Pregnant Uterus Research Articles

Uterine leiomyoma in a 14 – year – old girl: Case report and literature review

Background: Uterine leiomyomas are benign tumors arising from the smooth muscle cells of the uterus or extracellular matrix, that are very common among women of reproductive age between 30 and 50 years of age. However, their incidence is extremely rare in women under 15-year-old (<1%) with unknown etiology. Ultrasound and magnetic resonance imaging (MRI) comfirms the location, number, size of mass, which plays an important role in prognosis and treatment. Leiomyomas have been managed in a variety of methods and are considered to decide the most optimal way to preserve fertility in adolescents. Case: A 14 year of age female patient was admitted with increased abdominal volume and pelvic mass over 6 months. Physical examination revealed the mass from the pelvic, corresponding in size to a pregnant uterus of 18 weeks (fundal height is 14cm). Ultrasound and MRI showed a uterine leiomyoma type 2 -5 (FIGO) and a differential diagnosis of leiomyosarcoma. The patient was managed successfully with complete tumor resection through abdominal myomectomy to preserve fertility. Histological results confirmed the final diagnosis was “benign degeneration of uterine leiomyoma”. Summary and conclusion: Although the occurrence of uterine leiomyomas in adolescents is very rare, this diagnosis is considered since a pelvic mass in this age group is discovered. Through rare but the differential diagnosis of uterine leiomyoma in the young population is leiomyosarcoma. Myomectomy is a suitable management to preserve fertility.

Inversion of uterus due to prolapsed submucous fundal fibroid

Inversion of uterus is rarely encountered by gynecologist during practice; inversion in a non- pregnant uterus is further rarer; only case reports are published in literature on non-puerperal uterine inversion. We present a case of a 40-years multipara who had a history of irregular and excessive vaginal bleeding associated with severe lower abdominal pain during vaginal bleeding for two years. She was referred from general hospital with suspicion of cervical cancer. Being a rare clinical condition diagnosis and management of uterine inversion is challenging. High index of clinical suspicion is necessary which can be aided by radiographic imaging. Our case was diagnosed as a case of complete uterine inversion secondary to fundal fibroid clinically. She underwent abdominal hysterectomy with bilateral salpingectomy with bilateral sacrospinous vault suspension after resuscitation with fluids, blood transfusion and broad-spectrum antibiotics.

Regulatory mechanisms of HMGB1 and its receptors in polycystic ovary syndrome-driven gravid uterine inflammation.

High-mobility group box 1 (HMGB1) is critical for inflammatory homeostasis and successful pregnancy, and there is a strong association among elevated levels of HMGB1, polycystic ovary syndrome (PCOS), chronic inflammation and pregnancy loss. However, the mechanisms responsible for PCOS-driven regulation of uterine HMGB1 and its candidate receptors [toll-like receptor (TLR) 2 and 4] and inflammatory responses during pregnancy remain unclear. In this study, we found a gestational stage-dependent decrease in uterine HMGB1 and TLR4 protein abundance in rats during normal pregnancy. We demonstrated that increased expression of HMGB1, TLR2 and TLR4 proteins was associated with activation of inflammation-related signalling pathways in the gravid uterus exposed to 5α-dihydrotestosterone and insulin, mimicking the clinical features (hyperandrogenism and insulin resistance) of PCOS and this elevation was completely inhibited by treatment with the androgen receptor (AR) antagonist flutamide. Interestingly, acute exposure to lipopolysaccharide suppressed HMGB1, TLR4 and inflammation-related protein abundance but did not affect androgen levels or AR expression in the gravid uterus with viable fetuses. Furthermore, immunohistochemical analysis revealed that, in addition to being localized predominately in the nuclear compartment, HMGB1 immunoreactivity was also detected in the cytoplasm in the PCOS-like rat uterus, PCOS endometrium and pregnant rat uterus with haemorrhagic and resorbed fetuses, possibly via activation of nuclear factor κB signalling. These results suggest that both AR-dependent and AR-independent mechanisms contribute to the modulation of HMGB1/TLR2/TLR4-mediated uterine inflammation. We propose that the elevation of HMGB1 and its receptors and disruption of the pro-/anti-inflammatory balance in the gravid uterus may participate in the pathophysiology of PCOS-associated pregnancy loss.

7407 A Self-Made Bag Assisted LESS in Ovarian Teratomectomy during Pregnancy

<h3>Study Objective</h3> To show how ovarian teratoma during Pregnancy can be safely managed with laparoendoscopic single-site surgery. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> The reported incidence of ovarian cysts in pregnancy varies from 0.05% to 1.2%, Compared with open surgery, laparoscopic surgery adnexal cyst during pregnancy does not increase the risk of mother and fetus. LESS has better postoperative recovery. However, conventional laparoscopic surgery is safer than LESS. <h3>Patients or Participants</h3> The patient was a 31-year-old woman, gravida 3, para 2, at gestational age of 15 weeks who was diagnosed with 5.6*4.1cm right ovarian teratoma and 2.0*2.3cm left ovarian cyst. Teratomectomy was performed at the same time of the previous cesarean section in 2018. <h3>Interventions</h3> A Self-made Bag Assisted LESS approach to ovarian teratoma with several key strategies to minimize fetal impact, ovarian damage, blood loss: 1. Make a retrieval bag before surgery with inner packaging bag of the disposable suction tube. 2. Place the affected ovary in the retrieval bag and pull the bottom of the retrieval bag to the umbilicus. To reduce the stimulation of the uterus by surgical procedures. 3. Cut the surface of the affected ovary with a cold blade to reduce ovarian damage. 4.Cut the teratoma pedicle with an ultrasonic knife to reduce bleeding. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> When performing an ovarian cystectomy under LESS, we could use upside-down specimen bag to remove the cyst from abdominal cavity conveniently, quickly and with no pollution. Self-made specimen bag is cost-saving, convenient to use. The operation has the least impact on the pregnant uterus and avoids the impact on the fetus. And cold knife and suture are used in the operation to maximize the protection of ovarian function.

Non-genomic uterorelaxant actions of corticosteroid hormones in rats: An in vitro and in vivo study

AimsWe aimed to identify the short-term effects of a glucocorticoid (GC) and a mineralocorticoid (MC) on non-pregnant and late pregnant rat uterine contractions to estimate their tocolytic potential. MethodsThe in vitro contractility studies were performed with uterine tissues from non-pregnant and 22-day pregnant SPRD rats. The cumulative dose-response of fludrocortisone (FLU) and dexamethasone (DEX) was measured alone or in the presence of steroid receptor antagonist mifepristone (MIF) or spironolactone (SPR). [35S]GTPγS and cAMP immunoassays were carried out to detect the activated G-proteins and cAMP, respectively. The in vivo uterine action of single doses of FLU and DEX was measured by smooth muscle electromyography. The results were statistically analyzed with an unpaired t-test. ResultsFLU and DEX relaxed both pregnant (33 and 34%) and non-pregnant (37 and 34%) uteri in vitro. MIF inhibited the relaxing effect of DEX, especially in the pregnant uterus, but reduced the effect of FLD only in non-pregnant tissues. GTPγS studies showed a MIF-sensitive elevation in activated G-proteins both in pregnant and non-pregnant uteri by DEX, whereas FLU induced activation only in non-pregnant samples. DEX relaxed pregnant and non-pregnant uteri in vivo in a MIF-sensitive way. SignificanceDEX can inhibit contractions in the late pregnant uterus in a non-genomic manner, while FLU seems to be ineffective. Its action is mediated by a G-protein-coupled receptor that can be blocked by mifepristone. Further investigations are necessary to determine the required dose and duration of GCs in the therapy of premature birth.

What type of uterine anomalies had an additional effect on pregnancy outcomes, compared to other uterine anomalies? An evaluation of a large population database

Objective To compare pregnancy risks between different congenital uterine anomalies utilizing other congenital anomalies as a control group in a large population database. Design, setting, and sample A retrospective population-based cohort study from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) included 3,846,342 births (2010–2014). Of them, 6195 deliveries were to women with bicornuate uteri, 798 with arcuate uteri, 2255 with didelphys uteri, 802 with unicornuate uteri and 1404 with septate uteri. Main outcome measures and results After adjustment for confounders, women with bicornuate uteri were more likely to deliver vaginally (aOR 1.4, 95%CI: 1.1–1.9), p = .01), less likely to deliver by cesarean (CD) and had lower risk of small for gestational age (SGA) (aOR 0.8, 95%CI: 0.7–0.9, p = .03) when compared to the other anomalies (aOR 0.6, 95%CI: 0.5–0.6, p = .0001). Pregnant women with arcuate uterus had lower risks of preterm delivery (PTD) (aOR 0.6, 95%CI: 0.5–0.8, p = .0001), less chance of operative vaginal delivery (aOR 0.5, 95%CI: 0.2–0.9, p = .04), and higher risk for CD (aOR 1.6, 95%CI: 1.4–2, p = .0001). Pregnant women with didelphys uteri had higher risk of preterm premature rupture of membranes (PPROM) (aOR 1.6, 95%CI: 1.3–1.9, p = .0001), PTD (aOR 1.5, 95%CI: 1.3–1.6, p = .0001), CD (aOR 1.4, 95%CI: 1.2–1.5, p = .0001) and wound complications (aOR 1.6, 95%CI: 1.1–2.4, p = .02). Pregnant unicornuate uteri had increased risks of PTD (aOR 1.4, 95%CI: 1.1–1.6, p = .0001), CD (aOR 2, 95%CI: 1.6–2.5, p = .0001) and of SGA (aOR 1.8, 95%CI: 1.4–2.3, p = .0001). Pregnant septate uteri had higher risk of chorioamnionitis (aOR 1.5, 95%CI: 1.1–2.1, p = .048) and CD (aOR 1.4, 95%CI: 1.2–1.6, p = .0001). Conclusions We demonstrated that there are different risks for certain adverse pregnancy and neonatal outcomes in diverse uterine anomalies as compared to the other anomalies.

Pregnancy preparation: redistribution of CCR7-positive cells in the rat uterus.

Changes in the endometrium prior to implantation may be critical in predicting pregnancy outcomes. This study shows that the endocrine system directs positional changes in CCR7+ cells before implantation, which may be critical for developing maternal tolerance. Suppression of the maternal immune system is vital for the implantation of the semi-allogeneic embryo. Although progress in understanding the dialogue between mother and embryo has been made, key interactions between maternal immune cells, hormones, and chemokines remain elusive. Uterine expression of the C-C chemokine receptor type 7 (CCR7) could recruit T regulatory cells and facilitate localized immune suppression. To test this concept, Ccr7 mRNA and protein were assessed in uterine tissue. Ccr7 mRNA expression peaked at day 4 in pregnant rat uteri and then declined at days 5 and 6. CCR7 protein showed similar quantitative changes. To test if female sex steroids affected the spatial distribution of CCR7-expressing cells, uteri from ovariectomized rats, progesterone-pretreated rats (2 mg daily), and progesterone-pretreated rats injected with estradiol (0.2 µg) were analyzed. Progesterone increased CCR7-positive (+) cells in the antimesometrial stroma. Progesterone and estradiol increased CCR7+ cells in the mesometrial stroma. Estradiol increased the density of cluster of differentiation 4 (CD4) positive cells in the mesometrial stromal region over progesterone alone. The density of cells expressing the T regulatory cell marker, forkhead box protein 3 (FOXP3), increased in the antimesometrial stroma in response to progesterone alone. Progesterone and estradiol increased FOXP3+ cells in the antimesometrial region of the stroma. Co-localization of CCR7, CD4, and FOXP3 in the stroma suggests CCR7+ cells are T regulatory cells. Polarization of CCR7+ cells in the endometrial stroma was an intrinsic response regulated by sex steroids and did not require the presence of an embryo.

PSIII-2 The Microrna Profile of day 30 Pregnant Ipsilateral or non-Pregnant Bovine Uterus

Abstract MicroRNAs (miRNAs) have been used as biomarkers for various health issues and physiological states, and could be utilized as a tool to detect pregnancy loss. The objective of this study was to determine the variation in miRNA abundance between pregnant and non-pregnant uteri of cows at day 30 post-insemination. Uterine samples were collected from pregnant (n = 4) and non-pregnant (n = 4) cows, and snap frozen in liquid N2. Isolation of uterine RNA was performed using the mirVANA kit and RNA quantification and quality assessed. Eight libraries were generated (4 biological replicates per group) and subjected to RNAseq procedures and bioinformatic analysis by LC Sciences (Houston, TX, USA). Raw sequence data were analyzed using the ACGT101-miR program (LC Sciences, Houston, TX) removing extraneous sequence information. The remaining sequences ranging in size for 18 to 26 nucleotides were mapped to known bovine miRNA sequences (miRbase 22.1) and the bovine genome. Significant and differentially abundant miRNAs were analyzed using normalized deep sequencing counts and were subjected to ANOVA (P &amp;lt; 0.05). There were 55 significant (P &amp;lt; 0.05) differentially abundant microRNAs of which 35 were upregulated in open samples and 20 were upregulated in pregnant samples. Target prediction was performed using TargetScan for differentially abundant miRNA. Functional enrichment analysis of the miRNA target genes was conducted using the Database for Annotation, Visualization and Integrated Discovery (DAVID 2021). Gene targets were analyzed using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. The top 5 KEGG pathways across all significant and differentially abundant miRNAs were pathways in cancer, PI3K-Akt signaling pathway, MAPK signaling pathway, human papillomavirus infection, and metabolic pathways. These results show that there is variation in the abundance of miRNAs between pregnant and open cows at day 30 post-insemination.

Changes in arterial blood vessels and VEGF and Ang-1 expression in pregnant and non-pregnant yak uterine caruncle.

We investigated the structural features of arterial blood vessels in yak uterine caruncle and the effects of the expression of vascular regulation-related factors on angiogenesis in pregnant and non-pregnant yak uterus. Three-dimensional specimens of the uterine artery of non-pregnant and pregnant yaks were produced to observe and measure the distribution characteristics and number of arterial vessels in the uterus and caruncle in the two periods. The uterine caruncle structure was observed and analysed by haematoxylin-eosin staining. The expression features of vascular endothelial growth factor (VEGF) and angiopoietin-1 (Ang-1) in the uterine caruncle were detected with immunohistochemistry, quantitative real-time PCR (qRT-PCR) and western blotting. The length and number of blood vessels in the caruncle were increased, the degree of curvature was decreased, and the folding was more complicated during pregnancy as compared with that during non-pregnancy. The immunohistochemical results demonstrated that VEGF and Ang-1 were mainly expressed strongly in the mucosal epithelial cytoplasm. The glandular lumen of the uterine gland, lymphocytes and the media and adventitia of blood vessels are widely distributed, and they are all positive. VEGF and Ang-1 mRNA and protein levels were highest in pregnancy, followed by that in the luteal phase and in the follicular phase, and three stages were significantly different (p < .05). These findings provide an anatomical reference and theoretical basis for improving the diagnosis and treatment of yak reproductive disorders and other diseases in high-altitude and low-oxygen environments.

OP-1 - IL-18 induces appropriate inflammatory responses contributing placental development and fetal growth

IL-18 has pro- and anti-inflammatory effects. However, only a few studies have demonstrated its role in reproduction. Here, we developed the fetal growth restriction model mouse and examined the effect of IL-18 on fetal growth. The C57BL/6 female mice were mated with the BALB/c male mice, the anti-IL-18 neutralizing antibody was administered intraperitoneally, and the placenta and birth weight were measured. The pregnant uteri were analyzed using flow cytometry, western blotting, and immunofluorescence staining. The blockade of IL-18 significantly decreased in placenta and birth weight compared with control. The blockade of IL-18 also induced a decreased production of IFN-γ in the uterine T cells and NK cells, M2-polarization of uterine macrophages, and suppressed IL-12 production. Histologically, the vascular remodeling failure of the placental labyrinth was shown in mice with the blockade of IL-18. Importantly, we found that macrophages and smooth muscle cells are essential sources of IL-18. These findings indicate that IL-18 enhances an appropriate type 1 immune response leading to the proper placental development and fetal growth via the feedback between IFN-γ and IL-12.

Preterm Spontaneous Rupture of A Scarred Unicornuate Pregnant Uterus: A case report

&lt;p&gt;Uterine rupture is a life-threatening obstetrical complication. Most cases of uterine rupture are associated with a trial of labor with previous cesarean delivery or having a history of myomectomy. Herein, we describe a 33 year-old female with a spontaneous uterine rupture at 28 + 4 weeks gestation age resulting in a demised fetus. Fetal bradycardia and an irregular protruding &amp;ldquo;mass&amp;rdquo; over the left upper abdomen with no fetus in a boggy uterus were identified by sonography. An emergent cesarean section was performed and on entering the peritoneal cavity, a complete expulsion of the fetus and placenta from the uterine cavity was noted. A flaccid fetus without heartbeat with a large uterine ruptured scar extending from the left lower segment to left lateral wall were found. A right unicornuate uterus was confirmed later by hysterosalpingography and MRI. Spontaneous uterine rupture should be listed in the differential diagnosis of an acute abdomen during pregnancy.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Maternal IL-33 critically regulates tissue remodeling and type 2 immune responses in the uterus during early pregnancy in mice

The pregnant uterus is an immunologically rich organ, with dynamic changes in the inflammatory milieu and immune cell function underlying key stages of pregnancy. Recent studies have implicated dysregulated expression of the interleukin-1 (IL-1) family cytokine, IL-33, and its receptor, ST2, in poor pregnancy outcomes in women, including recurrent pregnancy loss, preeclampsia, and preterm labor. How IL-33 supports pregnancy progression invivo is not well understood. Here, we demonstrate that maternal IL-33 signaling critically regulates uterine tissue remodeling and immune cell function during early pregnancy in mice. IL-33-deficient dams exhibit defects in implantation chamber formation and decidualization, and abnormal vascular remodeling during early pregnancy. These defects coincide with delays in early embryogenesis, increased resorptions, and impaired fetal and placental growth by late pregnancy. At a cellular level, myometrial fibroblasts, and decidual endothelial and stromal cells, are the main IL-33+ cell types in the uterus during decidualization and early placentation, whereas ST2 is expressed by uterine immune populations associated with type 2 immune responses, including ILC2s, Tregs, CD4+ T cells, M2- and cDC2-like myeloid cells, and mast cells. Early pregnancy defects in IL-33-deficient dams are associated with impaired type 2 cytokine responses by uterine lymphocytes and fewer Arginase-1+ macrophages in the uterine microenvironment. Collectively, our data highlight a regulatory network, involving crosstalk between IL-33-producing nonimmune cells and ST2+ immune cells at the maternal-fetal interface, that critically supports pregnancy progression in mice. This work has the potential to advance our understanding of how IL-33 signaling may support optimal pregnancy outcomes in women.

Twin to Twin Transfusion Syndrome

Introduction: Collateral arterial growth is an effective adaptation process to maintain blood supply in myocardial tissue distal to a coronary stenosis and in other vascular beds where feeding arteries are obstructed (1) . The drive for outgrowth and remodelling of arterial collaterals is an increased shear stress due to an enlarged blood flow occurring after the event of stenosis in a near by conduit artery. Remodelling includes increased growth of the diameter and length of the collateral, causing the characteristic tortuous or cork screw appearance (1) .Whilst collateral growth is generally beneficial, we will present evidence that arterial collateral out growth occurred in a monochorionic twin placenta where it jeopardised the pregnancy by causing the twin to twin transfusion syndrome (TTTS).Objective: to report a case of twin-to-twin transfusionCase Report: Reporting a case experienced and taken care in our Clinic Fetomaternal RS. Dr .M. Jamil Hospital. A 34 years old woman, gravida 2, para1, at 31 weeks and 6 days amenorrhea, because her pregnant uterus was too large for gestational Referral to tertiary center followed. At 32 weeks and 2 days amenorrhea biometry indicated estimated fetal weights of 1950 and 1450 g (Hadlock), oligohydramnios and polyhydramnios (amniotic fluid index:23cm. No structural anomaly of the heart was seen. No interventions, one course of corticosteroids were administered for fetal lung maturation. At 33 weeks a slight decrease in heart rate variability of the smaller twin was observed. A Caesarean section under spinal anesthesia was performed. Two girls were delivered of 1585 g and 2135 g and in good condition (Apgar scores 8 and 9 after 1 and 5 min in both girls). The monochorionic diamniotic placenta weighed 740 g. The cord of the recipient was centrally inserted and that of the donor velamentally. Placenta was born monochorion, diamnion.Conclusion: TTTS is caused due to unidirectional deep arteriovenous (AV) anastomoses with the superficial short comings. Hypovolemia, oliguria and oligohydramnion occurs in the donor fetus. Hypervolemia, polyuria and polyhydramnios occurs in the recipient fetus

Emerging Trend in the Aetiological Pattern of Ruptured Pregnant Uterus in Northern Nigeria

Emerging Trend in the Aetiological Pattern of Ruptured Pregnant Uterus in Northern Nigeria

Uptake of Phosphate, Calcium, and Vitamin D by the Pregnant Uterus of Sheep in Late Gestation: Regulation by Chorionic Somatomammotropin Hormone.

Minerals are required for the establishment and maintenance of pregnancy and regulation of fetal growth in mammals. Lentiviral-mediated RNA interference (RNAi) of chorionic somatomammotropin hormone (CSH) results in both an intrauterine growth restriction (IUGR) and a non-IUGR phenotype in sheep. This study determined the effects of CSH RNAi on the concentration and uptake of calcium, phosphate, and vitamin D, and the expression of candidate mRNAs known to mediate mineral signaling in caruncles (maternal component of placentome) and cotyledons (fetal component of placentome) on gestational day 132. CSH RNAi Non-IUGR pregnancies had a lower umbilical vein–umbilical artery calcium gradient (p < 0.05) and less cotyledonary calcium (p < 0.05) and phosphate (p < 0.05) compared to Control RNAi pregnancies. CSH RNAi IUGR pregnancies had less umbilical calcium uptake (p < 0.05), lower uterine arterial and venous concentrations of 25(OH)D (p < 0.05), and trends for lower umbilical 25(OH)D uptake (p = 0.059) compared to Control RNAi pregnancies. Furthermore, CSH RNAi IUGR pregnancies had decreased umbilical uptake of calcium (p < 0.05), less uterine venous 25(OH)D (vitamin D metabolite; p = 0.055), lower caruncular expression of SLC20A2 (sodium-dependent phosphate transporter; p < 0.05) mRNA, and lower cotyledonary expression of KL (klotho; p < 0.01), FGFR1 (fibroblast growth factor receptor 1; p < 0.05), FGFR2 (p < 0.05), and TRPV6 (transient receptor potential vanilloid member 6; p < 0.05) mRNAs compared to CSH RNAi Non-IUGR pregnancies. This study has provided novel insights into the regulatory role of CSH for calcium, phosphate, and vitamin D utilization in late gestation.

Case Report: Incidental finding of didelphys uterus in a multigravida woman at Caesarean delivery

Didelphys uterus is one of the rarest Müllerian duct anomalies (MDA) of the female genital tract. Many remain undiagnosed due to possibilities of successful pregnancies and vaginal deliveries in those without or with mild forms of associated cervical and/or vaginal anomalies. Due to this, data on didelphys uterus in pregnancy are rare, with most cases seen during routine ultrasound in pregnancies’ Caesarean section for other obstetric indications. This case was a 36-year-old G4P1+2 female who had successful vaginal delivery in her preceding pregnancy; in index pregnancy, she presented with fetal footling breech in labour and had an emergency caesarean section during which uterine didelphys was diagnosed. Many pregnant women with didelphys uterus will deliver vaginally and, as such, remain undiagnosed. Its presence is one of the possible reasons for persistent abnormal presentations like fetal breech presentation, especially in women with prior successful vaginal deliveries. Early recognition and availability of facilities for management of such incidentally found cases of uterine didelphys will prevent many of the complications associated with pregnancy with them.

Spontaneous Rupture of an Unscarred Non-Laboring Gravid Uterus at Term: A Case Report

Background: Rupture of the pregnant uterus is life-threatening for the mother and fetus. Most ruptures occur in women who have had a previous transmyometrial surgical incision, typically for cesarean delivery. Rupture of the unscarred uterus is rare, but the incidence is increasing. It is associated with higher major maternal and neonatal morbidity than cases of rupture of the scarred uterus. Case presentation: Here we presented a case of 36 years old gravida 4 para3 presented at gestational age of 38 weeks with vomiting of ingested matter mixed with blood and abdominal pain of 12 hours and, initially diagnosed to have Placenta previa, severe anemia secondary to acute blood loss secondary to upper gastrointestinal bleeding, Intrauterine fetal death. Finally diagnosed to have uterine rupture and total abdominal hysterectomy done. Conclusion: A high index of suspicion is needed in pregnant patients presenting with sudden onset of abdominal pain so as not to miss uterine rupture and its complications.

Expression of IGFS and IGF1R in the pregnant uterus and placenta of dogs

Expression of IGFS and IGF1R in the pregnant uterus and placenta of dogs

Critical Steps to Performing a Successful Single-site Laparoscopic Myomectomy for Large Pedunculated Myoma during Pregnancy

To demonstrate tips and tricks for the successful use of single-site laparoscopic surgery for pedunculated myomectomy during pregnancy. Stepwise demonstration with narrated video footage. An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0010 with a symptomatic 12-cm degenerating pedunculated myoma refractory to conservative pain management. Recent literature has indicated that most laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be used in cases unresponsive to conservative management [1]. However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy have been sparse [2]. Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single-site surgery without any complications [3-6]. Using laparoscopy in myomectomy compared with laparotomy during pregnancy permits decreased postoperative pain, quicker recovery, and lowered risk of postoperative complications [5,7,8]. Single-site laparoscopic surgery also aids in improved patient cosmesis and can be used for the myoma removal. Literature has demonstrated that single-site laparoscopy is safe and feasible during all stages of pregnancy [3,4]. Nevertheless, this approach may be challenging for inexperienced surgeons owing to the lack of triangulation and crowding of instruments in single-site laparoscopy [5]. At 21 weeks and 3 days pregnancy, our patient underwent single-incision laparoscopic surgery myomectomy. A 2.5-cm skin incision was made at the umbilicus to the abdominal cavity, and a GelPOINT Mini was inserted. Through the laparoscope, we can observe that a 12-cm pedunculated myoma was protruding from the right uterine fundus on a 4-cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the myoma. Subsequently, an Endo Catch bag was placed around the myoma and brought up to the umbilical incision. Using a scalpel, bag-contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50 cc and the total operative time was 123 minutes. The extended operating time was caused by slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and she was discharged home on postoperative day 2. At 38 weeks, she successfully delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single-site entry technique uses the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through a 2.5-cm incision, the surgeon placed a suture in the myoma stalk because other hemostasis agents such as vasopressin are contraindicated in pregnancy. 3. Owing to difficulties related to single-site surgery, the surgeon should possess extensive expertise in single-site surgery. 4. Manipulation of the uterus should be minimized to reduce the disturbance of the pregnant uterus. 5. V-loc suture allows for faster and simplified uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5-mm accessory port can be placed. 7. During tissue extraction, gentle traction should be used to reduce provoking the pregnant uterus. 8. When transecting the myoma stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus. Single-incision laparoscopic surgery myomectomy for pedunculated myoma may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon, the patient may benefit from faster specimen removal and recovery.

Laparoscopic abdominal cerclage during pregnancy: a simplified approach

Cervical insufficiency is a major cause of second-trimester pregnancy loss and spontaneous preterm delivery. Transabdominal cervicoisthmic cerclage is usually performed before pregnancy for patients of cervical insufficiency, in whom transvaginal cervical cerclage procedure cannot be placed or has failed previously. Performing a transabdominal cerclage becomes a huge challenge owing to the enlargement of the pregnant uterus in patients who were indicated for transabdominal cervicoisthmic cerclage but were missed before pregnancy. Here, we have outlined an easy and effective surgical procedure as needle-free laparoscopic trans-broad-ligament cervicoisthmic cerclage during early second-trimester. Laparoscope with 4 trocars was established, after expanding the trigonum of ureter, ovarian vascular and ascending branch of uterine artery. The needleless Mersilene tape was inserted in a posterior-to-anterior direction of bilateral trigonums, tightening the knot toward the bladder uterine reflection and simultaneously pushing the loop behind the uterus, directed to the cervix progressively. The tape was then tied anteriorly at the cervico-isthmic junction with 5 to 6 intracorporeal square knots after transvaginal ultrasound determined the presence of systolic velocity of uterine artery with first knot. The primary feature of our procedure was that the needleless Mersilene tape was inserted centrally from the broad ligaments, lateral to the uterine vessels, and finally tied above the uterosacral ligament at the level of the uterine isthmus, without dissecting the bladder off from lower uterine segment and without separating the uterine vessels from the lateral wall of the cervix. We performed this procedure on 10 patients with pregnancy outcomes and there was no pregnancy loss. This procedure proved to be an accessible and effective surgical technique for transabdominal cerclage of the uterine cervix during early-second trimester, with affirmative prognosis.