Comparability of perioperative morbidity between abdominal myomectomy and hysterectomy for women with uterine leiomyomas.

OBJECTIVE: The aim of this study was to compare the perioperative morbidity associated with abdominal myomectomy with that of hysterectomy. STUDY DESIGN: This was a retrospective cohort study of 394 women at an academic medical center. Main outcome measured was perioperative morbidity, with the following secondary outcomes: febrile morbidity, hemorrhage, unintended major surgical procedures, life-threatening events, and rehospitalization. RESULTS: Morbidity was associated with myomectomy and hysterectomy in 39% and 40% of cases, respectively. The crude odds ratio for morbidity of myomectomy with respect to hysterectomy was 0.93 (95% confidence interval, 0.63-1.40). Women who underwent myomectomy were significantly younger, weighed less, and had a smaller preoperative uterine size. In a multivariable analysis that accounted for these differences the odds ratio increased to 1.46 (95% confidence interval, 0.77-2.77) but still was not statistically elevated. The study had >90% power to detect a clinically relevant 15% absolute difference in overall morbidity between the 2 groups. CONCLUSION: No clinically significant difference in perioperative morbidity between myomectomy and hysterectomy was detected. Myomectomy should be considered a safe alternative to hysterectomy.

The management of hydrosalpinges before in-vitro fertilization and embryo transfer.

Several recent studies have shown that the presence of hydrosalpinges adversely affects clinical pregnancy rates achieved with in-vitro fertilization and embryo transfer. Hydrosalpinx fluid may be toxic to the endometrium or embryo, or may mechanically interfere with implantation. Some authors recommend surgical correction of hydrosalpinges before in-vitro fertilization and have shown promising results with this approach. Proper patient selection for this therapy still needs to be defined.

Postoperative day 1 serum human chorionic gonadotropin level as a predictor of persistent ectopic pregnancy after conservative surgical management.

OBJECTIVE: To determine characteristics predictive of persistent ectopic pregnancy (EP). DESIGN: Retrospective cohort study. SETTING: Tertiary care, university hospital. PATIENT(S): All women treated surgically for an EP whose postoperative hCG levels were followed until complete resolution or determination of a persistent EP over a 54-month period. MAIN OUTCOME MEASURE(S): Final outcome defined as successful treatment or persistent EP. RESULT(S): Twenty-six (17.7%) of 147 patients were diagnosed with a persistent EP. An inverse relationship was noted between the percent decrease in hCG at postoperative day 1 and the incidence of persistent EP. A significantly greater percentage of persistent EPs were noted when the postoperative day 1 hCG fell < 50% from the initial preoperative hCG level (relative risk = 3.51 [1.25 to 6.68]). No case of persistent EP was noted if the postoperative day 1 hCG declined by > or = 77%. Surgical time differed significantly (129 minutes versus 101 minutes) between cases treated successfully as compared with cases in which conservative treatment failed. No other preoperative or intraoperative variables were found to be significantly different. CONCLUSION(S): Although no single postoperative hCG value is predictive of conservative surgical treatment for EP, a day-1 postoperative hCG value may be used as a predictor of persistent EP.

Hydrosalpinx fluid enhances human trophoblast viability and function in vitro: implications for embryonic implantation in assisted reproduction.

OBJECTIVE: To assess the effects of hydrosalpinx fluid on human cytotrophoblast viability and function in vitro. DESIGN: Human cytotrophoblasts obtained from third-trimester placentas were cultured in vitro with hydrosalpinx fluid, and cell viability and protein production were assayed. SETTING: A university hospital. PATIENT(S): Ten hydrosalpinx fluid samples obtained from seven women with clearly diagnosed hydrosalpinges. INTERVENTION(S): Recovery of hydrosalpinx fluid by transvaginal aspiration or at the time of surgery. MAIN OUTCOME MEASURE(S): Cell viability was assessed by the XTT assay. Secretion of trophoblast oncofetal fibronectin (tropho-uteronectin) and beta-hCG by cultured trophoblasts was determined by Western blot and ELISA of the culture media. RESULT(S): With increasing concentrations of hydrosalpinx fluid from 0% to 20%, there was a significant increase in trophoblast cell viability (1.63-fold increase in 20% hydrosalpinx fluid). Likewise, both Western blot and ELISA assays demonstrated a significant increase in tropho-uteronectin production by trophoblasts with increasing hydrosalpinx fluid concentrations (3.76-fold increase in 20% hydrosalpinx fluid). beta-Human chorionic gonadotropin production also increased significantly in the presence of hydrosalpinx fluid (3.31-fold increase in 20% hydrosalpinx fluid). CONCLUSION(S): These findings suggest that hydrosalpinx fluid improves human trophoblast viability in vitro and enhances the production of tropho-uteronectin and beta-hCG by these cells.

Dating of pregnancy by trimesters: a review and reappraisal.

Many patients and obstetricians divide the events of human pregnancy into three intervals traditionally termed "trimesters." This system presumably arose from an equal division of the "9 months of pregnancy" into 3-month intervals. There are several problems with this system that follows pregnancy by months or trimesters. First, the average human pregnancy lasting 280 days or 40 weeks is not evenly divisible by three, leaving one to wonder how long each trimester is. Second, conversion from "weeks pregnant" to "months pregnant" is often an estimate that can foster misunderstanding between the patient and her obstetrician. Last, following pregnancy by the Gregorian calendar does not reflect embryonic or fetal developmental milestones. We propose a revision of this system to one in which natural embryonic and fetal developmental landmarks are used instead of trimesters to define the progressive stages of pregnancy. These landmarks occur approximately at 5-week intervals allowing a more simple division of pregnancy into four 10-week quartiles, each with two 5-week intervals. This article reviews many of these important landmarks within this framework. This system emphasizes a developmentally based way of understanding the events of pregnancy for both the patient and the obstetrician.

Endometrial integrin expression in women exposed to diethylstilbestrol in utero.

OBJECTIVE: To determine if the endometrium of women exposed in utero to diethylstilbestrol (DES) demonstrates altered integrin expression compared with normal fertile controls. DESIGN: Case control study. Expression of eight integrins in 15 luteal phase endometrial biopsies from DES-exposed women were compared with 17 biopsies from age- and cycle day-matched controls. All patients were ovulatory. Endometrial biopsies were performed in the luteal phase, and all were histologically "in phase." SETTING: Infertility practice of an academic teaching hospital. PATIENTS: Women exposed in utero to DES and matched fertile controls. MAIN OUTCOME MEASURES: Intensity of endometrial integrin immunohistochemical staining by the semiquantitative HSCORE technique. RESULTS: Endometrial stroma of DES-exposed women demonstrated greater expression of the integrin subunits alpha 5 and alpha v. No differences were noted between DES-exposed women and fertile controls in the glandular epithelial expression of integrin subunits alpha 1, alpha 2, alpha 3, alpha 6, and alpha v nor the stromal staining of subunits of alpha 6 and beta 3. Epithelial expression of integrin subunits beta 3 and alpha 4, reliable luteal markers of uterine receptivity, were similar in DES and control patients. CONCLUSIONS: Markers of uterine receptivity are similar in the endometrium of women exposed in utero to DES compared with normal fertile controls. Interesting differences exist in stromal integrin expression between groups, though the significance of this finding is uncertain at present. It is unlikely that DES-exposed women have significantly altered endometrial function as a cause of infertility.

Integrins as markers of uterine receptivity in women with primary unexplained infertility.

OBJECTIVE: To assess uterine receptivity in women with unexplained infertility using integrin cell adhesion molecules as markers. DESIGN: Prospective, controlled study design. PATIENTS: Eighty-seven nulliparous women with unexplained infertility and 32 fertile and infertile parous controls. MAIN OUTCOME MEASURE: Immunohistochemical staining for alpha 1, alpha 4, and beta 3 integrin subunits in endometrial biopsies obtained during the window of implantation (days 20 to 24), using the semiquantitative HSCORE by two observers in a blinded fashion. RESULTS: All endometrial biopsies from parous controls contained positive immunostaining for the alpha 1, and beta 3 integrin subunits in glandular epithelium. Some samples from parous controls were missing the alpha 4 subunit. In contrast, compared with parous controls, biopsies from women with unexplained infertility had reduced significantly beta 3 expression, with similar expression of alpha 1 and alpha 4. Two distinct defects in integrin expression were identified: "out-of-phase" samples that lacked beta 3 because of histologic lag (type I defects) and "in-phase" endometrium that still failed to express this integrin (type II defects). These subclassifications accounted for 26% and 39% of the total unexplained infertility group, respectively. CONCLUSIONS: Abnormal endometrial integrin expression was a frequent finding in women with unexplained infertility. These data suggest that defective uterine receptivity may be an unrecognized cause of infertility in this population of women.

Recurrent squamous cell carcinoma of the cervix with pulmonary lymphangitic metastasis.

A case report and review of the world literature are presented to examine all the reported cases of cervical carcinoma manifesting as pulmonary lymphangitic carcinomatosis in order to better understand this rare condition. The clinical and pathologic features of this disease process are reviewed, as are potential treatment options. We present the first reported case of an immunocompromised patient with cervical carcinoma and pulmonary lymphangitic metastasis with a prospective diagnosis made by transbronchial biopsy. Given that this condition carries a uniformly fatal prognosis, unwanted therapy may result from a missed diagnosis. A prospective pathologic diagnosis by transbronchial biopsy may guide appropriate therapy in these patients.

Aberrant integrin expression in the endometrium of women with endometriosis.

Integrins are ubiquitous cell adhesion molecules that undergo dynamic alterations during the normal menstrual cycle in the human endometrium. The alpha v beta 3 vitronectin receptor integrin is expressed in endometrium at the time of implantation, but its presence is delayed in endometrium that is assessed to be out of phase using classical histological features. To investigate the expression of this integrin in women with endometriosis, we assessed the presence of the beta 3-subunit throughout the menstrual cycle in 268 "in-phase" endometrial biopsies, using immunohistochemistry. The beta 3-subunit was expressed on endometrial epithelium after days 19-20 of the menstrual cycle. In 241 women whose biopsies were obtained after day 19, a lack of beta 3 expression was found to be closely related to the diagnosis of endometriosis (by Wilcoxon test, P = 0.02). This defect in integrin expression was associated with nulliparity, inversely related to the stage of disease, and occurred despite the presence of in-phase histological features. In a prospective double blind assessment of this integrin, we found endometrial beta 3 analysis to have a high specificity and positive predictive value as a nonsurgical diagnostic test for minimal and mild endometriosis. In conclusion, aberrant integrin expression in the native endometrium is associated with the finding of endometriosis and may identify some women with decreased cycle fecundity due to defects in uterine receptivity.