Accuracy of Sentinel Lymph Node Mapping After Previous Hysterectomy in Patients with Occult Cervical Cancer.

BACKGROUND In patients with a diagnosis of occult cervical cancer made on a hysterectomy specimen after surgery for a benign indication, lymph node assessment is crucial to determine treatment. We aimed to compare sentinel lymph node (SLN) mapping between patients with postoperative diagnosis of occult cervical carcinoma and patients with cervical cancer and uterus in situ. METHODS A retrospective analysis of cervical cancer patients International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIA disease undergoing laparoscopic SLN mapping was performed. Patients were divided into two groups: those with a diagnosis of occult cervical cancer made on a hysterectomy specimen (group 1) and those with a diagnosis of cervical cancer and uterus in situ (group 2). Tracers used for SLN mapping included technetium-99m ((99m)Tc), blue dye, and indocyanine green. After detection and excision, the SLN was sent for frozen section analysis, and the planned surgical procedure was aborted in case of metastatic disease in favor of a chemoradiotherapeutic treatment. RESULTS Groups 1 and 2 included 9 and 62 patients, respectively. Clinicopathologic characteristics were similar among the two groups. Overall and bilateral detection rates were 66.6 and 33.3 and 95.1 and 87 % in groups 1 and 2, respectively (p < 0.05). No false-negative SLNs were identified in either group, with a negative predictive value of 100 %. CONCLUSIONS SLN mapping in occult cervical cancer patients has lower detection rates compared to patients with uterus in situ. In these patients, proper management of their disease has already failed before diagnosis, and additional mistakes may definitely compromise attempts at cure

Fetal Cerebellar Vermis Circumference Measured by 2-Dimensional Ultrasound Scan: Reference Range, Feasibility and Reproducibility.

Purpose: To provide 2-dimensional ultrasonographic (2D-US) normograms of cerebellar vermis biometry, as well as to evaluate the feasibility and the reproducibility of these measurements in clinical practice. Materials and Methods: A prospective cross-sectional study of 328 normal singleton pregnancies between 18 and 33 weeks of gestation. Measurements of the fetal cerebellar vermis circumference (VC) in the mid-sagittal plane were performed by both a senior and a junior operator using 2D-US. VC as a function of gestational age (GA) was expressed by regression equations. In 24 fetuses 3-dimensional (3D) reconstructed planes were obtained in order to allow comparisons with 2D-US measurements. The agreement between 2D and 3D measurements and the interobserver variability were assessed by interclass correlation coefficients (ICC). Results: Satisfactory vermis measurements could be obtained in 89.9% of cases. The VC (constant= - 12.21; slope=2.447; r=0.887, p<0.0001) correlated linearly with GA. A high degree of consistency was observed between 2D and 3D ultrasound measurements (ICC=0.846 95% CI 679-0.930) as well as between measurements obtained by different examiners (ICC=0.890 95% CI 989-0.945). Conclusion: 2-dimensional ultrasonographic measurements of cerebellar vermis throughout gestation in the mid-sagittal view seem to be feasible and reproducible enough to be potentially used in clinical practice. Such measurements may supply a tool for accurate identification of posterior fossa anomalies, providing the basis for proper counseling and management and of these conditions

Hypertension in pregnancy

PURPOSE OF REVIEW Hypertension in pregnancy contributes substantially to perinatal mortality and morbidity of both the mother and her child. High blood pressure is mainly responsible for this adverse outcome, in particular when associated with preeclampsia. Although preeclampsia is nowadays a well-known clinical-obstetrical entity, and screening for this complication has been part of routine care during pregnancy for nearly 100 years, its cause is still enigmatic. RECENT FINDINGS Profound changes of the demographic development of our society, the worldwide rising prevalence of obesity and metabolic disorders, and progress in reproductive medicine will inevitably modify the prevalence of many medical problems in pregnancy. Complications such as gestational diabetes mellitus, chronic hypertension, and preeclampsia will rise and an interdisciplinary approach is necessary to handle these women during pregnancy and also after delivery. Indeed, it is now well established that these women and their offspring born large or small-for-gestational age are at increased risk for severe cardiovascular and metabolic complications later in life. SUMMARY Knowledge of the pregnancy course is not only important for an obstetrician but also increasingly inevitable for the general practitioner. Recognition, classification, and adequate management of hypertensive pregnancy disorders and associated complications may considerably reduce perinatal death and morbidity

Die laparoskopische Cerclage als Therapieoption bei Zervixinsuffizienz

Background: The traditional surgical treatment for cervical insufficiency is vaginal placement of a cervical cerclage. However, in a small number of cases a vaginal approach is not possible. A transabdominal approach can become an option for these patients. Laparoscopic cervical cerclage is associated with good pregnancy outcomes but comes at the cost of a higher risk of serious surgical complications. The aim of the present study was to evaluate intraoperative and long-term pregnancy outcomes after laparoscopic cervical cerclage, performed either as an interval procedure or during early pregnancy, using a new device with a blunt grasper and a flexible tip. Methods: All women who underwent laparoscopic cervical cerclage for cervical insufficiency in our institution using the Goldfinger® device (Ethicon Endo Surgery, Somerville, NJ, USA) between January 2008 and March 2014 were included in the study. Data were collected from the patients' medical records and included complications during and after the above-described procedure. Results: Eighteen women were included in the study. Of these, six were pregnant at the time of laparoscopic cervical cerclage. Mean duration of surgery was 55 ± 10 minutes. No serious intraoperative or postoperative complications occurred. All patients were discharged at 2.6 ± 0.9 days after surgery. One pregnancy ended in a miscarriage at 12 weeks of gestation. All other pregnancies ended at term (> 37 weeks of gestation) with good perinatal and maternal outcomes. Summary: Performing a laparoscopic cervical cerclage using a blunt grasper device with a flexible tip does not increase intraoperative complications, particularly in early pregnancy. We believe that use of this device, which is characterized by increased maneuverability, could be an important option to avoid intraoperative complications if surgical access is limited due to the anatomical situation. However, because of the small sample size, further studies are needed to confirm our findings.Die Therapie einer Zervixinsuffizienz besteht aktuell in der vaginalen Cerclage. In einigen wenigen Fällen ist dies nicht möglich, sodass die laparoskopische zervikale Cerclage eine Therapieoption sein kann, die aber mit einem höheren Risiko intraoperativer Komplikationen assoziiert ist. Das Ziel unserer Studie besteht darin, sowohl die intraoperative Sicherheit als auch die Langzeitergebnisse der mit einem „neuen“ Instrument durchgeführten laparoskopischen zervikalen Cerclage – präkonzeptionell oder in der Frühschwangerschaft durchgeführt – zu evaluieren. Methoden: Eingeschlossen wurden alle Frauen, bei denen zwischen Januar 2008 und März 2014 eine laparoskopische zervikale Cerclage mittels dem Goldfinger®-Instrument (Ethicon Endo Surgery, Somerville, NJ, USA) aufgrund einer Zervixinsuffizienz durchgeführt wurde. Es wurden alle Daten der Patientinnen inklusive der peri- und postoperativen Komplikationen der oben beschriebenen Operationstechniken gesammelt. Ergebnisse: Achtzehn Frauen wurden in unsere Studie eingeschlossen. Zum Zeitpunkt der durchgeführten laparoskopischen zervikalen Cerclage waren 6 Patientinnen schwanger. Die mittlere Operationsdauer betrug 55 ± 10 Minuten. Es traten keine ernsthaften peri- und postoperativen Komplikationen auf. Alle Patientinnen konnten nach 2,6 ± 0,9 Tagen aus dem Spital entlassen werden. Bei einer Patientin kam es zu einem Abort in der 12. SSW. Bei allen anderen Schwangerschaften kam es zur Geburt am Termin (> 37. SSW) mit gutem perinatalen und maternalen Outcome. Zusammenfassung: Das Durchführen einer laparoskopischen zervikalen Cerclage mit diesem flexiblen Instrument scheint die intraoperative Komplikationsrate – insbesondere in der Frühschwangerschaft – nicht zu erhöhen. Die Verwendung des flexiblen und sehr gut manövrierbaren Instruments ist eine interessante Möglichkeit bei Patientinnen mit anatomisch schwierigen Verhältnissen und der Notwendigkeit einer zervikalen Cerclage. Um die guten Resultate zu bestätigen sind weitere Studien notwendig

Accuracy of Sentinel Lymph Node Mapping After Previous Hysterectomy in Patients with Occult Cervical Cancer.

BACKGROUND In patients with a diagnosis of occult cervical cancer made on a hysterectomy specimen after surgery for a benign indication, lymph node assessment is crucial to determine treatment. We aimed to compare sentinel lymph node (SLN) mapping between patients with postoperative diagnosis of occult cervical carcinoma and patients with cervical cancer and uterus in situ. METHODS A retrospective analysis of cervical cancer patients International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIA disease undergoing laparoscopic SLN mapping was performed. Patients were divided into two groups: those with a diagnosis of occult cervical cancer made on a hysterectomy specimen (group 1) and those with a diagnosis of cervical cancer and uterus in situ (group 2). Tracers used for SLN mapping included technetium-99m ((99m)Tc), blue dye, and indocyanine green. After detection and excision, the SLN was sent for frozen section analysis, and the planned surgical procedure was aborted in case of metastatic disease in favor of a chemoradiotherapeutic treatment. RESULTS Groups 1 and 2 included 9 and 62 patients, respectively. Clinicopathologic characteristics were similar among the two groups. Overall and bilateral detection rates were 66.6 and 33.3 and 95.1 and 87 % in groups 1 and 2, respectively (p < 0.05). No false-negative SLNs were identified in either group, with a negative predictive value of 100 %. CONCLUSIONS SLN mapping in occult cervical cancer patients has lower detection rates compared to patients with uterus in situ. In these patients, proper management of their disease has already failed before diagnosis, and additional mistakes may definitely compromise attempts at cure

Laparoscopic Indocyanine Green Sentinel Lymph Node Mapping in Pregnant Cervical Cancer Patients.

We present cases of 2 pregnant patients with early-stage cervical cancer who have undergone indocyanine green (ICG) sentinel lymph node (SLN) mapping followed by laparoscopic SLN biopsy, pelvic lymphadenectomy, and cervical conization. Eight milliliters of ICG were injected in the 4 quadrants of the cervix after having obtained an adequate pneumoperitoneum and having inspected the abdominal cavity. SLNs were identified in both hemipelvises in both patients. In the final pathologic analysis, both SLNs and non-SLNs were negative for metastatic disease. No adverse events from ICG injection were recorded. ICG SLN mapping seems to be feasible in pregnant cervical cancer patients

Laparoscopic Ultrasound-Guided Repair of Uterine Scar Isthmocele Connected With the Extra-Amniotic Space in Early Pregnancy.

We present a video of an ultrasound-guided laparoscopic surgical management of a large uterine scar isthmocele connected with the extra-amniotic space in early pregnancy. A case of a pregnant patient who was diagnosed with a large isthmocele connected with the extra-amniotic space on routine ultrasound at 8 weeks of gestational age is presented. The uterine defect was successfully sutured laparoscopically under ultrasound guidance. The pregnancy continued uneventfully, and a healthy baby was delivered via cesarean section at 38 weeks gestational age