Sonographische Merkmale der Endometriose in Korrelation mit klinischer Symptomatik und intraoperativem Befund

Einleitung: Die Endometriose, das Vorkommen von Gebärmutterschleimhaut außerhalb der Gebärmutterhöhle, ist eine der häufigsten Erkrankungen von Frauen im reproduktiven Alter. Die negativen Auswirkungen auf das Leben der betroffenen Frauen sind vielfältig und betreffen die Menstruation, das Sexualleben, die Miktion, die Defäkation und nicht zuletzt die Familienplanung. Bis heute gilt die Operation als invasives Verfahren als Goldstandard zur Diagnosestellung. Dabei existieren auch nichtinvasive diagnostische Möglichkeiten wie die klinische Untersuchung mit der Sonographie, deren Stellenwert bislang nicht ausreichend evaluiert wurde. Insbesondere ist bis heute unklar, welche Bedeutung der Ultraschall für die Diagnostik der einzelnen Endometrioseentitäten Peritoneal-, Ovarial-, tief infiltrierende Endometriose und Adenomyosis uteri hat. Ziel dieser Arbeit war es, die Wertigkeit sonographischer, hysteroskopischer und laparoskopischer Kriterien für die Diagnostik der einzelnen Endometrioseentitäten zu untersuchen. Methodik: Zur prospektiven Validierung der sonographischen und operativen Diagnosekriterien wurden die Daten von Patientinnen, die im Zeitraum vom 01.01.2017 bis zum 31.12.2018 in der Endometriose-Sprechstunde der Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin des Universitätsklinikums des Saarlandes in Homburg ambulant behandelt und im Verlauf wegen Endometriose operiert wurden, ausgewertet. Dabei wurden Patientinnen mit Myomen von der finalen Datenanalyse ausgeschlossen. Einschlusskriterium war zudem, dass die Patientin zum Zeitpunkt des Studieneinschlusses im reproduktiven Alter (18 bis 45 Jahre) war. Bei jeder Patientin erfolgte die Anamnese. Zudem wurden jeweils acht sonographische, vier hysteroskopische und acht laparoskopische (davon zwei im Rahmen der Chromopertubation) für eine bestimmte Endometriose-Entität spezifische Kriterien erhoben. Das Vorkommen dieser Kriterien wurde mit dem postoperativen histologischen Befund korreliert. Die Auswertung der Daten aller Patientinnen erfolgte mit Hilfe von Microsoft Excel Version 2007 (Microsoft Corporation, Redmond, WA, USA). Nach Rücksprache mit dem hiesigen Institut für Medizinische Statistik verzichteten wir wegen des monozentrischen Charakters der Arbeit auf eine statistische Analyse mit der Ermittlung statistischer Signifikanz. Es erfolgte stattdessen eine deskriptive Analyse. Ergebnisse: In dieser Arbeit wurden 90 Patientinnen prospektiv für den Zeitraum von Januar 2017 bis Dezember 2018 betrachtet. 65 Patientinnen hatten eine histologisch gesicherte Endometriose, davon 20 eine Peritonealendometriose, 9 eine tief infiltrierende Endometriose, 11 eine Ovarendometriose und 25 eine Adenomyosis uteri. Ihnen wurde eine Vergleichsgruppe mit ebenfalls prämenopausalen Patientinnen (n=25) gegenübergestellt, bei denen sich postoperativ die Diagnose Endometriose im histopathologischen Befund nicht bestätigte. Bei der Diagnostik der Ovarialendometriose und der Adenomyosis uteri waren mindestens 3 für die jeweilige Endometriose-Entität spezifische sonographische Kriterien präoperativ nachweisbar. Im Kontrollkollektiv ließen sich maximal zwei sonographische Kriterien nachweisen. Im Rahmen der Hysteroskopie waren bei allen 25 Patientinnen mindestens 2 hysteroskopische Merkmale nachweisbar. Die Laparoskopie ermöglichte dagegen den Nachweis einer bestehenden Peritonealendometriose. Bei einer Peritonealendometriose ließ sich bei allen 20 Patientinnen eine ausgeprägte Dysmenorrhoe (VAS ≥ 7) nachweisen. Diskussion: Anders als bei der Ovarialendometriose und der Adenomyosis uteri ließ sich bei der Peritonealendometriose kein Nutzen der Ultraschalldiagnostik feststellen. Der sonographische Befund korrelierte hier nicht mit der Histologie. Bei der Diagnostik der tief infiltrierenden Endometriose fand sich in einzelnen Fällen ein Nutzen der Sonographie. Zur Diagnostik der Peritonealendometriose erscheint die Anamnese mit dem Leitsymptom Dysmenorrhoe am geeignetsten. Das Ausmaß der Dysmenorrhoe korrelierte jedoch nicht mit dem Endometriosestadium gemäß der rASRM-Klassifikation. Intraoperativ ermöglichte die Hysteroskopie eine relativ zuverlässige Diagnosestellung der Adenomyosis. Sie stellt zusammen mit der Laparoskopie und ggf. Chromopertubation den Goldstandard bei der Diagnosestellung der meisten Formen einer Endometriose dar. Schlussfolgerung: Wir konnten in dieser Arbeit eine hohe diagnostische Treffsicherheit des Ultraschalls zur präoperativen Diagnostik der Adenomyosis uteri und der Ovarendometriose nachweisen. Die Hysteroskopie erlaubt in vielen Fällen die Detektion einer Adenomyosis uteri. Für die Feststellung einer Endometriose des Peritoneums hat neben der Anamnese (Dysmenorrhoe ≥ VAS 7) nur die Laparoskopie einen Stellenwert. Somit bleibt die Laparoskopie der Goldstandard bei der Diagnostik der meisten klinisch manifesten Endometrioseerkrankungen

Prenatal Diagnosis of Bovine Aortic Arch Anatomic Variant

Fetal aortic arch development is an early and complex process that depends on many genetic and environmental factors. The final aortic arch varies greatly; it may take the form of a normal arch, anatomic variant (AAAV) with a common origin to that of the innominate artery and left common carotid artery (formerly known as “bovine aortic arch” (with an incidence of up to 27%)) or one of multiple pathological conditions. The present study aimed to establish the feasibility and impact of prenatal anatomic arch variants’ diagnosis. A retrospective study of 271 fetal second- and third-trimester anomaly scans was performed in our tertiary center. Examinations that evaluated the sagittal aortic arch were included and the branching pattern was assessed. Additionally, a literature data search based on the terms “common origin of innominate artery and left common carotid artery”, “bovine arch”, “bovine aortic” and “aortic arch anomalies” was performed. Results that referred to prenatal AAAV were retained and the papers evaluated. In our study, the AAA incidence was 1.93%, with 4 out of 5 cases being arch type B. All cases had minor associated conditions but a good postnatal outcome. An anatomic aortic variant with a common IA and LCCa prenatal diagnosis was found in a small number of studies; most of the cases described in pediatric and adult series were related to cardiac surgery for stenting, aneurysm or thoracic-associated diseases. The incidence of AAAV varied from 6 to 27% depending on the population studied (highest incidence in African individuals). The variant was highly associated with aortic dissection, pulmonary and cerebral embolism and increased risks of incidents during surgery. Diagnosing AAAV during a routine anatomic scan is feasible and diagnoses can be made when anomaly scans are performed. Awareness of the condition is important for postnatal surgery when other cardiac anomalies are found; this can prevent accidents with simple changes to the patient’s lifestyle, and, in the case of surgery, means we can adopt the correct surgical approach

Foetal Intrapartum Compromise at Term : Could COVID-19 Infection Be Involved? A Case Report

The impact of the SARS-CoV-2 infection on pregnancy has been studied and many reports have been published, mainly focussing on complications and in utero transmission with neonatal consequences. Although the effects of other viruses on foetuses are well known, the impact of maternal COVID-19 during pregnancy is not completely understood. We report a case of acute foetal intrapartum hypoxia without other risk factors than maternal COVID-19 disease 2 weeks previous to birth at term. Placental histological changes suggested that the viral infection could have been the culprit for the unfavourable outcome during labour. The neonate was promptly delivered by Caesarean section. Neonatal intensive care was started, including therapeutic hypothermia. The procedure was successful, the evolution of the neonate was favourable, and she was discharged after 10 days. Follow-up at 2 months of life indicated a normal neurological development but a drop in head growth. The case raises the idea that pregnancies with even mild COVID-19 symptoms may represent the cause of neonate compromise in a low-risk pregnancy. An important follow-up in the neonatal period and infancy is required to identify and treat any subsequent conditions. Further long-term studies are necessary to identify a cause–effect relationship between COVID-19 pregnancies and the whole spectrum of neonatal and infant consequences

Persistent Left Superior Vena Cava Significance in Prenatal Diagnosis : Case Series

The persistent left superior vena cava (PLSVC) is a congenital heart anomaly reported in 0.3–0.5% of the general population and can be associated with congenital heart diseases in up to 8% of cases. Prenatal identification of PLSVC is important to prompt an extended cardiac and extracardiac fetal examination. We retrospectively reevaluated anomaly scans performed in our unit in a 2-year interval according to the national guidelines to evaluate the incidence of PLSVC and its association with prenatal morbidity. In our population, the incidence of PLSVC was 0.31%, and we found a low association with cardiac and extracardiac anomalies. The standard sections (three-vessel and trachea view, four-chamber view and outflow tract’s view) are insufficient to exclude cardiac anomalies whenever PLSVC is found. In our case series, only one newborn required postnatal surgery for total pulmonary vein anomaly, and at 2 years of life all babies had a normal evolution. Prenatal diagnosis of PLSVC can raise counseling issues; therefore, awareness of its good outcome when isolated and need for an extended examination to rule out other anomalies is very important

Physical Activity and the Impact of Continued Exercise on Health-Related Quality of Life Prior to and during Pregnancy: A German Cohort Study

The goal of this study was to examine how regular physical activity before and during pregnancy affected life quality throughout pregnancy. Between July 2020 and May 2021, 218 pregnant women were recruited from 11 outpatient clinics for this survey. Data were collected prospectively in a panel format beginning with the 10th gestational week over a 20-week period. Prior to pregnancy, a previous time point was also defined. The International Physical Activity Questionnaire, the EQ-5D-3L questionnaire, and the EQ-VAS questionnaire were used to collect data on the duration and intensity of daily physical exercises, as well as to assess health-related quality of life and selfestimated health status. The final survey included data from 113 women. During pregnancy, physical activity decreased dramatically. The duration of strenuous activities, but not moderate activities, was significantly reduced. Continuous physical activity independently predicted higher life quality scores at all points of assessment. Cases who participated in moderate and strenuous activities on a regular basis had higher self-estimated health status scores than cases who only participated in moderate activity. Instead of focusing solely on specific types of physical activity, we believe that strategies for motivating all pregnant women to be constantly active should be developed

Acute Sheehan's syndrome manifesting initially with diabetes insipidus postpartum: a case report and systematic literature review

Purpose Acute Sheehan’s syndrome is a rare, but potentially life-threatening, obstetric event that can be complicated by diabetes insipidus. Little information on the diagnosis and treatment of Sheehan’s syndrome with diabetes insipidus is available. We report on a 28-year-old patient who developed acute Sheehan’s syndrome with diabetes insipidus after giving birth, and on a systematic review of similar cases. Methods We performed a systematic review of the literature cataloged in PubMed and Google Scholar using the keywords “Sheehan syndrome” OR “Sheehan's syndrome” AND “diabetes insipidus” to identify relevant case reports published between 1990 and 2021. Eight Reports met the inclusion criteria (English-language abstracts available, onset in the puerperium, information about the day of the onset). Results In the present case, postpartum curettage was necessary to remove the residual placenta. The total amount of blood loss was severe (2500 ml). On the second day postpartal, the patient developed polyuria. Laboratory analysis revealed hypernatremia with increased serum osmolality and decreased urinary osmolality. Hormone analysis showed partial hypopituitarism involving the thyroid, corticotropic, and gonadotropic axes. The prolactin level was elevated. Brain magnetic resonance imaging showed pituitary gland infarction. Desmopressin therapy was initiated and resolved the polyuria. Hormone replacement therapy was administered. Four months later, the patient was well, with partial diabetes insipidus. The literature review indicated that this case was typical in terms of symptoms and disease onset. Most reported cases involve hypotension and peripartum hemorrhage, but some patients without hemorrhage also develop Sheehan’s syndrome. Elevated prolactin levels are uncommon and associated with poor prognosis in patients with Sheehan’s syndrome. Conclusion Acute Sheehan’s syndrome with diabetes insipidus involves nearly all pituitary hormone axes, indicating severe disease. Prolactin elevation could suggest that a case of Sheehan’s syndrome is severe

The Impact of the Microbiological Vaginal Swab on the Reproductive Outcome in Infertile Women

Background: The thesis on which this paper is based intended to investigate whether the result of the microbiological vaginal swab has an influence on the outcome of the fertility treatment. Methods: The microbiological vaginal swabs of patients who received fertility treatment at Saarland University Hospital were evaluated. Depending on the microorganisms detected, the swab result was classified as inconspicuous, intermediate, or conspicuous. The SPSS software was used to determine the correlation between the swab result and the outcome of the fertility treatment. Results: Dysbiosis was associated with a worse outcome of fertility treatment. The pregnancy rate with a conspicuous swab was 8.6%, whereas it was 13.4% with an inconspicuous swab. However, this association was not statistically significant. Furthermore, an association of endometriosis with dysbiosis was found. Endometriosis was more frequent with a conspicuous swab result than with an inconspicuous result (21.1% vs. 17.7%), yet the correlation was not statistically significant. However, the absence of lactobacilli was significantly associated with endometriosis (p = 0.021). The association between endometriosis and a lower pregnancy rate was also statistically significant (p = 0.006). Conclusion: The microbiological vaginal and cervical swabs can be used as predictors for the success of fertility treatments. Further studies are needed to assess the impact of transforming a dysbiotic flora into a eubiotic environment on the success of fertility treatments

The Impact of SARS-CoV-2 Infection on Premature Birth—Our Experience as COVID Center

Information about the impact of SARS-CoV-2 infection on pregnant women is still limited and raises challenges, even as publications are increasing rapidly. The aim of the present study was to determine the impact of SARS-CoV-2 infection on preterm birth pregnancies. We performed a prospective, observational study in a COVID-only hospital, which included 34 pregnant women with SARS-CoV-2 infection and preterm birth compared with a control group of 48 healthy women with preterm birth. The rate of cesarean delivery was 82% in the study group versus 6% for the control group. We observed a strong correlation between premature birth and the presence of COVID-19 symptoms (cough p = 0.029, fever p = 0.001, and chills p = 0.001). The risk for premature birth is correlated to a lower value of oxygen saturation (p = 0.001) and extensive radiologic pulmonary lesions (p = 0.025). The COVID-19 pregnant women with preterm delivery were older, and experienced an exacerbation of severe respiratory symptoms, decreased saturation of oxygen, increased inflammatory markers, severe pulmonary lesions and decreased lymphocytes

Can SARS-CoV-2 Induce Uterine Vascular Anomalies and Poor Contractile Response?—A Case Report

We are reporting a case of a 36 year-old Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) positive hypertensive primigravida with postpartum uterine atony that required emergency subtotal hysterectomy at Saint John Hospital Bucur Maternity Bucharest. The maternity was designated as the Coronavirus Disease 2019 (COVID-19) Maternity for Bucharest and Ilfov County since March 2020. The patient was mildly symptomatic for SARS-CoV-2, infection confirmed with reverse transcription polymerase chain reaction (RT-PCR). The caesarean section was performed and a live male fetus was born, 2630 g and Apgar Score of 9 (the male fetus was negative for SARSCoV-2). Postpartum hysterectomy with adnexal preservation was performed because of uterine atony. The postoperative evolution was favorable. The patient was discharged with her baby 10 days after birth. Given the limited resources, the placenta, the umbilical cord and the uterus were not tested for SARS-CoV-2. The pathology exam revealed that on the maternal side there were specific uterine atony lesions as well as endometrial and miometrial ischaemia. The placenta had nonspecific findings: chronic ischemic lesions with small villi, fibrin deposits in the materno-fetal interface. The peculiarity of the case is that we report the morphological findings of the placenta and uterus resulted from intrapartum uterine atonia in a patient with gestational arterial hypertension, premature birth and COVID-19. Further studies are required to characterize the pattern of such intricate conditions

Sonographic features of adenomyosis correlated with clinical symptoms and intraoperative findings : a case-control study

Purpose Adenomyosis is a common disease of females during their reproductive age. As of today, histologic examination of the uterus after hysterectomy constitutes the gold standard for diagnosis. The aim of this study was to determine the validity of sonographic, hysteroscopic, and laparoscopic criteria for the diagnosis of the disease. Methods This study included data collected from 50 women in the reproductive age of 18–45 years, who underwent a laparoscopic hysterectomy in the gynecology department of the Saarland University Hospital in Homburg between 2017 and 2018. The patients with adenomyosis were compared with a healthy control group. Results We collected data of anamnesis, sonographic criteria, hysteroscopic criteria and laparoscopic criteria and compared it with the postoperative histological results. A total 25 patients were diagnosed with adenomyosis postoperatively. For each of these; at least three sonographic diagnostical criteria for adenomyosis were found compared with a maximum of two for the control group. Conclusion This study demonstrated an association between pre- and intraoperative signs of adenomyosis. In this way, it shows a high diagnostic accuracy of the sonographic examination as a pre-operative diagnostic method of the adenomyosis