Magdy Mikhail

Risk factors for persistent cervical intraepithelial neoplasia grades 1 and 2: managed by watchful waiting.

Objective: This study examines risk factors for persistent cervical intraepithelial neoplasia (CIN) and examines whether human papillomavirus (HPV) testing predicts persistent lesions. Materials and Methods: Women with histologically diagnosed CIN 1 or CIN 2 (n = 206) were followed up every 3 months without treatment. Human papillomavirus genotyping, plasma levels of ascorbic acid, and red blood cell folate levels were obtained. Cervical biopsy at 12 months determined the presence of CIN. Relative risk (RR) was estimated by log-linked binomial regression models. Results: At 12 months, 70% of CIN 1 versus 54% of CIN 2 lesions spontaneously regressed (p < .001). Levels of folate or ascorbic acid were not associated with persistent CIN at 12 months. Compared with HPV-negative women, those with multiple HPV types (RRs ranged from 1.68 to 2.17 at each follow-up visit) or high-risk types (RRs range = 1.74-2.09) were at increased risk for persistent CIN; women with HPV-16/18 had the highest risk (RRs range = 1.91-2.21). Persistent infection with a high-risk type was also associated with persistent CIN (RRs range = 1.50-2.35). Typing for high-risk HPVs at 6 months only had a sensitivity of 46% in predicting persistence of any lesions at 12 months. Conclusions: Spontaneous regression of CIN 1 and 2 occurs frequently within 12 months. Human papillomavirus infection is the major risk factor for persistent CIN. However, HPV testing cannot reliably predict persistence of any lesion.

Inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair.

Graft augmentation for repair of recurrent pelvic organ prolapse is commonly used in reconstructive pelvic surgery. The reported complications are mainly late onset. We report a case of early-onset inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair. A 49-year-old presented with a recurrent and symptomatic posterior vaginal wall defect. She underwent an uneventful site-specific repair and bovine graft augmentation. Her early postoperative course was complicated by inflammatory response to the graft presenting as intense pelvic floor spasm and urinary retention. The condition was managed conservatively and resolved subsequently. One year later, the patient continues to be asymptomatic. Transient intense pelvic floor spasm and urinary retention can be the result of inflammatory reaction following graft augmentation with bovine pericardium for posterior vaginal wall defect repair.

Compliance with follow-up in an inner-city population treated with intramuscular methotrexate for suspected ectopic pregnancy

To evaluate compliance with follow‐up among inner‐city patients with ectopic pregnancy treated with methotrexate, in addition to assessing outcome.

Impact of hormones on female sexual function and dysfunction.

The female sexual response cycle is a complex system composed of physiologic changes, psychological, and cultural factors. Female sexual dysfunction (FSD) encompasses a variety of sexual problems, including low desire or interest, diminished arousal, difficulties with orgasm, and dyspareunia. Research in female sexual function and dysfunction has lagged significantly behind males despite our current knowledge that FSD can occur in as many of 80% of the female population. Basic science research exists but also identifies serious gaps in our fundamental knowledge of this area. The purpose of this article was to review our current understanding of the effects of hormones on normal physiologic sexual responses in women, female sexual function and dysfunction, and the available treatment options for the various components of FSD.

Plasma uric acid levels in women with cervical intraepithelial neoplasia

Abstract: The objective of this study was to determine the association of plasma levels of uric acid, an endogenous antioxidant, in women with cervical intraepithelial neoplasia (CIN), while controlling for the confounding effects of human papillomavirus (HPV) infection, age, smoking, and use of oral contraception. Plasma-reduced and oxidized uric acid levels were determined in 650 women by high-performance liquid chromatography, employing electrochemical technique. The findings demonstrated that 1) plasma-reduced uric acid (PRUA) levels in women with CIN (n = 311) were significantly lower (P < 0.05) compared with women in a control group (n = 339); 2) according to multiple logistic regression analysis, PRUA levels were negatively (P = 0.0113) and HPV infection were positively associated (P < 0.0001) with CIN, after controlling for the confounding effects of the studied factors; 3) according to multiple regression analysis, there was a 31% decrease in CIN risk for each incremental increase of 1mg/dl of PRUA; and 4) according to polychotomous logistic regression analysis, independent of HPV infection, PRUA level was inversely associated with the histopathological graded severity of CIN. We have previously reported decreased plasma levels of exogenous antioxidants, for example, vitamins C and E, in women with CIN independent of HPV infection. The data suggest that plasma deficiencies of several antioxidants in HPV-infected uterine cervical tissue may create an oxidative environment that renders the tissue susceptible to free radical damage. It may be speculated that chronic free radical-induced tissue damage in the context of persistent HPV infection may be involved in the pathogenesis of CIN.

Placental tumor necrosis factor-α protein expression during normal human gestation.

Abstract Objective: Placental tumor necrosis factor-α (TNF-α) is a cell signaling protein. During pregnancy, TNF-α induces synthesis of matrix metalloproteinases (MMPs) which allows cytotrophoblasts to reach the spiral arteries deeper within the uterine decidua. TNF-α also augments apoptosis of vascular smooth muscle cells surrounding these arteries. In this study, chorionic villi TNF-α protein expression throughout normal human gestation were investigated. Methods: Placental chorionic villi tissues obtained from elective surgical terminations of pregnancy and from uncomplicated term births were assayed using EIA kits (Cayman Chemicals, Ann Arbor, MI, Item # 589201). Results: The median, 25th percentile and 75th percentile values in the first (N = 99), second (N = 58) and third trimester (N = 42) were: 36.46, 27.25, 45.90 pg/100 mg tissue; 55.43, 40.09, 110.88 pg/100 mg tissue; and 16.63, 9.32, 31.92 pg/100 mg tissue, respectively. Conclusions: Variations in placental TNF-α protein expression noted at different trimesters may suggest gestational age specific roles for the cytokine. The increase in TNF-α protein expression observed in the second trimester may be involved in upregulating synthesis of MMP and in augmenting apoptosis of vascular smooth muscle cells of the spiral arteries. A failure in this second trimester increase in TNF-α protein could contribute to gestational compromise.

Residents Experience and Blood Loss in Primary Cesarean Sections

Objective: Compare the Estimated Blood Loss (EBL) between residents performing primary cesarean sections based on their level of training and their associated variables, including the combination of surgeon and assistant experience, demographic variables and different techniques in the procedure. Methods: Retrospective analysis of patients who had a primary cesarean section performed by residents from the Obstetrics and Gynecology Residency Program that attended the Labor and Delivery between August 2011 through December of 2012. 278 patients were included. Demographic and pertinent data was extracted from patient’s electronic medical record. The surgeons and assistants were categorized depending on their level of training in the residency program (Post Graduate Year [PGY]1,2,3,4). Results: 278 patients were included in the study, of them 133 were considered emergent cesarean sections mean cEBL of 832 ± 490, 74 urgent with 829 ± 513 cc, 67 scheduled with 884±167cc and 4 elective with 825 ± 52cc with with an observed Estimated Blood Loss (oEBL) of 873cc ± 182, change in hematocrit of 5.14& ± 3.13 and a calculated (cEBL) of 832.5 ± 490 cc. time in minutes was different between 1 and 2 layers closure (57.4 vs. 67.7 minutes) and their cEBL 734 vs. 662cc. Conclusions: There is a difference in cEBL and change in hematocrit in primary cesarean sections done by residents based on their surgical experience. Time, cEBL, change in Hto is influenced by the years of training of the surgical team. Higher BMI was associated with more surgical time and change in Hto. 2 layer closures were found to consume more surgical time.

Advanced Extrauterine Pregnancy at 33 Weeks with a Healthy Newborn

Abdominal pregnancy is a very rare form of ectopic pregnancy, associated with high morbidity and mortality for both fetus and mother. It is, and often, seen in poor resource nations, where early diagnosis is often a major challenge due to poor prenatal care and lack of medical resources. An advanced abdominal pregnancy with a good fetal and maternal outcome is therefore a more extraordinary occurrence in the modern developed world. We present a case of an abdominal pregnancy at 33.4 weeks in an individual with no documented prenatal care, who arrived in a hospital in the Bronx, in June 25th 2014, with symptoms of generalized, severe lower abdominal pain. Upon examination it was found that due to category III fetal tracing an emergent cesarean section was performed. At the time of laparotomy the fetus was located in the pelvis covered by the uterine serosa, with distortion of the entire right adnexa and invasion to the right parametrium. The placenta invaded the pouch of Douglas and the lower part of the sigmoid colon. A massive hemorrhage followed, followed by a supracervical hysterectomy. A viable infant was delivered and mother discharged on postoperative day 4.

Maternal body mass index does not affect neonatal umbilical artery blood gas parameters.

This study was undertaken to assess the impact of obesity on fetal well-being in glucose-tolerant and nonhypertensive women. Medical charts of all patients admitted to the labor and delivery department at our institution between January, 2011 and July, 2011 were retrospectively reviewed. Patients with diabetes/impaired glucose tolerance or hypertension were excluded. A total of 100 women, 50 lean and 50 obese, were included. Umbilical artery blood gas parameters (BGPs) were compared in lean (<25 kg/m2) and obese (≥30 kg/m2) women. Obese and lean women were comparable with respect to all baseline characteristics. There was no difference in any of the BGP or Apgar scores between obese and lean patients. Pearsons correlation coefficient found no significant correlation between BMI and BGP/Apgar scores. Maternal obesity does not seem to affect BGP and fetal well-being in glucose-tolerant and nonhypertensive women.

Coenzyme Q10 and α-tocopherol concentrations in cervical intraepithelial neoplasia and cervix cancer

Abstract Objective: To determine any association between plasma coenzyme Q10 (CoQ10) and α-tocopherol levels and severity of cervical intraepithelial neoplasia (CIN) and cervical cancer. Methods: Plasma levels of total CoQ10 and α-tocopherol were measured by high-performance liquid chromatography in patients with biopsy-confirmed CIN (n = 55) and cervical cancer (n = 20) and in normal women with no abnormal Pap test results (n = 27). Cervicovaginal lavages containing epithelial cells (CVC), obtained from the same subjects, also were analyzed for CoQ10 concentrations. Results: The mean plasma levels of CoQ10 and α-tocopherol were significantly (P = 0.001) lower in patients with CIN and cervical cancer compared with controls. Levels of CoQ10 from CVC were measurable and also were significantly (P = 0.001) lower in women with CIN. Conclusion: The findings suggest that CoQ10 and α-tocopherol antioxidants may play a role in the pathogenesis of CIN. The decrease in CoQ10 and α-tocopherol levels may be caused by deficient dietary intake in women with CIN. Alternatively, low antioxidant levels may reflect increased utilization to counteract oxidative stress.