Junctional zone thickening: an endo-myometrial unit disorder

Adenomyosis is a disease defined by histopathology, mostly of hysterectomy specimens, and classification is challenged by the disagreement of the histologic definition. With the introduction of Magnetic Resonance Imaging (MRI) and two- and three-dimensional ultrasound, the diagnosis of adenomyosis became a clinical entity. In MRI and US, adenomyosis ranges from thickening of the inner myometrium or junctional zone to nodular, cystic, or diffuse lesions involving the entire uterine wall, up to a well-circumscribed adenomyoma or a polypoid adenomyoma. The absence of an accepted classification and the vague and inconsistent terminology hamper basic and clinical research. The sub-endometrial halo seen at US and MRI is a distinct entity, differing from the outer myometrium by its increased nuclear density and vascular structure. The endometrium and the sub-endometrial muscularis or archimetra are of Müllarian origin, while the outer myometrium is non-Mullerian mesenchymal. The junctional zone (JZ) is important for uterine contractions, conception, implantation, and placentation. Thickening of the JZ can be considered inner myometrium adenomyosis, with or without endometrial invasion. Changes in the JZ should be considered a different entity than myometrial clinically associated with impaired conception, implantation, abnormal uterine bleeding, pelvic pain and obstetrical outcome. Pathology of the basal endometrium and JZ is a separate entity and should be identified as an endo-myometrial unit disorder (EMUD).

From complication to litigation: The importance of non-technical skills in the management of complications

Complications do occur in daily clinical life and can sometimes lead to litigation, which adversely affect the entire health care system, leading to a loss of confidence in medical providers, an increase in defensive medical practice and high professional indemnity insurance costs. Some complications are inevitable but can be minimised by completing a structured training programme. The likelihood of litigation can be reduced when adequate and clear information is given to the patient preoperatively. Non-technical skills are essential in complication management and crucial if confronted with litigation. Checklists and documentation of medication and surgical steps should be routine in all surgeries. Awareness of the complexity of the planned operation, theatre set-up and equipment are important in preventing complications. Mental preparation of surgeons is of the utmost importance in order to be able to confront any problem. When complications occur, remaining calm, calling for assistance, effective team leadership and harmony in the team are important in managing the situation. Good and effective communication with the patient and relatives, offering explanations, apologies and timely intervention without delays reduce the risk of litigation and strengthen any defence in court.

Prevention and Management of Complications in Laparoscopic Myomectomy

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

Vaginal lichen sclerosus: report of two cases

BACKGROUND

Lichen sclerosus most commonly affects the genital area. Contrarily to lichen planus, the involvement of the oral or vaginal mucosa is rare. Only four cases of vaginal lichen sclerosus have been described in the literature.

CASE REPORT

The authors report two cases of postmenopausal women with a history of vulvar pruritus and burning. Both presented with lesions of the vaginal mucosa compatible with lichen sclerosus, and genital prolapse. Vaginal biopsies confirmed the diagnosis. Initial treatment with topical clobetasol was effective in one of the patients, but in the other patient line therapy with pimecrolimus, triamcinolone, and retinoids was needed.

CONCLUSION

Vaginal lichen sclerosus may be underdiagnosed and genital prolapse may favour the development of vaginal lesions.

Uncommon presentations of an uncommon entity: OHVIRA syndrome with hematosalpinx and pyocolpos

Müllerian malformations result from defective fusion of the Müllerian ducts during development of the female reproductive system. The least common form of these malformations is Herlyn-Werner-Wunderlich syndrome characterized by obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). The most common presentation of this syndrome is a mass secondary to hematocolpos, pain, and dysmenorrhea. Clinical diagnosis is very challenging and requires imaging studies in which ultrasound and MRI play an essential role in the diagnosis, classification and treatment plan. We report two cases of this syndrome, featuring two very rare clinical presentations: hematosalpinx and pyocolpos. The clinical course of the pathology is not standard and each patient is treated accordingly.

Implementation of minimal invasive gynaecological surgery certification will challenge gynaecologists with new legal and ethical issues

The introduction of a certification / diploma program in Minimal Invasive Surgery (MIS) is expected to improve surgical performance, patient's safety and outcome. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) and the ESHRE Certification for Reproductive Endoscopic Surgery (ECRES) provides a structured learning path, recognising different pillars of competence. In order to achieve a high level of competence a two steps validation is necessary: (a) the individual should be certified of having the appropriate theoretical knowledge and (b) the endoscopic psychomotor skills before entering in the diploma programme reflecting the surgical competence. The influence of such an educational and credentialing path could improve safety and offer financial benefits to the hospitals, physicians and healthcare authorities. Moreover the medicolegal consequences can be important when a significant amount of surgeons possess the different diplomas. As the programs are becoming universally accessible, recognised as the best scientific standard, included in the continuous medical education (CME) and continuous professional development (CPD), it is expected that a significant number of surgeons will soon accomplish the diploma path. The co-existence and practice of both non-certified and certified surgeons with different degrees of experience is unavoidable. However, it is expected that national health systems (NHS), hospitals and insurance companies will demand and hire doctors with high and specific proficiency to endoscopic surgery. When medico-legal cases are under investigation, the experts should be aware of the limitations that individual experience provides. The court first of all examines and then judges if there is negligence and decides accordingly. However, lack of certification may be considered as negligence by a surgeon operating a case that eventual faces litigation problems. Patients' safety and objective preoperative counselling are mandatory, directly connected to MIS certification while eliminating any dispute of surgeons' credibility.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system

STUDY QUESTION

How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies?

SUMMARY ANSWER

The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system.

WHAT IS KNOWN ALREADY

Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment.

STUDY DESIGN, SIZE AND DURATION

The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies.

MAIN RESULTS AND THE ROLE OF CHANCE

The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system.

LIMITATIONS, REASONS FOR CAUTION

The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare.

WIDER IMPLICATIONS OF THE FINDINGS

The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research.

STUDY FUNDING/COMPETING INTERESTS

None.

The European Academy laparoscopic "Suturing Training and Testing'' (SUTT) significantly improves surgeons' performance

The efficiency of suturing training and testing (SUTT) model by laparoscopy was evaluated, measuring the suturingskill acquisition of trainee gynecologists at the beginning and at the end of a teaching course. During a workshop organized by the European Academy of Gynecological Surgery (EAGS), 25 participants with three different experience levels in laparoscopy (minor, intermediate and major) performed the 4 exercises of the SUTT model (Ex 1: both hands stitching and continuous suturing, Ex 2: right hand stitching and intracorporeal knotting, Ex 3: left hand stitching and intracorporeal knotting, Ex 4: dominant hand stitching, tissue approximation and intracorporeal knotting). The time needed to perform the exercises is recorded for each trainee and group and statistical analysis used to note the differences. Overall, all trainees achieved significant improvement in suturing time (p < 0.005) as measured before and after completion of the training. Similar significantly improved suturing time differences (p < 0.005) were noted among the groups of trainees with different laparoscopic experience. In conclusion a short well-guided training course, using the SUTT model, improves significantly surgeon's laparoscopic suturing ability, independently of the level of experience in laparoscopic surgery.

KEY WORDS

Endoscopy, laparoscopic suturing, psychomotor skills, surgery, teaching, training suturing model.

Computer-aided diagnosis in hysteroscopic imaging

The paper presents the development of a computer-aided diagnostic (CAD) system for the early detection of endometrial cancer. The proposed CAD system supports reproducibility through texture feature standardization, standardized multifeature selection, and provides physicians with comparative distributions of the extracted texture features. The CAD system was validated using 516 regions of interest (ROIs) extracted from 52 subjects. The ROIs were equally distributed among normal and abnormal cases. To support reproducibility, the RGB images were first gamma corrected and then converted into HSV and YCrCb. From each channel of the gamma-corrected YCrCb, HSV, and RGB color systems, we extracted the following texture features: 1) statistical features (SFs), 2) spatial gray-level dependence matrices (SGLDM), and 3) gray-level difference statistics (GLDS). The texture features were then used as inputs with support vector machines (SVMs) and the probabilistic neural network (PNN) classifiers. After accounting for multiple comparisons, texture features extracted from abnormal ROIs were found to be significantly different than texture features extracted from normal ROIs. Compared to texture features extracted from normal ROIs, abnormal ROIs were characterized by lower image intensity, while variance, entropy, and contrast gave higher values. In terms of ROI classification, the best results were achieved by using SF and GLDS features with an SVM classifier. For this combination, the proposed CAD system achieved an 81% correct classification rate.

Color multiscale texture classification of hysteroscopy images of the endometrium

The objective of this study was to investigate the diagnostic performance of a Computer Aided Diagnostic (CAD) system based on color multiscale texture analysis for the classification of hysteroscopy images of the endometrium, in support of the early detection of gynaecological cancer. A total of 416 Regions of Interest (ROIs) of the endometrium were extracted (208 normal and 208 abnormal) from 45 subjects. RGB images were gamma corrected and were converted to the YCrCb color system. The following texture features were extracted from the Y, Cr and Cb channels: (i) Statistical Features (SF), (ii) Spatial Gray Level Dependence Matrices (SGLDM), and (iii) Gray Level Difference Statistics (GLDS). The Probabilistic Neural Network (PNN), statistical learning and the Support Vector Machine (SVM) neural network classifiers were also applied for the investigation of classifying normal and abnormal ROIs in different scales. Results showed that the highest percentage of correct classification (%CC) score was 79% and was achieved for the SVM models trained with the SF and GLDS features for the 1x1 scale. This %CC was higher by only 2% when compared with the CAD system developed, based on the SF and GLDS feature sets computed from the Y channel only. Further increase in scale from 2x2 to 9x9, dropped the %CC in the region of 60% for the SF, SGLDM, and GLDS, feature sets, and their combinations. Concluding, a CAD system based on texture analysis and SVM models can be used to classify normal and abnormal endometrium tissue in difficult cases of gynaecological cancer. The proposed system has to be investigated with more cases before it is applied in clinical practise.

Color based texture--classification of hysteroscopy images of the endometrium

The objective of this study was to develop a CAD system for the classification of hysteroscopy images of the endometrium based on color texture analysis for the early detection of gynaecological cancer. A total of 416 Regions of Interest (ROIs) of the endometrium were extracted (208 normal and 208 abnormal) from 40 subjects. RGB images were gamma corrected and were converted to the HSV and YCrCb color systems. The following texture features were extracted for each channel of the RGB, HSV, and YCrCb systems: (i) Statistical Features, (ii) Spatial Gray Level Dependence Matrices and (iii) Gray Level Difference Statistics. The PNN statistical learning and SVM neural network classifiers were also investigated for classifying normal and abnormal ROIs. Results show that there is significant difference (using the Wilcoxon Rank Sum Test at a=0.05) between the texture features of normal and abnormal ROIs of the endometrium. Abnormal ROIs had higher gray scale median, variance, entropy and contrast and lower gray scale median and homogeneity values when compared to the normal ROIs. The highest percentage of correct classifications score was 79% and was achieved for the SVM models trained with the SF and GLDS features for differentiating between normal and abnormal ROIs. Concluding, a CAD system based on texture analysis and SVM models can be used to classify normal and abnormal endometrium tissue. Further work is needed to validate the system in more cases and organs.

The effect of color correction of endoscopy images for quantitative analysis in endometrium

The objective of this study was to develop a standardized protocol for the capturing and analysis of endoscopy digital images for subsequent use in a Computer Aided Diagnosis (CAD) system in gynaecological cancer. Images were captured at optimum illumination and focus at 720x576 pixels using 24 bits color in the following cases: (i) for a variety of testing targets from a color palette with known color distribution, (ii) different viewing angles and distances from calf endometrium, and (iii) images from the human endometrium. Images were then gamma corrected and their classification performance was compared against that of nonqamma corrected images. No significant difference in texture features was found between the close up and panoramic views, and between angles, either before or after gamma correction. There was significant difference in certain texture features between normal and abnormal endometrium, both before and after gamma correction. Our findings suggest that proper color correction can significantly impact CAD system performance, and we recommend its application prior to quantitative texture analysis in gynaecological endoscopy.

Texture analysis of the endometrium during hysteroscopy: preliminary results

The objective of this study is to investigate the usefulness of texture analysis in the endometrium during hysteroscopy in endoscopic imaging of the uterine cavity. Endoscopy images from the endometrium from three subjects, at optimum illumination and focus, were frozen and digitized at 720x576 pixels using 24 bits color. Regions of interest (ROI) of normal (N=61) and abnormal (N=69) regions were manually selected by the physician. ROI images were converted into gray scale and statistical features (SF) and spatial gray level dependence matrix features (SGLDM) were computed. The nonparametric Wilcoxon rank sum test at a=0.05 was carried out for comparing the differences between normal and abnormal tissue. There was significant difference between normal and abnormal endometrium for the SF features variance, energy and entropy and for the SGLDM feature of angular second moment. There was no significant difference for the SF features mean, median, and SGLDM features of contrast, correlation and homogeneity.

Texture-based classification of hysteroscopy images of the endometrium

The objective of this study was to classify hysteroscopy images of the endometrium based on texture analysis for the early detection of gynaecological cancer. A total of 418 regions of interest (ROIs) were extracted (209 normal and 209 abnormal) from 40 subjects. Images were gamma corrected and were converted to gray scale. The following texture features were extracted: (i) statistical features, (ii) spatial gray level dependence matrices (SGLDM), and (iii) gray level difference statistics (GLDS). The PNN and SVM neural network classifiers were also investigated for classifying normal and abnormal ROIs. Results show that there is significant difference (using Wilcoxon rank sum test at a=0.05) between the texture features of normal and abnormal ROIs for both the gamma corrected and uncorrected images. Abnormal ROIs had lower gray scale median and homogeneity values, and higher entropy and contrast values when compared to the normal ROIs. The highest percentage of correct classifications score was 77% and was achieved for the SVM models trained with the SF and GLDS features. Concluding, texture features provide useful information differentiating between normal and abnormal ROIs of the endometrium.

H19 and IGF2 gene expression in human normal, hyperplastic, and malignant endometrium

We examined H19 and insulin-like growth factor 2 (IGF2) gene expression in normal endometrium (12 cases), hyperplasia (27 cases), and cancer (27 cases) by non-radioactive in situ hybridization. H19 was not expressed in the epithelium of normal endometrium, but its frequency of expression was 15% in hyperplastic and 60% in neoplastic epithelium. In stroma cells, H19 frequency of expression was 75% in normal endometrium, 55% in hyperplasia, and 37% in carcinoma. According to the grade of endometrial cancer cell differentiation, H19 showed increased frequency and level of expression in the epithelium from well to moderately and poorly differentiated tissues. Our results indicate that H19 expression in epithelial cells of endometrial hyperplasia and cancer merits further investigation and could be useful as a complementary histopathologic and prognostic marker among other modalities in endometrial cancer. IGF2 expression did not appear useful for diagnostic or prognostic purposes.

Transvaginal laparoscopy proposed as an investigation procedure for patients at high-risk for ovarian cancer

Transvaginal laparoscopy (TVL) was performed in 23 patients at high risk for ovarian cancer (OC). The patients were placed in the lithotomy position after sedation and a veres needle was inserted in the posterior vaginal vault. A trocar followed and warm normal saline was injected into the pelvis. The needle was removed and a telescope connected to a light source and monitor was introduced. Excellent visualization was achieved in all cases examined and the average time of TVL was 30 min. All patients except one found TVL a simple and painless procedure. TVL helped in the diagnosis of six benign ovarian lesions and ruled out OC in the other 17 cases. TVL is an easy method to learn with reliable results. TVL can reduce the number of unnecessary laparoscopies and/or laparotomies and it seems to be useful in ruling out OC.

Ovulation induction and risk of endometrial cancer: a pilot study

OBJECTIVE

To determine whether women with endometrial carcinoma are more likely to have been exposed to fertility drugs, in particular clomiphene, than healthy population controls.

STUDY DESIGN

A nationwide case-control, pilot study. About 128 living women 35-64 years old, with a histologically confirmed diagnosis of endometrial carcinoma that was first diagnosed and reported to The Israel Cancer Registry between 1 January 1989 and 31 December 1992 were enrolled. The controls were 255 women from the same dialing areas selected by random digit dialing. A variety of demographic and clinical parameters were compared between cases and controls. A multivariate logistic model, controlling for age, was used to assess the independent effects of factors found to be significantly associated with endometrial cancer on univariate analysis.

RESULTS

About 7 women with endometrial carcinoma (5.5%) and 10 healthy controls (3.9%) reported that they had used any fertility drug (crude odds ratio (OR) 1.4; 95% confidence interval (CI) 0.47-4.2). Use of fertility drugs did not meet the criteria for entry into the logistic model. The following parameters were found to be independently associated with endometrial cancer controlling for age, European-American background OR=2.2, (95% CI 1.3-3.7, P=0.004); nulliparity OR=2.7 (95% CI 1.1-6.5, P=0.03); history of infertility OR=1.8 (95% CI 1.0-3.3, P=0.05); BMI> or =27 OR=2.3 (95% CI 1.4-3.9, P=0.001). The use of oral contraceptives and IUD were found to be protective, OR=0.29 and 0.37, respectively, (95% CI 0.14-0.61, P=0.001 and 0.19-0.70, P=0.003, respectively).

CONCLUSIONS

We found no evidence that the use of ovulation induction agents, including clomiphene citrate, are associated with a higher risk of endometrial carcinoma. The association between infertility drugs and endometrial carcinoma should be examined in other, larger studies.

Expression of the imprinted H19 oncofetal RNA in epithelial ovarian cancer

STUDY

To examine the expression of the imprinted maternally expressed H19 gene in benign, low malignant potential (borderline) and malignant surface epithelial ovarian tumors.

DESIGN

In situ hybridization for H19 RNA using S-labeled and digoxigenin-labeled probes was performed on paraffin sections of ovarian surface epithelial tumors. The serous tumors included nine section cystadenomas, twelve serous tumors of low malignant potential and twenty serous carcinomas, grade I-IIII (FIGO classification). A smaller group included two mucinous cystadenomas, four mucinous tumors of low malignant potential and two mucinous cystadenocarcinomas.

RESULTS

H19 expression was found to be positive in 6/9 (67%) serous cystadenomas, 9/12 (75%) of serous tumors of low malignant potential and 13/20 (65%) of invasive serous carcinomas. Expression in mucinous tumors was confined to the stroma beneath the epithelial lining.

CONCLUSION

H19 is expressed in the majority of serous epithelial tumors. Taking into consideration the high percentage of H19 expressing serous ovarian neoplasms we suggest that H19 RNA may be used as an adjuvant tumor marker for the diagnosis and mainly for staging and follow-up of patients with serous ovarian carcinoma.

High risk pregnancy outcome following induction of labour

OBJECTIVE

To evaluate whether induction of labour, performed in a high risk obstetric population, when medically indicated, carries an increased risk for operative delivery and maternal and fetal complications. The secondary goal was to study the effect of the various induction methods used on these outcomes and labour time.

STUDY DESIGN

This study was carried out at a level [1] university hospital. A group of 210 women who were induced for various indications, were compared to our general parturient population. Main outcome measures were cesarean section (CS) and instrumental delivery rates, intra-partum and post-partum complications, APGARs 1' and 5' and labour time by induction method.

RESULTS

No significant increase in the rates of primary CS (8.6 vs. 7.1%) and instrumental delivery (15.7 vs. 12.7%), were found in the induction high risk group as compared to our general obstetric population. Intra-partum complications and fetal outcome were comparable in both groups. A comparison of methods of induction used (oxytocin, PgE2, Amniotomy) revealed a less favorable outcome with the oxytocin induction method which showed an elevated intra-partum complication rate (P < 0.01) and a tendency toward lower Apgar scores and higher CS rate.

CONCLUSIONS

Induction of labour performed in a high-risk obstetric population is safe, carrying no significant increase in CS and neonatal complication rates. Of the three methods of induction used, oxytocin induction showed the least favorable outcome for both mother and her offspring.

Effect of epidural analgesia on duration and outcome of induced labor

OBJECTIVE

To evaluate the effect of epidural block on the duration of labor and maternal and fetal outcome in induced-labor patients.

METHOD

210 women admitted for induction of labor at a level III university hospital, during the year 1991, were studied. Of these, 112 were given an epidural block and 98 served as controls. Outcome measures studied were: induction time and time in labor, c-section and instrumental delivery rates, intra-partum and post-partum complications, and Apgar scores at 1 and 5 min.

RESULT

Multiple regression analysis revealed that epidural analgesia, before and after adjustment for confounding factors, significantly prolonged labor time (P < 0.0001) and was associated with an increase in instrumental delivery rates (P < 0.04). A significant reduction in intra-partum complication rate (FHR changes, meconium) was observed (OR = 0.32; P < 0.03), while c-section rate and Apgar scores were not found to be influenced by epidural analgesia.

CONCLUSION

Epidural anesthesia, significantly prolongs labor time in induced patients. While instrumental delivery was more prevalent in these parturients, c-section rate was not increased and intra-partum complications were significantly reduced in these patients.

The product of the imprinted H19 gene is an oncofetal RNA

AIMS/BACKGROUND

The H19 gene is an imprinted, maternally expressed gene in humans. It is tightly linked and coregulated with the imprinted, paternally expressed gene of insulin-like growth factor 2. The H19 gene product is not translated into protein and functions as an RNA molecule. Although its role has been investigated for more than a decade, its biological function is still not understood fully. H19 is abundantly expressed in many tissues from early stages of embryogenesis through fetal life, and is down regulated postnatally. It is also expressed in certain childhood and adult tumours. This study was designed to screen the expression of H19 in human cancer and its relation to the expression of H19 in the fetus.

METHODS

Using in situ hybridisation with a [35S] labelled probe, H19 mRNA was detected in paraffin wax sections of fetal tissues from the first and second trimesters of pregnancy and of a large array of human adult and childhood tumours arising from these tissues.

RESULTS

The H19 gene is expressed in tumours arising from tissues which express this gene in fetal life. Its expression in the fetus and in cancer is closely linked with tissue differentiation.

CONCLUSIONS

Based on these and previous data, H19 is neither a tumour suppressor gene nor an oncogene. Its product is an oncofetal RNA. The potential use of this RNA as a tumour marker should be evaluated.

The impact of endometrial preparation on implantation following cryopreserved-thawed-embryo transfer

The efficacy of three protocols of endometrial preparation (spontaneous cycles, A: artificial preparation, B; ovarian stimulation, C) for cryopreserved-thawed human embryo transfer (CT-ET). The implantation and clinical pregnancy rates per cycle in 236 women undergoing 381 consecutive CT-ETs were evaluated according to the endometrial preparation protocol. No statistically significant difference was found in implantation rates per embryo transfer (A = 5.6%, B = 5.6%, C = 4.6%) and clinical pregnancy rates per cycle (A = 16.9%, B = 16.5%, C = 15.6%) between the three endometrial preparation protocols used. In conclusion, the specific method of endometrial preparation for CT-ET had no significant impact upon the implantation rate.

Predictive score for vaginal birth after cesarean section

OBJECTIVE

Our purpose was to evaluate the relative weight of the different variables that may influence the chances of vaginal birth after one cesarean delivery, with the aim of developing a predictive score for success of such a trial.

STUDY DESIGN

In this retrospective study, which covered a 10-year period (1981 to 1990), 471 women who attempted vaginal birth at a level III university hospital after one abdominal delivery were studied as to the subsequent delivery outcome. An attempt to identify possible prognostic factors for success of such a trial was made.

RESULTS

A trial of labor was successful in 368 (78.1%) of women and 103 (21.9%) had a repeat cesarean section. Variables of significant predictive value were vaginal birth before cesarean section (odds ratio 1.8), malpresentation (odds ratio 1.9), pregnancy-induced hypertension (odds ratio 2.3), and Bishop score > or = 4 (odds ratio 6.0). Cephalopelvic disproportion and failure to progress did not demonstrate a significant predictive value (odds ratio 0.81) for success or failure in subsequent delivery. In fact, 63.8% of women with this indication have successfully undergone vaginal delivery. Maternal age (odds ratio 0.9) had no bearing on vaginal delivery success rates, whereas both macrosomia (odds ratio 0.2) and intrauterine growth retardation tended to decrease the chances for vaginal birth after cesarean section.

CONCLUSIONS

A trial of labor after one cesarean section should be encouraged in most women who are willing to attempt it, provided no obstetric contraindication exists. A scoring system that may help to identify women with a greater chance for vaginal delivery is proposed.

Comparison between nafarelin acetate and D-Trp6-LHRH for temporary pituitary suppression in in vitro fertilization (IVF) patients: a prospective crossover study

PURPOSE

Nafarelin acetate is a new gonadotropin releasing (GnRH) agonist analogue with unique potency, intranasal administration, and convenient storage. Hence, nafarelin was considered as an alternative for temporary pituitary suppression in patients undergoing ovulation induction in IVF. A crossover treatment in a prospective study was performed including 40 women with bilateral obstructed tubes and normal ovarian function, treated in 80 ovulation induction cycles using the long protocol. Twenty patients used nafarelin acetate 600 micrograms/daily in their first cycle and received D-Trp6-LHRH, 0.5 mg/daily, in their following cycle. The other 20 women used decapeptyl in their cycle and received nafarelin in the second.

RESULTS

Estradiol suppression was achieved by both D-Trp6-LHRH and nafarelin at equal time intervals. The average total number of ampoules (P = 0.0005) and the length of administration of hMG required for ovarian stimulation (P = 0.0002) and the time interval between GnRHa initiation to oocyte retrieval (P = 0.04) was significantly lower in nafarelin cycles. The number and the distribution between large and small follicles as well as the average number of oocytes retrieved did not differ between the two GnRH analogues.

CONCLUSION

Our results demonstrate that nafarelin acetate is comparable to D-Trp6-LHRH for temporary pituitary suppression used for controlled ovarian stimulation in IVF patients. However, using nafarelin ovarian stimulation was achieved with few ampoules of hMG, administered for a shorter period of time, thus with a lesser cost.

Prophylactic antibiotics in abdominal hysterectomy

BACKGROUND

The cephalosporins, which have been widely used in gynecologic surgery, are considered by many to be the drug of choice for chemoprophylaxis. However, their benefit in total abdominal hysterectomy has remained controversial. This study was done to evaluate the effectiveness of the commonly used cephalosporins in preventing inflammatory complications which may occur after elective abdominal hysterectomy.

STUDY DESIGN

A MEDLINE and manual review of the literature from the past 15 years (1977 to 1991), using the terms "prophylactic antibiotics," "abdominal hysterectomy," and "cephalosporins," was performed. Seventeen prospective trials using cephalosporin prophylaxis alone for 24 hours perioperatively were evaluated. A meta-analysis of the 2,752 study and control patients abstracted was performed to compare postoperative infection and febrile morbidity rates.

RESULTS

The cephalosporin group as well as the various generations and individual drugs were found to be useful in preventing postoperative infection (p < 0.001). Febrile morbidity, however, was effectively prevented (p < 0.001) by first but not by some second and third generation drugs. Multivariate analysis revealed no advantage for the newer, more expensive second and third generation cephalosporins studied. When adjusted for confounding factors, the number of doses, the amount of the dose, and the route of administration had significant impact on the outcome events.

CONCLUSIONS

Chemoprophylaxis with cephalosporins was found to be effective in preventing posthysterectomy infectious complications. A single dose, preoperative injection of first (cefazolin) or second (cefoxitin) generation cephalosporin, when administrated intravenously, has been shown to yield the best, cost-effective clinical results.

Cesarean scar endometriosis

A mass located in a scar area during examination is an infrequent phenomenon. Such a mass can be associated with keloid, hematoma, granuloma, hernia or neoplasm. Two cases of scar endometriosis are reported. The late onset of symptoms after surgery (average 4.5 years) is the usual reason for misdiagnosis. Awareness of this infrequent and late postoperative complication would increase the detection rate. Surgical excision remains the treatment of choice and should be accomplished without complications.

Recurrent gestational trophoblastic disease following in-vitro fertilization

Recurrence of gestational trophoblastic disease (GTD) following two attempts at in-vitro fertilization (IVF)/embryo transfer is reported in a childless couple after 17 years of unsuccessful trials of ovulation induction. The diagnosis of bilateral tubal obstruction was finally established, indicating IVF treatment. After the first IVF/embryo transfer treatment, the woman developed GTD and was treated with methotrexate. After a second IVF attempt, GTD was again diagnosed. This time there was no response to methotrexate, thus necessitating second-line chemotherapy. Etoposide, methotrexate, actinomycin D, cyclophosphamide, oncovine was used, and after only four treatment cycles the beta-human chorionic gonadotrophin (HCG) dropped to < 5 mIU/ml. After 26 months of follow-up, the beta-HCG continues to be undetectable. Preimplantation evaluation and ovum donation are described as measures to minimize the risk for GTD recurrence in a future IVF/embryo transfer.

Sonographic evaluation of fetal head extension and maternal pelvis in cases of breech presentation

BACKGROUND

To investigate whether sonographic examination of the fetal head extension, pelvic adequacy and fetal position, could replace the traditional x-ray method in the evaluation of the breech in labor.

METHODS

Seventy-two parturients admitted in labor with a breech presentation were prospectively evaluated by a newly proposed ultrasonographic approach. The head extension, obstetric conjugate and fetal attitude obtained were further compared to the gold standard radiologic measurements.

RESULTS

A highly significant correlation between ultrasonic and x-ray measurements for the fetal head extension (r = 0.8696; p < 0.0001), obstetric conjugate (r = 0.8931; p < 0.0001), as well as high reliability (95.5%) in diagnosing the breech variant by ultrasound have been found.

CONCLUSIONS

Ultrasonic evaluation of breech presentation, as performed by the proposed method, is simple, easy to perform and compares well with the standard radiologic studies. It is suggested that modern ultrasonic technique, which carries no risk of ionizing radiation, may replace traditional x-ray examination of the breech in labor.

Ovarian cysts: a clinical dilemma

The rapid development of ultrasound technology and its routine application during gynecological examinations has led to the more frequent detection of ovarian cysts. Such cysts can be diagnosed at any age or stage of a woman's life, and detected as early as the fetal stage or as late as the postmenopause. Ovarian cysts in female fetuses are usually detected during screening in pregnancy and followed after delivery as neonates. A few months are usually sufficient for spontaneous regression, although symptomatic cysts should be promptly operated. In fertile women, most cases present benign functional cysts which disappear after menstruation or can be managed easily with the combined oral contraceptive pill. When pregnancy is complicated with an adnexal mass, the second trimester is the preferable time of action in cases when operation is demanded. Transvaginal sonography plays an important role, not only in the detection of ovarian cysts but also in the diagnosis of malignancy. Large cysts, multiloculi, septa, papillae and increased blood flow are all suspected signs of neoplasia. The incidence of ovarian cancer increases with age and is predominantly a disease of peri- and postmenopausal women with an average patient age of 50-59 years. Vaginal sonography has been established as the examination of choice in screening and follow-up of patients, with complementary color Doppler studies and determination of serial serum levels of CA-125. If a malignant cyst is suspected, at any age, explorative laparotomy should be performed promptly. Sonographic or computerized tomographic scanner aspiration procedures, as well as laparoscopic surgery, should be reserved for diagnostic or therapeutic purposes in low-risk cancer patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperreactio luteinalis associated with non-immune hydrops fetalis--the role of pituitary hormones

The level of pituitary hormones was measured in the serum and cysts' aspirate in a case of hyperreactio luteinalis (HL) complicating non-immune hydrops fetalis. The level of follicular stimulating hormone (FSH), prolactin and growth hormone (GH) was within normal range for pregnancy in both the serum and cysts' aspirate. The importance of increased luteinizing hormone (LH) level which was demonstrated in the cysts' fluid should further be determined.

Comparison of cefonicid and cefazolin prophylaxis in abdominal hysterectomy

One hundred and sixty-four patients undergoing abdominal hysterectomy for benign diseases were prospectively evaluated. The efficacy and safety of surgical prophylaxis with a single dose of the long-acting cefonicid was compared to the standard three dose regimen of cefazolin. Prophylaxis was successful in 82 of 85 (96.5%) patients receiving cefonicid and in 77 of 79 (97.5%) patients receiving cefazolin. No serious adverse effects were encountered with both drugs. It is concluded that single dose intravenous cefonicid, when given preoperatively, is as safe and effective as the standard multiple dose regimen of cefazolin in patients undergoing elective abdominal hysterectomy.