生殖医学杂志最新文献

Background: Upper abdominal pregnancy is rare. Most patients present with hemoperitoneum, requiring emergency laparotomy.

Case: A 32-year-old woman presented with acute abdominal pain and an elevated beta-human chorionic gonadotropin (β-hCG) level. Ultrasound, computerized tomography (CT) scans, and laparoscopy failed to locate the source of elevated hCG. Subsequent positron emission tomography (PET)-CT demonstrated a cystic mass in the left pararenal region with no increased uptake. Repeated ultrasound scan revealed a live fetus implanted laterally to the abdominal aorta. After failing to respond to methotrexate at the usual dosage, a regimen used in gestational trophoblastic neoplasia was given. The pregnancy underwent miscarriage afterwards, and the hCG level gradually returned to normal.

Conclusion: The site of an ectopic pregnancy should be sought thoroughly to avoid missing an abdominal pregnancy and hence disastrous hemoperitoneum. While medical therapy with high-dose methotrexate is not a standard treatment, it can be considered after failing the traditional therapy, provided that there is adequate treatment monitoring and expertise in handling the side effects of the medication.

Background: Vulvar carcinoma is usually diagnosed after a patient notices bleeding, pruritis, or a lesion. We describe a case of vulvar carcinoma presenting as an isolated lymph node metastasis in the setting of negative pelvic examinations, with interval development of a vulvar lesion.

Case: A 45-year-old woman presented with a left groin mass, and a biopsy revealed squamous cell carcinoma of unknown primary. She underwent an extensive work-up including several evaluations by gynecologic oncologists, all with negative results. Only after 11 months of clinical monitoring did a vulvar lesion appear and the primary tumor was diagnosed.

Conclusion: Cancers of unknown primary site presenting in an inguinal lymph node are relatively rare. Vulvar carcinoma should remain in the differential diagnosis even in the setting of a previously negative pelvic examination.

Objective: To determine if asking residents to discuss their specific learning objectives with the attending physician prior to beginning a surgical case would improve the educational experience in the operating room.

Study design: This was a prospective nonrandomized cohort study utilizing a self-administered questionnaire. Prior to the intervention, residents and attendings were asked to fill out surveys evaluating the educational experience in the operating room. Subsequently, attending physicians were instructed to ask residents at the beginning of the surgery, "What are your goals for this surgical case?" During this intervention period, the same anonymous survey was filled out. Preintervention and postintervention answers were compared by t test and Fisher's exact test.

Results: A total of 49 preintervention and 47 postintervention resident-attending survey pairs were collected. After implementation of the intervention, 100% of residents reported having surgical goals for the procedure as compared to 45% prior to the intervention (p<0.0001). Additionally, during the intervention residents reported they were better able to maximize learning opportunities and were more satisfied with their participation in the case. Attending physicians were more likely to be aware of resident learning objectives after the intervention.

Conclusion: We propose the routine addition of an educational pause to the surgical time out.

Objective: To compare 2 different risk factor models for the prediction of shoulder dystocia.

Study design: We performed a retrospective study of women with vaginal deliveries at a single institution over an 8-year period. Two distinct multivariable logistic regression models were used to evaluate the occurrence of shoulder dystocia: a traditional model used information based on birthweight and macrosomia, and a clinical model used information based on esti-mated fetal weight and suspected macrosomia.

Results: Of the 13,998 deliveries analyzed, there were 221 cases of shoulder dystocia (1.6%). In addition to the macrosomia or suspected macrosomia variables, the final models included prolonged second stage of labor, diabetes status, and oxytocin use. Neither model was highly sensitive or highly specific, and neither demonstrated a cutoff threshold that yielded a clinically viable PPV.

Conclusion: Despite the presence of 1 or more risk factors for shoulder dystocia, its occurrence remains largely an unpredictable clinical event.

Objective: To investigate the effect of azoospermia type on fertilization and clinical pregnancy rates when microdissection testicular sperm extraction (TESE) is performed for sperm retrieval in nonobstructive azoospermia (NOA).

Study design: STUDY DESIGN: Patients who underwent microdissection TESE for NOA and conventional TESE for obstructive azoospermia (OA) were included in the study. Intracytoplasmic sperm injection (ICSI) results were compared between groups.

Results: The mean ages in the 2 groups were similar. FSH and LH levels in the NOA group were significantly higher than those of the OA group. Between groups there was no statistically significant difference in testosterone levels. The sperm retrieval rate was 58.56% in NOA. Fertilization and clinical pregnancy rates were similar for patients with NOA and OA.

Conclusion: In patients with NOA, microdissection TESE accurately determines active spermatogenesis areas via the high identification power of the operative microscope. From these areas surgeons can collect healthier spermatozoa, which can result in better ICSI outcomes, the results of which are similar to those with OA.

Background: This report describes the fetal heart rate (FHR) tracing in a pregnancy complicated by antenatal spontaneous rupture of fetal vessels on the placental surface that resulted in a live birth.

Case: 36-year-old woman, G2P1001, was being followed with weekly antenatal testing for gestational diabetes type A2 on insulin with possible intrauterine growth restriction. She presented for an office visit at 37.5 weeks' gestation with a complaint of decreased fetal movement. The FHR pattern demonstrated minimal baseline variability with an occasional spontaneous deceleration not associated with a contraction, an absence of recurrent decelerations, and no accelerations. The antenatal evaluation is discussed, and portions of the FHR tracing and the placental findings at delivery are provided.

Conclusion: The FHR pattern did not fit with what is usually depicted with uteroplacental insufficiency or umbilical cord entrapment. In addition, even though the fetus is anemic, the process may occur too quickly for a sinusoidal pattern to develop.

Background: Folate supplementation in women of reproductive age has a well-established role in the prevention of neural tube defects. Methotrexate is a commonly used drug which functions by inhibiting normal folate metabolism in active cells. An association between fetal methotrexate exposure and myelomeningocele might be expected, considering this relationship. However, to our knowledge, no cases of myelomeningocele secondary to in utero methotrexate exposure have been reported.

Case: We present the case of a gravid patient who, having received methotrexate for management of an ectopic pregnancy, was lost to follow-up and returned several weeks later carrying an intrauterine pregnancy. The fetus was found prenatally to be suffering from multiple congenital anomalies. At birth the infant demonstrated many of the abnormalities commonly associated with fetal methotrexate syndrome, including craniosynostosis and talipes equinovarus. Most interestingly, the newborn was also diagnosed with a lumbar myelomeningocele and concomitant type II Chiari malformation, as is often associated with such a neural tube defect.

Conclusion: Methotrexate exposure may impact the fetal risk of myelomeningocele. Patients should be counseled thoroughly on the importance of follow-up care.

Objective: To determine whether there are differences between grand multiparous and non-grand multiparous women regarding obstetric risk factors, obstetric compli- cations, and pregnancy out- come.

Study design: A retro- spective case control study was conducted between the years 2011-2012. The study group included grand. mul- tiparous women'(≥5 previous deliveries). The control group included non-grand multiparous women (<5 deliveries) who gave birth immediately after the grand multiparous woman and matched according to parity.

Results: Prenatal care was less adequate in the grand multiparous group (p<0.001). A higher rate of maternal anemia was found in the grand multiparous group as compared to the multiparous group (p<0.001). Grand multiparity was associated with higher rates of amniot- ic fluid disorders such as oligohydramnios, polyhydram- nios, and meconium-stained amniotic fluid (p<0.001). Grand multiparity was also associated with higher. birth weight and a lower rate. of instrumental delivery (p<0.001). Higher parity was not a risk factor for di- abetic disorders, hypertension, and cesarean delivery.

Conclusion: Grand multiparity is a risk factor for inadequate prenatal care, maternal anemia, and amni- otic fluid disorders and is .associated with lower rates of instrumental deliveries and higher birth weight. However, it does not increase the risk for diabetes, hypertension, and cesarean .deliveries.

Objective: To explore the efficacy of laparoscopic surgery without auxiliary treatment for type II cesarean scar pregnancy (CSP-II).

Study design: This was a case series of 7 patients with CSP-II who underwent laparoscopic surgery without auxiliary treatment between April 2014 and April 2015. All cases were diagnosed by ultrasound, confirmed by laparoscopy, and managed by laparoscopic resection of scar and gestational tissue and wound repair.

Results: All 7 patients had successful surgeries without complication. Uterine scar and gestational tissues were resected, while also preserving the uterus. The operation time was 70.1 ± 16.3 min and blood loss was 65.7 ± 32.1 mL. Serum β-hCG levels 24 hours after surgery declined by 84.8 ± 9.4%. Serum β-hCG levels went back to <5 IU/L in all 7 patients by 14.4 ± 4.3 days after surgery. The time interval between surgery and first menstruation was 35.3 ± 4.5 days.

Conclusion: These results suggest the possibility that skilled surgeons could use laparoscopy without auxiliary pretreatment to remove gestational tissues and uterine scar defect and to repair the wound in patients with CSP-II.

Background: Purple urine bag syndrome is a rare, benign phenomenon of bacterial colonization. The syndrome affects mainly women and is usually asymp- tomatic. Factors influencing the development of purple urine bag syndrome stem from the pathophysiology of indigo production by bac- teria, and from extrinsic fac- tors.

Case: This case report de- scribes a woman with a complex history placing her at higher risk for developing this syndrome. However, with conservative management she did not develop any complications from this rare syndrome.

Conclusion: Although mainly benign, those popu- lations particularly susceptible to this phenomenon are intrinsically at risk for further complications such as sepsis and altered mental status and must be managed accordingly.