Epstein–Barr Virus and Cytomegalovirus in Autoimmune Diseases

Epstein–Barr Virus and Cytomegalovirus in Autoimmune Diseases
O. BARZILAI a , Y. SHERER a , M. RAM a , D. IZHAKY a , J.M. ANAYA b , AND Y. SHOENFELD a , c
a Center for Autoimmune Diseases, Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel b Cellular Biology and Immunogenetics Unit, CIB-Universitario del Rosario, Medellin, Colombia c Sackler Faculty of Medicine, Incumbent of the Laura Schwarz-Kip Chair for Research of Autoimmune Diseases, Tel Aviv University, Tel Aviv, Israel
Address for correspondence: Yehuda Shoenfeld, M.D., F.R.C.P., Department of Medicine B and Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel. Voice: +972-3-5302652; fax: +972-3-5352855.
shoenfel@post.tau.ac.il
Copyright 2007 New York Academy of Sciences
KEYWORDS
autoimmunity • EBV • cytomegalovirus • autoimmunity • multiplexed assay
ABSTRACT
Abstract : To date, it is believed that the origin of autoimmune diseases is one of a multifactorial background. A genetic predisposition, an immune system malfunction or even backfire, hormonal regulation, and environmental factors all play important roles in the pathogenesis of autoimmune diseases. Among these environmental factors, the role of infection is known to be a major one. Epstein–Barr virus (EBV) and cytomegalovirus (CMV) are considered to be notorious as they are consistently associated with multiple autoimmune diseases. A cohort of 1595 serum samples, of 23 different autoimmune disease groups, was screened for evidence of prior infection with EBV and CMV. All samples were screened for antibodies against EBV nuclear antigen-1 (IgG), EBV viral capsid antigen (IgG and IgM), EBV early antigen (IgG), EBV heterophile antibody, and CMV (IgG and IgM) antibodies using Bio-Rad's BioPlex 2200. A new association is proposed between EBV and polymyositis, as results show a significant increase in titers of various EBV target analytes when compared with healthy controls. Our results also support prior information suggesting the association between EBV and multiple autoimmune diseases, including SLE, antiphospholipid syndrome, rheumatoid arthritis, multiple sclerosis, pemphigus vulgaris, giant cell arthritis, Wegener's granulomatosis, and polyarteritis nodosa (PAN). Elevated CMV IgG titers were observed in sera of SLE patients. Our data support the theory that EBV is notoriously associated with many autoimmune diseases. CMV appears to be associated to autoimmune diseases as well, yet establishing this theory requires further investigation

Screening for vaginal shedding of cytomegalovirus in healthy pregnant women using real-time PCR: Correlation of CMV in the vagina and adverse outcome

Screening for vaginal shedding of cytomegalovirus in healthy pregnant women using real-time PCR: Correlation of CMV in the vagina and adverse outcome of pregnancy
Kaori Tanaka 1, Hideto Yamada 2, Mashiho Minami 2, Soromon Kataoka 2, Kei Numazaki 3, Hisanori Minakami 2, Hiroyuki Tsutsumi 1 *
1Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
2Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
3Department of Virology 3, National Institute of Infectious Diseases, Tokyo, Japan

email: Hiroyuki Tsutsumi (tsutsumi@sapmed.ac.jp)

*Correspondence to Hiroyuki Tsutsumi, Department of Pediatrics, Sapporo Medical University School of Medicine, Chuo-ku S-1, W-16, Sapporo 060-8543, Japan.

Funded by:
Ministry of Education, Culture, Sports, Science and Technology of Japan; Grant Number: 17659510
Ministry of Health, Labor and Welfare of Japan

Keywords
cytomegalovirus • real-time PCR • miscarriage • pregnancy • vaginal swab


Abstract
The impact of cytomegalovirus (CMV) infection of the genital tract during pregnancy on adverse pregnancy outcomes is not understood fully. A real-time PCR assay was used to determine vaginal shedding of CMV in 993 healthy pregnant Japanese women and the results were compared with the outcome of pregnancy. CMV DNA was detected in 76 (7.7%) of the women. The outcome of pregnancy could be determined finally in 848 women, of whom 60 (7.1%) were CMV positive. The carriers of CMV had an increased miscarriage rate (RR 6.96, 95% CI 2.04-23.84, P < 0.01). These findings suggest that latent genital tract CMV infection predisposes to adverse pregnancy outcomes. J. Med. Virol. 78:757-759, 2006. © 2006 Wiley-Liss, Inc.



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Accepted: 1 March 2006

LAPAROSCOPY INFORMATION

Laparoscopy 090107
LAPAROSCOPY INFORMATION
The laparoscope is placed in an incision in the
belly button in order to see. Other incisions
may also be made for lasers and instruments
for major surgery. Dr. Martin is usually assisted
by surgical assistants or by hospital personnel.
Other doctors in practice or in training will be
introduced to you if they are present.
Laparoscopy is usually an out-patient procedure.
• You may be asleep from 1 to 4 hours.
• Common side effects include operative pain,
shoulder pain, bloating, bleeding, bladder
spasm, itching when shaved, sore throat, and
leaking of the flotation fluid.
• Nausea and vomiting may occur following
surgery. Have a plastic bag and towels in
your car in case this happens going home.
• 1 in 150 patients stay overnight due to
nausea, drowsiness or pain.
Problems such as bleeding, urinary retention,
infection, pneumonia, allergy or leg clots require
hospitalization in 1 in 400 basic laparoscopies.
Long term pain from scarring, nerve entrapment,
or tissue damage can follow any surgery. Major
problems may require surgery or blood
transfusion. The chance of a major problem is
reported at 1 in 1,250 sterilization laparoscopies
and 1 in 100 complex laparoscopies. More than
1 in 20 of some difficult cases may require open
surgery. Hysterectomy, decreased sexuality,
paralysis, colostomy, coma or death is rare. The
chance of problems increases with time,
difficulty, previous surgery, adhesions and
weight. Surgery may be limited or stopped if
there is increased risk. Other possibilities exist
and I am unable to guarantee a successful
completion or outcome of any surgery.
On rare occasion, unexpected cancer may be
found. Fertility patients generally benefit by
waiting for the accuracy of permanent sections.
Patients who are not interested in preserving
fertility may wish to proceed to hysterectomy on
the basis of a quicker but less accurate frozen
section in order to avoid a second surgery.
Pictures may be taken during surgery to show
you what was seen and done. They are also
used to teach other patients and other surgeons.
After surgery
• You should avoid any activities that
require concentration for 2 days.
• You may have soreness, tenderness, burning
or tingling for 3 weeks to 12 weeks.
• You can usually return to work and normal
tasks by 3 to 10 days.
• You may take 3 to 10 weeks for your
energy to return.
• You can usually start having sex after your
post-op visit.
If your tubes are scarred, you will need
sonograms and blood pregnancy tests early in
pregnancy to check for tubal pregnancy.
Treatment by 3 to 4 weeks may save the tubes.
Laparoscopy generally has fewer problems than
open surgery (laparotomy). However, some
problems can be hard to control at laparoscopy
and open surgery may be needed to care for
an emergency and to limit severe damage. In
some situations, open surgery is safer and better
than laparoscopy. Additional preparation such
as medication, bowel prep or banking your own
blood may be useful in some situations. Open
surgery generally requires 1 to 5 days in the
hospital, 2 to 8 weeks for recovery, and 2 to 6
months for complete return of energy. If there
are reasons for this before surgery, we will make
plans for decisions about open surgery.
Otherwise, we will stop and make decisions
later when this can be delayed safely and
reasonably.
Your insurance plan may not cover the total cost
of extensive operative laparoscopy. In addition,
some insurance plans have participating
physicians. You should clarify your insurance
coverage before you schedule surgery.
Please read this at home and ask questions before the day of surgery.
Dan C. Martin, M.D. UT Medical Group, Inc. 7945 Wolf River Boulevard, Suite 320 Germantown, TN 38138
Phone: 901-347-8331 - Fax: 901-347-8188
Laparoscopy090107
POSTOPERATIVE INSTRUCTIONS
LAPAROSCOPY
HYSTEROSCOPY / D&C
After surgery your concentration and energy
levels will be low due to the surgery and
anesthesia. For the first 48 hours, do not
make decisions, drive a car, use electrical
appliances or participate in activities that
require concentration or energy. If you have
stairs to go up, do so when you are rested.
You can usually resume light to moderate
activities in one to three days. Major
activities and heavy lifting can be resumed
two to five days after surgery. You can
usually return to work by two to five days.
You may be sore and have less energy than
normal for three to ten weeks.
You can usually start having sex after your
post-op visit.
Call the office with:
Vaginal bleeding heavier than a
menstrual flow,
Temperature over 100 degrees for more
than four hours,
Cramping abdominal pain more than a
menstrual period,
Nausea with vomiting, or
Any questions you have.
LAPAROSCOPY
Expect abdominal swelling for two to six
weeks. You may notice a knot in the area of
the incision. This is the absorbable stitch
before it has had time to dissolve. The
incision may be tender for one to four
weeks. You may have spotting or bleeding
for 10 days.
You may have shoulder pain particularly in
the right shoulder. This pain is related to
irritation from surgery and from the gas that
remains after surgery. This may get better if
you lay on your right side to move the gas to
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abdomen to push out the gas; this may leak
out of the incision and may have a small
amount of blood.
You may experience vaginal drainage of a
blue dye if it was used to check the tubes.
You can start on regular diet today / ______.
Your bandaids can be taken off tomorrow.
The steristrips should stay on for five days.
You can bath or shower with the Steristrips.
HYSTEROSCOPY AND/OR D&C
(DILATATION AND CURETTAGE)
A small amount of bleeding is common for
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after the bleeding has stopped. Call if this is
heavier than a menstrual period or lasts more
than 10 days.
HYSTEROSALPINGOGRAM (X-RAY)
After a hysterosalpingogram, you may
experience vaginal drainage of the dye.
MEDICATION
Pain medication, gas medication, and other
medications should be taken as prescribed.
Use Aleve 220 mg or Motrin 600 mg every
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Dan C. Martin, M.D. UT Medical Group, Inc. 7945 Wolf River Boulevard, Suite 320 Germantown, TN 38138
Phone: 901-347-8331 - Fax: 901-347-8188

MULTI-FOCAL EXTRA-UTERINE ENDOMETRIAL STROMAL SARCOMA (ESS): A VERY RARE COMPLICATION OF ENDOMETRIOSIS ASSOCIATED WITH ELEVATED SERUM CA-125

Endometrial stromal sarcomas (ESS) in the female
genital tract are uncommon and are usually of
uterine origin.1,2,3 Extra-uterine ESS are extremely
rare. Only 86 cases have been reported in the
literature.2,4 More than 50% of the cases were associated
with pre-existing endometriosis. We report a case of
extrauterine low grade ESS associated with extensive
endometriosis of the pelvis. We suspected that the tumor
was a primary ovarian carcinoma due to elevated serum CA-
125.
Case Report
The patient was a 45-year old premenopausal, multiparous
female (8 + 2). The patient presented with lower
abdominal pain of 6 months duration associated with nausea
and constipation.
Her medical history included myomectomy for
leiomyomas 17 years prior to this presentation. The patient
was diabetic and hypertensive. Physical examination
revealed a mass in the abdominal-pelvic region measuring
15 x 12 centimeters. Serum CA-125 was three times the
normal range (197 mmol/L). Abdominal pelvic
ultrasonography revealed an abdomino-pelvic mass of mixed
echogenecity measuring 13 x 13 centimeters and located on
the right side of the pelvis. The uterus was normal in size. A
CT scan of the abdomen and pelvis showed a large
heterogenous pelvi- abdominal mass with the epicenter in
the region of the pelvic wall (Figure 1). The mass appeared
adherent to the uterus and bowel wall. Laparotomy was
performed and a mass adherent to the fundus of the uterus,
the pelvic cul-de-sac and the bowel was found. There were
multiple variable-sized nodules found in the wall of the
pelvis, fallopian tubes and pelvic peritoneum. Total
abdominal hysterectomy and bilateral salpingooophorectomy
with debulking was performed. The patient
was given progesterone therapy (MegaceR ) and was
discharged.
Grossly the tumor was
composed of multiple yellow-tan
fleshy nodules with focal cystic
areas. Focal areas of hemorrhage
and necrosis were identified. The
tumor was near the right adnexa.
The uterus, fallopian tubes and
MULTI-FOCAL EXTRA-UTERINE ENDOMETRIAL STROMAL SARCOMA (ESS):
A VERY RARE COMPLICATION OF ENDOMETRIOSIS ASSOCIATED WITH
ELEVATED SERUM CA-125
W.A. Mourad, MD FRCPC; B. Abdelghaffar, MD; A.Tulbah, MD FRCPA; M.Tulbah, MD; J. Subhi, MD
From the Department of Pathology and Laboratory Medicine, King Faisal Specialist
Hospital and Research Centre, Riyadh, Saudi Arabia
Correspondence to:
Dr. W. Mourad
P.O. Box 3354 MBC 10
Riyadh 11211
Saudi Arabia
Accepted for publication:
December 2002
Figure 1. Pelvic CT scan showing a heterogenous mass
attached to the left pelvic wall.
CASE REPORT
181 ¥ Annals of Saudi Medicine ¥ 2003 May-July, Volume 23 www.kfshrc.edu.sa/annals
ovaries showed multiple tumor nodules. Microscopically, the
tumor consisted of diffuse sheets of small closely packed
cells with uniform round oval nuclei with coarse, evenly
dispersed chromatin and small inconspicuous nucleoli. The
cytoplasm was scanty and its boundaries were not well
defined. A distinct vascular pattern was identified (Figure
2). This pattern was more prominent on the reticulin stain
(Figure 3). Mitotic figures were less than 1 in 10 /high power
field. No cellular atypia or pleomorphism were identified.
The tumor was strongly positive for estrogen and
progesterone receptors (Figure 4). Multiple deposits of the
tumor were identified in the omentum. The ovaries and tubes
showed multiple foci of tumor and endometriosis (Figure
5). The endometrium showed cystic hyperplasia without
evidence of ESS.
Discussion
Extra-uterine ESS are very rare neoplasms. We found
86 cases in the literature.2,4,8-10 Young et al. studied 23 cases
of ovarian ESS and found 9 cases to be primarily in the
uterus.10 In his study only 10 cases appeared to be well
documented extra-uterine ESS. Chang et al. reported 20
cases.4 We found that 48 of the 86 reported cases arose in
the ovary and 33 were of extra-ovarian origin, including the
vaginal septum, fallopian tube, broad ligament, and
abdominal cavity. Thirty seven cases were documented as
associated with endometriosis.2,4,8,10 It seems from the
Mourad et al.
Multi-Focal Extra-Uterine ESS
2 3
4 5
www.kfshrc.edu.sa/annals Annals of Saudi Medicine ¥ 2003 May-July, Volume 23 ¥ 182
literature and from our case that ESS is closely related to
endometriosis and represents an exceedingly rare
complication of that common disease.
Our patient presented with abdominal and back pain,
constipation, a pelvic mass and ascites. Radiological
investigation showed a multi-cystic pelvic mass close to the
ovary with an associated elevation of serum CA-125. This
clinical and radiographic presentation is suggestive of an
ovarian neoplasm. Eighty-two percent of ovarian epithelial
tumors are associated with elevated levels of serum CA-125.
A pelvic mass with elevated levels of CA-125 would suggest
ovarian carcinoma. The latter, however, is associated with
levels of CA-125 above 1000 mmol/L in most reported cases.
Elevation of serum CA-125 in endometriosis is usually less
than 1000 mmol/L. Mild elevation of CA-125 in our case
(197 mmol/L) is probably related to pelvic endometriosis.
There have been reports showing evidence of elevated serum
CA-125 in association with extensive endometriosis.3,6
These reports suggest that endometriosis may cause
mesothelial hyperplasia, which may lead to elevation of
serum CA-125. Barbieri et al. found elevated serum levels
of CA-125 in half of the patients with advanced endometriosis
they have studied. They also found that the levels could be
raised in pregnancy, leiomyomata and pelvic inflammatory
disease
Extra-uterine ESS usually behaves like its endometrial
counterpart,1,4,10 but its behavior is dependent on the grade
of the tumor. Low grade tumors with a low mitotic rate and
lacking atypia and pleomorphism behave in a more benign
manner than the high grade neoplasms.7,8,10
The role of hormonal therapy is well documented in these
low grade tumors.1,2,5,7,8 Steroid receptor detection by
immunohistochemistry is valuable. It was also noted that
tumors that expressed both estrogen and progesterone
Figure 2. Section of pelvic tumor showing polygonal cells with indistinct cell boundaries with coarse nuclear chromatin and a
prominent vascular pattern. Figure 3. Prominent vascular pattern of the tumor as seen on the reticulin stain. Figure 4. Strong
expression of the tumor cells for estrogen receptors. Notice the lack of expression in the blood vessels. Figure 5. Focus of
andometriosis in soft tissue adjacent to the fallopian tube.
2 3
4 5
Mourad et al.
Multi-Focal Extra-Uterine ESS
183 ¥ Annals of Saudi Medicine ¥ 2003 May-July, Volume 23 www.kfshrc.edu.sa/annals
3. Barbeiri R, Niloff J, Bast J, Schatzel E, Kistner R, Knapp R.
Elevated serum concentrations of CA 125 in patients with advanced
endometriosis.Fertil Steril 1986;45: 630-4.
4. Chang K, Crabtree G, Lim-Tan S, Kempson R, Hendrickson M.
Primary extra-uterine endometrial stromal neoplasms: A
clinicopathologic study of 20 cases and review of the literature. Int J
Gynecol Pathol 1993;12:282-96.
5. Katz L, Merino M, Sakamoto H, Schwartz P. Endometrial Stroma
Sarcoma: A Clinocopathologic study of 11 cases with determination
of Estrogen and Progestin Receptor Levels in Three cases. Gyn
Oncol 1987;26:87-97.
6. Myers T, Arena B, Granai C. Pelvic endometriosis mimicking
advanced ovarian cancer: Presentation with pleural effusion, ascites,
and elevated serum CA125 level. Am J Obstet Gyn 1995;173(3):
966-7
7. Nordal R, Kristensin G, Karen J, Stenwig A, Petersen E, Trope C.
The Prognostic Significance of Surgery, Tumor size, Malignancy
Grade, Menopausal Status, and DNA Ploidy in Endometrial Stroma
Sarcoma. Gyn Oncol 1996;62:254-9.
8. Shakfeh SM, Woodruff D. Primary Ovarian Sarcomas: Report
of 46 cases and review of the literature. Obstet Gynecol Surv 1987;
42:331-49.
9. Shiraki M, Otis C, Powell J. Endometrial Stromal Sarcoma arising
from ovarian and extraovarian endometriosis Ð Report of two cases
and review of the literature. Surg Pathol 1991;4(4):333-42.
10. Young R, Prat J, Scully R. Endometrioid Stromal Sarcoma of
the Ovary: A Clinicopathological analysis of 23 cases. Cancer 1984;
53: 1143-55.
receptors have benefited from progesterone therapy;
especially low grade tumors.1,5,8 Baggish et al. reported a
case of pulmonary nodule of low grade ESS which recurred
three years after surgery.1 The patient received progesterone
therapy and the lesion disappeared within 15 months. Katz
et al. followed four patients treated with progesterone.5 All
patients were free of disease after follow-up of 2 to 6 years.
Treatment by progesterone should be long term because
of the possibility of recurrence after discontinuation of
therapy.5,8 It also appears that treatment with total abdominal
hysterectomy and salpingo-oophorectomy with debulking of
any residual tumor in addition to hormonal therapy would
be sufficient treatment for these neoplasms.
We believe that extra-uterine ESS is an exceedingly rare
complication of endometriosis and that on rare occasion can
be associated with an elevated level of serum CA-125 if the
endometriosis is extensive. These levels, however, do not
reach the values reached in primary ovarian carcinomas.
References
1. Baggish M, Woodruff D. Uterine Stromatosis. Clinicopathologic
features and Hormone Dependency. Obstet Gynecol 1972; 40:4.
2. Baiocchi G, John J, Kavanagh J, Wharton J. Endometrioid
Stromal Sarcomas arising from ovarian and extraovarian
endometriosis: Report of two cases and review of the literature.
Gynecol Oncol 1990;36: 147-51.

Elevation of tumour marker CA-125 in serum & body fluids: interpret with caution

Commentary
Elevation of tumour marker CA-125 in serum & body
fluids: interpret with caution
Indian J Med Res 125, January 2007, pp 10-12
The cancer antigen (CA) -125 is a high molecular
mass glycoprotein produced both by ovarian cancer
cells as also by normal cells of tissues derived from
coelomic epithelium. Serum CA-125 levels are used
as a marker of tumour activity in patients known to
have ovarian carcinoma1 and commercial tests for
serum CA-125 have been available since 1983. In
women with histologically proven ovarian
carcinoma, levels of serum CA-125 are elevated
>35 U/ml in more than 80 per cent of cases. Levels
are also measured after debulking surgery and during
chemotherapy.
Response to chemotherapy is quite usefully
assessed in ovarian carcinoma patients who have a
high persisting level of serum CA-125 after surgery.
It provides the oncologist with a marker of disease
activity that should drop progressively with each
successive dose of treatment. Ease of access to the
glycoprotein marker in the blood is crucial to its
practical use in the clinic. Relapse after completion
of treatment for ovarian carcinoma may also be
monitored using serum CA-125 levels, especially in
those patients who had a high tumour marker level
prior to their initial treatment. A relatively small
proportion, nearly 20 per cent, of ovarian carcinoma
patients will not produce elevated serum CA-125
levels and is termed “marker negative”. Repeated
measurement of this marker will not usually provide
useful information and can be omitted.
However, elevation of CA-125 levels may occur
in malignant conditions other than ovarian cancer,
in benign diseases and in 1-2 per cent of normal
healthy individuals. Some of the malignant
conditions associated with elevated tumour marker
include lung, bladder, gastric, hepatic and pancreatic
cancers, leukaemia, non-Hodgkin’s lymphoma and
mediastinal teratoma. This tumour marker is also
elevated in pleural effusion associated with Meigs’
syndrome secondary to ovarian fibroma and pseudo-
Meigs’ syndrome related to other benign pelvic
tumours2.
Benign conditions associated with elevated CA-
125 levels are diverse and include cardiac failure,
pleuropulmonary diseases, chronic liver disease,
connective tissue disease, peritoneal dialysis and
recent surgery. In a Spanish study of 380 randomly
selected patients attending a general hospital clinic,
16 per cent had CA-125 levels greater than 35 U/
ml3. The most frequent diagnoses in women were
pulmonary diseases and heart failure, and the most
frequent diagnosis in men was hepatic cirrhosis.
These benign conditions generally represent injury
or proliferation of mesothelial cells leading to serosal
effusions (pleural effusion or ascites). Given the
similar embryonic developmental origins of
peritoneal and pleural lining cells, it is hardly
surprising that irritation or inflammation of either
tissue results in an elevated secretion of CA-125 into
the fluid.
Serum CA-125 levels are generally found to be
higher in malignant conditions compared to benign
conditions. Any cut-off value should be interpreted
with caution. Levels exceeding 1000 U/ml have
been described in benign conditions associated with
10
massive pleural effusion and ascites4. Kalantri et
al5 in this issue have studied CA-125 levels in
pleural effusion and ascitic fluid. In this study, all
patients with ascites and 70 per cent with pleural
effusion had elevation of tumour marker in body
fluid when the aetiology was tuberculous or
pyogenic. Levels of tumour marker were
significantly higher in ascitic fluid compared with
pleural effusion leading to suggestion that
peritoneal epithelium had a greater capacity to
secrete CA-125 than pleural epithelium. Their
findings are in contrast with another recent study
from India where elevated CA-125 in peritoneal
fluid was found in only one out of 36 patients with
TB peritonitis6. Measurement of ascitic fluid levels
of tumour markers like CA-125 has never been a
routine part of ovarian cancer management in the
clinic, for various reasons. Likewise, CA-125 levels
in pleural fluid are not routinely measured for
ovarian or other cancers. Simultaneous
measurement of CA-125 in serum and body fluids
and/or simultaneous assay of CA-125 with a panel
of other tumour markers may improve diagnostic
accuracy in malignant and non-malignant diseases.
Elevation of CA-125 in serum, and less
commonly in other body fluids, will continue to
challenge the diagnostic acumen of physicians. The
challenges are likely to be greater for physicians
managing patients of South Asian ethnicity. The first
scenario can be of a female patient with large pleural
effusion, negative tuberculin skin test, negative TB
smears, negative cytology and markedly elevated
CA-125 level. While in a 20 yr old the diagnosis of
malignant effusion may be difficult to accept but in
a 70 yr old such a diagnosis can be easily proposed
by the physician and a terminal prognosis accepted
by the family. Systemic symptoms of anorexia,
weight loss and cachexia are common to TB, cancer
and other systemic diseases. In tuberculous pleural
effusion smear examinations for acid fast bacilli are
rarely positive. TB culture takes several weeks to
report and the yield of positive culture result is low.
In such a case needle pleural biopsy would be the
investigation of choice as it is minimally invasive
and is likely to be positive showing chronic
granulomatous inflammation in majority of patients
with TB effusion.
Differentiation between abdominal TB and
malignancy may be even more difficult. Abdominal
distension, abdominal pain, abdominal mass and
weight loss are common symptoms. Abdominal TB
is associated with omental thickening, mesenteric
lymphadenopathy, pelvis or tubo-ovarian mass,
ascites and elevation of CA-125 levels in serum and
ascitic fluid. Ascitic fluid examination reveals an
exudate with lymphocyte predominance. Yield of TB
smear and culture remains very low. Tuberculin skin
test has limited usefulness in high prevalence area
and a negative skin test may be seen in many patients
with histologically confirmed abdominal TB7. While
detection of Mycobacterium by polymerase chain
reaction has high sensitivity but availability, cost and
quality control are important limiting factors in
developing countries. Peritoneal biopsy (e.g.,
laparoscopic) would clinch the diagnosis in such
cases. Response to anti-TB therapy is apparent within
few weeks, with symptoms improving first but
resolution of inflammatory masses may take several
months.
Chronic liver disease, secondary to viral or toxic
cause, is another common medical condition that is
prevalent in South Asian developing countries. In
advanced disease stages, rapidly declining general
health is associated with abdominal distension and
pleural effusion. Pleural effusion is a transudate that
is often large (hepatic hydrothorax). This may be
recurrent mimicking malignancy and may become a
source of considerable discomfort. Very high levels
of CA-125 may suggest an underlying ovarian cancer
but raised tumour marker may also occur with
hepatocellular carcinoma or simply due to presence
of large amount of ascites and pleural effusion4.
Decisions based on elevated tumour marker may lead
to inappropriate management and suboptimal
symptom palliation.
HUSSAIN & CAMILLERI: CA-125 IN SERUM & BODY FLUIDS 11
From an oncologist’s point of view, it would
seem that there will be limited general application
of a test on ascitic or pleural fluid that does not
reliably distinguish between different malignant
tumours or indeed between benign and malignant
causes. The lack of specificity of this glycoprotein
makes its measurement unhelpful as a screening tool.
Serum CA-125 should, therefore, not be used as a
screening tool for picking up asymptomatic cases of
ovarian cancer. The American College of Physicians
(ACP), The European Group on Tumour Markers
(EGTM), The European Society of Medical
Oncology (ESMO), The National Institute for Health
(NIH) and The National Academy for Clinical
Biochemistry all agree on this point. Research is
ongoing on algorithms that calculate risk of ovarian
cancer based on serial CA-125 values and referral of
patients at highest risk for transvaginal sonography.
Use of the algorithm is currently being evaluated in
a trial with 200,000 women in the UK that will test
critically the ability of a two-stage screening strategy
to improve survival in ovarian cancer8.
A general physician may remember that some
common medical conditions can be associated with
elevated tumour marker in serum and in body fluids.
Cardiac failure and chronic liver disease can be
picked up by a careful bedside clinical examination.
Tuberculosis may be less easy to confirm and indeed
facilities for further confirmatory tests, in many under
resourced areas, may either be not readily available
or beyond the financial means. A therapeutic trial of
anti-TB medications for 4-6 wk would be justified if
doubt persists about the final diagnosis.
Finally from a researcher’s perspective, CA-125
is an ovarian tumour marker and the challenge is to
detect early stage ovarian cancer that can be cured
with currently available therapy. CA-125 is also a
marker of mesothelial proliferation and there is still
much to learn about the mechanisms of CA-125
production at various sites in the body and its
utilization in medical conditions other than ovarian
carcinoma.
Syed Fayyaz Hussain* & Philip Camilleri+
Kettering General Hospital &
University of Leicester, UK &
+Radiotherapy & Oncology Department
Northampton General Hospital, UK
*For correspondence:
e-mail: Syed.Hussain@kgh.nhs.uk
References
1. Bast RC Jr, Xu FJ, Yu YH, Barnhill S, Zhang Z, Mills GB.
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13 : 179-87.
2. Timmerman D, Moerman P, Vergote I. Meig’s syndrome
with elevated serum CA 125 levels: two case reports and
review of the literature. Gynecol Oncol 1995; 59 : 405-8.
3. Miralles C, Orea M, Espana P, Provencio M, Sanchez A,
Cantos B, et al. Cancer antigen 125 associated with multiple
benign and malignant pathologies. Ann Surg Oncol 2003;
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4. Hussain SF, Grayez J, Grigorian A, Green JT. A female
with massive pleural effusion and marked elevation of CA-
125. Postgrad Med J 2004; 80 : 300-1.
5. Kalantari Y, Naik G, Joshi SP, Jain A, Phatak S, Chavan
R, et al. Raised CA-125 in non-malignant pleural and
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12 INDIAN J MED RES, JANUARY 2007

Ovarian cancer in a woman previously diagnosed with endometriosis and an extremely high serum CA- 125 level

Ovarian cancer in a woman previously diagnosed
with endometriosis and an extremely high serum CA- 125
J. H. Check’, M. L. Check’, D. Kiefer’, J. Aikins* Jr.
‘The lJniversi@ of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden,
Cooper Hospital/University Medical Centel; Department of Obstetrics and Gynecology,
Division of Reproductive Endocrinology & Infertility, Camden, New Jersey (USA);
‘Department of Gynecologic Oncology
Summary
83
level
Purpose: Follow-up of a woman with a serum CA-125 level > 1000 U/mL where laparoscopy only found endometriosis.
Methods: Case report - re-evaluation several years later.
Results: Extensive clear-cell carcinoma of ovary with metastases leading to death.
Corklusion: This case suggests that bilateral oophorectomy should be performed in women not desiring any more children if the
serum CA-125 level is very high even if only endometriosis is found initially.
Key words: CA-125; Clear cell carcinoma;‘Ovary; Endometriosis.
Introduction
Elevations in serum CA-125 levels have been associated
with epithelial ovarian cancer [2-41. However, an elevation
of this glycoprotein has been found in benign conditions
of the pelvis [5-II].
One of the benign conditions associated with elevated
CA-125 levels is endometriosis [6, 7, 10-161. Some cases
have been reported with serum CA-125 levels over 1,000
U/mL in women without ovarian cancer but with a diagnosis
of endometriosis [ 1, 16-211. The highest level to
date recorded was 9,300 IU/mL in a woman with a rnptured
endometriotic cyst [20], and the highest recorded
level without cyst rupture was 6,114 IU/mL [21].
The question arises as to whether women with very
high CA-125 levels and endometriosis have any greater
risk of developing subsequent ovarian carcinoma. When
high CA-125 levels are present in women no longer considering
pregnancy, the demonstration of endometriosis
involving the ovaries would normally result in oophorectomy
as performed by Nagara et al. [22]. The first case
report of a woman presenting with a serum CA-125 level
>I ,000 IU/mL was reported by Check et al. [ 11. However
for this patient who had a CA-125 level as high as 1,385
IU/mL, oophorectomy was refused by the 46-year-old
woman and she insisted on laparoscopy only with laser
fulguration of endometriosis for pelvic pain [I]. Unfortunately,
this woman, who was the first one described with
these extremely high levels, subsequently developed
ovarian carcinoma as described herein.
Case Report
A 46-year-old nulligravida with amenorrhea presented with
severe recurrent pelvic pain in 1989. She demonstrated a
24x23~22 mm cyst with low level internal echoes on the right
ovary. CA-125 was 149 IU/mL. Her levels were watched for five
Revised manuscript accepted for publication February 26,200 1
Clm. Exp. Obst. & Gyn. - MN: 0390.6663
XXVIII, n. 2, 2001
consecutive months and the levels rose to 231, 274, 267, 400,
and 1,385 IU/mL, respectively, as previously described [I].
Based on the very high CA-125 levels, the presumptive diagnosis
was possible ovarian cancer and referral to a gynecologic
oncologist with probable exploratory laparotomy was recommended
[l]. However the patient, who was a nun and a medical
technologist, refused laparotomy stating that she had almost
died from an arrhythmia related to her lupus cardiomyopathy
when having previous surgery.
She found a reproductive endocrinologist who was willing to
perform a laparoscopy with Yag laser fulguration of endometriosis
[ 11. The ovarian biopsy revealed ovarian stroma with
hemosiderin-laden macrophages, consistent with, but not diagnostic
of, endometriosis [1], since endometrial glands and
stromas were not identified. Postoperatively the CA- 125 level
was 122 IU/mL and five months later it was 150 IU/mL and
there was a recurrence of a right ovarian cyst [l]. Four years
following surgery her CA-125 dropped to 64 IU/mL.
The woman stopped coming for evaluation of the CA-125
level or pelvic sonography until May of 1999 (5 years from her
CA- 125 level of 64 IU/mL in 1994) complaining of marked
fatigue. An abdominal mass was easily palpated. Abdominal
ultrasound (she could not withstand the vaginal probe) showed
a 177x101~129 mm mass with complex echoes with an irregularly
shaped dense area and fluid seen inside of the mass. Fluid
was found in the left lower quadrant measuring 53x67~60 mm.
Hydronephrosis of the right kidney was found.
A CT scan of the abdomen and pelvis showed a large pelvic
mass measuring 14.4x10.7x12.0 cm with cystic and solid components
noted. The mass had septations and two foci of calcifications.
The mass was anterior to the uterus and midline. Also
severe right hydroureteral neophrosis and dilatation of the left
ureter secondary to this large mass was also noted.
Laparotomy was performed and the large tumor was excised
and identified as a clear cell carcinoma. The woman died one
year later.
Discussion
One of the problems with using the CA-125 assay to
diagnose ovarian cancer is that some ovarian cancers do
not demonstrate high CA-125 levels until they become
84 J. H. Check, M. L. Check, D. Kiefer; .I. Aikins Jr.
very advanced and some benign lesions, e.g. endometriosis,
may present with extremely high serum CA-125
levels. One study found that if the serum CA-125 level
was >I,000 IUlmL, 89% had gynecologic cancer, 7%
non-gynecologic cancers and 3% benign conditions [ 181.
One could certainly question that had bilateral oophorectomy
been performed when the CA-125 was so high ten
years earlier, might early cancer have been detected in the
patient described and could advanced metastatic disease
have been averted? Unfortunately, the patient refused
bilateral oophorectomy [I]. Frequent co-occurrence of
endometriosis in the same ovary has been found [23, 241.
However, it is possible that histopathological evaluation
of both ovaries might have found nothing more than
endometriosis.
There have been several publications suggesting that
the presence of endometriosis is associated with a greater
chance of developing carcinoma of the ovary [25-311.
The first case of suspected malignant transformation in
endometriosis was published in 1925 [32]. According to
15 published reports to date the incidence of ovarian
endometriosis in ovarian cancer is closely related to
histologic type, 3.3% - serous type, 3.0% - mutinous
type, 39.2% - clear cell type, and 21.2% - endometroid
type [24, 29, 33-451.
The number of reported cases of endometriosis and
very high CA-l 25 levels are small [ 1,221 and at least one
of them has already presented with advanced carcinoma
of the ovary several years later. It is possible that some
clinicians might use the aforementioned case report as an
example of how benign endometriosis can present with
very high CA- 125 levels and thus use this case as a precedent
for merely ablating endometriotic implants if they
are present [I]. The IO-year follow-up of this case, as
reported herein, strongly suggests that bilateral oophorectomy
be performed if the woman has finished child
bearing. For those who still desire another child this case
could suggest unilateral oophorectomy on the side of
endometriosis (if bilateral disease is not present) with
subsequent removal of the contralateral ovary after delivery.
For those patients not adhering to these suggestions
then close monitoring every six months with pelvic sonography
should be performed.
Now that the first case reported with serum CA-125
levels >l,OOO IU/mL has subsequently developed ovarian
cancer, it is imperative to aggressively follow all subsequent
cases with such high levels with serial ultrasound
and perhpas consider prophylactic oophorectomy if no
further children are desired.
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Address reprint requests to:
JEROME H. CHECK, M.D., Ph.D.
7447 Old York Road
Melrose Park, PA 19027

Ovarian Endometrioma Associated With Extremely Elevated Serum CA-125 Levels: Utility of Imaging in a Diagnostic Dilemma

Introduction
Serum CA-125, a tumor associated antigen, is elevated in
epithelial ovarian carcinomas, and mildly elevated in some
women with benign gynecologic disorders. Despite the low
positive predictive value for malignancy, CA-125 levels greater
than 300 IU/ml are usually associated with malignancy
even in premenopausal patients. However, serum CA-125 levels
greater than 1000 IU/ml has occasionally been reported
in patients with ovarian endometriosis (1,2). Elevated CA-
125 levels in patients with endometrioma can cause a diagnostic
dilemma mimicking ovarian cancer. Moreover, endometrioma
has occasionally been shown to be accompanied
by malignant ovarian tumors (3,4). We report a rare case of
ovarian endometrioma with extremely elevated serum CA-
125 levels, and discuss the utility of imaging features in the
assessment of potential malignancy.
Case Report
A 26-year-old nulligravid woman without previous history
of gynecologic disorder was seen for preconceptional counseling.
Her menstrual cycle was regular (30/5/2), and she
was on day 23 of her cycle. Physical and pelvic examinations
were unremarkable. The complete blood count and blood
biochemistry were within normal limits. Transvaginal ultrasonography
examination showed a well-delineated 4x3 cm
biloculated cystic mass within right ovary with low-level internal
echoes (Figure 1). The serum CA-125 level was 2229
IU/ml (Enzyme immunoassay, upper reference limit, <35
IU/ml). CA 19-9 and CA 15-3 levels were normal. Transabdominal
Doppler ultrasound revealed no abnormal vascularity.
Magnetic resonance (MR) imaging of the pelvis showed
the mass to be homogeneously hyperintense on T1-weighted
images (Figure 2A), which shaded on T2-weighted sequences.
The wall and the septum were hypointense on both T1-
and T2-weighted images. The internal signal remained high
on fat-saturated sequences (Figure 2B). There was no evidence
for a mural nodule, solid component or enhancement
after intravenous injection of gadolinium. Based on the imaging
features, the lesion was considered to be an endometrial
cyst without evidence of associated malignancy. Subsequ-
244 Artemis, Vol. 5(3); 2004
Ovarian Endometrioma Associated With Extremely Elevated
Serum CA-125 Levels: Utility of Imaging in a Diagnostic
Dilemma
Aysun KARABULUT1, Nevzat KARABULUT2, A. Baki YA⁄CI2
1Clinic of Obstetrics and Gynecology, Denizli State Hospital, Denizli, Turkey
2Department of Radiology, Pamukkale University Hospital, Denizli, Turkey
CASE REPORT
Abstract
Elevated CA-125 levels in patients with endometrioma can create a diagnostic dilemma. We report the sonographic and
magnetic resonance imaging findings in a case of ovarian endometrioma with a serum CA-125 level of 2229 IU/ml, and discuss
the utility of imaging features in the assessment of potential malignancy.
Keywords: endometrioma, endometriosis, CA-125, ultrasonography, magnetic resonance imaging
Özet
Yüksek Serum CA-125 Düzeyinin Efllik Etti¤i Ovaryan Endometrioma: Tan›sal ‹kilemde
Görüntüleme Yöntemlerinin Yararlar›
Endometriomal› hastalarda afl›r› yüksek CA-125 düzeyleri tan›sal zorluk ç›karabilir. Bu çal›flmada serum CA-125 düzeyi
2229 IU/ml olan over endometriomal› bir olguda sonografik ve manyetik rezonans görüntüleme bulgular› sunulmufl ve potansiyel
malignitenin tayininde görüntüleme yöntemlerinin yararl›l›¤› tart›fl›lm›flt›r.
Anahtar sözcükler: endometriyoma, endometriozis, CA-125, ultrasonografi, manyetik rezonans görüntüleme
Corresponding Author: Dr. Aysun Karabulut
Hastane Cad. Umut Apt. No: 5/3 20010 Denizli, Türkiye
Phone : +90 (258) 262 32 52
+90 (532) 569 33 57
Fax : +90 (258) 373 86 97
E-mail : aysunkarabulut@yahoo.com
ent CA-125 level on day of 3 of her next cycle was 738
IU/ml. At laparoscopy, a right ovarian endometrioma with
brown fluid was detected. Adhesions were seen in the fimbrial
end of the right ovarian tube. The uterine serosa and the
left adnexa were normal. A right cystectomy was performed
and adhesions were lysed along with neosalpingostomy. Histopathologic
examination confirmed the diagnosis of endometrioma.
On the 15th postoperative day, serum CA-125 level
dropped to 79 IU/ml.
Discussion
Endometriosis is a common gynecologic disorder that affects
women of reproductive age, and characterized by endometriomas
(chocolate cysts), peritoneal implants and adhesions.
Endometriomas are complex lesions containing multiple hemorrhagic
cysts that have blood products of different ages
within them. Although the disease is recognized as benign,
endometriosis is occasionally accompanied by malignant
ovarian tumors, especially endometrioid and clear cell adenocarcinoma
(3,4). CA-125, a high molecular weight
glycoprotein, was reported to be elevated in moderate-to-severe
endometriosis (5). CA-125 levels increase with the stages
of endometriosis, omental adhesions and rupture of endometrioma.
In a series of 685 women with endometriosis,
Cheng et al. (5) reported that patients with preoperative CA-
125 levels higher than 65 IU/ml were at high risk for advanced
stages of endometriosis or severe pelvic adhesions or
rupture. They reported a mean CA-125 level of 427.47 IU/ml
in patients with ruptured endometrioma and that of 77.96
IU/ml in patients with unruptured cysts. Associated peritoneal
inflammation is a strong contributor of elevated CA-125
levels. In our patient, there was no sign of rupture at laparoscopy,
but the fimbrial adhesions might in part be the cause of
the abnormally high tumor marker.
Extremely elevated serum CA-125 levels are occasionally
associated with endometriosis (1,2). A serum CA-125 level
of 3890 IU/ml was reported in a patient with endometriosis
(1), and that of 6114 IU/ml and 9357 IU/ml in a patient with
ruptured endometrioma (2). The size of the endometriomas
associated with elevated CA-125 levels is generally large. In
our case, the size of the lesion was 4x3 cm, smaller than the
previously reported cases. The timing of blood sample for
CA-125 is crucial, because elevated CA-125 levels greater
than 1000 IU/ml have been reported during menstruation (6).
Therefore, sampling should not be done during or immediately
after menstruation when tumor marker determination is
required. However, serum samples were obtained during
menstruation in most of the case reports showing extremely
high CA-125 levels (1,2). The CA-125 level was 2229 IU/ml
during luteal phase in our patient and 738 IU/ml during
menstruation. We cannot explain the reason of decline of the
marker during menstruation.
Elevated CA-125 levels in patients with endometriosis can
create diagnostic problems mimicking ovarian cancer. Furthermore,
malignant transformation has been reported as a rare
complication of endometriosis, with an incidence of 0.6-
245
Figure 1. Transvaginal sonography shows biloculated cystic
mass with low-level internal echoes.
Figure 2. T1-weighted MR images without (A) and with (B)
fat-suppression reveals bilobed cystic mass in the right adnexa
containing hyperintense fluid and surrounded by hypointense
wall. Fat-suppression (B) increases lesion conspicuity
and differentiates endometrioma from fatcontaining ovarian
masses.
a
b
Artemis, 2004; Vol 5(3)
1.0% (3,4). Imaging findings can aid to diagnose or exclude
an associated ovarian cancer. Ultrasound is usually performed
as an initial study in the evaluation of pelvic diseases
during reproductive years. Endometriomas have been described
as having a homogeneous low-level echogenicity within
loculated cysts and they are better appreciated by transvaginal
ultrasound over transabdominal ultrasound in part by the
better definition of the degree of internal echogenicity. Although
the absence of mural nodule or solid components is
helpful in the exclusion of carcinoma, sonographic evaluation
is limited in ruling out ovarian malignancy (7). It may also
be difficult on sonography to detect echogenic endocystic
vegetations. Conversely, blood clot or focal fibrosis caused
by recurrent hemorrhage may show focal wall nodularity on
sonography, which is difficult to differentiate from malignant
findings (7). The value of Doppler ultrasound is limited
and confusing because low resistance blood flow was reported
in cases of endometrioma (1-3). MR imaging is superior
to ultrasound in the characterization of adnexal masses with
sensitivity and specificity of greater than 90% in the detection
of endometriomas (8). Therefore, patients with indeterminate
sonographic findings and in whom there is suspicion of
endometriosis may benefit from MR imaging. The addition
of fat-saturated T1-weighted imaging has improved diagnostic
accuracy in the evaluation of both endometriomas and peritoneal
implants by augmenting lesion conspicuity, and differentiating
lipid-containing ovarian masses from those containing
blood (8). Endometriomas are characteristically homogeneously
hyperintense on T1-weighted images and heterogeneous
high and central low signal intensity or shading on
T2-weighted sequences. They are surrounded by a low signal
intensity wall representing hemosiderin or fibrous capsule.
The presence of blood degradation products such as methemoglobin
and hemosiderin, protein and the viscosity of the
cyst contribute to MR imaging signal. Chronicity of cyst
contents is directly proportional to the iron concentration and
viscosity with a corresponding decrease in the T2 relaxation
times. Tanaka et al. (4) reported MR imaging features of
ovarian carcinoma in 10 patients with endometriosis. The
presence of low signal intensity mural nodule on T1-weighted
images, the absence of low signal intensity on T2-weighted
images and enhancement of nodule on postcontrast T1-
weighted images were shown in endometriomas associated
with carcinoma. The sonographic features of the lesion in our
case were consistent with endometrial cyst and Doppler investigation
did not reveal abnormal vascularity. MR imaging
confirmed the diagnosis of endometrioma without evidence
of malignant transformation such as low signal intensity
mural nodule enhancing on postcontrast T1-weighted
images. The exclusion of associated malignancy by the
complementary imaging findings in our case helped us undertake
laparoscopic cystectomy protecting the ovary instead
of an extensive surgery for ovarian carcinoma.
This case illustrates the diagnostic dilemma clinicians’ encounter
when a CA-125 level is abnormally high in the presence
of pelvic mass. Imaging findings are helpful in the diagnosis
of endometriomas and the assessment of malignancy in
patients with an adnexal mass and extremely elevated tumor
markers. In a daily practice, ultrasound is adequate for diagnosis
and planning operative approaches in most cases. MR
imaging can be used as problem-solving tool in patients with
indeterminate clinical and sonographic findings due to its superiority
in the characterization of adnexal masses.
References
1. Atabekoglu CS, Sonmezer M, Aydinuraz B, Dunder I. Extremely elevated
CA 125 level due to an unruptured large endometrioma. Eur J Obstet
Gynecol Reprod Biol 2003;110:105-6.
2. Kurata H, Sasaki M, Kase H, Yamamoto Y, Aoki Y, Tanaka K. Elevated
serum CA125 and CA19-9 due to the spontaneous rupture of ovarian
endometrioma. Eur J Obstet Gynecol Reprod Biol 2002;105:75-6.
3. Heaps JM, Nieberg RK, Berek JS. Malignant neoplasms arising in
endometriosis. Obstet Gynecol 1990;75:1023-8.
4. Tanaka YO, Yoshizako T, Nishida M, Yamaguchi M, Sugimura K, Itai Y.
Ovarian carcinoma in patients with endometriosis: MR imaging findings.
AJR 2000;175:1423-30.
5. Cheng YM, Wang ST, Chou CY. Serum CA-125 in preoperative patients at
high risk for endometriosis. Obstet Gynecol 2002;99:375-80.
6. Imai A, Horibe S, Takagi A, Takagi H, Tamaya T. Drastic elevation of
serum CA125, CA72-4 and CA19-9 levels during menses in a patient with
probable endometriosis. Eur J Obstet Gynecol Reprod Biol 1998;78:79-81.
7. Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas:
diagnostic performance of US. Radiology. 1999;210:739-45.
8. Gougoutas CA, Siegelman ES, Hunt J, Outwater EK. Pelvic endometriosis:
various manifestations and MR imaging findings. AJR 2000;175:353-58.
246
A. Karabulut et al. Artemis, 2004; Vol 5(3)

Elevated Rising CA 125 with Adenomyosis -------------------------------------------------------------------------------- To cite this paper: Mitchel

Elevated Rising CA 125 with Adenomyosis

--------------------------------------------------------------------------------

To cite this paper:
Mitchel S. Hoffman, William N. Spellacy. Journal of Gynecologic Surgery. March 1, 2001, 17(1): 33-34. doi:10.1089/104240601750200387.

--------------------------------------------------------------------------------



Mitchel S. Hoffman, MD
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of South Florida College of Medicine Tampa, Florida
William N. Spellacy, MD
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of South Florida College of Medicine Tampa, Florida
Elevated serum CA 125 is useful in the management of ovarian cancer but has also been associated with several benign conditions. This is a report of a patient with an elevated, rising serum CA 125 level who was found to have a benign process. A 48-year-old woman with a 16-week-size uterus was thought to have leiomyomata uteri. Her serum CA 125 level was initially 150 u/ml; on repeat determination 10 weeks later, it was 391 u/ml. Laparotomy with bilateral salpingo-oophorectomy and hysterectomy revealed pathologic changes only in the uterus, the uterine weight being 718 g. Histologically, the lesion proved to be extensive adenomyosis. Severe uterine adenomyosis may be associated with both an elevated and a rising serum CA 125 level.


This paper was cited by:
Serum CA-125 Levels in Women with Uterine Leiomyomata And A Review of The Literature
Marisa Fraraccio Baker, Joan McCarthy, William N. Spellacy, Rosemary P. Cardosi
Journal of Gynecologic Surgery. Mar 2007, Vol. 23, No. 1: 19-22

RCOG Response to LIFE Claims on Link Between Abortion and Breast Cancer

RCOG Response to LIFE Claims on Link Between Abortion and Breast Cancer
"There are many factors which could increase the numbers of women diagnosed with breast cancer - women are delaying childbirth and having less babies than thirty years ago. The NHS Breast Screening Programme established in 1989 also means more cases that would not have previously been diagnosed are now being identified.

"The important thing to note is that to our knowledge there is no new evidence that proves a causal link between abortion and breast cancer. We like others are awaiting Professor Beral's evaluation of the research in this area.

"LIFE are mischief making and we do not support the sensational reporting of this study which serves no other function than causing anxiety amongst women. We reiterate our advice to women that no causal link between abortion and breast cancer has been proven and that this report should not influence women in making decisions about abortion at difficult times in their life."
Date published: 04/12/2001 - 01:00Published by: Simon KempNo of comments: 0

Communicating the health risks and benefits of repeat caesareans or VBAC

Communicating the health risks and benefits of repeat caesareans or VBAC
The study surveyed 21 women from 2 city hospitals in Bristol and Dundee. Uncertainty in decision making, information provision and decision-making roles were examined by researchers, as these were considered to be the main factors behind women opting for a repeat caesarean section or vaginal birth after caesarean (VBAC).

Women who chose to have a caesarean section did so because they were afraid of vaginal birth or were convinced that a vaginal birth was not for them, or wanted to have control over the birth. Women choosing VBAC did so because they were influenced by the shorter recovery time after birth, wanted the experience of a natural delivery or feared having to go through another caesarean section. Uncertainty and anxiety in choosing the method of delivery was a result of conflicting opinions between women and their partners, or among their health professionals.

The information these women received about caesarean sections was mostly about procedural issues rather than the health risks and benefits of the different methods of delivery. Many women felt that it would be helpful to receive information after the first caesarean section.

In terms of decision-making roles, the majority of women felt that their doctors allowed them the choice of delivery, unless complications developed and intervention was required, and favoured this ‘hands-off' approach. Some women however, would have liked more guidance from their obstetricians.

Clare Emmett, lead researcher of the study said, “ The study explored the experiences of women with previous caesarean section making the decision about mode of delivery in a subsequent pregnancy. Most of the women interviewed felt able to make their own choice between vaginal birth after caesarean or repeat elective caesarean section and healthcare professionals were generally found to be supportive of that choice.

However, it seemed that the women were not always provided with comprehensive and balanced information about the risks and benefits of the delivery options to support their decision-making.”

Phil Steer, editor of BJOG said, “This study is unique as it places the obstetrician at the centre of expert information provision for women who are unsure about whether to have a repeat caesarean or VBAC. The ‘consumerist' approach towards decision making means that women are encouraged to make their own decisions instead of relying solely on their doctor's recommendations.

Obstetricians need to adopt more flexibility by tailoring the information they provide to women. The research shows that they need to talk about safety issues alongside information about procedures and statistics. If handled well, women should feel more confident to make informed choices.”

ENDS

For more information on this release, and to request a pdf of the paper, please contact Gerald Chan at gchan@rcog.org.uk . To speak to Professor Phil Steer, call 020 8846 7892, or email p.steer@imperial.ac.uk . To speak to Clare Emmett, call 0117 3313830 (Tue and Wed only) or email clare.emmett@bristol.ac.uk .

Notes

Emmett C, Shaw A, Montgomery A, Murphy D on behalf of the DiAMOND study group. Women's experience of decision making about mode of delivery after a previous caesarean section: the role of health professionals and information about health risks. BJOG 2006; 113:1438-1445.
Date published: 22/11/2006 - 01:00Published by: Simon KempNo of comments: 0
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Planned Caesarean decreases risk of complications in Breech Babies

Planned Caesarean decreases risk of complications in Breech Babies
The benefits of a planned caesarean compared with a planned vaginal birth were initially shown in the main report of the Term Breech Trial, an international multicentre randomised controlled trial which enrolled 2088 women from 121 centres in 26 countries.

The Trial compared planned Caesarean with planned vaginal birth for women with a singleton fetus in a frank or complete breech presentation at term at 37 weeks or more.

However, much of the concern around planning a vaginal birth for a singleton fetus in breech presentation at or near term has been the worry that the delivery of the head may not follow immediately after the rest of the body, either because the pelvis is too small, the fetal head is deflexed, or because the cervix is not completely dilated. This new report shows that there is also concern that the labour may be a problem for the fetus.

The results show a seven fold reduction in risk of adverse outcome due to labour with a planned caesarean compared with a planned vaginal birth, with close to a three fold reduction in risk of adverse outcome due to delivery.

Dr Mary Hannah says, “The results clarify that the problem with planning a vaginal birth for a breech baby at term is not just the concern of a higher risk of a difficult vaginal delivery. There is also a higher risk of problems because of the labour. The findings also raise questions as to whether a planned caesarean may be a better method of delivery for some babies that are presenting head first (or cephalic) for whom the labour is of concern.”

Ends

Notes to Editor:

Of the 2088 women enrolled in the Breech Term Trial, entry and outcome data were received for 2083 women, or whom 1041 were randomised to the planned caesarean group and 1042 were randomised to the planned vaginal birth group.

For more information please contact:

Dr Mary Hannah, Maternal Infant and Reproductive Health Research Unit, Centre for Research in Women’s Health, University of Toronto, Suite 751, 790 Bay Street, Toronto, Canada. Telephone: 001-416-351-3775 or email mary.hannah@sw.ca
Date published: 04/10/2003 - 01:00Published by: Simon KempNo of comments: 0
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BJOG press release

Vitamin E appears to relieve painful periods and reduce blood loss

Vitamin E appears to relieve painful periods and reduce blood loss
A paper in April’s edition of the British Journal of Obstetrics and Gynaecology (BJOG) describes a large randomised controlled trail in which 278 girls aged 15-17 years were given 200 units of vitamin E twice a day over four consecutive menstrual periods, and the magnitude of the reduction in pain and blood loss was significantly greater in the vitamin E group than in the placebo.

Dysmenorrhoea is a condition that primarily affects schoolgirls and leads, for many, to a major disruption in their lives on a monthly basis.

Mr Peter Bowen-Simpkins says, “This is particularly exciting because such treatment is readily available over the counter, is free from side effects, avoids the use of hormones or pain relievers and appears to be very effective. This may be a breakthrough in a condition affecting thousands of young girls.”

Ends

For further information please contact:
Dr Saedideh Ziaei at: ziaei_99@yahoo.com or Mr Peter Bowen-Simpkins through the RCOG press office on 020 7772 6357.
Date published: 07/04/2005 - 01:00Published by: Simon KempNo of comments: 0
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BJOG press release

Saving women's lives

Saving women's lives
Known as the RCOG International Office , the Royal College of Obstetricians and Gynaecologists (RCOG) and the Liverpool School of Tropical Medicine (LSTM) will team up in an international initiative to improve the standards of women's health in developing countries.

Liverpool Associates in Tropical Health (LATH), the project management and consultancy arm of LSTM, is the third partner.

This initiative is an important and timely one, as more than half a million women die each year through pregnancy related conditions because they do not have access to the most basic healthcare which women in developed countries take for granted. The RCOG International Office hopes to reduce these horrific figures through working with health ministries, international donors, UN agencies and other international organisations in Third World countries.

RCOG International Office aims to improve the quality of antenatal, delivery and postnatal services and to help make these increasingly available to poor women worldwide. Strategies range from developing a simple but lifesaving manual for use in rural clinics, where one midwife may be struggling alone, raising awareness about clinical standards in women's healthcare in impoverished states, to mobilising RCOG members to volunteer their expertise in developing countries, in partnership with governments and local colleagues, including midwives and doctors.

Dr Nynke van den Broek, Senior Clinical Lecturer in Reproductive Health at the Liverpool School of Tropical Medicine and an RCOG Member, helped set up the partnership. She said: "More than 80% of these deaths are caused by conditions which we are very able to prevent or treat: bleeding, obstructed labour, eclampsia, infection and unsafe abortions. We hope our alliance will help to mobilise efforts so that we can change these horrific figures.

"The issue of women's health comes on and off the global agenda. However, what is clear is that all women need to have access to essential obstetric and gynaecological care. They need to have a skilled birth attendant, not just a relative. They also need to have a facility to which they can go if a problem develops. For a lot of women this is not yet available.

"Almost half the members of the RCOG are in developing countries. We hope that by pulling together our expertise, we can achieve something meaningful."

Professor Jim Dornan, RCOG Vice President, agreed, saying: "The vast majority of maternal deaths are preventable by simply having appropriately trained staff with the correct equipment at the bedside.

This Memorandum of Understanding between us will improve quality where it is needed by producing guidelines, standards of care and lifesaving skills courses that provide technical knowledge to empower those who have the ability to change health systems."

The partners are already involved in Safe Motherhood programmes in Nigeria, Kenya and Malawi, which has the highest maternal mortality rates in the world. They also train health workers from around the world on the Diploma in Reproductive Medicine which they run jointly at the school.

A pilot of the new Life Saving Skills course will be held in Liverpool at LSTM on 3 – 5 July. The formal launch of RCOG International Office will be held in London at the RCOG on 14 September.

ENDS

For more information about RCOG International, please contact Gerald Chan, RCOG Head of Communications & External Affairs on email gchan@rcog.org.uk or call 020 7772 6446.

NOTES TO EDITORS:
The Royal College of Obstetricians and Gynaecologists ( www.rcog.org.uk ) is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. Its main aim is to improve

standards in Women's Reproductive Health so that optimum levels in clinical and service provision are available to specialists and users.

To achieve this, the RCOG is responsible for developing clinical best practice standards, running membership examinations, conducting postgraduate training activities, including the co-ordination of a

continuing professional development programme and organising conferences and courses for the discipline.

The RCOG has more than 11,500 members, approximately half are based overseas. To support the professional needs of its membership, it is engaged in several ongoing initiatives such as:

Providing expert guidelines and advice in Clinical Governance and Standards and patient information
Providing postgraduate training opportunities including Special Skills and Subspecialty training
The Liverpool School of Tropical Medicine ( http://www.liv.ac.uk/lstm/ ) is a world renowned centre of excellence whose mission is to promote improved health, particularly for the people of less developed countries in the tropics and sub-tropics.

It aims to achieve this through the creation of effective links with governments, organisations and institutions and by responding to the health needs of communities by:

Providing and promoting high quality education and training
Conducting first class research and disseminating the result of that research
Developing systems and technologies for health care and assisting in their transfer and management
Providing appropriate consultancy services
Liverpool Associates in Tropical Health ( www.lath.com ) is celebrating its' 20 th anniversary this year. LATH is a wholly-owned subsidiary of the Liverpool School of Tropical Medicine, and is charged with the coordination of the School's consultancy activities. All LATH's surplus revenues are invested in the School's pioneering work in tropical medicine and international health. The organisation prides itself on channelling LSTM's charitable mission into a values-led approach, delivering sustainability through capacity development and continually putting issues of equality and vulnerability to the fore . LATH brings strong expertise and experience in programme management and technical experience of health systems in less developed countries. It works across the wide spectrum of international health including malaria, TB, HIV/AIDS, NTDs and health systems – planning, financing, equity and access, human resources, and procurement.
Date published: 27/06/2006 - 01:00Published by: Simon KempNo of comments: 0
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RCOG Press release

Use of steroid in preterm birth appears safe

Use of steroid in preterm birth appears safe
Potent steroids given before birth can reduce the complications of preterm birth and markedly improve the survival of premature babies. Currently no other treatment is as effective, but there has been increasing concern that exposure to steroids before birth may alter the development of the cardiovascular system leading to blood pressure problems in adult life.

But researchers in New Zealand looked at the effects of a single course of dexamethasone in a fetal experimental model, and demonstrated only temporary changes in blood pressure suggesting no long-term adverse effects. Their study suggests that a single course of prenatal steroids for the prevention of fetal respiratory distress syndrome in premature infants can be continued safely.

Dr Laura Bennet, lead author says, “Steroids don’t just target the lungs and there has been great concern in recent years that steroids given to mums before they deliver, which crosses over to the fetus, may affect the normal development of fetal organs such as the heart and brain. Numerous studies have disturbingly shown that repeated or continuous exposure of the fetus to steroids is bad raising the important question: should we stop using steroids altogether? This would of course have consequences for the well-being of newborn babies.

Our study aimed to see if a single course of treatment had the same bad effects on the fetal cardiovascular system as repeated treatments do. Our results show that it does not appear to, and this is very reassuring. We are currently conducting more experiments to verify these results and to make sure that even limited exposure of the fetus to steroids really does not cause problems at this most vulnerable time in life.”

Ends
Date published: 31/01/2005 - 01:00Published by: Simon KempNo of comments: 0
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BJOG press release

Too much exercise in early pregnancy may cause pre-eclampsia

Too much exercise in early pregnancy may cause pre-eclampsia
Danish and Norwegian researchers studied 85,139 pregnant women enrolled in the Danish National Birth Cohort (DNBC) between 1996 and 2002. Data collected included information about maternal BMI, whether women smoked, their demographic background and recorded cases of pre-eclampsia. This was compared against data about the amount of physical activity undertaken during pregnancy, measured as the amount of time in minutes spent each week exercising.

Physical activity was defined by researchers as specific forms of sport such as jogging, cycling, swimming, or ball and racket games. It did not include work-based physical activity. Each activity was categorised as vigorous, moderate or a mixture, depending on the rate of energy expenditure, measured in metabolic equivalents (METs).

Researchers found physical inactivity was more common in younger women, underweight or obese women, smokers, women who have had more than one child and those with lower socio-economic status. Women with high levels of physical activity (270 mins/week to 419 mins/week, and 420 mins per week or more) were associated with increased risks of severe pre-eclampsia (odds ratios 1.65 and 1.78 respectively compared with non-exercising women), although the absolute risks were still small (1.18% and 1.29% respectively). Moderate to low exercise levels (<270 mins/week) showed no association with severe pre-eclampsia. Cycling and brisk walking over long durations was also associated with an increased risk of severe pre-eclampsia. 75 - 269 mins/week of jogging was also associated with an increased risk (odds ratio 2.61). However, once again, the absolute level of risk was small (1.7%).

These findings are contrary to the researchers’ initial hypothesis that exercise may have a positive effect on the maternal body. Official guidance from the US, Denmark and Norway recommend that pregnant women should take at least 30 minutes of physical exercise each day. This has general benefits for health and did not appear to be associated with a pre-eclampsia risk (although neither did it appear to reduce risk). Studies on non-pregnant subjects have demonstrated how increased levels of exercise protect against hypertension and have an effect on lowering triglycerides, cytokines and insulin resistance (factors known to be higher in pre-eclamptic women). Researchers of the present study believe that a plausible biological explanation for their findings is that intense physical activity induces oxidative stress in the mother and this in turn contributes to the development of pre-eclampsia.

Senior author, Dr Sjurdur F. Olsen, from the Statens Serum Institut in Copenhagen, Denmark and Adjunct Professor of Nutrition at the Harvard School of Public Health in Boston, USA said “Recommendations have been issued in several countries that pregnant women should exercise at least 30 minutes each day. An important underlying contention is that this can reduce risk of pre-eclampsia. In our study, we were unable to substantiate that physical activity in early pregnancy has a protective effect against pre-eclampsia.

“Another unexpected finding was that leisure time exercise, in amounts that were only slightly higher than the recommended amount, seemed even to be associated with an increased risk of severe types of pre-eclampsia.

“Further research is needed in other large prospective cohort databases which are now emerging in several countries. Until that has happened, recommendations in the field should remain unchanged.”

Professor Philip Steer, BJOG editor-in-chief, said “Clinical guidelines in the UK stress that selective and moderate exercise during pregnancy can be beneficial. These include aerobic and strength-conditioning exercises. While general fitness is a good thing in many respects, these data suggest that it may be unwise to exercise to peak fitness levels.

“This new research is useful as it provides us with an indication of how much exercise pregnant women should take. As with everything in life, too much of a good thing can be bad for you, and moderation in all things remains a good policy.”

ENDS

Notes
BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Wiley-Blackwell. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote ‘BJOG' or ‘BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal.

This study was funded by the March of Dimes Birth Defects Foundation and the EU’s Early Nutrition Programming Project, EARNEST.

For further information, please contact the senior author of the paper, Dr Sjurdur F. Olsen, please call +4522289568 or email sfo@ssi.dk . To speak to Professor Philip Steer, please call +44 (0) 20 7772 6446 or email mailto:p.steer@imperial.ac.uk?Subject=Email%20from%20RCOG%20website.
Date published: 03/12/2008 - 01:00Published by: Simon KempNo of comments: 0
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BJOG press release Eclampsia

RCOG releases updated guidance on air travel during pregnancy

RCOG releases updated guidance on air travel during pregnancy
Evidence suggests there is no reason why women with uncomplicated singleton pregnancies should not travel by air. The RCOG advises that these women should avoid air travel at 37 weeks of gestation as birth is usually expected at this stage. For women with uncomplicated multiple pregnancies, it is 34 weeks.

Although cabin pressure can result in dehydration, there has been concern it could also lead to a range of conditions such as preterm labour, preterm rupture of the membranes and placental abruption for women in advanced stages of pregnancy (after 32 weeks of gestation). There is no evidence that air travel can lead to these adverse pregnancy outcomes. To prevent dehydration, women should avoid caffeine and alcohol and maintain a good fluid intake during the flight.

The increase in altitude in the plane could result in some discomfort in the ears and nose. Motion sickness (made worse by morning sickness) may also be experienced.

A particular concern is deep venous thrombosis (DVT). The risk of DVT is increased during air travel because of the long periods of immobility and the cramped seating arrangements during medium to long-haul flights (four hours and more). The current advice is for women to wear properly fitted graduated elastic compression stockings during the flight to reduce the risk of DVT.

To help prevent DVT, pregnant women are encouraged to have some physical movement by walking along the aisles every 30mins where possible and by doing some light stretching to increase their blood circulation.

The common risk factors indicating that pregnant women should not travel by air or will need to take special precautions or treatment include:

Severe anaemia
Recent development of sickle cell crisis
Recent obstetric haemorrhage
Nephrotic syndrome (a kidney condition)
Wearing a cast from a recent fracture in the leg
An ear infection (otitis media) and inflammation of the sinuses (sinusitus)
Serious respiratory problems marked by breathlessness
Recent gastrointestinal surgery
Previous DVT (where treatment to prevent recurrent thrombosis is usually required)
Severe obesity
Professor Ian Greer, from The Hull York Medical School, who produced the Opinion Paper on behalf of the RCOG said “Women should be reassured that commercial air travel is not associated with specific problems in pregnancy, and that with simple precaution those with an uncomplicated singleton pregnancy can travel safely up to 37 weeks.

“Pregnant women with the particular conditions, or indeed any medical condition that concerns them, should seek specific medical advice before travelling.”

Professor Steve Thornton, Chair of the RCOG Scientific Advisory Committee, said “One of the most common questions we get from pregnant women is whether or not it is safe to fly when pregnant. This Opinion Paper addresses many of the issues and makes sensible recommendations.

“Whilst it is generally safe for women with low risk pregnancies to fly, there are increased risks of deep vein thrombosis (DVT). Women unsure about these risks or other medical conditions are advised to speak to their GP, midwife or obstetrician.”

ENDS

Notes
To speak to Professor Ian Greer or Professor Steven Thornton, please call the RCOG press office on 020 7772 6446 or 6357.

SAC Opinion Paper no. 1 Air Travel during Pregnancy (October 2008)

NICE’s guidance on air travel and pregnancy Antenatal care : routine care for healthy pregnant women (March 2008), please see section 5.14, pp. 101 – 102

Caesareans associated with fewer subsequent pregnancies

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Caesareans associated with fewer subsequent pregnancies
The study followed 25,371 women who had delivered at the Aberdeen Maternity Hospital between 1980 and 1997 and showed that women who had undergone a caesarean section were less likely to have had a subsequent pregnancy. Just 66.9% of those who had a caesarean section went on to have a further pregnancy, compared with 71.6% who had had an instrumental vaginal delivery and 73.9% who had had a spontaneous vaginal delivery. Whether or not the caesarean was elective or emergency had no bearing on the incidence of subsequent pregnancy.

The average length of time to the next pregnancy following a caesarean section was 36.3 months compared with 31.8 months following an instrumental vaginal delivery and 30.4 months following a spontaneous vaginal delivery.

Women who delivered by caesarean section were also more likely to have an ectopic in their next pregnancy compared with women who had delivered spontaneously (9.5 per 1000 pregnancies compared to 5.7 per 1000 pregnancies)

All the information was then compared to a similar study* conducted at the same hospital but from 1964 to 1983. The current study suggests that the difference in incidence of subsequent pregnancy between caesarean section and spontaneous vaginal delivery is smaller than that previously reported. Overall, a greater proportion of women had a subsequent pregnancy in the current study compared with the Hall study (72% vs 68.0%).

Jill Mollison, lead author says, “This study highlights an association between mode of delivery and subsequent pregnancy. This is an important finding against the background of rising caesarean section rates. Future studies should focus on exploring whether failure to conceive is due to voluntary or involuntary factors and compare this across different modes of delivery.”

Mr Peter Bowen-Simpkins from the RCOG says, “Those involved in the delivery of obstetric care should be aware of the association and consider its implications when making a decision to perform a caesarean section.”
Date published: 01/08/2005 - 01:00Published by: Simon KempNo of comments: 0
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The study followed 25,371 women who had delivered at the Aberdeen Maternity Hospital between 1980 and 1997 and showed that women who had undergone a caesarean section were less likely to have had a subsequent pregnancy. Just 66.9% of those who had a caesarean section went on to have a further pregnancy, compared with 71.6% who had had an instrumental vaginal delivery and 73.9% who had had a spontaneous vaginal delivery. Whether or not the caesarean was elective or emergency had no bearing on the incidence of subsequent pregnancy.

The average length of time to the next pregnancy following a caesarean section was 36.3 months compared with 31.8 months following an instrumental vaginal delivery and 30.4 months following a spontaneous vaginal delivery.

Women who delivered by caesarean section were also more likely to have an ectopic in their next pregnancy compared with women who had delivered spontaneously (9.5 per 1000 pregnancies compared to 5.7 per 1000 pregnancies)

All the information was then compared to a similar study* conducted at the same hospital but from 1964 to 1983. The current study suggests that the difference in incidence of subsequent pregnancy between caesarean section and spontaneous vaginal delivery is smaller than that previously reported. Overall, a greater proportion of women had a subsequent pregnancy in the current study compared with the Hall study (72% vs 68.0%).

Jill Mollison, lead author says, “This study highlights an association between mode of delivery and subsequent pregnancy. This is an important finding against the background of rising caesarean section rates. Future studies should focus on exploring whether failure to conceive is due to voluntary or involuntary factors and compare this across different modes of delivery.”

Mr Peter Bowen-Simpkins from the RCOG says, “Those involved in the delivery of obstetric care should be aware of the association and consider its implications when making a decision to perform a caesarean section.”
Date published: 01/08/2005 - 01:00Published by: Simon KempNo of comments: 0

Abdominal surgical incisions for caesarean section

[Intervention Review]
Abdominal surgical incisions for caesarean section

Matthews Mathai1, G Justus Hofmeyr2

1Department of Making Pregnancy Safer, World Health Organization, Geneva, Switzerland. 2Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa

Contact address: Matthews Mathai, Department of Making Pregnancy Safer, World Health Organization, Avenue Appia 20, Geneva, CH 1211, Switzerland. mathaim@who.int. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD004453.pub2
This version first published online: 24 January 2007 in Issue 1, 2007. Last assessed as up-to-date: 6 November 2006. (Help document - Dates and Statuses explained).

This record should be cited as: Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD004453. DOI: 10.1002/14651858.CD004453.pub2.
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Abstract


Background
Caesarean section is the commonest major operation performed on women worldwide. Operative techniques, including abdominal incisions, vary. Some of these techniques have been evaluated through randomised trials.


Objectives
To determine the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section.


Search strategy
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2006).


Selection criteria
Randomised controlled trials of intention to perform caesarean section using different abdominal incisions.


Data collection and analysis
We extracted data from the sources, checked them for accuracy and analysed the data.


Main results
Four studies were included in this review.

Two studies (411 participants) compared the Joel-Cohen incision with the Pfannenstiel incision. Overall, there was a 65% reduction in reported postoperative morbidity (relative risk (RR) 0.35, 95% confidence interval (CI) 0.14 to 0.87) with the Joel-Cohen incision. One of the trials reported reduced postoperative analgesic requirements (RR 0.55, 95% CI 0.40 to 0.76); operating time (weighted mean difference (WMD) -11.40, 95% CI -16.55 to -6.25 minutes); delivery time (WMD -1.90, 95% CI -2.53 to -1.27); total dose of analgesia in the first 24 hours (WMD -0.89, 95% CI -1.19 to -0.59); estimated blood loss (WMD -58.00, 95% CI -108.51 to - 7.49 ml); postoperative hospital stay for the mother (WMD -1.50, 95% CI -2.16 to -0.84); and increased time to the first dose of analgesia (WMD 0.80, 95% CI 0.12 to 1.48) compared to the Pfannenstiel group. No other significant differences were found in either trial.

Two studies compared muscle cutting incisions with Pfannenstiel incision. One study (68 women) comparing Mouchel incision with Pfannenstiel incision did not contribute data to this review. The other study (97 participants) comparing the Maylard muscle-cutting incision with the Pfannenstiel incision, reported no difference in febrile morbidity (RR 1.26, 95% CI 0.08 to 19.50); need for blood transfusion (RR 0.42, 95% CI 0.02 to 9.98); wound infection (RR 1.26, 95% CI 0.27 to 5.91); physical tests on muscle strength at three months postoperative and postoperative hospital stay (WMD 0.40 days, 95% CI -0.34 to 1.14).


Authors' conclusions
The Joel-Cohen incision has advantages compared to the Pfannenstiel incision. These are less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.


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Plain language summary

Abdominal surgical incisions for caesarean section
In a caesarean section operation, there are various types of incisions in the abdominal wall that can be used. These include vertical and transverse incisions, and there are variations in the specific ways the incisions can be undertaken. The review of studies identified 4 trials involving 666 women. The Joel-Cohen incision showed better outcomes than the Pfannenstiel incision in terms of less fever for women, less postoperative pain, less blood loss, shorter duration of surgery and shorter hospital stay. However, the trials did not assess possible long-term problems associated with different surgical techniques.






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