No abstract

Characterization of the implanting human fetus as an allograft prompted a field of research in reproductive immunology that continues to fascinate and perplex scientists. Paternal- or partner-derived alloantigens are present in the maternal host at multiple times during the reproductive process. They begin with exposure to semen, continue through implantation and placentation, and may persist for decades in the form of fetal microchimerism. Changes in maternal immune responses that allow allogenic fertilization and survival of semiallogenic concepti to delivery must be balanced with a continued need to respond appropriately to pathogenic invaders, commensals, cell or tissue damage, and any tendency toward malignant transformation. This complex and sophisticated balancing act is essential for survival of mother, fetus, and the species itself. We will discuss concepts of alloimmune recognition, tolerance, and ignorance as they pertain to mammalian reproduction with a focus on human reproduction, maternal immune modulation, and the very earliest events in the reproductive process, fertilization and implantation.

Surgical site infections (SSI) are the most common surgical complication. Perioperative antibiotics can reduce SSI when used properly. Despite guidelines from The American College of Obstetrics and Gynecology, non-indicated antibiotic use is widespread which exposes women to unnecessary risks. This study represents a quality improvement analysis assessing surgeon compliance with established guidelines regarding antibiotic use in gynaecological surgery. This is a single centre, retrospective study examining gynaecological procedures over two years. Cases were identified using Current Procedure Terminology codes. Perioperative antibiotics were used contrary to published guidelines in 199 of 1046 cases. Three variables were independently associated with inappropriate administration of perioperative antibiotics: entrance into abdominal cavity, higher EBL, and longer procedures. Impact statement Overuse of antibiotics has unintended consequences including allergic sequelae, extended length of hospital stay, increased healthcare costs, and the formation of antibiotic-resistant organisms. Antibiotic stewardship programmes have been shown to reduce the number of resistant pathogens, decrease incidence of Clostridium difficile colitis, and decrease length of hospital stay without increasing infection rates. Further outcomes-based research is needed regarding the use of antibiotic stewardship programmes in gynaecological surgery.

OBJECTIVES: Here we sought to describe patient characteristics, preoperative presentation and evaluation, as well as intra-and postoperative outcomes in cases of leiomyosarcoma as compared to women without leiomyosarcoma undergoing hysterectomy at a single institution. MATERIALS AND METHODS: From January 2005 to April 2014, a retrospective case-control study of patients undergoing hysterectomy for leiomyosarcoma versus temporally matched controls was performed. RESULTS: A total of 31 cases of leiomyosarcoma were compared with 124 hysterectomy controls at Magee-Womens Hospital. The majority of leiomyosarcomas were in postmenopausal women (60% vs. 32.8%; p¼0.05) with a mean age of 55.2 who were less likely to have undergone bilateral tubal ligation (3.2% vs. 30.6%, p¼0.002). Preoperative exam showed uterine enlargement (19 vs. 9 weeks, p <0.001) in concordance with a primary presenting complaint of a pelvic mass in 35% of patients with leiomyosarcoma vs. 8.9% of the controls (p¼0.001). Women with leiomyosarcoma tended to be less likely to present with abnormal bleeding (32.3% vs 51.6%; p¼0.054) or prolapse (0% vs. 18.5%; p¼0.008). LDH was not significantly different between the groups (p¼0.473). Half of all patients had endometrial sampling performed, with 50.0% of the samples in the LMS group demonstrating malignancy compared to only 14.3% in controls (p<0.001). 48.4% of leiomyosarcoma cases underwent multiple imaging modalities preoperative with CT being utilized significantly more frequently than in controls (67.7% vs. 24.2%; p<0.001). There was no difference in the number of fibroids on preoperative imaging between the two groups (48.4% vs. 45.3%; p¼0.837). Interestingly, while 82.9% of controls with preoperative fibroids on imaging were confirmed to also have fibroids on final pathology, this correlated in only 26.7% of leiomyosarcoma cases. Although leiomyosarcoma was rarely identified preoperatively, 77.4% of cases were performed by a gynecologic oncologist (p <0.001) with 83.9% of hysterectomies performed via an open rather than a minimally invasive approach (p<0.001). Intraoperative differences were noted in estimated blood loss (828 mL vs. 150 mL; p<0.001) and uterine weight (1833g vs. 234g; p<0.001), but not in time or complications. Morcellation occurred in 6.5% leiomyosarcomas vs. 19.5% controls (p¼0.083). Survival at the end of the study was 91.5% in controls and 48.3% in leiomyosarcoma patients (p<0.001). CONCLUSION: Risk stratification suggests that leiomyosarcomas becomes more frequent in postmenopausal women presenting with a pelvic mass. We were unable to find other pre-operative indicators that reliably predict leiomyosarcoma. Comparison of preoperative imaging and specimen pathology suggests that uterine pathology in leiomyosarcoma cases may be misdiagnosed as benign fibroids preoperatively. Furthermore, endometrial sampling is benign in half of leiomyosarcoma cases and should not be reassuring in the correct clinical setting. Morcellation appears to be an overall rare event with the majority o...