Correlation between asymmetric dimethylarginine maternal plasma levels and preeclampsia.

OBJECTIVE: To aim of our study is to support the correlation between blood pressure and asymmetric dimethyl argine (ADMA) concentrations as a possible marker for early diagnosis of the preeclampsia syndrome. STUDY DESIGN: We attempted to calculate in 38 pregnant women with preeclampsia (group A) plasma levels of the main inhibitor to nitric oxide synthase (NOS), which is ADMA, and to compare our findings with the levels of ADMA in 36 non preeclamptic pregnant women (group C) and also with the levels in 29 pregnant women who had a history of preeclampsia in previous pregnancies (group B). Maternal venous EDTA plasma samples of 5 ml were collected and analyzed to measure the ADMA concentrations in each subject. Statistical analysis was performed using the Graph Pad Instat Mann-Whitney test, unpaired, non parametric test, two-tail p values. RESULTS: There was no statistical difference between the three groups regarding maternal and gestational age (24-32 weeks). There was a significant statistical difference between the three groups regarding ADMA levels. The two-tailed p value between group A and group C (normal group) was < 0.001, between group A and group B < 0.002 and between group B and group C < 0.002. CONCLUSION: In conclusion we have observed that ADMA probably fulfills many of the criteria to be characterized as a preeclamptic factor and an accurate cut-off point matched to each week of pregnancy should be determined.

Pregnancy-associated breast cancer--a review analysis.

UNLABELLED: The aim of the present review was to assess the relationship between pregnancy and/or lactation and breast cancer, the influence of pregnancy on mortality and prognosis of the disease, the consequences of breast cancer to the current pregnancy and also to discuss the future perspective for women's fertility. MATERIALS AND METHODS: Articles were obtained from Medline (1988 present) using as keywords breast cancer, pregnancy, breastfeeding, lactation, carcinoma and pregnancy. RESULTS: Unfortunately, delays in diagnosis and treatment are common during pregnancy and the prognosis is thus worsened. Nulliparity, early menarche and late age at first pregnancy are associated with increased risk for breast cancer. Breastfeeding confers a protective effect on risk of breast cancer, which appears to be related to the duration of breastfeeding. In cases of advanced metastatic disease during the first 14 to 15 weeks of pregnancy when chemotherapy is necessary for prompt treatment, termination of pregnancy may be proposed, particularly if the patient is ER-positive. Modified radical mastectomy is probably the procedure most frequently used today. In general chemotherapy should be delayed until after 14 to 15 weeks of gestation and radiation should be reserved until post delivery. Several authorities generally advise that future pregnancy should be delayed for at least two years after breast cancer treatment. CONCLUSION: Breast cancer has an equivalent prognosis in pregnant and non pregnant patients when matched by age and stage at diagnosis. Women are invariably best treated by multidisciplinary teams.

Verification of the accuracy of cervical cytology reports in women referred for colposcopy.

OBJECTIVE: To verify the accuracy of cervical cytology in correlation with colposcopic and histological findings. DESIGN/SETTING/POPULATION/METHODS: In this retrospective chart review study 545 women, referred to the outpatient clinic for colposcopy, were included in the study. During the 4-year study period, two consultants performed the colposcopies and further necessary procedures, whereas patient charts were reviewed by two of the co-authors. RESULTS: The median age of the study population was 35 years (range: 16-65). Thirty-four percent of the cases were new and 11% of the women were referred after receiving their first ever cervical smear. Ninety-two percent (503/545) of the colposcopies were satisfactory. Concordance between colposcopic findings and the histology report was 87%, whereas concordance between cytology and histology reports was as low as 60% for HPV-related lesions, 72% for LGSIL and 86% for HGSIL. "See and Treat" was offered to 53 (10%) women and 48 (90.5%) of them had high-grade lesions on histology justifying treatment at the first visit. CONCLUSIONS: The concurrent use of cytology and colposcopy provides better chances for earlier detection of lesions demanding intervention; 80%-90% of patients with severe dyskaryotic smears will have a histology report confirming CIN III. See and treat management can be decided sometimes, if supported by the colposcopic findings, and an audit should confirm accuracy to, at least, 90% of cases.

D-dimer levels as a predicting factor for DIC following single twin death: a case report and review of the literature.

BACKGROUND: Intrauterine death of one twin in the second or third trimester occurs in about 1% of all twin pregnancies. The retention in utero of the dead fetus may be associated with maternal disseminated intravascular coagulation. CASE: We present the case of a diamniotic monochorionic pregnancy with intrauterine death of the first twin at 24 weeks. The pregnancy reached 33 weeks. In our case although all coagulation factors were within normal limits, D-dimer levels were significantly high, without any evidence though of any clotting problems to the mother. CONCLUSION: The role of D-dimers is practically unknown in multiple pregnancies. It seems that the interpretation of elevated D-dimer levels is still of limited value for prediction or prognosis of thromboembolic complications of multiple pregnancies.

Intravenous administration of iron sucrose for treating anemia in postpartum women.

BACKGROUND: To compare the efficacy of oral and intravenous administration of iron supplements for treating postpartum anemia. METHODS: One hundred and four anemic postpartum women were studied prospectively. The criteria for the diagnosis of anemia were Hb<8 gr/dl and ferritine<10 microg/dl. They were randomised into two groups. Group A consisted of 78 women who received i.v. a total amount of 300 mg iron sucrose in three days. Group B consisted of 26 women, who received orally 800 mg iron proteinsuccinylate daily for four weeks. RESULTS: At the end of the study, in group A the increase of Hb mean level was 4.6 gr/dl and of ferritin mean level was 105 mg/L. In group B the increase in hemoglobin mean level was 2.3 gr/dl and ferritin mean level was 68 mg/L. There was significant difference in the increase of hemoglobin level (p=0.0001) and also in the increase in ferritin level (p=0.0004) between the two groups. CONCLUSION: Intravenous administration of iron sucrose seems to be safe and it helps postpartum women to recover early from anemia.

Incidental diagnosis of atypical polypoid adenomyoma in a young infertile woman.

Atypical polypoid adenomyoma (APA) is considered to be a rare, benign form of a polypoid mass that exhibits glandular and squamous epithelial cell proliferation with varying degrees of atypia in association with cellular smooth muscle stroma. More frequently it manifests during the reproductive and premenopausal age with a reported mean age of 40 years. The published series indicates an average risk of endometrial carcinoma of 8.8% in women with a history of polypoid adenomyoma. The differential diagnosis of APA includes complex endometrial hyperplasia with atypia, invasive adenocarcinoma, adenofibroma, adenosarcoma and carcinosarcoma. The recognition of these unusual benign uterine tumors is very important, because they can easily be misdiagnosed. Treatment may vary depending on the patient's age, her desire to preserve fertility and the severity of her symptoms. We present a case of an infertile 39-year-old woman with an incidental diagnosis of APA.

A four-year retrospective study of amniocentesis: one centre experience.

AIM: Monitor the performance of the amniocentesis procedure for prenatal diagnosis and particularly the acquisition of results (time to get, success in getting them). MATERIALS AND METHODS: This is a retrospective review of case notes of all pregnant women undergone amniocentesis in our department during the period 2002-2005. Two main operators performed the procedure, using 22 gauze needle usually and 20 gauze should longer needle was needed. Sevendy three patients undergone amniocentesis. The reasons for having this procedure were: increased risk for Down syndrome in 68% (50/73), maternal request in 24% (18/73), suspicious ultrasound findings in 4% (3/73) and family history in 3% (2/73). Maternal age ranged from 20 to 45 years and the gestation time that amniocentesis was performed was 15 to 23 weeks. Fluorescence in situ hybridization (FISH) and culture were used in order to obtain karyotype results. RESULTS: In 92% (67/73) of cases one needle pass was needed. FISH and culture were performed in 96% (70/73) of cases, FISH only in 3% (2/73) and culture only in 1% (1/73). The chromosome results were normal in 93% (68/73) of cases, Down's syndrome in 4% (3/73) and Edwards syndrome in 3% (2/73). The outcome of pregnancies was: live births in 89% (65/73), stillbirths at 32 weeks and 35 weeks in 3% (2/73), miscarriages in 1% (1/73 at 19 weeks, 3 weeks after the amniocentesis), terminations in 7% (5/73, due to chromosomal abnormalities). Sixty one women delivered at term (84%) and 6 women (8%) delivered preterm. CONCLUSION: The post amniocentesis rate of miscarriage is calculated at 1% in our centre. FISH analysis can relieve stress of couples by reducing the waiting time for results.

Tension free vaginal tape underneath bladder base: does it prevent cystocele recurrence?

OBJECTIVE: The target of the current prospective study was to assess the effectiveness of the polypropylene tapes in preventing recurrence of cystocele formation when placed underneath the bladder base. MATERIALS AND METHODS: Twenty-two Caucasian women, predominantly postmemopausal with marked descent of the anterior, middle and/or posterior pelvic segment, participated in the study. Vaginal reconstructive surgery including anterior colporrhaphy and Kelly placation, posterior colpoperineorrhaphy and/or hysterectomy, was undertaken in all subjects. The polypropylene tape was placed not under the midurethra, as often performed in stress urine incontinence (SUI) cases, but underneath the bladder base as an adjunct to the anterior colporrhaphy sutures. The postoperative follow up lasted 2 years and was carried out every 4 months. The assessment of the anatomic result included evaluation of the operated sites and the position of the tapes inserted on clinical grounds and after perineal sonography. Urodynamic assessment was performed in the presence of urinary incontinence. RESULTS: In all patients the postoperative correction of the anterior vaginal wall was sufficient, 14 subjects did not present genitourinary symptoms and therefore were considered as cured; three patients were designated as improved because despite sufficient anatomic correction of the anterior vaginal segment they reported urinary incontinence symptoms. Retropubic haematoma occurred in 1 patient, transient urge incontinence in 1, transient stress incontinence in 1, and persistent stress incontinence also in 1. There was no erosion of the tape noticed. Mean residual urine was 30 ml, mean bladder base distance to the inferior edge of the symphysis pubis was 1.2 cm and the mean total vaginal length was 7 cm. CONCLUSION: Despite the relative short follow up period and the limited number of patients enrolled, we conclude from our study that the use of polypropylene tapes as an adjunct for fortification of the anterior pelvic segment could provide an option in preventing recurrence of cystocele formation.

A prospective two years study of first trimester screening for Down syndrome.

INTRODUCTION: Nowadays maternal age of pregnant women has increased in most developed countries. The rate of women above 35 years old constitutes about 15% of pregnancies. AIM: The aim of our study is to prove that by first trimester screening, the number of women who have indication for invasive prenatal diagnostic procedure is significantly reduced. MATERIALS AND METHODS: This prospective study lasted two years from 02/2005 to 02/2007. The participants to our study were 531 pregnant women with a mean maternal age of 30 years (19-42). We used the first trimester screening test for Down's syndrome. The biochemical blood test of free b-hCG (beta human chorionic gonadotropin) and PAPP-A (pregnancy associated plasma protein A) and the measurement of nuchal translucency were performed between 11-13 weeks +6 days (mean gestational age 12 weeks +2 days). RESULTS: In our study group, 69 women (12%) were 35 years old or more. The risk estimate for Down syndrome was 1 in 300 or more in 14 (2%) cases. In all these 14 cases we offered CVS (chorionic villus sampling) or amniocentesis. CONCLUSION: It is a fact that although the risk of any individual 36 years old is higher, most abnormalities (approximately 70%) occur in the low risk population. With the first trimester screening the sensitivity of detecting DOWN syndrome reaches 90%. Our study confirms that by first trimester screening, the number of women who have indication for invasive prenatal diagnostic procedure is significantly reduced. As a result the cost for prenatal diagnosis of the population and also the risk of iatrogenic missed miscarriages is also reduced. Finally, this screening method gives the advantage of early diagnosis.

Ligation of internal iliac artery for severe obstetric and pelvic haemorrhage: 10 year experience with 11 cases in a university hospital.

Bilateral iliac artery ligation is an effective second-line procedure to control massive obstetric and gynaecological haemorrhage, it is life-saving in certain cases and has the advantage that it preserves fertility, which is particularly important in young women of low parity. Bilateral ligation of internal iliac arteries is a life-saving procedure in cases of massive obstetric haemorrhage. It has the advantage of preserving fertility compared with the commonly performed emergency obstetric hysterectomy. It has also proved effective in cases of secondary pelvic haemorrhage in gynaecological operations. We report here a case series of 11 women who had bilateral internal iliac artery ligation for severe pelvic haemorrhage in a period of 10 years in our department. Ten of them were obstetric cases and one was a case of haemorrhage following vaginal hysterectomy. The outcome was favourable in 10 out of the 11 cases and there was only one case of massive postpartum haemorrhage where the procedure failed and required an emergency hysterectomy.

Anterior vaginal wall reconstruction: anterior colporrhaphy reinforced with tension free vaginal tape underneath bladder base.

OBJECTIVE: To assess the effectiveness of the polypropylene tape in preventing cystocele recurrence. METHODS: Fifty Caucasian women aged 50-77 years (mean age 66.6 years), with stage II-IV pelvic organ prolapse, enrolled into the study. Vaginal reconstructive surgery included an anterior colporrhaphy on all patients, posterior colpoperineorrhaphy on 28 patients and hysterectomy on 36 patients. Patients were divided into a study group of 28 women and a control group of 22 women. As reinforcement to the anterior colporrhaphy procedure, in the study group a polypropylene tape (TVT-O) was placed underneath the bladder base and fixed with polyglactin sutures. Postoperative follow-up was carried out every 4 months (total 48 months). The assessment of the anatomic result included both clinical evaluation of the operated sites and perineal sonography. RESULTS: The mean postoperative distance of the bladder base to the inferior edge of the symphysis pubis was 1.5 cm (range: 1.0-2.2 cm) in the study group and 2.8 cm (range: 2.0-3.8) in the control group. Postoperatively, there were two cases of stress incontinence and two cases of urge incontinence, one in each group. No case of tape erosion was noted, no dyspareunia and no recurrent cystocele in the study group. Four cases of recurrent cystocele (20%) were reported in the control group. CONCLUSION: While the preliminary results of our study are encouraging, larger series of patients and longer follow-up are required to verify the effectiveness of the aforementioned modification.

Anorexia nervosa in pregnancy: a case report and review of the literature.

Anorexia nervosa is a complex illness rarely encountered in pregnant women. It is a disorder characterized by markedly decreased food intake accompanied by a distorted body image, resulting in an inability to maintain the body weight within 85% of ideal body weight. We describe a case of a pregnant woman diagnosed with anorexia nervosa at 28 weeks of gestation. Her body mass index was 17 kg/m(2). A live male infant weighing 2,08 kg was delivered prematurely via vaginal delivery at 35 weeks of gestation. Pregnant women with anorexia nervosa may have a higher risk of hypertension, miscarriage, difficult labour, premature delivery and intrauterine growth restriction. Management of pregnancy complicated with anorexia nervosa requires involvement of a multidisciplinary team and hospitalization in severe cases.

Knowledge and practice of contraception among Greek female medical students.

OBJECTIVE: In Greece, modern contraceptive methods are used on a limited scale. This study aimed to investigate the knowledge as well as the practice of contraception among female medical students in Greece. STUDY DESIGN: Knowledge and practice of contraception of 102 female graduating medical students were assessed with a self-administered, anonymous questionnaire. RESULTS: Most students were using condoms as the only contraceptive method (45.1%) and 16.7% were not applying any contraceptive method at all. Oral contraceptives were used as only contraceptive means by 4.9% of the students and in combination with condoms by another 4.9%. Condoms were thought to be the most effective contraceptive method available by 28.4% of the students, whereas 4.9% responded that they did not consider any contraceptive method to be effective. Only 55.9% of the students had ever asked their gynaecologist about contraception. CONCLUSION: Much more time should be spent in teaching contraception in the Greek medical schools to ensure the delivery of adequate family planning guidance by future practitioners.

A case of unilateral Horner's syndrome after combined spinal epidural anesthesia with ropivacaine 10mg/mL for cesarean section.

We report a case of transient unilateral Horner's syndrome during the setting of combined spinal epidural anesthesia for elective cesarean section using ropivacaine 10mg/mL. The pathophysiology of Horner's syndrome and the possible mechanisms in relation to combined spinal epidural anesthesia are also presented.

Simultaneously detected primary malignant tumors of ovary and endometrium with unusual histology.

A case of a mucinous adenocarcinoma of the ovary with a synchronous endometroid tumor of the endometrium with focal features of undifferentiated carcinoma and deep myometrial invasion is reported. A review of the literature revealed that our case is interesting in view of the fact that simultaneous presentation of primary ovarian and endometrial neoplasms is rare and usually related to low-stage ovarian lesions and well-differentiated and superficial endometrial carcinomas in contrast to our case with the focal features of undifferentiated carcinoma and the deep myometrial invasion. These double tumors usually present in premenopausal subfertile women with abnormal uterine bleeding. The prognosis in most of the cases is surprisingly good even after total abdominal hysterectomy and bilateral oophorectomy alone without adjuvant chemotherapy or irradiation.

Early antiplatelet and antithrombotic therapy in patients with a history of recurrent miscarriages of known and unknown aetiology.

OBJECTIVES: To assess the efficacy of early thromboprophylaxis throughout pregnancy in women with previous history of first trimester recurrent miscarriages of unknown aetiology. METHODS: Low dose aspirin and low molecular weight heparin (LMWH) were administered from the day of detection of the fetal heart up to the 37th week, in two groups of patients of known (Group A, n = 24) and unknown aetiology recurrent miscarriages (Group B, n = 27). RESULTS: The success rate (viable pregnancy >24 weeks) was high and equally effective in both Groups A and B (83.3% and 85.1%, respectively). The complications recorded (pre-eclampsia, IUGR, placenta abruptio, injection site heamatomas and skin reactions) were more prevalent in Group A but of no significant difference. No abnormal bleeding was observed during vaginal delivery or caesarean section. CONCLUSIONS: Our results reaffirm previous reports that the use of LMWH in combination with low dose aspirin throughout pregnancy is safe and effective. It was also shown that the treatment is equally effective against recurrent miscarriages in both groups of patients, of known and unknown aetiology.

Fine needle aspiration cytology of the ovary: is it reliable?

PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate the cytologic findings from the fluid of ovarian cysts in comparison with the histologic diagnosis. METHODS: Over a four-year period all women with single ovarian cysts and no evidence of malignancy from ultrasound examination and tumour marker levels were included in the study. Prior to removal of the cyst, fluid was aspirated from the cyst and prepared for cytologic examination. Subsequently the ovarian cyst wall and biopsy from the ovary were sent for histologic examination. The cytologic findings were compared to the histologic diagnosis. RESULTS: The material of the study was 120 ovarian specimens from 107 women. Twenty-four (20%) of the specimens submitted for cytology were non diagnostic and a comparison between cytologic and histologic findings was possible in 96 cases. The sensitivity and the specificity of fine needle aspiration (FNA) cytology of the ovary was 25% and 97%, respectively. CONCLUSIONS: FNA cytology of the ovary is an accurate method for predicting benign ovarian histologic findings in carefully selected populations.