Bilateral vulvar lipomas in a premenopausal woman: A case report.

Vulvar lipomas are benign mesenchymal neoplasms that are usually well defined, small and painless. They closely resemble the pathology and presentation of lipomas at other sites. They are commonly found in young and middle-aged women but can also be diagnosed in infants. A case of bilateral vulvar lipomas in a 37-year-old woman is reported. The diagnosis was made clinically and confirmed via surgical excision and histopathology.

Correlation Between Placental Matrix Metalloproteinase 9 and Tumor Necrosis Factor-α Protein Expression Throughout Gestation in Normal Human Pregnancy.

Matrix metalloproteinases (MMPs), specifically MMP-9 plays a role in human placentation. The enzyme confers an invasive ability to cytotrophoblasts and degrades the endometrial matrix as the cells infiltrate the decidua to keep up with placental growth. Since tumor necrosis factor-α (TNF-α) can induce the synthesis of MMP-9, we investigated the patterns of changes in and correlation between placental villous MMP-9 and TNF-α expressions throughout normal human gestation. Placentas were obtained from 179 normal pregnant women who underwent elective abortion or term delivery. Chorionic villi isolated from placental samples were grouped as first, second, and third trimester (70/7-130/7, 131/7-236/7, and 370/7-424/7 weeks, respectively). Chorionic villous TNF-α and MMP-9 proteins were assayed using enzyme immunoassay kits. There were significant differences in MMP-9 and TNF-α protein expressions among the trimester groups ( P = .001). The MMP-9 protein increased progressively with an increase in gestational age (GA), but TNF-α peaked in the second trimester. Within each trimester group, we searched for the effects of variation of GA in days on the 2 variables. A significant positive correlation between MMP-9 and GA was noted in the first trimester ( r = 0.364, P = .005). No other comparisons were significant. When GA was controlled for, partial correlation revealed a significant positive correlation between TNF-α and MMP-9 only in the second trimester ( r = 0.300, P = .018). We hypothesize that the TNF-α peak and the positive correlation between TNF-α and MMP-9 in the second trimester of normal human gestation could contribute toward a successful pregnancy outcome.

Urinary Incontinence in Pregnant Young Women and Adolescents: An Unrecognized At-Risk Group.

OBJECTIVES: The aims of this study were to determine the prevalence of urinary incontinence (UI) in pregnant young women and adolescents, characterize UI subtype, and identify characteristics associated with UI. METHODS: This was a cross-sectional study of pregnant females aged 25 years or below, presenting for routine obstetrical care at a New York City community hospital. Subjects were stratified into 2 groups: adolescents (age, ≤19 years) and young adults (age, >19 years). Demographic and obstetric data were collected. The 3 Incontinence Questions questionnaire was used to screen and evaluate UI symptoms. RESULTS: A total of 98 young females with a mean age of 20.3 ± 2.6 years were enrolled. Most participants were nulliparous (64%). Of parous women, route of previous obstetric delivery was primarily vaginal (83%). Mean gestational age at recruitment was 34.5 ± 7.5 weeks. The prevalence of UI was 52%. Urinary incontinence was associated with the following conditions: strenuous activity, 73%; urinary urgency, 67%; and absence of either, 20%. However, the most predominant UI subtype was with strenuous activity (63%). There was no statistical difference detected in demographic characteristics (such as age, parity, mode of delivery, race, education, and trimester of pregnancy) between continent and incontinent pregnant females (P > 0.18). No differences were appreciated between pregnant adolescents and young adult females with UI (P > 0.18). CONCLUSIONS: Urinary incontinence was present in 52% of pregnant females aged 25 years or below. By age group, approximately 50% of both adolescents and young adults reported UI during pregnancy. Continent and incontinent patients did not seem to differ demographically. Our study highlights the extent of UI in this segment of the population. This data may support the need for services targeting UI prevention and early intervention in this newly identified at-risk group.

Placental tumor necrosis factor-α protein expression during normal human gestation.

OBJECTIVE: Placental tumor necrosis factor-α (TNF-α) is a cell signaling protein. During pregnancy, TNF-α induces synthesis of matrix metalloproteinases (MMPs) which allows cytotrophoblasts to reach the spiral arteries deeper within the uterine decidua. TNF-α also augments apoptosis of vascular smooth muscle cells surrounding these arteries. In this study, chorionic villi TNF-α protein expression throughout normal human gestation were investigated. METHODS: Placental chorionic villi tissues obtained from elective surgical terminations of pregnancy and from uncomplicated term births were assayed using EIA kits (Cayman Chemicals, Ann Arbor, MI, Item # 589201). RESULTS: The median, 25th percentile and 75th percentile values in the first (N = 99), second (N = 58) and third trimester (N = 42) were: 36.46, 27.25, 45.90 pg/100 mg tissue; 55.43, 40.09, 110.88 pg/100 mg tissue; and 16.63, 9.32, 31.92 pg/100 mg tissue, respectively. CONCLUSIONS: Variations in placental TNF-α protein expression noted at different trimesters may suggest gestational age specific roles for the cytokine. The increase in TNF-α protein expression observed in the second trimester may be involved in upregulating synthesis of MMP and in augmenting apoptosis of vascular smooth muscle cells of the spiral arteries. A failure in this second trimester increase in TNF-α protein could contribute to gestational compromise.

Placental Oxidative Status throughout Normal Gestation in Women with Uncomplicated Pregnancies.

The effects of gestational age on placental oxidative balance throughout gestation were investigated in women with uncomplicated pregnancies. Placental tissues were obtained from normal pregnant women who delivered at term or underwent elective pregnancy termination at 6 to 23 + 6 weeks of pregnancy. Placental tissues were analyzed for total antioxidant capacity (TAC) and lipid peroxide (malondialdehyde, MDA) levels using commercially available kits. Two hundred and one placental tissues were analyzed and the mean ± SD MDA (pmol/mg tissue) and TAC (µmol Trolox equivalent/mg tissue) levels for first, second, and third trimester groups were 277.01 ± 204.66, 202.66 ± 185.05, and 176.97 ± 141.61, P < 0.004 and 498.62 ± 400.74, 454.90 ± 374.44, and 912.19 ± 586.21, P < 0.0001 by ANOVA, respectively. Our data reflects an increased oxidative stress in the placenta in the early phase of normal pregnancy. As pregnancy progressed, placental antioxidant protective mechanisms increased and lipid peroxidation markers decreased resulting in diminution in oxidative stress. Our findings provide a biochemical support to the concept of a hypoxic environment in early pregnancy. A decrease in placental oxidative stress in the second and third trimesters appears to be a physiological phenomenon of normal pregnancy. Deviations from this physiological phenomenon may result in placental-mediated disorders.

Advanced extrauterine pregnancy at 33 weeks with a healthy newborn.

Abdominal pregnancy is a very rare form of ectopic pregnancy, associated with high morbidity and mortality for both fetus and mother. It is, and often, seen in poor resource nations, where early diagnosis is often a major challenge due to poor prenatal care and lack of medical resources. An advanced abdominal pregnancy with a good fetal and maternal outcome is therefore a more extraordinary occurrence in the modern developed world. We present a case of an abdominal pregnancy at 33.4 weeks in an individual with no documented prenatal care, who arrived in a hospital in the Bronx, in June 25th 2014, with symptoms of generalized, severe lower abdominal pain. Upon examination it was found that due to category III fetal tracing an emergent cesarean section was performed. At the time of laparotomy the fetus was located in the pelvis covered by the uterine serosa, with distortion of the entire right adnexa and invasion to the right parametrium. The placenta invaded the pouch of Douglas and the lower part of the sigmoid colon. A massive hemorrhage followed, followed by a supracervical hysterectomy. A viable infant was delivered and mother discharged on postoperative day 4.

Induction of labor at 41 weeks of pregnancy among primiparas with an unfavorable Bishop score.

OBJECTIVE: To determine the rate and factors associated with the successful Induction of Labor (IOL) in nulliparous patients undergoing scheduled IOL at 41 weeks of gestational age (GA) with an unfavorable cervix. DESIGN: This was a retrospective analysis that included nulliparous patients who presented to the Labor and Delivery unit at the Bronx Lebanon Hospital Center between 2011 and 2012 for elective IOL at 41 weeks of GA. The Bishop score was assessed upon admission and IOL agents were used in compliance with ACOG guidelines in different combinations, based on the obstetrical team preference. SETTING: Labor and Delivery Unit of the Bronx Lebanon Hospital. POPULATION: Nulliparous patients with 41 weeks of pregnancy for elective induction of labor. SAMPLE: Seventy-six patients were included in the study. GA was confirmed using a combination of the last menstrual period and a dating sonogram during pregnancy. METHODS: This was a retrospective chart review that included nulliparous patients who presented to the Labor and Delivery unit at the Bronx Lebanon Hospital Center between October 2011 and October 2012 for elective IOL at 41 weeks of gestational age with an unfavorable cervix defined as a Bishop score of 6 or less. MAIN OUTCOME MEASURES: The overall successful rate of IOL in a combination of different maternal factors with different agents for induction in nulliparous patients undergoing scheduled IOL with an unfavorable Bishop score at 41 weeks of GA was 51.32 %. RESULTS: Factors associated with successful IOL were younger age [22.3 years vs. 25.1(p = 0.015)], lower BMI [25 vs. 28.1(p = 0.46)] and lower maternal weight [64.75 kg vs. 74.02 (p = 0.28)]. Maternal height was not a contributing factor; the artificial rupture of membranes, epidural anesthesia and the prostaglandins used did not contribute. Use of cervical balloon and oxytocin was associated with failed IOL. CONCLUSIONS: Patients undergoing IOL at 41 weeks with an unfavorable cervix had a successful rate of 51.32 %. Younger maternal age, lower weight, and lower BMI were associated with successful IOL.

Maternal body mass index does not affect neonatal umbilical artery blood gas parameters.

This study was undertaken to assess the impact of obesity on fetal well-being in glucose-tolerant and nonhypertensive women. Medical charts of all patients admitted to the labor and delivery department at our institution between January, 2011 and July, 2011 were retrospectively reviewed. Patients with diabetes/impaired glucose tolerance or hypertension were excluded. A total of 100 women, 50 lean and 50 obese, were included. Umbilical artery blood gas parameters (BGPs) were compared in lean (<25 kg/m(2)) and obese (≥ 30 kg/m(2)) women. Obese and lean women were comparable with respect to all baseline characteristics. There was no difference in any of the BGP or Apgar scores between obese and lean patients. Pearson's correlation coefficient found no significant correlation between BMI and BGP/Apgar scores. Maternal obesity does not seem to affect BGP and fetal well-being in glucose-tolerant and nonhypertensive women.

Compliance with follow-up in an inner-city population treated with intramuscular methotrexate for suspected ectopic pregnancy.

OBJECTIVE: To evaluate compliance with follow-up among inner-city patients with ectopic pregnancy treated with methotrexate, in addition to assessing outcome. METHODS: Retrospective analysis of all patients evaluated for first-trimester bleeding and diagnosed with ectopic pregnancy at the Bronx Lebanon Hospital Center, New York, USA, from October 2007 to March 2011. Compliance and complications were evaluated for all patients who received medical treatment with methotrexate. RESULTS: Ninety-nine patients with hemodynamically stable ectopic pregnancies were identified. Therapy with methotrexate was effective in 87 (87.9%) cases. Only 10 (10.1%) patients were fully compliant during follow-up after methotrexate administration. There were no differences according to ethnicity. Number of follow-up visits after treatment significantly affected compliance. CONCLUSION: Improvements in selection criteria for therapy and simplification of follow-up for patients with medically managed ectopic pregnancy are required.

Risk factors for persistent cervical intraepithelial neoplasia grades 1 and 2: managed by watchful waiting.

OBJECTIVE: : This study examines risk factors for persistent cervical intraepithelial neoplasia (CIN) and examines whether human papillomavirus (HPV) testing predicts persistent lesions. MATERIALS AND METHODS: : Women with histologically diagnosed CIN 1 or CIN 2 (n = 206) were followed up every 3 months without treatment. Human papillomavirus genotyping, plasma levels of ascorbic acid, and red blood cell folate levels were obtained. Cervical biopsy at 12 months determined the presence of CIN. Relative risk (RR) was estimated by log-linked binomial regression models. RESULTS: : At 12 months, 70% of CIN 1 versus 54% of CIN 2 lesions spontaneously regressed (p < .001). Levels of folate or ascorbic acid were not associated with persistent CIN at 12 months. Compared with HPV-negative women, those with multiple HPV types (RRs ranged from 1.68 to 2.17 at each follow-up visit) or high-risk types (RRs range = 1.74-2.09) were at increased risk for persistent CIN; women with HPV-16/18 had the highest risk (RRs range = 1.91-2.21). Persistent infection with a high-risk type was also associated with persistent CIN (RRs range = 1.50-2.35). Typing for high-risk HPVs at 6 months only had a sensitivity of 46% in predicting persistence of any lesions at 12 months. CONCLUSIONS: : Spontaneous regression of CIN 1 and 2 occurs frequently within 12 months. Human papillomavirus infection is the major risk factor for persistent CIN. However, HPV testing cannot reliably predict persistence of any lesion.

Impact of hormones on female sexual function and dysfunction.

The female sexual response cycle is a complex system composed of physiologic changes, psychological, and cultural factors. Female sexual dysfunction (FSD) encompasses a variety of sexual problems, including low desire or interest, diminished arousal, difficulties with orgasm, and dyspareunia. Research in female sexual function and dysfunction has lagged significantly behind males despite our current knowledge that FSD can occur in as many of 80% of the female population. Basic science research exists but also identifies serious gaps in our fundamental knowledge of this area. The purpose of this article was to review our current understanding of the effects of hormones on normal physiologic sexual responses in women, female sexual function and dysfunction, and the available treatment options for the various components of FSD.

Effects of oral, vaginal, and transdermal hormonal contraception on serum levels of coenzyme q(10), vitamin e, and total antioxidant activity.

The use of the transdermal contraceptive patch is associated with greater bioavailability of ethinyl estradiol (EE) compared with contraceptive vaginal ring or oral contraceptives (OC). We compared the influences of three contraceptive methods (OC, vaginal ring, and transdermal patch) on serum levels of coenzyme Q(10), alpha-tocopherol, gamma-tocopherol and total antioxidant capacity in premenopausal women. Blood samples from 30 premenopausal women who used hormonal contraception for at least 4 months were collected. Forty subjects who did not use any contraception were studied as control. Serum levels of coenzyme Q(10), alpha-tocopherol and gamma-tocopherol were measured by high-pressure liquid chromatography. Serum samples were also assayed for total antioxidant capacity (TAOC). Serum levels of coenzyme Q(10) and alpha-tocopherol were found to be significantly lower (P < .05) in all three contraceptive users compared with controls. Contraceptive patch users had the lowest levels of coenzyme Q(10) levels compared with normal subjects. Serum TAOC levels were significantly lower (P < .05) among the contraceptive user groups. Alterations in coenzyme Q(10) and alpha-tocopherol induced by hormonal contraception and the potential effect(s) of exogenous ovarian hormones should be taken into consideration in future antioxidant research.

Factors influencing long-term pessary use.

INTRODUCTION AND HYPOTHESIS: We aimed to identify factors contributing to successful pessary use for over 1 year. METHODS: A chart review was conducted composed of 150 women at Montefiore Medical Center, using a pessary for over 1 year. Characteristics of those who continued pessary usage were compared with those who discontinued use by using Chi-square, Fisher's exact test, logistic regression model, receiver-operator characteristic curve, and Kaplan-Meier survival curves. RESULTS: Thirty-five women (23%) discontinued using pessaries (DP) after a year, while 115 women (77%) continued (CP). There was no difference in multiple characteristics. The DP group had more patients with stress incontinence, p = 0.17. Older age at pessary insertion showed higher continued use (OR = 1.083, CI: 1.033-1.136). Patients with a history of prolapse repair surgery were more likely to discontinue pessary use. CONCLUSIONS: Age greater than 72 years was associated with continued pessary use and history of hysterectomy or prolapse surgery, and stress incontinence were associated with discontinuation.

Regional heterogeneity in expression of the sphingosine-1-phosphate pathway in the female rat lower urinary tract.

OBJECTIVE: We investigated the existence and regional distribution of sphingosine-1-phosphate regulatory enzymes and receptors in the lower urinary tract and determined the functional role of sphingosine-1-phosphate receptors in the bladder. STUDY DESIGN: Lower urinary tract tissue from 10 female rats was harvested for real-time reverse transcriptase-polymerase chain reaction or organ bath physiology, whereas blood serum was obtained for high-performance liquid chromatography determination of sphingosine-1-phosphate levels. Statistical analysis included the Student t test and analysis of variance. RESULTS: All 3 sphingosine-1-phosphate receptors and major enzymes were expressed throughout the lower urinary tract, but expression and physiologic force generation varied among regions. Sphingosine-1-phosphate was detected in serum. CONCLUSION: We provide novel data that the sphingosine-1-phosphate signaling pathway regulatory proteins exist throughout the female rat lower urinary tract, but that relative expression exhibits regional heterogeneity corresponding with lower urinary tract contractile response to sphingosine-1-phosphate. Our study suggests that sphingosine-1-phosphate signaling is important in the lower urinary tract and identifies this pathway as a possible target for altering bladder smooth muscle tone.

Human immunodeficiency virus (HIV) antigens and RNA in HIV-seronegative women with cervical intraepithelial neoplasia.

While investigating whether proteins retrieved by cervicovaginal lavages (CVL) from women with cervical intraepithelial neoplasia (CIN) might correlate with risk of progression to invasive cervical cancer, we unexpectedly identified HIV gag and env glycoprotein in CVL from women with HIV-negative serology. HIV antigens were consistently identified by mass spectrometry (MS) in CVL from 4 women but were absent in CVL from the remaining 16 women. HIV serologies of all 20 patients were negative for both HIV-1 and HIV-2 antibodies. To validate the unexpected MS findings we performed Western blot (WB) and immunoaffinity chromatography (IC) analysis of CVL for HIV proteins, viral load assays of paired CVL and blood samples, and immunohistochemical HIV p24 expression in cervical biopsy specimens. WB analysis of CVL for prostate-specific antigen (PSA) was performed to exclude semen contamination as the source of HIV proteins. WB and IC results demonstrated the presence of HIV-1 gp41 and p24 antigens in four CVL that were identified by MS to have the HIV proteins. Despite negative serology, HIV RNA in CVL and HIV p24 in cervix biopsies were detected in patients with HIV antigen-positive CVL. HIV p24-positive CVL were PSA negative. All 20 subjects remained HIV seronegative throughout the study. Women with HIV proteins and RNA were comparatively older. Our findings suggest that CVL HIV proteins in women with CIN could be markers for unrecognized HIV exposure or subclinical infection. Proteomic screening of cervical secretions may be useful in identifying seronegative women exposed to HIV and/or at risk for AIDS.

Nerve injury during uterosacral ligament fixation: a cadaver study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to identify nerve(s) vulnerable to entrapment during uterosacral ligament fixation (USLF), which could cause postoperative lower extremity pain previously described in the literature. METHODS: Preserved cadavers in a medical anatomy course were used. Before the students' pelvic dissections, a 2-0 prolene suture was placed in the middle third of each left uterosacral ligament visualized. The sutures were re-evaluated at the end of the course. RESULTS: Nine sutures remained in place after the course, and one entrapped a nerve. It was part of the inferior hypogastric plexus, included fibers from S2 and S3, and radiated to the bladder and rectum. The posterior femoral cutaneous nerve was lateral and posterior to this nerve. CONCLUSIONS: The inferior hypogastric plexus is vulnerable during USLF. Entrapment of S2 and S3 fibers could cause pain in their respective dermatomes and could be responsible for the postoperative pain previously described.

Gross and microscopic hematuria: guidelines for obstetricians and gynecologists.

Although gross hematuria is a relatively uncommon condition in general obstetrics and gynecology practice, microscopic hematuria is a common incidental finding during routine antepartum or gynecologic office visits. The proper evaluation and treatment options are understudied in females. In fact, work-up of females is controversial, and no consensus guidelines exist at this time. Pregnancy increases the number of potential diagnoses. The majority of published literature on hematuria in pregnancy is in the form of case reports, and esoteric diagnoses are disproportionately represented. The purpose of this review is to summarize existing literature regarding the evaluation, differential diagnosis, and treatment of hematuria in women, with special emphasis on pregnancy and the diagnosis and treatment of microscopic hematuria.

Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles.

We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).

Anatomic variations of the pelvic floor nerves adjacent to the sacrospinous ligament: a female cadaver study.

Our objective was to document variations in the topography of pelvic floor nerves (PFN) and describe a nerve-free zone adjacent to the sacrospinous ligament (SSL). Pelvic floor dissections were performed on 15 female cadavers. The course of the PFN was described in relation to the ischial spine (IS) and the SSL. The pudendal nerve (PN) passed medial to the IS and posterior to the SSL at a mean distance of 0.6 cm (SD = +/-0.4) in 80% of cadavers. In 40% of cadavers, an inferior rectal nerve (IRN) variant pierced the SSL at a distance of 1.9 cm (SD = +/-0.7) medial to the IS. The levator ani nerve (LAN), coursed over the superior surface of the SSL-coccygeus muscle complex at a mean distance of 2.5 cm (SD = +/-0.7) medial to the IS. Anatomic variations were found which challenge the classic description of PFN. A nerve-free zone is situated in the medial third of the SSL.

Rupture of a tuboovarian abscess into the anterior abdominal wall: a case report.

BACKGROUND: Rupture of a tuboovarian abscess is a life-threatening emergency. The current standard of care is surgery to manage the onset of peritonitis and sepsis. CASE: A 34-year-old woman presented with gradually worsening abdominal pain over several weeks. She had fever, pelvic tenderness, an elevated white blood cell count and ultrasonographic evidence of a tuboovarian abscess. After 48 hours of triple antibiotic therapy without a clinical improvement, she underwent surgery, during which she was found to have an abscess that had ruptured into the abdominal wall. A supracervical hysterectomy/bilateral salpingo-oophorectomy and surgical debridement of the subcutaneous tissue was performed, with wet to dry dressing changes of the surgical wound. Over the following 18 months, the patient required extensive wound care for recurrent bouts of wound drainage. CONCLUSION: Rupture of a tuboovarian abscess usually presents with sudden worsening of the patient's condition. Delays in surgical debridement and drainage increase the rate of associated mortality. Atypical presentations may present as cases resistant to conventional medical therapy, with fewer of the associated risks of life-threatening peritonitis and subsequent sepsis. Our patient represents the first reported case of extraperitoneal spillage of abscess contents from rupture of a tuboovarian abscess into the anterior abdominal wall.