Georgios Maroulis

Clinical evaluation of women with PMB. Is it always necessary an endometrial biopsy to be performed? A review of the literature

BackgroundEndometrial carcinoma is the most distressing cause of abnormal vaginal bleeding. The intention of clinical management in the case of postmenopausal bleeding is to achieve an accurate diagnosis without overinvestigation.MethodWe studied the available literature on the diagnostic evaluation of postmenopausal women with vaginal bleeding, accentuating the most important aspects on this topic: the accuracy of sonography and endometrial biopsy in predicting endometrial hyperplasia and endometrial carcinoma.ResultsThe accuracy of the above tests in predicting endometrial hyperplasia and endometrial carcinoma is a subject of continuing debate. Μοreover, in the last decades, there has been an explosion of publications indicating that ultrasound may be useful in predicting endometrial pathology.ConclusionSince advanced endometrial carcinoma has been known to occur in cases without noticeable endometrial thickness on ultrasound, the clinician should beware of the diagnostic evaluation of postmenopausal women with vaginal bleeding.

Pregnancies and their obstetric outcome in two selected age groups of teenage women in Greece

Aim: The aim of this study was to evaluate the outcome of pregnancies in adolescents in the Department of Obstetrics and Gynaecology of Democritus University of Thrace, North-Eastern Greece. Material and methods: We retrospectively reviewed 194 cases of adolescent pregnancies, with an average maternal age of 16.5 years, from 1st January 2006 to December 30th 2008. Socioeconomic characteristics, type of delivery and complications, such as preterm labor, preeclampsia, intra- and post-partum complications, were evaluated. Results: The median age at first intercourse was 14.2 years and the average period between first intercourse and pregnancy was 1.2 years. Most teen mothers (86.6%) did not use any contraceptive method. Among the teen mothers recruited for the study, 89.7% were married. Adolescent pregnancies accounted for 9.02% of all deliveries (2150) in our Department. In 49 (25.3%) of the pregnant adolescents, no previous pregnancy was reported. The rates of preterm birth of teen mothers were 11.3%, 41.3% and 47.4% in correlation to <32 weeks, 32–34 weeks and >34 weeks, respectively. In 95.4% of the cases, deliveries were not complicated. According to our results, the main complications, especially in very young girls, are preterm labor, anaemia, hypertensive disease, obstructed labor after premature rupture of the membranes and increased neonatal mortality and morbidity. Antenatal care is often inadequate. Conclusion: Early teenage pregnancies have always been considered of increased risk for obstetric complications. Prevention of adolescent pregnancy, by wide use of effective contraception programs, would decrease its frequency and intensive care of pregnant adolescents may reduce the pregnancy complications.

Turner's syndrome and pregnancy: has the 45,X/47,XXX mosaicism a different prognosis? Own clinical experience and literature review

Turners syndrome is characterized by an ovarian failure which occurs in most cases before puberty and leads to infertility. In less than 10% of women with Turner syndrome, puberty may occur and spontaneous pregnancies is possible but with a high risk of fetal loss, chromosomal and congenital abnormalities. We present the case of a 33-year-old woman with a mosaic Turners syndrome karyotype 45,X/47,XXX who conceived spontaneously and had two successful pregnancies. Short stature was the only manifestation of Turners syndrome. In the present report, we reviewed the available literature on the fertility of women with Turners syndrome and the phenotypic effects of mosaicism for a 47,XXX cell line in Turners syndrome.

The role of lymphadenectomy in uterine leiomyosarcoma: review of the literature and recommendations for the standard surgical procedure

Uterine sarcomas are rare and aggressive gynaecologic malignancies with poor prognosis, arising from myometrial or endometrial tissue. These rare cancers can be aggressive, and account for a greatly disproportionate amount of deaths from uterine cancers. The histological uterine sarcomas classification includes carcinosarcomas (malignant mesodermal mixed tumors), accounting for 40% of cases, leiomyosarcomas (40%) and endometrial stromal sarcomas (10–15%). Each group of these tumors presents differences in diagnosis, prognostic factors, treatment, and outcome. Uterine leiomyosarcomas typically affects women in their sixth decade of life, presenting with atypical symptoms such as abnormal uterine bleeding and abdominal pain. The optimal treatment of uterine leiomyosarcomas is surgery, including total abdominal hysterectomy and bilateral salpingooophorectomy. The aim of this study was to conduct a systematic review of the literature regarding the standard surgical procedure of uterine leiomyosarcomas and investigate whether lymphadenectomy affects the 5-year DSS, as well as other relevant clinical outcomes, in women with uterine leiomyosarcomas. For this purpose, MEDLINE, EMBASE, and the Cochrane Library databases were reviewed, and a critical account of the management strategies of these tumors is presented.

Diagnosis and laparoscopic management of a rudimentary uterine horn in a teenage girl, presenting with haematometra and severe endometriosis: Our experience and review of literature

Summary A unicornuate uterus is a rare congenital malformation of the female genital tract, which appears in about 1/1000 women and is characterized by significant anatomic variability. In the most common type, a noncommunicating rudimentary horn coexists with the unicornuate uterus. The diagnosis of this anomaly is usually delayed, as it remains asymptomatic until adolescence and its initial symptoms are atypical. As a result, it is often diagnosed after the appearance of severe complications, such as haematometra, endometriosis, infertility and ectopic pregnancy. We report a case of a teenage girl presenting with dysmenorrhoea, endometriosis and haematometra secondary to a noncommunicating rudimentary horn. The diagnosis of the anomaly was based on magnetic resonance imaging (MRI) and laparoscopy. The excision of the symptomatic rudimentary horn and the ipsilateral fallopian tube was also performed laparoscopically. A review of the literature follows, focusing mainly on the diagnosis and laparoscopic management of a unicornuate uterus and its complications in adolescence. Laparoscopy is an accurate diagnostic tool, which also carries significant advantages in effective surgical management of congenital uterine anomalies, especially in young women.

The contribution of hysteroscopy to the detection malignancy in symptomatic postmenopausal women

Abstract Hysteroscopic evaluation of endometrial cavity is widely used in cases of abnormal uterine bleeding. The aim of the present study is to compare the hysteroscopic and histological findings in women suffering from postmenopausal bleeding. Between 1990 and 2009, 425 women aged 47–83 years were included in the study. None of the women had received hormonal therapy or had any malignancy in the past. All women underwent diagnostic hysteroscopy and histologic sampling of the endometrial cavity. Hysteroscopy was successfully completed in 423 women and was suggestive of malignant lesions in 23 cases, which were confirmed histologically. The hysteroscopic findings in three cases were suggestive of atrophic endometrium, atypical hyperplasia and endometrial carcinoma, and the histologic diagnosis confirmed endometrial carcinoma (two cases) and one uterine sarcoma. Hysteroscopy proves to be a safe and effective technique in the diagnosis and management of abnormal uterine bleeding.

Should lymphadenectomy be performed in early stage I and II sarcomas of the corpus uteri

Aim:  The aim of this study was to investigate the impact of radical lymphadenectomy as a prognostic factor in the management of uterine sarcomas.

Assessment of the feasibility of bipolar coagulation use to reduce hemorrhage in myomectomy performed by minilaparotomy

Abstract The major problem with myomectomy is excessive bleeding from increased uterine blood supply, and this can be a life-threatening condition and prolong postoperative stay. The aim of our study was to evaluate our experience in symptomatic myoma excision with bipolar electrode by mini-laparotomy; we compared 67 procedures with bipolar electrode, in normal saline as distension fluid, to 42 cases performed with unipolar electrode. All participants were pre-menopausal women who had symptomatic myomas ≤ 10 cm and had similar demographic characteristics. According to our findings we observed a mean of 159.04 ml (SD 50.59) of blood loss during the unipolar method and a mean of 104.47 ml (SD 50.55) during the bipolar method. Postoperative complications were more frequent in the unipolar group. The group treated with bipolar coagulation was associated with less recurrence of myoma, independent of their location, and an increased postoperative pregnancy rate. In our experience the use of bipolar coagulation led to a satisfactory improvement of the surgical treatment of symptomatic myoma in women who wished to retain their uteri.

Differential Diagnosis of Ectopic Pregnancy - Morbidity and Mortality

The term ectopic pregnancy refers to a gestation in which the fertilized ovum implants on any tissue other than the endometrial membrane lining the uterine cavity. Fig 1 presents the various types of ectopic pregnancy and their relative frequencies The classic clinical symptoms of ectopic pregnancy are pelvic pain, amenorrhea, and vaginal bleeding , spotting (40-50%). However, only 50% of patients present typical symptomatology. Patients may present with other symptoms common to early pregnancy, including nausea (frequently after rupture), breast fullness, fatigue, abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia . Physical findings during examination should be pelvic unilateral tenderness, especially on movement of cervix (75%), enlarged uterus or palpable adnexal mass; crepitant mass on one side or in culde-sac (50%). Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture. Body temperature ranges from 37.2 to 37.8 0C while the pulse is variable: normal before but rapid after rupture. Today, using modern diagnostic techniques, most ectopic pregnancies may be diagnosed prior to rupturing [1]. Diagnosis of ectopic pregnancy has been greatly improved by the advent of rapid serum beta-human chorionic gonadotropin (beta-HCG) tests and then the widespread adoption of transvaginal pelvic ultrasonography (TVUS) [2]. Serum beta-HCG levels can definitively rule out pregnancy if negative, although there have been case reports of pathology-proven ruptured ectopic pregnancy and hemorrhagic shock despite an undetectable serum beta-HCG [3]. In the early stages of a normal intrauterine pregnancy (IUP), the serum beta-HCG rises along a well-defined curve. Therefore, serial beta-HCG tests can be useful for determining the ultimate location of a pregnancy of unknown location. The lower limit of normal rise in beta-HCG (using a 99% confidence interval) is 53% in 2 days [4]. Patients with a beta-HCG level that falls more than 50% in 2