Deep microbial analysis of multiple placentas shows no evidence for a placental microbiome.

OBJECTIVES: To resolve the controversy regarding the presence of a microbiota in the placenta. DESIGN: Classical and molecular microbiological study. SETTING: All samples were collected during caesarean section. POPULATION: A total of 28 human placentas and six murine placentas. METHODS: All 28 human placentas were checked for 16S rRNA gene amplification products. Three locations from four selected human placentas and three 'environmental controls' for each placenta were placed in seven culture media. The four selected human placentas were further analysed using Gram stain, immunohistochemistry for bacteria, electron microscopy, and TaqMan RT-qPCR. Six placentas from three SPF mice were cut into four pieces each, and further analysed for 16S rRNA gene amplification. MAIN OUTCOME MEASURES: Microbiological and molecular evidence of bacteria. RESULTS: None of the placental cultures used for the full analysis, or their environmental cultures, was positive for bacterial growth. None of the other methods showed any evidence of bacteria. Immunohistochemistry showed negligible bacterial counts. None of the murine placentas showed evidence of 16S rRNA gene amplification. CONCLUSIONS: Our results support that the fetal environment in the womb is sterile. Based on the immunohistochemistry and the limit of detection of the other methods used, if a placental microbiome exists, it is of extreme low biomass, and thus its effect on clinical phenotypes is probably minor, if it exists at all. TWEETABLE ABSTRACT: Using several microbiological and molecular methods in parallel, we found no compelling evidence of bacteria in human and mouse placentas.

Correlation between changes in liver stiffness and preeclampsia as shown by transient elastography.

OBJECTIVE: The aim of this study was to evaluate the use of Fibroscan as a measure of liver transient elastography in women with preeclampsia and compare the results with a group of normotensive controls. MATERIALS AND METHODS: In this prospective observational case-control study, women at 24-41 weeks gestation who were diagnosed with preeclampsia using standard criteria, between January 2012 and December 2013, were included. The Fibroscan test was performed by a hepatologist 1-7 days postpartum. A control group consisted of low-risk women with normal pregnancy outcomes. RESULTS: Fibroscan results for fibrosis were significantly higher in the 32 preeclamptic women compared to the 16 normotensive women (mean 4.57 kPa vs. 3.66 kPa respectively, P = 0.01). There was no difference in liver steatosis between women with preeclampsia and normotensive women (226 vs. 225 kPa, respectively, P = 0.442) Conclusions: Fibroscan results for fibrosis were significantly higher in postpartum preeclamptic women (although within the normal range). Further studies are required in order to evaluate the usefulness of Fibroscan as an additional test in the evaluation and management of preeclampsia.

Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement.

AIMS: To assess the rate of parametrial involvement in a large cohort of patients who underwent radical hysterectomy for cervical cancer and to suggest an algorithm for the triage of patients to simple hysterectomy or simple trachelectomy. METHODS: Multicenter retrospective study of patients with cervical cancer stage I through IIA who underwent radical hysterectomy and pelvic lymphadenectomy. The patients were divided into 2 groups according to whether or not the parametrium was involved. The two groups were compared with regard to the clinical and histopathological variables. Logistic regression of the variables potentially assessable prior to definitive hysterectomy such as age, tumor size, lymph-vascular space invasion (LVSI) and nodal involvement was performed. RESULTS: Five hundred and thirty patients had specific histological data on parametrial involvement and in 58 (10.9%) patients, parametria was involved. Parametrial involvement was significantly associated with older age, tumors larger than 2 cm, deeper invasion, LVSI, involved surgical margins, and the presence of nodal metastasis. By triaging patients with a tumor ≤ 2 cm and no LVSI, the parametrial involvement rate was 1.8% (2/112 patients). With further triage of patients with negative nodes, the rate of parametrial involvement was 0% (0/107 patients). CONCLUSION: Using a pre-operative triage algorithm, patients with early small lesions, no LVSI and no nodal involvement may be spared radical surgical procedures and parametrectomy. Further prospective data are urgently needed.

A multicenter validation of computerized tomography models as predictors of non- optimal primary cytoreduction of advanced epithelial ovarian cancer.

AIMS: To compare the validity of four predictive models of preoperative computerized tomography (CT) scans in predicting suboptimal primary cytoreduction in patients treated for advanced ovarian cancer. PATIENTS AND METHODS: Preoperative CT scans of patients with stage III/IV epithelial ovarian cancer who underwent primary cytoreductive surgery at one of four medical centers were reviewed by radiologists blinded to surgical outcome. The validity of each set of CT criteria previously published by Nelson, Bristow, Dowdy, and Qayyum as predictors of suboptimal cytoreduction was assessed. RESULTS: Data of 123 patients were evaluated. Optimal cytoreduction (largest diameter of residual tumor < or =1cm) was obtained in 90 (73.2%) patients. All CT models were able to significantly predict surgical outcome (p<0.02). The respective sensitivity, specificity, and accuracy of the CT models to predict sub-optimal cytoreduction was 64%, 64% and 64% for Nelson's criteria, 70%, 64% and 66% for Bristow's criteria, 79%, 60%, and 65% for Dowdy's criteria, and 67% 57% and 60% for Qayyum's criteria. CONCLUSIONS: Apart from Dowdy's criteria, the accuracy rates of CT predictors of suboptimal cytoreduction in the original cohorts could not be confirmed in this cross validation. This study underscores the difficulty in devising universally applicable selection criteria or models that reliably predict surgical outcome across institutions and surgeons.

Huge acoustic neurinomas presenting in the late stage of pregnancy. Treatment options and review of literature.

BACKGROUND: Even though vestibular schwannomas rarely present during pregnancy, symptoms may appear or worsen particularly in this period. The clinical picture may include tinnitus, hearing abnormalities, and in large tumors, brain-stem and cerebellar compression with involvement of additional cranial nerves. Large vestibular schwannomas (also known as Acoustic Neurinomas) present a great challenge in peripartum management of both the mother and the fetus. MATERIAL AND METHOD: We present a case of a 24-year old woman, with headache, papilledema, ataxia, and multiple cranial nerve weakness, diagnosed in the 35th week of pregnancy. MRI demonstrated a huge vestibular schwannoma compressing the brainstem and causing obstructive hydrocephalus. RESULT: In the presence of high intra-cranial pressure a ventriculo-peritoneal shunt was first inserted, enabling delay of tumor surgery until after delivery. A successful elective cesarean section followed at 37 weeks, and radical tumor surgery was performed a week later. Maternal and fetal outcome were excellent. DISCUSSION: The options, sequence and timing of the neurosurgical and obstetrical interventions are discussed. Other reports of large vestibular schwannomas that presented during pregnancy are reviewed. Advances in neurosurgery, neuroradiology, neuroanesthesiology and obstetrics are highlighted, and their impact on outcome is discussed in comparison to the poor results reported in the past. Emphasis is made on the importance of early diagnosis, that necessitates high-index of suspicion by the obstetrician, in any pregnant woman presenting abnormal neurological signs. CONCLUSION: We conclude that with a cooperative team approach, maternal and fetal prognosis can today be excellent, even in cases of large vestibular schwannomas diagnosed in the late stage of pregnancy.

Indomethacin for preterm labor: a randomized comparison of vaginal and rectal-oral routes.

OBJECTIVE: To compare the efficacy of intravaginal and intrarectal plus oral indomethacin for the treatment of preterm labor. METHODS: Between December 1996 and November 1998, 46 eligible gravidas admitted with singleton pregnancies and idiopathic preterm labor before 33 gestational weeks were randomized to receive 200 mg of intravaginal or intrarectal plus oral indomethacin. RESULTS: Twenty-three subjects were allocated to each study group. The interval from initiation of treatment to delivery was significantly longer in the intravaginal indomethacin group (26.5 +/- 5.7 versus 12.6 +/- 3.7 days; P =.007). Delivery was delayed by more than 7 days in 18 of 23 subjects (78%) in the intravaginal indomethacin group compared with ten (43%) in the intrarectal plus oral indomethacin group (P =.03). Birth weights were significantly higher (2306 +/- 436 versus 1862 +/- 232 g; P =.002) and hospitalization in a neonatal intensive care unit (NICU) (3.1 +/- 0.8 versus 9.3 +/- 3. 7 days; P =.001) and mechanical ventilation (1.4 +/- 0.2 versus 5.3 +/- 1.6 days; P =.001) were significantly shorter in the intravaginal indomethacin group. CONCLUSION: Intravaginal indomethacin is more effective than intrarectal plus oral application in delaying preterm labor and is associated with higher birth weights, shorter NICU stays, and shorter intervals of mechanical ventilation.

High risk pregnancy outcome by route of delivery.

This review examines the preferred route of delivery in accordance with neonatal and maternal outcome of three high risk pregnancy conditions: multiple pregnancy; delivery after cesarean section; and delivery of infants with macrosomia to mothers with gestational diabetes mellitus. The most common feature of all these conditions is the lack of information, based on large prospective controlled studies, available to the treating physician for choosing the delivery route of choice and for minimizing morbidity and mortality of both infant and mother.

Ruptured tubo-ovarian abscess complicating transcervical cryopreserved embryo transfer.

OBJECTIVE: To present a rare infectious complication related to transcervical ET, without prior transvaginal puncture. DESIGN: Case report. SETTING: Hadassah University Hospital, IVF-ET unit. PATIENT: One patient undergoing cryopreserved-thawed ET. INTERVENTIONS: Artificial preparation of the endometrium with E2 and P, followed by transcervical intrauterine cryopreserved-thawed embryo transfer. RESULTS: After ET, severe pelvic inflammatory disease (PID) with ruptured tubo-ovarian abscess was diagnosed and treated. CONCLUSIONS: Severe PID including tubo-ovarian abscess formation should be considered a potential complication after ET, even without transvaginal oocyte aspiration.

Delivery following intracytoplasmic injection of mature sperm cells recovered by testicular fine needle aspiration in a case of hypergonadotropic azoospermia due to maturation arrest.

This is the first reported delivery following intracytoplasmic sperm injection (ICSI) of mature live testicular sperm cells collected in a case of hypergonadotrophic azoospermia with maturation arrest. The 30 year old couple presented with primary infertility of 11 years duration, the man being submitted in childhood to five orchidopexy operations for the treatment of cryptorchism. He had elevated serum follicle stimulating hormone (FSH; 18.8 IU/I), an atrophic left testis and a normal sized right testis, the biopsy of which diagnosed maturation arrest and focal scarring. The couple refused donor insemination for religious reasons and the only option was an attempt at testicular sperm collection. Multiple testicular and epididymal fine needle aspirations were performed, using an aspiration handle loaded with 20 ml syringe and 21-23 gauge butterfly needles. The mature spermatozoa recovered were used to inseminate the oocytes by ICSI. Prior to this procedure, the patient's wife underwent ovulation induction using a long protocol of mid-luteal gonadotrophin-releasing hormone analogue/human menopausal gonadotrophin (GnRHa/HMG). At oocyte retrieval, ten oocytes were recovered. Eight live sperm cells were recovered from the aspirates of the right testis. Following ICSI into four metaphase II and two metaphase I oocytes, one mature oocyte was fertilized, cleaved and was transferred to the uterus 48 h after oocyte retrieval. The patient conceived and delivered a 3300 g boy at term. In conclusion, our results demonstrate that this novel approach should be considered in cases with hypergonadotrophic azoospermia due to testicular failure. Further experience is needed to establish the exact criteria for its use.

Treatment of vulvar lichen sclerosus in the elderly: an update.

Lichen sclerosus et atrophicus is a disorder of the skin that can occur anywhere on the body and in all age groups but mainly affects middle-aged and elderly women in the vulvoperineal area. It consists of ivory or pink papules or macules that eventually coalesce into thin, gray, parchment-like areas. Clinically, the main symptoms are severe and intractable itching and vaginal soreness with dyspareunia. Although it has been described to be associated with an increased risk for epithelial malignancy this, in fact, very rarely occurs. The exact nature of LSA is still unknown. The accumulation of evidence does little to clarify its pathogenesis and etiology. The different reports indicate at least three general possibilities; autoimmune, metabolic, and more recently infectious etiology. The coexistence of such diverse findings in one disease entity may indicate one of the two; either we are facing a group of very similar conditions, which will be separated in the future into several closely related clinical entities, each with its own etiology, or that all findings represent a complex multi-step single pathogenetic mechanism. The latter possibility seems more probable because it has previously been suggested that B. burgdorferi, a recent prime suspect in the pathogenesis of LSA, may induce both metabolic and autoimmune abnormalities in the course of infection. New therapeutic options and attitudes emerge that dramatically improved the conservative treatment of this disease (Table 5).(ABSTRACT TRUNCATED AT 250 WORDS)