Ruptura uterina e invasión trofoblástica a la vejiga. Reporte de un caso / Uterine rupture and trophoblastic invasion to the bladder. A case report

Resumen ANTECEDENTES: La ruptura uterina por placenta percreta es una complicación extremadamente rara, su incidencia varía de 0.02-0.08% y cuando se relaciona con invasión placentaria a la vejiga, ocurre en aproximadamente 1 de cada 10,000 nacimientos, con una mortalidad materna y fetal estimada de 9.5 y 24%, respectivamente. CASO CLÍNICO: Paciente de 27 años, con 26 semanas de embarazo, antecedente de una cesárea, que acudió al servicio de Urgencias por dolor abdominal súbito, compatible con abdomen agudo y deterioro hemodinámico. El ultrasonido abdominal reportó líquido libre en la cavidad, por lo que se decidió practicarle una laparotomía exploradora, en donde se encontró ruptura uterina con invasión trofoblástica a la vejiga y 2500 cc de hemoperitoneo. Se practicó cesárea-histerectomía, pinzamiento de arterias uterinas por vía abdominal y ligadura de arterias hipogástricas; debido a la invasión trofoblástica vesical, durante la disección se lesionó la vejiga. La recién nacida pesó 850 g, talla 32 cm, Ballard 27 SDG, Apgar 7/8, pérdida sanguínea total de 3500 cc, con permanencia de 5 días en la unidad de cuidados intensivos (12 días totales de estancia hospitalaria). La paciente evolucionó favorablemente. CONCLUSIONES: Por su rareza y trascendencia es importante conocer este tipo de alteraciones y no pasar por alto la búsqueda intencionada de factores de riesgo y signos clínicos (hemorragia vaginal o hematuria), que hacen que la detección oportuna sea el objetivo para lograr el éxito en el tratamiento.

Abstract BACKGROUND: The Uterine rupture by placenta percreta is an extremely rare complication between the 0.02-0.08% frequency, the concomitant incidence of placental to bladder invasion occurs in approximately 1 in every 10,000 births, and when this occurs maternal and fetal mortality increases by 9.5% and 24% respectively. CLINICAL CASE: A 27 years-old patient, with 26 weeks of gestation (SDG), antecedent of a caesarean, who goes to the emergency department for sudden abdominal pain, compatible with acute abdomen and hemodynamic deterioration, abdominal ultrasound was performed reporting free liquid in cavity, enters the operating room for exploratory laparotomy, finding uterine rupture with presence of trophoblastic invasion to bladder, 2500cc of hemoperitoneum, cesarean section hysterectomy, clamping of uterine arteries via abdominal and ligation of hypogastric arteries, by bladder trophoblastic invasion, during dissection the bladder was injured; a newborn with a weight of 850gr, size 32cm, Ballard 27SDG, APGAR 7/8, total blood loss 3500cc, course 5 days in the Intensive Care Unit (ICU) and 12 days of hospital stay was obtained, the patient progressed favorably , it is graduated with reference to gynecological urology. CONCLUSIONS: Knowledge of this type of diagnostic entities is fundamental, given its rarity and transcendence, the intentional search for risk factors, clinical signs such as vaginal bleeding or hematuria, make timely detection the goal to achieve success in the treatment.

Clinical Research on Detecting the Serum Amyloid A Level of Pregnant Woman in Early Primary Unexplained Recurrent Spontaneous Abortion / 现代检验医学杂志

Objective To research the serum amyloid A(SAA)levels of primary unexplained recurrent early pregnancy loss (REPL),and discuss the viability of regarding the SAA as a independent indicator of REPL.Methods A prospective study was conducted among 96 women with missed spontaneous abortion at Baoji Maternal and Child Care Hospital from January to December 2014.A control group was formed of pregnant women with no history of REPL.Serum samples of both groups were collected to measure SAA levels by enzyme linked immunosorbent assay.The association between SAA and primary unexplained REPL were analyzed according to the multiple factors Logistic models,and the diagnostic value of SAA to RE-PL were detected through receiver operating characteristic.Results Median SAA level was significantly higher among women with REPL(50 μg/ml,interquartile range 26.0~69.0 μg/ml),than that in the control group(11.6 μg/ml,inter-quartile range 6.2~15.5 μg/ml,P=0.000<0.01).The diagnose value of SAA to REPL was perfect good(AUC=0.91), and the most accurate value was 18 μg/ml.The SAA level was an independent indicator of primary unexplained REPL,after adjusting for maternal age and gestational age(OR:1.12,P=0.000).Conclusion Elevated SAA levels found among women with primary unexplained REPL could represent a novel biomarker for this complication of pregnancy.

Study on the relationship of serum HCG levels and serum KI-67 expression with the depth of trophoblast invasion in tubal pregnancy / 中国综合临床

Objective To explore the relationship of depth of trophoblastic invasion with trophoblast cell activity and serum β-hCG according to the expression of proliferation antigen Ki-67 which viewed as an indicator of cell proliferation activity.Methods Fallopian tube specimens collected from 108 patients who underwent operation treatment for fallopian tubal pregnancy in our hospital were investigated by light microscopic examination.They were divided into three groups according to the depth of trophoblastic infiltration: Ⅰ group (stage): trophoblastic invasion of tubal mucosa,Ⅱ group(stage): trophoblastic invasion of the muscularis,Ⅲ group(stage): trophoblast invasion of serosa layer(muscularis penetration).The expression of Ki-67 was detected by SP method and blood β-hCG was detected within 2 hours of preoperative.The level of β-hCG,the expression of Ki-67 and the depth of trophoblast invasion were analyzed.Results Mean level of serumβ-hCG in Group Ⅰ,Ⅱ and Ⅲ were(1416.64 ± 859.94)U/L,(3380.33 ± 2392.36)U/L and(6999.33 ± 4949.90)U/L respectively.Positive expression rate of cell proliferation antigen Ki-67 in Group Ⅰ,Ⅱ and Ⅲ were 21.95％,53.66％ and 6.40％ respectively.There were significant difference on the expression of Ki-67 between group Ⅰ and group Ⅱ,group Ⅱ and Ⅲ group,group Ⅰ and group Ⅲ(x2 =3.94,4.07,4.35,respectively,P ＜ 0.05).The serumβ-hCG level also displayed statistics difference in the three groups(F =9.914,P ＜ 0.01).The positive expression of Ki-67 and serum β-hCG level were positively correlated with each other(r =0.678,P ＜ 0.05)Conclusion The high level of the serum β-hCG indicates high expression of Ki-67 and deeper trophoblast invasion of tubal wall.

Células natural killer endometriais: o que são? O que fazem? O que devemos saber? / Endometrial natural killer cells: what are they? What do they do? What do we need to know?

As células natural killer endometriais, também chamadas células natural killer uterinas, têm recebido especial atenção no campo da imunologia reprodutiva. Teorias que consideram alterações na resposta imune como uma causa de infertilidade conjugal e de falhas nos tratamentos de reprodução assistida têm ponderado um possível envolvimento negativo das células natural killer endometriais. As células natural killer são linfócitos que podem ser identificados no sangue periférico e no endométrio, apresentando diferenças fenotípicas e funcionais importantes. As células periféricas não se alteram com a fase do ciclo menstrual e implantação, sendo que as células natural killer endometriais apresentam variações durante o ciclo menstrual e período peri-implantacional, com menores concentrações durante a fase proliferativa e aumentando na segunda fase do ciclo. A célula natural killer endometriais participam nas várias fases da implantação, invasão trofoblástica, placentação e desenvolvimento fetal e no desenvolvimento da gestação humana até aproximadamente 20 semanas.

Endometrial natural killer cells have been given special attention in reproductive immunology. The relation between the endometrial natural killer cells and alterations in the immune response as a cause of couples infertility and failure in assisted reproduction treatment have been studied in several theories. Natural killer cells are lymphocytes that may be identified in peripheral blood and endometrium, with phenotypical and functional differences between them. Peripheral natural killer cells do not change with the menstrual cycle or implantation, as opposed to endometrial natural killer cells which present lower concentration in the proliferative phase and higher concentration in the luteal phase. Endometrial natural killer cells play an important role in the implantation, trophoblastic invasion, placentation, fetal development and development of the human pregnancies up to 20 weeks of gestation.

The Prediction of Depth of Trophoblastic Invasion in Tubal Pregnancy / 대한산부인과학회잡지

OBJECTIVES: To evaluate the relation between diagnostic clinical parameters and the depth of trophoblastic invasion in tubal pregnancy and decide the most predictable parameter. Methods: Total 50 patients who were confirmed as tubal pregnancy pathologically, from Jan. to Dec. 1997, were included in this study. Menstrual missed periods was calculated by clinical history, volume of gestational mass was calculated as sphere, beta-hCG was titered with preoperative blood sample. All surgical specimens were examined pathologically and divided into two groups such as intraluminal and extraluminal, defined as intact tubal musculature and trophoblastic invasion beyond musculature, n=22 and n=28, respectively. Statistical analysis was performed among three parameters and between each parameter and the depth of trophoblastic invasion. Statistical analysis included were Student's t-test, Chi square, linear regression, and linear correlation analysis using SPSS statistical package and statistical significance was determined as p<0.05. RESULTS: There was a correlation between volume of gestational mass and beta-hCG(p<0.05), but not between beta-hCG and missed period or volume of gestational mass and missed period. beta-hCG level was 1843.7+/-1524.7 mIU/ml(Mean+/-SD) in intraluminal and 12144.3+/-10561.6 mIU/ml(Mean+/-SD) in extraluminal. There was a predictive correlation between beta-hCG and the depth of trophoblastic invasion(p<0.05), and cut off level 3,500 mIU/ml showed the highest sensitivity, specificity, positive predictive value, negative predictive value, 0.79, 0.86, 0.88, 0.76, respectively. Two parameters(volume of gestational mass and missed period) had no ability to predict whether intraluminal or extraluminal. CONCLUSION: We suggest that successful medical treatment of tubal pregnancy depend on lesional intactness of vasculature for drug delivery. In patient selection for medical treatment, it should be important to predict intraluminal type because of intact vasculature. Of clinical parameters, beta-hCG is single most predictive parameter, cut off level of 3,500 mIU/ml was the most reasonable level in this study.