生殖医学杂志最新文献

Background: Fetal hemorrhage is rare but can result in rapid fetal compromise. Abnormally located fetal vessels within the membranes increase the risk for their rupture and subsequent hemorrhage. The classic example of this is vasa previa.

Case: We present a case of acute fetal hemorrhage resulting from a ruptured fetal vessel. During induction of labor, significant fetal heart rate deceleration occurred, coinciding with acute vaginal bleeding and amniotomy. A depressed, live female neonate was delivered by emergency cesarean section. Examination of the placenta revealed a velamentous cord insertion and a ruptured fetal vessel coursing through the chorioamniotic membranes. Neonatal resuscitation included red blood cell transfusion for hypotension and low hematocrit. The neonate made a full recovery.

Conclusion: Acute fetal hemorrhage from the rupture of aberrant fetal vessels often coincides with rupture of membranes. Identifying ruptured fetal vessels abnormally coursing through the chorioamniotic membranes on examination of the placenta provides supporting evidence for suspected fetal hemorrhage.

Background: Achalasia is an esophageal smooth muscle disorder characterized by failure of the lower esophageal sphincter to relax with swallowing.

Case: A 17-year-old primigravid woman with an intrauterine pregnancy at 31+3 weeks reported an unintentional 22.5 kg weight loss in 2 years. Her body mass index was 15.9. Her symptoms included nausea, regurgitation, and worsening dysphagia. MRI suggested achalasia. She was started on total parenteral nutrition until she developed bacteremia. An esophagogastroduodenoscopy with Duotube placement and botulinum toxin A injections were performed. Tube feeds were initiated and continued until the Duotube became obstructed. The patient delivered at 37+4 weeks with mild preeclampsia. A postpartum barium swallow test indicated achalasia.

Conclusion: A history of dysphagia to solids and/or liquids with weight loss should raise clinical suspicions for achalasia.

Objective: To investigate the relationship between STAT3 gene polymorphism and missed abortion (MA), and the influence of STAT3 gene polymorphism on the expression of VEGF and survivin.

Study design: The missed abortion group included 188 cases of MA. The control group consisted of 200 cases of surgically induced abortion in normal pregnancy. All patients were of Han ethnicity from P.R. China. STAT3 gene from patients' peripheral blood was detected using fluorescent probe real-time quantitative polymerase chain reaction (PCR), which was further analyzed to clarify genotype frequency. Survivin and VEGF mRNA levels in particular genotypes were also detected using qPCR.

Results: The STAT3 rs1053004 C/C genotype incidence in the MA group was significantly higher than that in the control group (p<0.05), while the STAT3 rs1053004 T/T and T/C genotypes showed no significant difference between the 2 groups (p>0.05). The STAT3 gene locus rs1053023 genotypes of the 2 groups were not significantly different, either (p>0.05). Furthermore, survivin and VEGF mRNA levels in the peripheral blood of the patients with STAT3 gene loci rs1053004 C/C were significantly decreased as compared to the control group (p<0.05).

Conclusion: Our study identified the STAT3 rs1053004 C/C as a high-risk genotype in MA with lower survivin and VEGF transcription levels in the peripheral blood.

Objective: To determine if there are any differences in the patient populations that choose subdermal implants versus intrauterine devices (IUDs) for contraceptive purposes.

Study design: Retrospective chart review. Electronic medical records of women who presented to the University of Texas Medical Branch in Galveston's Regional Maternal Child Health Program Clinics in southeast Texas from March 2011 to March 2013 and received a subdermal implant or IUD were reviewed. Differences in characteristics of women who chose either form of contraception were determined.

Results: A total of 356 charts were reviewed. Of those, 188 (53%) women chose the subdermal implant and 168 (47%) chose an IUD. Patients who chose subdermal implants were more likely to have had a long-acting reversible contraceptive (LARC) method previously (p<0.01), previous vaginal deliveries (p<0.001), and an interval from delivery to LARC placement of >1 year (p<0.001). LARC choice was race-specific in that, when compared to Caucasian women, African-American women were significantly more likely to choose an IUD, while Hispanic women were significantly more likely to choose subdermal implants (p=0.002).

Conclusion: Different populations choose subdermal implants versus IUDs for contraception. Further research is needed to determine etiologies for these differences.

Objective: To present a case series of pregnant women with nephrotic syndrome, describe maternal and fetal outcomes, and propose treatment strategies.

Study design: A retrospective cohort case review of 11 pregnant women with nephrotic syndrome was performed over 2 years. Treatment regimens and trends were recorded. Linear regression was used for continuous outcomes, and logistic regression for categorical outcomes (p<0.05).

Results: On first admission, 3 of 11 patients had a serum creatinine >1.4 mg/dL; all 11 exhibited an antepartum increase in creatinine. Two required antepartum dialysis, and 3 were dialyzed postpartum. Initial mean 24-hour urine protein was 10,522 mg (2,160-36,603) and increased to 26,220 mg (4,650-49,980). Pregravid weight increased from a mean 95 kg (BMI 33.8) to 112 kg (BMI 39.9) at time of delivery. Mean antepartum and postpartum diuresis was 33.2 L (±25.8) and 5.2 L (±8.2), respectively. Mean serum albumin levels were 2 g/dL. Ten patients received intravenous diuretics and 9 received intravenous albumin. Mean gestational age at delivery was 34w 3d (30.4-38.4).

Conclusion: Pregnant women with nephrotic syndrome can be managed successfully by a collaborative team of obstetricians and nephrologists with careful diuresis, repletion of albumin, and administration of anticoagulants, when necessary, to deliver a healthy, probably preterm, neonate.

Objective: To determine if residency training in the use of forceps and vacuums in vaginal deliveries is associated with their use in postgraduate practice.

Study design: We surveyed all Ob/Gyn residency graduates of 4 academic programs from 2004-2012. The average number of vacuums and forceps performed per graduating resident was linked to respondents, who were then grouped by self-report as using forceps alone, vacuums alone, or both in practice. Multivariable logistic regression determined predictors of use of forceps and vacuums in practice

Results: The response rate was 61.2% (n=200). Those practicing obstetrics (n=171) were classified as forceps only (24%), vacuums only (22%), or both (54%). Use of forceps in practice was greater for those who graduated within the last 5 years (OR 7.55, 95% CI 2.37-24.07), felt inadequately trained in vacuums (OR 4.58, 95% CI 1.23-17.00), cared for a patient population <50% privately insured (OR 4.08, 95% CI 1.58-10.52), and performed more forceps in residency (OR 1.69, 95% CI 1.31-2.18 per 5 forceps performed on average). The only significant predictor of vacuum use was the number of vacuum deliveries performed in residency (OR 3.71, 95% CI 2.28-6.01 per 5 vacuums performed on average).

Conclusion: Independent practice pattern for operative vaginal delivery reflects residency training for both vacuums and forceps.

Background: Cesarean scar pregnancy (CSP) is a type of ectopic pregnancy with the gestation sac located on a previous cesarean scar. Recurrent CSP (RCSP) is the occurrence of 2 or more consecutive CSPs. Until this case, there have been only 8 previous reported cases of RCSPs in the English-language literature.

Case: A 30-year-old, Chinese woman was admitted to our hospital for RCSP. We had successfully terminated her first CSP by a series of treatments including uterine arterial embolization with local methotrexate injection, mifepristone, and misoprostol administration, as well as an ultrasound-guided suction curettage evacuation. However, this time we performed only a transvaginal CSP lesion resection, which achieved an improved outcome.

Conclusion: This case highlights the likelihood of RCSP and the need for transvaginal CSP lesion resection to decrease the risk of RCSP in CSP patients who desire future pregnancy.

Background: Pemphigus vulgaris is a rare autoimmune bullous disease characterized by mucosal erosions. Pathogenic autoantibodies are directed against desmoglein 3, leading to intraepidermal blister formation. The oral cavity is typically the initial and most common site of involvement, but the female genital tract can also be involved. We present a case of pemphigus vulgaris presenting as chronic vulvovaginal erosions.

Case: A 59-year-old woman presented with a rare sore in her mouth and an 18-month history of vaginal burning, irritation, and white discharge. Previous workup included negative vaginal culture for yeast, nondiagnostic vulvar biopsy, and normal cervical smear. Clobetasol cream had provided minimal relief. Biopsy of an erosion of the vulvar vestibule showing loss of epidermis with acantholysis prompted indirect immunofluorescence testing. High titer immunoglobulin G antibodies directed against epithelial cell surfaces confirmed a diagnosis of pemphigus vulgaris, explaining an 18-month history of isolated chronic vulvovaginal erosions.

Conclusion: Female genital tract involvement by pemphigus vulgaris usually occurs in the setting of extensive involvement at other sites, most notably the oral mucosa. Primary involvement of the genital mucosa is unusual. Confirmatory diagnosis is made with testing for autoantibodies, either with direct or indirect immunofluorescence or enzyme-linked immunosorbent assay.

Objective: To investigate the risk factors that impact the efficacy of interventional treatment of intractable postpartum hemorrhage (IPH).

Study design: A total of 64 IPH patients were admitted and received interventional treatment at First Hospital of Shanxi Medical University from January 2012 to September 2014, among whom 57 cases were successfully treated (bleeding stopped), while 7 cases failed. The clinical data of the success group and the failure group were observed for the multivariate analysis of the possible reasons that might cause hemostatic failure.

Results: The univariate analysis of each suspected factor of hemostatic failure showed that history of uterine scar, combined use of uterotonics, uterine inertia, and placenta exhibited statistically significant differences between the 2 groups (p<0.05); the multivariate logistic regression analysis showed that history of uterine scar and combined use of uterotonics were the risk factors for the interventional treatment failure of IPH, with OR values of 11.23 (95% CI 1.26~100.22) and 12.83 (95% CI 1.05-156.34), respectively.

Conclusion: History of uterine scar and combined use of uterotonics were the risk factors for interventional treatment failure of IPH.

Background: Cesarean scar ectopic pregnancies (CSPs) are becoming more prevalent and can have an extremely poor prognosis, with high morbidity and mortality. Management guidelines for patients desiring conservative treatment should be established to improve outcomes.

Case: A 33-year-old woman with a conservatively managed CSP now in the second trimester presented from an outside institution. After thorough counseling regarding potential maternal morbidity and extreme prematurity in the newborn based on clinical findings of progressive cervical shortening and vaginal spotting with a significant drop in hemoglobin, she abandoned conservative therapy and underwent a hysterectomy with the previable fetus in situ.

Conclusion: As pregnancy progresses, danger to the mother and fetus can become severe and imminent. Progressive cervical shortening may be associated with much more significant bleeding than evidenced by spotting, indicating the importance of using cervical shortening in abandonment of conservative management to reduce impending morbidity and mortality.