Delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture

A 30-year-old woman experienced severe abdominal pain 8 days after vaginal delivery. The patient was diagnosed with hemoperitoneum due to rupture of the left uterine artery pseudoaneurysm, which was confirmed via ultrasound with color Doppler and computed tomography scans. This patient was treated with bilateral uterine artery embolization to maintain fertility. A uterine artery pseudoaneurysm that causes delayed postpartum hemorrhage can occur after cesarean section or vaginal delivery. A uterine artery pseudoaneurysm can be fatal, so its detection and diagnosis are critical. Herein, we report a case of delayed postpartum hemoperitoneum due to uterine artery pseudoaneurysm rupture.

Safety of cesarean delivery through placental incision in patients with anterior placenta previa

OBJECTIVE: To demonstrate the safety of fetal delivery through placental incision in a placenta previa pregnancy. METHODS: We examined the medical records of 80 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between May 2010 and May 2015 at the Department of Obstetrics and Gynecology, Chungbuk National University Hospital. Among the women with placenta previa, those who did not have the placenta in the uterine incision site gave birth via conventional uterine incision, while those with anterior placenta previa or had placenta attached to the uterine incision site gave birth via uterine incision plus placental incision. We compared the postoperative hemoglobin level and duration of hospital stay for the mother and newborn of the two groups. RESULTS: There was no difference between the placental incision group and non-incision group in terms of preoperative and postoperative hemoglobin change, the amount of blood transfusions required by the mother, newborns with 1-min or 5-min Apgar scores below 7 points or showing signs of acidosis on umbilical cord blood gas analysis result of pH below 7.20. Moreover, neonatal hemoglobin levels did not differ between the two groups. CONCLUSION: Fetal delivery through placental incision during cesarean section for placenta previa pregnancy does not negatively influence the prognosis of the mother or the newborn, and therefore, is considered a safe surgical technique.

Increased expression of nuclear factor kappa-B p65 subunit in adenomyosis

OBJECTIVE: Nuclear factor kappa-B (NF-κB) is a critical proinflammatory regulator that has been suggested to play a pivotal role in the pathogenesis and pathophysiology of endometriosis. In the present study, we aimed to evaluate whether the expression of NF-κB p65 subunit is increased in the eutopic endometrium and/or in the adenomyosis nodule of women with adenomyosis. METHODS: Thirty-three women with histologically confirmed adenomyosis after laparoscopic or transabdominal hysterectomy were recruited. Women with carcinoma in situ of uterine cervix without evidence of adenomyosis or endometriosis (n=32) served as controls. Formalin-fixed, paraffin-embedded archival tissues were sectioned and immunostained utilizing a monoclonal anti-human NF-κB p65 subunit antibody, and the immunoreactivity of NF-κB p65 subunit was compared between women with and without adenomyosis. RESULTS: The immunoreactivities of both the nuclear and the cytoplasmic NF-κB p65 subunit were significantly increased in the stromal cells in the eutopic endometrium as well as in the adenomyosis nodule of women with adenomyosis compared with controls, respectively. The nuclear expression of NF-κB p65 subunit was significantly higher in the glandular cells in the eutopic endometrium as well as the adenomyosis nodule of women with adenomyosis compared with controls, respectively. CONCLUSION: The expression of NF-κB p65 is increased in the eutopic endometrium and adenomyosis nodule of women with adenomyosis, which strongly suggest that NF-κB plays a critical role in the pathogenesis and/or pathophysiology of adenomyosis.

A case of spontaneous hemoperitoneum by uterine vessel rupture in pregnancy

A 27-year-old pregnant woman, para 1, was transferred to our hospital at 29+3 weeks of gestation complaining of abdominal pain. She was diagnosed with hemoperitoneum based on ultrasonography. An emergency laparotomy was performed, and the bleeding was confirmed to be caused by ruptured surface blood vessels on the uterine fundus. Hemostasis with compression was successfully performed to sustain the pregnancy, and the patient delivered a full-term baby. Spontaneous hemoperitoneum during pregnancy caused by rupture of uterine blood vessels is very rare. It requires rapid diagnosis and surgical treatment because it increases the morbidity of the fetus and mother. In most incidences of spontaneous hemoperitoneum during pregnancy, a cesarean delivery is performed along with a simultaneous emergency laparotomy. However, in this case, the pregnancy was maintained to full term after surgical hemostasis, which prevented neonatal complications due to premature birth.

Myometrial relaxation of mice via expression of two pore domain acid sensitive K⁺ (TASK-2) channels

Myometrial relaxation of mouse via expression of two-pore domain acid sensitive (TASK) channels was studied. In our previous report, we suggested that two-pore domain acid-sensing K⁺ channels (TASK-2) might be one of the candidates for the regulation of uterine circular smooth muscles in mice. In this study, we tried to show the mechanisms of relaxation via TASK-2 channels in marine myometrium. Isometric contraction measurements and patch clamp technique were used to verify TASK conductance in murine myometrium. Western blot and immunehistochemical study under confocal microscopy were used to investigate molecular identity of TASK channel. In this study, we showed that TEA and 4-AP insensitive non-inactivating outward K⁺ current (NIOK) may be responsible for the quiescence of murine pregnant longitudinal myometrium. The characteristics of NIOK coincided with two-pore domain acid-sensing K⁺ channels (TASK-2). NIOK in the presence of K⁺ channel blockers was inhibited further by TASK inhibitors such as quinidine, bupivacaine, lidocaine, and extracellular acidosis. Furthermore, oxytocin and estrogen inhibited NIOK in pregnant myometrium. When compared to non-pregnant myometrium, pregnant myometrium showed stronger inhibition of NIOK by quinidine and increased immunohistochemical expression of TASK-2. Finally, TASK-2 inhibitors induced strong myometrial contraction even in the presence of L-methionine, a known inhibitor of stretch-activated channels in the longitudinal myometrium of mouse. Activation of TASK-2 channels seems to play an essential role for relaxing uterus during pregnancy and it might be one of the alternatives for preventing preterm delivery.

Comparison of HE4, CA125, and Risk of Ovarian Malignancy Algorithm in the Prediction of Ovarian Cancer in Korean Women

This study is a multi-center clinical study, which aimed to compare CA125, HE4, and risk of ovarian malignancy algorithm (ROMA) in predicting epithelial ovarian cancer of Korean women with a pelvic mass. Prospectively, serum from 90 Korean women with ovarian mass was obtained prior to surgery. For control group, serum from 79 normal populations without ovarian mass was also obtained. The HE4 and CA125 data were registered and evaluated separately and ROMA was calculated for each sample. Total 67 benign tumors and 23 ovarian cancers were evaluated. Median serum levels of HE4 and CA125, and ROMA score were significantly higher in patients with ovarian cancer than those with benign ovarian tumor and normal population (P < 0.001). In ROC curve analysis for women with a pelvic mass, area under the curve (AUC) for HE4 and ROMA was higher than CA125. Statistical differences in each study compared to CA125 were marginal (P compared to CA125; 0.082 for HE4 and 0.069 for ROMA). Sub-analysis revealed that AUC for HE4 and ROMA was higher than AUC for CA125 in post-menopausal women with a pelvic mass, but there were no statistically significant differences (P compared to CA125; 0.160 for HE4 and 0.127 for ROMA). Our data suggested that both HE4 and ROMA score showed better performance than CA125 for the detection of ovarian cancer in women with a pelvic mass. HE4 and ROMA can be a useful independent diagnostic marker for epithelial ovarian cancer in Korean women.

A Case Report of Heterokaryotypic Monochorionic Twin Pregnancy with Discordant for Turner Syndrome / 대한주산의학회잡지

Monochorionic twins with discordant karyotypes are rare and mostly caused by post-zygotic mitotic nondisjunction. A 32 year old nulliparous woman at 11 weeks of gestation with spontaneous twin pregnancy was referred to our hospital. An amniocentesis was performed in both amniotic sacs at 15 weeks of pregnancy. One fetus in monochorionic twin pregnancy was diagnosed with Turner syndrome with cystic hygroma, and the other fetus was normal. Because of high mortality rate in abnormal fetuses, the umbilical cord coagulation was performed using radiofrequency ablation to prevent the damage of co-twin that may be caused by the demise of one fetus. After delivery, chorionicity of placenta was ascertained by pathologic exam. Postnatal findings of physical exam, abdominal and brain sonography were normal in the surviving neonate.

Mechanism of Relaxation Via TASK-2 Channels in Uterine Circular Muscle of Mouse

Plasma pH can be altered during pregnancy and at labor. Membrane excitability of smooth muscle including uterine muscle is suppressed by the activation of K+ channels. Because contractility of uterine muscle is regulated by extracellular pH and humoral factors, K+ conductance could be connected to factors regulating uterine contractility during pregnancy. Here, we showed that TASK-2 inhibitors such as quinidine, lidocaine, and extracellular acidosis produced contraction in uterine circular muscle of mouse. Furthermore, contractility was significantly increased in pregnant uterine circular muscle than that of non-pregnant muscle. These patterns were not changed even in the presence of tetraetylammonium (TEA) and 4-aminopyridine (4-AP). Finally, TASK-2 inhibitors induced strong myometrial contraction even in the presence of L-methionine, a known inhibitor of stretchactivated channels in myometrium. When compared to non-pregnant myometrium, pregnant myometrium showed increased immunohistochemical expression of TASK-2. Therefore, TASK-2, seems to play a key role during regulation of myometrial contractility in the pregnancy and provides new insight into preventing preterm delivery.

Ovarian follicular and peritoneal fluid prostaglandin E2 and F2a levels according to the clinical symptoms in the women with endometriosis / 대한산부인과학회지

OBJECTIVE: The purpose of the present study was to determine whether a relationship exists between the clinical symptoms (dysmenorrhea and infertility) and prostaglandin (PG) concentrations in follicular and peritoneal fluid in the women with endometriosis during the late follicular phase of the menstrual cycle. METHODS: Thirty patients with pelvic endometriosis diagnosed by pelvic surgery were enrolled. Eight patients were suffering from severe dysmenorrhea and 11 had history of primary or secondary infertility among them. Endometriosis patients were grouped by the presence of each symptom and compared with 33 control patients without endometriosis. Peritoneal fluid was collected in the beginning of peritoneal opening and dominant follicular fluid was aspirated by syringe needle at the time of operation. Then PGE2 and PGF2a concentration were measured at each tube. RESULTS: Follicular fluid PGF2a levels were increased in 30 endometriosis patients (P=0.003), and the levels were significantly higher in 11 patients with infertility compared with the control (P=0.001). Peritoneal fluid PGF2a levels were significantly higher in 8 patients with severe dysmenorrhea compared with the others or the control (P=0.028). Follicular or peritoneal fluid PGE2 levels were not different between any group and the control. There was no significant correlation between size of endometrioma and each PG levels. CONCLUSION: Severe dysmenorrhea in endometriosis patients would be related with the high level of peritoneal fluid PGF2a concentration, and infertility in endometriosis would be related with the high level of follicular fluid PGF2a concentration.

A Preliminary Comparison of Efficacy of Intravaginal Misoprostol with Intravenous Sulprostone for Termination of Second-Trimester Pregnancy / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to compare the efficacy of intravaginal misoprostol and that of intravenous sulprostone for termination of second-trimester pregnancy. METHODS: Fouty-six patients were randomly assigned to misoprostol and sulprostone group, and the misoprostol group was further divided into two groups according to gestational age. In the misoprostol group, the patients at or before 20 weeks of gestation received 400 microgram of intravaginal misoprostol every 4 hours until labor pain was established, 200 microgram every 6 hours after 20 weeks of gestation. In the sulprostone group, intravenous sulprostone was infused at the speed of 100 microgram/hr regardless of gestational age. RESULTS: At or before 20 weeks of gestation, the mean time from induction to completion of termination was shorter, and the success rate within 24 hours was higher in the misoprostol group than in the sulprostone group (9.0 vs. 20.2 hours; 86% vs 50%). After 20 weeks, the mean induction time was longer at misoprostol group than sulprostol group but, there was no significant difference in success rate within 24 hours (14.7 vs. 7.1 hours; 83% vs. 86%). There was no significant difference in the prevalence of complication between two groups. CONCLUSION: Misoprostol is superior to sulprostone for termination of pregnancy at or before 20 weeks of gestation, but both have almost equal effectiveness after 20 weeks of gestation. Considering less cost and complication, the efficacy of misoprostol should be further investigated for termination of second-trimester pregnancy.

A Case of Large Cell Neuroendocrine Carcinoma accompanied with Adenocarcinoma of the Uterine Cervix / 대한산부인과학회지

Large cell neuroendocrine carcinoma of the uterine cervix is a rare and highly aggressive cervical neoplasm. Metastases and recurrences of the tumor are common. Cervical large cell neuroendocrine carcinomas are distinctive cervical carcinomas that are frequently misdiagnosed and have unfavorable prognosis. So prudential care must be considered for proper diagnosis and multimodal treatment may be required for better survival. We experienced one case of large cell neuroendocrine carcinoma accompanied with adenocarcinoma of the uterine cervix in 52 year old woman. The uterine cervix covered and infiltrated with adenocarcinoma cells and attached polypoid mass (3.2 x 2.1 cm) composed of large cell neuroendocrine carcinoma cells. The diagnosis was confirmed by immuno-staining using cytokeratin (+), synaptophysin (+), chromogranin (+), neuron-specific enolase (+), CD 56 (+), and vimentin (-). So we report the case with brief review of the literature.

Expression of Aquaporin-4 in Placenta of Preeclampsia / 대한산부인과학회지

OBJECTIVE: This study was to determine whether aquaporin-4, which plays role as a transcellular water channel, is expressed in human placenta, and to compare the degree of its expression between preeclamptic women and normal pregnant women. METHODS: Placentas were obtained from severely preeclamptic women and normal pregnant women who were delivered neonates by cesarean section before the onset of labor in the Chungbuk National University Hospital. Immunohistochemistry with aquaporin-4 antibody was performed using paraffin-embedded tissue section. Signal of aquaporin-4 expression was observed with light microscope. RESULTS: Immunohistochemistry demonstrated expression of aquaporin-4 in the placentas of both preeclamptic women and normal pregnant women. The degree of expression was not different in both group. CONCLUSION: Aquaporin-4 was expressed in the human placenta, but may not be related to the pathogenesis of preeclampsia.

Influence of Tumor Necrosis Factor-alpha on Expression of Insulin-like Growth Factor-II, Insulin-like Growth Factor Binding Protein-1, 2, 3, 5 in Cultured Human Luteinized Granulosa Cells / 대한산부인과학회지

OBJECTIVE: To investigate the influence of tumor necrosis factor (TNF)-alpha on the expression of insulin-like growth factor (IGF)-II, insulin-like growth factor binding protein (IGFBP)-1, 2, 3, and 5 mRNA in cultured human luteinized granulosa cells. METHODS: Human luteinized granulosa cells were obtained from the follicular fluid by transvaginal oocyte aspiration from infertile patients undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF). The cells were cultured for 72 hours with TNF-alpha at concentrations of 1.0, 10.0, and 100.0 ng/mL, respectively. The cells not treated with TNF-alpha were served as control. Riverse transcription-polymerase chain reaction (RT-PCR) had been used to examine the expression of IGF-II, IGFBP-1, 2, 3, and 5 mRNA. Results were analyzed with Kolmogorov-Smirnov test and analysis of variance (ANOVA) and statical significance was defined as p<0.05. RESULTS: The expressions of IGF-II mRNA in 10.0 and 100.0 ng/mL of TNF-alpha groups were significantly lower than the control group (p<0.05, p<0.05, respectively). The expressions of IGFBP-2 mRNA were seemed to be decreased in 10.0 and 100.0 ng/mL of TNF-alpha groups than the control group (p=0.05, p=0.06, respectively). The expression of IGFBP-3 mRNA was seemed to be increased in 100.0 ng/mL of TNF-alpha group than the control group (p=0.08). There were no statistically significant differences in the expressions of IGFBP-1 and 5 in all groups. CONCLUSION: TNF-alpha might play a role as a regulator of human ovarian physiology by modulating the expression of IGF-II in luteinized granulosa cells.

Cauda Equina Syndrome by Disc Prolapse after Caesarian Section Delivery / 대한주산의학회잡지

Cauda equina syndrome develops as rapidly progressive neurologic deficit of lower extremities and urogenital system often resulting in serious outcome such as complete irreversible paraparesis, therefore prompt diagnosis and decompression is mandatory. However, if it occurs after childbirth, it may be overlooked being regarded as symptoms related to pregnancy and delivery. We experienced a cauda equina syndrome by prolased disc in a 32-year-old woman just after Caesarian section who was managed with prompt decompressive surgery and achieved favorable result. Because of the importance of early detect and prompt decompression for cauda equina syndrome and possible occurrence at perinatal period, we report this case reviewing the literature especially concerning about changes of spine and disc during pregnancy and after delivery.

Detection of HBV in Blood and Blood Products by PCR

The aim of this study was to establish a PCR for detecting of the hepatitis B virus (HBV) in blood and blood products. A primer pair set was designed to amplify a 513 bp fragment in the S-region of the HBV genome in the first PCR and a 233 bp fragment of first PCR amplicon in the second PCR with Rubisco (internal control). In order to assess the specificity of the PCR results, all the samples were tested cross-reactivity or interference in the assay. This method did not result in cross-reactivity with the non-HBV (HAV, HCV, HIV, CMV, HPV 18&6b, parvovirus B19/ or HSV 1&2) positive samples and was unaffected. In case of the HBV spiked blood products such as the immunogloubulin and coagulation factors, the lower detection limit of this method for the HBV DNA is 62.5 IU/ml. The PCR method is fully established in this study and will be a valuable method for the detection of the HBV in a variety of blood products, particularly, those derived from starting materials with a high titer of virus.

Expression of Aquaporin-8 in Placenta of Preeclampsia / 대한산부인과학회잡지

OBJECTIVE: This study was to determine whether aquaporin-8, which plays a role as a transcellular water channel, is expressed in human placenta, and to compare the degree of its expression between preeclamptic women and normal pregnant women. METHODS: Placentas were obtained from severely preeclamptic women and normal pregnant women who were delivered babies by cesarean section before the onset of labor in the Chungbuk National University Hospital. In situ hybridization with aquaporin-8 cRNA probe was performed using paraffin-embedded tissue section. Signal of aquaporin-8 expression was observed with light microscope. RESULTS: In situ hybridization demonstrated strong expression of aquaporin-8 mRNA in the placentas of both preeclamptic women and normal pregnant women. The degree of expression was the same in both group. CONCLUSION: Aquaporin-8 in human placenta may not be related to the pathogenesis of preeclampsia.

Development of Multiplex PCR Detection of Blood-borne Viruses by Nucleic Acid Hybridization

Polymerase chain reaction (PCR) has been used as a substitute for conventional serological methods in order to provide blood or blood products free from contaminating viruses and recently attempts have focused to detect 2 or 3 viruses by a single multiplex PCR (M-PCR) reaction. We were able to detect human immunodeficiency virus type 1 (HIV-1), hepatitis C virus (HCV), hepatitis B virus (HBV) and human cytomegalovirus (HCMV) simultaneously by a single M-PCR. However detection by gel electrophoresis of the products from M-PCR suffers from drawbacks such as low sensitivity and product sizes. Here we report enhanced detection systems of M-PCR based on nucleic acid hybridization with arrays built on membrane. Membrane array was manufactured by spotting appropriate probe DNAs on nylon membrane. Single or multiplex PCR was performed and the PCR products were labeled with DIG and allowed to hybridize with the membrane array. Results indicate that nonspecific hybridization was not observed for membrane DNA array. Additionally, membrane array method could detect small amount of viruses that were not detectable by conventional gel electrophoresis. At least 25-fold, and in some cases more than 125-fold increases in sensitivity was obtained with DNA array method. Thus, the nucleic acid hybridization with membrane array could be applied for the detection of M-PCR of viruses in blood or blood products.

Successful Full-term Live Birth after Selective Fetal Reduction Procedure in Patient with Heterotopic Cornual Pregnancy / 대한산부인과학회잡지

Heterotopic pregnancy refers to the simultaneous occurrence of an ectopic gestation with an intrauterine one. The incidence of heterotopic pregnancy in the general population is about 1 to 30,000 pregnancies, but it has been increased due to the rise in pelvic inflammatory disease (PID), pelvic surgery, intrauterine device (IUD), and assisted reproductive technologies (ART), such as in vitro fertilization and embryo transfer (IVF-ET). However, an interstitial or cornual pregnancy accounts for only 2-4% of all tubal pregnancies and has been described only rarely in the setting of a heterotopic pregnancy. We have experienced a case of heterotopic pregnancy with cornual pregnancy after IVF-ET which was successfully treated by selective fetal reduction (SFR) procedure while maintaining the viability of the intrauterine gestation. We presented with brief review of literatures.

A Case of Combined Ectopic Gestation with Cervical and Tubal Components / 대한불임학회지

Ectopic pregnancy is a common medical problem that is difficult to diagnose and potentially may lead to significant mortality or morbidity. The incidence of ectopic pregnancy is definitely increasing due to the rise in pelvic inflammatory disease (PID), pelvic surgery, intrauterine device (IUD), and assisted reproductive technologies, such as in vitro fertilization and embryo transfer (IVF-ET). Combined ectopic gestations are much rare and their true incidence is unknown. Multiple ectopic gestations may occur in a variety of locations. The majority involve one or both fallopian tubes. We report a case of combined tubal and cervical pregnancies, and discuss their management.

Analysis of HCV positive plasma and manufacturing of HCV RNA national standard candidate / 대한수혈학회지

BACKGROUNDS: Standardization of nucleic acid amplification techniques (NAT) which can be achieved by the use of standard to validate reproducibility and sensitivity in each assay run is necessary before the introduction of such methods for routine screening of blood and blood products for viral contaminants. The objective of this study was to analyze the serological and genotypic characteristics of HCV positive plasmas and to manufacture the HCV RNA national standard candidate. METHODS: We obtained three plasmas from Blood Transfusion Research Institute, Korea, with highly positive HCV RNA plasmas (#37, #40, #46) and with normal plasma for dilution. All the plasmas were confirmed by enzyme immunoassay (EIA) test for anti-HIV, HBsAg, anti-HCV and by polymerase chain reaction(PCR) for HBV DNA, HIV RNA, HCV RNA. The genotypes of those were confirmed by INNO-LiPA HCV II. HCV RNA national standard candidate was manufactured by dispensing the diluted plasma into about 2,000 vials. Each vial was rapidly frozen using liquid nitrogen and was kept in refrigerator at -70 degrees C. RESULTS: All plasmas were identified as anti-HIV, HBsAg, HBV DNA, and HIV RNA negative plasmas. The genotypes of those were confirmed as 1b for #37, 1b or 2 for #40 and 2a or 2c for #46, respectively. Sample #37 was selected as the candidate material. After manufacturing, we obtained 1,944 vials for the candidate. CONCLUSION: In this study, we analyzed HCV positive plasmas and manufactured the HCV RNA national standard candidate. In near future, this material would be established for national standard to increase in the safety of blood and blood products in Korea.