Marek Klimek

Spontaneous uterine rupture at 35 weeks' gestation, 3 years after laparoscopic myomectomy, without signs of fetal distress.

Laparoscopic myomectomy (LM) is a recently developed surgical technique, and every obstetrician should be aware of its possible complications, which can occur not only during labor but also during pregnancy. We report a case of a primigravid woman who was hospitalized at 35 weeks’ gestation because of irregular abdominal pain. She conceived spontaneously 3 years after LM. After a 20‐h stay on the obstetrician ward due to increased abdominal tenderness and vaginal bleeding, the patient was qualified for an emergency cesarean section without any symptoms of fetal distress in cardiotocography. During cesarean section a newborn with 9 Apgar points was delivered and a rupture of the uterine wall was seen. Dehiscence of the pregnant uterus following LM is an incidental case, and can therefore be misdiagnosed. Close attention should be paid to every pregnancy in previously operated uteri as the dehiscence of the pregnant uterus can occur without symptoms of fetal distress.

The Role of RCAS1 and Oxytocinase in Immune Tolerance during Pregnancy

Objectives: To determine and compare the level of RCAS1 (receptor-binding cancer antigen expressed in SiSo cells) in placentas at term as well as oxytocinase/cystine amino peptidase (CAP) serum level a few days before labor in order to evaluate their possible role in the regulation of maternal immune response during pregnancy and in initiation of labor. Methods: We estimated the RCAS1 content in 44 placental tissue samples, using Western blot method. We also assessed CAP serum level by its enzymatic activity, using L-cystine-di-β-naphthylamide as a synthetic substrate. The statistical analysis was performed using Shapiro-Wilk procedure. Student’s t test was applied to compare the differences between parametric data. A value of p < 0.05 was considered significant. Results: RCAS1 was found in all placental tissue samples examined. The differences in the RCAS1 relative amount depended on the onset of labor, with the highest level in induced labor and the lowest in spontaneous labor. The differences were also observed in the CAP serum level with the highest level in pregnant women whose labor was induced. Conclusions: We have observed a link between the expression of the two proteins examined and the onset of the labor. Therefore, we posit that RCAS1 and CAP may play a role in the downregulation of the maternal immune response during pregnancy and may participate in the initiation of the labor.

The Obstetrical History in Patients with Pfannenstiel Scar Endometriomas – An Analysis of 81 Patients

Introduction: The participation of immune tolerance during pregnancy was suggested to be an important factor predisposing to the implantation of decidual cells after cesarean section in Pfannenstiel scar. Delivery at term is related to the termination of immune tolerance to fetal antigens that is maintained throughout pregnancy. Substantial proportion of cesarean section deliveries is performed before the onset of true term labor. The aim of this study was to analyze the clinical symptoms of spontaneous beginning of labor in pregnant women in whom cesarean sections were performed and in whom Pfannenstiel scar endometriomas were observed during follow-up. Materials and Methods: We have retrospectively analyzed 81 patients following the surgical removal of scar endometrioma after cesarean section. Obstetrical histories of cesarean sections in the number of 5,370 preceding the occurrence of the scar endometrioma were analyzed. These data were collected in six different Gynecological and Obstetrical wards in Malopolska Province in Poland. Analysis of data was started by the retrospective evaluation of regular uterine contractions, uterine cervix ripening before cesarean section and the indications for surgery. Results: In 67 women from the group of 81 patients cesarean sections were performed with unripe uterine cervix and without the presence of regular uterine contractions. Elective indications for cesarean sections were predominant in this group of women. The relative risk of scar endometriomas occurrence following cesarean sections performed before onset of labor in comparison to cesarean sections following spontaneous onset of labor was statistically significantly higher [RR = 2.16, 95% CI = 1.21–3.83; OR = 2.18, 95% CI = 1.22–3.89]. Conclusions: Cesarean section performed before spontaneous onset of labor may increase substantially the risk of occurrence of scar endometriomas.

The placental RCAS1 expression during stillbirth

BackgroundIndependently of the fetal death cause the beginning and course of stillbirth is closely related with the growing cytotoxic activity at the maternal-fetal interface. RCAS1 participates in the inhibition of maternal immune response during pregnancy. The alterations of RCAS1 protein expression in placental cells seem to determine the beginning of the labor and participate in the placental abruption. The aim of the present study was to investigate RCAS1 expression in placentas obtained following stillbirths or normal term births. Methods: RCAS1 expression was evaluated by Western blot method with the use of monoclonal anti-RCAS1 antibody in 67 placental tissue samples. Pregnant women were divided into four groups according to the mode of labor onset – spontaneous or induced, and the type of labor, stillbirth or labor at term. Placental beta-Actin expression was chosen as a control protein. Relative amounts of placental RCAS1 were compared with the use of Students t-test, whereas beta-Actin control data were compared with the use of Mann-Whitney U test. Results: The average relative amount of RCAS1 was significantly lower in women with induced stillbirths than in women with induced labor at term. Similarly, significantly lower RCAS1 placental levels were observed in patients with spontaneous stillbirths than in women with spontaneous labor at term. Significant differences in RCAS1 expression were also observed with the respect to the beginning of the stillbirth: spontaneous and induced. Lowest RCAS1 placental levels were observed in women with spontaneous stillbirth. Conclusions: These preliminary results indicate that the alterations of RCAS1 expression in the human placenta may be involved in the changes of maternal immune system that take place during stillbirth.

The length of menstrual bleeding and the risk of urogenital infections in the context of the activity of hemoglobin-derived microbicidal peptides

OBJECTIVE Well-known natural unspecific antimicrobial factors acting in the vagina are additionally reinforced during menstrual bleeding by hemocidins--a recently discovered novel class of microbicidal peptides generated proteolytically from hemoglobin. The aim of the presented research was to investigate the relation between the average length of menstrual bleeding and the frequency of urogenital infections. We expected that the shorter menstrual bleeding might increase the risk of urogenital infections because is synonymous with the shorter period of exposition on bactericidal action of hemocidins. STUDY DESIGN The study contains statistical analysis of an average declared length of menstrual bleeding in the group of 267 young, sexually active women with the symptoms of urogenital infections. The control group consisted of 300 young healthy women. RESULTS The length of menstrual bleeding in the group of patients with urogenital infections (average 4.35 days) was statistically significantly shorter than in the control group (average 4.95 days). The average length of the menstrual cycle was equal and counted ca. 28 days in both groups. CONCLUSION The length of menstrual bleeding seems to be a significant factor in the vaginal ecology maintenance.

Analysis of Free Hemoglobin Level and Hemoglobin Peptides from Human Puerperal Uterine Secretions

Objective: Hemocidins are a novel class of antibacterial peptides generated proteolytically from hemoglobin. These peptides play a particularly important role in maintaining vaginal homeostasis during menstrual bleeding. To investigate the hemoglobin fragmentation process during the last stages of pregnancy, we examined uterine secretion (lochia) samples from a group of 22 healthy women who underwent cesarean delivery at term. Methods: Patients were divided into three groups: (1) the elective cesarean deliveries without symptoms of spontaneous labor, (2) the nonelective cesarean deliveries with spontaneous beginning of labor, and (3) the nonelective cesarean deliveries during advanced labor. The samples were subjected to chromatographic estimation of free hemoglobin and peptides. In three representative patients the identification of all lochial peptides was performed. Results: All samples contained a significant amount of free hemoglobin and its level increased with labor progression. The presence of peptide fractions was also detected in most lochia samples. They were confirmed to be human hemoglobin fragments, almost identical to the recently described bactericidal hemocidins from menstrual discharge. The level of peptides also increased during labor. The subgroup with advanced labor demonstrated the highest amount of hemocidins. Conclusions: The presented results prove that proteolysis of free hemoglobin in the female upper reproductive tract begins together with the clinical symptoms of normal labor. We speculate that cesarean delivery affects molecular mechanisms involved in antibacterial hemocidins generation and, in effect, might be responsible for the increased risk of gynecologic infections in cesarean deliveries.

The Effectiveness of Adrenocorticotropin Repeated Doses in High Risk Pregnancies

Objective: The aim of this study was to assess the effect of two kinds of adrenocorticotropin (ACTH)-depot repeated doses administered to pregnant women who underwent infertility treatment. Material and Methods: The study population included 424 pregnant women with singletons. Two hundred and forty-two women received repeated 0.5 mg doses of ACTH, whereas 182 women also were treated for infertility but did not receive any therapy. The ACTH-treated patients were subdivided into two subgroups: (1) 142 patients received only series of three 0.5 g ACTH-depot injections every other day in the first and/or second trimester with occasionally single ACTH-depot doses in the third trimester, (2) 100 patients received only single 0.5 mg ACTH-depot doses for the entire duration of pregnancy. Clinical symptoms of threatened abortion and preterm delivery as well as very low or decreasing levels of serum oxytocinases were indications for the hormonal therapy. Low oxytocinase serum levels, recurrent abortion and preterm delivery characterize pregnant women with hypothalamic insufficiency. Results: Women who received only single doses of the ACTH-therapy for the entire duration of pregnancy had a statistically significant longer gestation, and higher newborn mass and length than patients who received a series of three hormonal injections as well as control women who had no clinical or laboratory indication for such therapy. Conclusions: ACTH-depot injection results in the oxytocinase increased serum level, a decreased number of abortion and preterm deliveries and prolonged duration of pregnancy. Single repeated doses of the ACTH-depot therapy had statistically significant better results in the prolongation of pregnancy, newborn mass and length than a serial hormonal dosage.