Hypothesis: Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting.
Objective To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients. Methods Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR. Results Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy. Conclusion Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies.
Ovarian vein thrombosis (OVT) is an uncommon but potentially serious complication in the early postpartum. Two case studies seem to prove the point: Case 1 A 24-year-old woman was transferred to our hospital with the chief complaint of abdominal pain radiating to the right thigh, vomit, diarrhea, and a slight pyrexia (37.6 °C rectal). Five days earlier, she had a spontaneous vaginal delivery after labor induction. The woman appeared slightly distressed because of pain; vital signs were found to be normal and the CRP elevated (129.9 mg/L). Abdominal examination was remarkable for tenderness by palpation in the right lower quadrant with no rebound tenderness or guarding. Pelvic examination was remarkable for mild right adnexal tenderness. Abdominal-pelvic computer tomography with contrast medium revealed a 2.5-cm OVT having extended into the inferior vena cava for 14 cm with a slight peripheral edema. The patient was treated with nadroparin 0.6 cc (5700 IU) bid and warfarin 5 mg since the attainment of the therapeutic INR range. Case 2 A 31-year-old twin-pregnant woman had an emergency cesarean section at 35 gestational weeks because of hypertension complicated by increased liver enzymes, diuresis contraction, and continuous lower back pain bilaterally radiating to the groins. One day after delivery, CT scan that was performed because of onward anemia showed a pelvic, perihepatic, and perisplenic blood effusion, and a 1-cm right OVT extended to the inferior vena cava below renal veins for 28 mm. She underwent exploratory laparotomy and blood transfusion, and because of respiratory insufficiency she was transferred to a second level center with ICU facility, where she was placed under a suprarenal inferior vena cava filter, and AngioJet Rheolytic Thrombectomy for acute pulmonary embolism was performed.
Microinvasive adenocarcinoma (MIAC) of the uterine cervix is rare in pregnancy. Published data on conservative treatment of MIAC both in pregnant and nonpregnant women are scarce. A conservatively treated case of MIAC in a 13-week-pregnant woman after a diagnosis of atypical glandular cells (AGC) on pap smear at the 6th week of pregnancy is presented. The problems of suspected adenocarcinoma in situ (AIS) on biopsy and MIAC on cone biopsy in pregnancy, as well as the risks and benefits of a conservative treatment are discussed. After colposcopic guide laser cervical conization and expression of informed consent the patient underwent followup and vaginal delivery at 40 weeks plus 3 days of gestation. In this case, no obstetric complication has been recorded after the cervical conization, and after a followup of 18 months the patient was alive and free of disease, with negative results as far as pap smear, colposcopy, HPV status, and cervical curettage are concerned. In a stage Ia1 disease of endocervical type, with clear margins and without lymph-vascular space invasion, cervical conization performed during the second trimester may be considered a definitive and safe treatment, at least up to delivery, after expression of informed consent by the woman.
In pseudomyxoma peritonei (PMP), KRAS and GNAS mutations are frequent. We hypothesized that these mutations may contribute to the suppression of antitumor immunity: KRAS may induce GMCSF expression, while GNAS may enhance the expression of cyclic adenosine monophosphate and A2AR signaling. This study aimed to explore possible mechanisms facilitated by KRAS and GNAS mutations for escaping immune surveillance. Additionally, we looked for new potential therapeutic and prognostic targets in this rare disease which is poorly characterized at the molecular level. GM-CSF, A2AR, CD73, CD39, and PD-L1 expression was investigated by immunohistochemistry in 40 PMPs characterized for GNAS and KRAS mutational status. Immune cell populations were studied by immunohistochemistry and nanostring nCounter®. Following the criteria of a prognostic nomogram reported for PMP, we stratified the patients into two different risk groups, with 28 “low-risk” and 12 “high-risk” patients. We observed the expression of GM-CSF (74%); CD39 (37%); CD73 (53%); A2AR (74%); and PD-L1 (16%) which was unrelated to GNAS or KRAS status. The tumor microenvironment showed the presence of CD4+ T cells (86%); CD8+ T cells (27%); CD20+ B (67%); CD15+ cells (86%); and CD163+ M2 macrophages (67%), while CD56+ NK cells were absent. CD163 expression (27%) in PMP tumor cells was associated with poor prognosis. GNAS mutation and A2AR expression were not associated with a specific immune transcriptional signature. However, the expression assay revealed 21 genes associated with prognosis. The “high-risk” patients exhibited worse progression-free survival (HR = 2.3, CI 95%: 1.1–5.1, p = 0.034) and significant downregulation of MET, IL8, PPARG, DTX4, HMGA1, ZIC2, WNT5B, and CCRL2. In conclusion, we documented the presence of immunosuppressive factors such as GM-CSF, A2AR, and PD-L1 in PMP. These factors were not associated with GNAS and KRAS status and could be explored as therapeutic molecular targets. Additionally, a set of potential prognostic biomarkers, including CD163 expression in tumor cells, deserve further investigation.
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