Alessandra J. Ainsworth

KLF11 is an Epigenetic Mediator of DRD2/Dopaminergic Signaling in Endometriosis.

Endometriosis is a heterogeneous, recalcitrant disease that affects 10% of reproductive-age women. Resistance to conventional therapy critically raises the need for novel treatment options that target specific, dysregulated underlying molecular mechanisms. Dopamine receptor 2 (DRD2) has been shown to be associated with vascularity and fibrosis in endometriosis. Transcription factor KLF11 has been implicated in the pathogenesis of several human endocrine and reproductive tract diseases including endometriosis. KLF11 recruits epigenetic cofactors for regulation of target genes; dysregulation of critical target genes and associated signaling pathways results in diverse disease phenotypes. KLF11 regulates the expression of DRD2 in neurons. We investigated the regulation of DRD2 by KLF11 in the established eutopic and ectopic endometrial cell lines as well as in an animal model of endometriosis. KLF11 binding and activation of the DRD2 promoter was conserved across species. Promoter activation was reflected in correspondingly increased gene expression in an endometrial cell line and in primary endometriotic cells. In vivo, disease relevance was further evaluated in a surgically induced murine endometriotic model using Klf11−/− and wild-type mice. Consistent with loss of Klf11-mediated activation, lesions in Klf11−/− animals were associated with progressive fibrosis and decreased Drd2 expression. KLF11 binds specific epigenetic corepressors to repress several target genes. Activation of DRD2 by KLF11 could not be explained simply by loss of corepressor binding and is thus likely due to selective coactivator recruitment; identification of the precise pathway is the focus of ongoing investigation. Characterization of pharmacologically reversible epigenetic regulatory mechanisms has translational relevance in health and disease.

Improved detection of mineral oil toxicity using an extended mouse embryo assay

PurposeSuccessful in vitro fertilization (IVF) relies on sound laboratory methods and culture conditions which depend on sensitive quality control (QC) testing. This study aimed to improve the sensitivity of mouse embryo assays (MEA) for detection of mineral oil toxicity.MethodsFive experiments were conducted to study modifications of the standard mouse embryo assay (MEA) in order to improve sensitivity using clinical grade mineral oil with known peroxide concentrations. Assessment of blastocyst development at either 96xa0h or in an extended MEA (eMEA) to 144xa0h was tested in each experiment. In experiment 1, ability to detect peroxides in oil was compared in the MEA, eMEA, and cell number at 96xa0h. In experiment 2, serial dilutions of peroxide in oil were used along with time-lapse imaging to compare sensitivity of the morphokinetic MEA to the eMEA. Culture conditions that may affect assay sensitivity were assessed in experiments 3–5, which examined the effect of group versus individual culture, oxygen concentration, and protein supplementation.ResultsExtended MEA and cell counts identified toxicity not detected by the routine endpoint of blastocyst rate at 96xa0h. The eMEA was fourfold more sensitive than the standard MEA, and this sensitivity was similar to the morphokinetic MEA. Group culture had a protective effect against toxicity, while oxygen concentration did not affect blastocyst development. Protein supplementation with HSA had a protective effect on blastocyst development in eMEA.ConclusionsThe standard MEA used by manufacturers does not detect potentially lethal toxicity of peroxides in mineral oil. While group culture may mask toxicity, protein supplementation and oxygen concentration have minimal effect on assay sensitivity. The eMEA and time-lapse morphokinetic assessment are equally effective in detection of peroxide toxicity and thus provide manufacturers and end-users a simple process modification that can be readily adopted into an existing QC program.

An unusual case of abnormal uterine bleeding due to classical Hodgkin lymphoma identified by endometrial biopsy

Abnormal uterine bleeding is one of the most common reasons for patients to attend gynecology clinics. The present report documents a case of abnormal uterine bleeding caused by endometrial involvement secondary to classical Hodgkin lymphoma. The patient providedwritten informed consent for the publication of details of the diagnosis. A female patient aged 44 years who was uniparous presented for evaluation at the study institution owing to intermittent fever and adenopathy. During evaluation, the patient reported irregular bleeding, and gynecology consultationwas sought. Thepatienthad ahistory of regular periods, occurring every 30 days and lasting 7 days. However, the patient reported a week of spotting and another week of bleeding with the passage of large clots in the month before evaluation. Uterine fibroids were documented during computed tomography evaluation. An office hysteroscopy was performed; limited visualization was achieved owing to ongoing bleeding, and an endometrial biopsy sample was collected. The endometrial biopsy sample revealed multifocal, small lymphohistiocytic foci containing scattered large atypical cells demonstrating markers that were consistent with lymphoma but of uncertain significance (Fig. 1). Subsequently, a supraclavicular lymph node biopsy sample was obtained. A diagnosis of classical Hodgkin lymphoma of mixed cellularity type was made. It is uncommon for lymphoma to involve the female genital tract; when present, this could represent a primary site of disease or secondary involvement from disseminated disease. Secondary involvement is more common and occurs in 7%–30% of patients with disseminated disease, with approximately 2500 patients affected each year [1]. The ovary is the most common site for involvement of lymphoma in the genital tract, followed by the cervix and endometrium [2]. Of lymphomas involving the endometrium, abnormal uterine bleeding is themost common symptom at presentation, followed by pelvic mass and localized pain [1,2]. Most occurrences of genital-tract lymphoma described in the literature are non-Hodgkin lymphomas, usually of B-cell lineage, and most commonly diffuse large B-cell lymphomas [2–4]. Uniquely, the present case demonstrated that classical Hodgkin lymphoma can be found in the endometrium at disease onset. To avoid misdiagnoses, lymphoma Abnormal uterine bleeding Endometrium Hodgkin lymphoma

Use of Genetic Testing after Abnormal Screening Ultrasound: A Descriptive Cohort Study

Background/Aims: The study aimed to characterize the use of genetic testing after abnormal screening ultrasound. Methods: We performed a retrospective review of patients undergoing genetic testing after abnormal ultrasound. Genetic evaluation consisted of noninvasive prenatal screening (NIPS) or amniocentesis. Classification of ultrasound findings, type of genetic testing, and results were collected. Results: A total of 139 subjects underwent genetic evaluation after abnormal screening ultrasound. Screening via NIPS was pursued by 61 (44%) patients while 78 (56%) proceeded directly to amniocentesis. Patients electing for amniocentesis had more cardiac, neurologic, and gastrointestinal malformations while soft markers for aneuploidy prompted more NIPS screening. Results were negative in 85% of the NIPS group compared to 60% of the amniocentesis group. Only 8% of patients who underwent NIPS proceeded to diagnostic testing. Conclusion: Patients pursuing NIPS after abnormal ultrasound had more soft markers of aneuploidy. Patients pursuing diagnostic testing were more likely to have major structural malformations and more total abnormalities identified. Patients who proceeded directly to amniocentesis were more likely to have abnormal genetic testing.

Lessons learned from a single institution’s retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia

OBJECTIVESnTo evaluate the risk of emergent cesarean delivery with the use of neuraxial anesthesia for external cephalic version in a single practice.nnnBACKGROUNDnRandomized trials have shown increased external cephalic version success when neuraxial anesthesia is used, without additional risk. We hypothesized that in our actual clinical practice, outside the confines of randomized trials, neuraxial anesthesia could be associated with an increased risk of emergent cesarean delivery.nnnMETHODSnThis retrospective cohort study included all women who underwent external cephalic version at a single institution with and without neuraxial anesthesia. The primary outcome was the incidence of emergent cesarean delivery (defined as delivery within 4hours of version). Secondary outcomes were version success and ultimate mode of delivery.nnnRESULTSnA total of 135 women underwent external cephalic version procedures; 58 with neuraxial anesthesia (43.0%) and 77 without (57.0%). Location of the procedure, tocolytic therapy, and gestational age were different between groups. An increased rate of emergent cesarean delivery was found in procedures with neuraxial anesthesia compared to procedures without (5/58 (8.6%) compared to 0/77 (0.0%); 95% CI for difference, 1.4 to 15.8%; P=0.013).nnnCONCLUSIONnIn this single hospitals practice, patients who may be at higher risk of complications and have a lesser likelihood of success were provided NA for ECV. As a result, the use of neuraxial anesthesia for external cephalic version was associated with a higher rate of emergent cesarean delivery. Obstetric and anesthetic practices should evaluate their patient selection and procedure protocol for external cephalic version under neuraxial anesthesia.

Does Regional Anesthesia for External Cephalic Version Increase the Risk of Emergent Cesarean Delivery? [8C]

INTRODUCTION: Previous studies have shown improved success without additional complications when external cephalic version (ECV) is performed with neuraxial anesthesia (NA). The purpose of this study was to evaluate the effect of NA at the time of ECV on emergent cesarean delivery (CD), procedure success, and subsequent vaginal delivery. METHODS: Women who underwent ECV at Mayo Clinic between January 1, 2010 and December 31, 2014 with and without NA were retrospectively studied. The primary outcome was the rate of emergency CD (delivery within 4 hours of ECV). Secondary outcomes were ECV success and ultimate mode of delivery. Outcomes were compared using the chi-square test. RESULTS: A total of 135 patients underwent 144 ECV procedures with NA use in 65 (45.1%) procedures. Increased rates of emergent CD were found with NA compared to procedures without NA (6 [9.2%] versus 0 [0%], P=.006). ECV success was unaffected by NA (36 [55.4%] successful ECV with NA versus 38 [48.1%] without NA, P=.38). Successful ECV led to subsequent vaginal delivery in only 55 (38.2%) women. CONCLUSION: NA for ECV increased the risk of emergent CD without impacting ECV success. These findings differ from previous randomized controlled trials (RCTs). The increased risk and decreased success of our ECVs compared to ECVs performed in the context of RCTs could be explained by patient selection, variation in operator experience or technique, or variation in anesthetic management. Future studies should further evaluate the risk of NA for ECV in true practice scenarios outside of RCTs.

Does Maternal Body Mass Index or Weight Gain Affect External Cephalic Version Success? [19H]

INTRODUCTION: External cephalic version (ECV) has been demonstrated to reduce the number of cesarean deliveries for fetal malpresentation. Numerous factors have been identified that affect the success rate; however, the effect of maternal weight parameters (body mass index [BMI] and weight gain) remains unclear. The purpose of this retrospective study is to evaluate the impact of maternal weight parameters on ECV success. METHODS: This is a retrospective cohort study including all women who underwent an attempted ECV at our academic, tertiary care institution from January 1, 2010 through December 31, 2014. Data were manually abstracted from the electronic medical record and included baseline maternal characteristics and ECV success. BMI was categorized as normal (less than 25), overweight (25–29), or obese (greater than 30). RESULTS: During the study period, 135 women underwent a total of 137 procedures (2 women had ECV attempts in 2 different pregnancies). One patient was excluded from analysis as data for pre-pregnancy BMI was unavailable. ECV was successful in 71 cases (52%). Pre-pregnancy BMI and BMI at the time of ECV showed a non-significant trend toward higher success rates with lower BMI (P=.87, 0.32, respectively). Additionally, mean maternal weight gain was not significantly different among successful and unsuccessful ECV (P=.56). CONCLUSION: Maternal BMI or weight gain do not appear to significantly impact ECV success. These results can be used when counseling women about the chance of successful ECV, and weight parameters should not be considered a contraindication to the procedure.