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Exosomes are nanosized membrane-bound microvesicles that originate from the endosomal compartment and convey cell-cell contact 'by proxy', transporting signals/packages of information between donor and recipient cells locally and/...
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Exosomes are nanosized membrane-bound microvesicles that originate from the endosomal compartment and convey cell-cell contact 'by proxy', transporting signals/packages of information between donor and recipient cells locally and/or at a distance. Exosomes are produced by a variety of immune, epithelial and tumor cells. Upon contact, exosomes transfer molecules that can render new properties and/or reprogram the recipient cells. Recently, it was discovered that the syncytiotrophoblast of human placenta continuously and constitutively secretes exosomes throughout pregnancy. These exosomes, delivered directly in the maternal blood surrounding the chorionic villi of the placenta, are immunosuppressive and pluripotent carrying proteins, mRNA and miRNA that can influence a number of biologic mechanisms and promote the fetal allograft survival. The current knowledge regarding placental exosomes and their role in pregnancy is summarized and discussed in this article.Keywords: exosomes,human reproduction,immunotolerance,MICA/B,microvesicles,NKG2D,NKG2D ligands,placenta,pregnancy,ULBP
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Objetivo: Determinar las características epidemiológicas, clínicas y quirúrgicas de las pacientes con enfermedad pélvica inflamatoria. Dise?o: Estudio descriptivo, tipo serie de casos. Lugar: Servicio de Ginecología del Hosp...
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Objetivo: Determinar las características epidemiológicas, clínicas y quirúrgicas de las pacientes con enfermedad pélvica inflamatoria. Dise?o: Estudio descriptivo, tipo serie de casos. Lugar: Servicio de Ginecología del Hospital Nacional Cayetano Heredia de Lima, Perú. Participantes: Mujeres con diagnóstico de enfermedad pélvica inflamatoria. Intervenciones: Se obtuvo los datos demográficos, antecedentes ginecológicos, criterios clínicos y tipo de intervención quirúrgica de 199 pacientes con enfermedad pélvica inflamatoria, entre enero de 1999 y diciembre de 2005. Principales medidas de resultados: Características de presentación de la enfermedad pélvica inflamatoria. Resultados: La frecuencia de enfermedad pélvica inflamatoria fue 3,2%, encontrándose una mayor presentación durante la segunda y cuarta décadas de la vida. Las características demográficas más frecuentes fueron el estado civil conviviente (40,7%) y secundaria completa (54,8%). El promedio de edad de inicio de la actividad sexual fue 18 a?os, siendo 50,3% monógama. Sobre conducta sexual, las relaciones contra natura correspondieron a 34,2% y las relaciones durante la menstruación a 47,7%. El antecedente de infección de transmisión sexual se presentó en 7,0%. El método anticonceptivo más empleado fue el dispositivo intrauterino (33,6%). El hallazgo clínico más frecuente fue el dolor pélvico (92,5%). Se realizó diagnóstico por laparoscopia en 14,6% y por laparotomía en 28,6%, siendo salpingitis el diagnóstico quirúrgico más frecuente (47,7%). Conclusiones: Las características epidemiológicas de nuestra población de estudio difieren de otras poblaciones en lo que respecta al grupo etáreo, grado de instrucción, estado civil, comportamiento sexual y empleo de métodos anticonceptivos. La clínica constituyó la forma más frecuente de diagnóstico de esta patología y el diagnóstico quirúrgico más frecuente fue salpingitis.
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Background Chronic pelvic pain affects ～15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for ch...
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Background Chronic pelvic pain affects ～15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities associated with changes in chronic pelvic pain severity over time. Objective We sought to describe trends and factors associated with chronic pelvic pain severity over a 1-year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects. Study Design This was a prospective 1-year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age >50 years. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was chronic pelvic pain severity at 1 year on an 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0–3, moderate 4–6, severe 7–10). Secondary outcomes included functional quality of life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year. Results Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10–4/10, P P P P P ?= .04), controlling for baseline pain, treatment effects (surgery), age, and referral status. Conclusion Improvements in chronic pelvic pain severity, quality of life, and health care utilization were observed in a 1-year cohort in an interdisciplinary setting. Higher pain catastrophizing at baseline was associated with greater chronic pelvic pain severity at 1 year. Consideration should be given to stratifying pelvic pain patients by catastrophizing level (rumination, magnification, helplessness) in research studies and in clinical practice.
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Background Insufficient evidence evaluates which pelvic organ prolapse surgery is best suited to an individual woman based on the stage of her prolapse. Objective We sought to compare prolapse recurrence rates following sacrocolpo...
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Background Insufficient evidence evaluates which pelvic organ prolapse surgery is best suited to an individual woman based on the stage of her prolapse. Objective We sought to compare prolapse recurrence rates following sacrocolpopexy and uterosacral ligament suspension after stratifying by preoperative Pelvic Organ Prolapse Quantification stage. Study Design We compared all women who underwent minimally invasive sacrocolpopexy or vaginal or minimally invasive uterosacral ligament suspension from 2009 through 2015 at a large academic center. All women with preoperative and postoperative Pelvic Organ Prolapse Quantification data were included. Patients were grouped by preoperative Pelvic Organ Prolapse Quantification stage for analysis. Recurrence rates following sacrocolpopexy and uterosacral ligament suspension were compared for patients presenting with stage II, III, and IV prolapse, adjusting for potential confounders in regression models. Prolapse recurrence was defined as any retreatment for prolapse or any Pelvic Organ Prolapse Quantification point beyond the hymen. Results Of 756 women, 633 underwent sacrocolpopexy (83.7%) and 123 (16.3%) underwent uterosacral ligament suspension. In all, 189 (25%) had preoperative Pelvic Organ Prolapse Quantification stage II prolapse, 527 (69.7%) stage III, and 40 (5.3%) stage IV. Patients were predominantly Caucasian (97.3%) with mean age 59.8 ± 9.5 years. Compared to uterosacral ligament suspension patients, more sacrocolpopexy patients had undergone prior prolapse repair (20.9% vs 5.7%, P ? P ?=?.034). Characteristics of the groups were otherwise similar. Median follow-up was 41.0 (interquartile range 13.0-88.8) weeks. Stage II prolapse patients had similar recurrence rates following sacrocolpopexy or uterosacral ligament suspension (6.0% vs 5.0, P ?= 1.00). However, stage III prolapse patients were more likely to experience recurrence following uterosacral ligament suspension (25.7% vs 7.8%, P Conclusion Sacrocolpopexy resulted in a lower prolapse recurrence rate than uterosacral ligament suspension for stage III prolapse. However, there was no difference in recurrence rate among women with preoperative stage II prolapse, suggesting mesh augmentation may not be indicated for these patients. Larger prospective trials are necessary for confirmation.
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Background Pelvic inflammatory disease is a female genital tract disorder with severe reproductive sequelae. Because of the difficulties in diagnosing pelvic inflammatory disease, it is not a reportable condition in many states. F...
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Background Pelvic inflammatory disease is a female genital tract disorder with severe reproductive sequelae. Because of the difficulties in diagnosing pelvic inflammatory disease, it is not a reportable condition in many states. Females seeking care in emergency departments are a sentinel population for pelvic inflammatory disease surveillance. Objective The objective of the study was to determine trends in diagnoses of acute pelvic inflammatory disease in a nationally representative sample of emergency departments. Study Design All emergency department visits among females aged 15–44 years with an International Classification of Diseases , ninth revision, Clinical Modification diagnosis code indicating pelvic inflammatory disease during 2006–2013 were assessed from the HealthCare Utilization Project Nationwide Emergency Department Sample. Total and annual percentage changes in the proportion of pelvic inflammatory disease emergency department visits were estimated using trend analyses. Results While the number of emergency department visits among females aged 15–44 years during 2006–2013 increased (6.5 million to 7.4 million), the percentage of visits due to pelvic inflammatory disease decreased from 0.57% in 2006 to 0.41% in 2013 (total percentage change, –28.4%; annual percent change, –4.3%; 95% confidence interval, –5.7% to –2.9%). The largest decreases were among those aged 15-19 years (total percent change, –40.6%; annual percentage change, –6.6%; 95% confidence interval, –8.6% to –4.4%) and living in the South (total percentage change, –38.0%; annual percentage change, –6.2%; 95% confidence interval, –7.8% to –4.6%). Females aged 15-19 years who lived in the South had a 47.9% decrease in visits due?to?pelvic inflammatory disease (annual percentage change, –8.4%, 95% confidence interval, –10.4 to –6.5). Patients living in ZIP codes with the lowest median income ( $64,000, total percent change, –24.4%; annual percent change, –3.8%; 95% confidence interval, –5.2% to –2.4%). The percentage of emergency department visits due to pelvic inflammatory disease was highest among patients not charged for their visit, self-paying, or those covered by Medicaid, with total percentage changes in these 3 groups of –27.8%, –30.7%, and –35.1%, respectively. Patients with Medicaid coverage had the largest decrease in visits with a diagnosis of pelvic inflammatory disease (total percent change, –35.1%; annual percent change, –5.8%; 95% confidence interval, –7.2% to –4.3%). Conclusion Nationally representative data indicate the percentage of emergency department visits with a pelvic inflammatory disease diagnosis decreased during 2006–2013 among females aged 15-44 years, primarily driven by decreased diagnoses of pelvic inflammatory disease among females aged 15–19 years and among women living in the southern United States. Despite declines, a large number of females of reproductive age are receiving care for pelvic inflammatory disease in emergency departments. Patients with lower median income and no or public health insurance status, which may decrease access to and use of health care services, consistently had the highest percentage of emergency department visits due to pelvic inflammatory disease. Future research should focus on obtaining a better understanding of factors influencing trends in pelvic inflammatory disease diagnoses and ways to address the challenges surrounding surveillance for this condition.
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Background Pelvic organ prolapse is a common condition that frequently coexists with urinary and fecal incontinence. The impact of prolapse on quality of life is typically measured through condition-specific quality-of-life instru...
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Background Pelvic organ prolapse is a common condition that frequently coexists with urinary and fecal incontinence. The impact of prolapse on quality of life is typically measured through condition-specific quality-of-life instruments. Utility preference scores are a standardized generic health-related quality-of-life measure that summarizes morbidity on a scale from 0 (death) to 1 (optimum health). Utility preference scores quantify disease severity and burden and are widely used in cost-effectiveness research. The validity of utility preference instruments in women with pelvic organ prolapse has not been established. Objective The objective of this study was to evaluate the construct validity of generic quality-of-life instruments for measuring utility scores in women with pelvic organ prolapse. Our hypothesis was that women with multiple pelvic floor disorders would have worse (lower) utility scores than women with pelvic organ prolapse only and that women with all 3 pelvic floor disorders would have the worst (lowest) utility scores. Study Design This was a prospective observational study of 286 women with pelvic floor disorders from a referral female pelvic medicine and reconstructive surgery practice. All women completed the following general health-related quality-of-life questionnaires: Health Utilities Index Mark 3, EuroQol, and Short Form 6D, as well as a visual analog scale. Pelvic floor symptom severity and condition-specific quality of life were measured using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, respectively. We measured the relationship between utility scores and condition-specific quality-of-life scores and compared utility scores among 4 groups of women: (1) pelvic organ prolapse only, (2) pelvic organ prolapse and stress urinary incontinence, (3) pelvic organ prolapse and urgency urinary incontinence, and (4) pelvic organ prolapse, urinary incontinence, and fecal incontinence. Results Of 286 women enrolled, 191 (67%) had pelvic organ prolapse; mean age was 59 years and 73% were Caucasian. Among women with prolapse, 30 (16%) also had stress urinary incontinence, 39 (20%) had urgency urinary incontinence, and 42 (22%) had fecal incontinence. For the Health Utilities Index Mark 3, EuroQol, and Short Form 6D, the pattern in utility scores was noted to be lowest (worst) in the prolapse?+ urinary incontinence?+ fecal incontinence group (0.73-0.76), followed by the prolapse?+ urgency urinary incontinence group (0.77-0.85) and utility scores were the highest (best) for the prolapse only group (0.80-0.86). Utility scores from all generic instruments except the visual analog scale were significantly correlated with the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire total scores (r values –0.26 to –0.57), and prolapse, bladder, and bowel subscales (r values –0.16 to –0.50). Utility scores from all instruments except the visual analog scale were highly correlated with each other (r?= 0.53-0.69, P Conclusion The Health Utilities Index Mark 3, EuroQol, and Short Form 6D, but not the visual analog scale, provide valid measurements for utility scores in women with pelvic organ prolapse and associated pelvic floor disorders and could potentially be used for cost-effectiveness research.
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Abstract It is difficult to prenatally identify 5p deletion (?) syndrome. Here, we report five cases of 5p‐ syndrome diagnosed by invasive prenatal diagnosis. Of them, three had a small cerebellum in the second trimester. In one ...
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Abstract It is difficult to prenatally identify 5p deletion (?) syndrome. Here, we report five cases of 5p‐ syndrome diagnosed by invasive prenatal diagnosis. Of them, three had a small cerebellum in the second trimester. In one case, a prominent renal pelvis and an absent nasal bone were also found in the first trimester. However, there were no abnormal ultrasound findings in the other two cases. Two cases had noninvasive prenatal testing and one showed a ‘5p‐ syndrome positive result’ because of reduced amount of cell‐free DNA in 5p. Two had combined first‐trimester screening performed where one had a high‐risk result for trisomy 18 and a low pregnancy‐associated plasma protein‐A level. Two cases of 5p‐ syndrome resulted from a parental balanced translocation. Prenatal diagnosis will only be made on invasive prenatal diagnosis for abnormal ultrasound findings with small cerebellum, abnormal prenatal screening or a parental reciprocal translocation involving 5p.
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Background Injury to the levator ani muscle or pelvic nerves during pregnancy and vaginal delivery is responsible for pelvic floor dysfunction. Objective We sought to demonstrate the presence of smooth muscular cell areas within t...
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Background Injury to the levator ani muscle or pelvic nerves during pregnancy and vaginal delivery is responsible for pelvic floor dysfunction. Objective We sought to demonstrate the presence of smooth muscular cell areas within the levator ani muscle and describe their localization and innervation. Study Design Five female human fetuses were studied after approval from the French Biomedicine Agency. Specimens were serially sectioned and stained by Masson trichrome and immunostained for striated and smooth muscle, as well as for somatic, adrenergic, cholinergic, and nitriergic nerve fibers. Slides were digitized for 3-dimensional reconstruction. One fetus was reserved for electron microscopy. We explored the structure and innervation of the levator ani muscle. Results Smooth muscular cell beams were connected externally to the anococcygeal raphe and the levator ani muscle and with the longitudinal anal muscle sphincter. The caudalmost part of the pubovaginal muscle was found to bulge between the rectum and the vagina. This bulging was a smooth muscular interface between the levator ani muscle and the longitudinal anal muscle sphincter. The medial (visceral) part of the levator ani muscle contained smooth muscle cells, in relation to the autonomic nerve fibers of the inferior hypogastric plexus. The lateral (parietal) part of the levator ani muscle contained striated muscle cells only and was innervated by the somatic nerve fibers of levator ani and pudendal nerves. The presence of smooth muscle cells within the medial part of the levator ani muscle was confirmed under electron microscopy in 1 fetus. Conclusion We characterized the muscular structure and neural control of the levator ani muscle. The muscle consists of a medial part containing smooth muscle cells under autonomic nerve influence and a lateral part containing striated muscle cells under somatic nerve control. These findings could result in new postpartum rehabilitation techniques.
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Background The classification of hypertensive disorders of pregnancy is based on the time at the onset of hypertension, proteinuria, and other associated complications. Maternal hemodynamic interrogation in hypertensive disorders ...
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Background The classification of hypertensive disorders of pregnancy is based on the time at the onset of hypertension, proteinuria, and other associated complications. Maternal hemodynamic interrogation in hypertensive disorders of pregnancy considers not only the peripheral blood pressure but also the entire cardiovascular system, and it might help to classify the different clinical phenotypes of this syndrome. Objective This study aimed to examine cardiovascular parameters in a cohort of patients affected by hypertensive disorders of pregnancy according to the clinical phenotypes that prioritize fetoplacental characteristics and not the time at onset of hypertensive disorders of pregnancy. Study Design At the fetal-maternal medicine unit of Ziekenhuis Oost-Limburg (Genk, Belgium), maternal cardiovascular parameters were obtained through impedance cardiography using a noninvasive continuous cardiac output monitor with the patients placed in a standing position. The patients were classified as pregnant women with hypertensive disorders of pregnancy who delivered appropriate- and small-for-gestational-age fetuses. Normotensive pregnant women with an appropriate-for-gestational-age fetus at delivery were enrolled as the control group. The possible impact of obesity (body mass index ≥30 kg/m 2 ) on maternal hemodynamics was reassessed in the same groups. Results Maternal age, parity, body mass index, and blood pressure were not significantly different between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and hypertensive disorders of pregnancy/small-for-gestational-age groups. The mean uterine artery pulsatility index was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group. The cardiac output and cardiac index were significantly lower in the hypertensive disorders of pregnancy/small-for-gestational-age group (cardiac output 6.5 L/min, cardiac index 3.6) than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group (cardiac output 7.6 L/min, cardiac index 3.9) but not between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and control groups (cardiac output 7.6 L/min, cardiac index 4.0). Total vascular resistance was significantly higher?in the hypertensive disorders of pregnancy/small-for-gestational-age group than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group and the control group. All women with hypertensive disorders of pregnancy showed signs of central arterial dysfunction. The cardiovascular parameters were not influenced by gestational age at the onset of hypertensive disorders of pregnancy, and no difference was observed between the women with appropriate-for-gestational-age fetuses affected by preeclampsia or by gestational hypertension with appropriate-for-gestational-age fetuses. Women in the obese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and obese/hypertensive disorders of pregnancy/small-for-gestational-age groups showed a significant increase in cardiac output, as well as significant changes in other parameters, compared with the nonobese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and nonobese/hypertensive disorders of pregnancy/small-for-gestational-age groups. Conclusion Significantly low cardiac output and high total vascular resistance characterized the women with hypertensive disorders of pregnancy associated with small for gestational age due to placental insufficiency, independent of the gestational age at the onset of hypertension. The cardiovascular parameters were not significantly different in the women with appropriate-for-gestational-age or small-for-gestational-age fetuses affected by preeclampsia or gestational hypertension. These findings support the view that maternal hemodynamics may be a candidate diagnostic tool to identify hypertensive disorders in pregnancies associated with small-for
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Background Preeclampsia is a major cause of perinatal morbidity and mortality. First-trimester screening has been shown to be effective in selecting patients at an increased risk for preeclampsia in some studies. Objective We soug...
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Background Preeclampsia is a major cause of perinatal morbidity and mortality. First-trimester screening has been shown to be effective in selecting patients at an increased risk for preeclampsia in some studies. Objective We sought to evaluate the feasibility of screening for preeclampsia in the first trimester based on maternal characteristics, medical history, biomarkers, and placental volume. Study Design This is a prospective observational nonintervention cohort study in an unselected US population. Patients who presented for an ultrasound examination between 11-13+6 weeks’ gestation were included. The following parameters were assessed and were used to calculate the risk of preeclampsia: maternal characteristics (demographic, anthropometric, and medical history), maternal biomarkers (mean arterial pressure, uterine artery pulsatility index, placental growth factor, pregnancy-associated plasma protein A, and maternal serum alpha-fetoprotein), and estimated placental volume. After delivery, medical records were searched for the diagnosis of preeclampsia. Detection rates for early-onset preeclampsia ( Results We screened 1288 patients of whom 1068 (82.99%) were available for analysis. In all, 46 (4.3%) developed preeclampsia, with 13 (1.22%) having early-onset preeclampsia and 33 (3.09%) having late-onset preeclampsia. Using maternal characteristics, serum biomarkers, and uterine artery pulsatility index, the detection rate of early-onset preeclampsia for either 5% or 10% false-positive rate was 85%. With the same protocol, the detection rates for preeclampsia with delivery 37 weeks’ gestation were not improved by the addition of biomarkers. Conclusion Screening for preeclampsia at 11-13+6 weeks’ gestation using maternal characteristics and biomarkers is associated with a high detection rate for a low false-positive rate. Screening for late-onset preeclampsia yields a much poorer performance. In this study the utility of estimated placental volume and mean arterial pressure was limited but larger studies are needed to ultimately determine the effectiveness of these markers.
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