Epithelioid trophoblastic tumor of the lower uterine segment and cervical canal:A case report

BACKGROUND Epithelioid trophoblastic tumor(ETT) is the rarest type of gestational trophoblastic tumor(GTT). It has been reported that more than 50% of ETTs arise in the uterine cervix or the lower uterine segment. Here, we report a case of ETT within the lower uterine segment and cervical canal and discuss its manifestations,possible causes, and related influencing factors.CASE SUMMARY A 35-year-old woman(gravida 7, miscarriage 3, induction 2 with 1 being twins,para 2 of cesarean section, live 2), who had amenorrhea for 9 mo after breastfeeding for 22 mo after the last cesarean section, was diagnosed with ETT. The lesion was present in the lower uterine segment and endocervical canal with severe involvement of the anterior wall of the lower uterine segment and the front wall of the lower uterine segment where the cesarean incisions were made.Laboratory tests showed slight elevation of serum beta-human chorionic gonadotropin. Intraoperative exploration showed the presence of a normal-sized uterus body with an enlarged tumor in the lower uterine segment. The surface of the lower uterine segment was light blue, the entire lesion was approximately about 8cm × 8 cm × 9 cm, with compression and displacement of the surrounding tissue.Histological examination diagnosed ETT. Immunohistochemical analysis showed positive expression of p63, with a Ki-67 proliferation index of 40%.CONCLUSION A search of the PubMed database using the search terms "cesarean section" and "epithelioid trophoblastic tumor" retrieved nine articles, including 13 cases of ETT and ETT-related lesions, all 13 cases had a history of cesarean section, and the lesions were all located at the cesarean section incision on the anterior wall of the lower uterine segment. The present case is the 14th reported case of ETT after cesarean section. Therefore, we deduced that cesarean section trauma had an important effect on the occurrence of ETT at this site.

Measurements of the Lower Uterine Segment at Term in Women with Previous Cesarean Delivery

Purpose: To evaluate the accuracy of sonographic measurements of the lower uterine segment (LUS) thickness at term in predicting uterine scar defects in women with previous Cesarean delivery (CD). Methods: Eighty-nine pregnant women who underwent CD between 37 and 41 weeks of gestation from 2013 to 2015 were enrolled in this study and divided into two groups. Group A consisted of women with previous CD, and Group B consisted of women with previous vaginal deliveries. We performed an ultrasound evaluation of the myometrial and full thickness of LUS (mLUS and fLUS) transvaginally before a CD and evaluated the appearance of LUS during surgery, which was defined as follows: grade I, well-developed;grade II, thin without visible content;grade III, translucent with visible content;and grade IV, either dehiscence or rupture. Results: The median mLUS and fLUS were 1.50 and 4.07 mm in the group A, and 2.75 and 5.37 mm in the group B. We observed significant differences in the median mLUS and fLUS between grades I/II (2.07 and 4.37 mm) and grades III/IV (0.67 and 2.52 mm). Both mLUS and fLUS were predictive factors for grades III/IV and cutoff values were 0.97 mm of mLUS and 3.13 mm of fLUS, having a sensitivity of 87.5% and 75.0%, and a specificity of 87.7% and 91.4% in mLUS and fLUS measurement, respectively. Conclusion: Sonographic measurements of LUS at term may be a feasible and reliable method to predict uterine rupture or uterine dehiscence in women with prior CD.

Application of Abdominal Aortic Balloon Occlusion Combined with Tourniquet in Pregnant Women with Severe Placenta Accreta Spectrum

Objective Abdominal aortic balloon occlusion(AABO)is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum(PAS).The aim of this study was to investigate the benefits,potential risks,and characteristics of AABO combined with tourniquet binding of the lower uterine segment(LUS)in treatment of pregnant women with PAS.Methods In this study,64 pregnant women with PAS scores greater than 5 were enrolled as research subjects and divided into two groups.Group A(n=34)underwent normal operative procedures including tourniquet binding of the LUS.Group B(n=30)underwent AABO combined with tourniquet binding of the LUS.General clinical characteristics,ultrasonography PAS score,intraoperative blood loss(IBL),blood loss within 24 h after surgery(24-h BL),postoperative complications,and neonatal data of the two groups were retrospectively reviewed.The influencing factors of IBL for the two groups were analyzed.Results The amounts of IBL,24-h BL,total input red blood cell,and the incidence of disseminated intravascular coagulation were significantly lower in group B than in group A(P<0.05),and this difference was even more significant in the subgroup of placenta percreta(PAS scores≥10).Further multivariate linear analysis showed that the combined therapy of AABO and tourniquet could independently predict lower IBL than normal operative procedures did(P=0.001).Conclusion AABO combined with tourniquet binding of the LUS could improve the outcomes of pregnant women with severe PAS and reduce serious peripartum complications of AABO.

Clinical Analyses of 66 Cases of Mid-trimester Pregnancy Termination in Women with Prior Cesarean

Background：The rate of cesarean delivery has significantly increased in China in the last decade.Women with prior cesarean history tend to have a higher risk of uterine rupture during termination of the pregnancy in mid-trimester than those without such a history.The aim of our study was to evaluate the influences of the potential risk factors on uterine rupture in women with prior cesarean.Methods：We conducted this retrospective study of women with prior cesarean section,who underwent mid-trimester pregnancy termination between January 2006 and December 2013 in Peking Union Medical College Hospital.The protocol was oral administration ofmifepristone and misoprostol for the patients with the gestational ages below 16 weeks or intra-amniotic injection of ethacridine lactate （EL） for those with at least 16 weeks of gestational ages.The thickness of the lower uterine segment （LUS） was measured before the termination of pregnancy.Logistic regression was used to study the risk factors of uterine rupture.Results：The total rate of successful abortion was 93.9％ （62/66）.Four patients failed in induction,and one of them received curettage,whereas the other three experienced uterine rupture （4.5％）.The successful rates of abortion were 85.7％ （30/35） for women treated with mifepristone-misoprostol and 86.1％ （31/36） for those treated with EL.There was a significant difference in the mean LUS thickness between the uterine rupture group （3.0 ± 2.0 mm） and the nonrupture group （7.0 ± 3.0 mm） （P ＜ 0.05）.The LUS thickness of＜3 mm was associated with uterine rupture during mid-trimester pregnancy termination in women with prior cesarean （odds ratio,94.0; 95％ confidence interval 4.2-2106.1） after adjusted maternal age,gestational age,interdelivery interval and prior cesarean section.Severe bleeding that required transfusion occurred in one case （1.5％）.Conclusions：Both the mifepristone-misoprostol and the EL regimens were effective and safe for the termination of mid-trimester pregnancy in women with prior cesarean.A thinner LUS is associated with a relatively high risk of uterine rupture.