Use of aromatase inhibitors in menopausal deep endometriosis: a case report and literature review.

We report and review the clinical effectiveness of aromatase inhibitors in a patient with refractory, recurrent and infiltrating endometriosis. We demonstrate excellent clinical, radiological and endoscopic responses after failure of multiple other modalities. Our case and the literature show that single-agent letrozole is capable to treat deep infiltrative endometriosis involving the rectum and the urinary tract. The use of aromatase inhibitor treatment of endometriosis in postmenopausal women makes sense, is safe and is well tolerated. Difficult cases of deep infiltrative endometriosis might require use of combined surgical and medical treatment modalities. Multidisciplinary involvement of the gynecologist, bowel surgeon, urologist and invasive radiologist might be needed. Aromatase inhibitors should be considered to be an integral part of the armamentarium in the management of women with endometriosis, especially in refractory cases that have failed conventional therapeutic modalities.

Long-term outcome of postmenopausal women with non-atypical endometrial hyperplasia on endometrial sampling.

OBJECTIVE: To assess the long-term outcome of postmenopausal women diagnosed with non-atypical endometrial hyperplasia (NEH). METHODS: This was a retrospective study of women aged 55 or older who underwent endometrial sampling in our academic medical center between 1997 and 2008. Women who had a current or recent (< 2 years) histological diagnosis of NEH were included in the study group and were compared with those diagnosed with atrophic endometrium (AE). Outcome data were obtained until February 2018. The main outcomes were risk of progression to endometrial carcinoma and risk of persistence, recurrence or new development of endometrial hyperplasia (EH) ('persistent EH'). Logistic regression analysis was used to identify covariates that were independent risk factors for progression to endometrial cancer or persistent EH. RESULTS: During the study period, 1808 women aged 55 or older underwent endometrial sampling. The median surveillance time was 10.0 years. Seventy-two women were found to have a current or recent diagnosis of NEH and were compared with 722 women with AE. When compared to women with AE, women with NEH had significantly higher body mass index (33.9 kg/m2 vs 30.6 kg/m2 ; P = 0.01), greater endometrial thickness (10.00 mm vs 6.00 mm; P = 0.01) and higher rates of progression to type-1 endometrial cancer (8.3% vs 0.8%; P = 0.0003) and persistent NEH (22.2% vs 0.7%; P < 0.0001). They also had a higher rate of progression to any type of uterine cancer or persistent EH (33.3% vs 3.5%; P < 0.0001). Women with NEH had a significantly higher rate of future surgical intervention (51.4% vs 15.8%; P < 0.0001), including future hysterectomy (34.7% vs 9.8%; P < 0.0001). On multivariable logistic regression analysis, only NEH remained a significant risk factor for progression to endometrial cancer or persistence of EH. CONCLUSIONS: Postmenopausal women with NEH are at significant risk for persistent EH and progression to endometrial cancer, at rates higher than those reported previously. Guidelines for the appropriate management of postmenopausal women with NEH are needed in order to decrease the rate of persistent disease or progression to cancer. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Nonimmune hydrops fetalis due to congenital syphilis associated with negative intrapartum maternal serology screening.

We present an unusual case, in which a woman presenting with markedly decreased fetal movements at 29 weeks gestation following a recent increase in fundal height was noted sonographically to have fetal hydrops consisting of scalp edema, marked hepatomegaly, ascites, and polyhydramnios. No lethal structural congenital anomaly was noted. Admission laboratory examinations revealed a negative antibody screen and a negative RPR. Emergent cesarean section was performed due to prolonged fetal bradycardia during biophysical profile testing. The acidotic hydropic neonate weighing 1825 g was resuscitated yet succumbed at 3 hr of life following intravenous administration of antibiotics. Neonatal blood was RPR positive at 1:16. Postmortem pathology examination demonstrated severe multiorgan system failure secondary to overwhelming congenital syphilis. Extensive extramedullary hematopoiesis was noted and histopathology with Dieterle stains revealed numerous hepatic spirochetes. Postpartum reexamination of the maternal blood with serial dilutions revealed a positive RPR at 1:1024. This case emphasizes that initial negative screening for syphilis may be seen despite overwhelming infection, a condition that has been termed the "prozone effect."

Immunophenotypic characterization of human fetal liver hematopoietic stem cells during the midtrimester of gestation.

OBJECTIVE: Our purpose was to define the extent to which gestational age influences the number of fetal liver cells that coexpress phenotypic markers associated with hematopoietic stem cells and major histocompatibility antigens. STUDY DESIGN: Fetal liver cells from abortuses of 9 to 24 weeks of gestation were studied (n = 61). Low-density nucleated liver cells were isolated on a discontinuous density gradient and subsequently incubated with antibodies that recognize markers of hematopoietic stem cells (i.e., CD33, CD34, CDw90, CD117, and CD123). Human leukocyte antigen class I (A, B, C) and class II (DR) antigens were also determined on these cells. Each sample was analyzed by immunocytochemistry and flow cytometry. Analysis of variance was used for statistical analysis. RESULTS: Of the markers measured, only the percentage of CD123-positive cells increased significantly with gestational age (p < 0.01). The percentage of triple-positive cells (CD34+, CD117+, and CD123+) increased with age but did not reach significance (p = 0.05). Human leukocyte A, B, and C antigens were expressed on all nucleated cells from 9 to 24 weeks of gestation. Human leukocyte DR antigen, however, was expressed only on 50% of these cells. The percentage of cells that expressed both hematopoietic stem cell markers and DR antigen did not vary with gestational age. CONCLUSIONS: From 9 to 24 weeks of gestation the number of human fetal liver hematopoietic stem cells that coexpress major histocompatibility antigens increases with advancing gestational age, largely because the percentage of these cells remains constant while the liver mass increases.