Evangelos Makrakis

Creation of a neovagina following Williams vaginoplasty and the Creatsas modification in 111 patients with Mayer- Rokitansky-Kuster-Hauser syndrome

OBJECTIVE Evaluation of the Creatsas modification of Williams vaginoplasty for the creation of neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome). DESIGN Record of perioperative and postoperative results and complications. Follow-up evaluations of patients yearly after the operation. SETTING Division of Pediatric-Adolescent Gynecology and Gynecologic Corrective Surgery, University of Athens (tertiary referral center). PATIENT(S) One hundred eleven patients with MRKH syndrome. INTERVENTION(S) Surgical creation of neovagina using the Williams vaginoplasty technique (group A: 10 patients) or the Creatsas modification of the previous method (group B: 101 patients). MAIN OUTCOME MEASURE(S) Length and width of the neovagina, and the quality of sexual life postoperatively. RESULT(S) A functioning vagina of 10 to 12 cm depth and 5 cm width was created in eight of the patients in group A (80%) and in 98 of those in group B (97.02%). A vagina of 7 to 9 cm depth and 2 to 3 cm width was created in the rest of the patients in both groups. In group A, two wound openings were reported (20%); in two of the patients hemorrhage occurred during the first intercourse, compared to none in group B. A satisfactory sexual life was reported from 94.4% of the patients and an adequate one from 4.16% of them. CONCLUSION(S) The Creatsas modification of Williams vaginoplasty is a simple and effective technique for the creation of a functioning neovagina in young women with vaginal aplasia.

Low-molecular-weight heparin versus intravenous immunoglobulin for recurrent abortion associated with antiphospholipid antibody syndrome

To compare low‐molecular‐weight (LMW) heparin plus low‐dose aspirin with intravenous immunoglobulin (IVIG) in the treatment of antiphospholipid antibody syndrome in women with recurrent spontaneous abortions before 10 weeks of gestation.

Hysteroscopy in Women with Implantation Failures after In Vitro Fertilization: Findings and Effect on Subsequent Pregnancy Rates

OBJECTIVE To evaluate hysteroscopic findings and estimate the effect of hysteroscopy on achieving a pregnancy in women with a history of 2 implantation failures after in vitro fertilization (IVF). DESIGN Prospective observational and matched case control study. DESIGN CLASSIFICATION II-2. SETTING Private assisted reproduction units. PATIENTS A total of 1475 patients with a history of 2 consecutive implantation failures after IVF who had a hysteroscopy were studied; there were 414 matched pairs of women with a similar history who either had or did not have a hysteroscopy. INTERVENTIONS Hysteroscopy (diagnostic or operative), IVF/intracytoplasmic sperm injection cycle. MEASUREMENTS AND MAIN RESULTS Hysteroscopic findings, clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) were measured. In all, 36.6% of the study population had abnormal hysteroscopic findings and 22.2% had unsuspected findings; women with abnormal hysteroscopic findings showed significantly increased CPR and increased OPR in a new IVF cycle compared with those with a normal hysteroscopy result. Women who had a hysteroscopy showed significantly increased CPR and OPR compared with matched control subjects who did not have the procedure. Hysteroscopy and appropriate therapy significantly increased the chances of achieving a subsequent clinical and ongoing pregnancy. CONCLUSION Women with 2 implantation failures after IVF had a remarkably high possibility for unsuspected abnormalities seen at hysteroscopy. Hysteroscopy could serve as a positive prognostic factor for achieving a subsequent pregnancy.

Elevated circulating IL-1β and TNF-alpha, and unaltered il-6 in first-trimester pregnancies complicated by threatened abortion with an adverse outcome

The purpose of the present study was to examine the profile of selected proinflammatory cytokines in maternal serum of first-trimester pregnancies complicated by threatened abortion (TACP) and its relevance to obstetric outcome. Serum levels of Th1-type cytokines interleukin-1beta (IL-1beta), tumor necrosis factor alpha (TNF-alpha), and Th2-type cytokine interleukin 6 (IL-6) were measured, by ELISA, in 22 women with TACP and adverse outcome at admission (group A) and compared with the corresponding levels of 31 gestational age-matched women with TACP and successful outcome at admission (group B1) and discharge (group B2) and 22 gestational age-matched women with first-trimester uncomplicated pregnancy (group C) who served as controls. Mann-Whitney U or Wilcoxon test was applied as appropriate to compare differences between groups. IL-1beta and TNF-alpha were detected with significantly higher levels in group A, compared to all other groups. On the contrary, IL-6 levels were detected with no significant difference among all the other groups studied. It is concluded that in first-trimester TACP with adverse outcome, a distinct immune response, as reflected by elevated maternal IL-1beta, TNF-alpha, and unaltered IL-6 levels, is relevant to a negative obstetric outcome.

Report of 7 Uterine Rupture Cases After Laparoscopic Myomectomy: Update of the Literature

The objective of this article is to report 7 previously unpublished uterine rupture cases in pregnancy after laparoscopic myomectomy and to update the medical literature. All cases were reported to the Board of Endoscopic Gynecologic Surgery (Athens, Greece) from 1998 to 2011. Myomas were single in 85.7% of patients, subserosal or pedunculated in 85.7%, and ≤5 cm in 71.4%. Bipolar diathermy was the sole method used for hemostasis in 28.6%, and could be characterized as excessive in 85.7%. A 2-layer closure with stitches of the myometrium was performed in just 14.3% of cases. Mean (SD) time between surgery and pregnancy was 1.4 (0.5) years. Uterine rupture occurred at 34 weeks of gestation or later in 85.7%, and during labor in 14.3% of cases. All women survived. Fetal demise was reported in 1 twin pregnancy (both fetuses) with rupture at 24 weeks of gestation. Laparoscopic myomectomy should be performed by adequately trained and experienced surgeons. Excessive use of diathermy for hemostasis should be avoided, and multiple-layer suturing should always be used for repairing the myometrial defect in cases of intramural and subserosal myomas with deep intrusion.

Clinical value of endometrial pinopodes detection in artificial donation cycles

The aim of the study was to investigate the clinical value of pinopode detection in women with a history of multiple implantation failures after participation in assisted reproduction programmes. Forty-six women with primary infertility, three or more previous implantation failures in assisted reproduction programmes and indication for the use of donated oocytes underwent a mock cycle of endometrial preparation, based on a standard protocol. Endometrial samples were taken on days 6 and 8 of progesterone administration, and were examined under scanning electron microscope for detection and evaluation of pinopodes. The most receptive endometrial day (the day on which fully developed pinopodes can be demonstrated) was determined for each woman. In 73.91%, a new modified transfer cycle was suggested and applied by altering the timing between IVF and progesterone commencement days; 76.47% achieved a clinical pregnancy within two attempts and 67.64% delivered a healthy baby. Among women with no indication for modification of their transfer cycle, only 33.33% achieved a pregnancy and 25% delivered a healthy baby. The difference in the outcomes between transfer cycles with and without modification was significant. In conclusion, detection of pinopodes in women with multiple implantation failures can be of great clinical value.

Vascular Endothelial Growth Factor and Placenta Growth Factor in Intrauterine Growth-Restricted Fetuses and Neonates

The angiogenic factors vascular endothelial growth factor (VEGF) and placenta growth factor (PlGF) are respectively up- and downregulated by hypoxia. We aimed to study circulating levels of the above factors in intrauterine growth restriction (IUGR) and to correlate their levels with the customized centiles of the infants. The study included 25 IUGR and 25 appropriate for gestational age (AGA) full-term, singleton infants and their mothers. Maternal (MS), fetal (UC), and neonatal day 1 (N1) and 4 (N4) blood was examined. MS and N1 PlGF, as well as UC VEGF levels correlated with the customized centiles of the infants (r= 0.39, P=.007, r=0.34, P=.01, and r= -0.41, P=.004, resp). Furthermore, UC, N1, and N4 VEGF levels were higher in girls (r=0.36, P=.01, r=0.33, P=.02, and r=0.41, P=.005 resp). In conclusion, positive and negative correlations of examined factors with the customized centiles of the infant could rely on placental function and intrauterine oxygen concentrations-both being usually lower in IUGR cases-while higher VEGF levels in girls should possibly be attributed to the stimulating action of estrogens.

Matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in plasma/serum and urine of women during term and threatened preterm labor: a clinical approach.

Objective: To explore the concentrations of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in plasma, serum and urine of women during term and threatened preterm labor. Methods: Plasma and urine proMMP-9 as well as serum and urine TIMP-1 were evaluated in 60 healthy pregnant women; 20 of them presented in term labor following an uncomplicated pregnancy, 20 of them presented with threatened preterm labor and intact membranes at 24-36 gestational weeks and 20 of them were at 24-40 gestational weeks with no evidence of uterine contractions or other pregnancy complications. Data were analyzed with non-parametric statistical tests and cut-off values were determined with receiver operator characteristic curves. Results: ProMMP-9 values were significantly higher and TIMP-1 values were significantly lower in cases with uterine term or preterm contractions compared to non-labor status; and in cases with preterm contractions that progressed to true preterm labor compared to those in which contractions were arrested. Conclusions: Alterations in the concentrations of proMMP-9 and TIMP-1 can be detected in plasma or serum and urine of pregnant women experiencing term or preterm uterine contractions. The altered values of proMMP-9 and TIMP-1 could possibly identify the inevitable progress of preterm contractions to true preterm labor.

The outcomes of hysteroscopy in women with implantation failures after in-vitro fertilization: findings and effect on subsequent pregnancy rates.

Purpose of review To update information on the findings of hysteroscopy in women with implantation failures after in-vitro fertilization (IVF) as well as on the effect of the procedure on subsequent pregnancy rates. Recent findings Information from three review publications indicates that the incidence of abnormal hysteroscopic findings in women with repeated implantation failures (RIFs) varies between 25 and 50%, whereas by pooling data from randomized studies, hysteroscopy significantly increases the clinical pregnancy rate (CPR) on the subsequent IVF cycle (pooled RR = 1.57, 95% CI: 1.29–1.92, P < 0.00001). Two recent clinical articles reported that the incidence of abnormal hysteroscopic findings in RIF patients was approximately 37%: the one study reported no differences in CPR between RIF patients with abnormal versus normal hysteroscopy; the second study reported significantly increased CPR in RIF patients with abnormal or treated hysteroscopic findings compared to those with a normal hysteroscopy, as well as in RIF patients having a hysteroscopy compared to controls not having the procedure. Summary There is accumulated evidence that hysteroscopy is beneficial for women experiencing implantation failures after IVF. Not only the correction of hysteroscopic findings improves the pregnancy rates, at least when compared to controls not having a hysteroscopy, but also the procedure itself may have a positive prognostic value for achieving a subsequent pregnancy.

Sigmoid colon cancer during pregnancy

Colorectal carcinoma during pregnancy is a rare event. We report a 23-year-old primigravida with advanced stage adenocarcinoma of the sigmoid colon diagnosed at 34 weeks of gestation. A healthy female infant was delivered by cesarean section. The treatment of choice was chemotherapy. The patient died 3 months after delivery.