Nulligravid Women Research Articles

Surgical management of an ectopic pregnancy in the setting of an unexpected Müllerian anomaly: intraoperative and postoperative implications

ObjectiveTo describe the intraoperative and postoperative implications arising from the unexpected diagnosis of a Müllerian anomaly during the surgical management of an ectopic pregnancy. DesignVideo article. SettingAcademic Center. Subject(s)A 39-year-old nulligravid woman with anovulation and irregular menstrual cycles presented to the office. Her urine pregnancy test was incidentally positive; serum β-human chorionic gonadotropin (β-hCG) level was 5,644 mIU/mL. Outpatient transvaginal ultrasonography (TVUS) demonstrated a 2.1 x 1.7 x 2.2-cm thick-walled structure in the left adnexa without an intrauterine pregnancy. These findings were highly suspicious for a left tubal ectopic pregnancy. The patient was consented for laparoscopy with planned left salpingectomy. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. InterventionDiagnostic laparoscopy did not show an obvious left tubal ectopic pregnancy. Instead, a right unicornuate uterus with a dilated rudimentary left uterine horn was seen. Both fallopian tubes and ovaries appeared normal. These laparoscopic findings were consistent with an ectopic pregnancy in the rudimentary horn. However, in the absence of informed consent for a hemi-hysterectomy and no evidence of ectopic rupture or bleeding within the pelvis, we decided to proceed with excision of the ectopic pregnancy from the uterine horn. An incision was made over the anterior surface of the uterine horn, and the pregnancy sac was dissected from the underlying myometrium and excised in its entirety. Left salpingectomy was also performed. The patient was discharged home the same day, and her β-hCG levels decreased to <5 mIU/mL within 28 days of surgery. Main Outcome MeasuresComplete resolution of a left rudimentary uterine horn ectopic pregnancy through surgical excision of the pregnancy sac without hemi-hysterectomy. ResultsPostoperative hysterosalpingography (HSG) demonstrated a right unicornuate uterus with normal fill and spill of the right fallopian tube. Magnetic resonance imaging (MRI) of the pelvis confirmed the findings of a right unicornuate uterus with a non-communicating left rudimentary uterine horn that did not contain any endometrial tissue. Thus, the patient did not require an interval hemihysterectomy. She underwent letrozole and intrauterine insemination treatment 5 months after the initial surgery, which resulted in a clinical intrauterine pregnancy. However, this pregnancy was terminated in the early second trimester due to findings of trisomy 18. She conceived naturally one year later, and this pregnancy resulted in a full-term vaginal birth at 39 weeks gestation. ConclusionUndiagnosed or unexpected Müllerian anomalies can impact the standard intraoperative and postoperative management of ectopic pregnancies.

Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review.

Intrauterine devices (IUDs) are considered a reliable contraceptive option for women,but they can come with side effects. There is a disconnect in standard guidelines for IUD insertion within and without the U.S. The objective of this review was to address a gap in the literature regarding official procedures for pain management during IUD implantation.This scoping review was initiated using keywords to extract relevant articles from multiple databases: U.S. National Library of Medicine National Institutes of Health (PubMed), MEDLINE (Ovid), and Excerpta Medica dataBASE (EMBASE, Ovid). Initially, 457 articles were identified and after a rigorous screening and selection process, 37 articles were chosen to be further assessed to ascertain if they met the study's inclusion criteria. Those 37 articles were further evaluated fully to check for relevancy. From that process, 19 articles were chosen for the review, and all passed quality assessment evaluations using the JB Appraisal Tools. To best address the research question, the data from the 19 articles were divided into three categories: 1) circumstantial factors, 2) non-pharmacological methods, and 3) pharmacological methods. Circumstantially, women with previous vaginal deliveries experienced the lowest pain during the procedure, and nulligravid (never pregnant) women experienced the most pain. Lower pain scores were reported by lactating women compared to non-lactating. Black women experienced the most anticipated pain compared to other races. Regarding non-pharmacological methods, different insertion techniques, tools, and the use of a cold compress were found to not affect the level of pain during IUD insertion. Lastly, it was shown that pharmacological methods such as lidocaine gel, lidocaine paracervical block, and lidocaine combined with either diclofenac or prilocaine decreased pain scores at different time stamps of the procedure. Also, oral ketorolac and a vaginal combination of misoprostol and dinoprostone helped reduce pain.Findings from this scoping review revealed a lack of uniformity across practices when performing IUD insertions, possibly due to differences in procedures across circumstantial factors, non-pharmacological methods, and pharmacological methods. More research is needed to investigate the intricacies of pain with IUD insertion. Moving forward, especially following a potential increase in the use of IUDs after the reversal of Roe v. Wade, establishing this gap may lead to a more refined standardized protocol to mitigate pain with IUD insertions.

Bliss procedure for undescended ovaries

To highlight a novel surgical approach for the management of undescended ovaries in those presenting with infertility, to allow for potential transvaginal egg retrieval. The video demonstrates a novel surgical approach for mobilization and oophoropexy of undescended ovaries to allow for future transvaginal egg retrieval in the context of artificial reproductive technology (ART). Case report. Institutional Review Board approval is not required because this was not a human study. Patient consent was obtained for video footage. Hospital. We present a 26-year-old nulligravid woman with a unicornuate uterus, a high riding-right ovary, and an undescended left ovary with prior laparoscopic remnant uterine horn resection. Because of her 9 years of infertility and a prior unsuccessful ovarian mobilization and oophoropexy, she was referred for consideration of a repeat laparoscopic bilateral ovarian mobilization and oophoropexy. Surgical intervention for undescended ovaries. Postoperative ovarian location and postoperative pain. The patient reported minimal pain postoperatively at 6 weeks. Multiple follow-up imaging revealed both ovaries behind the uterus (antral follicle counts 15), with easy transvaginal access for future ART. Undescended ovary is uncommon and usually requires no treatment. However, intervention may be required in the context of infertility and ART, where transvaginal egg retrieval is impossible because of the location of the ovaries. This is the first educational video to our knowledge highlighting a novel surgical approach for the management of undescended ovaries.

Prevalence of pelvic floor dysfunction and associated risk factors among Nulligravida college students: a cross-sectional study

BackgroundPelvic floor dysfunction (PFD) is a global health problem affecting millions of women worldwide. Vaginal childbirth has been reported to be the most important factor in the etiology of PFD though a prior study also reported a high prevalence of PFD in nulliparous women. Some previous studies had suggested Urinary incontinence before pregnancy as a major risk factor for incontinence later in life, thus prevention of PFD has become a major priority in women’s health, and identification of women at risk is a key element in current prevention strategies It is therefore necessary to investigate the prevalence and risk factors for PFD in Nulligravida women who have never been pregnant to enable preventative measures especially as it regards lifestyle modification.MethodsParticipants were 160 Nulligravida students aged between 17 and 26 years. They were screened for pelvic floor dysfunction using an Australian pelvic floor questionnaire which assessed their bladder function, bowel function, pelvic organ prolapse, and sexual function. Descriptive statistics of frequency and percentage were used to summarize categorical variables. Univariate analysis of Fisher’s exact test and Wilcoxon rank-sum test were conducted to show the association of categorical and continuous variables with pelvic floor dysfunction (PFD) respectively. The risk factors of PFD with p values < 0.05 were considered significant. All analyses were performed using R Statistical Computing Programming version 4.2.2.ResultsThe prevalence of having at least one of any of the PFD was 73.1% while the prevalence of bladder, bowel, prolapse, and sex dysfunction were 25.63% (41/160), 53.75% (86/160), 1.88% (3/160), and 23.13% (37/160) respectively. BMI was not a significant risk factor for any type of PFD while multi-variable logistic regression identified the level of study, height, history of UTI, and non-sport participation as significant (p < 0.05) risk factors for at least one type of PFD with Odd ratio of 4.91, > 100, 8.47, and 2.86 respectively.ConclusionThere is high prevalence of PFD among Nulligravida students, with non-participation in sports and history of urinary tract infections being the main significant risk factors.

SAT368 Severe Hyperandrogenism in a Young Woman with Elevated BMI: A Case Study of The Role of Weight Loss in The Management of PCOS

Abstract Disclosure: S. Rodriguez Ortega: None. I.R. Bass: None. Background: Increased adiposity enhances the phenotypic expression and severity of hyperandrogenism in women with Polycystic Ovarian Syndrome (PCOS). Weight loss has been associated with improved endocrine features in women with PCOS and elevated Body Mass Index (BMI). Bariatric surgery can be an effective means of significant weight loss and restoration of the hypothalamic pituitary axis. Case Presentation: A 21-year-old Hispanic nulligravid woman presented with history of oligomenorrhea, weight gain and hirsutism. Her symptoms started after menarche at 15 years old with irregular periods, hair growth on her face and neck, and rapid weight gain. She was evaluated by an endocrinologist and was found to have an elevated total testosterone level by LC/MS on several different occasions: 309ng/dl, 259ng/dl and 229 ng/dl, as well as elevated androstenedione 346 ng/dl (41-262ng/dl). She was treated with metformin and oral contraceptive pill for two years and then referred for second opinion. On our physical exam, she had a BMI of 44.60 kg/ m2, a deep voice, Ferriman Gallwey score of 12 and acanthosis nigricans. OCPs were held for three months for accurate testing and work up revealed total testosterone 164.7 ng/dl (10.0-55.0 ng/dl), sex hormone binding globulin 25.4 nmol/L (24.6-112.0 nmol/L), bioavailable testosterone 84.3ng/dL (51.4%), DHEAs 375 µg/dl (110-431.7 µg/dl), and androstenedione 264 ng/dl (41-262 ng/dl). Other causes of hyperandrogenism such as hyperprolactinemia, hypothyroidism and congenital adrenal hyperplasia were ruled out. MRI pituitary from outside facility was reviewed and was normal. MRI abdomen and pelvis with/without contrast was performed, which demonstrated normal adrenal glands and an 8.1 cm midline pelvic cyst, containing a 0.7 cm enhancing solid nodule. She was referred for surgery for concern for possible virilizing tumor. The cyst was surgically removed and intra-operative ovarian exploration and cytopathology from pelvic washing were negative. She was referred for bariatric surgery and underwent a sleeve gastrectomy. After 6 weeks, she lost 30lbs, BMI improved to 37.1 kg/ m2 and her menses resumed. Repeat labs showed improvement in her androgens: total testosterone 64.8ng/dl, SHBG 104nmol/L, androstenedione 127ng/dl. After 8 months, she lost 110lbs and has dramatic improvement in her hirsutism and clearance of her acanthosis nigricans. Conclusion: Sustained lifestyle changes and weight loss are a mainstay in the treatment of patients with PCOS and obesity. Bariatric surgery results in durable weight loss and restores the normal physiological balance of sex hormones and improves signs and symptoms of hyperandrogenism. Presentation Date: Saturday, June 17, 2023

Impact of an accessory cavitated uterine mass on fertility: case presentation and review of the literature

We report a case of an accessory cavitated uterine mass (ACUM) in a patient with infertility and chronic pelvic pain. In addition, we summarize the literature to better characterize ACUM diagnosis and management. A comprehensive literature search using the PubMed database was performed through April 2023. Historical ACUM diagnostic criteria were applied as inclusion criteria. Descriptive statistics and statistical evaluation were reported. A 31-year-old nulligravid woman presented with chronic pelvic pain, dysmenorrhea, primary infertility, and history of endometriosis. Three-dimensional ultrasonography identified an ACUM and laparoscopic excision provided complete resolution of symptoms. Subsequently, she conceived without assistance twice with uncomplicated vaginal deliveries. A total of 154 articles were identified, 34 papers met inclusion criteria and were individually reviewed, consisting of 70 reported cases. The most common presenting complaints were dysmenorrhea (81.4%), chronic pelvic/abdominal pain (54.1%), and refractory pain (34.3%). Diagnostic imaging included magnetic resonance imaging (62.9%) and transvaginal ultrasound (55.7%). Management included resection via laparoscopy (75.7%) or laparotomy (18.6%), or hysterectomy (5.7%). Of cases with reported outcomes, 90.7% had complete relief of symptoms after surgery. ACUM often presents with dysmenorrhea, chronic pelvic pain, or abdominal pain and is identifiable on magnetic resonance imaging as a hyperenhancing mass. Three-dimensional transvaginal ultrasound can also accurately identify ACUM. A total of 90.7% of patients had complete relief of symptoms after intervention. It is important to identify ACUM early to relieve pain and reduce unnecessary interventions. Like our patient, other reports have demonstrated concomitant infertility and endometriosis. However, further investigation is needed to explore the association between infertility and ACUM.

Poster 227: The Impact of Hip Arthroscopy on Pregnancy-Related Decision-Making and Outcomes among Female Patients: A Single Surgeon’s Experience

Objectives: Women of reproductive age are among the most frequent recipients of hip arthroscopic procedures in the U.S., and anecdotal evidence suggests that some female patients consider pregnancy a factor in their decision to undergo, delay, or avoid such surgeries. In addition, anatomical changes during pregnancy may exacerbate existing hip pathologies such as femoroacetabular impingement (FAI) and labral tears, potentially leading to greater pain and risk of complications during gestation, labor, and delivery. However, the impact of hip pain and arthroscopy on pregnancy-related decision-making and outcomes is poorly understood. The aims of this study were to determine (1) how pregnancy planning affected patients’ decisions to pursue hip arthroscopy, (2) whether undergoing hip arthroscopy affected hip pain before and after pregnancy, and (3) whether hip arthroscopy was associated with any pregnancy-related complications. Methods: We retrospectively studied female patients aged 18-45 years who underwent hip arthroscopy for the treatment of FAI and/or labral tears at our center from 2010-2021. Subjects were identified using a prospectively-collected single-surgeon database. Eligible subjects were administered an electronic survey that assessed obstetrical history, concerns about how their hip pain and/or the process of undergoing hip arthroscopy could affect future pregnancies, location and intensity of hip pain at various time points (before surgery, after surgery, during pregnancy), and complications experienced during pregnancy. Hip pain intensity was reported on a 10-point Visual Analog Scale (VAS). Subjects also completed the modified Harris Hip Score (mHHS). Continuous variables were compared within groups with Wilcoxon signed rank test and between groups with Kruskal-Wallis test. Fisher’s exact test was used to compare categorical variables between groups. P-values &lt; 0.05 were considered significant. Results: A total of 86 patients completed the survey. Mean age at time of surgery was 32.3 ± 6.4 years (range 18 - 45), mean BMI was 24.5 ± 4.7 (range 18.7 – 39.8), and mean follow-up time was 52.0 ± 34.3 months (range 6 – 146). 47 patients (54.7%) had been pregnant at least once. Half of the cohort reported moderate or high concern that their hip pain would worsen during a future pregnancy, while a slight majority felt that hip surgery would not raise their risk of complications during pregnancy (56.0%) or impair hip function after pregnancy (51.2%). 27 patients (31.4%) had become pregnant after hip surgery at an average of 6.3 ± 1.4 months (range 2 – 8) postoperative, of whom 13 (48.2%) cited hip pain as a factor in getting surgery before pregnancy and 9 (33.3%) reported delaying a planned pregnancy to undergo surgery. Patients who became pregnant after surgery experienced a significant increase in VAS hip pain during pregnancy (p = 0.02), most commonly during the third trimester, though pain resolved after pregnancy in most (19 of 27, 70.4%). Five patients (5 of 27, 18.5%) experienced a miscarriage and the most common complication reported was vaginal/perineal tear (13 of 27, 48.1%). Of the 39 nulligravid patients, 28 (71.2%) were considering a future pregnancy and 32 (84.2%) did not consider hip pain to be a factor in their nulligravid status. There was no significant difference in mHHS at latest follow-up between nulligravid patients, patients who had not been pregnant since hip surgery, and patients who got pregnant after hip surgery (mean 79.6 vs 80.0 vs 79.6, p = 0.94). Conclusions: Most female hip arthroscopy patients were not concerned that their surgery would have a negative impact on their pregnancy outcomes or hip function after pregnancy. Within the hip arthroscopy population, although hip pain was exacerbated during pregnancy, most patients experienced a resolution of pain following delivery. Pregnancy-related complications did not occur more frequently in the hip arthroscopy cohort compared to the wider U.S. population. Patient-reported hip outcomes were comparable between nulligravid women and those who had only been pregnant prior to surgery.

Predictors of Fertility-Awareness-Based Method Use Among Women Trying to Conceive and Women Contemplating Pregnancy.

Fertility-awareness-based methods have been linked to shorter time to conception; however, little is known about the predictors of fertility-awareness-based method use among women who are currently or will soon be trying to conceive. The aim of this study was to identify predictors of fertility-awareness-based methods use among women trying to conceive or contemplating pregnancy within the next year. Women participating in the Nurses' Health Study 3 were asked if they were trying to become pregnant or contemplating pregnancy and whether they are using fertility-awareness-based methods. Multivariable negative binomial regression was used to identify predictors for a number of fertility-awareness-based methods used. Among the 23,418 women asked about pregnancy intention since 2015, 955 were trying to conceive, and 2,282 were contemplating pregnancy within the next year. The three most used fertility-awareness-based methods among women trying to conceive were menstrual cycle tracking, ovulation prediction kits, and cervical mucus monitoring. Among women contemplating pregnancy, the three most commonly used methods were menstrual cycle tracking, cervical mucus monitoring, and basal body temperature monitoring. The ongoing duration of pregnancy attempts and gravidity were associated with the number of methods used among women actively trying to conceive. When compared with women who were trying for 2 months or less, the number of methods was 29% higher when trying for 3-5 months, 45% higher when trying for 6-12 months, and 38% higher when trying for more than 1 year. Compared with nulligravid women, the number of methods was lower for women with a history of two or more pregnancies. Among women contemplating pregnancy, those who were married or in a domestic partnership used more fertility-awareness-based methods than unpartnered women. No other significant predictors of fertility-awareness-based method use were identified. Duration of ongoing pregnancy attempt and gravidity were the only significant predictors for the number of fertility-awareness-based methods used among women actively trying to conceive, whereas partnership was the only significant predictor of the number of fertility-awareness-based methods among women contemplating pregnancy.

Abstract #1406879: Not Always PCOS: A Case of Virilizing Steroid Cell Ovarian Tumor

Ovarian steroid cell tumors (SCTs) are a rare type of sex-cord stromal tumors that account for 0.1% of all ovarian tumors. These tumors can occur at any age and typically secrete hormones such as androstenedione and testosterone. We report a young woman with known microprolactinoma who presented with secondary amenorrhea and virilization and was found to have a steroid secreting ovarian SCT. A 32-year-old nulligravid woman with history of infertility presented for evaluation for amenorrhea. Three years ago, she developed oligomenorrhea and was subsequently found to have hyperprolactinemia and an 8mm pituitary microadenoma. Thyroid function tests and IGF-1 at the time were normal, no other workup was obtained. She was started on cabergoline, though after developing full body hives was switched to bromocriptine. Despite prolactin normalization from 69.9 to 14.7 ng/mL and shrinkage of pituitary adenoma to 7mm after 1 year of therapy, she developed amenorrhea, acne, and new facial hair. Her testosterone was found elevated 212ng/dL and she states was then diagnosed with PCOS. In light of no clinical improvement and mental health issues, she self-discontinued her bromocriptine and was lost to follow up. Upon current presentation she reported last menstrual period 24 months ago, continued acne and facial hair, and now temporal hair loss and deepening voice. Ferriman-Gallwey score was 20/36. She did not have clinical signs of Cushing’s syndrome. Repeat prolactin was 195ng/mL, pituitary MRI showed 3mm microadenoma, and bromocriptine was resumed. Workup for her hyperandrogenism revealed testosterone of 137ng/dL (ref 8-60), androstenedione 972 ng/dL (41-262), DHEA-S 284 mcg/dL (84.8-378), 17-OH-progesterone 23ng/dL, and hCG <0.5mIU/mL. Late night salivary cortisol levels were elevated to 0.213, 0.429, and 0.552mcg/dL (<0.090) with ACTH 27.3pg/mL (9.72-63.3). CT scan showed normal adrenal glands. A pelvic ultrasound revealed a 2.2cm left ovarian vascular mass. She underwent left salpingo-oophorectomy and pathology confirmed a 2.4cm benign steroid cell tumor. Follow up after surgery is currently ongoing. Amenorrhea despite prolactin normalization and signs of severe hyperandrogenism such as testosterone >150ng/dL, male pattern baldness, and vocal deepening should prompt physicians to consider androgen-secreting tumors. Our patient was found to have a rare ovarian SCT—these tumors can lead to precocious puberty in adolescents, virilization in adults, Cushing’s syndrome, and infertility. Our patient reports significant clinical improvement postoperatively.

Abstract #1405095: PCOS Diagnosis Leading to a Delayed Diagnosis of Cushing's Disease

Polycystic ovarian syndrome (PCOS) is a common disorder affecting pre-menopausal women. Diagnostic criteria for PCOS include menstrual irregularities, biochemical or clinical hyperandrogenism and/or evidence of polycystic ovaries on ultrasound. Any 2 of the above is sufficient for a diagnosis of PCOS. However, PCOS is a diagnosis of exclusion so other pathologies should be investigated including hypercortisolemia. We present a case of Cushing's Disease in which the patient’s clinical features were previously attributed to a diagnosis of PCOS delaying appropriate intervention. A 22-year-old nulligravida woman with no significant past medical history presented to the Ob/Gyn clinic with complaints of amenorrhea and infertility. Patient noted irregular menstrual cycles since attaining menarche, she denies any headaches, galactorrhea but reported facial hirsutism and weight gain. She was initially diagnosed with PCOS but had continued amenorrhea despite treatment with medroxyprogesterone acetate. Additional work up was ordered by Gyn which noted mildly elevated Prolactin at 30.84 ng/ml. MRI head/brain subsequently ordered noted a large T2 weighted hyperintense lesion measuring 2.2 x 1.65 x 2.0 cm involving the sella with extension suggesting a pituitary macro-adenoma. Patient was referred to endocrinology for additional work up. Further evaluation showed normal repeat prolactin level with dilution study normal at 11.9 ng/ml. She was found to have secondary hypogonadism with FSH - 5.32 mIU/ml, LH- 2.1IU/L and estradiol level at < 20 pg/ml. She also had secondary hypothyroidism with TSH 0.88 mIU/ml and free T4 at 0.64 ng/dl. Morning Cortisol was at 19.13 ug/uL with baseline ACTH elevated at 127 pg/ml. This showed adequate adrenal function but concern for ACTH dependent hypercortisolemia. She had 2 failed 1 mg dexamethasone suppression test with cortisol level at 10.92 ug/uL and 20.91 ug/uL with adequate dexamethasone levels. She had 2 elevated 24-hour urine cortisol at 72ug/24hr and 81ug/24hr. She also had 2 elevated midnight salivary cortisol level at 0.338ug/dl and 0.349ug/dl. Other labs showed normal IGF-1 and normal DHEA-S. Patient was diagnosed with Cushing Disease and underwent successful transsphenoidal resection of the pituitary macroadenoma. Post operative cortisol was <2 ug/ul, she was initiated on hydrocortisone 20mg am and 10mg pm. Patient had continued monitoring for recovery of hypothalamic-pituitary-axis. A month after the surgery, patient got pregnant and was continued on her hydrocortisone and levothyroxine replacement. In our case the diagnosis and treatment of Cushing's disease was delayed due to clinical features mimicking PCOS. PCOS is a diagnosis of exclusion, and our case illustrates the importance of excluding the other endocrine pathologies, such as Cushing's disease, to prevent delaying the appropriate treatment and to mitigate the risk of increased morbidity and mortality that may be associated with them.

A-39 year old, nulligravida woman with giant leiomyomas: a case report

Introduction: The most common neoplasm of the uterus, uterine leiomyomas, or fibroids, are benign growths that affect 20–30% of women between the ages of 30 and 50. The smooth muscle of the uterus gives rise to leiomyomas. In this case report, we sought to highlight the case of a 39-year-old nulligravida lady with a fast expanding abdominal mass and abdominal pain. Case Presentation: The gynecologist department at Dr. Kariadi General Hospital Semarang received a visit from a 39-year-old nulligravida lady complaining of a fast-expanding lump in her belly and extreme weight loss over the past year. During the abdominal exam, an immovable mass that could have been an 8-month pregnancy was felt in the midline of the abdominal area, extending from the lower abdomen to the epigastric area. Ascites were also discovered. The multislice computerized tomography (MSCT) results showed a solid lobulated inhomogeneous mass with internal calcification which extended from the abdominal cavity to the pelvic cavity and visualized the size of (anteroposterior 21.7 cm x laterolateral 24.1 cm x craniocaudal 36.8 cm), compressing the surrounding bowel structures, liver, spleen, and bladder. Several lymphadenopathies were also discovered. A frozen section, a bilateral salpingo-oophorectomy, and a total abdominal hysterectomy were performed. The results of the histology suggested a benign leiomyoma. Her vital signs were steady after surgery, and she fully recovered. The patient was called for a follow-up one week after being released for surgical suture removal and evaluation. The patient was discharged on the sixth postoperative day in good condition. Conclusion: In determining if uterine smooth muscle tumors are benign or malignant, clinical characteristics, physical examination, imaging, and pathological findings are still considered very useful. The histopathology examination is still the most reliable diagnostic tool. The decision to perform a hysterectomy on this patient was determined accordingly to the tumor's size, probability of malignancy, and increasing morbidity.

First live birth after uterine transposition

To our knowledge, to report the first case of live birth of a child after uterine transposition (UT), pelvic radiotherapy, and subsequent uterine repositioning. Case report. Tertiary referral cancer hospital. A 28-year-old nulligravid woman with left iliac and thoracic synchronous myxoid low-grade liposarcoma, which was resected with close margins. The patient underwent UT before undergoing pelvic (60 Gy) and thoracic (60 Gy) radiation on October 25, 2018. After radiotherapy, her uterus was reimplanted in the pelvis on February 20,2019. The patient became pregnant in June 2021 and experienced an uneventful pregnancy until 36 weeks, when the patient started preterm labor and had a cesarean section delivery on January 26,2022. A boy was delivered after a gestation period of 36 weeks and 2 days (2686 g and 46.5 cm), with Apgar scores of 5 and 9, respectively; both mother and child were discharged the following day. After 1 year of follow-ups, the infant maintained normal development and the patient showed no signs of recurrence. To our knowledge, this case of the first live birth after UT is a proof-of-concept for the viability of UT as a procedure to prevent infertility in patients requiring pelvic radiotherapy.

Surgical management of inguinal endometriosis: Case report and surgical video

Introduction: Inguinal endometriosis is a rare type of extra-pelvic endometriosis, which may occur in the absence of symptoms of intra-pelvic endometriosis. This case report highlights the importance of considering inguinal endometriosis in the workup of an inguinal mass and demonstrates a step-by-step surgical approach to management, with an accompanying video. Case Report: We encountered a case of a 31-year-old nulligravid woman who presented with a painful right inguinal mass. The patient underwent diagnostic laparoscopy, which was notable for Stage 1 intra-pelvic endometriosis, without involvement of the internal inguinal ring or round ligament. The inguinal mass was carefully resected from nearby vessels, muscles, and nerves. Pathology confirmed endometriosis. Conclusion: Gynecologists, in collaboration with a multidisciplinary team, should be prepared to workup, diagnose, and surgically manage inguinal endometriosis. When this condition is suspected, imaging should be obtained, and tissue biopsy may be considered, provided that a hernia has been ruled out. Surgical management is typically recommended and should entail diagnostic laparoscopy and excisional surgery.

Multimodal measurements of levator bowl volume in nulligravid asymptomatic women: endovaginal ultrasound versus MRI.

Measurements of levator bowl volume using advanced imaging, may be predictive of pelvic floor muscle function. The aim of this study was to compare the volume of the levator bowl using both magnetic resonance imaging (MRI) and endovaginal ultrasound (EVU) of healthy asymptomatic women. All participants underwent a comprehensive interview including completion of the Pelvic Floor Distress Inventory Questionnaire-20 questionnaire, pelvic examination with a pelvic organ prolapse quantification evaluation, MRI, and EVU. The pelvic floor was segmented using Slicer and the MRI segmentations were trimmed using two methods: soft-tissue landmarks and the field of view (FOV) of the ultrasound volume. The levator bowl volume of the 3D segmented shapes was measured using Blender's 3D printing toolkit. Normality was tested using the Shapiro-Wilks test and comparisons were made using self-paired t tests. The final analysis included 19 patients. Levator bowl volume measured via MRI was larger than that measured in EVU (46.1 ± 7.9 cm3 vs 27.4 ± 5.9 cm3, p<0.001). Reducing the FOV of the MRI to that of EVU caused the MRI volume to be much closer to the EVU volume (35.5 ± 3.3 cm3 vs 27.4 ± 5.9 cm3, p<0.001); however, it remained significantly larger. Levator bowl volume measured using MRI was larger than that measured using EVU no matter the method of delineation of the levator muscles. Although EVU is safe, cheap, and easy to perform, it captures a smaller volume of levator bowel than MRI.

Age-related changes in CD4+ T and NK cell compartments may contribute to the occurrence of pregnancy loss in advanced maternal age

A recent study characterized novel immune cell subsets (T, NK, and γδ T cell subsets) related to recurrent pregnancy loss (RPL). This study aims to assess whether these RPL-related immune cell subsets are affected by aging. The percentages of peripheral blood immunes cells from nulligravida women (NGW), women with a history of normal pregnancy (NP), and women with a history of pregnancy loss (PL) were detected by flow cytometry. The correlations between maternal age and cell percentages were assessed. We found a significant positive correlation between PL and maternal age. The percentages of effector memory CD4+ T (CD3+ CD4+ CD45RA¯ CCR7¯), terminally differentiated CD4+ T (CD3+ CD4+ CD45RA+ CCR7¯), and mature NK cells (CD3¯ CD56+lo) significantly increased with maternal age. A significant decrease in the percentage of Naïve CD4+ T cells (CD3+ CD4+ CD45RA+ CCR7+) with age was observed in women from the NP group. Women aged 35 or older had significantly higher percentages of effector memory CD4+ T cells, terminally differentiated CD4+ T cells, and mature NK cells than younger women. Maternal age positively correlates with terminally differentiated CD4+ T, effector memory CD4+ T, and mature NK cell percentages. In contrast, an inverse correlation was observed between Naïve CD4+ T cell and age among women from the NP group. Our findings indicate that age-related CD4+ T and NK cell dysregulation might be involved in the pathogenesis of PL in women with advanced maternal age. The underlying mechanism needs further investigation.

Effects of Hydrosalpinx on Endometrial Receptivity and Uterine Microbiome: An Interesting Case of Double Uterus with Unilateral Hydrosalpinx

Endometrial receptivity array (ERA)—an objective tool used in assisted reproductive technology—is used for personalized embryo transfer in in vitro fertilization. Hydrosalpinx affects implantation through various mechanisms. However, its effects on ERA are not well established. In this case report, we present the diagnosis and treatment of a 34-year-old nulligravida woman with infertility for two years, obesity, double uterus with unilateral hydrosalpinx and right kidney deficiency. Based on ERA results, endometrial microbiome metagenomic analysis (EMMA), analysis of infectious chronic endometritis (ALICE), and CD138 immunostaining, the patient was treated with hormonal replacement cycle and amoxicillin/clavulanic acid. After one week of amoxicillin/clavulanic acid administration, the vitirified-warmed 4AA blastocyst was transferred to the left uterus—which was absent of hydrosalpinx and easily accessible to transfer and pregnancy was achieved. To the best of our knowledge, this case study is the first one in which we found that there were no differences between the left and right uterus in ERA, EMMA, ALICE, and CD138 immunostainings. Hence, we suggest that hydrosalpinx does not necessarily cause endometrial changes in all cases. Further research to evaluate the effects of hydrosalpinx on implantation with ERA and EMMA/ALICE is warranted.

Increased Intima-Media Thickness of Carotid and Femoral Arteries in Women with Early Preeclampsia

Background: Preeclampsia can increase the risk of cardiovascular diseases (CVDs) later in life. Also, increased intima-media thickness (IMT) of the carotid artery was introduced as an independent risk factor for CVDs. Objectives: This study aimed to evaluate and compare the IMT of carotid and femoral arteries between women with early preeclampsia and normotensive pregnant and nulligravid women. Methods: In this study, which was conducted between May 2019 and January 2020, three groups of women were evaluated: early-onset preeclamptic pregnant women, normotensive pregnant women, and nulligravid women. The IMTs of the common femoral artery, superficial femoral artery, common carotid artery, carotid bulb, and internal carotid artery were measured using B-mode ultrasound. Results: A total of 100 women were enrolled in each group. The means ± SD of age in preeclamptic, normotensive and nulligravid women were 27.78 ± 3.23, 27.16 ± 3.09, and 27.11 ± 2.95, respectively. The mean gestational age of the two pregnant groups was nearly 32 weeks. Based on the results, the mean systolic blood pressure, diastolic blood pressure, and arterial pressure were significantly higher in the preeclamptic group compared to the other groups (P &lt; 0.001). The mean IMT of both sides of the common carotid artery, carotid bulb, internal carotid artery, common femoral artery, and superficial femoral artery was significantly higher in the preeclamptic group compared to normotensive pregnant and nulligravid women (P &lt; 0.001). Conclusion: Preeclampsia was associated with the increased IMT of common and internal carotid arteries, as well as common and superficial femoral arteries. Therefore, IMT measurements in preeclamptic women can provide an opportunity to identify those who may benefit from early screening and preventive care to reduce the risk of CVDs in the future.

Women’s knowledge, attitudes and views of preconception health and intervention delivery methods: a cross-sectional survey

BackgroundSeveral preconception exposures have been associated with adverse pregnancy, birth and postpartum outcomes. However, few studies have investigated women’s knowledge of and attitudes towards preconception health, and the acceptability of potential intervention methods.MethodsSeven primary care centres in the West of England posted questionnaires to 4330 female patients aged 18 to 48 years. Without providing examples, we asked women to list maternal preconception exposures that might affect infant and maternal outcomes, and assessed their knowledge of nine literature-derived risk factors. Attitudes towards preconception health (interest, intentions, self-efficacy and perceived awareness and importance) and the acceptability of intervention delivery methods were also assessed. Multivariable multilevel regression examined participant characteristics associated with these outcomes.ResultsOf those who received questionnaires, 835 (19.3%) responded. Women were most aware of the preconception risk factors of diet (86.0%) and physical activity (79.2%). Few were aware of weight (40.1%), folic acid (32.9%), abuse (6.3%), advanced age (5.9%) and interpregnancy intervals (0.2%), and none mentioned interpregnancy weight change or excess iron intake. After adjusting for demographic and reproductive covariates, women aged 18–24-years (compared to 40–48-year-olds) and nulligravid women were less aware of the benefit of preconception folic acid supplementation (adjusted odds ratios (aOR) for age: 4.30 [2.10–8.80], gravidity: aOR 2.48 [1.70–3.62]). Younger women were more interested in learning more about preconception health (aOR 0.37 [0.21–0.63]) but nulligravid women were less interested in this (aOR 1.79 [1.30–2.46]). Women with the lowest household incomes (versus the highest) were less aware of preconception weight as a risk factor (aOR: 3.11 [1.65–5.84]) and rated the importance of preconception health lower (aOR 3.38 [1.90–6.00]). The most acceptable information delivery methods were websites/apps (99.5%), printed healthcare materials (98.6%), family/partners (96.3%), schools (94.4%), television (91.9%), pregnancy tests (91.0%) and doctors, midwives and nurses (86.8–97.0%). Dentists (23.9%) and hairdressers/beauticians (18.1%) were the least acceptable.ConclusionsOur findings demonstrate a need to promote awareness of preconception risk factors and motivation for preconception health changes, particularly amongst younger and nulligravid women and women with lower incomes. Interventions to improve preconception health should focus on communication from healthcare professionals, schools, family members, and digital media.

Giant Deep Aggressive Angiomyxoma of The Vulva: A Rare Case Report

Background: Deep Aggressive Angiomyxoma (DAA) is a rare benign tumor with about 250 cases reported worldwide. It was first reported in 1983. This tumor is commonly found in women of reproductive age, with the highest incidence in the 3rd and 4th decades of life. DAA is most often found in the pelvic, genital, inguinal region, or perineum. Case Report: Nulligravida woman 52 years old, with enlargement of the vulva that had felt since ± 20 years ago. A mass was found on local examination of the right vulva with a size of ±50x40x10cm, which was supple, mobile, and with no pain. Enlarged inguinal lymphadenopathy was also observed. MRI showed a well-defined lesion at the right vulvar region (which visualized the size of ± AP 14.95 x LL 31.80 x CC 15. 3 cm) with the signal intensity hypointense on T1WI, hyperintense on T2WI and FatSat, restricted on DWI, with no enhancement was seen. A wide excision was conducted, and post-excision measurements showed a right vulvar mass size was 50x42x10cm, with 14.8kg in weight. Conclusion: DAA is a rare benign tumor that can disturb patients. The nature of the tumor should be evaluated carefully using radiological and pathological approaches. A wide excision can remove the tumor completely, but control and follow-up are mandatory to evaluate the completeness of the procedure and monitor for any relapse.

Quantifying the physiologic motions of the pelvic viscera during evacuation in nulligravid asymptomatic women.

Pelvic organ prolapse (POP) is often diagnosed during an in-office examination, which looks for motion of the vaginal wall while performing a strain maneuver. It is believed that the pelvic organs in adequately supported women are relatively stationary. This study was aimed at investigating the physiological displacements of pelvic organs using MR defecography. This prospective cohort study included 19 volunteers. Midsagittal slices representing rest and the maximum movement of the posterior vaginal fornix during three maneuvers were identified. Normalized axes for analysis were defined as the x' (line connecting the inferior-posterior-most point on the pubic symphysis to the anterior edge of the sacrococcygeal joint) and the y' (line orthogonal to the x axis that passed through the sacral promontory). The positions of the posterior vaginal fornix, mid-vagina, bladder neck, anorectal junction, and hymen were recorded. These subjects were then analyzed using the current radiological grading system of POP to determine any overlap between asymptomatic subjects and diagnostic ranges of POP. Evacuation caused the most motion in the landmarks. The majority of the motion of the landmarks was along the y axis. The posterior vaginal fornix experienced significant descent (125% of the initial distance) without much anterior-posterior translation (7% of the initial distance) during defecation. All landmarks experienced similar trends. We have shown that there is significant rotational motion of the pelvic organs around the pubic bone in adequately supported women. This motion when described using radiological grading is likely to be considered mild or moderate prolapse, which may contribute to overdiagnosis of POP.