Trans-arterial embolization of acquired uterine arteriovenous malformation after Cesarean section: A case series.

BACKGROUND: Acquired uterine arteriovenous malformation (AVM) is a rare condition due to traumatic episodes in cesarean section. The patient can suffer from life-threatening hemorrhage or recurrent vaginal bleeding. Establishing this diagnosis is difficult, often misdiagnosed due to lack of information and number of cases. Trans-Arterial Embolization (TAE) procedure is rarely performed in our center. All of the cases were found with history of massive bleeding and diagnosed lately after recurrent bleeding history. Even though promising, one of our cases failed to be managed with TAE. It is important to diagnose early symptoms of AVM in order to prevent the life threatening event. CASE PRESENTATION: In these case series, four cases of AVMs after cesarean procedures will be reviewed. One could be diagnosed in less than a month but the other three took several months. The symptom of vaginal bleeding might occur a few weeks after the procedure is done, and most patients need transfusion and hospitalization. Three out of four patients were initially sent to the hospital in order to recover from shock condition, and one patient was sent for a diagnostic procedure. AVMs diagnostic was established with ultrasound with or without angiography. Three of our cases were succeeded by performing TAE procedure without further severe vaginal bleeding. One case failed to be treated with embolization and had to proceed with hysterectomy. CONCLUSION: AVM should be considered early-on in patient with abnormal uterine bleeding and history of cesarean section. Embolization is still the first-choice treatment of AVMs, otherwise definitive treatment is hysterectomy in a patient without fertility need, or impossible to perform TAE.

Knowledge, attitude, intention, and religion aspect toward fertility preservation among obstetrics and gynecology residents in Indonesia: A cross-sectional study.

BACKGROUND: The lack of knowledge from healthcare providers regarding fertility preservation will certainly affect the patient's knowledge, attitude, behavior, and also perspective. Obstetrics and Gynecology (OB/GYN) residents may most likely be the first line professionals to integrate fertility preservation technologies into their practice which plays an important task in giving an understanding of the relationship between age and fertility for patients. OBJECTIVE: This study aims to assess OB/GYN resident knowledge and beliefs regarding age-related fertility decline, intentions, and religion aspect toward fertility preservation. MATERIALS AND METHODS: A cross-sectional study was conducted on 92 Indonesian OB/GYN residents at the Cipto Mangunkusomo Hospital between November and December 2017. Data were collected using a questionnaire which had four sections, knowledge, attitude, intention, and religion aspect toward fertility preservation. RESULTS: The majority of participants believed that an OB/GYN should encourage discussions about potential childbearing desires (96.74%) and age-related fertility decline (94.57%) with patients, of which 79.34% believed that these discussions should be part of a woman's annual health examination. Cancer patients are likely to undergo oocyte cryopreservation than people who choose career as priority. From the religion aspect, fertility preservation options such as sperm, oocyte, embryo, and ovarian cortex cryopreservation were accepted by most residents with varied religions, while oocyte and sperm donor methods were unacceptable (48% and 57%, respectively) because of the belief that oocyte/sperm should only be given to legitimate partners, but many still do not know that oocyte and sperm donor were prohibited by all religions. CONCLUSION: Age-related fertility decline and frozen egg storage should be discussed during annual woman wellness examinations by OB/GYN specialists.

Anti-Mullerian hormone levels in female cancer patients of reproductive age in Indonesia: A cross-sectional study.

Background: Efforts in reproductive preservation for cancer patients have become one of the important aspects of cancer management. In fact, decline in reproductive function is known to occur after exposure to anti-cancer treatments. Measuring anti-Müllerian hormone (AMH) levels is known to be the best parameter in predicting ovarian reserves, which indicates reproductive function. In total, 68% of cancer survivors of reproductive age who underwent anti-cancer treatments suffer from infertility. Meanwhile, ovarian reserves also decrease with increasing age. There is ongoing debate on whether the ovarian reserves of cancer patients could be reduced long before exposure to anti-cancer therapy. Therefore, it is important to know whether ovarian reserves in cancer patients decrease before or after anti-cancer therapy. This can help predict the reproductive function in such cases and the effectiveness of ovarian preservation efforts. Methods: A cross-sectional study was conducted, comparing the AMH levels of 44 female cancer patients of reproductive age before cancer therapy, to 44 non-cancer patients of reproductive age (age matched) . The AMH was determined from blood.The biological ages from both groups were adjusted using the Indonesian Kalkulator of Oocytes. Results: The median age in both groups was 28 years old. The AMH levels in the blood of the cancer group were found to be significantly lower in contrast to those in the non-cancer group (1.11 [0.08-4.65] ng/ml vs. 3.99 [1.19- 8.7]; p- value <0.001). Therefore, the biological age in the cancer group was 10 years older than that of the non-cancer group, indicating that ovarian aging occurs earlier in cancer patients. Conclusions: AMH levels of cancer patients of reproductive age were already reduced before cancer therapy, given an older biological age, in contrast to that of the non-cancer patients. Proper counseling and implementation of fertility-preserving methods is highly recommended in this group of patients.

Extrapelvic endometriosis in abdominal wall scar and PPAR gamma expression: A case report.

INTRODUCTION: Endometriosis is a frequent gynecological disorder. Its findings on the abdominal wall are rare cases, usually reported with a history of former surgery. The activation of PPARy expression could be one of alternative non-hormonal treatment for endometriosis. PRESENTATION OF CASE: A patient, 34 years old, suspected of endometriosis since 5 years ago because of pain during menstruation. Since the last 4 months, she had worsening of dysmenorrhea and palpable lumps during menses. She had previously performed cesarean section surgeries 3 times and a laparotomy cystectomy due to left endometriosis cyst. From ultrasound examination, on the abdominal wall (submusculus) there is a firmly defined hypoechoic mass, sized 32 × 10 × 15 mm, derived from the mass of endometriosis. DISCUSSION: The endometriosis findings on the abdominal wall are rare cases. Symptoms usually are cyclic pain which is also accompanied by a palpable lump. A meta-analysis of 16 studies concluded that sensory excitatory threshold and pain tolerance approached the lowest value shortly before and during menstruation. In humans, administration of PPARy agonists reduced pain symptoms. Counseling to patients is given about the possibility of recurrence. CONCLUSION: PPAR expressivity assessment has not been used as a target for endometriosis therapy. Further studies separating epithelial tissue and stroma can be performed to prove the role of PPARγ in the pathogenesis of endometriosis.

Factors associated with the utilization of long-acting reversible contraceptives among family planning clients at the Pameungpeuk Rural Hospital, Indonesia.

Background: Uncontrolled population development can prompt an assortment of populace issues and can be one of the reasons for increasing maternal death rates. The utilization of contraceptives in Indonesia was progressively dominated by injectable contraceptives and pill contraceptives in 2015 (52.21% and 24.36%, respectively). However, the rate of termination of the use of short-acting contraceptives by family planning clients was higher than other methods, therefore the use of short-acting contraceptives is less efficient than long acting reversible contraceptives (LARCs)  for longer term spacing because it is easy to skip a treatment for economic or other reasons, which can result in unintended pregnancy. Therefore, the National Family Planning Program in Indonesia is encouraging the use of LARCs to control population growth. Pameungpeuk is a region which has the second largest population, with the highest total fertility rate in South-West Java. The proportion of active users of LARCs in Pameungpeuk is very low (10.66%). This study aimed to analyze factors associated with the utilization of LARCs among family planning clients at the Pameungpeuk Rural Hospital. Methods: This study design was cross-sectional with systematic random sampling. The sample group in this study was 84 family planning clients. We performed statistical analyses using chi-square test. Results: We found significant associations between the age of women (p=0.024), the cost of contraception (p=0.022), knowledge (p=0.042), beliefs (p=0.002), skill of health workers (p=0.008) and support from health workers (p=0.014). However, education (p=0.212), family income (p=0.087), attitude (p=0.593), exposure to information on LARCs (p=0.378), support from partners (p=0.094), support from friends (p=0.414) and the support of community leaders (p=0.367) had no significant association with the utilization of LARCs. Conclusions: These findings highlight a critical need for improved education among family planning clients at the Pameungpeuk rural hospital regarding the use of LARCs for both medical and elective reasons.