Enlarged Uterus Research Articles

An odd case of immune-mediated necrotizing myopathy, complicated with sagittal, transverse and sigmoid sinus thrombosis

INTRODUCTION: Immune-mediated necrotizing myopathy (IMNM) is a rare variant of immune-mediated inflammatory myopathy (IMIM) that exhibits a severe prognosis and is unresponsive to conventional treatment. (1,2)Notably, the incidence of immune-mediated inflammatory myopathies (IMIMs) is low, estimated at 1.16 to 19/million/year and only 3-6% of IMIMs are diagnosed as IMNM. (1,3–5). Systemic inflammation has been found to play a crucial role in promoting the onset of cerebral venous thrombosis. (6,7) MATERIAL AND METHODS: We present the case of a 46-years-old Chinese woman, without any known prior pathology, who was referred to the Rheumatology Department for symmetrical, proximal muscle weakness of the limbs, dysphagia for solid food, and weight loss (5 kg within 2 months). The pathologic clinical examination revealed itchy erythematous plaques on the posterior thoracolumbar region and signs of muscle weakness. Laboratory workup showed significant inflammatory syndrome, severe muscle and hepatic cytolysis syndrome, and positivity for thyroid-specific autoantibodies but with normal thyroid function, positivity for antinuclear antibodies (more precisely: SS-A, Ro-52, SS-B), and myositis antibodies (SRP, Ro-52, SAE1, PM-Scl, MDA5). The CT scan of the thoracic, abdominal, and pelvis showed fibrosis of the lungs, hepatic hypertrophy, and an enlarged uterus, further diagnosed by transvaginal ultrasound as adenomyosis. The positive diagnosis is immune-mediated necrotizing myopathy. Differential diagnoses included dermatomyositis, toxic/infectious myositis, hypothyroidism, and neuro-muscular diseases (5,8). The initial treatment was made with glucocorticoids (pulse therapy followed by oral therapy) and immunosuppressants (Mycophenolate Mofetil – stopped because of severe dyspepsia and myelosuppression). After five days of pulse therapy, the patient developed muscle weakness and paresthesia on the left side of the body, and the cerebral CT scan revealed sagittal, transverse, and sigmoid sinus thrombosis. Thrombophilia screening uncovered the positivity of the lupus anticoagulant. (9) RESULTS: The patient was treated with anticoagulants (low molecular weight heparin, and afterward Vitamin K antagonist), low doses of oral glucocorticoids, and immunosuppressant (Methotrexate), without any other adverse event. CONCLUSION: In the presence of the lupus anticoagulant, even though the antiphospholipid syndrome is not confirmed, the only anticoagulant therapy that has proven its efficacy is the Vitamin K antagonist. Immune inflammatory myopathies, like IMNMs, create a significant inflammatory status that leads to hypercoagulability and endothelial injury, which exposes collagen and tissue factors, promoting further platelet aggregation, and can even lead to cerebral thrombosis. (2,6)

Recurrence of Uterine Fibroids After Conservative Surgery or Radiological Procedures: a Narrative Review.

The present narrative review aims to discuss the available data on the incidence and the risk factors of uterine fibroids (UFs) recurrence after different types of conservative surgical or radiologic procedures in women wishing to preserve their uterus. UFs are the most common benign tumors in women all over the world. Clinical presentation, including abnormal uterine bleeding (AUB), pelvic pain, bulky symptoms, and infertility affect patients' quality of life, and a large variety of conservative treatments are available especially for those with desire of pregnancy. Fertility sparing surgery, by either laparoscopy, hysteroscopy or laparotomy, or radiological interventions (uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound), are the most common therapeutic approaches. However, the genetic or acquired predisposition to UFs remain despite the treatments, and the recurrences are frequently described in a large percentage of patients. The most relevant risk factors for recurrence of UFs are young age at the first surgery, incomplete fibroid resection, the presence of multiple lesions, an enlarged uterus, and the coexistence with other pelvic diseases. The discussion on the possible medical strategy to reduce the recurrence is an open field of clinical investigation, in particular by using hormonal drugs.

Adnexal Torsion in the Second Trimester of Pregnancy: A Case Report and Review of the Literature

Acute abdomen in pregnancy is one of the biggest diagnostic and therapeutic challenges today. Despite advances in medical technology, the preoperative diagnosis of acute abdominal conditions is still inaccurate. Torsion of the adnexa, which refers to complete or partial rotation of the adnexa, resulting in obstruction of venous and lymphatic reflux in the ovary, is a common gynecological emergency. Torn adnexa affect both the ovary and the fallopian tube, and rarely affect only one of them. Adnexal torsion occurs more frequently in the first and early second trimester than in the third trimester. It is difficult to diagnose in advanced pregnancy because of nonspecific symptoms and signs of acute abdomen as well as ultrasound limitations due to uterine enlargement complicate diagnosis. Late diagnosis and delayed surgical treatment result in ovarian loss and fetal endangerment. It is important to thoroughly evaluate the adnexa at the 1st ultrasound examination in pregnancy and to monitor the observed formations.

#378 : Intrauterine Suture of Levonorgestrel Intrauterine Device Under Hysteroscopy

Background and Aims: Levonorgestrel-releasing intrauterine system (LNG-IUS) is an effective and long-term treatment for adenomyosis, especially for patients who have severe dysmenorrhea symptoms but a strong desire to preserve their uterus. However, expulsion of the device for patients with an enlarged uterus remains a problem. In this study, an LNG-IUS was stitched on the posterior wall of the uterus under hysteroscopy, which can be an alternative method to this problem. Methods: 21 patients with adenomyosis who had previously been treated with the LNG-IUS and experienced expulsion for at least one time were enrolled. The fixation of the LNG-IUD on the posterior wall of the uterus was performed with a 4-0 Ethicon polypropylene non-absorbable suture through an endoscopic needle driver and a knot-pushing device. Results: During the postoperative follow-up, all patients experienced complete remission of their symptoms: a significant decrease in menstrual flow, relief of dysmenorrhea, and improvement in quality of life. No expulsion of device and other compilations were found. Conclusions: In patients with adenomyosis suffering from dysmenorrhea or heavy menstrual blood loss, suture fixation of an LNG-IUS using the hysteroscopic cold knife surgery system is a minimally invasive and effective alternative treatment for patients with an enlarged uterus and decreases the risk of LNG-IUS expulsion.

SAT481 Metastatic Choriocarcinoma, A Rare Cause of hCG-Mediated Hyperthyroidism

Abstract Disclosure: S. Jain: None. M. Crabtree: None. C. Houston: None. Background: Structural homology between human chorionic gonadotropin (hCG) and thyrotropin stimulating hormone (TSH) allows high levels of hCG to exert thyrotropic effects via TSH receptors. Although hCG-mediated hyperthyroidism is most frequently encountered in the context of pregnancy, it also occurs rarely as a paraneoplastic syndrome. We present a case of hCG-mediated hyperthyroidism due to metastatic choriocarcinoma in a postmenopausal woman. Case Presentation: A previously healthy 59-year-old woman was evaluated for shortness of breath and found to have multiple lung nodules concerning for metastatic malignancy. Further imaging demonstrated an enlarged heterogeneous uterus with an enlarged endometrial cavity. Endometrial biopsy revealed poorly differentiated carcinoma with some areas of possible squamous differentiation. Subspecialty cytopathology review was requested. One week after biopsy, the patient was brought to the emergency department with acute hypoxic respiratory failure following a seizure. She was found to be febrile, tachycardic, hypertensive, and minimally responsive. Head CT revealed a left frontal brain mass with surrounding vasogenic edema, concerning for metastasis. Laboratory evaluation revealed TSH of 0.03 mIU/L (normal 0.35-4.94) and free T4 of 2.30 ng/dL (normal 0.70-1.48). Thyroid stimulating immunoglobulin was negative. Beta-hCG was found to be significantly elevated at 982,093 mIU/mL after 1:100 dilution. She was started on treatment with propranolol, dexamethasone, and chemotherapy with etoposide and cisplatin. Meanwhile, cytopathology review identified scattered cells with features of choriocarcinoma and positive hCG immunostaining, felt to represent a diagnosis of poorly differentiated choriocarcinoma. After one cycle of chemotherapy, the patient’s beta-hCG decreased to 477,668 mIU/mL and free T4 decreased to 1.05 ng/dL. Due to progressive worsening of her clinical status, she was transitioned to palliative care and passed away on hospital day 14. Discussion: Hyperthyroidism mediated by hCG is most often seen in patients with hyperemesis gravidarum, gestational transient thyrotoxicosis, or gestational trophoblastic disease. Our case underscores the importance of considering hCG-mediated hyperthyroidism outside the context of pregnancy. Rare paraneoplastic sources of hCG include choriocarcinoma, seminoma, and other germ cell tumors. Hyperthyroidism in these cases is usually subclinical or mild, but instances of thyroid storm have been reported with metastatic disease. Beta blockers, glucocorticoids, and thionamides can be used as temporizing measures, but definitive therapy requires treatment of the causative malignancy. Presentation Date: Saturday, June 17, 2023

Insights from the maternal lineage of the F2 generation after exposure to an environmentally relevant dose of benzo(a)pyrene in the male rats of F0 generation.

Benzo(a)pyrene (BaP) is a substance with the potential to induce endocrine disruption in the F0 generation and cause adverse multigenerational effects (F1 generation) for reproductive parameters in rats. The objective of this study was to investigate the occurrence of transgenerational inheritance in the reproductive aspects of male and female rats belonging to the F2 generation (MF2). This investigation was conducted following the exposure of male rats from the F0 generation to BaP to assess potential effects on subsequent generation from the maternal lineage (F1). For that, juvenile male Wistar rats (F0) were orally exposed to BaP (0.1µg/kg/day) for 31 consecutive days. In adulthood, they were mated with untreated females to obtain female offspring (F1), which later produced the MF2. In the MF2 generation, both males and females exhibited increased body weight on postnatal day (PND) 1. In MF2 males, we observed delayed preputial separation, altered pup weight, reduced levels of follicle-stimulating hormone (FSH), increased intratesticular testosterone levels, decreased type A sperm, epididymal disturbances, reduced 5 α-reductase activity, increased testicular proliferation, and alterations in testicular antioxidant enzymes. In MF2 females, we noted morphological uterine enlargement, reduced sexual activity, and decreased progesterone levels. The findings suggest that the alterations observed in both MF2 males and females can be attributed to modifications in the sperm from F0 generation, which were subsequently transmitted to F1 females and MF2 generation due to BaP exposure.

The New Anti-Estrogens with Anti-Cancer Properties for Breast Cancer

Purpose: Considering the high prevalence of breast cancer and the radiation sensitivity of breast tissue, it is necessary to optimize the treatment process of this tumor, especially when using radiation therapy methods.
 The present study was conducted to investigate the effect and complications of new anti-estrogens on the effectiveness of breast cancer treatment.
 Materials and Methods: Articles were searched in PubMed, Science direct, Embassy, Cochran, and Scopus databases using the keywords Cancer AND Anti-estrogen, Breast Cancer AND anti-estrogen AND mice, Breast cancer And anti-estrogen AND rat. The authors reviewed the abstract and full text of the articles and the relevant studies were selected for systematic review.
 Results: The anti-estrogens used in the reviewed studies included TAM, RAL, SS1020, SS1010, GW5638, OSP, 4-OHTAM, and TOR. Anti-estrogen-related side effects included liver and uterine complications, especially in the case of using TAM anti-estrogen (54%). Moreover, uterine hypertrophy was observed using GW5638, RAL, and SS1010 anti-estrogens; while it happened with a lower percentage than TAM, 16%, 14%, and 13%, respectively. Side effects were significantly reduced by reducing the prescribed dose. So that this reduction for TAM is from 54% to 33%. In relation to the effect of antiestrogens on tumor treatment, the most effective and least complications were related to the antiestrogen "SS1020".
 Conclusion: Based on the results of reviewed studies, SS1020, which has no estrogenic and genotoxic activity, was safe and the most effective anti-estrogen against breast cancer in animals and also in humans.

Hereditary leiomyomatosis and renal cell cancer syndrome

Introduction: Hereditary leiomyomatosis and renal cell cancer syndrome (HLRCC) is a rare autosomal dominantly inherited cancer predisposing syndrome giving rise to cutaneous and uterine leiomyomatosis, leiomyosarcoma and renal cell cancer. Patients with this syndrome harbours germline pathogenic variants in the fumarate hydratase (FH) gene.Case presentation: A 28-year-old Sri Lankan female, a product of a consanguineous marriage with strong family history of young onset fibroids presented with progressive dysmenorrhea, menorrhagia and irregular menstrual cycles for 2 years duration. There was recent onset lower abdominal colicky pain lasting for 3-5 min occurring during the post coital and intermenstrual period over 2 months. Examination did not reveal abnormal skin lesions or abdominal masses.Ultrasound examination revealed enlarged uterus with 2 large fibroids in the posterior wall and fundus of the uterus. She underwent laparoscopic myomectomy without perioperative complications. Histology revealed a leiomyoma with morphological features supporting the variant “fumarate hydratase deficient leiomyoma”.Whole exome sequencing of the patient revealed her to be harbouring a pathogenic variant c.878T>G| p:Val293Gly in the FH gene for which she was heterozygous confirming that she had inherited the cancer predisposing syndrome of hereditary leiomyomatosis and renal cell cancer(HLRCC). Postoperatively her symptoms resolved, and she was able to sustain an uncomplicated pregnancy one year after. Currently she is closely followed up for future development of tumors including renal cell cancer bothclinically and via imaging.Conclusion: HLRCC is a rare autosomal dominantly inherited cancer syndrome predisposing to skin, uterine and renal tumors warranting surveillance at a younger age.

Specimen extraction techniques utilized in minimally invasive surgery for women with uterine cancer and an enlarged Uterus: A quality assurance study (1108)

Specimen extraction techniques utilized in minimally invasive surgery for women with uterine cancer and an enlarged Uterus: A quality assurance study (1108)

A Rare Case of Leiomyomatosis Peritonalis Disseminata

Leiomyomatosis Peritonalis Disseminata (LPD), also known as disseminated peritoneal leiomyomatosis is an extremely rare disease in women and men where there is a rapid increase in peritoneal and subperitoneal nodules mainly of smooth muscle cells. It is a benign condition, however, its diagnosis can mimic or degenerate into peritoneal leiomyosarcoma, making the diagnosis tricky. In addition, clinical manifestations can be very nonspecific.
 We discuss the case of a 38-year-old nulliparous patient who presented to the clinic with a 2-year history of lower abdominal swelling and a 5-month history of severe menorrhagia. Intraoperative findings showed an enlarged uterus with subserosal fibroids and several deposits on the serosa and intestines. The patient had Total hysterectomy and bilateral-salpingoophorectomy. Because malignant transformation has been reported to potentially occur almost 10 years from initial diagnosis, patients should be monitored by repeat ultrasound scans.

Uterine Hyperplasia Causes, Symptoms Consequences and Principles of Treatment

In this article, the causes, symptoms, consequences, and treatment principles of Uterine Hyperplasia are described in detail, as well as an example of research conducted by world scientists.

Unmasking the Hidden Fetus: Introducing the Circled Delta Sign and Reversed Circled Delta Sign for Accurate Identification on Abdominal Radiography.

BACKGROUND Ionizing radiation poses potential health risk to fetuses, including growth retardation, organ malformations, neurological effects, fetal death, and cancer. Therefore, pregnant women rarely undergo X-ray imaging, unless absolutely necessary. However, they can be inadvertently exposed to X-rays while undergoing an examination without being aware of their pregnancy. Given that the likelihood of a fetus appearing on an abdominal radiograph is low, physicians can be unfamiliar with the appearance of a fetus on such images. If a fetus incidentally appears on an abdominal radiograph, the clinician can encounter difficulties in identifying the fetus, potentially leading to unexpected harm during subsequent imaging procedures. CASE REPORT A 41-year-old woman presented with symptoms of postprandial abdominal pain, abdominal fullness, and urinary frequency. Abdominal radiography revealed a large mass with calcifications in the pelvis and lower abdomen, raising suspicion of a large pelvic tumor, such as a teratoma. However, subsequent ultrasound unexpectedly revealed that the woman was actually 6 months pregnant. The presumed tumor was an enlarged uterus, and the presumed calcifications were the fetus's bones. Before X-ray, the woman had denied being pregnant, mistakenly attributing her condition to excess weight and irregular menstrual cycles. Fortunately, the use of ultrasound instead of computed tomography prevented radiation exposure to the fetus, and the baby was delivered in a healthy state at full term. CONCLUSIONS To avoid unintended harm to fetuses, clinicians should consider the possibility of pregnancy when evaluating a pelvic mass in women of childbearing age. To aid clinicians in accurately identifying fetuses on abdominal radiography and thereby reduce the likelihood of misdiagnosis, we propose the "circled delta sign" and the "reversed circled delta sign".

Sleep deprivation disturbs uterine contractility and structure in pregnant rats: role of matrix metalloproteinase 9 and transforming growth factor-β.

Sleep deprivation (SD) during pregnancy can impact the delivery procedure, with prolongation of the labor duration. Matrix metalloproteinase-9 (MMP9) and transforming growth factor-β (TGF-β) are regulators of uterine remodeling. Their dysregulation is vital for abnormal placentation and uterine enlargement in complicated pregnancies. Therefore, this study aims to explore the outcome of SD throughout pregnancy on ex vivo uterine contractility, MMP9 and TGF-β, and uterine microscopic structure. A total of 24 pregnant rats were divided into two groups. From the first day of pregnancy, animals were exposed to partial SD/6h/day. Uterine in vitro contractile responses to oxytocin, acetylcholine, and nifedipine were assessed. Additionally, uterine levels of superoxide dismutase and malondialdehyde and uterine mRNA expression of MMP9, TGF-β, and apoptotic biomarkers were analyzed. The results showed that SD significantly reduced uterine contractile responses to oxytocin and acetylcholine, while it augmented the relaxing effect of nifedipine. In addition, it significantly increased oxidative stress status, MMP9, TGF-β, and apoptotic biomarkers' mRNA expression. All were accompanied by degeneration of endometrial glands, vacuolization with apoptotic nuclei, and increased area% of collagen fibers. Finally, increased uterine MMP9 and TGF-β mRNA expression during SD clarified their potential role in modulating uterine contractility and structure.

Penerapan Yoga Prenatal dan Aromaterapi Lavender Untuk Meningkatkan Kualitas Tidur Ibu Pada Kehamilan Trimester Ketiga

In a woman's life cycle, there is a phase of pregnancy which is a time of great change. These changes are not only related to physical changes, but also psychological ones which are a consequence of the growth of the fetus in the womb. When entering the third trimester, more and more complaints are felt by the mother, which has a negative impact on the quality of sleep for pregnant women. Some physical changes in third-trimester pregnant women that can affect the quality of the mother's sleep are the presence of back pain due to the enlarged uterus due to the increased burden of the fetus it contains so that it affects the mother's posture and it is difficult to determine a comfortable sleeping position. This activity was carried out for 40 days starting with coordinating with the Head of the Puskesmas, outreach to the community until implementation. This activity involved six students, two supervisors and one yoga instructor with the target of 30 pregnant women. The application of prenatal yoga and lavender aromatherapy can significantly improve the quality of sleep for pregnant women.

P-323 Associations between endometrial microbiome and the local immune cell composition during the mid-secretory phase

Abstract Study question Is there an association between the endometrial microbiome and the local immune cell composition during the mid-secretory phase? Summary answer The percentage of endometrial neutrophils was negatively related to the highest number of microorganisms, while B-cells and T-helpers were positively related to certain bacterial taxa. What is known already Endometrial receptivity is strongly influenced by the local immune cell composition and its inflammatory status. Meanwhile, many studies on the endometrial microbiome and its impact on receptivity are arising. Knowing that bacterial composition has an effect on the immune system, it is worth studying the potential associations between the microbiome and immune cell populations in the endometrium during the mid-secretory phase. This relationship could adjust the magnitude of inflammation which has a strong effect on embryo implantation process. Investigations on the endometrial bacterial communities’ effect on the local immune cell composition could be applied in improving assisted reproductive technologies. Study design, size, duration Prospective observational study performed between April 2021 and January 2023 in a private in vitro hospital. Endometrial biopsies were collected from 30 women aged between 34 and 45 years during the mid-secretory phase, on day 7 after LH surge. Patients with history of recent inflammatory disease, chronic endometritis, recent antibiotic treatment, endocrinological disorders, autoimmune diseases, oncological diseases, moderate or severe endometriosis, adenomyosis, uterine hyperplasia, and endometrial polyps were not included. Participants/materials, setting, methods B cells, T cells, T helpers, NK cells, macrophages and neutrophils in the endometrial stroma were identified by immunohistochemical staining with antibodies against CD79α (IS62, Dako), CD3 (BRB063, Zytomed), CD4 (IS649, Dako), CD56 (А00121-0007, ScyTek), CD14 (Е-AB-71017, Elabscience) and neutrophil elastase (950334, NOVUSBIO), respectively. The immune cell percentages were calculated by HALO image analysis software (version 2.3, IndicaLabs). Endometrial microbiota (EM) composition was analyzed after DNA isolation using 16S rRNA (v4-v5 region) gene sequencing. Main results and the role of chance Totally 271 bacterial species and 668 genera were identified in the endometrial samples. The median (range) immune cell percentages found were: 0.083% (0.49) B-cells, 0.974% (4.93) T-cells, 0.066% (0.44) T-helpers, 0.931% (5.36) NK-cells, 1.129% (3.11) macrophages and 0.207% (3.86) neutrophils. Spearman analysis revealed significant correlations between T-helpers percentage and the relative abundance of Cutibacterium acnes (R = 0.475, p = 0.012) and its genus Cutibacterium (R = 0.477, p = 0.012) as well as between B-cells and the relative abundance of Bacteroides vulgatus (R = 0.532, p = 0.003) and its genus Bacteroides (R = 0.457,p = 0.013). NK-cells presence was not related to any of the found bacterial species or genus (p > 0.05). Neutrophils demonstrated significant correlations with the relative abundance of the highest number of species: Prevotella melaninogenica (R = −0.404, p = 0.03), Butyrivibrio crossotus (R = 0.433,p = 0.02), Moraxella osloensis (R = −0.433, p = 0.019), Blautia sp. (R = 0.427, p = 0.021), Alicyclobacillus acidocaldarius (R = −401,p = 0.031) also related with the T-cells percentage (R = −0.380, p = 0.042) and Acinetobacter lwoffii (R = −0.458, p = 0.008) also related with the macrophages (R = −0.454, p = 0.013). Among the studied species Alloprevotella tannerae was showing significant correlations with neutrophils (R = −0.0602, p = 0.001), macrophages (R = −0.416, p = 0.025) and T-cells (R = −0.464, p = 0.011). At genus level, most of the bacteria were related to the neutrophils – Pseudoalteromonas (R = −0.540, p = 0.002), Aliterella (R = −0.617, p<0.001), Endhydrobacter (R = −0.433,p = 0.019) and AKIW781 (R = −0.493, p = 0.011). Aliterella and AKIW781 were also related to the macrophages (R = −0.473, p = 0.01 and R = −0.423, p = 0.031, respectively) and T-cells (R = −0.387, p = 0.038 and R = −0.519, p = 0.007, respectively). Limitations, reasons for caution The study was limited in sample size. Wider implications of the findings The results of this study indicated that there is a quantitative relation between the main endometrial immune cells and the endometrial core microbiome. The association between these two determinants of endometrial receptivity could help in understanding the fine tuning of the endometrium for accepting the embryo. Trial registration number The current research was funded by National Science Fund, Ministry of Education, Bulgaria, Contract № KP-06-N53/14/16.11.2021.

P-715 NGS-based metagenome analysis of endometrial microbiome in women with implantation failure after in vitro fertilization: results of a prospective cohort study

Abstract Study question We aimed to compare the endometrial microbiome between pregnant and non-pregnant women after frozen embryo transfer (FET) with euploid embryos. Summary answer Specific bacteria taxa had significantly higher relative abundance in the endometrium of patients with implantation failure after FET with euploid embryos. What is known already Several studies revealed a significant association between the endometrial microbiome composition, including the abundance of Lactobacilli and pathogen species and the occurrence of implantation failure or miscarriage. However, there is still scarce information about the influence of relative abundance of certain bacteria taxa on the pregnancy outcome in patients with idiopathic infertility and FET. Study design, size, duration In this prospective observational cohort study endometrial biopsies were collected from 30 women aged between 34 and 45 during the mid-luteal phase (LH + 7) in a natural cycle. FET was performed with euploid embryos (after preimplantation genetic testing for aneuploidy (PGT-A)), up to 6 months after the biopsy. The exclusion criteria for the patients were history of recent inflammatory disease, chronic endometritis, recent antibiotic treatment, moderate or severe endometriosis, adenomyosis, uterine hyperplasia, and endometrial polyps. Participants/materials, setting, methods Endometrial microbiota composition was analyzed using 16S rRNA (v4-v5 region) next generation sequencing (NGS). The sequencing data was assigned to bacterial taxonomy and the background-contaminated bacteria were excluded from the analysis. The Student t-test or Mann-Whitney U test for the relative abundance of each bacteria taxa were applied according to normal or not normal distribution of data. A Bonferroni correction was applied to the significant levels obtained. Main results and the role of chance The performed analysis of 30 patients with different clinical outcomes, including no pregnancy (n = 16), clinical pregnancy confirmed by ultrasound (n = 14) revealed differences in the endometrial microbiome composition. Baseline characteristics including age, BMI and duration of infertility were comparable between the studied groups of patients. In total, 271 distinct bacterial species and 668 bacterial genera were identified. The number of unique species, found in non-pregnant women was 62 (22.88%), while in pregnant patients it was 39 (14.39%). Among them, bacteria with high frequency of occurrence such as Cutibacterium granulosum, Isoptericola, Acetomicrobium, Marivivens, Syntrophomonas and Bacteroides were found only in patients with unsuccessful implantation while Bosea was present only in women with successful implantation. Based on the analysis of bacteria relative abundance, Lactobacillus was the most prevalent genus in both groups. The abundance of this genus was not significantly different between the studied groups. In contrast, Serratia marcescens, Delftia, Massilia, Glutamicibacter, Lactococcus and Staphyloccocus were significantly enriched in the non-pregnant group (p < 0.05). Limitations, reasons for caution Our study is a single-center study with a relatively small sample size. Wider implications of the findings The microbiome showed specific composition in pregnant compared to non-pregnant women. It could be hypothesized that an appropriate treatment for optimization of endometrial microbiome content in women with diagnosed microbiome dysbiosis could be beneficial for improvement of pregnancy rates. Trial registration number The current research was funded by National Science Fund, Ministry of Education, Bulgaria, Contract № KP-06-N53/14/16.11.2021.

P-317 Associations between endometrial microbiome composition and cellular senescence

Abstract Study question Is there an association between the percentage of senescent cells and microbiome composition in human endometrium? Summary answer We found that cellular senescence is negatively associated with the relative abundance of certain bacterial taxa. What is known already Recent studies indicated that endometrial microbiome characteristics and certain levels of cellular senescence are essential for the establishment of normal endometrial receptivity and successful embryo implantation. The secretion of senescence-associated secretory phenotype (SASP) components is responsible for immune cell activation and might cause endometrial dysbiosis. On the other hand, some studies suggest that the presence of specific metabolic groups of bacteria and their metabolites could influence cellular stress response that might suppress the development of senescent cells. However, the direct relationship between the quantity of senescent cells and microbiome content in the endometrium has never been studied. Study design, size, duration This was a prospective observational cohort study performed between April 2021 and January 2023. Endometrial biopsies were collected from 30 women aged between 34 and 45 during the mid-luteal phase (LH + 7) in a natural cycle. Each biopsy was divided for genetic and immunohistochemical analyses. The exclusion criteria were history of recent inflammatory disease, chronic endometritis, recent antibiotic treatment, endocrinological disorders, autoimmune diseases, oncological diseases, moderate or severe endometriosis, adenomyosis, uterine hyperplasia, and endometrial polyps. Participants/materials, setting, methods We used immunohistochemical biomarker p16ink4a (MAD-000690QD–7, Master Diagnostica) to identify senescent cells. The percentages of positively stained cells in the endometrial stroma and in the luminal epithelium were calculated by HALO image analysis software (version 2.3, IndicaLabs). Endometrial microbiota composition was analyzed after DNA isolation from the endometrial samples using 16S rRNA (v4-v5 region) gene sequencing. Statistical analysis was performed by Spearman’s correlation test using SPSS v.21 (IBM Corp., Armonk, NY, USA). Main results and the role of chance A total of 271 distinct bacterial species and 668 genera were identified across the studied 30 endometrial samples. The percentage of p16+ senescent endometrial stromal cells ranged from 0 to 1.7%, with a mean value of 0.37%, while the percentage of p16+ luminal epithelial cells ranged between 2.5% and 74.0%, with a mean value of 21.5% Spearman analysis revealed significant negative correlation between the percentage of p16+ stromal cells and the relative abundance of Porphyromonas sp. (R = −0.41, p = 0.03) and Sphingobacterium sp. (R = −0.37, p = 0.05). The percentage of p16+ luminal senescent cells correlated negatively with the abundance of Micrococcus luteus (R = −0.44, p = 0.02), Moraxella osloensis (R = −0.37, p = 0.05), Rubellimicrobium sp. (R = −0.46, p = 0.02), Stenotrophomonas sp. (R = − 0.45, p = 0.03), Chryseobacterium sp. (R = −0.41, p = 0.04), Carnobacterium sp. (R = −0.40, p = 0.04), Deinococcus sp. (R = −0.38, p = 0.05), and Enhydrobacter sp. (R = − 0.37, p = 0.05). Limitations, reasons for caution The study was limited in sample size. The assessment includes only endometrial samples from the mid-luteal phase of the cycle. Wider implications of the findings We found that the level of senescence is negatively associated with the relative abundance of certain bacteria taxa in human endometrium, including some related to impaired reproductive function and early embryonic development arrest. These findings suggest a possible specific interaction between senescent cells and microbiome that might influence endometrial receptivity. Trial registration number The current research was funded by National Science Fund, Ministry of Education, Bulgaria, Contract № KP-06-N53/14/16.11.2021

Robotic vNOTES Techniques for Hysterectomy in a Patient with a 16-week Sized Uterus and a Body Mass Index of 70

To demonstrate the surgical techniques for robotic vNOTES hysterectomy with bilateral salpingo-oophorectomy (BSO) in a World Health Organization class 3 obesity patient (body mass index=70) as well as large fibroid uterus (16 weeks sized). Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 50-year-old G0 with postmenopausal vaginal bleeding with an enlarged uterus; her endometrial biopsy showed complex endometrial hyperplasia with atypia. The surgical exposure for extremely obese patients with a concomitantly large uterus can be very challenging transabdominally due to the patient being unable to tolerate the Trendelenburg position and abdominal gas pressure [1-5]. Therefore, transvaginal NOTES can be an alternative option for these types of challenging patients. However, although there are clear benefits of vNOTES surgery in obese patients, we still need to be thoughtful and deliberate in handling this kind of surgery [6]. Several key success factors that aid in the completion of the surgery include 1. Appropriate patient positioning (Trenguard Position) as tolerated. 2. Initial vaginal section of hysterectomy. 3. Successful port placement. 4. Trendelenburg, as far as tolerated. 5. Harnessing the robotic camera for anterior colpotomy. 6. Utilizing alternative surgical exposure techniques: air seal for maintaining gas pressure for optimizing exposure, lap pad for thermal isolation, and maintaining the uterus for safe exposure during BSO. 7. After identification of the bilateral ureters, the broad, round, and uterine ovarian ligaments were transected with vessel sealer (less thermal spread), and the cystectomy was completed. (Supplemental Video 1) 8. BSO was completed. 9. In-bag uterine tissue extraction. 10. Vaginal cuff closure with V-Loc barbed suture. Robotic-assisted NOTES hysterectomy with BSO is feasible and safe in extremely obese patients with large uterus. The combination of all these strategies could aid in the feasibility and safety of patients with these challenging pathology and morbidity.

Low-grade endometrial stromal sarcoma: differential with uterine leiomyoma: A rare case report

Endometrial stromal tumors are extremely rare uterine malignancy, mainly among young females. Herein, we report a case of low-grade endometrial stromal tumor in a 19-year-old women who presented with the non-specific symptoms of lower abdominal pain, swelling and vaginal bleeding similar to the uterine leiomyoma. Ultrasound finding showed bulky uterus with multiple fibroid and degenerative changes. Contrast enhanced computed tomography (CECT) displayed diffusely enlarged uterus with heterogenous enhancement of the solid cystic mass with normal bilateral tubes and ovary. Considering the patient in the reproductive age group and her fertility status, she was operated with surgical subtotal hysterectomy. Histopathological examination and immunohistochemistry confirmed the diagnosis of Low-Grade Endometrial Stromal Sarcoma (LG-ESS). Patient was closely followed up for recurrence. Endometrial Stromal Sarcoma (ESS) should be included in the differential diagnosis of uterine leiomyoma to avoid recurrence of the lesion.

Hemoperitoneum as a result of bleeding from a vein lying on the capsule of subserous leiomyoma of uterus (Clinical case)

Leiomyoma is a benign tumor of the uterus and it is considered to be the most sensitive tumor of the female genital organs. The tumor can have submucosal, intramural, and subserosal localizations, each of which has specific features of the course and complications. The article describes the clinical observation of a case of intra-abdominal bleeding, which was caused by the rupture of a vein lying on the capsule of a subserous uterine leiomyoma.Literature data about the leiomyoma frequency and its localization are presented in the article, as well as an explanation of the complexity of the true assessment of the frequency of this pathology, the peculiarities of a described case from a clinical and pathomorphological point of view. A review of the literature allowed to find 125 descriptions of clinical cases of bleeding from the vessel of the subserosal node during the last 100 years.The presented clinical case is interesting from the point of diagnosis. The picture of an “acute abdomen” by leiomyoma is most often associated with a blood circulation disorder of the node, and in this case it was caused by a rupture of a vessel due to twisting of the node and bleeding from the vessel. The patient with a history of subserous leiomyoma of the uterus was hospitalized with complaints of discomfort in the lower abdomen.During the objective examination, an enlarged uterus up to 16 weeks of pregnancy was diagnosed, and during ultrasound examination a leiomyoma node in the uterine fundus, which was twice larger than the uterus size itself, and up to 500 ml of blood in the abdominal cavity were found. During surgery, a subserous node in the uterus fundus with partial torsion was found, the source of bleeding was established – a vein on the posterior wall of the uterus. The patient was operated by conservative myomectomy, histological examination confirmed uterine leiomyoma, the patient was discharged in satisfactory condition.Recent systematic literature reviews have shown that myomectomy is a better surgical procedure compared to hysterectomy, as it reduces the prevalence of shock and blood loss in patients.