Ka Wang Cheung

Towards complete eradication of hepatitis B infection from perinatal transmission: review of the mechanisms of in utero infection and the use of antiviral treatment during pregnancy

Hepatitis B infection remains the most common form of chronic hepatitis. Mother to child transmission occurs despite immunoprophylaxis with vaccination and immunoglobulin. In utero infection is suggested to account for most of the cases with immunoprophylaxis failure. Infants who suffer from hepatitis B infection at birth have a higher risk of becoming chronic carriers and may develop liver cirrhosis or hepatocellular carcinoma in the future. Infected germ cells, transplacental infection, invasive prenatal diagnostic tests and various perinatal factors are possible factors leading to in utero infection and subsequent immunoprophylaxis failure. Hepatitis B e antigen positive status and high viral load increase the risk of immunoprophylaxis failure. Recent evidence shows promising results regarding the use of antiviral treatment in late gestation to suppress viral load, so as to decrease the risk of vertical transmission. This review discusses the possible mechanisms of in utero infection and the use of antiviral treatment during pregnancy.

An unusual cause of postpartum collapse: Undiagnosed myasthenia gravis

Discussion Fetal ascites is not a frequent ultrasound fi nding. An underlying pathology or associated disorder occurs in 92% of cases. A careful search for the aetiology of ascites should be undertaken. It is frequently associated with several pathologies such as parvovirus, cardiac malformation or dysfunction and aneuploidy. DHS is a rare cause of ascites with a relatively benign prognosis (Ami et al. 2009). It is defi ned by mild anaemia, increased mean corpuscular volume and increased mean corpuscular haemoglobin concentration. DHS is caused by a defect in the ionic permeability of the red blood cell membrane (S á nchez et al. 2005). Th e pathophysiology of fetal oedema in DHS is unclear. It is likely that it would result from the dysfunction of an ion channel, or an ion channel regulating protein in red cells (Ogburn et al. 2001). Th is dysfunction would be expressed, in the prenatal or perinatal period, in endothelial cells. As a result, fl uid may be extruded in diff erent cavities. But the exact red cell membrane defect and the way the ascites is produced remain unknown. Th e exact prevalence of DHS is not yet known. Th e responsible gene maps to 16q23-q24 but the mutant gene responsible is unknown (Carella et al. 1998). Commonly, symptomatology includes a mild and wellcompensated haemolytic anaemia associated with a high reticulocyte count. Splenectomy is not indicated in DHS due to increased risk of thrombosis. Th e osmotic gradient ektacytometric curve shows a left ward shift (Vicente-Guti é rrez et al. 2005). Some patients with DHS develop prenatal oedema. Eleven cases of prenatal oedema due to DHS have been described in the literature (Ami et al. 2009; Basu et al. 2003; Entezami et al. 1996; Grootenboer et al. 1998; Grootenboer-Mignot et al. 2003; Vicente-Guti é rrez et al. 2005). Fetal ascites have been detected with ultrasound examination in all cases between 15 and 32 weeks ’ gestation. No predictive factor exists for severity of fetal oedema in DHS families. Th e severity of the eff usions may vary from ascites to severe hydrops. Five cases of fetal hydrops have been described and only one case of ascites and pleural eff usion is reported (Grootenboer-Mignot et al. 2003). Th ere is no evidence in the literature suggesting that the variable expressivity of the fetal disease depends on the sex of the fetus. Diagnosis was confi rmed for all newborns by ektacytometry. Th e degree of fetal anaemia is not related to the intensity of oedema. Oedema commonly resolves in late gestation or within weeks of birth and never recurs (Basu et al. 2003, Grootenboer-Mignot et al. 2003). It does not change substantially aft er blood transfusion or drainage of ascites and tends to resolve spontaneously. In these cases, intrauterine transfusions would not be justifi ed by the intensity of anaemia and would not reduce the oedema (Grootenboer-Mignot et al. 2003). Non-invasive management is reasonable (Entezami et al. 1996). Because fetal oedema will resolve spontaneously, both family and medical teams should be confi dent. To conclude, fetal oedema without obvious cause should raise the possibility of DHS even in the absence of any known family history. Th e prognosis of this pathology is less severe than other fetal ascites causes.

Recurrence of Carcinoma of Appendix Presenting as Vulvar Swelling: A Case Report

BACKGROUND Adenocarcinoma of the vulva is rare and can develop as metastatic recurrence originating from the appendix. Vulvar swelling can be one of the presenting symptoms and should not be presumed to be lymphedema unless possible malignant metastasis has been excluded. CASE We report a case of vulvar swelling arising after hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aotic lymphadenectomy, and appendectomy for presumed ovarian malignancy. Pathology revealed stage IV carcinoma of the appendix. The patient presented with vulvar swelling 12 months after the operation. An erythematous vulva with multiple hard nodular growths was found on examination. Biopsy confirmed recurrence of adenocarcinoma of the appendix. CONCLUSION Recurrent carcinoma of the appendix can metastasize to the vulva and may present as vulvar swelling.

Hysterectomy for abnormal cervical smear when local excision is not possible.

Objective To review the outcomes of those women who underwent hysterectomy because of an abnormal cervical smear where local excision was considered technically not possible. Materials and Methods A retrospective chart review was performed for all women who had hysterectomy at a university-affiliated hospital, carried out during the period between January 2000 and June 2012, because of cervical neoplasia. Results Fifty-six women were identified. The mean (standard deviation [SD]) age of the women at the time of hysterectomy was 61.4 (8.2) years. Two women (3.6%) had cervical carcinoma, and adjuvant treatment was required in both cases. Being postmenopausal and older than 50 years and having a history of previous local excisional procedure were associated with a higher risk of high-grade cervical intraepithelial neoplasia found during hysterectomy (p > .005). During a mean (SD) follow-up of 42.3 (30.8) months after hysterectomy, 35.7% of women had persistent cytologic abnormality after hysterectomy, with 19.6% having subsequent histologically proven vaginal intraepithelial neoplasia (VAIN). Women’s age, route of hysterectomy, previous local excision, degree of cytologic abnormality before hysterectomy, presence of VAIN before hysterectomy, and final histology of the hysterectomy specimen could not predict subsequent VAIN after hysterectomy. Conclusions Hysterectomy seems to be an appropriate option in management, but further surgery or adjuvant therapy may be needed. Women should also be aware of the possibilities of persistent cytologic abnormalities including VAIN, but unfortunately, no predictive factor for its occurrence can be identified.

Immunoprophylaxis Failure of Infants Born to Hepatitis B Carrier Mothers Following Routine Vaccination

*Department of Obstetrics and Gynaecology, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China; Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China; Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong SAR, China; kDepartment of Obstetrics and Gynaecology, Tuen Mun Hospital, Hong Kong SAR, China; Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong SAR, China; and Department of Paediatrics and Adolescent Medicine, the University of Hong Kong, Hong Kong SAR, China

Pregnancy outcomes of women randomized to receive real versus placebo acupuncture on the day of fresh or frozen-thawed embryo transfer

INTRODUCTION Acupuncture is commonly used in various aspect of Western medicine in recent years including in-vitro fertilization (IVF) treatment. Although there are many clinical trials of acupuncture in IVF and the Cochrane meta-analysis did not find benefit of adjuvant acupuncture for IVF, there is no report on the pregnancy outcomes of women who had received acupuncture during their IVF treatment. OBJECTIVES To compare the pregnancy outcomes of women randomized to receive real versus placebo acupuncture during their IVF treatment. METHODS A retrospective chart review was performed on the 212 women with on-going pregnancies after receiving real or placebo acupuncture by sterile disposable stainless steel needles or Streitbergers placebo needles to the acupoints before and after the embryo transfer on the day of fresh or frozen-thawed embryo transfer. The pregnancy outcomes were obtained from the Hospital Authority Clinical Management System for deliveries in the public sector or from a self-returned questionnaire if those in the private sector. RESULTS No significant differences were found between the demographics of the two groups including their age, gravida, parity and the duration of subfertility. Maternal adverse outcomes including gestational diabetes and hypertensive disorder were comparable for the real acupuncture group (35.3% and 4.4% respectively) and the placebo acupuncture group (39.7% and 5.5% respectively). None of the patients had placenta accreta. The preterm delivery (<37 weeks gestation) rate in the real acupuncture group (23/86, 26.7%) was similar to that in the placebo acupuncture group (25/97, 25.8%). No statistical significant difference was found in the mode of delivery. There were no significant differences between the two groups for Apgar scores and birthweight. CONCLUSION Acupuncture during IVF treatment does not influence pregnancy outcomes.

Pyoadénomyose: rare complication de l'adénomyose

Figure 2 Ud’adenomyose uterine et de diabete de type 2 connus s’est presentee avec de la fievre et une douleur abdominale basse. L’examen abdominal a revele un uterus tendu, dont la taille equivalait celle d’un uterus a 18 semaines de grossesse. Les examens ont revele une leucocytose, une hyperglycemie et une acidose metabolique. La tomodensitometrie a revele de multiples collections liquidiennes hypodenses a paroi epaisse, rehaussees par le produit de contraste, a l’interieur de l’uterus, compatibles avec des abces uterins (figure 1, fleches). Comme la patiente repondait mal au traitement antibiotique, on a pratique une hysterectomie abdominale totale et une salpingoovariectomie bilaterale. Pendant l’operation, on a trouve de nombreuses poches de collections liquidiennes purulentes, a l’interieur du myometre atteint d’endometrioide, compatibles avec la pyoadenomyose (figure 2). Les examens histologiques ont confirme la presence d’adenomyose avec formation d’abces.

Pyoadenomyosis: A Rare Complication of Adenomyosis

49-year-old nulliparous woman with known uterine Aadenomyosis and type 2 diabetes mellitus presented with fever and lower abdominal pain. Abdominal examination showed an 18 weeks’ size tender uterus. Investigations identified leukocytosis, hyperglycemia, and metabolic acidosis. Computed tomography showed multiple rim-enhancing hypodense collections within the uterus compatible with uterine abscesses (Figure 1, arrows). After a poor response to antibiotic treatment, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Intraoperatively, multiple sinuses with purulent collections were noted within the adenomyomatoid myometrium compatible with pyoadenomyosis (Figure 2). Histological examination confirmed adenomyosis with formation of abscesses.

Response: Cystic Endosalpingiosis or Multicystic Mesothelioma?

To the Editor: We thank Drs. Wong and Lee for their interest in our article reporting a case of endosalpingiosis [1], and for raising the issue of differentiating endosalpingiosis frommesothelioma. Having encountered both conditions [1,2], we have a similar view on the pathogenesis of these lesions. We agree that the difficulty in determining the histology of these lesions based on their gross appearance, along with the inconsistency in the literature, have caused confusion among clinicians in reaching a definitive diagnosis. After reviewing the literature, however, we believe that the differentiation of these 2 conditions should rely mostly on histological examination with histoimmunochemistry, rather than based simply on gross appearance or anatomic location. Various terminology is used in the literature to describe benign pelvic cystic structures, including pelvic inclusion cyst [3], benign multicystic mesothelioma [4,5], m€ullerian cyst [2], and endosalpingiosis [6,7]. Benign multicystic mesothelioma and multilocular peritoneal inclusion cyst are essentially the same disease entity. The difference in terminology may be related to the disease’s controversial etiology and pathogenesis [3–5]. Some authors believe that the formation of these cystic lesions is reactive in nature, through peritoneal reaction due to chronic irritation, whereas others characterize it as a true neoplasm (mesothelioma) [8]. It occurs most commonly in women of reproductive age with a history of previous abdominal surgery, endometriosis, leiomyoma, or pelvic inflammatory disease [3–5], but occurrence in men has been reported as well. Microscopically, the cysts are lined by flat or cuboidal cells [3–5], and positive calretinin [3,6] and negative PAX-8 [5] results on histoimmunochemistry suggest the presence of mesothelial cells. On the other hand, endosalpingiosis, also known asm€ullerian cyst, is usually diagnosed by histological identification of ectopic tubal type ciliated glandular epithelium [6,7], supported by positive PAX-8 [6] and negative CD10 [5] on histoimmunochemistry. Speculated to derive from the secondary m€ullerian system, it has been found in other locations apart from the uterus, including the urinary bladder and vermiform appendix [7]. Although both endosalpingiosis and mesothelioma are considered benign, the clinical importance of these conditions can be significant. The previously reported possible associations between mesothelioma and renal agenesis [5], and between endosalpingiosis and borderline or low-grade serous neoplasms [6], require further study.

Sonographic characteristics of the uterus in asymptomatic women after second-trimester medical termination of pregnancy.

The purpose of this study was to evaluate the sonographic characteristics of the uterus after apparently uncomplicated second‐trimester medical termination of pregnancy and to follow the evolution of these findings until the return of menstruation.