervical septa

OBJECTIVE

To review the diagnosis and management of 3 variations of incomplete müllerian duct fusion and reabsorption.

DESIGN

Narrated video delineating the surgical management of 3 müllerian anomalies; this video was deemed exempt from review by the institutional review board of the Mayo Clinic.

SETTING

Tertiary care academic medical center.

PATIENT(S)

This video focuses on 3 müllerian anomalies: complete septate uterus with a single septate cervix (septate uterus unicollis); complete septate uterus with duplicated cervix (septate uterus bicollis); and complete duplication of the uterus and cervix (uterine didelphys).

INTERVENTION(S)

Magnetic resonance imaging (MRI), cervical septoplasty, operative hysteroscopy, and uterine septoplasty.

MAIN OUTCOME MEASURE(S)

Several variations of uterine malformations exist. In our practice, we differentiate complete septate uteri as either unicollis or bicollis via MRI and vaginal examination. The bicollis presentation can be identified on MRI by the "lambda sign," which is seen as the 2 cervices that diverge as they enter the vagina. This is in comparison with the unicollis presentation when the single septate cervix can be traced with parallel lines as it enters the vagina. The circle method is described in this video to help distinguish between a single and duplicated cervix on examination.

RESULT(S)

The cervical and uterine septa were resected completely in the patient with a complete septate uterus unicollis. In contrast, the uterine septum was resected completely and the 2 cervical canals were not incised in the case of the complete septate uterus bicollis. Although uterine and cervical septa resection is controversial, our practice is to avoid the incision of the 2 cervical canals in cases that are more clearly consistent with a bicollis classification.

CONCLUSION(S)

Müllerian anomalies represent a continuum of disorders caused by different degrees of disruption in embryogenesis. MRI with vaginal gel and vaginal examination are tools to help classify the anomaly and guide surgical management.

Analysis of maternal and neonatal outcomes using cervical cerclage or conservative treatment in singleton gestations with a sonographic short cervix

To investigate the effect of cervical cerclage or conservative treatment on maternal and neonatal outcomes in singleton gestations with a sonographic short cervix, and further compare the relative treatment value.A retrospective study was conducted among women with singleton gestations who had a short cervical length (<25 mm) determined by ultrasound during the period of 14 to 24 weeks' gestation in our institution. We collected clinical data and grouped the patients according to a previous spontaneous preterm birth (PTB) at <34 weeks of gestation or second trimester loss (STL) and sub-grouped according to treatment option, further comparing the maternal and neonatal outcomes between different groups.In the PTB or STL history cohort, the cerclage group had a later gestational age at delivery (35.3 ± 3.9 weeks vs 31.6 ± 6.7 weeks) and a lower rate of perinatal deaths (2% vs 29.3%) compared with the conservative treatment group. In the non-PTB-STL history cohort, the maternal and neonatal outcomes were not significantly different between the cerclage group and conservative treatment group. More importantly, for patients with a sonographic short cervix who received cervical cerclage, there was no significant difference in the maternal and neonatal outcomes between the non-PTB-STL group and PTB or STL group.For singleton pregnant with a history of spontaneous PTB or STL and a short cervical length (<25 mm), cervical cerclage can significantly improve maternal and neonatal outcomes; however, conservative treatment (less invasive and expensive than cervical cerclage) was more suitable for those pregnant women without a previous PTB and STL history.

Single port laparoscopy combined with vaginal cervicovaginal reconstruction in a patient with congenital atresia of the cervix

OBJECTIVE

To introduce an innovation that combines single port laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using a small intestinal submucosa (SIS) graft in a patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum (U2aC4V4).

DESIGN

Video article introducing a new surgical technique.

SETTING

University hospital.

PATIENT(S)

A 15-year-old patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum had primary amenorrhea and cyclic lower abdominal pain. The magnetic resonance imaging did not show hematometra and the endometrium was 6 mm when she had lower abdominal pain.

INTERVENTION(S)

A neovagina (depth, 7 cm; width, 2.5 cm) was created using the Wharton-Sheares-George neovaginoplasty. By single laparoscopy, the bladder was separated from the anterior surface of the uterus. With the mold in the neovagina created by the assistant, the apex of neovagina was opened. Then the lower uterine segment was exposed and incised. A T-shaped intrauterine device was connected to an 8-cm-long catheter scissored from a 14-F Foley catheter and was inserted into the uterus to prevent cervical or vaginal stenosis. The upper end of the graft was applied onto the lower uterine segment with delayed absorbable sutures. The lower end was sutured to the high vaginal or vestibular mucosa.

MAIN OUTCOME MEASURE(S)

The feasibility and effect of combination single port laparoscopic with vaginal cervicovaginal reconstruction in the congenital atresia of cervix.

RESULT(S)

The operation was successful. The operating time was 90 minutes. Hospitalization was 3 days. There were no intraoperative and postoperative complications. The patient had resumption of menses at three cycles postoperatively, and she had no dysmenorrhea. No cervical or vaginal stenosis occurred because of the Foley catheter.

CONCLUSION(S)

Single port laparoscopic combined with vaginal cervicovaginal reconstruction provided a minimally invasive, safe, and effective surgical option for the young patient with congenital atresia of cervix. It was successful and without complications or cervical or vaginal stenosis.

EVALUATION OF THE RISK FACTORS OF CERVICAL INSUFFICIENCY IN WOMEN WITH INFERTILITY ASSOCIATED WITH ANOVULATION

Cervical insufficiency is a common problem in obstetrical care. There are not enough studies about its development in women with infertility. The aim of the article was to determine the risk factors of the development of cervical insufficiency in women with infertility associated with anovulation. The object of the study were 308 pregnant women (110 pregnant women with cervical insufficiency and without infertility, 92 pregnant women with infertility associated with anovulation and with cervical insufficiency, 76 pregnant women with infertility associated with anovulation and without cervical insufficiency, 30 pregnant women without cervical insufficiency and infertility (controls)). We analyzed the data of obstetrical anamnesis, gynecological diseases, extragenital pathology. In fertile women with cervical insufficiency the traumatic factor of the cervix (previous labors, gynecological procedures connected with cervical dilatation) was the main in the development of this pathology. While in the women with infertility associated with anovulation the forming of cervical insufficiency was associated with hormonal reasons (hyperandrogenism (OR=3.04, 95 % CI=1.15-8.05, p=0.03), diminished ovarian reserve (OR=6.00, 95 % CI=1.97-18.24, p=0.002), controlled ovarian stimulation with gonadotropin and clomiphene citrate use (OR=3.69, 95% CI=1.93-7.04, p<0.001), use of additional reproductive technology (OR=1.95, 95 % CI=1.05-3.63, p=0.03).

Artificial intelligence and amniotic fluid multiomics: prediction of perinatal outcome in asymptomatic women with short cervix

OBJECTIVE

To evaluate the application of artificial intelligence (AI), i.e. deep learning and other machine-learning techniques, to amniotic fluid (AF) metabolomics and proteomics, alone and in combination with sonographic, clinical and demographic factors, in the prediction of perinatal outcome in asymptomatic pregnant women with short cervical length (CL).

METHODS

AF samples, which had been obtained in the second trimester from asymptomatic women with short CL (< 15 mm) identified on transvaginal ultrasound, were analyzed. CL, funneling and the presence of AF 'sludge' were assessed in all cases close to the time of amniocentesis. A combination of liquid chromatography coupled with mass spectrometry and proton nuclear magnetic resonance spectroscopy-based metabolomics, as well as targeted proteomics analysis, including chemokines, cytokines and growth factors, was performed on the AF samples. To determine the robustness of the markers, we used six different machine-learning techniques, including deep learning, to predict preterm delivery < 34 weeks, latency period prior to delivery < 28 days after amniocentesis and requirement for admission to a neonatal intensive care unit (NICU). Omics biomarkers were evaluated alone and in combination with standard sonographic, clinical and demographic factors to predict outcome. Predictive accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) with 95% CI, sensitivity and specificity.

RESULTS

Of the 32 patients included in the study, complete omics, demographic and clinical data and outcome information were available for 26. Of these, 11 (42.3%) patients delivered ≥ 34 weeks, while 15 (57.7%) delivered < 34 weeks. There was no statistically significant difference in CL between these two groups (mean ± SD, 11.2 ± 4.4 mm vs 8.9 ± 5.3 mm, P = 0.31). Using combined omics, demographic and clinical data, deep learning displayed good to excellent performance, with an AUC (95% CI) of 0.890 (0.810-0.970) for delivery < 34 weeks' gestation, 0.890 (0.790-0.990) for delivery < 28 days post-amniocentesis and 0.792 (0.689-0.894) for NICU admission. These values were higher overall than for the other five machine-learning methods, although each individual machine-learning technique yielded statistically significant prediction of the different perinatal outcomes.

CONCLUSIONS

This is the first study to report use of AI with AF proteomics and metabolomics and ultrasound assessment in pregnancy. Machine learning, particularly deep learning, achieved good to excellent prediction of perinatal outcome in asymptomatic pregnant women with short CL in the second trimester. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Surgical management of complex atypical endometrial hyperplasia in a woman with rare genitourinary anomalies: unicornuate uterus with rudimentary horn, ipsilateral ectopic ovary and pelvic kidney

AIM

According to the so far published literature, only one case of endometrial cancer in a patient with unicornuate uterus has been reported. This is a case report study, presenting a rare case of complex atypical endometrial hyperplasia in a woman with unicornuate uterus and multiple genitourinary anomalies.

CASE REPORT

A 43-year old G1P1 woman presented with episodes of menometrorrhagia and anemia. She had previous surgical history of laparoscopy due to infertility, in which she was diagnosed with unicornuate uterus with a rudimentary left uterine horn and ipsilateral ectopic ovary in the anatomic place of the left kidney. Dilatation and curettage was performed. Histology showed complex atypical endometrial hyperplasia. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, in an extremely interesting operation due to the multiple genitourinary anomalies. The uterus with a 6-centimeter uterine myoma and the adnexae were removed en block. Great effort was put into dissecting the left fallopian tube which arised from the cervix and via the rudimentary horn led to the left ectopic ovary that was located at the left kidneys' anatomic space. The patient recovered well and final histology was negative for malignancy.

DISCUSSION

All necessary imaging examinations have to be scheduled prior to surgical intervention in order to give valuable anatomic information in cases of women diagnosed with Mullerian abnormalities.

[PREVENTION OF PRETERM BIRTH IN TWINS WITH SHORT MID-TRIMESTER CERVICAL LENGTH LESS THAN 25MM -COMBINED TREATMENT WITH ARABIN'S CERCLAGE PESSARY AND INTRAVAGINAL MICRONIZED PROGESTERONE COMPARED WITH CONSERVATIVE TREATMENT]

BACKGROUND

Twin pregnancies with short mid-trimester cervical length have a high rate of preterm births.

OBJECTIVES

To compare combined treatment of Arabin cerclage pessary, and intravaginal micronized progesterone to conservative treatment for the prevention of preterm births in twins pregnancies with short cervical length in second trimester of pregnancy.

METHODS

A retrospective study that compared twin pregnancies with short ≤25mm cervix in second trimester 16-28 gestational weeks treated with combined treatment of Arabin cervical pessary and intravaginal micronized progesterone 200mg TID to a control group with conservative treatment for the prevention of preterm.

RESULTS

The treatment group included 32 patients and the control group 26 patients. Average week at admission was 23 ± 2.2 vs 25 ±3.1 weeks, average cervical length at admission 14.1 ± 2.2 mm vs 13 ±2.1 mm respectively. Average week of delivery 34.4 ±3.9 vs. 33.4 ±4.1, p=0.6 and incidence of delivery ≤28weeks was 9.4% vs. 34% p=0.04.

CONCLUSIONS

The treatment group had a lower incidence of preterm birth before 28 weeks. Further prospective studies are needed to assess preterm birth prevention treatments efficacy and the use of Arabin cervical pessary in twins.

Uterine Didelphys with Bilateral Cervical Agenesis in a 15-Year-Old Girl

BACKGROUND

Isolated uterine didelphys requires no treatment in contrast to cervical agenesis, which requires a hysterectomy. Because of this, correct diagnosis of Müllerian anomalies is paramount for making recommendations for patient care.

CASE

A 15-year-old girl presented to clinic with pelvic pain and primary amenorrhea. Uterine didelphys with bilateral cervical agenesis was diagnosed using imaging. Hysterectomy was recommended and diagnosis was confirmed at surgery and according to anatomic pathology.

SUMMARY AND CONCLUSION

Our patient with uterine didelphys with bilateral cervical agenesis presented a diagnostic challenge, because, to our knowledge, it has never been reported before in the literature. Her pattern of anomalies had significant implications for future fertility. Radiology exam was vital to confirming this diagnosis in a young, virginal female patient.

Vaginal atresia and cervical agenesis combined with asymmetric septate uterus: A case report of a new genital malformation and literature review

RATIONALE

A combination of Vaginal atresia and septate uterus as a novel genital malformation has been reported the first time. It offers a support for the bidirectional theory.

PATIENT CONCERNS

A 23-year-old woman presented with the inability to perform intercourse. The unprecedented variant was misdiagnosed by magnetic resonance imaging and ultrasonography as low vaginal atresia associated with complete septate uterus with functional endometrium in both the cavities.

DIAGNOSES

The correct diagnosis was made and confirmed intraoperatively as a genital malformation, vaginal atresia and cervical agenesis associated with septate uterus.

INTERVENTION

laparoscopic and hysteroscopic diagnosis the novel malformation never been reported and a vaginal stent was recommended postoperatively.

OUTCOMES

This rare clinical variant made misdiagnosis. Intraoperatively, unprecedented genital malformation was confirmed. There are no vaginal atresia cases in the literature with a septate functional uterus and single agenesis cervix.

LESSONS

Confirmed diagnosed by operation instead of depending on the imaging should be used for rare genital anomaly.

A Simple Method for Excluding Uterine Canalization Defects Using Two-Dimensional Ultrasound in Infertile Women

OBJECTIVE

To compare the uterine transverse diameter (UTD) in women with normal uteri and women with uterine canalization defects as well as to assess its performance for ruling out such defects.

STUDY DESIGN

Retrospective analysis of prospectively collected data in a series of selected women with primary or secondary infertility. Measurement of UTD and 3D volume acquisition for subsequent off-line analysis was performed in order to identify possible canalization defects. UTD of the normal uterus, measured by 2D ultrasound, was compared to that of arcuate, subseptate, and septate uteri. ROC curve was plotted to determine the best UTD cutoff for differentiating normal from abnormal uteri.

RESULTS

A total of 421 women were ultimately evaluated. UTD was significantly larger in women with arcuate (53.3 mm, SD 6.3, p<0.05), subseptate (55.0 mm, SD 6.7, p<0.05), and septate (56.0 mm, SD 4.8, p<0.05) uterus as compared with the normal uterus (45.9 mm, SD 7.1). ROC curve showed that the best UTD cutoff for ruling out the presence of a uterine canalization defect was 45 mm (AUC 0.809, 95% CI 0.768–0.849).

CONCLUSION

Measurement of UTD may be a simple and practical method for ruling out a uterine canalization defect in infertile women.

Clinical characteristics of congenital cervical atresia and associated endometriosis among 96 patients

OBJECTIVE

To describe the anatomic variety of congenital cervical atresia and to explore the relationship between this disorder and pelvic endometriosis.

METHODS

In a retrospective study, records were reviewed for 96 patients with a confirmed diagnosis of congenital cervical atresia treated at a center in Beijing, China, between January 1984 and October 2014. Data on demographic parameters, symptoms, anatomic features, and endometriosis were obtained and analyzed.

RESULTS

Of the 96 patients, 54 (56%) had pelvic endometriosis, 23 (24%) had a uterine malformation, 75 (78%) had a vaginal malformation, and 12 (13%) had a urinary malformation. The patients with a delay from first symptoms to surgery of more than 1year had a higher incidence of endometriosis than did those with a delay of 1year or less (45/71 [63%] vs 7/23 [30%]; P=0.006), and this trend was not related to the severity of endometriosis (P=0.658). Among the 31 patients with unilateral endometrial cysts, 20 (65%) had left-sided cysts and 11 (35%) had right-sided cysts (P=0.005).

CONCLUSION

More than half of patients with congenital cervical atresia had pelvic endometriosis. Early diagnosis and surgery seem to be necessary to prevent endometriosis among patients with congenital cervical atresia.

Delivery of double singleton pregnancies in a woman with a double uterus, double cervix, and complete septate vagina

Uterine anomalies involving a double uterus, double cervix, also known as didelphys uterus, and complete septate vagina are rarely seen and have an associated fertility problem. However, artificial reproductive technology with embryo transfers can help solve this fertility challenge. Conception in the uterus in just one side is commonly seen for embryos, which are always transferred through the usually used (dilated) vagina. We here present a patient with the above uterine anomaly who conceived with the aid of in vitro fertilization and embryo transfer to both uterine cavities under general anesthesia, which resulted in successful double singleton pregnancies with one fetus in each uterus. With intensive prenatal care, the pregnancy course for each fetus was rather uneventful. Although both fetuses were in cephalic presentation, cesarean section was performed at the 39(th) week of gestation with good outcomes in order to preclude anticipated difficulties if the baby had been delivered through the rarely dilated vagina. However, order of birth between the two fetuses was a crucial decision during the operation.

Accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of Müllerian duct anomalies using ESHRE-ESGE consensus on the classification of congenital anomalies of the female genital tract

OBJECTIVE

To establish the accuracy of three-dimensional ultrasound (3D-US), compared with magnetic resonance imaging (MRI), for diagnosing uterine anomalies, using the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) consensus on the classification of congenital anomalies of the female genital tract.

METHODS

Sixty women with uterine anomalies suspected after examination by conventional two-dimensional ultrasound were evaluated with 3D-US and MRI. These data were analyzed retrospectively to confirm the presence and type of uterine malformation in accordance with the ESHRE-ESGE consensus. Sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were calculated, using MRI as the gold standard, and agreement between the two methods was evaluated by kappa index.

RESULTS

Compared with MRI, for the diagnosis of normal uteri, 3D-US had a sensitivity of 83.3%, specificity of 100%, PPV of 100%, NPV of 98.2% and kappa index of 0.900. For dysmorphic uteri and for hemi-uteri, the sensitivity, specificity, PPV and NPV were all 100%, and kappa was 1.00. For septate uteri, the sensitivity was 100%, specificity was 88.9%, PPV was 95.5%, NPV was 100% and kappa was 0.918. For bicorporeal uteri, the sensitivity was 83.3%, specificity was 100%, PPV was 100%, NPV was 98.2% and kappa was 0.900.

CONCLUSIONS

3D-US is highly accurate for diagnosing uterine malformations, having a good level of agreement with MRI in the classification of different anomaly types based on the ESHRE-ESGE consensus.

Nearly Normal Congenital Cervical Fragmentation: A Hard-To-Diagnose and Successful End-To-End Anastomosis

BACKGROUND

Congenital cervical fragmentation is a very rare genital tract malformation that usually presents in adolescence with primary amenorrhea and cyclic, monthly, lower abdominal pain. We report a nearly normal case of congenital cervical fragmentation and successful end-to-end anastomosis.

CASE

A 15-year-old girl presented with primary amenorrhea with cyclic, monthly lower abdominal pain lasting for 15 months without any abnormal imaging findings (pelvic CT scan, ultrasonography, and hysteroscopy). Misdiagnosis and appendectomy was performed at the time of the initial lower abdominal pain. Diagnostic combined hysteroscopy and laparoscopy were performed in our hospital, and cervical fragmentation was diagnosed. A converted laparotomy end-to-end anastomosis was performed successfully, and regular menstruation was restored after the operation.

SUMMARY AND CONCLUSION

The malformation of nearly normal congenital cervical fragmentation is existent and hard to diagnose. As long as the patient has persistent primary amenorrhea with cyclic, monthly lower abdominal pain, even if no abnormal findings on imaging, obstructive malformation of the reproductive duct should be the primary suspicion. Diagnosis and treatment should occur as early as possible to preserve the patient's fertility. End-to-end anastomosis is the best method for this type of patient.

Hysteroscopic management of congenital external cervical os stenosis using a "no-touch" technique in an adolescent

BACKGROUND

Congenital external cervical os stenosis, one type of congenital cervical atresia, is particularly rare, and no case has been documented so far.

CASE

A 12-year-old virginal patient with a history of mild vaginal bleeding for 14 days and lower abdominal pain for 10 days during her menarche was diagnosed with congenital external cervical os stenosis. Using a "no touch" technique, the diagnosis was further confirmed through a diagnostic hysteroscopy, and the narrow external cervical os was successfully corrected by resectoscopy, leaving the hymen intact. The patient was free of any symptoms postoperatively.

RESULTS AND CONCLUSION

We discuss the above-mentioned case and data already published in the literature. Congenital external cervical os stenosis in non-sexually active patients can be managed by diagnostic and operative hysteroscopy using a "no touch" technique while keeping the hymen intact.

The legacy of the Cartwright report: "lest it happen again"

The 1987 Cartwright Report into events at New Zealand's National Women's Hospital catalysed sweeping changes to promote and protect patients' rights. A generation on, it is comfortable to believe that such sustained and deliberate violations of patient rights "couldn't happen here" and "couldn't happen now." And yet, contemporary examples beg a different truth. Three of Cartwright's messages hold an enduring relevance for health practitioners and patients: the need for patients to be respected as people; to be supported to make informed choices; and to have their voices heard, even when they whisper. These challenges cannot be met in isolation from broader determinants of patients' rights and will require social, technological, and cultural change in order to prevent another "unfortunate experiment."

Cervicovaginal atresia with hematometra: restoring menstrual and sexual function by utero-coloneovaginoplasty

BACKGROUND

Cervicovaginal atresia is a rare Mullerian anomaly. The management of cervicovaginal atresia has evolved from historical recommendations of hysterectomy to various reconstructive procedures more recently. The latter carries a risk of significant morbidity and unknown fertility. We present our experience in the management of this complex anomaly.

METHODS

Twenty patients with cervicovaginal atresia were operated in our hospital from January 2004 through December 2013. The details of their anatomical variations and functional outcomes were analyzed.

RESULTS

Eighteen out of twenty patients had cervical agenesis. Two patients had cervical hypoplasia. All patients underwent utero-coloneovaginoplasty. Post operatively, all patients have regular menstrual cycles. One patient is married, sexually active and has satisfactory coital function. One patient had a bowel anastomotic leak that required a diversion ileostomy. Two patients developed mild stenosis. One patient has mild neovaginal mucosal prolapse. No patient has developed pyometra.

CONCLUSION

Patients with cervicovaginal atresia need to be counselled about the various reconstructive options available and the potential risks. Social and economic factor play a significant role in determining the plan of management. For patients from conservative societies, utero-coloneovaginoplasty provides a safe conduit for the passage of menstrual flow and coitus, at the cost of permanent infertility.

Double cervix: clarifying a diagnostic dilemma

OBJECTIVE

Although double cervix is often considered to indicate uterus didelphys, it may be challenging to determine the true associated anomaly as double cervix occurs with other müllerian anomalies. Our purpose is to report the frequency of uterine müllerian anomalies that occur with a double cervix and identify imaging or clinical criteria to help classify the associated anomaly.

STUDY DESIGN

After institutional review board approval, an electronic search was performed to identify patients with double cervix and pelvic magnetic resonance imaging (MRI) between 1976-2010 (using International Statistical Classification of Diseases and Related Health Problems, Edition 9 and Hospital International Classification of Diseases Adapted codes). MRIs were reviewed to classify the müllerian anomaly. Clinical characteristics including cervical canal thickness, intercervical distance and orientation were recorded. Kruskal-Wallis and χ(2) tests were used to test for differences in patient and imaging characteristics across müllerian anomalies.

RESULTS

There were 64 patients who met inclusion criteria: 32 (50%) septate uterus, 27 (42%) uterus didelphys and 5 (8%) bicornuate uterus. Cervical canal divergence was present in 34% (11/32) with septate uterus, 26% (7/27) with uterus didelphys, and none with bicornuate uterus. Mean intercervical distance was significantly greater (P < .001) in uterus didelphys (12.05 mm) compared with septate (5.43 mm) or bicornuate uterus (5.40 mm).

CONCLUSION

Septate uterus is as common as uterus didelphys, and considerably more common than bicornuate uterus, in women with a double cervix. Although a widened intercervical distance may support the MRI diagnosis of uterus didelphys, careful evaluation of the uterine fundus is required for correct diagnosis when encountering a double cervix.

Three-dimensional ultrasound and magnetic resonance imaging assessment of cervix and vagina in women with uterine malformations

OBJECTIVES

To investigate the accuracy of three-dimensional ultrasound (3D-US) with respect to magnetic resonance imaging (MRI), and compared to clinical examination, in the assessment of cervix and vagina in women with uterine malformations.

METHODS

In this prospective study, 16 patients diagnosed with uterine malformation with cervical involvement underwent 3D-US examination. The acquisition of cervical volumes was transvaginal, with four cases repeated in the peri-ovulation period, while vaginal volumes were acquired by transperineal imaging following filling of the vagina with gel. MRI was performed in 13 patients using endovaginal gel. All cases underwent clinical examination, comprising bimanual gynecological examination and speculoscopy. Diagnostic concordance of each of the methods with the gold standard was calculated.

RESULTS

3D-US cervical examinations revealed 12 cases of duplicate cervix, two of complete septate cervix and two of incomplete septate cervix. Images of the cervical canal in the peri-ovulation period were judged subjectively to be better in quality, but did not lead us to change any diagnosis. 3D-US vaginal examinations revealed four cases with a vaginal dividing wall and two with a blind hemivagina. None of the 3D-US findings contradicted the clinical findings of the cervix; however, clinically we observed two cases with vaginal dividing wall that had not been diagnosed with 3D-US. MRI diagnosed nine cases of duplicate cervix, three of complete septate cervix, one of incomplete septate cervix, five of vaginal dividing wall and two of blind hemivagina. One case diagnosed as complete septate cervix was in fact a duplicate cervix on 3D-US and on clinical examination. Compared with the gold standard, both 3D-US and MRI were highly efficient in the diagnosis of anomalies of the cervix and vagina. The overall diagnostic concordance of 3D-US with clinical examination (kappa, 0.84; 95% CI, 0.62-1) was slightly inferior to that of MRI with clinical examination (kappa, 0.9; 95% CI, 0.72-1), but this difference was not statistically significant.

CONCLUSIONS

The acquisition of isolated cervical volumes, without including the uterus, defines the extent of the ectocervix and the limits of the cervical canal in uterine malformations. The use of endovaginal gel makes possible the diagnosis of associated vaginal anomalies with 3D-US.

[First year experience using arabin cervical pessary with intravaginal micronized progesterone for the prevention of preterm birth in patients with mid-trimester short cervix]

BACKGROUND

Arabin cervical pessary is a silicone ring pessary for the prevention of preterm birth (PTB] for pregnant women at risk with second trimester short uterine cervix. Progesterone supplementation has been found to prevent PTB.

OBJECTIVE

To review our first year of experience using Arabin cervical pessary with intravaginal micronized progesterone in the prevention PTB.

METHODS

The study included patients (pt) with singleton and twin pregnancies at 16-30 weeks with uterine cervical length < or = 25 mm treated with Arabin cervical pessary and intravaginal progesterone over one year from September 2011 to September 2012. Progesterone treatment was continued until 34 weeks and pessary was extracted at 36 weeks or in cases of preterm labor, bleeding or other medical indications.

RESULTS

The study group included 43 patients, 31 (72.1%) singleton and 12 (27.9%) twins. The average week at admission was 25+2 weeks [w] [SD +/- 3.05], and the average cervical length at admission was 13.5 mm (SD +/- 5.0). A total of 11 patients had previous PTB; in 2 patients the pessary was placed after cerclage failure. The average week of delivery was 35 + 5 weeks SD +/- 3.2 (singleton 36 + w SD +/- 2.6, twins 33 + 4 SD +/- 4.1, p = 0.05); the average time between pessary insertion to delivery 72.1 days SD +/- 26.2 (singleton 76.3 SD +/- 22.9 twins 60.2 SD +/- 28.9 p = 0.02), in 23 patients (53.5%) the pessary was extracted at > or = 36 + 6w, 5 patients 111.6%) delivered < or = 32w (2 singleton, 3 twins, p = 0.08) and 18 patients (41.8%) reported increased vaginal discharge.

CONCLUSION

The use of cervical pessary in conjunction with intravaginal progesterone is safe and feasible. Patients with twin pregnancies had a significantly higher rate of preterm birth compared to singleton pregnancies. Further research is needed to assess device efficacy.

Management of a late-presenting complex--an unclassified uterine anomaly in the presence of large leiomyomas

This is a case report of a unique, late-presenting, Müllerian anomaly in an infertile patient. The authors discuss the diagnostic challenges of characterizing distorted gynecological anatomy by Müllerian anomalies in the presence of sizeable coexisting fibroids. This case report adds new insight to the already-existing understanding of Müllerian anomalies by demonstrating how a symptomatic and benign uterine pathology can complicate the diagnosis and management of patients with Müllerian defects.

Cervical dysgenesis with transverse vaginal septum with imperforate hymen in an 11 year old girl presenting with acute abdomen

This case highlights the importance of careful evaluation of girls presenting with imperforate hymen as this is accompanied by other female reproductive tract anomalies. It is of utmost importance that a correct timely diagnosis is made so that the right treatment can be chosen with the perspective of future fertility. Cervical dysgenesis associated with vaginal septum and imperforate hymen has not been reported in literature so far. Present case highlights the simple mode of management with a successful outcome.

Laparoscopic reconstructive management of cervical agenesis

OBJECTIVE

To asses the viability of laparoscopic management of cervical agenesis.

DESIGN

Case report.

SETTING

II. Gynaecology and Obstetrics Dpt. at the University Hospital of F.D. Roosevelt, Banská Bystrica, Slovakia.

METHODOLOGY

Diagnostic management and laparoscopic technique.

RESULTS

Congenital agenesis of the cervix is a rare anomaly of the inner genital. It may be associated with vaginal aplasia and less frequently with other anomalies like an incomplete fusion of müllerian ducts. Hysterectomy was frequently used to resolve main symptoms with respect to frequent complications associated with reconstructive surgery. Recently we can see a comeback to reconstructive surgery as a result of new medical technologies (new antibiotics and antibacterial sutures). Laparoscopic surgery is considered to be the main approach. The treatment strategy is related to a detailed individual pre-surgery investigation. Success of the surgical treatment is measured by normal menstruation and restored fertility. In this article we report the laparoscopic approach in creating the uterovaginal anastomosis in 20-year old women with cervical agenesis and duplex uterine anomaly and review the treatment options.

CONCLUSION

Laparoscopic treatment of cervical agenesis is eligible and might be considered as a first-line treatment option.

Successful pregnancy after uterovaginal anastomosis in patients with congenital atresia of cervix uteri

We present a case of successful pregnancy after effective uterovaginal anastomosis in a 26-years-old patient with congenital atresia of the cervix uteri. She spontaneously achieved pregnancy after four years of uterovaginal anastomosis. Gestation was at the eighth lunar month and the delivery was done by cesarean section due to rapidly progressing fetal asphyxia. The patient gave birth to a live healthy male, weighing 1,950 g, with an Apgar score of 5 and 8 at 1 and 5 min, respectively. The postoperative course was uneventful, and leakage of lochia was normal.

Huge abdominal mass secondary to a transverse vaginal septum and cervical dysgenesis

Transverse vaginal septum is a rare occurrence. When it co-exists with cervical dysgenesis, it is even rarer. Primary amenorrhea with cyclic pain is one manifestation in post-pubertal women. A case of transverse vaginal septum with vaginal atresia and cervical dysgenesis is presented. Presentation as a huge abdominal mass and severe anaemia posed diagnostic challenges. A two-staged management is described as well as variation in management of the septum. The involvement of the patient in her follow up is also stressed.

Normal and abnormal epithelial differentiation in the female reproductive tract

In mammals, the female reproductive tract (FRT) develops from a pair of paramesonephric or Müllerian ducts (MDs), which arise from coelomic epithelial cells of mesodermal origin. During development, the MDs undergo a dynamic morphogenetic transformation from simple tubes consisting of homogeneous epithelium and surrounding mesenchyme into several distinct organs namely the oviduct, uterus, cervix and vagina. Following the formation of anatomically distinctive organs, the uniform MD epithelium (MDE) differentiates into diverse epithelial cell types with unique morphology and functions in each organ. Classic tissue recombination studies, in which the epithelium and mesenchyme isolated from the newborn mouse FRT were recombined, have established that the organ specific epithelial cell fate of MDE is dictated by the underlying mesenchyme. The tissue recombination studies have also demonstrated that there is a narrow developmental window for the epithelial cell fate determination in MD-derived organs. Accordingly, the developmental plasticity of epithelial cells is mostly lost in mature FRT. If the signaling that controls epithelial differentiation is disrupted at the critical developmental stage, the cell fate of MD-derived epithelial tissues will be permanently altered and can result in epithelial lesions in adult life. A disruption of signaling that maintains epithelial cell fate can also cause epithelial lesions in the FRT. In this review, the pathogenesis of cervical/vaginal adenoses and uterine squamous metaplasia is discussed as examples of such incidences.

Prediction of preterm birth using the cervical consistency index

OBJECTIVES

To assess the diagnostic power of a new cervical consistency index (CCI) obtained using transvaginal sonography for the prediction of spontaneous preterm birth (PTB) and to establish reference ranges for this new variable.

METHODS

Included in this prospective cross-sectional study were 1115 singleton pregnancies at 5-36 weeks of gestation. Anteroposterior cervical diameter was measured before (AP) and after (AP') application of pressure on the cervix using the transvaginal probe. The index was calculated using the formula: CCI=((AP'/AP) × 100). Cervical length was also measured. The outcomes evaluated were spontaneous PTB before 32, 34 and 37 weeks. Logistic regression and analysis of receiver-operating characteristics (ROC) curves were performed to evaluate the diagnostic power of CCI and cervical length (adjusted for gestational age). Intraclass correlation coefficients (ICCs) and Bland-Altman analysis were used to evaluate intra- and interobserver variability.

RESULTS

In the 1031 women with follow-up, the rate of spontaneous PTB before 32 weeks was 0.87%, before 34 weeks was 2.13% and before 37 weeks was 7.76% (n=80). There were 31 (3.01%) iatrogenic PTBs before 37 weeks. An inverse linear correlation between gestational age and CCI was observed, with regression equation: CCI (in %)=89.8 - 1.35 × (GA in weeks); r(2)=0.66, P<0.001. Cervical length showed an inverse quadratic, though non-significant, relationship with gestational age: CL (in mm)=31.084 - 0.0278× (GA in weeks)(2) + 1.0772× (GA in weeks); r(2)=0.076, P<0.14. The intra- and interobserver ICCs for CCI were 0.99 (95% CI, 0.988-0.994) and 0.98 (95% CI, 0.973-0.987), respectively. The area under the ROC curve for CCI in the prediction of spontaneous PTB before 32 weeks was 0.947, for spontaneous PTB before 34 weeks it was 0.943 and for spontaneous PTB before 37 weeks it was 0.907. For a 5% screen-positive rate, CCI had a sensitivity of 67%, 64% and 45% for prediction of spontaneous PTB before 32, 34 and 37 weeks, respectively, with equivalent values of 11%, 9% and 11% for cervical length.

CONCLUSIONS

CCI shows a clear inverse linear relationship with GA. Assessment of CCI is reproducible and is effective in the prediction of spontaneous PTB. This new variable appears to provide better prediction of spontaneous PTB than does cervical length.

Transvaginal ultrasonographic measurement of cervical length in asymptomatic high-risk women with a short cervical length in the previous pregnancy

OBJECTIVE

To determine if asymptomatic women at high risk of preterm delivery who had a short cervical length in their previous pregnancy and delivered at term are at increased risk of having a short cervical length in their next pregnancy, and whether they are at increased risk of preterm birth.

METHODS

This retrospective cohort study included high-risk (those with a history of spontaneous preterm birth, uterine anomaly or excisional treatment for cervical dysplasia) asymptomatic women who were pregnant with a singleton gestation delivering between April 2003 and March 2010, who had had a previous pregnancy and who had transvaginal ultrasonographic cervical length measurement performed at 16-30 weeks' gestation in both pregnancies. Comparison was among women who had a short cervical length (< 3.0 cm) in their previous pregnancy but delivered at term in that pregnancy (Short Term Group), women with a history of a normal cervical length (≥ 3.0 cm) in their previous pregnancy delivering at term (Long Term Group), and women who had a short cervical length (< 3.0 cm) in their previous pregnancy delivering preterm (Short Preterm Group). Primary outcomes were spontaneous preterm birth at < 37 weeks' gestation and cervical length. Secondary outcomes were spontaneous preterm birth at < 35 weeks and < 32 weeks, low birth weight, maternal outcomes and neonatal morbidity.

RESULTS

A total of 62 women were included. Women in the Short Term Group were more likely to have a short cervical length in their next pregnancy compared with those in the Long Term Group (10/23 (43.5%) vs. 4/26 (15.4%), respectively) but not as likely as women in the Short Preterm Group (9/13 (69.2%); P=0.003). Women in the Short Term Group were not at an increased risk of spontaneous preterm birth at < 37 weeks in the next pregnancy compared with women in the Long Term Group (2/23 (8.7%) vs. 2/26 (7.7%), respectively), but women in the Short Preterm Group were at an increased risk (6/13 (46.2%); P<0.0001). Compared with women in the Short Term and Long Term groups, women in the Short Preterm Group were also at an increased risk of threatened preterm labor (6/23 (26.1%) and 4/26 (15.4%) vs. 9/13 (69.2%), respectively; P=0.002) and of receiving corticosteroids for fetal lung maturation (6/23 (26.1%) and 4/26 (15.4%) vs. 11/13 (84.6%), respectively; P<0.0001).

CONCLUSION

Although high-risk asymptomatic women with a short cervical length in their previous pregnancy who delivered at term are at increased risk of having a short cervix in their next pregnancy, they are not at increased risk of preterm birth.

Universal cervical-length screening to prevent preterm birth: a cost-effectiveness analysis

OBJECTIVE

To determine whether routine measurement of second-trimester transvaginal cervical length by ultrasound in low-risk singleton pregnancies is a cost-effective strategy.

METHODS

We developed a decision analysis model to compare the cost-effectiveness of two strategies for identifying pregnancies at risk for preterm birth: (1) no routine cervical length screening and (2) a single routine transvaginal cervical length measurement at 18-24 weeks' gestation. In our model, women identified as being at increased risk (cervical length < 1.5 cm) for preterm birth would be offered daily vaginal progesterone supplementation. We assumed that vaginal progesterone reduces preterm birth at < 34 weeks' gestation by 45%. We also assumed that a decreased cervical length could result in additional costs (ultrasound scans, inpatient admission) without significantly improved neonatal outcomes. The main outcome measure was incremental cost-effectiveness ratio.

RESULTS

Our model predicts that routine cervical-length screening is a dominant strategy when compared to routine care. For every 100,000 women screened, $12,119,947 can be potentially saved (in 2010 US dollars) and 423.9 quality-adjusted life-years could be gained. Additionally, we estimate that 22 cases of neonatal death or long-term neurologic deficits could be prevented per 100,000 women screened. Screening remained cost-effective but was no longer the dominant strategy when cervical-length ultrasound measurement costs exceeded $187 or when vaginal progesterone reduced delivery risk at < 34 weeks by less than 20%.

CONCLUSION

In low-risk pregnancies, universal transvaginal cervical length ultrasound screening appears to be a cost-effective strategy under a wide range of clinical circumstances (varied preterm birth rates, predictive values of a shortened cervix and costs).

Association of Pap smear abnormalities with autoimmune disorders

Recently, it is hypothesized that there might be an association between immunological disorders and cervical premalignant and malignant abnormalities. Related studies have been generally focused on some particular autoimmune disease, specially the Systemic Lupus Erythematosus (SLE). This study aimed at comparing the rate of Pap smear abnormalities in female patients with autoimmune diseases and normal counterparts. In a case-control setting, 118 female patients with various autoimmune diseases (the case group) and 118 healthy female counterparts (the control group) were recruited in Tabriz Imam Reza Teaching Centre in a 24 months period of time. The two groups were matched for demographics and known risk factors of cervical malignancy. Frequencies of abnormal Pap smear testing were compared between the two groups. The autoimmune disorders were SLE (74 patients), rheumatoid arthritis or RA (32 patients), systcmic sclerosis or SS (7 patients) and ankylosing spondylitis or AS (5 patients) in the case group. Frequency of abnormal Pap smear testing was significantly higher in the case group comparing with that in the controls (7.6% vs. 1.7%; p = 0.03). Frequency of abnormal Pap smear testing was higher in the patients with SLE (8.1%) and RA (9.3%) comparing with that in the controls; However, these differences were marginally nonsignificant (p = 0.06 and p = 0.07, respectively). Frequency of cases with abnormal Pap smear testing was not statistically different between the autoimmune disorders (p = 0.99). Based on these findings and in conclusion, there might be an association between the autoimmune disorders and occurrence of premalignant or malignant lesions in cervix. Further studies with larger samples sizes are recommended.

Abnormal cervical appearance: what to do, when to worry?

Many clinicians encounter cervical lesions that may or may not be associated with cytologic abnormalities. Such abnormalities as ectropion, Nabothian cysts, and small cervical polyps are quite benign and need not generate concern for patient or clinician, whereas others, including those associated with a history of exposure to diethylstilbestrol, cervical inflammation, abnormal cervical cytology, and postcoital bleeding, should prompt additional evaluation. Further, in some patients, the cervix may be difficult to visualize. Several useful clinical suggestions for the optimal examination of the cervix are presented.

[A woman with a special cervix]

A 40-year-old woman (nulligravida) presented with abnormal cervical cytology. At colposcopy a double external uterine os was discovered with a levonorgestrel intra uterine contraceptive device placed in the opening on the left side. Ultrasound revealed an uterus bicornis bicollis. Despite frequent examinations, the abnormality had not been discovered earlier. Therefore, contraception and cervical cytology sampling had most likely been inadequate.

Abnormal cervical cytology in the diagnosis of uterine papillary serous carcinoma: earlier detection of a poor prognostic cancer subtype?

OBJECTIVE

Early detection of uterine papillary serous (UPSC), clear cell (CCC), and grade 3 endometrioid carcinomas (G3EC) - all poor prognostic variants of endometrial carcinoma (EC) - is of particular clinical relevance. The study objective was to assess the utility of liquid-based cytology (Pap) in the detection of high-grade EC.

STUDY DESIGN

A retrospective, two-institution analysis of patients diagnosed with UPSC, CCC, or G3EC with a preoperative Pap from 1999 to 2010 was conducted.

RESULTS

One hundred and one patients were evaluated; 51.5% had UPSC, 27.7% had CCC, and 20.8% had G3EC. Stage I/II disease was found in 69.3% of patients, and 46/101 patients (45.5%) had abnormal Paps. Significantly more patients with UPSC had abnormal Paps (65.7%) than those with CCC (25%) or G3EC (23.8%; p < 0.001). An abnormal Pap was the only presenting clinical finding in a significant number of asymptomatic UPSC patients (26.9%) compared with 4% of patients with CCC and G3EC (p = 0.005). On multivariate analysis, UPSC histology was the only variable associated with an abnormal Pap.

CONCLUSIONS

A high incidence of abnormal cervical cytology was observed in women with high-grade EC, particularly in UPSC patients. Although hypothesis generating, a proportion of asymptomatic UPSC patients had abnormal cytology, signifying that Pap smear screening may help detect the disease before the patient develops symptoms.

Borderline micropapillary serous tumor of the ovary detected during a cesarean section due to a transabdominal cervico-isthmic cerclage in a patient with congenital cervical hypoplasia: a rare case

A young woman with polycystic ovary syndrome and congenital cervical hypoplasia conceived with clomifen citrate treatment after placement of a transabdominal cervico-isthmic cerclage. Her pregnancy successfully reached term and cesarean section was performed to preserve the cerclage for the next pregnancy; when the ovaries were explored an irregular structure was detected on the left ovary. A wedge biopsy was done and the pathological assessment of the specimen was borderline micropapillary serous tumor of the ovary. The patient wanted to preserve her fertility, therefore a fertility-sparing staging surgery was performed six months after the cesarean section. There was no residual tumor in the left ovary, but there was a borderline tumor in the right ovarian biopsy specimen (frozen section was negative). Two months after staging surgery the patient conceived with IVF and delivered twins at the 33rd week of pregnancy with cesarean section. At her second cesarean section the right ovary and abdomen appeared normal on inspection, but the cerclage tape was in the endocervical canal and was thus removed. To our knowledge this is the second reported case of transabdominal cerclage tape migration into the endocervical canal. The patient is clinically disease-free 18 months after her second cesarean section. The clinical findings, treatment modalities, management and prognosis are discussed together with a literature review of a patient with a serous borderline ovarian tumor and congenital cervical hypoplasia.

[Uterine cervix agenesis--uterovaginal anastomosis]

PURPOSE

Atresia of the uterine cervix is an uncommon Mullerian anomaly. Until ten years ago many authors recommended hysterectomy as the first line treatment in case of uterine cervix atresia. Recent advances in reproductive technology and laparoscopic surgical techniques mean that conservative surgery is a possibility and should be considered as the first line treatment option. Surgical treatment of uterine cervical atresia appears to be a good choice of treatment with good functional result.

MATERIALS AND METHOLOGY

We report a case of a 19-year-old woman who was admitted to our Department with amenorrhea and pelvic pain. Examination found no communication between vagina and uterus. The patient under general anesthesia was placed in a lithotomy position, allowing both abdominal (laparoscopy) and vaginal approach. A large dissection between the bladder and the uterus and later between the rectum and the uterus was performed. An incision was made on the uterine fundus and a probe to identify the upper limit of artretic tissue of the cervix was inserted. The atretic tissue was resected as for the cervical conisation until the uterine cavity was reached. Then the uterus was sutured to the high vaginal mucosa with separate stitches. A Foley catheter was inserted in the uterine cavity for 21 days. During the entire post-operative treatment the patient received antibiotics, oral contraceptives and vaginal douche. Four months after the surgery a hysteroscopic evaluation revealed that the communication between the uterus and the vagina was healed.

CONCLUSIONS

The result of our surgery confirms that uterine atresia may be successfully treated by utero-vaginal anastomosis.

Combined retropubic balloon vaginoplasty and laparoscopic canalization: a novel blend of techniques provides a minimally invasive treatment for cervicovaginal aplasia

We studied the operative and functional outcomes of combined retropubic balloon vaginoplasty and laparoscopic canalization (RBV-LC) for treatment of cervicovaginal aplasia. The RBV-LC procedure was performed successfully in 4 cases of cervicovaginal aplasia within 35-40 minutes primary operative time. Cystoscopy was performed to ensure bladder and urethral integrity. Endoscopically monitored canalization with laparoscopic canalization is a feasible, effective, less invasive way for management of cervicovaginal aplasia.

[Fissura pelvina with an abdominal hernia and ectopic bladder aperture in a female German Holstein calf]

A three-days-old female black and white German Holstein calf showed a high-graded enlargement of the abdomen.The animal was born at a dairy farm and it was sired by a bull used in artificial insemination.The examination of the animal showed a ventral cleft of the pelvis due to a missing closure of the pelvis symphysis. The abdominal hernia occurred in consequence of the cleft pelvis. Furthermore, the calf had an ectopic bladder aperture, but an urethra could not be found. A permanent and uncontrollable urine drip along an aperture on the hernial sack was observed. The defects were present since birth and not caused by a trauma.

Young woman with severe abdominal pain: conclusion

A 17-year-old girl presented to a fire station complaining of severe abdominal pain one afternoon. The patient appeared acutely ill and had an initial blood pressure of 62 mmHg by palpation and a heart rate of 110 beats per minute. A flight crew was summoned to the scene. History obtained only through a Spanish-speaking interpreter revealed the patient to be approximately 6 months pregnant and without any prenatal care. Physical assessment revealed the patient to be alert and oriented but weak, pale, and diaphoretic. The abdomen examination demonstrated diffuse, severe tenderness and guarding to palpation. There was no evidence of vaginal bleeding or signs of imminent delivery. A repeat blood pressure by the flight crew was 82 mmHg by palpation.

Laparoscopic hemi-hysterectomy in treatment of a didelphic uterus with a hypoplastic cervix and obstructed hemi-vagina

OBJECTIVE

Maldevelopment of the Müllerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix and obstructed hemi-vagina.

CASE REPORT

We report a patient with this anomaly who was treated by laparoscopic hemi-hysterectomy and hysteroscopic resection of hemi-vagina. A 16-year-old patient who had complained of vaginal pus-like discharge on and off for 1 year was diagnosed by MRI to have a double uterus with obstructed right hemi-vagina and ipsilateral renal agenesis. After hysteroscopic identification of hypoplasia of the right uterine cervix, laparoscopic resection of the right uterus and right fallopian tube and hysteroscopic assisted resection of the vaginal septa were performed successfully.

CONCLUSION

We think that combined laparoscopy and hysteroscopy may be an effective alternative in the management and diagnosis of Mullerian anomalies.