Lymph Node Ratio Is a Strong Prognostic Factor in Patients with Early-Stage Cervical Cancer Undergoing Minimally Invasive Radical Hysterectomy

Purpose@#To determine whether the prognostic impact of lymph node ratio (LNR), defined as the ratio between the number of positive lymph nodes and removed lymph nodes, differs between open and minimally invasive surgical approaches for radical hysterectomy (RH) in node-positive, early-stage cervical cancer. @*Materials and Methods@#We retrospectively identified 2009 International Federation of Gynecology and Obstetrics stage IB1-IIA2 patients who underwent primary type C RH between 2010 and 2018. Among them, only those with pathologically proven lymph node metastases who received adjuvant radiation therapy were included. The prognostic significance of LNR was investigated according to open surgery and minimally invasive surgery (MIS). @*Results@#In total, 55 patients were included. The median LNR (%) was 9.524 (range, 2.083–62.500). Based on receiver operating characteristic curve analysis, the cut-off value for LNR (%) was determined as 8.831. Overall, patients with high LNR (≥8.831%;n=29) showed worse disease-free survival (DFS) than those with low LNR (<8.831%, n=26) (p=0.027), whereas no difference in overall survival was observed. Multivariate analyses adjusting for clinicopathologic factors revealed that DFS was adversely affected by both MIS [adjusted hazard ratio (HR), 8.132; p=0.038] and high LNR (adjusted HR, 10.837; p=0.045). In a subgroup of open surgery cases, LNR was not associated with disease recurrence. However, in a subgroup of MIS cases, high LNR was identified as an independent poor prognostic factor for DFS (adjusted HR, 14.578; p=0.034). @*Conclusion@#In patients with node-positive, early-stage cervical cancer, high LNR was associated with a significantly higher disease recurrence rate. This relationship was further consolidated among patients who received MIS RH.

Delayed diagnosis of gestational diabetes mellitus and perinatal outcomes in women with large for gestational age fetuses during the third trimester

Objective@#We evaluated the incidence of newly diagnosed gestational diabetes mellitus (GDM) during the 3rd trimester in women with suspected large for gestational age (LGA) fetuses on ultrasound and assessed their perinatal outcomes. @*Methods@#A retrospective cohort study was performed. Singleton pregnant women with suspected LGA on the 3rd trimester ultrasound and whose results of GDM screening at midpregnancy had been normal were enrolled. All participants were retested with 100-g oral glucose tolerance test (OGTT) within 2 days after diagnosis of LGA. We compared perinatal outcomes between the newly diagnosed with GDM group and the non-GDM group. @*Results@#Among 169 pregnant women, 13% (23/169) were newly diagnosed with GDM. The women in the GDM group had a higher HbA1c level at diagnosis (5.8 vs. 5.3, P<0.01) and earlier gestational age at delivery (38.0 vs 38.9 weeks of gestation, P=0.003) than those in the non-GDM group. The rate of cesarean delivery (CD) was significantly higher in the GDM group than that in the non-GDM group (73.9%, vs. 49.3%, P=0.028) with similar proportions for the indications of CD except CD on maternal request (CDMR). The CDMR rate was higher in the GDM group than nonGDM group (41.2% vs. 23.6%) but it did not reach statistical significance. There were no significant differences in the obstetrical and neonatal complications between the two groups. @*Conclusion@#Among pregnant women with suspected LGA, 13% were newly diagnosed with GDM in late pregnancy. Nonetheless, there were no differences in the perinatal outcomes between women with newly diagnosed GDM and those without GDM. However, concerns over shoulder dystocia appear to increase CD rates in the GDM group.

Can the cervical length in mid-trimester predict the use of vacuum in vaginal delivery?

Delayed diagnosis of gestational diabetes mellitus and perinatal outcomes in women with large for gestational age fetuses during the third trimester

Objective@#We evaluated the incidence of newly diagnosed gestational diabetes mellitus (GDM) during the 3rd trimester in women with suspected large for gestational age (LGA) fetuses on ultrasound and assessed their perinatal outcomes. @*Methods@#A retrospective cohort study was performed. Singleton pregnant women with suspected LGA on the 3rd trimester ultrasound and whose results of GDM screening at midpregnancy had been normal were enrolled. All participants were retested with 100-g oral glucose tolerance test (OGTT) within 2 days after diagnosis of LGA. We compared perinatal outcomes between the newly diagnosed with GDM group and the non-GDM group. @*Results@#Among 169 pregnant women, 13% (23/169) were newly diagnosed with GDM. The women in the GDM group had a higher HbA1c level at diagnosis (5.8 vs. 5.3, P<0.01) and earlier gestational age at delivery (38.0 vs 38.9 weeks of gestation, P=0.003) than those in the non-GDM group. The rate of cesarean delivery (CD) was significantly higher in the GDM group than that in the non-GDM group (73.9%, vs. 49.3%, P=0.028) with similar proportions for the indications of CD except CD on maternal request (CDMR). The CDMR rate was higher in the GDM group than nonGDM group (41.2% vs. 23.6%) but it did not reach statistical significance. There were no significant differences in the obstetrical and neonatal complications between the two groups. @*Conclusion@#Among pregnant women with suspected LGA, 13% were newly diagnosed with GDM in late pregnancy. Nonetheless, there were no differences in the perinatal outcomes between women with newly diagnosed GDM and those without GDM. However, concerns over shoulder dystocia appear to increase CD rates in the GDM group.

Mesenchymal Stem Cells Ameliorate Renal Inflammation in Adriamycin-induced Nephropathy

Mesenchymal stem cells (MSCs) ameliorate the renal injury in Adriamycin (ADR)-induced nephropathy, but the mechanisms underlying their efficacy remain incompletely understood. In this study, we demonstrated that MSCs increased the survival, recovered body weight loss, and decreased proteinuria and serum creatinine levels in ADR-treated mice. MSCs also prevented podocyte damage and renal fibrosis by decreasing the expression of fibronectin, collagen 1α1, and α-smooth muscle actin. From a mechanistic perspective, MSCs inhibited renal inflammation by lowering the expression of CCL4, CCL7, CCL19, IFN-α/β, TGF-β, TNF-α, and chitinase 3-like 1. In summary, our data demonstrate that MSCs improve renal functions by inhibiting renal inflammation in ADR-induced nephropathy.

Erratum: Correction of Acknowledgements

The Acknowledgements was published incorrectly. The authors apologize for any inconvenience that it may have caused.

Effectiveness and safety of sublingual misoprostol in medical treatment of the 1st trimester miscarriage: experience of off-label use in Korea

OBJECTIVE: This study was conducted to determine the effectiveness and safety of medical treatment with sublingual misoprostol (MS) in the 1st trimester miscarriage under the approval by Health Insurance Review and Assessment Service (HIRA) for off-label usage by the single medical center in Korea. METHODS: A retrospective cohort study was performed in one institution between April 2013 and June 2016. Ninety-one patients diagnosed with miscarriage before 14 weeks of gestation and wanted to try medical treatment were included. A detailed ultrasound scan was performed to confirm the diagnosis. Patients took 600 microgram (mcg) of MS sublingually at initial dose, and repeated the same dose 4–6 hours apart. Successful medical abortion was defined as spontaneous expulsion of gestational products (including gestational sac, embryo, fetus, and placenta). If gestational products were not expelled, surgical evacuation was performed at least 24 hours later from the initial dose. Information about side effects was obtained by medical records. RESULTS: About two-thirds of patients had a successful outcome. The median interval time from pill to expulsion was 18 hours in the successful medical treatment group. There was no serious systemic side effect or massive vaginal bleeding. Presence or absence of vaginal spotting before diagnosis of miscarriage, uterine leiomyomas, subchorionic hematoma, or distorted shape of gestational sac on ultrasound scan were not statistically different between the two groups. CONCLUSION: Medical treatment with sublingual MS can be a proper option for the 1st trimester miscarriage, especially for the patient who want to avoid surgical procedure. We can reduce the unnecessary sedation or surgical intervention in the patients with the 1st trimester miscarriage.

Ruptured Corpus Luteal Cyst: Prediction of Clinical Outcomes with CT

OBJECTIVE: To evaluate the determinant pretreatment CT findings that can predict surgical intervention for patients suffering from corpus luteal cyst rupture with hemoperitoneum. MATERIALS AND METHODS: From January 2009 to December 2014, a total of 106 female patients (mean age, 26.1 years; range, 17–44 years) who visited the emergency room of our institute for acute abdominal pain and were subsequently diagnosed with ruptured corpus luteal cyst with hemoperitoneum were included in the retrospective study. The analysis of CT findings included cyst size, cyst shape, sentinel clot sign, ring of fire sign, hemoperitoneum depth, active bleeding in portal phase and attenuation of hemoperitoneum. The comparison of CT findings between the surgery and conservative management groups was performed with the Mann-Whitney U test or chi-square test. Logistic regression analysis was used to determine significant CT findings in predicting surgical intervention for a ruptured cyst. RESULTS: Comparative analysis revealed that the presence of active bleeding and the hemoperitoneum depth were significantly different between the surgery and conservative management groups and were confirmed as significant CT findings for predicting surgery, with adjusted odds ratio (ORs) of 3.773 and 1.318, respectively (p 5.8 cm and concurrent active bleeding, the OR for surgery increased to 5.786. CONCLUSION: The presence of active bleeding and the hemoperitoneum depth on a pretreatment CT scan can be predictive warning signs of surgery for a patient with a ruptured corpus luteal cyst with hemoperitoneum.

The clinical significance of D-dimer concentrations in patients with gestational hypertensive disorders according to the severity

OBJECTIVE: Pregnancy is a major risk factor of thromboembolism, and the patients with preeclampsia (PE) are known to have higher risk of thromboembolic complications than normal pregnant women. D-dimer is a well-established laboratory marker for the screening of venous thromboembolism (VTE), but the concentrations of d-dimer tend to increase physiologically in pregnant women throughout the gestational age. We performed this study to evaluate the clinical significance of d-dimer concentrations in patients with gestational hypertensive disorders (GHD) according to the severity. METHODS: Retrospective cohort study was performed in one institution. Singleton pregnant women with GHD were enrolled, and their antepartum concentrations of d-dimer were measured as a part of routine evaluation for patients suspected with PE. Patients with multiple gestations, rheumatic diseases, autoimmune diseases, or suspected VTE were excluded. A categorization of severity about PE was based on the general criteria. RESULTS: In 73.3% of study population, their d-dimer concentrations exceeded the normal range (>0.55 mg/L). A significantly greater proportion of pregnant women had excessive concentrations of d-dimer in the severe GHD than in the non-severe GHD (89.8% vs. 53.7%; P<0.01). Patients with severe GHD had significantly higher median concentrations of d-dimer than those with non-severe GHD (median [range], 2.00 mg/L [0.11 to 7.49] vs. 0.71 mg/L [0.09 to 5.39]; P<0.01) although their earlier gestational ages of sampling. CONCLUSION: Maternal concentrations of d-dimer were significantly elevated in patients with severe features than those without severe features among those with GHD. Some pregnant women with GHD can have markedly elevated concentrations of d-dimer without any evidence of current VTE.

Gestational Age-specific Cut-off Values Are Needed for Diagnosis of Subclinical Hypothyroidism in Early Pregnancy

During the first trimester of pregnancy, thyroid-stimulating hormone (TSH) >2.5 mIU/L has been suggested as the universal criterion for subclinical hypothyroidism. However, TSH levels change continuously during pregnancy, even in the first trimester. Therefore the use of a fixed cut-off value for TSH may result in a different diagnosis rate of subclinical hypothyroidism according to gestational age. The objective of this study was to obtain the normal reference range of TSH during the first trimester in Korean gravida and to determine the diagnosis rate of subclinical hypothyroidism using the fixed cut-off value (TSH >2.5 mIU/L). The study population consisted of pregnant women who were measured for TSH during the first trimester of pregnancy (n=492) and nonpregnant women (n=984). Median concentration of TSH in pregnant women was lower than in non-pregnant women. There was a continuous decrease of median TSH concentration during the first trimester of pregnancy (median TSH concentration: 1.82 mIU/L for 3+0 to 6+6 weeks; 1.53 mIU/L for 7+0 to 7+6 weeks; and 1.05 mIU/L for 8+0 to 13+6 weeks). Using the fixed cut-off value of TSH >2.5 mIU/L, the diagnosis rate of subclinical hypothyroidism decreased significantly according to the gestational age (GA) at TSH (25% in 3+0 to 6+6 weeks, 13% in 7+0 to 7+6 weeks, and 9% for 8+0 to 13+6 weeks, P<0.001), whereas the diagnosis rate was 5% in all GA with the use of a GA-specific cut-off value (P=0.995). Therefore, GA-specific criteria might be more appropriate for the diagnosis of subclinical hypothyroidism.

A case of vulvar hematoma with rupture of pseudoaneurysm of pudendal artery

Vulvar hematomas are uncommon outside of the obstetric population and may be the result of trauma to the perineum. Vulvar hematomas most often present with low abdominal pain and urologic and neurologic symptoms. The vulva has rich vascularization that is supplied by the pudendal artery, a branch of the anterior division of the internal iliac artery. We describe a rare case of a 15-cm-sized vulvar hematoma with the suggested rupture of a pseudoaneurysm of the left pudendal artery without trauma injury. A 14-year-old girl presented with sudden pain and swelling in her left labium and was successfully treated with selective arterial embolization and surgical evacuation. We provide a literature review and discuss patient treatment and management strategies.

Uterine infarction in a patient with uterine adenomyosis following biochemical pregnancy / 대한생식의학회지

Adenomyosis is a common gynecological disorder characterized by the presence of endometrial glands and stroma deep within the myometrium associated with myometrial hypertrophy and hyperplasia. Focal uterine infarction after IVF-ET in a patient with adenomyosis following biochemical pregnancy has not been previously reported, although it occurs after uterine artery embolization in order to control symptoms caused by fibroids or adenomyosis. We report a case of a nulliparous woman who had uterine adenomyosis presenting with fever, pelvic pain and biochemical abortion after undergoing an IVF-ET procedure and the detection of a slightly elevated serum hCG. Focal uterine infarction was suspected after a pelvic magnetic resonance imaging demonstrated preserved myometrium between the endometrial cavity and inner margin of the necrotic myometrium. This case demonstrates that focal uterine infarction should be considered in the differential diagnosis of acute abdominal pain, vaginal bleeding and infectious signs in women experiencing biochemical abortion after an IVF-ET procedure.

Metastatic malignant melanoma with peritoneal seeding in a young woman: A case report

Malignant melanomas of the uterus, either primary or metastatic, are extremely rare. They can be mistaken as other tumors, such as uterine sarcomas during diagnosis. We describe here the first case of a metastatic melanoma of the uterus with peritoneal seeding in a young woman. It was first diagnosed as a uterine sarcoma from a frozen-section biopsy.

Effects of insulin-sensitizing agents and insulin resistance in women with polycystic ovary syndrome / 대한생식의학회지

OBJECTIVE: The aim of this study was to investigate the effect of insulin sensitizing agents on hormonal and metabolic parameters as well as menstrual patterns in women with polycystic ovary syndrome (PCOS). METHODS: One hundred and twenty-three patients with PCOS were included. Metformin was administered to patients at 1,500 mg or 1,700 mg daily for 3 months. If the patients had no improvement of the menstrual cycle or metformin-related adverse effects developed, the patients changed medication to a daily dose of either 15 mg pioglitazone or up to 45 mg. Then resumption of a regular menstrual cycle or recovery of ovulation was evaluated. Hormonal and metabolic profiles were compared between the response and non-response group to insulin sensitizing agents. RESULTS: One hundred and five patients with PCOS were treated with metformin for 3 months. Forty-eight patients (45.7%) showed improvement of menstrual cycle regularity after 3 months of metformin use, whereas 57 patients (54.3%) had no change. The mean free testosterone measured after 3 months of treatment was significantly lower in metformin responders than in non-responders. The other parameters did not differ between the groups. Of the 23 patients who used pioglitazone for 3 to 6 months, 19 patients (82.6%) showed improvement in their menstrual cycles. CONCLUSION: Metformin treatment seems to be effective for the improvement of menstrual cyclicity irrespective of insulin resistance in women with PCOS. When metformin related adverse effect occurred, pioglitazone would be effective for aiding the resumption of the menstrual cycle.

The actual circumstances of blood loss in the laparoscopic myomectomy: Anemia after laparoscopic myomectomy / 대한산부인과내시경학회지

OBJECTIVE: This study was designed to assess the actual circumstances of post-operative anemia and associating factors, during the laparoscopic myomectomy. METHODS: A retrospective chart review of 172 patients who underwent laparoscopic myomectomy from 2008 to 2009 was performed. Characteristics of patients (age, parity, body mass index, and preoperative gonadotropin releasing hormone agonists injection) and fibroids (the largest diameter, number, width, type and location), and surgical outcomes (operating time, pre- and post-operative hemoglobin level, blood loss, hospital stay, and complications, including transfusion) were retrieved. RESULTS: One patient (0.6 %) required transfusion and significant hemoglobin change (> or =2.0 g/dL) occurred in 45 patients, after laparoscopic myomectomy. The largest diameter, width, type, and location of fibroids, and pre-operative gonadotropin releasing hormone agonist injection were not associated with the hemoglobin change (p=0.193, 0.172, 0.764, 0.741, and 0.954 respectively). Multivariate analysis revealed that nulliparity (p=0.195, 95% confidence interval (CI): 0.286-1.291) was not a risk factor, but long operating time (> or =90 min; p=0.048, 95% CI: 1.008-5.054) and multiple myoma (> or =3 in number; p=0.009, 95% CI: 1.320-6.717) were independent risk factors for significant hemoglobin change. CONCLUSION: In our data, symptomatic anemia after laparoscopic myomectomy was uncommon. In addition, the only useful predictive factor for hemoglobin change during the laparoscopic myomectomy was a multiplicity of myoma.

Cryopreservation of Umbilical Cord as a Source of Mesenchymal Stromal Cells and Growth Factors / 대한수혈학회지

BACKGROUND: Umbilical cord (UC) is a promising source of mesenchymal stromal cells (MSCs). We compared the characteristics of MSCs from cryopreserved UC with those from fresh tissues, and demonstrated the possibility of UC cryopreservation for acquisition of MSCs from cryopreserved UC. METHODS: Each UC was sliced into two types (1~2 mm3 vs. 0.5 cm), and cryopreserved in liquid nitrogen using different media (autologous cord blood plasma, aCBP vs. RPMI 1640). A fresh aliquot of 1~2 mm3-sized UC was used as control tissue. After one week, the cryopreserved tissues were thawed and cultured. For the 0.5 cm UC, a slicing step into 1~2 mm3 was needed. Cell count, viability, proliferative activity, and surface antigens were determined from harvested MSCs. Several growth factors (EGF, IGF-1, PDGF, TGF-beta, bFGF, and VEGF), were measured from the culture supernatant. RESULTS: Eleven UC were enrolled in the study. Efficiencies of obtaining MSCs were higher in cryopreserved UC using RPMI 1640, compared with use of aCBP; the same result was observed for 0.5 cm sized UC, compared with 1~2 mm3 sized UC. No difference in proliferative activity was observed between MSCs from fresh and cryopreserved UC. The amount of growth factors in culture supernatant using RPMI 1640 was larger than that of fresh tissues. CONCLUSION: We obtained growth factors from the supernatant as well as MSCs from cryopreserved UC. As with a cord blood bank, in the future, cryopreservation of UC for acquisition of both MSCs and growth factors would be possible in a time of need.

Bone Mineral Density and Factors influencing Bone Mineral Density in College Women

PURPOSE: The purpose of this study was to identify the levels of bone mineral density (BMD) and to explain the factors influencing BMD among female college students in Korea. METHODS: A cross-sectional study was conducted with 144 college women. Lifestyle factors were determined by self-report questionnaire. Body composition was measured by body composition analyzer and bone mineral density was measured by ultrasound bone densitometry. Data were analyzed using SPSS for windows, version 19.0. RESULTS: The mean BMD at calcaneus site was 0.56 g/cm2 (mean T-score=-0.22). The incidence of osteopenia was 21.5%. Factors predicting BMD were menarche age (r=-.22, p=.009) and height (r=-.18, p=.030) with 7% of explained variance. CONCLUSION: These results suggest that health care professionals need to provide young women with program that is intended to affect their intention toward osteoporosis preventive behavior change.

Decrease in acceptance of genetic amniocentesis after alteration of social conditions toward pregnancy termination / 대한산부인과학회지

OBJECTIVE: To investigate the effect of alteration of social conditions towards pregnancy termination on the acceptance of genetic amniocentesis. METHODS: Retrospective review of medical records was conducted for women ( 35 years in the 2010 group (5/30, 17%) were less likely to accept genetic amniocentesis than 2009 group (15/30, 50%; P=0.01). Similar results were observed in those who were indicated for genetic amniocentesis. (9/35, 26% vs 19/34, 56%; P=0.02). Acceptance rate of genetic amniocentesis was increased for those who were referred from private clinic, but without statistical significance (15/21, 71% vs 13/14, 93%; P=0.20). CONCLUSION: After strict regulation of pregnancy termination, acceptance rate of genetic amniocentesis was significantly decreased among women who had increased risk for chromosomal abnormalities or neural tube defect at our center. Whereas, there were no significant change in acceptance rate for those who were referred for amniocentesis from private clinic.

Analysis of Maternal and Neonatal Factors Affecting Hematopoietic Parameters of Cord Blood / 대한수혈학회지

BACKGROUND: Cord blood (CB) is a useful source of hematopoietic stem cells. In public CB banks, only CB units with good hematopoietic potential are processed and stored because the processing and storage of CB are cost-consuming and labor-intensive procedures. Presently, we sought to determine factors correlated with, and influential to, hematopoietic parameters of CB units donated from Korean neonates and their mothers. METHODS: A total of 1,696 CB units that were donated and processed from August 1 - December 31, 2007 were enrolled. Donated CB volume, total nucleated cells (TNC), total mononucleated cells (MNC), CD34+ cells after processing, and cell viability before and after processing were analyzed according to sex and delivery method. We also determined whether maternal age, neonatal factors (gestational age, birth weight, sex, delivery method), CB volume, and processing time were correlated with hematopoietic parameters of CB. RESULTS: CB of female neonates had significantly higher mean TNC and CB obtained from vaginal delivery had significantly higher mean TNC, MNC, and CD34+ cells. The counts of TNC, MNC, and CD34+ cells were significantly positively correlated with CB volume, gestational age, and birth weight. Counts of TNC, MNC, and CD34+ cells, and pre- and post-viability of CB were significantly negatively correlated with processing time. CONCLUSION: The present data provide a baseline for standard methods of collection, processing, and storage in cord blood banking.

The Subjectivity of Attitudes Toward Life Support Care / 간호학회지

PURPOSE: The purpose of this study was to categorize adult's subjectivity of their attitudes towards life sustaining treatment, and thereby understand the differences among these life sustaining treatment types using Q methodology. METHODS: Q-methodology, which provides a method of analyzing the subjectivity of each item, was used. Thirty selected Q-statements received from 52 adults were classified into a shape of normal distribution using a 7 point scale. The collected data was analyzed using a QUANL pc program. RESULT: Four types of attitudes toward life sustaining treatment were identified. Type I is called one's autonomy type. Type II is called potentiality of resuscitation type. Type III is called DNR (Do not resuscitation) type. Type IV is calledone's effort type. CONCLUSION: The results of the study indicate that different approaches of life support care programs are recommended based on the four types of life sustaining treatment attitudes among Korean adults.