Thyroid nodules in a young patient trying to conceive

Noduli tiroidieni la o pacientă tânără care doreşte sarcina

Cristina Vasiliu1, Simona Elena Albu1, Mara Cârşote2, Ana Valea3, Claudiu Tupea4, Anda Dumitraşcu4, Diana Păun5, Constantin Dumitrache5
1. “Carol Davila” University of Medicine and Pharmacy; Bucharest University Emergency Hospital, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest; “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
3. “I. Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca; Clinical County Hospital, Cluj-Napoca, Romania
4. “C.I. Parhon” National Institute of Endocrinology; Monza Oncoteam, Bucharest, Romania
5. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 

Introduction. Up to 50-70% of the population (women seem more affected than men) have a thyroid nodule (TN) of various dimensions, especially less than 1 cm. The incidence is age-related, but the prevalence is also consistent in women of reproductive age. The investigations in order to conceive usually involve the thyroid panel and the accidental ultrasound detection of a TN is a relatively frequent scenario. The relationship with low fertility rate is less strong, with the exception of autoimmune thyroid background. Aim. To introduce a series of cases with TN detected during investigations for fertility. Method. These are two case reports. The hormonal and imagery profile is provided. Case 1. We present the case of a 26-year-old non-smoking female coming from a nonendemic area. She is nulipara. The personal and family medical history is irrelevant. She has regular menses and seeks for fertility. The gynecological exam is normal, so she was referred for endocrine assays. The thyroid blood tests showed normal TSH (1.3 µUI/mL), calcitonin (4.3 pg/mL; N: 1-4.8 pg/mL) and TPO antibodies (10 UI/mL; N<35 UI/mL). Thyroid ultrasound shows right lobe of 4.9/2.1/2.1 cm, and left lobe of 4.6/1.7/1.4 cm. The right lobe is displayed by a hypoechoic TN (peripheral halo, vascularised) of 2.1/1.5/3.2 cm, with another of 0.7/0.4/0.4 cm, without lymph nodes involvement. Due to high dimensions and ultrasound features, the patient was referred for surgery. Case 2. A 34-year-old smoking female, coming from a nonendemic area, was admitted for fertility issues. She has four healthy children (the oldest 8 years ago), with the same partner. She presents irregular menses for the last five months. TPOAb are positive (270 UI/mL), with a normal thyroid function (TSH = 2.3 µUI/mL; N: 0.5-4.5 µUI/mL). The thyroid ultrasound pattern is hypoechoic, with a few TN of maximum 0.3 cm. The clinical examination accidentally revealed lipomas at the skull of 2 cm (confirmed at computed tomography). The lipid profile was normal, unrelated to thyroid and skull anomalies. Conclusions. Both cases had thyroid anomalies most probably unrelated to fertility issues.

Keywords: thyroid, nodule, ultrasound


Diabetes mellitus and pregnancy

Diabetul zaharat în sarcină 

Oana-Denisa Bălălău1, Marinela Chioveanu2, Romina-Marina Sima1, Liana Pleş1, Anca Daniela Stănescu1
1. Bucur Maternity, “St. John” Emergency Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Diabetes Department, Sanador Hospital, Bucharest, Romania

Gestational diabetes represents a diabetes diagnosed during pregnancy, in the second or third trimester, which is not type 1 diabetes or preexisting type 2 diabetes. Diabetes diagnosed in the first trimester of pregnancy is defined as preexisting diabetes. The prevalence of diabetes in pregnancy is steadily increasing in the USA, most of which are gestational diabetes (approximately 90% of cases). The other types of diabetes in pregnancy are type 1 and type 2 diabetes mellitus. Preexisting type 2 diabetes mellitus represents approximately 8% of all types of diabetes in pregnancy. The increase in the prevalence of gestational diabetes occurred in parallel with the increase in the prevalence of obesity. Materials and method. Type 1 diabetes mellitus and preexisting type 2 diabetes mellitus are associated with a greater risk of maternal and fetal complications than gestational diabetes. Among the most common complications are spontaneous abortion, fetal anomalies (anencephaly, microcephaly, congenital heart disease, caudal regression), macrosomia, neonatal hypoglycemia, neonatal hyperbilirubinaemia, and others. The diagnosis of gestational diabetes is performed with either one-step or two-step strategy in pregnant women between 24 and 28 weeks of gestation. Diabetes screening is also recommended at the first prenatal visit for women with risk factors for diabetes. Also, gestational diabetes has been associated with an increase in the risk of developing maternal type 2 diabetes, as high as 50-70% after 15-25 years. Therefore, there is recommended to test the women with gestational diabetes, between 4-12 weeks postpartum, using the oral glucose tolerance test (OGTT). If it is normal, the test should be performed every one to three years. Conclusions. The management of diabetes in pregnancy involves nutritional medical therapy and/or pharmacological treatment, in order to obtain glycemic targets that have been associated with the lowest risk of maternal and fetal complications. Considering the possibility of diabetes’ complications (retinopathy) during pregnancy, it is also necessary to screen for them in women with preexisting diabetes.

Keywords: gestational diabetes, diabetes complications, glycemic targets

 

Factors influencing the pacient in choosing a contraceptive method

Factorii care influenţează alegerea de către pacientă a metodei contraceptive 

Manuela Neagu, Alina Buşan, Elena Nada, Alina Bordea, Nicolae Rusu, Marjan Onabi, Corina Georgescu, Cristina Neagu
“Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

Introduction. Nowadays, the multitude of contraceptive methods allows the individualization of the contraceptive treatment according to the needs and wishes of the patient. Materials and method. We performed a retrospective study at the “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Family Planning Center, analyzing the factors influencing the patients when requesting the starting of contraception. We analyzed the recommended and the chosen contraceptive method, the availability of the method, and the associated pathology. The patients were divided into three lots, corresponding to three particular chronological periods. Lot A: 2004-2005, when the National Contraceptive Program offered seven free contraceptive methods to large patient groups. Lot B: 2013-2014, a period during which a certain type of oral contraceptive was temporarily withdrawn from marketing. Lot C: a period without any free contraceptive method available. Results. In group A, 93% of patients chose the recommended contraceptive method and 78% of them with no additional costs. In group B, 56% of patients chose the recommended contraceptive method, 88% of them refusing to take oral contraceptives. In group C, 80% of patients chose the recommended contraceptive method, and 56% of those who opted for another contraceptive method invoked financial issues. Conclusions. In all these groups, the factors that influenced the choice of the contraceptive method varied over time. In lot A, the medical recommendation was decisive, in lot B the choice of the contraception was made under the influence of the strong negative mediatizations of a certain contraceptive method, and in lot C the lack of free contraceptive methods influenced the patient’s decision.

Keywords: contraceptive methods, starting contraception, availability of treatment


Restless legs syndrome in pregnancy – pathophysiological aspects and management

Sindromul picioarelor neliniştite în sarcină – aspecte fiziopatologice şi conduită terapeutică 

Roxana Elena Bohîlţea1,2, Natalia Ţurcan2, Oana Teodor2, Alexandru Baroş1,2, Ducu Ioniţă2, Monica Mihaela Cîrstoiu1,2
1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Bucharest University Emergency Hospital, Romania  

Restless legs syndrome (Willis-Ekbom disease), characterized by the urgent need for leg movement during rest periods, has a significantly increased incidence during gestational period, being three times more frequent in pregnancy compared to the general population. Approximately one in five women will experience symptoms typical for this syndrome during pregnancy, especially during the last trimester. In terms of pregnancy prognosis, restless legs syndrome has been associated with an increased incidence of gestational hypertension, preeclampsia, depressive disorder, chronic fetal distress, intrauterine growth restriction, prematurity, and caesarean delivery. Poor nighttime sleep quality associated with marked sleepiness, physical and psychic inefficiency throughout the day are the main factors leading to therapeutic behavior requirement. The main etiological factors involved are genetic predisposition, iron and folate deficiency, elevated estrogen levels and nerve compression. Although treatment differs depending on symptoms severity and associated conditions, the first line of therapeutic approach includes iron supplementation, physiotherapy and psychotherapy. In case of severe, refractory symptomatology significantly impacting the quality of life, the allowed treatment includes the minimum effective dose of clonazepam (0.25 mg/day) and carbidopa-levodopa (25/100 mg). For extreme cases, refractory to the aforementioned medication, oxycodone therapy may be considered also at the lowest dose. In spite of the transient appearance of the restless legs syndrome during pregnancy, these cases require specific monitoring due to possible associated conditions.

Keywords: restless legs, pregnancy, treatment


Monitoring and management of pregnancies complicated with fetal heart arrhythmias

Monitorizarea şi managementul sarcinilor complicate cu aritmie cardiacă fetală

Natalia Ţurcan2, Roxana Elena Bohîlţea1,2, Oana Teodor2, Alexandru Baroş1,2, Ducu Ioniţă2, Monica Mihaela Cîrstoiu1,2
1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Bucharest University Emergency Hospital, Romania

With a relatively frequent incidence of 1-2%, fetal heart arrhythmias may represent a sign of compromised fetal status. Most arrhythmias are isolated, but in some cases they are associated with structural or functional cardiac abnormalities. A series of specific investigations, such as the detection of anti-Ro/SSA and La/SSB autoantibodies in lupus patients, may indicate the etiology. Detailed echocardiography, specialized echocardiography and cardiotocographic monitoring can direct the management towards expectative or further fetal cardiology consult. Fetal arrhythmias with irregular rhythm, translating intermittently blocked beats, have good prognosis, are well tolerated and can rarely progress to significant cardiac pathology. Thus, the presence of 3-5 extrasystoles per minute with normal heart rate requires high-level fetal heart echocardiography and weekly monitoring of heart rate. Tachycardia or bradycardia associated with fetal cardiac extrasystoles have indication for specialized fetal cardiac evaluation based on detailed echocardiography and weekly cardiotocographic monitoring, along with rigorous fetal movement monitoring by the mother. Fetal sinus tachycardia can be considered normal if it occurs sporadically during fetal movements. The indication of transplacental treatment occurs in case of fetal hydrops or persistent tachycardia (>220 beats/min), digoxin being the reference drug. Fetal bradycardia frequently associates a background cardiac pathology, heterotaxia or long QT syndrome. The presence of fetal heart arrhythmias is not an absolute indication of birth by caesarean section if there is the possibility of continuous fetal monitoring, otherwise it is the best option.

Keywords: management, fetal arrhythmia, echocardiography


Abdominal cerclage

Cerclajul abdominal

Ciprian-Andrei Coroleucă1,3, Cătălin-Bogdan Coroleucă1,3, Diana Comandaşu1,3, Diana Mihai1,3, Cornel Petre Brătilă2,3, Elvira Brătilă1,3
1. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynaecology, Bucharest, Romania
2. Euroclinic Hospital of Minimally Invasive Surgery, Regina Maria Clinical Center, Bucharest, Romania
3. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

The abdominal cerclage is a therapeutic procedure that performs a reliable cervical canal obliteration in specific selected cases. The abdominal cerclage is indicated for cervico-isthmic incompetence in patients who had repeatedly failed transvaginal cerclage, and also in those with anatomical abnormalities represented by a very short or absent cervix due to congenital or surgical conditions. The paper aims to present a series of eight cases in which abdominal cerclage was performed. The abdominal cerclage can be performed through open abdominal route or laparoscopic. The procedure can be practiced prophylactically before conception or during pregnancy, in the first trimester of gestation either prophylactically, or as an emergency solution for imminent abortion. The abdominal cerclage is a safe procedure, with an excellent fetal outcome, and is an alternative treatment for cervico-isthmic incompetence. The advantages of the abdominal cerclage are represented by the placement of the cerclage tape in close proximity of the internal os, the absence of a foreign body in the vagina (that could cause infection),  decreased risk of suture migration, and the ability to keep the suture in place for future pregnancies. The abdominal cerclage is the only therapeutic solution in patients with a history of recurrent abortions resulting from failed transvaginal cerclages, as well as in patients with very short or absent cervix.

Keywords: abdominal cerclage, cervico-isthmic incompetence, recurrent abortions


Laparoscopic tubal reanastomosis outcomes

Rezultatele reanastomozei tubare laparoscopice

Nicolae Gică1, Corina Mat1, Ruxandra Cigaran1, Anca Maria Panaitescu2, Gheorghe Peltecu3
1. Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
2. Lecturer of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy; Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
3. Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy; Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania 

Background. Encountered among methods of contraception, tubal sterilization is not a priority in Romania. The aim of this study is to present the reproductive outcome reported in Filantropia Clinical Hospital of Obstetrics and Gynecology after laparoscopic tubal reanastomosis. Case reports. We present two cases which underwent laparoscopic reversal. The first case opted for reversal tubal ligation after 7 years from her single caesarean section. Despite the unilateral recanalization achieved, the woman conceived after only 6 months. The second case was more challenging, taking into consideration the patient’s medical history. Despite both tubes being permeable at the end of the procedure, the patient did not conceive at that time. Conclusions. Our experience confirms that the main factors that can predict the success of tubal reanastomosis are the maternal age at the time of the reversal and the remaining length of the tube after recanalization.

Keywords: laparoscopic tubal reanastomosis, tubal ligation, tubal recanalization


Laparoscopic myomectomy in young women

Miomectomia laparoscopică la pacientele tinere

Nicolae Gică1, Corina Mat1, Ruxandra Cigaran1, Anca Maria Panaitescu2, Gheorghe Peltecu3
1. Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
2. Lecturer of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy; Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
3. Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy; Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania 

Uterine leiomyoma represents the most common benign tumour in women of reproductive age, with a prevalence of 20-50%. Most women are asymptomatic, but 30% of them report metrorrhagia, pelvic pain, dyspareunia, urinary and bowel symptoms or infertility. Symptomatic fibromas and the desire for childbearing are the most common indications for myomectomy. Some patients are candidates for laparoscopic myomectomy. Our study presents a series of case reports, surgical images, controverses and literature reviews. Laparoscopic myomectomy has numerous advantages than classical myomectomy, such as lower blood loss, reduced hospitalization, low overall morbidity and less postoperative pain. The rate of postoperative adhesions is lower for laparoscopic myomectomy.

Keywords: myomectomy, uterine fibromas, laparoscopic myomectomy


Vitamin A supplementation during pregnancy

Vitamina A în sarcină

Mihaela Boţ1,2, Mădălina Georgeta Iliescu2, Andreea Borislavschi2, Ana-Maria Plopan2, Aida Petca1,2
1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Obstetrics-Gynecology and Neonatology Clinic, “Elias” University Emergency Hospital, Bucharest, Romania

Vitamin A is an essential nutrient that plays a major role in the prevention of anemia and cell growth, and also in fetal development and in supporting metabolism during pregnancy. The main sources of vitamin A are carrots, broccoli, spinach, sweet potatoes, liver, eggs and milk. According to the American Pregnancy Association, the recommended daily allowance (RDA) of vitamin A for healthy women during pregnancy is 770 mcg/dl. Most studies have shown an association between high doses of preformed vitamin supplements and congenital birth defects in pregnant women. Birth defects described include malformations of the heart, lungs, eyes and skull. The risk of birth defects has been correlated with a preformed vitamin A consumption greater than 10000 IU/day, while doses of preformed vitamin A from supplements below 3000 mcg/day (10000 IU/day) showed no increase in the risk of birth defects. Furthermore, in women with vitamin A deficiency, some studies have shown that low-dose vitamin A consumption may be protective against birth defects. Also, there is no correlation between vitamin A from beta-carotene and the risk of birth defects. On the other hand, vitamin A deficiency leads to other problems, such as xerophthalmia, anemia, lowered immunity system during pregnancy and lactation, and even slower growth and development in children. In conclusion, vitamin A supplementation should only be recommended for pregnant women in areas where vitamin A deficiency is endemic. So, the focus should be on a diet that can provide the variety of nutrients needed in pregnancy.

Keywords: preformed vitamin A, supplements, birth defects, fetal development, high doses, diet


Velamentous cord insertion – importance of diagnostic assessment

Inserţia velamentoasă de cordon ombilical – importanţa diagnosticului 

Mihaela Boţ1,2, Mădălina Georgeta Iliescu2, Andreea Borislavschi2, Mona Zvâncă1,2, Aida Petca1,2, Ana Maria Plopan2
1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Obstetrics-Gynecology and Neonatology Clinic, “Elias” University Emergency Hospital, Bucharest, Romania

The normally insertion of the umbilical cord is directly into the central part of the placenta, providing oxygen and nutrition for the fetus. Velamentous cord insertion is an abnormal insertion of the umbilical cord, in which the umbilical vessels insert into and course through the amniotic membranes before reaching the placental mass. It has been more commonly associated with placenta praevia than with normally located placentas. Velamentous cord insertion may be prenatally detected on ultrasound examination. The criteria for ultrasound diagnosis are: the umbilical vessels diverging as they traverse the membrane, entering the placenta margin parallel to the uterine wall and connecting to the subchorionic vasculature. The cord insertion remains immobile even when the uterus is shaken. The use of color Doppler enhances the identification of the vessels, but a definitive diagnosis is made by gross examination of the placenta, membranes and cord, after delivery. Velamentous cord insertion has been correlated with some adverse perinatal outcomes, including caesarean delivery, preterm delivery, fetal growth restriction, placental abruption and low Apgar scores. All of these outcomes are likely secondary to a lack of protective Wharton jelly surrounding the fetal vessels, which are proned to compression, kinking and rupture during labor, leading to fetal heart rate abnormalities and even to fetal death. Kinking and compression are also correlated with thrombosis of the vessels, which leads to placental infarction, neonatal purpura and even amputation of fetal limbs or digits. Fetal death and exsanguination may occur when the rupture of the fetal membranes leads to the rupture of the vessels, which are attached to the chorion and the membranous vessels are typically close to or cover the cervix (vasa praevia). In conclusion, prenatal diagnosis of the velamentous cord insertion plays a critical role in the prevention of the fetal death and adverse perinatal outcomes.

Keywords: velamentous cord insertion, vasa praevia, ultrasound examination, caesarean delivery, preterm delivery, fetal death, fetal growth restriction, placental infarction


Laparoscopic myomectomy of large and multiple myomas – our experience

Miomectomia laparoscopică pentru mioame multiple voluminoase – experienţa noastră

A. Petca1,2, C. Oprescu1, R. Petca2, D. Radu1, A. Borislavschi1, A. Plopan1, M. Iliescu1, M. Boţ1,2
1. Obstetrics-Gynecology and Neonatology Clinic, “Elias” University Emergency Hospital, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Introduction. Laparoscopic myomectomy offers the possibility of a minimally invasive approach to treat large and medium sized (<12 cm) subserous and intramural multiple myomas, reducing  the risk of perioperative complications. Infertility has been linked with the appearance of uterine myomas. It is said that the laparoscopic approach of the myomas can improve fertility rates. In this paper, we detail our experience in laparoscopic myomectomy of large and multiple myomas and demonstrate improved fertility rates. Materials and method. A total of 145 patients were operated during the study period, between May 2012 and August 2018. The patients’ age was between 20 and 45 years old, and the indications were: meno-metrorrhagia, pain, pressure, infertility, recurrent abortion, size or rapid growth, or urinary symptoms. All patients who were included in this study had more or at least two myomas. Fertility results. In our 91 patients known with infertility, after laparoscopic myomectomy the rate of patients achieving pregnancy was 53.1% (43 patients). The 43 patients obtained 51 pregnancies. In patients in whom the only factor for infertility was the presence of myomas, the rate of achieving a pregnancy was 70% (17 patients), which is very encouraging, comparing to the group that had several other infertility factors, with a rate of 43% (23 patients). We didn’t report any uterine rupture. Conclusions. The use of laparoscopic surgery can reduce the hemorrhagic risk associated with laparotomy, improves the rate of obtaining a pregnancy, and preserves fertility. The small myomas must also be ablated because of the risk of growing afterwards.

Keywords: laparoscopy, leiomyomas, myomectomy, fertility, pregnancy, surgical outcomes


Laparoscopic approach of mature cystic teratoma

Abordul laparoscopic în tratamentul teratomului ovarian matur

A. Petca1,2, C. Oprescu1, R. Petca2, D. Radu1, A. Borislavschi1, A. Plopan1, M. Iliescu1, M. Boţ1,2
1. Obstetrics-Gynecology and Neonatology Clinic, “Elias” University Emergency Hospital, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Introduction. Ovarian mature cystic teratomas are commonly encountered in young women of reproductive age, accounting for up to 60% of benign ovarian masses and often present both diagnostic and management dilemmas. Infertility has been linked with the appearance of dermoid cysts. So far, various approaches and procedures were employed in surgical practices. In this work, we detail our experience in laparoscopic cystectomy of large and multiple ovarian teratomas and demonstrate improved fertility rates. Materials and method. A total of 35 patients were operated during the study period, between April 2015 and July 2018. The patients’ age was between 20 and 45 years old, and the indications were: pain in the lower abdomen, pressure, infertility, rapid growth or urinary symptoms. All patients who were included in this study had been diagnosed with transvaginal ultrasound scan. Fertility results. In our 20 patients known with infertility, after laparoscopic cystectomy the rate of patients achieving pregnancy was 60% (12 patients). The 12 patients obtained 15 pregnancies. We report that contents spillage occurred in seven patients (20%) and it was particularly associated with larger cysts. All cases were concluded laparoscopically, we didn’t convert any case to laparotomy. So far, we haven’t reported any recurrence after laparoscopic ovarian cystectomy. Conclusions. Although some investigators recommended for mature cystic teratoma >10 cm the laparotomic approach, we consider the laparoscopic approach as the gold standard for the management, including for very large cysts. The risk of chemical peritonitis after contents spillage is extremely rare, and can be certainly overcomed with thorough peritoneal lavage, using large quantities of warmed fluid.

Keywords: laparoscopy, ovarian teratomas, cystectomy, fertility, surgical outcomes


Clinical, morphological and immunohistochemical study of adenomyosis

Studiu clinic, morfologic şi imunohistochimic al adenomiozei 

Anca-Maria Istrate-Ofiţeru1,2,3, Sabina Berceanu2, Elvira Brătilă4, Claudia Mehedinţu4, Monica M. Cîrstoiu4, Răzvan G. Căpitănescu2,
Loredana Voicu2,3, Răzvan Ciortea5, Adrian V. Tetileanu6, Costin Berceanu2
1. Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
2. Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of  Craiova, Romania
3. PhD School, University of Medicine and Pharmacy of  Craiova, Romania
4. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
5. Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
6. Department of Obstetrics and Gynecology, Emergency County Hospital of Târgu-Jiu, Romania

Introduction. Adenomyosis is a benign pathology defined by the presence of endometrial glands in the miometrium, accompanied by chronic pelvic pain, infertility and vaginal bleeding. It is a hormonal dependent condition and is common in reproductive age. Adenomyosis areas differ from the normal endometrium by increased local production of estrogen or prostaglandins and resistance to progesterone action. Materials and method. The study included 23 patients, aged 26-52 years old, diagnosed with adenomyosis. Postoperatively obtained specimens were included in paraffin and studied histologically and immunohistochemically. The blocks were cut by the microtome, the sections were applied on simple slides for histological staining of Hematoxylin-Eosin and on Poly-L-lysin slides for the immunohistochemical stains. The antibodies were: anti-estrogen receptors (ER), anti-progesterone receptors (PR), anti-cytokeratin 7 (CK7), anti-cytokeratin 20 (CK20). Results. Classical Hematoxylin-Eosin staining showed the presence of mono-layered, cylindrical glandular epithelial tissue in the structure of the myometrium, and with immunohistochemistry we showed that these glands were of endometrial origin, being CK7-positive and negative at CK20, making a differential diagnosis with an eventual metastasis from the digestive tract. The receptors for estrogen and progesterone are present in the structure of these glands. Conclusions. Adenomyosis is a benign pathology diagnosed with certainty by histopathological examination. Receptors for estrogen and progesterone are features for endometrial tissue, and cytokeratins make the differential diagnosis with digestive epithelium.

Keywords: adenomyosis, pain, infertility, histology, im­mu­nohistochemistry


Ethanol sclerotherapy of an ovarian endometrioma

Alcoolizarea chistului endometriozic 

Mihaela Braga1, Elena Alina Bordea1, Raluca Dragomir1, Bogdan Marinescu1,2, Elvira Brătilă1,2, Andreea Carp-Velişcu1,2
1. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 

Endometriosis is a complex gynecological pathology, affecting between 6% and 10% of reproductive-age women. Endometriomas are ovarian cysts that are found in 17-44% of the women with endometriosis. The major two problems regarding this disease are pain and infertility. The conventional treatment of this pathology is laparoscopic surgery. Unfortunately, some patients need more than one surgery, due to some reasons: an incomplete initial procedure, recurrence or excision of new lesions. The greatest disadvantage of the surgical technique is the fact that, most of the times, it diminishes the ovarian reserve. In order to avoid this, a conservative treatment has been advocated. A new promising technique, that preserves ovarian reserve and lowers the recurrence rate, is sclerotherapy of the endometrioma. It consists of ultrasound-guided vaginal cyst aspiration and injecting 95% ethanol into the cyst cavity.

Keywords: endometrioma, poor ovarian reserve, recurrence, sclerotherapy, ethanol 95%


Angiogenic biomarkers for the prediction of preeclampsia

Potenţiali biomarkeri angiogenici pentru predicţia preeclampsiei 

Amira Moldoveanu, Daniela Oprescu
“Alessandrescu-Rusescu” National Institute for Mother and Child Health, Polizu Hospital, Bucharest, Romania

Preeclampsia (PE) is one of the main causes of maternal and neonatal morbidity and mortality worldwide. Current PE definitions are unsatisfactory in estimating the negative pathology outcomes. Preeclampsia is primarily a vascular disease, especially of the endothelium, and its pathology is thought to be due to placental hypoperfusion, hypoxia, oxidative stress and inflammation. An imbalance of pro-angiogenic and anti-angiogenic factors in the maternal circulation has been demonstrated during preeclampsia, specifically elevated levels of fms-like anti-angiogenic (sFlt-1) soluble tyrosine kinase and reduced growth factor pro-angiogenic placenta (PlGF). Estimating the sFlt-1/PlGF ratio allows the identification of women at high risk of imminent birth and maternal and neonatal unfavorable development. The diagnostic and prediction value of the sFlt1/PlGF ratio in patients at risk for placental-related disorders – namely, PE, HELLP, IUGR and dead fetus – has been demonstrated in recent literature, and the estimation of sFlt1/PlGF become an additional tool in managing these disorders, especially PE.

Keywords: preeclampsia, pregnancy, angiogenic biomarkers, anti-angiogenic biomarkers, IUGR


Rare case of umbilical cord hematoma in a term neonate

Caz rar de hematom de cordon ombilical la un nou-născut la termen

Diana-Elena Comandaşu1,2, Ciprian-Andrei Coroleucă1,2, Cătălin-Bogdan Coroleucă1,2, Diana Mihai1,2, Elvira Brătilă1,2
1. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

We present a rare case of postpartum umbilical cord hematoma with unknown cause in a term newborn. The neonate was born by caesarean section indicated for failure of medical induction of labour in a 28-year-old primipara with a 41-week pregnancy. The mother did not suffer from any pathology throughout gestation, presenting a morphologically normal foetus and negative urine and cervical cultures. She delivered a 3690-gram male newborn, with an Apgar score of 9 at one minute and 10 at five minutes, following an uncomplicated caesarean section. The newborn presented good postnatal adaptation, and breast alimentation was initiated in the first day of life. The C-reactive protein (CRP) of the newborn was negative and his evolution was favourable in the first two days of life. In the third day of life, the neonate presented swelling of the umbilical cord stump, with a dark-red coloration, suggestive for hematoma. Antibiotic prophylaxis and local antiseptic therapy were initiated, CRP was repeated and bacteriological samples were collected, the results being negative. After two days of local antiseptic treatment, the umbilical stump fell and the umbilicus presented normal appearance. The evolution of the neonate was good, and he was discharged in the fifth day of life. The mother did not present any sign of infection or thrombosis, with a physiological recovery. The particularity of the case is represented by the rarity of the pathology, until present only a few cases of umbilical cord haematoma being described in the specialty literature. The etiology in this case is idiopathic, the infectious, malformative, thromboembolic and mechanical causes being ruled out. The only risk factor in our case could be represented by the advanced gestational age (41 weeks of pregnancy), which could explain partially the frailty of the umbilical cord vessels.

Keywords: umbilical cord, hematoma, rare neonatal complication