Fertility preserving management for postpartum haemorrhage secondary to subinvolution of the placental implantation site

A 40-year-old woman presents with recurrent secondary postpartum haemorrhage (PPH) following her third normal vaginal delivery. Histology from subsequent evacuation of the uterus confirmed that she had subinvolution of the placental implantation site. Hysterectomy is the most common method of managing this condition and recurrent PPH, most often due to significant vaginal bleeding. We present a case of subinvolution of the placental implantation site with recurrent PPH managed with medical treatment alone, to offer a fertility-sparing treatment option.

P–366 MicroRNAs at the embryo-maternal interface have effects on endometrial cell proliferation

Study question Whether cell-free microRNAs are part of the embryo-maternal interactome with possible effects on processes related to implantation. Summary answer Specific microRNAs cause major transcriptomic changes in uterine cells and alter cellular proliferation which is pivotal for the implantation of the incoming embryo. What is known already A plethora of molecules present at the uterine luminal fluid including cytokines, growth factors, and adhesion proteins are involved in implantation. However little is known about the roles of extracellular microRNAs (miRNAs) at the embryo-maternal interface. MicroRNAs act mainly as gene regulators and a single miRNA can have thousands of gene targets. MiRNAs are released by blastocysts and uterine cells internalize miRNAs that are present in the extracellular environment. To date there is limited evidence on the molecular actions of these cell-free miRNAs and their effects on processes related to implantation. Study design, size, duration Human endometrial stromal cells (hESCs) were cultured in complete growth medium for 8 consecutive passages. A miRNA mimic experiment in 6 replications was carried out in which endometrial cells were transfected with miR–371a. Gene changes in the hESCs were studied with genome-wide microarray technology and the results were validated in vitro with PCR. Participants/materials, setting, methods The miR–371a mimic was transfected in hESCs using a Lipofectamine reagent. RNA was extracted and the samples were processed with microarray Clariom™ Human Assays using Affymetrix®. The transcriptomic profiles between transfected and control cells were compared using Partek®. Differentially expressed genes were considered significant when p-value was <0.05, false discovery rate, FDR ≤ 0.05 with Benjamini-Hochberg correction, and fold-change of > 1.5 or < –1.5. Functional enrichment analysis was carried out using WebGestalt and Enrichr. Main results and the role of chance MiR–371a altered the expression of 4.760 genes in endometrial cells (p < 0.05, fold-change 1.5). A total of 16 biological processes, 23 cellular components, and 24 molecular pathways were disrupted by this miRNA. WebGestalt analysis found 159 enriched categories including increase of negative cell cycle regulation, apoptosis signalling, and cycle arrest and decreased cell proliferation. Cell cycle was one of the most affected pathways in KEGG analysis with at least 54 genes dysregulated. Mammalian phenotype ontology analysis found 4.818 affected phenotypes, including decreased cell proliferation (58 genes), increased apoptosis (48 genes) and abnormal cell cycle (41 genes). Key-genes of endometrial proliferation at the window of implantation were significantly downregulated, including: CD44, PGR; IGFs, FGFs, and HAND2. Moreover, at least 25% decreased hESCs proliferation was verified in vitro after transfection. These negative effects of miR–371a in cell cycle could disturb implantation of the incoming embryo, since intense cellular proliferation is necessary for establishment of the implantation site. Limitations, reasons for caution These results are limited to miR–371a actions on human endometrial stromal cells. It is likely that miRNAs, cytokines, growth factors, and other molecules form complex regulatory networks that control uterine receptivity and embryo implantation. Wider implications of the findings: MiRNAs are important mediators of the embryo-maternal interactome. Their actions are likely involved in implantation-related processes including inter-cellular communication, decidualization, adhesion, invasion, and establishment of the implantation site. Embryo-secreted miRNAs change the transcriptome of the neighboring endometrial cells with effects on implantation-related pathways, serving thus secretory functions. Trial registration number N/A

Aneurysmal Degeneration of Fluoropolymer-Coated Paclitaxel-Eluting Stent in the Superficial Femoral Artery. A Rising Concern

Background: Although several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia™; Boston Scientific, Marlborough, MA, USA) implantation, aneurysmal degeneration after implanting Eluvia™ has raised clinical concerns. Here, we report a case with exacerbated aneurysmal degeneration on serial angiography and intravascular ultrasound 50 months after Eluvia™ implantation for a superficial femoral artery lesion.Case presentation: A 79-year-old woman with claudication in the right lower extremity decreasing her quality of life was referred to our hospital. Pre-procedural angiography showed severe stenosis from the middle-to-distal part of the right superficial femoral artery, and Eluvia™ was implanted with optimal expansion. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal stent edge restenosis at the Eluvia™ implantation site. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed vessel enlargement with a mean vessel diameter of 7.2-9.9 mm at the distal edge of the Eluvia™ implantation site. However, intermittent claudication on the right side recurred again 50 months after Eluvia™ implantation. Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Furthermore, peri-stent contrast staining was found at the distal part of the Eluvia™ implantation site. Intravascular ultrasound showed a further enlargement of mean vessel diameter to 11.9 mm at the distal edge of the Eluvia™ stent. Moreover, enlargement of the lumen and stent malapposition were also found, suggesting exacerbated aneurysmal degeneration 50 months after Eluvia™ implantation.Conclusions: We report a case with exacerbated aneurysmal degeneration on serial angiography and intravascular ultrasound 50 months after Eluvia™ implantation for an SFA lesion. Long-term follow-up should be mandatory for patients receiving Eluvia™ implants.

Ectopic pregnancy: a single-center experience over ten years

Purpose The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality. Methods This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, β-human chorionic gonadotropin (β-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA). Results The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10− 5) that was diagnosed in the 7th gestational week. The only association found was between the β-HCG level and LOS, with a linear regression β coefficient of 0.01 and a P-value of 0.04. Conclusion EP is a relatively common condition affecting approximately 1% of all pregnancies. β-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

Optimal Implantation Site of Orthodontic Micro-Screws in the Mandibular Anterior Region Based on CBCT

Background: To determine the optimal implantation site of orthodontic micro-screws based on cone beam computed tomography (CBCT) analysis in the mandibular anterior tooth region, provide a theoretical basis for orthodontic implant placement and improve post-implantation stability.Methods: Forty patients who underwent CBCT scanning were selected for this study. CBCT scanning was applied to measure the interradicular distance, buccolingual dimension, labial cortical bone thickness and lingual cortical bone thickness between mandibular anterior teeth at planes 2, 4, 6, and 8 mm below the alveolar ridge crest. The data were measured and collected to obtain a comprehensive evaluation of the specific site conditions of the alveolar bone.Results: The interradicular distance, buccolingual dimension and labial cortical bone thickness between the mandibular anterior teeth were positively correlated with the distance below the alveolar ridge crest (below 8 mm). The interradicular distance, buccolingual dimension, labial cortical bone thickness, and lingual cortical bone thickness were all greater than those in other areas between the lateral incisor root and canine incisor root 4, 6, and 8 mm below the alveolar ridge crest.Conclusion: The area between the lateral incisor root and the canine incisor root in planes 4, 6, and 8 mm from the alveolar ridge crest can be used as safe sites for implantation, while 8 mm below the alveolar ridge crest can be the optimal implantation site. An optimal implantation site can be 8 mm below the alveolar ridge crest between the lateral incisor root and the canine incisor root.

Leadless pacemakers: does location matter?

Funding Acknowledgements Type of funding sources: None. Introduction Leadless pacemakers (LPs) provide a viable alternative for patients who have an indication for pacing where transvenous pacing is not desirable or possible. Registries have demonstrated stable performance associated with LPs. There is preference towards implanting LPs into the trabeculated septum rather than the apex or free wall. We report our experience with the impact of the implantation site on acute and long-term electrical performance of LPs. Methods We ran a retrospective analysis on the first 100 LPS implanted at our centre. Two independent observers reviewed the fluoroscopic images and post-implant chest x-rays to classify the LPs’ positions. We obtained the recorded pacing threshold , R-wave amplitude and impedance of the devices at the time of implant and at the latest available routine device follow-up. We used one-way ANOVA testing to compare the acute and long-term electrical performance of the LPs between different implantation sites. Results We were able to classify the site of the LPs implants in a total of 90 patient. 84 Patients (60% male) 57.3± 22.16 years were included .23.8% of the patients presented with syncope. Indications for pacing were symptomatic sinus node dysfunction (33.3%), high grade AV block (34.5%), bradyarrhythmia associated with atrial tachyarrhythmias (28.6%) and other indications (3.6%). We had a 100% successful implant rate, 85.7% required ≤2 attempts and 71.4% required one attempt. A total of 32 implants were in the apex (38.1%), 26 in mid-septum (30.9 %), 13 in the apical septum (15.5%), 12 on the septal aspect of the right ventricular inflow (14.3%) and 1 implant (1.2%) in the septum of the RV outflow tract. The follow up period of the 84 patients was 3.09 ± 1.97 years. 100% of the LPs had the pacing thresholds <2.0 V @0.24 ms at the time of implant. Pacing threshold, R-wave amplitude, and impedance averaged at 0.67 ± 0.41 V, 10.86 ± 5.41 mV, and 775 ± 193.28 Ohms respectively at the time of implantation and 0.66 ± 0.39 V, 14.08 ± 6.14 mV, and 564.29 ± 96.76 Ohms at the last device check. There was no statistically significant difference in either the pacing thresholds or the impedance between implant sites. Post hocTukey’s analysis (excluding the outflow tract case) demonstrated significant statistical difference in the R-wave amplitudes between implants at the apex and the mid-septum both at the time of implantation (12.9 ± 6.1 mV and 8.53 ± 2.84 mV; p = 0.0196) and at follow up (15.97 ± 5.35 mV and 11.52 ± 5.01 mV; p = 0.0415). There were no differences between other sites Conclusions Our analysis demonstrated that aside from the difference between the sensed R wave amplitudes between LPs implanted at the apex and those implanted at mid-septum , there was no statistically significant difference in the acute or the long term electrical performance of implanted LPs regardless of the implantation site. A limitation to our analysis is the relatively low number of LP implants included in our analysis. Abstract Figure. Mean of parameters by validated position