Szu-Yuan Chou

Ultrasonographic evaluation of endometrial changes using computer assisted image analysis

Aim:  To examine the usefulness of a gray scale histogram and computer assisted image analysis software in assessing physiologic states of the endometrium with ultrasonography.

A comparative study of cutaneous manifestations of hyperandrogenism in obese and non-obese Taiwanese women

PurposeThe aim of the study was to investigate the impact of obesity on cutaneous manifestations of clinical hyperandrogenism.MethodsA total of 627 Taiwanese women of reproductive age were included.ResultsWomen with acne had a greater incidence of PCOS, hyperandrogenemia and hirsutism, and had higher serum total testosterone than women without acne. Obese women, even with significantly higher serum total testosterone levels, had lower incidence of acne than non-obese women, and this was found uniformly across the hyperandrogenemia and the non-hyperandrogenemia groups. Although BMI had a significantly positive correlation with serum total testosterone in the studied women, obese women presented less acne than the non-obese subjects.ConclusionsObese women, regardless of having higher serum testosterone levels, had a lower incidence of acne than non-obese women; however, the factuality was not found in hirsutism.

VERY EARLY STAGE ADENOCARCINOMA ARISING FROM ADENOMYOSIS IN THE UTERUS

OBJECTIVE Malignant transformations of adenomyosis in premenopausal women with normal endometrium are extremely rare. We report a case of adenocarcinoma arising from an adenomyotic focus in the uterus, which was found unexpectedly in a woman undergoing myomectomy for adenomyosis. CASE REPORT A 47-year-old premenopausal woman presented with massive vaginal bleeding and anemia. She was admitted and underwent myomectomy under the initial diagnosis of uterine leiomyoma. Microscopic studies revealed endometrioid adenocarcinoma, which was a malignant transformation of a focus of adenomyosis in the surgical specimen. A total hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymphadenectomy was then performed. Pathologic studies showed no residual tumors in the entire resected specimen except for the previous lesion. The endometrium had normal thickness with mild proliferative activity throughout the cavity. There was no atrophic or hyperplastic change in the whole endometrium. The adenocarcinoma was present exclusively in the myometrium, and a transition between the carcinoma and the adenomyotic glands was observed. CONCLUSION This case report presents evidence that adenocarcinoma may a rise de novo from an adenomyotic lesion in the uterus.

Recurrent Ipsilateral Ectopic Pregnancy After Partial Salpingectomy

Ectopic pregnancies are those that occur in any place other than the uterine cavity. During the last 20 years, the incidence of ectopic pregnancies has increased fourfold and now accounts for up to 2% of all pregnancies in the United States [1]. Ectopic pregnancy is an important issue during early pregnancy because of the associated maternal morbidity and even mortality [2]. Here, we present two patients with unusual ipsilateral tubal remnant ectopic pregnancies: one occurring in the proximal remnant of the fallopian tube and the other in the distal remnant of the fallopian tube. Both patients had undergone previous partial salpingectomies with laparoscopy. In Case 1, a 38-year-old multigravid woman with a history of previous ectopic pregnancy had undergone laparoscopic right partial salpingectomy 2 years prior to this admission. She had suffered from low abdominal pain for 2 days and had a positive pregnancy test result at the emergency department (ED) of Taipei Medical University–Wan Fang Medical Center. The concentration of serum β subunit of human chorionic gonadotropin (β-hCG) at the ED was 8,869 mIU/mL. The findings of a pretreatment ultrasound examination performed at the ED were consistent with an empty uterus with a moderate amount of cul-de-sac fluid. An ectopic pregnancy with internal bleeding was suggested. The patient underwent therapeutic laparoscopic surgery with diagnostic dilatation and curettage (D&C). The findings of the laparoscopic surgery revealed hemoperitoneum and a bulging mass about 2 cm in diameter at the proximal end of the previous partial salpingectomy remnant area (Figure 1). All the intra-abdominal bloody contents were evacuated during surgery, and the portion of the tube was removed and sent for pathologic examination. Corpus luteum was noted in the patient’s left ovary. Histopathologic examination of the laparoscopic specimen showed a fallopian tube with trophoblast, which was consistent with the findings of a tubal pregnancy. Examination of the D&C specimen showed the existence of decidual tissues. Our patient was, therefore, diagnosed with an ipsilateral ectopic pregnancy in the proximal tubal remnant portion of the previous partial salpingectomy. In Case 2, a 29-year-old multigravid woman with a history of previous ectopic pregnancy had undergone laparoscopic right partial salpingectomy 3 years prior to this admission. At presentation, she was suffering from severe low abdominal pain and had a positive pregnancy test result at the obstetrics and gynecology clinic of Taipei Medical University–Wan Fang Medical Center. The serum level of β-hCG on admission was 14,638 mIU/mL. The findings of a pretreatment transvaginal ultrasound examination performed at our

Ultrasonographic quantification of the endometrium during the menstrual cycle using computer-assisted analysis

OBJECTIVE Sonographic gray-scale histogram is used to assess the endometrial changes in the different phases of the menstrual cycle. The objective was to examine the usefulness of a gray-scale histogram and computer-assisted image analysis software in assessing normal physiologic states of the endometrium with sonography. MATERIALS AND METHODS Thirty-eight patients, who visited the Taipei Medical University-Wan Fang Hospital and matched the eligibility criteria, were categorized into one of three groups: (1) menstrual phase; (2) follicular phase; and (3) luteal phase of the menstrual cycle. Ultrasonography of the uterus was performed on each patient and the endometrium was analyzed with ImageJ image analysis software. RESULTS A statistically significant difference in signal intensity scores of the gray-level histogram, represented as m(j), was found among the three groups. CONCLUSION Sonographic images analyzed by using computer-assisted image analysis software and gray-level histogram are proven to be useful in assessing the physiological state of the endometrium.

Monitoring Medical Abortion Using Mifepristone/Misoprostol Combination with Ultrasonogram and Serum Human Chorionic Gonadotropin

OBJECTIVE The oral mifepristone/misoprostol combination (MMC) is safe for medical abortion in early pregnancy. The abortion status in MMC-treated pregnancies at Taipei Medical University-Wan Fang Medical Center was determined by ultrasonography, serum beta-human chorionic gonadotropin (beta-HCG), and histopathology. METHODS All women at less than 49 days since the last menstruation who asked for legal abortion were evaluated by ultrasonography. They then received 600 mg of oral mifepristone followed 48 hours later by 600 microg of misoprostol. Women who had vaginal spotting or bleeding after 14 days were included in this study and underwent transvaginal ultrasonography, serum beta-HCG measurement and vacuum aspiration or therapeutic dilatation and curettage (D&C) on day 14. Specimens were identified by histopathology. Abortion status was determined from linear regression of serum beta-HCG and endometrial thickness. RESULTS Of 35 women who underwent vacuum aspiration or therapeutic D&C, histopathology showed that 20 had decidual tissue and 15 had gestational tissue. Logistic regression showed that the distance measurement to the logistic regression line differed significantly between complete and incomplete abortion (p < 0.05). CONCLUSION In this study, serum beta-HCG assays in addition to ultrasonographic evaluation helped to discriminate abortion status after oral MMC.

Silent Uterine Rupture in an Unscarred Uterus

OBJECTIVE Uterine rupture is one of the most serious obstetric complications, with an increased risk of maternal and perinatal morbidity, and even mortality. CASE REPORT A multiparous woman came to our labor room at 41 weeks of gestation for induction of labor due to being post-term and having a nonreactive nonstress test. She had no history of abdominal or gynecologic surgery. Emergent cesarean section was performed due to prolonged decelerations shown on the fetal monitor. A 12 cm uterine laceration was identified after opening the abdominal cavity. Fortunately, her uterus was preserved and her postoperative condition was stable. CONCLUSION To avoid maternal and fetal morbidity, or even mortality, obstetricians should be aware of the possible existence of uterine rupture in an unscarred uterus.

Polycystic Ovarian Syndrome in Taiwanese Women

Polycystic ovary syndrome (PCOS) is an extremely common disorder in women of reproductive age. Diagnosis of PCOS is principally based on clinical and physical findings. Diagnostic criteria and PCOS definitions used by clinicians and researchers are almost as heterogeneous as the syndrome. Of those diagnosed with PCOS using the 2003 Rotterdam criteria, 61% fulfilled the 1990 National Institutes of Health criteria for unexplained hyperandrogenic chronic anovulation. Patient populations with the new phenotypes have less severe ovulatory dysfunction and less androgen excess than patients diagnosed using the 1990 National Institutes of Health criteria. These findings might be common across all female populations with PCOS, in Asian or Western countries. Data for clinical hyperandrogenism indicates that the prevalence of hirsutism in Taiwanese PCOS women is lower than that for Caucasian/Western women. The extent of metabolic abnormalities in women with PCOS may vary with phenotype, age and ethnicity. Obesity represents a major risk factor for metabolic syndrome and insulin resistance. Approximately 40–50% of all women with PCOS are overweight or obese. Obese subjects with PCOS have a higher risk of developing oligomenorrhea, amenorrhea and biochemical hyperandrogenemia than non-obese women with PCOS. Moreover, obese women with PCOS have significantly more severe insulin resistance, lower serum luteinizing hormone levels, and lower luteinizing hormone to follicle-stimulating hormone ratios than those of non-obese women with PCOS. PCOS women in Taiwan have a higher luteinizing hormone to follicle-stimulating hormone ratio and lower insulin resistance than those in PCOS women in Western countries. However, the average body mass index is significantly lower in Taiwanese PCOS women than in Western women, which might partially explain the difference between these two populations in terms of clinical and biochemical presentations. To further document the ethnic variation between women with PCOS in Taiwan and Western countries, future studies should pay attention to the effect of obesity on the diagnosis and clinical presentations of PCOS-related syndromes.

Sonographic quantification of endometrial changes after abortion with computer-assisted image analysis.

Objective. To examine the diagnostic feasibility of sonographic gray scale histograms to assess changes in the endometrium following abortion induced by mifepristone and misoprostol. Design. Retrospective study. Setting. Taipei Medical University‐Wan Fang academic medical center. Population or sample. A total of 109 patients who matched eligibility criteria were divided into three groups: (a) complete abortion, (b) normal menstrual cycles, and (c) incomplete abortion. Methods. Ultrasonographic examination of the uterus with fixed settings on each patient and sonographic gray scale histograms with image analysis software, using multivariate analysis by the partial least square model. Main outcome measures. Thickness, brightness, area and distribution of pixels of the endometrium and its contents. Results. The groups could be discriminated (p < 0.01, Kruskal–Wallis test) using the analyzed gray scale histograms. The classification between complete and incomplete abortion reached 97% sensitivity and 100% specificity. Conclusions. Partial least square analysis of gray scale histograms of the endometrium in ultrasonographic images is useful in assessing endometrial changes.

Malignant Fibrous Histiocytoma During Pregnancy: a Case Report

OBJECTIVE We present a case of a 38-year-old postpartum woman who had antepartal undiagnosed sarcoma with multiple metastasis. Although the patient underwent aggressive treatment with surgery and chemotherapy, she died 3 months after the vaginal delivery of a healthy female infant weighing 2,090 g at 35 weeks of gestation. CASE REPORT The patient had right shoulder pain and mild chest discomfort during the last trimester of the pregnancy. Six days after delivery, she came to our emergency room because her pain had become more severe. A humeral neck tumor with bone destruction was found in the right shoulder on X-ray. After detailed evaluation, right humeral surgery, cardiac surgery, and liver biopsy were performed. All the removed specimens were sent for pathologic examination, and the results showed a sarcoma favoring malignant fibrous histiocytoma with its primary origin in the left atrium. CONCLUSION Obstetricians should be aware that any non-specific complaint may be due to severe disease. It is better to evaluate all symptoms and signs that persist. In this case, early intervention such as radiologic imaging of the bone or echocardiography could have been performed during pregnancy to prevent tumor spread, maternal morbidity, and even death.