Obstetrics — drughealth A number of abnormalities can affect each of these processes and lead to infertility or pregnancy loss. In most women, spontaneous, cyclical ovulation at to day intervals continues throughout almost 40 years between the time of menarche and menopause. For women who never use contraception, there are approximately opportunities for pregnancy, which may occur with sexual intercourse on any of days the day of ovulation and the 2 preceding days. This narrow window available for fertilization is controlled by tightly regulated production of ovarian steroids that cause the optimal regeneration of endometrium that begins with the ending of menstruation. Should fertilization occur, the events that unfold after the initial implantation of the blastocyst onto the surface of the endometrium through to parturition result from a unique interaction between the trophoblasts of the fetus and the endometrium—decidua of the mother. The ability of mother and fetus to coexist as two distinct immunological systems results from endocrine, paracrine, and immunological modification of fetal and maternal tissues in a manner not seen elsewhere. The placenta mediates a unique fetal—maternal communication system, which creates a hormonal environment that helps initially to maintain pregnancy and eventually initiates the events leading to parturition. The following sections address the physiology of the ovarian—endometrial cycle, implantation, the placenta and fetal membranes, and the specialized endocrine arrangements between fetus and mother.
Endometrial cycle histology
Its cyclic structural changes mirror changes in metabolic functions, and both are regulated by ovarian estradiol and progesterone. Because of this interplay of structure, function, and ovarian hormonal stimuli, the endometrium is considered one of the most sensitive indicators of the hypothalamic-pituitary-ovarian hormonal axis. As a result, morphologic evaluation of the endometrium is used in diagnostic evaluation of infertile patients to determine whether ovulation is occurring Fig.
Schematic representation of steroid hormone-morphologic interactions during the endometrial cycle. Estradiol promotes endometrial proliferation, whereas after ovulation, progesterone converts estradiol-primed endometrium into secretory tissue. Postovulatory estradiol amplifies the progesterone effect, and after withdrawal of both estradiol and progesterone, the endometrial mucosa breaks down and regenerates within the period of menstruation.
John pathology report s date endometrium; fertilization in the endometrium histologically is the secretory phase. However, secondary tests include the endometrial dating of matchmaking games and ill-timed press
Prediction of post-operative thrombosis in the internal jugular vein Prediction of wound complications in ventral hernia repair Sarcoidosis Spinal dural arteriovenous fistula Vogt-Koyanagi-Harada disease. Aetna considers indocyanine green angiography-assisted internal limiting membrane peeling in macular hole surgery experimental and investigational because the safety and effectiveness of this approach has not been established.
Aetna considers intra-operative indocyanine green angiography during microsurgical subinguinal varicocelectomy experimental and investigational because the effectiveness of this approach has not been established. Aetna considers the Spy Elite System near-infrared angiography with indocyanine green experimental and investigational for breast reconstruction surgery, evaluation of anastomotic perfusion in colorectal surgery and mapping of sentinel lymph node in cutaneous melanoma, and all other indications because the safety and effectiveness of this approach has not been established.
Aetna considers indocyanine green fluorescence angiography experimental and investigational for intraoperative evaluation of residual parathyroid glands function and prediction of post-operative hypocalcemia risk after total thyroidectomybecause the effectiveness of this approach has not been established. Aetna considers the use of indocyanine green for sentinel lymph node mapping of other cancers e. Background Fluorescein angiography allows visualization of blood flow in retinal and choroidal tissues, permitting diagnostic support in many ocular diseases.
Dating the endometrial biopsy.
Its cyclic structural changes mirror changes in metabolic functions, and both are regulated by ovarian estradiol and progesterone. Because of this interplay of structure, function, and ovarian hormonal stimuli, the endometrium is considered one of the most sensitive indicators of the hypothalamic-pituitary-ovarian hormonal axis.
As a result, morphologic evaluation of the endometrium is used in diagnostic evaluation of infertile patients to determine whether ovulation is occurring Fig. Schematic representation of steroid hormone-morphologic interactions during the endometrial cycle. Estradiol promotes endometrial proliferation, whereas after ovulation, progesterone converts estradiol-primed endometrium into secretory tissue.
Postovulatory estradiol amplifies the progesterone effect, and after withdrawal of both estradiol and progesterone, the endometrial mucosa breaks down and regenerates within the period of menstruation.
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BRCA1 forms several distinct complexes through association with different adaptor proteins, and each complex forms in a mutually exclusive manner Wang et al. The deduced 1, residue protein with zinc finger domains near the N terminus. There appeared to be a complex pattern of alternative splicing. They noted that BRCA2 also includes a motif similar to the granin consensus at the C terminus of the protein.
Both BRCA1 and the granins localize to secretory vesicles, are secreted by a regulated pathway, are posttranslationally glycosylated, and are responsive to hormones. The authors stated that as a regulated secretory protein, BRCA1 appears to function by a mechanism not previously described for tumor suppressor products. As reviewed by Steeg , granins are a family of acidic proteins that bind calcium and aggregate in its presence. Known members of the granin family have been solely neuroendocrine or endocrine in origin; if BRCA1 is a granin it will necessarily expand the protein family boundaries.
In vitro transcription-translation resulted in a protein with an apparent molecular mass of about kD. They showed that this region of chromosome 17 contains a tandem duplication of approximately 30 kb which results in 2 copies of BRCA1 exons 1 and 2, of exons 1 and 3 of the adjacent gene that Brown et al.
MMPs are produced as inactive precursors that require activation by other peptidases, denaturants, or heat. Cell adhesion receptors known as integrins appear to have a role in MMP expression and function. Plasminogen, its activators, and its inhibitors appear to participate in this process. Human endometrium, embryos, and trophoblasts express both uPA and its receptor, and mutations in these have been associated with implantation failure.
Polycystic ovary syndrome PCOS is associated with elevated PAI-1 activity, which may contribute to the higher than expected rate of pregnancy loss via this pathway.
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Product of conception Villi Decidua 25 Post-menopausal cystic atrophy: Swiss-cheese endometrium mimics simple hyperplasia: Swiss-cheese endometrium mimics simple hyperplasia 26 Aglandular endometrium: Submucosal leiomyoma 27 Common artifacts: Accurate dating not possible Contaminants: Common artifacts Telescoping artifact Artifactual compression 29 Artifacts can be misleading and thus repeat biopsy will be justified if proper evaluation ofendometrium is hampered.
Artifacts can be misleading and thus repeat biopsy will be justified if proper evaluation ofendometrium is hampered. Perforation Uterine perforation Lipoleiomyoma 31 Endometrial metaplasias: Endometrial metaplasias Epithelial Mullerian: Endometrial metaplasias Endometritis with squamous metaplasia Icthyosis uteri 33 Papillary syncytial metaplasia mimicking Serous carcinoma or EIC: Endometrial polyp Endometrial polyp EIN in Endometrial polyp 38 Polyp if not appreciated by gynecologist or radiologist:
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Accessed November 28th, Diagrams Phases Proliferative phase: Early proliferative endometrium Mid proliferative days 8 – Mid proliferative endometrium and Ki67 staining Late proliferative days 11 –
Endometrial Pathology. Female genital tract Development 1. Ovary- Indifferent stage- Germ cells from yolk sac at 4th week of gestation 2. Uterus and fallopian tubes from Mullerian ducts at 6th week of gestation in absence of Features for Endometrial Dating.
A watch to check the frequency of uterine contraction Appropriate size brassiere s used after delivery For Baby Napkins for newborn 1 pack Small towel s Wet tissue paper 1 pack Avoid bringing a lot of money, fragile containers or valuable items to hospital. Two people only each time. Children under 12 years of age are not advised to go into the ward.
Extra lunch serving period: Relatives are allowed to bring in food and drink to mothers if condition allowed during the period of 12 noon to 1 pm daily. Antenatal Ward Discharge Information Pay for the hospital fee at the account office on the ground floor and get the medicine if any at the pharmacy on the ground floor in the Ambulatory Care Center from 9am to 6pm or at the pharmacy on the ground floor in the main hospital building after 6pm.
Indocyanine Green Angiography
Scattered lympho-cytes are normally present. To state as postovulatory day, subtract 14 The morphologic changes of the secretory phase begin 36 to 48 hours after ovulation. During the interval phase, the glands become more tortuous and begin to show subnuclear vacuoles Fig. At this time the stroma is indistin-guishable from that of the late proliferative phase.
Special stains for glycogen add little to routine histologic evaluation for establishing the presence of secretory changes. Subnuclear vacuoles are abundant by day 17, and by day 18 the vacuoles begin to move from the basal to the supranuclear cytoplasm Fig.
The attachment and implantation of an embryo into a mother’s uterus is the critical event that defines an embryo’s fate. Implantation is not an efficient process, and is successful only about 10–15% of the time. 1 As a hallmark of development, implantation marks the very beginning of life, and proceeds from the tentative first attachment reaction (apposition) to subsequent aggressive.
The biopsy is associated with few complications, is performed quickly, and generally is well tolerated by the patient. It has a high sensitivity for detecting endometrial cancer and hyperplasia, but it has a low sensitivity for detecting intracavitary lesions, including polyps and submucosal fibroids. Lesions encompassing a small surface area and cornual regions are likely to be missed.
Additionally, Huang and colleagues16 noted that preoperative pipelle biopsy more often underestimated than overestimated the final grade of endometrial cancer. Patients with persistent symptoms despite a trial of medical therapy, normal biopsy, and normal TVUS need further evaluation with SIS or hysteroscopy. When hysteroscopy is used alone and the patient has persistent symptoms, TVUS is helpful for excluding intramural fibroids and the rare causes of abnormal bleeding, including ovarian cancer or fallopian tube carcinoma.
A meta-analysis of 39 studies reviewing women premenopausal and postmenopausal with endometrial pipelle biopsy noted the following In these subjects, submucosal or intramural fibroids were missed and 63 endometrial polyps remained in situ. These intracavitary lesions rarely respond to hormonal therapy. The pelvic examination and findings dictate the appropriate investigation tools. In women with a bimanual examination indicating the uterus is less than 12 to 14 weeks in size, TVUS has been the gold standard method of imaging in the premenopausal patient.
It is minimally invasive and comfortable, and it helps triage patients who might require additional testing. However, it is difficult to determine if there is any intracavitary pathology Figs. A study by Breitkopf19 highlights the limitations of TVUS alone in the reproductive-age patient and strongly advocates, when possible, the additional of saline infusion to improve detection of intracavitary lesions and myometrial abnormalities.
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It is asserted that examination of the endometrium during the secretory phase yields more information about the time of ovulation, degree of progestational change, and normality of the endometrium than any other test used in sterility studies. Attention to qualitative changes in 8 morphological factors is most useful in dating the endometrial biopsy. During the 1st week of luteal activity, attention should be focused on changes occurring in gland epithelium: During the 2nd week , stromal changes including edema , predecidual reaction, stromal mitosis, and leukocytic infiltration are the key criteria.
Tissue from the fundus of the uterus gives the most reliable information.
Number: Policy. Aetna considers indocyanine green angiography medically necessary when it is used as an adjunct to fluorescein angiography in the diagnosis and management/treatment of any of the following conditions. Acute posterior multi-focal placoid pigment epitheliopathy; or Exudative senile macular degeneration; or Hemorrhagic detachment of retinal pigment epithelium; or.
Proliferative Phase Proliferative phase change. The glands are simple appearing as circles in cross-section. Mitotic activity is conspicuous. In the endometrium, proliferative activity occurs even before the complete cessation of menstruation, i. The glands at this earlier stage are relatively straight or, at most, slightly coiled and are found within relatively loose endometrial stroma. As the name suggests, there is brisk cell division with prominent mitotic activity in both the glands and the stroma.
Under the influence of oestrogen, the stroma is often the thickest at day After this, the rate of glandular growth relative to the stroma results in coiling of the glands as the cycle moves towards ovulation. The nuclei rather than centrally-located are pseudostratified, though they tend to be found in the basal half. Interval Phase The interval phase occurs over a short period of hours. The early interval phase is therefore indistinguishable from late proliferative phase without biochemical corrobation.
Histologic dating of the endometrium: Accuracy, reproducibility, and practical value
Evaluation of the status of the endometrium in infertile patients, including histological dating. 3. Evacuation of products of conception, either spontaneous abortions or termination of pregnancy.