Her-Young Su

Prospective randomized comparison of single-dose versus 1-day cefazolin for prophylaxis in gynecologic surgery

Background.  The purpose of this prospective, randomized study was to compare the efficacy of single‐dose versus 1‐day cefazolin prophylaxis for the prevention of postoperative gynecologic infections.

Major risk factors for stillbirth in different trimesters of pregnancy--a systematic review.

Stillbirth remains an event that has an important impact on global health issues. Different levels of health care between countries suggest that the stillbirth rate may be one of the indicators of the quality of a countrys medical system. In this review, major risk factors for stillbirth will be discussed, especially in different trimesters of pregnancy. Early identification of risk factors for stillbirth and appropriate antenatal management may reduce preventable stillbirths and improve general outcomes of pregnancy.

Extra-pelvic endometriosis presenting as a vulvar mass in a teenage girl

A 15-year-old girl had been experiencing a vulvar mass each month for 6 months. The mass was painful and swollen. She reported menstruating regularly since menarche 3 years earlier. Her medical history was unremarkable. On examination a solid eggsized mass involved the left labium major and extended to the clitoris without urethral or vaginal invasion. Ultrasonography showed a cystic mass measuring 5.6 x 4.1 cm/2 in diameter with hypoechoic and homogeneous content. Endometriosis was confirmed histopathologically from the endometriod focus endometrial glands and stroma after needle aspiration. Local excision and enucleation of the vulvar endometriosis was performed. Grossly the mass was cystic dark-yellowish with a capsule containing blood clots. Postoperative recovery was reported uneventful at a 4-month of follow-up visit. (excerpt)

Women with endometriosis have higher comorbidities: Analysis of domestic data in Taiwan.

Abstract Endometriosis, defined by the presence of viable extrauterine endometrial glands and stroma, can grow or bleed cyclically, and possesses characteristics including a destructive, invasive, and metastatic nature. Since endometriosis may result in pelvic inflammation, adhesion, chronic pain, and infertility, and can progress to biologically malignant tumors, it is a long‐term major health issue in women of reproductive age. In this review, we analyze the Taiwan domestic research addressing associations between endometriosis and other diseases. Concerning malignant tumors, we identified four studies on the links between endometriosis and ovarian cancer, one on breast cancer, two on endometrial cancer, one on colorectal cancer, and one on other malignancies, as well as one on associations between endometriosis and irritable bowel syndrome, one on links with migraine headache, three on links with pelvic inflammatory diseases, four on links with infertility, four on links with obesity, four on links with chronic liver disease, four on links with rheumatoid arthritis, four on links with chronic renal disease, five on links with diabetes mellitus, and five on links with cardiovascular diseases (hypertension, hyperlipidemia, etc.). The data available to date support that women with endometriosis might be at risk of some chronic illnesses and certain malignancies, although we consider the evidence for some comorbidities to be of low quality, for example, the association between colon cancer and adenomyosis/endometriosis. We still believe that the risk of comorbidity might be higher in women with endometriosis than that we supposed before. More research is needed to determine whether women with endometriosis are really at risk of these comorbidities.

Quantitative DNA methylation analysis of selected genes in endometrial carcinogenesis.

OBJECTIVE Most endometrial carcinomas appear to develop from precursors (e.g., endometrial hyperplasia) that progress for several years. Patients who are ultimately diagnosed with carcinoma often present clinically with complaints of abnormal vaginal bleeding years before diagnosis, which offers an opportunity for early diagnosis and curative treatment. The analysis of DNA methylation may be used as a method for detecting endometrial cancer (EC). To test the potential clinical application of this method, we used quantitative methylation analysis of five genes in a full spectrum of endometrial lesions. MATERIALS AND METHODS This hospital-based, prospective, case-controlled study was conducted on 68 patients, which included patients who had a normal endometrium (n = 18), hyperplasia of the endometrium (n = 24), and EC (n = 26). Methylation levels of the following genes were determined by using real-time methylation-specific polymerase chain reaction (PCR) amplification: zinc finger protein 177 (ZNF177), collagen type XIV α1 (COL14A1), dihydropyrimidinase-like 4 (DPYSL4), homeobox A9 (HOXA9), transmembrane protein with epidermal growth factor-like and two follistatin-like domains 2 (TMEFF2). The methylation index (MI) cutoff values for the different diagnoses were determined to test the sensitivity and specificity of the method and to generate the receiver operating characteristic (ROC) curves. The Mann-Whitney U test was used to test between-group differences in the MI. RESULTS The MI of the five genes was significantly higher in EC than the MIs in specimens of hyperplasia of endometrium and normal appearance (p < 0.001). The ROC analysis demonstrated that the sensitivity, specificity, and accuracy for detecting EC were 92.3%, 94.4%, and 95.1%, respectively, for ZNF177; 92.3%, 94.4%, and 95.7%, respectively, for COL14A1; 80.8%, 94.4%, and 81.4%, respectively, for HOXA9; 65.4%, 94.4%, and 89.5%, respectively, for TMEFF2; and 61.5%, 94.4%, and 63.3%, respectively, for DPYSL4. The combined testing of ZNF177 and COL14A1 had the best specificity (100%), but compromised sensitivity (88.5%). CONCLUSION Promoter methylation of ZNF177, COL14A1, HOXA9, DPYSL4, and TMEFF2 genes is a frequent epigenetic event in EC. Furthermore, the epigenetic hypermethylation of TMEFF2 may be a valuable marker for identifying undetected EC within endometrial hyperplasia.

Endometriosis of the colon and rectum mimicking colon cancer

Endometriosis is one of the most common benign gynecological disorders in women of reproductive age. Intestinal involvement occurs in 3% to 37% of patients with pelvic endometriosis usually affecting the rectosigmoid colon. The case of a woman who complained with symptoms of bowel obstruction is presented. Initially a diagnosis of irritable bowel syndrome was made at a local medical clinic and antidiarrheal agents were prescribed for her. However she suddenly developed intractable abdominal cramping and was admitted to the hospital via the emergency department 2 days after she went to the local medical clinic. A colonoscopy was performed on the following day identifying a fungating mass around 12 cm above the anal verge. (excerpt)

Uterine sarcoma part III—Targeted therapy: The Taiwan Association of Gynecology (TAG) systematic review

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Analysis of intrauterine fetal demise—A hospital-based study in Taiwan over a decade

OBJECTIVE To identify timing-specified risk factors for stillbirth, in order to help physicians to reduce preventable factors and stillbirths, and improve general outcomes of pregnancy. MATERIALS AND METHODS A retrospective analysis was performed of births registered in our hospital, a medical center in Taiwan, between September 1, 1999 and December 31, 2011. We collected basic characteristics from the medical records, including maternal and fetal conditions. All stillbirths were divided into two groups according to gestational age: the second trimester group and the third trimester group. Comparisons were made between these groups. RESULTS There were a total of 12,290 births and 121 stillbirths during our study period. The 121 stillbirths were divided into two groups: 67/121 (55.4%) were in the second trimester group and 54/121 (44.6%) were in the third trimester group. The overall incidence for intrauterine fetal demise was 0.98% (121/12,290). The increased risks in the third trimester stillbirths, as compared with the second trimester group, were significantly associated with males born, increased maternal body mass index (BMI) at delivery, habitual cigarette smoking, previous history of intrauterine fetal demise, and diabetic or hypertensive pregnancies. Unexplained causes (29.85%) were the most common causes of second trimester intrauterine fetal demise and the most common cause of third trimester intrauterine fetal demise was umbilical cord pathology (33.33%). CONCLUSION Management of any pregnant patient remains a challenge. Identifying upstream and cost-effective solutions will improve these pregnancy outcomes.

The accuracy of magnetic resonance imaging for preoperative deep myometrium assessment in endometrial cancer

OBJECTIVE To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) to detect deep myometrial invasion in patients with endometrial cancer. MATERIALS AND METHODS We retrospectively reviewed 66 cases of women with endometrial cancer, who underwent preoperative MRI assessment and surgical staging between January 2006 and October 2010. The MRI findings were then compared with the pathology results. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI in detecting deep myometrium invasion were evaluated. RESULTS The sensitivity, specificity, accuracy, PPV, and NPV results of MRI for the detection of deep myometrium invasion were 92.52%, 74.35%, 81.81%,71.42%, and 93.54%, respectively, with a kappa of 0.64. In the postmenopausal group, the values were 100%, 55.5%, 74.19%, 61.9%, and 100%. In the premenopausal women, they improved to 85.7%, 90.47%, 88.57%, 88.71%, and 90.47%. The sensitivity (100%) was better than the specificity (55.56%) in the postmenopausal women. The predictive value was markedly higher in the premenopausal women than the postmenopausal women (85.7% vs. 61.9%). CONCLUSION In patients with endometrial cancer, a preoperative MRI contributes to accurate staging, allowing planning for the scale of surgery and preoperative counseling. In our study, the pretreatment identification of myometrium invasion provided the opportunity for small-scale surgery in the premenopausal women with early endometrial cancer. However, for the postmenopausal patients, the standard surgical procedure is indicated even if the degree of myometrium invasion is low.

Successful treatment with recombinant blood factor VIIa in severe postpartum hemorrhage-induced disseminated intravascular coagulation.

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality worldwide. Uterine atony leading to postpartum hemorrhage (PPH) is the most common type seen [1]. Other factors include genital tract lacerations, retained placenta, uterine inversion, and acquired or inherited coagulopathy. The World Health Organization defines PPH as a blood loss in excess of 500 mL after delivery; the common sites for blood loss include the uterus, cervix, vagina, and perineum [2]. Massive PPH (> 1 L) accounts for > 10% of all maternal deaths and can lead to permanent morbidity [3]. Therapeutic management strategies include uterine compression with massage or manual compression, compression sutures (B-Lynch procedure), increasing intrauterine pressure with balloon catheters or gauze packing, and/or uterotonic agents or intravenous hemostatic agents such as tranexamic acid (Transamin) and recombinant activated blood factor VIIa (rfVIIa) [4]. We describe a case of refractory massive PPH. The bleeding persisted even though vaginal packing and uterine artery embolization were administered. Disseminated intravascular coagulation (DIC) then developed, which we successfully corrected with two injections of rfVIIa. Interventions with rfVIIa in cases of PPH have been reported in the past decade. The first report of the use of rfVIIa in an obstetric patient with DIC following PPH was by Plaat [5] in