María Luisa Sánchez-Ferrer

Endometriomas and deep infiltrating endometriosis in adulthood are strongly associated with anogenital distance, a biomarker for prenatal hormonal environment

STUDY QUESTION Is the length of the anogenital distance (AGD), a biomarker of the in-utero prenatal hormonal environment, associated with the presence of endometriomas and deep infiltrating endometriosis (DIE)? SUMMARY ANSWER Shorter AGD is associated with presence of endometriomas and DIE. WHAT IS KNOWN ALREADY It is debated whether hormonal exposure to estrogens in utero may be a risk factor for endometriosis in adulthood. AGD is a biomarker of prenatal hormonal environment and observational studies have shown an association between AGD and reproductive parameters in both sexes. STUDY DESIGN, SIZE, DURATION This case–control study of 114 women with endometriosis (endometriomas and/or DIE) and 105 controls was conducted between September 2014 and May 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS Cases were attending the Endometriosis Unit of the Hospital. Prevalent as well as incident cases, diagnosed by transvaginal ultrasound (TVUS), were included. Controls were women without endometriosis attending the gynecological outpatient clinic for routine gynecological exams. Participants completed health questionnaires, followed physical and gynecological examinations, including TVUS. Measurements from the anterior clitoral surface to the upper verge of the anus (AGDAC), and from the posterior fourchette to the upper verge of the anus (AGDAF) were obtained in all subjects. Unconditional multiple logistic regression was used to estimate the association between AGD measurements and presence of endometriomas and/or DIE while accounting for important confounders and covariates, including age, body mass index, vaginal delivery or episiotomy. MAIN RESULTS AND THE ROLE OF CHANCE AGDAF was related to presence of endometriomas and/or DIE. For all cases of endometriosis (endometriomas and DIE), women in the lowest tertile of the AGDAF distribution, compared with the upper tertile, were 7.6-times (95% CI 2.8–21.0; P-trend < 0.001) more likely to have endometriosis. With regard to DIE, women with AGDAF below the median, compared with those with AGDAF above the median, were 41.6-times (95% CI 3.9–438; P-value = 0.002) more likely to have endometriosis. LIMITATIONS, REASONS FOR CAUTION In case–control studies, information and selection bias has to be ruled out. Physicians conducting the measurement were blind to the status of the patients. Controls came from the same population as the cases. We adjusted for known and suspected confounders and covariates, but the possibility of residual confounding or chance findings should always be considered. As with all observational studies, causal inference is limited. WIDER IMPLICATIONS OF THE FINDINGS This study suggests that endometriosis, especially the DIE, might have a prenatal origin that may be traced back to the hormonal milieu in which the fetus develops. STUDY FUNDING/COMPETING INTEREST This work was supported by the Ministry of Economy and Competitiveness, ISCIII (AES), grant no. PI13/01237 and the Seneca Foundation, Murcia Regional Agency of Science and Technology, grant no. 19443/PI/14. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER Not applicable.

Fertility Preservation in Heterotopic Cervical Pregnancy: What Is the Best Procedure?

We describe a patient who underwent assisted reproduction techniques and was diagnosed with heterotopic cervical pregnancy, and then discuss the management of this entity, which is rare and has no standard protocols. Treatment consisted of intra-arterial methotrexate (50 mg/m2 body surface area) and simultaneous selective embolization of uterine arteries. The literature is also reviewed to identify other approaches and outcomes.

Uterine rupture in twin pregnancy with normal fetus and complete hydatidiform mole.

We describe a rare case of complete hydatidiform mole with twin live fetus (CHMTF) confirmed by histopathology, flow cytometry and polymerase chain reaction techniques. No malformations were observed, fetal karyotype was normal and β-human chorionic gonadotropin levels were high (>100,000 IU/ml). The patient was informed of the risks and decided to continue with the pregnancy, but at week 15, she had to undergo hysterectomy due to uterine rupture. She subsequently developed persistent trophoblastic disease (PTD) with pulmonary metastases that required treatment with polychemotherapy. Patients with CHMTF should be informed of all known risks, including the considerable risk of PTD, which is similar to or, even higher than that associated with a singleton complete mole. The risk does not appear to be increased by continuing the pregnancy. Because so few series have been published, there is a lack of evidence-based clinical management guidelines. To our knowledge, this is the first report of uterine rupture in CHMTF.

Conservative management of vesico-vaginal fistula after uterine and partial bladder necrosis due to embolization as a treatment for postpartum hemorrhage

Postpartum haemorrhage is a major cause of maternal mortality worldwide, and uterine atony its most common cause. Selective uterine artery embolization (UAE) is a safe conservative second-line treatment after uterotonics or uterine tamponade have failed and before surgical techniques are used in hemodynamically stable patients. Response rates range from 75-100 %. Complications are rare (6-9 %). Most common is postembolization syndrome (self-limited fever and pain within the first 24-48 hours). A rare (22 cases found) and severe complication is uterine necrosis, isolated or with bladder involvement (only three cases reported). All were treated with surgery (hysterectomy and partial cystectomy in cases with associated bladder necrosis). Regarding a vesicovaginal fistula after embolization, only 3 cases have been reported [1–3]. All resulted in hysterectomy (either total or subtotal).

Management of a Dichorionic Twin Pregnancy with a Normal Fetus and an Androgenetic Diploid Complete Hydatidiform Mole

We describe a rare case of complete hydatidiform mole with twin live fetus (CHMTF) confirmed by histopathology, flow cytometry, and polymerase chain reaction techniques. No malformations were observed, fetal karyotype was normal and β-human chorionic gonadotropin levels were increased (>100,000 IU/ml). Once the patient had been informed of the risks, it was decided to continue the pregnancy, but termination of pregnancy was necessary at week 13 + 5 due to maternal complications consisting of hyperthyroidism, hypertension and vaginal bleeding, followed by persistent trophoblastic disease (PTD). Patients diagnosed with CHMTF should be informed of all known risks, including the considerable risk of PTD, which is similar to - or according to some reports - even higher than that associated with a singleton complete mole and is not increased by continuing pregnancy. Due to the low number of series published, evidence-based clinical management guidelines are lacking.

Use of Eye Tracking as an Innovative Instructional Method in Surgical Human Anatomy

OBJECTIVE Tobii glasses can record corneal infrared light reflection to track pupil position and to map gaze focusing in the video recording. Eye tracking has been proposed for use in training and coaching as a visually guided control interface. The aim of our study was to test the potential use of these glasses in various situations: explanations of anatomical structures on tablet-type electronic devices, explanations of anatomical models and dissected cadavers, and during the prosection thereof. An additional aim of the study was to test the use of the glasses during laparoscopies performed on Thiel-embalmed cadavers (that allows pneumoinsufflation and exact reproduction of the laparoscopic surgical technique). The device was also tried out in actual surgery (both laparoscopy and open surgery). DESIGN We performed a pilot study using the Tobii glasses. SETTING Dissection room at our School of Medicine and in the operating room at our Hospital. PARTICIPANTS To evaluate usefulness, a survey was designed for use among students, instructors, and practicing physicians. RESULTS The results were satisfactory, with the usefulness of this tool supported by more than 80% positive responses to most questions. There was no inconvenience for surgeons and that patient safety was ensured in the real laparoscopy. CONCLUSION To our knowledge, this is the first publication to demonstrate the usefulness of eye tracking in practical instruction of human anatomy, as well as in teaching clinical anatomy and surgical techniques in the dissection and operating rooms.

Central pontine myelinolysis during pregnancy: Pathogenesis, diagnosis and management

Abstract Central pontine myelinolysis (CPM) is a rare condition usually caused by rapid sodium correction in hyponatraemia after a severe neurological syndrome. Only few cases have been reported during pregnancy, most of which were reported in patients with hyperemesis. We describe the successful management of the first case of twin pregnancy in a patient who presented with CPM after treatment for premature labour and then review the literature on CPM in pregnancy (aetiology, diagnosis and management). Our patient required emergency delivery to achieve electrolyte and fluid balance. At six months, the twins remained asymptomatic and the mother had minor sequelae. The aetiology is not clear, and there is no evidence regarding the optimal treatment or prognosis of CPM. In our patient, desmopressin-contaminated atosiban showed a certain probability in the Karch-Lasagne algorithm of a causality relationship between hyponatraemia and the drug. To our knowledge, this is the first case of myelinolysis reported in a twin pregnancy possibly related to desmopressin-contaminated atosiban.

Characterization of human peritoneal monocyte/macrophage subsets in homeostasis: Phenotype, GATA6, phagocytic/oxidative activities and cytokines expression

Peritoneal macrophages play a critical role in the control of infectious and inflammatory diseases. Although recent progress on murine peritoneal macrophages has revealed multiple aspects on their origin and mechanisms involved in their maintenance in this compartment, little is known on the characteristics of human peritoneal macrophages in homeostasis. Here, we have studied by flow cytometry several features of human peritoneal macrophages obtained from the peritoneal cavity of healthy women. Three peritoneal monocyte/macrophage subsets were established on the basis of CD14/CD16 expression (CD14++CD16−, CD14++CD16+ and CD14highCD16high), and analysis of CD11b, CD11c, CD40, CD62L, CD64, CD80, CD86, CD116, CD119, CD206, HLA-DR and Slan was carried out in each subpopulation. Intracellular expression of GATA6 and cytokines (pro-inflammatory IL-6 and TNF-α, anti-inflammatory IL-10) as well as their phagocytic/oxidative activities were also analyzed, in an attempt to identify genuine resident peritoneal macrophages. Results showed that human peritoneal macrophages are heterogeneous regarding their phenotype, cell complexity and functional abilities. A direct relationship of CD14/CD16 expression, intracellular content of GATA6, and activation/maturation markers like CD206 and HLA-DR, support that the CD14highCD16high subset represents the mature phenotype of steady-state human resident peritoneal macrophages. Furthermore, increased expression of CD14/CD16 is also related to the phagocytic activity.

Comparability between adult female anogenital distance and perineal measurements standardized by POP-Q system (GH and PB)

Anogenital distance (AGD) has been proposed as a marker of the prenatal hormonal milieu and potential environmental insults. The measures of the Pelvic Organ Prolapse‐Questionnaire (POP‐Q) system is being widely used in the evaluation of the perineum in women with POP pathologies. Genital hiatus (GH) and perineal body (PB) lengths have been related to both prolapse incidence and recurrence and for pessary treatment failure. The use of AGD in female human studies is now emerging and its comparability with other anthropometric measurements could be relevant. The aim of the study was to compare AGD and POP‐Q system in adult females.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.