Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy: A case report.

BACKGROUND: Heterotopic cesarean scar pregnancy (HCSP) is very rare and has a high risk of massive uterine bleeding. Preservation of concurrent intrauterine pregnancy (IUP) is one of the great challenges in the management of HCSP. No universal treatment protocol has been established when IUP is desired to be preserved. CASE SUMMARY: We report a case of HCSP at 8+ wk gestation in a 34-year-old woman with stable hemodynamics. A two-step intervention was applied. Selective embryo aspiration was performed first, and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later. Both steps were performed under ultrasound guidance. The patient had an uneventful course, and a healthy baby was delivered at 34+6 wk gestation. CONCLUSION: Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP. This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.

Blood tests for prediction of deep endometriosis: A case-control study.

BACKGROUND: Deep endometriosis (DE) is the most aggressive subtype of endometriosis. The diagnosis may be challenging, and no biomarkers that can discriminate women with DE from those without DE have been developed. AIM: To evaluate the role of blood hemostatic parameters and inflammatory indices in the prediction of DE. METHODS: This case-control study was performed at the Women's Hospital, Zhejiang University School of Medicine between January 2015 and December 2016. Women with DE and women with benign gynecologic disease (control group) eligible for gynecological surgery were enrolled. Routine plasma hemostatic parameters and inflammatory indices were obtained before surgery. Univariate and multivariate analysis were performed. Receiver operating characteristic (ROC) curves were generated, and areas under the curve (AUC) were calculated to assess the predictive values of the selected parameters. RESULTS: A total of 126 women were enrolled, including 31 with DE and 95 controls. Plasma fibrinogen (Fg, P < 0.01), international normalized ratio (P < 0.05), and C-reactive protein levels (P < 0.01) were significantly higher in women with DE compared with controls. Plasma hemoglobin (HB) levels (P < 0.05) and shortened thrombin time (P < 0.05) were significantly lower in women with DE than in controls. Plasma Fg levels [adjusted OR (aOR) 2.12, 95%confidence interval (CI): 1.31-3.75] and plasma HB levels (aOR 0.48, 95%CI: 0.29-0.78) were significantly associated with DE (both P < 0.05). ROC analysis showed that the diagnostic value of Fg or HB alone for DE was limited. The AUC of the combination of both markers as a dual marker index was 0.773 with improved sensitivity (67.7%) and specificity (78.9%) at cutoffs of 3.09 g/L and 126 g/L, respectively. CONCLUSION: The combination of Fg and HB was a reliable predictor of DE. A larger study is needed to confirm the findings.

Giant exophytic cystic adenomyosis with a levonorgestrel containing intrauterine device out of the uterine cavity after uterine myomectomy: A case report.

BACKGROUND: A cystic lesion arising from the myometrium of the uterus, termed as cystic adenomyosis, has chocolate-like, thick viscous contents and contains various amounts of endometrial stroma below the glandular epithelium. It is an extremely rare type of adenomyosis. CASE SUMMARY: Herein, we report an unusual case of a giant cystic mass in the pelvic cavity after uterine myomectomy. The patient complained of abnormal uterine bleeding and severe dysmenorrhea. After a levonorgestrel-containing intrauterine device (LNG-IUD) was inserted, her symptoms were greatly alleviated. However, the LNG-IUD was detected in the cystic cavity during the follow-up. For fear of the intrauterine device migrating into and damaging the surrounding viscera, surgical treatment was proposed. Therefore, laparoscopic resection of the lesion and removal of the LNG-IUD were performed and cystic adenomyosis with an LNG-IUD out of the uterine cavity was diagnosed. CONCLUSION: We believe that myomectomy breaking through the endometrial cavity may have been a predisposing factor for the development of cystic adenomyosis in this case.

Involvement of Cl(-)/HCO3(-) exchanger SLC26A3 and SLC26A6 in preimplantation embryo cleavage.

Bicarbonate (HCO3(-)) is essential for preimplantation embryo development. However, the mechanism underlying the HCO3(-) transport into the embryo remains elusive. In the present study, we examined the possible involvement of Cl(-)/HCO3(-) exchanger in mediating HCO3(-) transport into the embryo. Our results showed that depletion of extracellular Cl(-), even in the presence of HCO3(-), suppressed embryo cleavage in a concentration-dependent manner. Cleavage-associated HCO3(-)-dependent events, including increase of intracellular pH, upregulation of miR-125b and downregulation of p53, also required Cl(-). We further showed that Cl(-)/HCO3(-) exchanger solute carrier family 26 (SLC26) A3 and A6 were expressed at 2-cell through blastocyst stage. Blocking individual exchanger's activity by inhibitors or gene knockdown differentially decreased embryo cleavage and inhibited HCO3(-)-dependent events, while inhibiting/knocking down both produced an additive effect to an extent similar to that observed when CFTR was inhibited. These results indicate the involvement of SLC26A3 and A6 in transporting HCO3(-) essential for embryo cleavage, possibly working in concert with CFTR through a Cl(-) recycling pathway. The present study sheds light into our understanding of molecular mechanisms regulating embryo cleavage by the female reproductive tract.

[Association of menopausal specific fat distribution changes with metabolic risk factors].

OBJECTIVE: To investigate the association of menopausal specific fat distribution with metabolic risk factors. METHODS: Two hundred Chinese women including 110 premenopausal women aged 39.7±9.2 y and 90 postmenopausal women aged 55.4±4.6 years were enrolled. Total and regional fat depots including android fat and gynoid fat were measured by dual-energy X-ray absorptiometry. The differences of regional fat depot between pre-and post menopausal women were compared by covariate analysis. The association of regional fat changes with metabolic risk factors were analyzed by logistic models. RESULTS: Gynoid fat was significantly decreased in postmenopausal women after accounting for total fat changes. After adjusting covariates (including age, BMI, and %BF), the inverse associations of gynoid fat with metabolic risk factors still remained (OR=1.8-3.7,P<0.05). Furthermore, the interaction between menopause and gynoid fat was significantly in all logistic models (P<0.05). CONCLUSION: Android fat was increased whereas gynoid fat was decreased after menopause. Opposite to the detrimental effects of android fat, gynoid fat was inversely associated with metabolic risk factors, especially in postmenopausal women.

Clinical utility of serum reproductive hormones for the early diagnosis of ectopic pregnancy in the first trimester.

AIM: A tubal ectopic pregnancy (EP) in the first trimester remains a major life-threatening complication for the mother. We aim to determine whether serum reproductive hormones may be clinically useful in the early identification of a tubal EP. METHODS: A total of 109 age-matched patients with a serum ß-human chorionic gonadotropin (ß-hCG) concentration <2000 IU/L were enrolled, including 68 patients with a tubal EP, 22 with a viable intrauterine pregnancy (vIUP) and 19 with a non-viable intrauterine pregnancy (nIUP). Serum was collected during the first trimester of pregnancy and assayed for ß-hCG, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone (TE), progesterone (P), estradiol (E2) and prolactin (PRL) by using automated electrochemiluminescence immunoassays. RESULTS: Patients with an EP had significantly lower levels of daily ß-hCG variation (Δß-hCG/day), P and E2, and significantly higher levels of LH and FSH than IUP patients (P<0.05). As an EP diagnostic marker, progesterone demonstrated a sensitivity of 100% at the cutoff of 86.01 nmol/L. The combination of E2 with Δß-hCG/day reached a specificity of 100% for EP evaluation. To identify non-viable pregnancies (including EPs and nIUPs), progesterone demonstrated a sensitivity of 95.40% and a specificity of 90.91% at the cutoff of 63.2 nmol/L; the diagnostic power of the receiver operating curve was 0.9702. CONCLUSIONS: A combination of Δß-hCG/day, P and E2 may help distinguish EPs and nIUPs from vIUPs, facilitating earlier diagnosis and the timely implementation of medical treatment to prevent tubal rupture.

[Management of cesarean scar pregnancy by hysteroscopy combined with uterine artery embolism].

OBJECTIVE: To investigate safety and efficacy of hysteroscopy in treatment of cesarean scar pregnancy (CSP). METHODS: From Aug. 2003 to Dec. 2011, 33 cases with CSP treated by hysteroscopy guided by transabdominal ultrasound or laparoscopy were studied retrospectively in Women's Hospital, School of Medicine, Zhejiang University. The clinical characteristics including gestational age, myometrial thickness anterior to the CSP, ß-hCG level before treatment, success rate, cure rate, operative time, blood loss, time of serum ß-hCG resolution and CSP mass clearance, and complication were collected and analyzed. RESULTS: Median gestational age was 54 days (range, 37 - 140 days). Median level of ß-hCG before treatment was 15 000 U/L (range, 3.3 - 151 747 U/L). Mean thickness of anterior myometrium was 3.3 mm. Twenty-nine cases underwent uterine artery embolism (UAE) before hysteroscopy. Pouch in the anterior uterine isthmus with gestation masses implanted were observed in 30 cases (91%, 30/33). CSP masses progressed toward the pouch or uterine cavity in all cases was removed by cutting wire loop electrode combined with curettage. The mean operative time was (34 ± 10) minutes. Both success rate and cure rate were 94% (31/33). Salvage methotrexate (MTX) therapy was administrated in one case. Complication occurred in three cases (9%, 3/33). Both massive hemorrhage rate and hysterectomy rate were performed in two cases (6%, 2/33). No uterine perforation occurred. The mean time of hCG resolution was (22 ± 10) days. The mean time of CSP mass clearance was (21 ± 12) days. Four pregnancies were achieved in four cases: one term pregnancy and three abortions. No recurrent CSP occurred. CONCLUSION: Management of CSP by hysteroscopy combined with UAE is safe and effective.

[Clinical efficacy of Gengxueting and its effect on estrogen receptor and progesterone receptor in patients with hysteromyoma].

OBJECTIVE: To explore the clinical efficacy of Gengxueting (GXT) in treating hysteromyoma and its effects on estrogen receptor (ER) and progesterone receptor (PR). METHODS: Sixty-four hysteromyoma patients with surgical indication were equally assigned to the treated group and the control group. Patients in the treated group were treated with GXT one capsule every day for 90 consecutive days before surgical operation, while those in the control group were treated with surgery alone. Serum levels of reproductive hormones were determined in the follicular phase before medication and one day before operation by RIA, and colored Doppler ultrasound examination was conducted for measuring the size of uterus and myoma. Moreover the protein expressions of ER and PR in tumor and uterine muscular tissues were detected by immunohistochemistry assay with streptomycin avidin-biotin peroxidase complex method. RESULTS: In the treated group after medication, the serum level of estradiol was (167.0 +/- 85.9) pmol/L, progesterone (1.9 +/- 1.0) nmol/L, follicle-stimulating hormone (10.4 +/- 2.1) IU/L, and luteinizing (12.0 +/- 9. 8) IU/L, all reached the levels of early follicular phase, with the maximal size of myoma significantly decreased from (380.4 +/- 21.0) cm3 to (162.3 +/- 14. 8) cm3 (P < 0.01); and the ER and PR expressions in tumor tissue were significantly lower than those in the control group respectively (P < 0.01). CONCLUSION: Expressions of ER and PR in hysteromyoma tissue could be significantly reduced by medication of GXT, which leads to significant shrinkage of tumor size and improvement of clinical symptoms.

[Determination of interleukine-16 levels in peritoneal fluid and serum of women with endometriosis].

OBJECTIVE: To investigate the role of interleukine-16 (IL-16) in the pathogenesis of endometriosis. METHODS: Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of IL-16 in peritoneal fluid and serum specimens of 22 women with different stage endometriosis and 22 controls. RESULTS: The median levels of IL-16 in peritoneal fluid and serum were 290.5 pg/ml and 539.4 pg/ml in women with endometriosis, and 296.6 pg/ml and 778.1 pg/ml in controls, respectively; there was no significant difference between two groups (P>0.05). However, the IL-16 levels in peritoneal fluid and serum of patients with minimal/mild stage endometriosis and controls were all significantly higher than those of patients with moderate/severe endometriosis (P<0.01, <0.05). In addition, there was no statistical correlation of peritoneal IL-16 levels with those in serum (P>0.05). CONCLUSION: Reduced levels of IL-16 in peritoneal fluid and serum of women with advanced stage endometriosis may imply a role of IL-16 in the development and progression of endometriosis.