Ioannis Kalogiannidis

Biomarkers of endothelial dysfunction in preeclampsia and neonatal morbidity: a case–control study

OBJECTIVE To investigate the association of preeclampsia with angiogenic imbalance, and the correlation of levels of angiogenic and anti-angiogenic factors to complications in mother and fetus. STUDY DESIGN Serum samples were obtained from 40 women with established preeclampsia (study group) and from 40 normotensive women (control group). Epidemiological characteristics of the two groups were analyzed. The levels of the angiogenic (VEGF and PlGF) and anti-angiogenic (sFlt-1) factors of the two study groups were determined in serum using ELISA. Neonatal adverse outcomes (late preterm, early term, low birth weight (LBW), very LBW (VLBW), intrauterine growth restriction (IUGR), and neonatal intensive care unit (NICU) admission) between the groups of the study were analyzed, as well as the association between the biomarkers of the study and neonatal adverse outcomes of the preeclamptic group of patients. RESULTS sFlt-1 levels were significantly higher in the preeclamptic women compared to normotensive women (median (range): 21297 (690-32637)pg/ml vs. 846.45 (363-2867)pg/ml, respectively), whereas there was a significant decrease in the levels of VEGF (90 (90-211)pg/ml vs. 90.55 (90-521)pg/ml, respectively), as well as in the levels of PlGF (13.62 (8-532)pg/ml vs. 239.86 (61-685)pg/ml, respectively). The increased serum values of the anti-angiogenic sFlt-1 were associated with increased rates of late preterm and early term births and VLBW. CONCLUSION An imbalance between angiogenic and anti-angiogenic factors exists in preeclampsia and is associated with adverse maternal and neonatal outcomes.

Conservative management of young patients with endometrial highly-differentiated adenocarcinoma

Endometrial cancer is uncommon in young women. However, almost 5% of patients are younger than 40 years old. Progestins such as medroxyprogesterone acetate (MPA) and megestrol acetate (MA), have been used as a fertility-sparing approach in this group of patients, with different dose regimens of cyclic (14 days every month) or continuous therapy successfully used. According to the present data, the overall response rate was 73% in a median time of 4 months (range 1–15 months). Endometrial biopsy every 3 months was the common approach to evaluate the patients response during the treatment. The relapse rate was 36% in a median follow-up time of 22 months (range 6–73 months). Overall, 40% of patients who responded to the treatment successfully, conceived. Half of the patients used assisted reproductive technology to achieve an immediate pregnancy. Although, there are no definite recommendations concerning the conservative management of young patients with early stage endometrial cancer, progestin agents may be used in a selected group of patients for fertility-sparing reasons. After childbearing is completed, hysterectomy remains the standard treatment.

Parameters affecting latency period in PPROM cases: a 10-year experience of a single institution

Abstract Objective: To investigate the association of epidemiological and pregnancy-related parameters with the latency period achieved in cases of preterm premature rupture of membranes (PPROM). Method: A retrospective study was performed enrolling cases admitted in high-risk pregnancy unit (HRPU) with PPROM between 24 + 0 and 36 + 6 gestational week during 2002–2011. Cases with vaginal bleeding at admission, co-existing maternal or fetal pathology, placenta praevia, previous interventions in cervix or uterus, triplets or higher order pregnancies were excluded. Epidemiological parameters and latency period between admission due to PPROM and delivery were recorded. Obstetrical complications, mode of delivery, and neonatal morbidity parameters were also studied. A multivariate regression model was used to correlate latency period with epidemiological and pregnancy-related risk factors. Results: Overall, there were 319 cases of PPROM admitted, of which 303 (94.9%) met inclusion criteria. Median latency period was 5.2 d. The latency interval exceeded 48 h in 65.0% of cases (197/303). Emergency cesarean was demanded in 20.2% of cases, chorioamnionitis was diagnosed in 7.5% while 76.1% of neonates were admitted in neonatal intensive care unit. Higher gestational week at admission was associated with shorter latency interval (p < 0.001), twin pregnancy with shorter latency interval (p = 0.02), while latency interval was significantly lower in cases complicated with chorioamnionitis (p = 0.048). Conclusion: Gestational week at PPROM, twin gestation and chorioamnionitis are factors significantly affecting latency interval.

Primary primitive neuroectodermal tumor of the cervix confirmed with molecular analysis in a 23-year-old woman: A case report

Primitive Neuroectodermal Tumor (PNET) of the genital tract is very rare, especially in the cervix. A case report of a young woman with a diagnosis of PNET originating from the uterine cervix is presented here. A 23-year-old woman presented with abnormal uterine bleeding and sharp lower abdominal pain of two months duration. CT and MRI of the abdomen and thorax revealed the presence of a large mass in the uterine cervix, enlarged pelvic lymph nodes and broncho-pulmonary infiltrations with regional nodes. Pathological examination of the tumor revealed a malignant neoplasm composed predominantly of small cells, immunohistochemically positive for CD99, vimentin and c-Kit. Molecular testing demonstrated the expression of EWS/FLI1 fusion transcripts corresponding to the t(11;22)(q24;q12) translocation, which confirmed the diagnosis of PNET of the uterine cervix. Despite surgical excision and administration of the first cycle of adjuvant chemotherapy, the patient died from multiple-organ failure and cardiac arrest. PNET arising from the genital tract, especially in the uterine cervix, is very rare and presents a diagnostic challenge. A timely confirmation with molecular analysis is essential for the diagnosis of such a tumor at an unusual site as in the present case.

Operator experience reduces the risk of second trimester amniocentesis-related adverse outcomes

OBJECTIVE To investigate the impact of operator experience on amniocentesis-related adverse outcomes. STUDY DESIGN Retrospective study of mid-trimester amniocenteses performed by the same operator on singleton pregnancies in a single private institution during 1994-2007. Outcomes were hemorrhagic or dark amniotic fluid aspiration, insufficient volume aspiration, repeated puncture and fetal loss. Rates were estimated annually, as well as for every 10% of procedures up to the total number. The association of each outcome with epidemiological aspects was also examined. RESULTS In total, 5913 amniocenteses were performed. The overall rate of adverse outcomes was 5.4%. The total adverse outcome rate reduced from 10.2% in the first 10% of cases to 3.0% in the last 10% (P=.001). The rate of hemorrhagic fluid gradually decreased from 4.4% to 1.5% (P=.05) over the same intervals. The fetal loss rate was also reduced from 0.5% during the first half to 0.3% in the second half of the study period (P=NS). Logistic regression analysis indicated no significant correlations between adverse outcomes with any of epidemiological parameters of women undergoing amniocentesis. CONCLUSION Operator experience has a beneficial impact on preventing procedure-related adverse outcomes.

Mature Ovarian Teratoma with Carcinoid Tumor in a 28-Year-Old Patient

Introduction. Coexistence of carcinoid tumor inside a mature cystic teratoma is an extremely rare phenomenon, especially in young women. We present the case of a 28-year-old woman diagnosed with a right ovarian carcinoid and treated uneventfully with conservative surgical approach. Case Report. A 28-year-old woman, gravid 0, parity 0, presented to our department for her annual gynecological examination and Pap smear test. During her examination, a mobile cystic mass was detected in the right lower abdomen. Ultrasound indicated a right ovarian mass 10.5 × 6.3 cm, confirmed by CT scan. Further investigation revealed AFP levels (1539 ng/mL). The ovarian mass was excised by laparoscopy, leaving intact the remaining right ovary. Frozen sections showed a mature cystic teratoma. However, paraffin sections revealed the presence of a small carcinoid within the teratomas gastric-type mucosa. The patient was set to a close followup. Nine months postoperatively, ultrasound pelvis imaging and CT scan of the abdomen as well as serum tumor markers have shown no evidence of recurrence disease. Conclusion. Despite the weak evidence, fertility spare surgical approach for women wanting to preserve their genital tract might be a reasonable option.

Double GnRH-antagonist dose before HCG administration may prevent OHSS in oocyte-donor cycles: a pilot study

This pilot study evaluated the possibility of preventing early ovarian hyperstimulation syndrome (OHSS) by increasing the daily dose of gonadotrophin-releasing hormone (GnRH) antagonist administration (to twice a day) in oocyte-donor cycles stimulated with the antagonist protocol. The study included 72 oocyte donors who underwent ovarian stimulation using the GnRH antagonist protocol and might have had their cycle cancelled because of ovarian hyper-response. All women were donors presenting a rapid rise of oestradiol > or = 3000 pg/ml early in the stimulation period with more than 15 follicles of < or = 15 mm in diameter. By decreasing the rFSH dose to 75 IU a day with an additional daily dose of GnRH antagonist (0.25 mg twice a day), the oestradiol concentrations were lowered or reached a plateau before human chorionic gonadotrophin was given. A marked decrease in oestradiol concentrations and ovarian volume was observed on the day of oocyte retrieval and 3 days post retrieval. None of the donors needed coasting, were cancelled or developed OHSS. In over-responding oocyte donors, by increasing the usual GnRH-antagonist dose to twice a day during ovarian stimulation, the oestradiol rise can be blocked while a minimal follicular stimulation may continue without the risk of developing OHSS or affecting the outcome.

Conservative management of cervical pregnancy with intramuscular administration of methotrexate and KCl injection: Case report and review of the literature

We report the case of a cervical pregnancy successfully treated with intramuscular injection of methotrexate (MTX) and intramniotic administration of potassium chloride. A 41-year-old woman was admitted to our Department with the suspicion of ectopic pregnancy. Transvaginal ultrasound revealed empty endometrial cavity, gestational sac within the cervical canal and embryonic echo measuring crown rump length 1.5 mm. Serum beta human chorionic gonadotropine (β-HCG) was measured 28590 IU/L. No cardiac activity was detected. The diagnosis of a cervical pregnancy was made. Patient was treated with intramuscular administration of methotrexate (50 mg/m(2)) in combination with ultrasound-guided intramniotic injection of KCl (2 meq/mL). Gradual decrease of β-HCG levels as well as ultrasound observation of collapsed gestational sac was observed. No curettage was necessitated. Patient was discharged on day 10(th) and was set in follow-up on a weekly basis. β-HCG values were measured < 10 IU/L on 56(th) day after MTX administration. Intramuscular administration of MTX may be effective in treatment of cervical pregnancy without additional interventional measures.

Spontaneous Postpartum Rupture of an Intact Uterus: A Case Report

Rupture of uterus is an obstetrical complication characterized by a breach in the uterine wall and the overlying serosa. We report an unusual case of spontaneous rupture of an unscarred uterus in a 33-year-old woman, a day after her third successful vaginal delivery. A 33-year-old pregnant woman, gravid 3, para 3, was referred to our department at 39 gestational week because of rupture of membranes. Despite tocolysis administration, her pregnancy was delivered vaginally after 2 days, giving birth to a male neonate of 3,020 g with normal Apgar scores at first and fifth minute. Her uterus was intact and gynecological examination after delivery was normal without any potential signs or symptoms of pathology. However, the day following her labor, patient complained of left iliac fossa pain. Her blood tests revealed a CRP value at 27.6 mg/L, whereas the X-rays revealed an extensive impacted fecal mass in the colon. MRI revealed that the left lower myometrial part of the uterus was depicted abrupt, with simultaneous presence of hemorrhagic stuff. The decision of laparotomy was therefore made in order to further evaluate rupture of uterus and properly treat patient. And subtotal hysterectomy was performed. Postoperative follow-up period was not characterized by any complications and patient was finally discharged 4 days after hysterectomy.

Endometrial adenocarcinoma and mucocele of the appendix: an unusual coexistence.

Appendiceal mucocele is a rare clinical entity, which is however quite often associated with mucinous ovarian tumor. The coexistence of mucinous cystadenoma of the appendix and endometrial adenocarcinoma has not been reported before. A 49-year-old woman presented to our clinic with postmenopausal bleeding and no other symptom. Endometrial biopsy revealed endometrial adenocarcinoma of endometrioid type (grade I). Preoperative CT scanning revealed an appendiceal mucocele, and a colonoscopy confirmed the diagnosis. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and appendectomy. The final histopathological examination showed a mucinous cystadenoma of the appendix and confirmed the diagnosis of endometrioid endometrial adenocarcinoma. The coexistence of appendiceal mucocele and female genital tract pathology is rare. However, gynecologists should keep a high level of suspicion for such possible coexistence. Both the diagnostic approach and the therapeutic management should be multidisciplinary, most importantly with the involvement of general surgeons.