Cystoid macular edema secondary to paclitaxel therapy for ovarian cancer: A case report.

Paclitaxel is a member of the taxane agents that has demonstrated efficacy in ovarian cancer, both in first- and in second-line therapy. Counted among the side-effects of this drug are neurological disorders. In the present study, a rare case of a non-neuropathic ocular disorder, known as cystoid macular edema (CME), due to paclitaxel in patients treated for ovarian cancer is described. Macular edema, or CME, is a common cause of visual impairment that has been classically demonstrated by fluorescein angiograms, showing capillary leakage. CME without fluorescein leakage is rare, and its most common causes are juvenile X-linked retinoschisis, Goldmann-Favre syndrome, and niacin toxicity. At the present time, the mechanism associated with the form of CME that does not exhibit any signs of fluorescein leakage has not been elucidated due to an absence of histopathological studies. Several mechanisms have been proposed, although it is considered to occur due to disruption of the normal blood-retinal barrier by molecules with a molecular weight lower than that of fluorescein, which leads to fluid accumulation in the intracellular space. It is well known that taxane agents cause fluid retention, represented by edema, weight gain, and third-space fluid collection (pericardial, pleural, ascites), and this appears to be associated with their cumulative dose. The present case study confirms that macular edema associated with paclitaxel use exhibits spontaneous resolution following discontinuation of the causative agent. Taxane-associated maculopathy has been scarcely reported in the literature, but the gynecological oncologist should be alert to its possible development, and an ophthalmologic evaluation should be offered to all patients using paclitaxel.

Robotic-Assisted Conservative Excision of Retrocervical-Rectal Deep Infiltrating Endometriosis: A Case Series.

Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Colorectal DIE accounts for 70% to 93% of all the intestinal endometriotic sites and frequently needs a surgical approach. However, the indications for the surgical management of this condition are still controversial. From March 2010 to June 2014, we scheduled 33 consecutive patients presenting with retrocervical-rectal DIE of any diameter not involving the mucosa nor producing rectal stenosis >50% for laparoscopic robotic-assisted nerve-sparing rectal nodulectomy (LRN). All patients were examined preoperatively, at 3 months and 6 months postoperatively, and yearly thereafter. Dysmenorrhea, dyschezia, dyspareunia, and dysuria were evaluated on a 10-point visual analog scale. Among the 33 enrolled patients, 31 (93.9%) fulfilled the selection criteria and were submitted to LRN. In 1 out of 31 available patients (3.2%), a segmental bowel resection was considered necessary for prudential purpose at the end of the nodulectomy procedure. No laparotomic conversion was performed in any case. A wide variety of associated surgical procedures were performed in 25 of 30 patients (83.3%). No intraoperative complications were observed. One grade 3b and 2 grade 1 postoperative complications were recorded. The mean larger axis of the excised nodules measured on the formalin-fixed specimen was 26.4 mm. We found significant improvements in patient symptoms at a 3-month follow-up which persisted over the time. We observed 2 (6.7%) recurrences of intestinal endometriosis and 1 (3.3%) recurrence of chronic pelvic pain without clinical and/or radiologic evidence of endometriotic lesions. The mean follow-up time was 27.6 months. We believe that LRN is feasible and safe and shows promising results in terms of radicality, anatomic recurrence rate, and pain recurrence rate for treating isolated retrocervical-rectal DIE not involving the mucosa, without limiting this procedure to nodules smaller than 3 cm.

Tranfusion risk: is "two-step" vaginal delivery a risk for postpartum hemorrhage?

OBJECTIVE: In the active management strategy of third stage of labor, the optimal timing for clamping the umbilical cord after birth has been a subject of controversy. We want to evaluate if "two-step" delivery is a risk factor for postpartum hemorrhage (PPH), defined as need of transfusion, comparing to operative delivery, elective caesarean delivery and emergency caesarean delivery. METHODS: This is a retrospective cohort study conducted in division of Perinatal Medicine, Policlinico Abano Terme. We evaluated the need of transfusion in all cases of PPH verified in all single deliveries between January 2011 and December 2012. The main outcome measure was blood loss and red blood cell transfusion. RESULTS: We found 17 cases of PPH (0.88%). The distribution of PPH in relation to mode of delivery was 0.71%, 2.46% and 1.98% respectively for two-step vaginal delivery (RR = 0.81 (0.56-1.22)), emergency cesarean section (RR = 2.88 (1.27-7.77)) and operative vaginal delivery (RR = 2.88 (0.59-5.66)). In labor induction there is a stronger relative risk association between PPH and as emergency cesarean delivery (p < 0.05) as operative vaginal delivery (p < 0.05). CONCLUSION: "Two-step" delivery approach did not increase the risk of PPH with respect to operative delivery, elective caesarean section and emergency caesarean section.

Transvaginal sonography for preoperative assessment of deep endometriosis.

PURPOSE: To determinate transvaginal scan (TVS) accuracy in the preoperative evaluation of deep endometriosis in a large cohort of patients with subsequent laparoscopic assessment. METHODS: A retrospective study was performed in a tertiary referral center for endometriosis. Transvaginal scan reports were retrieved from an electronic database of all patients who underwent laparoscopy for pelvic pain or infertility in 2009. The accuracy of TVS was assessed for 10 different sites of pelvic endometriosis. RESULTS: Four hundred twenty women were included in the study. Sensitivity and specificity of TVS were 61% and 99%, respectively, for bladder endometriosis, 52% and 96% for endometriosis of rectovaginal septum, 65% and 99% for rectum endometriosis, and 69% and 98% for endometriosis of the sigmoid colon. CONCLUSIONS: TVS appears to be useful for the detection of endometriosis located in the bladder and involving the sigmoid colon, the rectovaginal septum, and the rectum.

Apoptosis in normal ovaries of women with and without endometriosis.

The aim of this study was to evaluate the factors predisposing to implants of endometriotic lesions in normal ovarian cortexes of women with and without endometriosis by assessing the expression of pro-apoptotic and anti-apoptotic factors and follicular density. Ovarian biopsies were performed during laparoscopy in 18 patients with endometrioma and in 10 healthy women. Detection of apoptosis was performed with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling assay. p53 and BCL2 proteins were assessed by immunohistochemistry. Quantitative real-time polymerase chain reaction was performed to evaluate BAX , BAK , BCL2 , BCL-XL , survivin and beta-actin ( ACTB ) expression. The p53 protein was positive in a significantly higher number of secondary follicles, whereas the B-cell chronic lymphocytic leukaemia/lymphoma 2 (BCL2) protein was positive in all follicles in unaffected tissue of endometriotic women, compared with the controls. Overexpression of the BCL2 and survivin genes and a decreased BAX and BAK gene expression were observed in the endometriotic group although only the difference in survivin expression was significant (P = 0.016). The BCL2 / BAX ratio showed an increased value in the ovarian cortex in controls compared with endometriosis patients. In conclusion, the reduction of apoptosis in unaffected tissue in women with endometriosis suggests that they may be predisposed to develop endometriosis.

Follicular growth and oocyte maturation in GnRH agonist and antagonist protocols for in vitro fertilisation and embryo transfer.

BACKGROUND: The aim of this study was to evaluate the response to treatment in a group of patients undergoing IVF and randomised to receive GnRH-antagonist or the GnRH-agonist. The endpoints were the pattern of follicular growth, the maturity of the oocytes collected, the embryo quality and the pregnancy outcome. METHODS: A total of 136 patients undergoing IVF were included. Sixty-seven patients were allocated to the GnRH antagonist and 69 patients to the GnRH agonist. GnRH antagonist was administered when the leading follicle reached a diameter of 12-14 mm. GnRH agonist was administered in a long luteal protocol. RESULTS: The mean numbers of oocytes retrieved and mature oocytes were significantly higher in the agonist than in the antagonist group (p < 0.02 and p < 0.01, respectively). Embryo quality, implantation rate, clinical pregnancy rates, ongoing pregnancy rate and miscarriage rate were similar in both groups. CONCLUSIONS: Better follicular growth and oocyte maturation are achieved with GnRH agonist treatment. However, both regimens seem to have similar efficacy in terms of implantation and pregnancy rates. Further studies clarifying the effect of the GnRH antagonist on ovarian function are needed, as well as a clear definition of the best period of the follicular phase for the GnRH antagonist administration.

Intrauterine insemination with recombinant or urinary human chorionic gonadotropin: A prospective randomized trial.

AIM: Our aim was to compare the efficacy and safety of recombinant and urinary human chorionic gonadotropin (rhCG and uhCG, respectively) for the induction of follicle maturation in women undergoing intrauterine insemination (IUI). METHODS: Patients were randomized to receive rhCG or uhCG. IUI was carried out 24 h (day 1) and 48 h (day 2) after hCG administration, except for all cases in which ovulation occurred after 24 h. RESULTS: The two treatments were comparable in terms of progesterone levels on day 7 and day 12. Pregnancy rates were comparable between the treatment groups. Of the 64 women who received rhCG, 29.7% became pregnant; there were 16.7% clinical pregnancies and 3.1% biochemical pregnancies per started cycle, and an ongoing pregnancy rate of 93.7% was reported. Of the 61 patients who received uhCG, 24.6% became pregnant; there were 15.9% clinical pregnancies and 1.1% biochemical pregnancies per started cycle, and ongoing pregnancy rate was 92.9%. No adverse effects were noted in either group. CONCLUSION: The recombinant products can be effectively used instead of urinary products; moreover, apart from the equivalent efficacy in ovulation induction and safety described in this study, it is necessary to consider the advantages provided by the recombinant form.