Lycopene nanoparticles promotes osteoblastogenesis and inhibits adipogenesis of rat bone marrow mesenchymal stem cells.

OBJECTIVE: Lycopene is a carotenoid and antioxidant with potent singlet oxygen quenching ability that reduces oxidative stress and promotes bone health. However, the cellular mechanisms by which lycopene influences bone metabolism are not known. MATERIALS AND METHODS: The present study investigated the effects of lycopene nanoparticles on the differentiation of rat bone marrow-derived mesenchymal stem cells into osteoblasts or adipocytes. RESULTS: In osteogenic medium, lycopene supplementation dose-dependently enhanced osteoblast differentiation, as evidenced by the transcription of Alpl, Runx2, Col1a1, Sp7, and Bglap, higher alkaline phosphatase activity, osteocalcin secretion and extracellular matrix mineralisation seen with Alizarin red S staining, and increased haem oxygenase levels. By contrast, lycopene in adipogenic medium inhibited adipocyte differentiation evidenced by decreases in the transcription of Tnfsf11, Tnfrsf11b, Pparg, Lpl, and Fabp4 and reduced fat accumulation observed by Oil Red O staining. CONCLUSIONS: Lycopene nanoparticles may promote bone health and are considered as a potential candidate for the prevention and/or treatment of bone loss conditions.

Medical management of early pregnancy failure with misoprostol with rupture of the cesarean section scar pregnancy.

PURPOSE: To report a case of ruptured uterus in the first trimester with the use of misoprostol for early pregnancy tailure in a woman with unrecognized cesarean section scar pregnancy. CASE: A 27-year-old woman, gravida 5 para 3+1, presented with abdominal pain and vaginal bleeding. Transvaginal ultrasonography revealed a fetus without fetal heart activity at nine weeks gestation, making the diagnosis of early pregnancy failure. Her previous deliveries were by cesarean section. She was managed medically with misoprostol. Seven hours after misoprostol administration, she developed sudden onset of severe abdominal pain. Repeat transvaginal ultrasonography diagnosed cesarean section scar pregnancy. Laparotomy revealed hemoperitoneum with rupture of cesarean section scar pregnancy. Subtotal hysterectomy was performed. CONCLUSIONS: Failure to recognize cesarean section scar pregnancy can result in a ruptured uterus in the first trimester with the use of misoprostol for early pregnancy failure. Increased awareness of the unexpected consequences of cesarean section is of paramount importance.

Failure of laparoscopic Vecchietti procedure in a woman with androgen insensitivity syndrome.

The authors describe a case with androgen insensitivity syndrome (AIS) who underwent the laparoscopic Vecchietti procedure for creation of a neovagina. Postoperatively, the patient achieved anatomic success, with a vaginal length of about eight cm, and she was advised to use vaginal dilators after discharge. The patient reported improved sexual function, but presented about six months later for shortening of her vagina and difficult vaginal intercourse. Physical examination revealed an obliterated vaginal canal about two cm long. Further examination revealed lack of vaginal epithelization. The patient was instructed to continue using vaginal dilators in combination with estrogen cream; however, the patient did not achieve a vaginal length > two cm. The authors believe that the laparoscopic Vecchietti procedure may not be appropriate for women with AIS due to lack of epithelization.

Urinary catheterization as a successful treatment option for post-cesarean section vesicouterine fistula.

Surgery, the usual treatment option for vesicouterine fistula (VUF), is often delayed to allow involution of the uterus. The authors report a case of successful treatment with urinary catheterization. A 39-year-old, gravida 7, para 6, woman presented at term with obstructed labor. She had one previous cesarean section followed by a vaginal birth before. She underwent emergency cesarean section. She was readmitted after one week because of pelvic collection. Aspiration revealed pus and urine. Retrograde cystogram and pelvic MRI confirmed the presence of VHF. Urinary bladder catheterization for six weeks resulted in the successful treatment of the fistula. Urinary catheterization in the early postpartum period can result in resolution of post-cesarean section VUF, without delaying surgical intervention if it becomes necessary.

Female genital mutilation/cutting: an update.

Female genital mutilation/cutting (FGM/C) is a cultural practice involving several types of external female genitalia cutting. FGM/C is known to occur in all parts of the world but is most prevalent in 28 countries in Africa and the Middle East and among immigrant communities in Europe, Australia, New Zealand, Canada, and the United States. Studies of FGM/C suffer from many methodological problems including inadequate analysis and an unclear reporting of results. The evidence to link FGM/C to infertility is weak. The management of epidermal clitoral inclusion cysts includes expensive investigations like comprehensive endocrinology tests and MRI resulting in unnecessary anxiety due to delay in surgical treatment. Similarly, unnecessary cesarean sections or rupture of the infibulation scar continue to occur because of the inadequate use of intrapartum defibulation. A significant amount of efforts is required to improve and correct the inadequate care of FGM/C women and girls.

Optimizing the modified laparoscopic Vecchietti procedure.

OBJECTIVE: To enhance the modified laparoscopic Vecchietti procedure. MATERIALS AND METHODS: A case series of five women with Mayer-Rokitansky-Küster-Hauser syndrome at the Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia underwent the modified laparoscopic Vecchietti procedure with intraperitoneal placement of sutures. This involved perforation of the vaginal dimple by a straight thread guide with two threads attached to the olive followed by pulling the two threads intra-peritoneally and through the abdominal wall to the traction device by grasping instruments under laparoscopic control. RESULTS: Intraperitoneal placement of the sutures was easily done without complications in all five women. The operative time was 50 ± 10 (mean ± SD) minutes. After five postoperative days, the average vaginal length was seven to 7.5 cm. Two women were able to have vaginal intercourse without problems. After six months to one year of follow up, the vaginal length was at least ten cm and no postoperative complications occurred. CONCLUSIONS: Intraperitoneal placement of sutures makes the modified laparoscopic Vecchietti procedure easy and appealing. Furthermore, it avoids potential damage to the vital structures at the pelvic side walls.

The use of fresh frozen plasma for reproduction in severe factor V deficiency.

OBJECTIVE: Severe factor V (FV) deficiency is rare. There are case reports describing pregnancy outcomes in women with FV deficiency and one case report of successful pregnancy following the use of fresh frozen plasma (FFP) in several cycles of ovulation induction and intrauterine insemination and at delivery. The authors report another case to support the use of FFP for reproduction. CASE: A 27-year-old woman with severe FV deficiency was given FFP at the time of ovulation induced with clomiphene citrate, human menopausal gonadotropin (hMG), and human chorionic gonadotropin. Intrauterine insemination (IUI) was done 35 hours later. She became pregnant with twins and delivered vaginally at 36 weeks of gestation with the prophylactic use of FFP. CONCLUSION: Fresh frozen plasma can be offered for reproduction to women with severe FV deficiency.

Prevalence of endometriosis at a university hospital in Jeddah, Saudi Arabia.

PURPOSE: To determine the prevalence of endometriosis in women who had gynecologic laparoscopy at a university hospital in Saudi Arabia. MATERIALS AND METHODS: The hospital records were reviewed to identify all women who had undergone gynecological laparoscopy between January 2008 and December 2013. RESULTS: A total of 190 gynecologic laparoscopies were performed. The indications for laparoscopy were infertility (n = 76; 40%), chronic pelvic pain (n = 34; 17.9%), infertility and chronic pelvic pain (n = 7; 3.7%), ectopic pregnancy (n = 30; 15.8%), pelvic mass (n = 12; 6.3%), removal of a missing intrauterine contraceptive device (n = 6; 3.2%); other indications were documented in 25 cases (13.1%). Endometriosis was diagnosed in 21 women (11.1%). The presenting complaints in women with endometriosis were pelvic pain (n = 7; 33.3%), infertility (n = 5; 23.8%), pelvic pain and infertility (n = 6; 28.6%), and pelvic mass (n = 2; 9.5%); the complaint was unknown in one patient (4.8%). CONCLUSION: Endometriosis was uncommon in women who had undergone gynecologic laparoscopy.

Near death of a pregnant Somali woman due to neglected eclampsia.

PURPOSE: To report a case of cardiac arrest of a Somali woman in labor due to neglected eclampsia. MATERIALS AND METHODS: A 16-year-old Somali primigravida was seen because of convulsions at 28 weeks gestation. She had two attacks of convulsions at home before coming to the hospital. She suffers from diabetes and is insulin-dependent. Her convulsions were controlled with diazepam. Vaginal examination showed a seven cm dilated cervix with high-breech. In the operating room, cardiac arrest occurred. RESULTS: Cesarean section was performed during resuscitation. The patient's maternal condition improved and was diagnosed with pulmonary edema and diabetic ketoacidosis. She was admitted to the intensive care unit (ICU) then transferred to the postnatal ward. She was discharged home and is in good general condition. CONCLUSION: Inadequate or lack of antenatal care of Somali pregnant women due to many factors, including ignorance, can result in medical catastrophic situations as illustrated in the current case.

Psychosexual and social consequences in a woman with undiagnosed Mayer-Rokitansky-Küster-Hauser syndrome.

PURPOSE: To report a woman with devastating psychosexual and social consequences as a result of undiagnosed Mayer-Rokitansky- Küster-Hauser syndrome (MRKH) syndrome. MATERIALS AND METHODS: An 18-year-old woman was referred after being divorced for "absent vagina and uterus". On examination, secondary sexual characteristics were normal. Vaginal and rectal examinations revealed absent vagina and uterus. Investigations showed normal hormonal profile, 46 XX karyotype, and normal intravenous pyelography. Pelvic ultrasonography and magnetic resonance imaging (MRI) confirmed the absence of the uterus and presence bilateral ovaries. RESULTS: A diagnosis of MRKH syndrome was made and she underwent successful modified laparoscopic Vecchietti operation for creation of a new vagina. Vaginal dilators were used after the surgery. Two years of follow up confirmed that vaginal length was about ten cm. CONCLUSION: The proper diagnosis, counseling, and prompt treatment of MRKH syndrome can prevent tragic consequences.

Urethral sex in a woman with previously undiagnosed Mayer-Rokitansky-Küster-Hauser syndrome.

PURPOSE: To report a case of urethral sex in a woman with previously undiagnosed Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. MATERIALS AND METHODS: A 32-year-old woman presented with severe pain, dysuria, and mild hematuria after each intercourse. Secondary sexual characteristics were normal. Vaginal and rectal examinations revealed an absent vagina and uterus. Further investigations showed a normal hormonal profile, a 46 XX karyotype, and a normal intravenous pyelography. Pelvic ultrasonography and magnetic resonance imaging (MRI) confirmed the absence of a uterus and the presence of bilateral ovaries. RESULTS: A diagnosis of MRKH syndrome was made and the patient underwent a modified Vecchietti operation for the creation of a new vagina. The urethral meatus was noticeably dilated. Postoperatively, the vaginal length was six to seven cm. Long-term follow-up revealed that she was able to have normal and satisfactory vaginal intercourse without any problems. CONCLUSION: Urethral intercourse is documented here for the first time in a case of misdiagnosed MRKH syndrome.

Pregnancy with 15 live fetuses and severe ovarian hyperstimulation syndrome after ovulation induction and intrauterine insemination.

The empirical use of ovulation induction and intrauterine insemination for male factor infertility, unexplained infertility, and anovulatory infertility can be associated with multiple gestation and ovarian hyperstimulation syndrome (OHSS). A 30-year-old lady was referred for fetal reduction of very high-order pregnancy. She became pregnant after ovulation induction and artificial insemination. The stimulation protocol included clomiphene citrate and fixed-dose gonadotropins. Triggering of ovulation was done with 5,000 units of human chorionic gonadotropins (hCG). Cycle monitoring was done with ultrasonography only. The patient was admitted to the hospital due to severe OHSS. Physical examination revealed that the uterus size was equivalent to 28 weeks gestation. Transvaginal ultrasonography (TVUS) and pelvic magnetic resonance imaging (MRI) showed 15 intrauterine gestational sacs with viable eight-week fetuses and 7 cm x 4.5 cm fluid collection. Both ovaries were enlarged. The right ovary was 12 cm x 5 cm and the left ovary was 10 cm x 6.5 cm. The patient had a spontaneous miscarriage of the 15 fetuses.

Misoprostol for labor induction in the second trimester in a woman with previous three cesarean deliveries and an intrauterine death of an anencephaly.

UNLABELLED: Termination of pregnancy in the second trimester for an intrauterine death of a fetus with anencephaly in a woman with previous three cesarean sections is a difficult clinical dilemma. A 34-year-old, gravida 4, para 3 woman was admitted at 20 weeks gestation for termination of pregnancy due to intrauterine death of a fetus with anencephaly. She had had three previous cesarean sections. She received two doses of 200 mcg misoprostol tablets vaginally 12 hours apart. Then two doses of 400 mcg misoprostol tablets were given vaginally 12 hours apart. There were no uterine contractions or cervical changes. Finally, she received five doses of 400 mcg misoprostol tablets vaginally every eight hours. The patient responded after the last dose and the fetus with the placenta aborted completely without complications. The estimated blood loss was 200 ml. CONCLUSION: Misoprostol can avoid hysterotomy for termination of pregnancy in the second trimester with history of previous three cesarean sections and an intrauterine death of a fetus with anencephaly.

Decreased serum sclerostin levels in patients with primary hyperparathyroidism: a cross-sectional and a longitudinal study.

UNLABELLED: Decreased serum sclerostin was evident in patients with primary hyperparathyroidism and was inversely related to parathyroid hormone (PTH). Sclerostin normalized earlier than biochemical bone turnover markers (BTMs) following parathyroidectomy. INTRODUCTION: There is limited information on the changes of serum sclerostin in conditions with chronic PTH excess in humans. The main objectives of the present study were to: (1) examine cross-sectionally the changes of serum sclerostin levels in patients with primary hyperparathyroidism (PHPT), (2) study the time course changes in serum sclerostin in PHPT patients following parathyroidectomy (PTX) followed up longitudinally for 12 months, and (3) compare the changes in serum sclerostin to that of BTMs. METHODS: We studied 60 PHPT patients and compared them with 74 PTX patients together with 268 age- and sex-matched healthy controls. Also, we followed 27 PTX patients longitudinally at 2, 4, 6, 10, 30, 60, 180, and 360 days postoperatively. Serum sclerostin, BTMs, and minerals were measured. Also, bone mineral density was determined by dual energy X-ray absorptiometry. RESULTS: Patients with PHPT exhibited significantly lower mean serum sclerostin [mean, in picomoles per liter; 95% confidence interval (CI)] (28.98; 27.94-30.03) than that obtained for PTX patients (37.01; 35.75-38.27) and healthy controls (46.22; 45.13-47.31) (P < 0.0001, for each case), respectively. Serum PTH inversely correlated with serum sclerostin (r = -0.651, P < 0.0001). Serum sclerostin was normalized in PTX patients by the tenth day postoperatively and remained within the expected reference range thereafter. CONCLUSIONS: Significantly decreased serum sclerostin was evidenced in PHPT patients as compared with PTX and euparathyroid controls. The inverse PTH and sclerostin relationship suggests that sclerostin is downregulated by PTH in humans. Serum sclerostin normalized earlier than BTMs following parathyroidectomy.

Vitamin D status in relation to obesity, bone mineral density, bone turnover markers and vitamin D receptor genotypes in healthy Saudi pre- and postmenopausal women.

UNLABELLED: The various factors that may contribute to vitamin D deficiency or insufficiency were examined among healthy Saudi pre- and postmenopausal women. Vitamin D deficiency was highly prevalent among studied Saudi women with obesity, poor sunlight exposure, poor dietary vitamin D supplementation and age as the main risk factors. INTRODUCTION: The various factors that may contribute to vitamin D deficiency or insufficiency in relation to bone health among Saudi women are not known. The main objectives of the present study were to determine the factors influencing vitamin D status in relation to serum 25-hydroxyvitamin D (25(OH)D), intact parathyroid hormone (PTH), bone turnover markers (BTMs), bone mineral density (BMD), and vitamin D receptor genotype (VDR) in healthy Saudi pre- and postmenopausal women. METHODS: A total number of 1,172 healthy Saudi women living in the Jeddah area were randomly selected and studied. Anthropometric parameters, socioeconomic status, sun exposure index together with serum levels of 25(OH)D, calcitriol, intact PTH, Ca, PO4, Mg, creatinine, albumin, and biochemical BTMs were measured. BMD was measured by a dual energy X-ray absorptiometry and VDR genotypes were also determined. RESULTS: About 80.0% of Saudi women studied exhibited vitamin D deficiency (serum 25(OH)D<50.0 nmol/L) with only 11.8% of all women were considered with adequate vitamin D status (serum 25(OH)D>75 nmol/L). Secondary hyperparathyroidism was evident in 18.5% and 24.6% in pre- and postmenopausal women with 25(OH)D<50 nmol/L. Serum 25(OH)D was lower (P<0.001) and intact PTH higher (P<0.001) in the upper quintiles of body mass index (BMI) and waist-to-hip ratio (WHR). Multiple linear regression analysis showed that BMI, sun exposure index, poor dietary vitamin D supplementation, WHR, and age were independent positive predictors of serum 25(OH)D values. CONCLUSIONS: Vitamin D deficiency is highly prevalent among healthy Saudi pre-and postmenopausal women and largely attributed to obesity, poor exposure to sunlight, poor dietary vitamin D supplementation, and age.

The effect of cigarette or sheesha smoking on first-trimester markers of Down syndrome.

OBJECTIVE: To investigate the influence of cigarette or sheesha smoking on first-trimester markers of Down syndrome. DESIGN: A prospective observational study. SETTING: Primary care centres and antenatal clinics of Maternity and Children Hospital, King Abdulaziz University Hospital and New Jeddah Clinic Hospital, Jeddah, Saudi Arabia. POPULATION: Women with a singleton pregnancy who were either nonsmokers (n = 1736) or cigarette smokers (n = 420) or sheesha smokers (n = 181). METHODS: Fetal nuchal translucency thickness (fetal NT), maternal serum free beta-human chorionic gonadotrophin (free beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) were measured at 11 weeks 0 days to 13 weeks 6 days of gestation in all women. Women were grouped according to smoking status, confirmed by maternal serum cotinine measurements, and analyte levels between groups were compared. MAIN OUTCOME MEASURES: Fetal NT, maternal serum free beta-hCG, PAPP-A and cotinine measurements. RESULTS: Compared with nonsmoking women, fetal NT was significantly increased and free beta-hCG and PAPP-A levels were significantly decreased in both cigarette and sheesha smokers. There were significant relationships between all three markers and the number of sheeshas consumed per day. CONCLUSIONS: Cigarette and sheesha smoking significantly affect first-trimester markers of Down syndrome (fetal NT, free beta-hCG and PAPP-A). Correction for this effect in women who smoke might improve the effectiveness of first-trimester screening for Down syndrome in these women. The underlying mechanism(s) relating smoking to the changes in first-trimester markers require further studies.

Abdominal myomectomy versus abdominal hysterectomy for symptomatic and big uterine fibroids.

OBJECTIVE: To compare abdominal myomectomy with abdominal hysterectomy in women with big and symptomatic uterine fibroids. METHODS: The hospital records at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia were reviewed to identify women who underwent abdominal myomectomy or abdominal hysterectomy between 1989 and 1999. Inclusion criteria were the presence of symptoms and size of the uterus equaling that of 12 weeks gestation or more. Women who underwent myomectomy as a treatment of infertility were excluded. RESULTS: During the study period, 111 women met the inclusion criteria. Thirty-eight women underwent abdominal myomectomy and 73 women underwent abdominal hysterectomy. Forty women were excluded because of myomectomy for infertility. Abdominal myomectomy was successfully performed in all women for whom it was scheduled. Hysterectomy, internal iliac ligation, or other procedures were not necessary to control the bleeding. The primary indication for myomectomy was abnormal vaginal bleeding in 23 women and pelviabdominal mass in 15 women compared to 6 women and 67 women in the hysterectomy group. There were statistically significant differences in the mean age and parity (p value 0.01 and <0.001) between women who underwent abdominal myomectomy and abdominal hysterectomy. The uterine size clinically (mean +/- standard deviation), size of largest myoma by ultrasonography, and from histopathology reports were 15.4 +/- 3.8, 11.8 +/- 2.8, and 13.6 +/- 3.2 compared to 17.9 +/- 4.4, 16.9 +/- 4.2, and 13.8 +/- 3.7 (p values not statistically significant). Similarly, there were no statistically significant differences in the pre- and postoperative hemoglobin, estimated blood loss, rate of blood transfusion, operative time, and numbers of days in hospital. CONCLUSION: Abdominal myomectomy for big and symptomatic uterine fibroids carries similar risks to abdominal hysterectomy.

Epidermal clitoral inclusion cyst after type I female genital mutilation.

OBJECTIVE: To document the occurrence of long-term sequelae after type I female genital mutilation (FGM) and describe the surgical treatment of epidermal clitoral inclusion cyst. STUDY DESIGN: Twenty-one women presented with epidermal clitoral inclusion cyst after type I FGM at the Department of Obstetrics and Gynecology at King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. The duration (mean +/- SD, range) of symptoms was 10.3 +/- 5.4, 2 to 20 years. They were treated by excision of the cyst with particular attention to preserve the remaining part of the clitoris. The technique involves making a vertical incision in the skin, dissecting and excising the cyst, removing the excessive skin, and reapproximating the skin edges. RESULTS: The procedure was done on all patients without intraoperative complications. All except one were discharged home on the second postoperative day. Follow-up showed no recurrence of symptoms. CONCLUSION: Long-term sequelae can occur after type I FGM. The surgical treatment of clitoral inclusion cyst is simple and effective.