<strong>Liane Deligdisch</strong> <br />Icahn School of Medicine at Mount Sinai, USA

Biography

Liane Deligdisch has graduated from Medical School in Bucharest , Romania and was trained in Obstetrics-Gynecology and Pathology in Romania, Israel and in the USA : Resident at the Boston Free hospital for Women, Harvard Medical  School,  Boston Mass. and Fellowship at The Mount Sinai Medical Center, N.Y. She is a tenured Professor of Pathology and Obstetrics-Gynecology since 1986, Founder of, and Director of the Division of Gynecologic Pathology and of the Course of Gynecologic Pathology at the Mount Sinai Icahn School of Medicine (Professor Emeritus since 2017). Author of 148 peer reviewed articles, most on Gynecologic Pathology, Editor of 7 textbooks. The 8th book on Hormonal Pathology of the Uterus will be published by Springer Verlag this year. She is a member of the French National Academy of Medicine since 2007

Abstract

The uterus and especially its internal layer, the endometrium are sensitive targets for steroid sex hormones, capable to modify structure and functions with promptness and versatility. Hormone therapy is used to counteract abnormal and deleterious functions or effects of “natural” hormones and is now widely prescribed being used by millions of women all over the world. It seems that most women would use at least some hormone therapy at some point of their life: adolescents and young women use hormonal contraceptives; reproductive technology for infertility includes hormonal ovulation stimulation; post-menopausal symptoms are frequently treated with hormone replacement therapy despite controversial data on their safety and efficiency; endometrial and myometrial benign and neoplastic proliferations are treated with hormone therapy, including reversal of premalignant lesions. Adjuvant breast cancer therapy with Tamoxifen is sometime associated with uterine abnormal proliferation and neoplasia.

The diagnosis of uterine tissue, mostly endometrial biopsies, from patients undergoing hormone therapy is often confusing and difficult to interpret due to the complexity of histologic changes. Permanently changing hormonal pharmaceutic products, regimens, dosages as well as new concepts of therapy are challenges for both users and medical prescribers.

<strong>Michail Shafir</strong><br />Icahn School of Medicine at Mount Sinai, USA

Biography

Michail Shafir MD MPH FACS, Clinical Professor of Surgery and Oncologic Sciences at Icahn School of Medicine at Mount Sinai in New York, has a long standing interest in Carcinoid and Neuroendocrine Tumors. He has written extensively on surgical treatment of neuroendocrine tumors involving multiple abdominal sites, including the gastro intestinal tract, pancreas and liver metastases, including cryoablation and radiofrequency ablation for non curatively resectable liver metastases. His work has been presented nationally and internationally

Abstract

Ovarian carcinoids are extremely rare (0.1 % of all ovarian neoplasms). We report on 67 patients from a single institution from 1994 to 2015.  Most benign tumors were diagnosed at surgery for pelvic mass. 29 cases were primary and 38 were metastatic. 93% of the primary tumors were unilateral, mostly with teratomas ,struma ovarii ,trabecular, mucinous and insular . Metastatic tumors were bilateral in 72% of which half were from small bowel, (mainly mucinous adenocarcinomas with neuroendocrine differentiation). All cases had neurosecretory granules ( chromogranin, synaptophysin and 67% expressed CDX2, signaling  intestinal origin. Mean age was 48 for the benign cases and 53 for the malignant ones. Carcinoid syndrome was present in 45% of the malignant cases. Surgery was performed in 95% of the cases and adjuvant treatment in 74%. Overall survival was 86% for benign tumors and 50% for malignant ones at 5 years.

In conclusion: ovarian carcinoids have generally a more indolent course than the more common ovarian cancers and have a better survival. Carcinoid syndrome is present mainly in metastatic tumors as well as well as proliferation index (Ki67), and cytologic atypia.

<strong>Nicholas Vivian John Pairaudeau</strong><br />University of Toronto, Canada

Biography

Nicholas Pairaudeau has been an Obstetrician and Gynecologist in practice since 1976. He trained in Obstetrics and Gynecology in the United Kingdom, Kings College Hospital, London University and transferred to The University of Toronto in 1973. In 1976 He took up his specialist practice at North York General Hospital, an affiliate of the University of Toronto. He still has a very busy practice of both Gynecology and Obstetrics, teaching, mentoring, as well as striving to be innovative in practice. He travels extensively, particularly in China, where he has visited from the North to the South, and he has been involved in teaching, mentoring, and assisting.  He is also a member of the Royal Society of Medicine, Royal of Surgeons Canada, SOGC, ESGE, AAGL, as well as an active member of the SLS, which is an organization based out of Florida in the USA.

Abstract

Hysterectomy is one of the most widely performed operations on Woman, yet the jury is still out as to the best way to remove the uterus. Though through advances with technology, the uterus can be removed through small incisions, the cost for these operations can be increasingly high, and third world countries have neither the resources or the training for these operations. The other issue is that with longer operations the effects on the body increase, and the time taken to operate increases the waiting list.

Historically, the earliest known hysterectomy recorded in the English literature was apparently by a Charles Clay in Manchester UK in 1843.(1) There were subsequently other gynecologists who performed hysterectomy and these were recorded in the medical literature of the Day.(2) In 1929 Dr Richardson published a complete full hysterectomy, including cervix as well ovaries(3). Since then various approaches have been described, including the original subtotal by laparotomy, to the more complete operations, with various techniques.(4)

With the pioneering work of Palmer in Paris, (5) with laparoscopy, in the late 1930s this became the modern and increasingly popular route for pelvic and abdominal surgery in the 1960s, after competing against culdoscopy in the USA. This set up Dr Semm(6) in Germany , and Dr Harry Reich in The USA to show that MIS, (minimally invasive surgery), laparoscopy hysterectomy was not only possible, but had many advantages over the more traditional way that was carried out over the world. They taught many gynecologists throughout the world, who later made various changes to the way that they taught.

BY 2000, the Robot began to be incorporated into nonmilitary, non-battlefield surgery, with mostly prostate surgery. By 2005, FDA approval, (7) was given for the Da Vinci Robot to be used in gynecological surgery.  As time went on, the operations that could be performed with the robot mushroomed.   

However, with all MIS, minimally invasive surgery, there were significant startup costs, and then there was the maintenance of the equipment.(8) Disposables contributed greatly to the cost of each operation, but there was no alternative to this system until recently. With the Senhance system. (9) Interesting variations in the technology needed for successful safe robotic surgery were and are still being developed.

However with all medical treatments there is a cost.  NO wealth no health is well known to persons in the third world. Gradually, modern gynecology surgery began to deviate with the original core approach to hysterectomy, laparotomy, to being replaced by more modern techniques, but leaving the third world with the challenge of no money and lack of the skills to complete the more advanced procedures.  Most conferences tend to focus on the latest, innovative, but also more expensive technology to remove the uterus. There is little enthusiasm for looking backwards, when gleaming new equipment that with experienced operators and assistants, can make these operations very impressive, with results that suggest that recovery is quicker and easier.

There is NO doubt that that in busy centres with highly skilled surgeons there are lower complications. And centres that embark upon regular reviews of performance are all too few. Only when we get some sort of level playing field, with studies that are not biased, superficial and lacking very basic data, are we able to really answer the question, what is the best way for a hysterectomy. 

<strong>John Studd</strong> <br />London PMS and Menopause Clinic, UK

Biography

Professor John Studd, DSc,MD,FRCOG was Consultant Gynaecologist at the Chelsea & Westminster Hospital, London and also Professor of Gynaecology at Imperial College. He qualified in 1962 and has worked and trained in Birmingham. Zimbabwe and London. He was Consultant Gynaecologist in Salisbury, Rhodesia and Consultant and Senior Lecturer at the University of Nottingham. His early research was on chronic renal disease and high blood pressure in pregnancy (MD thesis) but later started the first menopause clinic in Europe in Birmingham in 1969. This hormone treatment for the menopause was so controversial at that time that the clinic was closed down for three months following protests from the BMA. However, the optimism placed in HRT has been confirmed and John Studd has continued to work on specific treatments for menopausal symptoms. He pioneered the sequential oestrogen/progestogen treatment and also the continuous combined oestrogen/progestogen non-bleeding treatment. He has championed the use of hormone implants for women with osteoporosis or with severe depressive or sexual problems after the menopause and as an almost routine route of HRT after hysterectomy. He first described the use of oestrogen patches and oestrogen implants for the treatment of severe PMS. He is also shows the efficacy of moderately high dose transdermal oestrogens for the treatment of hormone responsive depression in women, particularly post-natal depression, pre-menstrual depression, menopausal depression and post-hysterectomy depression. He has a D.Sc. for 25 years of published work on oestrogen therapy in women. He has written more than 500 scientific articles and written or edited more than 25 post-graduate books on gynaecology. He needs to write one for the public, but that is much more challenging. He is Founder and Vice-President of the Royal Osteoporosis Society and has been a Council Member of the Royal College of Obstetricians and Gynaecologists for 20 years and a Past-President of the Section of Obstetrics and Gynaecology at the Royal Society of Medicine. In 2005-2007 Professor Studd was Chairman of the British Menopause Society. He is now in fulltime private practice and runs the London PMS & Menopause Clinic at 46 Wimpole Street London W1G8SD. At the same address he has The Osteoporosis Screening Centre for the assessment and treatment of osteoporosis. In 2008 he was awarded the Blair Bell Gold Medal of the Royal Society of Medicine which is given every five years for the obstetrician/gynaecologist who has made the greatest lifetime contribution to the specialty

Abstract

The effect of hormones on depression in women is recognised by most gynaecologists but it is neglected by psychiatrists.  This leads to a greater use of antidepressants or antipsychotic therapy often of doubtful benefit.

 

The concept of ‘Reproductive Depression’ is associated with depression occurring with changes  in ovarian hormones.  This is most obvious in menopausal depression, PMT and PMDD and becomes more troublesome with age.  Another example is post-natal depression which has been shown to improve considerably with oestrogens compared with a placebo.Later in life this is followed by menopausal depression which is more severe for the two or three years preceding the cessation of periods within the years called the ‘menopausal transition’.  We thus have three peaks of depression in women, PMS, postnatal depression and menopausal depression which often occurs in the same woman throughout her reproductive life.  There are other important aspects of history to consider such as these women are often well with no depression during pregnancy but develop postnatal depression. hey are usually well with prolonged breast feeding, and the postnatal depression now often cyclical only occurs when the breast feeding stops and when ovulation and the cycles reoccurs. The first challenge is to recognise the hormonal component of depression by the history and not be blood tests which are irrelevant .

 

Treatment consists of transdermal oestrogens by patch or by gel often with the addition of testosterone.  The ideal dosage would be Oestrogel, three to four measures daily and testosterone gel in the form of Testogel making one sachet/tube last for a week.  In women with a uterus they should have cyclical progesterone such as a natural progesterone, Utrogestan 100mgs for the first seven to twelve days of every calendar month.  It should be stressed that these patients particularly those with PMS are often progesterone intolerant and a short course of seven day is usually prescribed rather than the more orthodox twelve days.  Ultimately these women may choose to have a hysterectomy and bilateral oophorectomy with replacement oestradiol and testosterone which invariably cures premenstrual depression and other aspects of Reproductive Depression.

<strong>Bruno Mozzanega</strong> <br />University of Padua, Italy

Biography

Bruno Mozzanega, md, is author/co-author of over 180 scientific papers, included presentations in Congresses and abstracts. He wrote a textbook (Da Vita a Vita-IIIrd Ed. SEU, Rome,2013). He participated in researches about menopause since 1980, in particular concerning the oncogen and cardio-vascular risk, osteoporosis and coagulation disorders, the circulating levels of Insulin Like Growth Factors and their Binding Proteins during different schedules of HRT, the endometrial features in breast cancer patients treated by tamoxifen. He participated in the pioneer studies (1980) on the assay of sex steroids hormonal receptors in hormone dependent benign and neoplastic diseases. He collaborated in Molecular Biology researches concerning the endometrium in PCOS. Currently, he is highly interested in the mechanism of action of emergency contraceptives and actively works in forming high-school teachers and students in Reproduction knowledge and Fertility Control. He is the President of the Italian Society of Responsible Procreation (SIPRe, www.sipre.eu).

Abstract

Statement of the Problem - Emergency Contraceptive Pills (ECPs) are described as drugs that work  by either inhibiting or delaying ovulation without affecting implantation. In our opinion, however, EMA documents and the experimental papers indicate that they prevalently inhibit embryo-implantation.

Literature concerning LNG-ECPs - The EMA-EPAR on ellaOne® (Table 1, p.9)  reports that LNG never prevents ovulation when is taken in the most fertile days. On the contrary, it prevents the formation of an adequate corpus luteum.

Literature concerning UPA-ECPs - The EMA-CHMP Assessment-Report on ellaOne® (EMA/73099/2015, Table 2, p.7), evidences that 91.7% of women taking ellaOne® weekly for eight consecutive weeks have normal ovulation, with a permeable cervical mucus.

Besides, literature shows that ellaOne® prevents ovulation only when is taken in the first fertile day. Thereafter its anti-ovulatory effect drops sharply and becomes insignificant (8%) 36 hours before ovulation, in the most fertile days; its decreasing trend cannot explain a consistently high effectiveness in preventing pregnancies (?80%) that does not decrease depending on which of the five days it is taken after unprotected intercourse.

Lastly, Lira-Albarràn administered ellaOne® to women in the most fertile pre-ovulatory days: they had normal ovulation, but their endometrium, evaluated through samples obtained in the implantation window, became inhospitable: the expression of 1183 genes was exactly the opposite of that observed in the receptive pro-gestational endometrium. This agrees with information by EMA-CHMP Assessment-Report for ellaOne® (EMEA-261787-2009,p.8): after UPA administration “the proteins necessary to begin and maintain pregnancy are not synthesized.”

In EMA/73099/2015(p.9), EMA removed the warning against repeated administration of ellaOne ellaOne® within the same menstrual cycle, basing on HRA2914-554 study, where women were exposed to UPA-amounts equal to or higher than theose, potentially hepatotoxic, taken through Esmya®.

Conclusion - Emergency Contraceptives work prevalently by preventing embryo-implantation. People shall receive correct information.

<strong>Nicholas Vivian John Pairaudeau</strong> <br />University of Toronto, Canada

Biography

Nicholas Pairaudeau has been an Obstetrician and Gynecologist in practice since 1976. He trained in Obstetrics and Gynecology in the United Kingdom, Kings College Hospital, London University and transferred to The University of Toronto in 1973. In 1976 He took up his specialist practice at North York General Hospital, an affiliate of the University of Toronto. He still has a very busy practice of both Gynecology and Obstetrics, teaching, mentoring, as well as striving to be innovative in practice. He travels extensively, particularly in China, where he has visited from the North to the South, and he has been involved in teaching, mentoring, and assisting.  He is also a member of the Royal Society of Medicine, Royal of Surgeons Canada, SOGC, ESGE, AAGL, as well as an active member of the SLS, which is an organization based out of Florida in the USA.

Abstract

Introduction: Post-Partum Haemorrhage as defined by a blood loss of more than 500 ccs at vaginal delivery, and 1000 cc at C section is a worldwide Issue and is the leading cause of maternal mortality. It occurs between 5 to 15 % of deliveries, though rates vary in different parts of the world.

It appears from the world literature that this rate is increasing and is attributed to many causes including the association of increased labour induction, augmentation of labour, previous C section, placenta previa, and abnormal placentation.

After many years of watching how we conduct labour and delivery, despite this association of PPH and maternal morbidity and mortality, the use of new drugs and procedures the figures seem to rise. I see some marked deficiencies in the way we conduct a normal labor and delivery, and management of the third stage. With the advent of delayed cord clamping, and cord blood banking, the chances of post-partum haemorrhage can increase.

The proper management of potential post-partum hemorrhage starts in the prenatal clinic, a risk tool for PPH in Labour and delivery, the appropriate management of labour, and care in avoiding bleeding from perineal laceration or episiotomy and making every effort to get the uterus to contract. Medications to assist in the uterus to contract are recommended.  A normal placentation and with strong uterine contraction, the placenta will usually be delivered by 15 minutes. Care must be taken to check the placenta and that it is complete. Careful observation of the post-partum patient in the hour or two after delivery is paramount as up to 25 % of PPH occurs after leaving the delivery area.

With a full understanding of the antecedent factors leading up to a PPH, a very significant drop can be expected if standard precautions are taken. Even in the best hands however PPH can occur, and the sequence of practices that can deal with this mostly treatable complication of pregnancy will be outlined.

This session will go over the full picture from clinic to discharge from hospital and later 4 to 6-week post-partum check. Cases will be presented, and it is hoped that delegates enrolled in this session will bring their own cases too.

Conclusion: PPH contributes to significant morbidity and mortality in the world today, despite new drugs, devices and interventions. The session will allow us the explore the prevention, careful management of the three stages of labour, and reduction in PPH rates without incurring huge costs.

Keynote Speaker

Michael J Sinosich
DHM Pathology, Australia

Title: Non – Invasive prenatal screening

Time: 10:00-11:00 (Special Session)

<strong>Michael J Sinosich</strong> <br />DHM Pathology, Australia

Biography

Michael J Sinosich has completed his PhD on Trophoblast Physiology and PAPP-A. His research interests include non-invasive assessment of fetomaternal wellbeing. He is the Director of Prenatal Testing (DHM Pathology) and serves as Consultant at Pictor Ltd, a developer and manufacturer of multiplexed microELISA assay platform. He has published/presented numerous papers in reputed journals and holds several patents.

Abstract

Over the past several decades, Non-Invasive Prenatal Screening (NIPS) has undergone a complete metamorphosis. Early population screening programs were very simplistic, eg., application of maternal age as a single discriminator for identifying population of women of advance maternal age and, hence, requiring invasive testing (amniocentesis). Ultrasonography ushered in era of direct fetal visualisation and biometrics, whilst maternal serum AFP quantitation remained the biochemical marker for prenatal detection of open neural tube defects (oNTDs). However, the obstetric population demanded more. So, by 1990s, ultrasonography (NT thickness) was combined with first trimester biochemistry to raise clinical efficacy of screening for Trisomy 21.

 Demonstration of feto-placental derived extracellular or cell free (cf) DNA in maternal circulation, complemented with molecular technological advances, had introduced the era of NIPS based on cfDNA. Irrespective of sequencing technology, detection of targeted autosomal aneuploidies, such as, trisomy 21, was now in excess of 99%. Despite the hyper-marketing associated with NIPS, primary referrers and their patients soon learned the limitations of cfDNA-based aneuploidy screening and realised that, prior to initiating interventional management, ALL positive cfDNA results must be confirmed with invasive testing and karyotyping.


Figure1: Options for non-invasive prenatal screening and diagnostic options, relative to gestation age.

Global uptake of cfDNA based NIPS surpassed all expectations. Again, obstetric population demanded greater clinical coverage. Interpretive algorithms were refined to report sub-chromosomal disorders and, more recently, complete fetal chromosome enumeration. As these technical boundaries are continually pushed back, it should not be forgotten that the source of feto-placental cfDNA, in maternal circulation, often touted as “fetal”, is actually derived from placental trophoblast cell. Hence, regulatory recommendations for confirmation of abnormal cfDNA findings, prior to initiation of interventional management.

Conclusions: Designing the optimal prenatal healthcare assessment program, should include ultrasonography, first trimester biochemistry and cfDNA. Such a program offers enhanced detection of major autosomal aneuploidies, whilst simultaneously screening for fetal structure and polyploidy and pre- eclampsia.

<strong>Michael J Sinosich</strong> <br />DHM Pathology, Australia

Biography

Michael J Sinosich has completed his PhD on Trophoblast Physiology and PAPP-A. His research interests include non-invasive assessment of fetomaternal wellbeing. He is the Director of Prenatal Testing (DHM Pathology) and serves as Consultant at Pictor Ltd, a developer and manufacturer of multiplexed microELISA assay platform. He has published/presented numerous papers in reputed journals and holds several patents.

Abstract

Since the initial of Dennis Lo and colleagues (1997)1, describing the presence of “Presence of fetal DNA in maternal plasma and serum”, commercial investment and interest knew no bounds. Until the reality check of Sequenom, line between good science and commercial conflicts of interests had been breached.

Since the broad acceptance of cfDNA based aneuploidy screening, the past decade has provided many cautionary lessons:

1.      Source of cfDNA in maternal circulation:

Figure 1: Fetal gender assignment + RhD typing, at 10 weeks gestation (S Cheong MSc Thesis 2009).

In a multiplex RT-PCR assay, detection of male (SRY) foetuses was readily achieved. However, in one SRY positive case, the woman gave birth to a male baby, 10 years before submitting to test. At time of testing, the woman was neither pregnant nor sexually active.

2.      Fetal fraction (FF): One of the most critical parameters of cfDNA based NIPS is fetal fraction, ie., the abundance of extracellular feto-placental derived DNA relative to maternal derived extracellular (cf) DNA. In general, fetal fraction increases with gestation but is inversely related to maternal weight (or BMI). Unlike placental derived biochemistry, it is not possible to adjust FF with weight correction factor. For most NIPS technologies, FF limits range between 1 – 4%. Other factors which impact on FF, include, specimen integrity, maternal health. In cases where cfDNA testing failed, these women should be considered at increased risk for aneuploidy.

3.      Technical Vs Ethical: Major cfDNA NIPS service providers have technical capability to expand clinical coverage to include sub-chromosomal abnormalities and, even, full chromosome enumeration. Despite regulatory recommendations against population-based screening for genome-wide chromosome abnormalities and microdeletion syndromes, NIPS service providers continue to offer expanded cfDNA screening, for a slightly more expanded price.

Conclusions: The benefits (clinical efficacy) of targetted cfDNA NIPS for major autosomal aneuploidies has seen significant commercial force driving for the implementation of cfDNA NIPS as THE front line screening test. This concern regarding our understanding of cfDNA NIPS technology, its benefits and limitations, and associated commercial drivers, has led some concerned voices to openly question the quality of information and support provided by NIPS service providers.

Keynote Speaker

Michael J Sinosich
DHM Pathology, Australia

Title: Case studies of prenatal screening

Time: 11:30 - 12:30 (Special Session)

<strong>Michael J Sinosich</strong><br />DHM Pathology, Australia

Biography

Michael J Sinosich has completed his PhD on Trophoblast Physiology and PAPP-A. His research interests include non-invasive assessment of fetomaternal wellbeing. He is the Director of Prenatal Testing (DHM Pathology) and serves as Consultant at Pictor Ltd, a developer and manufacturer of multiplexed microELISA assay platform. He has published/presented numerous papers in reputed journals and holds several patents.

Abstract

Prenatal screening is the process by which we identify a population of pregnancies considered at increased risk for a disorder, such as, trisomy 21. Whilst some screens may be clinically more efficient at detecting targeted abnormalities, it should not be forgotten that, prior to initiation of clinical management, ALL abnormal screens should be followed with diagnostic investigations. In this presentation are detailed four case studies which highlight the need for vigilance and caution.

1.  Case 1: False Positive cfDNA                                 2. Case 2: False Negative cfDNA

              CFTS Risk: Tri 21 = 1/69366                                             CFTS Risk: Tri 21 = 1/5

              cfDNA = Tri 13 (High Risk)                                                cfDNA = Low risk

               Invasive Testing: 46XX                                                Invasive Testing: 47XX + 21

3.  Case 3: Fetal Development                                      4. Case 4: False Negative cfDNA

               CFTS Risk: Tri 21 = 1 / 28                                                CFTS Risk: Tri 21 = 14170

               cfDNA = Low risk                                                             cfDNA = Low risk

                   Invasive: 46XX                                                                Invasive: 69XXX

        Diagnosis: Skeletal dysplasia + FGR

The above 4 cases highlight the nature of screening, ie., identifying an at risk population requiring definitive investigation. The above cases also demonstrate that to maximise screening efficacy, we need to incorporate complementary screening modalities. Hence, early pregnancy screening programs should include feto-placental biochemistry, extracellular DNA and ultrasonography.

Keynote Speaker

Michael J Sinosich
DHM Pathology, Australia

Title: Cell based non-invasive prenatal screening

Time: 11:30 - 12:30 (Special Session)

<strong>Michael J Sinosich</strong> <br />DHM Pathology, Australia

Biography

Michael J Sinosich has completed his PhD on Trophoblast Physiology and PAPP-A. His research interests include non-invasive assessment of fetomaternal wellbeing. He is the Director of Prenatal Testing (DHM Pathology) and serves as Consultant at Pictor Ltd, a developer and manufacturer of multiplexed microELISA assay platform. He has published/presented numerous papers in reputed journals and holds several patents.

Abstract

Over the past decade, we have witnessed the convergence of molecular technology and physiology in the development of molecular diagnostics based on low abundance of template. Application of extracellular (or cell free, cf) DNA has impacted on every facet of healthcare, such as, prenatal screening, transplantation, oncology, regenerative and testing for infections. Furthermore, application of low template detection has been applied to food industry, environment, forensics and defence.


Figure 1: Investigative options for prenatal assessment of feto-maternal wellbeing

Presence of fetal cells in maternal circulation was first described over a century ago. By many, the holy grail of non-invasive prenatal screening is considered to be based on genomic (g) DNA derived from feto-placental cells. Target cells include fetal nucleated (fn) red blood cells (RBC), fetal leukocytes (fWBC) and trophoblast cells. For many decades, there have been numerous at developing a sustainable screening program based on gDNA.

Whilst it is generally accepted that concentration of fetal cells in maternal circulation is positively correlated to gestation, current isolation / enrichment protocols generally yield < 1 cell / mL of maternal blood. Fetal cell isolation / enrichment is based on various combinations of physico-chemical (charge, size) + positive/negative immunological confirmation. Single cells are excised by laser dissection. Whilst these processes provide single cells for genotyping, in general, the rate limiting step of immunological confirmation and laser dissection, renders these procedures non-viable for population screening. Clearly, here is situation in need for combination of microfluidics + AI.

Of the numerous efforts to develop robust fetal cell isolation workflow, most have failed to materialise and the remaining focus is now on trophoblast cells. Trophoblast cells are markedly different from blood cell components. Differences include, physical size, membrane physiology and immunological reactivities. Given that trophoblast cells are source of biochemistry markers (PAPP-A, F?hCG) and cfDNA for NIPS testing, then the same caution must be applied, ie., any positive findings based on trophoblast derived gDNA must be confirmed with definitive testing.

Conclusions: Progress towards the holy grail of non-invasive prenatal fetal genotyping has progressed immensely over the past decade. Proof of concept studies have demonstrated that preferred cellular target is trophoblast cell. Technology for single cell genomics is readily available from many commercial sources. So, the remaining challenge is to develop microfluidics applicable to population screening.

<strong>Pawel Szymanowski</strong> <br />Andrzej Frycz Modrzewski Krakow University, Poland

Biography

Pawel Szymanowski graduated medicine from the Medical School of Hannover and then did a specialization in gynecology and obstetrics in Germany where he worked for 15 years. He has been the head of department since 2006. His main focus over the years and still to today is urogynecology. In 2013 he moved to Poland where he has continued his work in urogynecology and operative gynecology. He is currently the head of the Department of Gynecology and Urogynecology at Andrzej Frycz Modrzewski Krakow University. In May 2017 he became the President of the Polish Urogynecological Association

Abstract

More than 30% of women in the western world suffer from different urogynecological diseases like urinary incontinence and pelvic organ prolapse (POP). In cases of POP the most commonly used operative procedure is still a hysterectomy with anterior and posterior colporrhaphy even though the uterus is not the cause of the prolapse. Instead POP is a result of different defects of fascia and ligaments in the pelvic floor. These defects should be accurately detected and taken into account when planning operative treatment. There are plenty of minimally invasive and uterus preserving laparoscopic methods dedicated to these defects such as: laparoscopic hystero-, colpo-, cervicosacropexy, pectopexy, laparoscopic lateral repair and laparoscopic colporrhaphy. The use of minimally invasive, uterus preserving methods in pelvic floor repair is less of a burden for the patients and reduces the hospitalization time and recurrence rates immensely. Finally preserving the uterus is also important for the sense of body integrity and helps to avoid mental health problems

<strong>Wioletta Katarzyna Szepieniec</strong> <br />Andrzej Frycz Modrzewski Krakow University, Poland

Biography

Wioletta K. Szepieniec graduated medicine from the Jagiellonian University in Krakow and did her specialization in gynecology and obstetrics in Germany where she worked for 10 years. Her main focus over the years and still to today is urogynecology but also breast surgery and aesthetic gynecology. In 2014 she moved to Poland where she has continued her work in urogynecology and operative gynecology. She is currently senior doctor of the Department of Gynecology and Urogynecology at Andrzej Frycz Modrzewski Krakow University

Abstract

Introduction  and  methods:  The  aim  of  this  study  is  to  show  a  novel  approach  of  the  repair  of  the  lateral  paravaginal  defect  causing  the  cystocele.  The  extraperitoneal  (preperitoneal)  approach  has  its  advantages  and  can  be  used  in  patients  with  comorbidities  and  in  obese  patients.  The  main  advantage  of  this  procedure  is  omitting  of  the  pneumoperitoneum  and  of  the  Trendelenburg  position  during  the  operation.  The  avoiding  of  peritoneal  adhesions  is  also  important.

Results:  This  study  presents  the  first  results  of  this  novel  approach  on  27  patients.  All  of  the  patients  have  a  cystocele  POP  Q  2  and  59%  of  them  concomitant  stress  urinary  incontinence  due  to  lateral  defect  of  the  vesico-vaginal  fascia.  Mean operation time was 80 minutes.  After  the  operation  by  all  of  the  patients  was  achieved  the  reduction  of  the  cystocele  to  POP  Q  I  or  0.  Follow-up  after  6  months  revealed  only  1  recurrence  of  the  cystocele.  Quality  of  life  was  controlled  with  PIFQ  Questionnaire  and  revealed  a  statistical  improvement  from  average  6,8  point  before  operation  to  average  0,7  points  after  (p<0,05).

Conclusion:  Preperitoneal  laparoscopic  lateral  defect  repair  is  a  relatively  fast  operation.  It  is  feasible  also  for  obese  women  and  for  patients  with  cardiac  risk,  because  of  the  omitted  Trendelenburg  position  and  pneumoperitoneum.  Postoperative  can  be  achieved  a  very  satisfied  effect  with  the  reduction  of  patient’s  complaints  and  reduction  of  the  cystocele.

<strong>Marjeta Logar ?u?ek</strong><br />University Medical Centre Ljubljana, Slovenia

Biography

On 24 February 2016, Marjeta Logar ?u?ek, MSc is defending her doctoral thesis at the Medical Faculty in Ljubljana. She spent the period between December 2013 and August 2015 researching the influence of health and educational intervention on raising the awareness and consequently improving the responsiveness of the Roma women with regard to their own care for reproductive health. Ms Logar ?u?ek was able to establish and confirm positive influences of education and training on the Roma women’s decisions regarding the choosing of possibilities for the use of health services in the area of reproductive health. A clear connection can also be seen between the use of educational materials and the women being more aware of the consequences of their own decisions. She was the first to start research into the awareness of reproductive health of the Roma women in Slovenia.

Abstract

A prospective interventional research was carried out (between December 2013 and August 2015) with the view to improving Roma women’s care for reproductive health. Within the framework of the entire research, it was carried out in three stages. At the beginning, interviews were conducted with Roma women in their settlement. Their answers provided an insight into their viewpoints regarding reproductive health, the behaviour of health care professionals and the decisions of the women to use the services of the women’s clinic. On the basis of the results of the qualitative analysis of the interviews, an educational leaflet was prepared. The leaflet, which was explained to each particular women that decided to participate in the research, helped raise the Roma women’s awareness regarding reproductive health. They become more familiar with different ways of making appointments, time frame and the need for preventive check-up appointments. 

The effectiveness of the leaflet has been checked in two ways, namely using a questionnaire given to all Roma women in the settlement, and two focus groups with health care professionals in the Trebnje health centre.

The results of the first part of the research have shown that the Roma women are still tightly connected to their cultural tradition which greatly influences their care for reproductive health. But significant changes can be observed in terms of their views becoming more and more similar to the majority population, which is particularly apparent in younger generation.

The usefulness of the leaflet is mostly seen in the provision of urgent data regarding the women’s clinic (69%) and in the training for finding a suitable time to see a doctor and make an appointment (73.5%). The answers of women in childbearing age and those before or past it are statistically significantly different. However, it needs to be remembered that educational materials distributed among Roma women have a desired effect only if certain conditions are fulfilled, such as literacy of the target group (at least partial) and the ability of the women to identify with the materials (in this case women in childbearing age.)

Health care professionals report that raising the health literacy marked the beginning of positive changes in the reproductive care of Roma women. It can be concluded that Roma women need and accept educational materials adapted to their values and tradition, which is changing under the influence of the majority population. 

<strong>Marya El Alami</strong> <br />University of Valencia, Spain

Biography

El Alami M. has completed her PhD at the age of 30 years from University of Valencia, Spain. She has 9 publications. She is a doctor of pharmacy and has a master degree on pharmacology. She speaks 5 languages.

Abstract

Statement of the problem: The key hallmark of stem cells is their ability to self-renew while keeping a differentiation potential. Intrinsic and extrinsic cell factors may contribute to a decline in these stem cell properties, and this is of the most importance when culturing them. Very much importance was given to the balance of nutrients, growth factors and pH buffers used to grow stem cells in vitro, little importance was given to the oxygen concentration in the culture media, as it was assumed that the ambiental 21% O2 was adequate for cell growth. Oxygen concentration has been closely linked to the maintenance of stemness and the widely used environmental 21% O2 concentration represents a hyperoxic non-physiological condition, that can impair stem cell behaviour by many mechanisms.


The aim of this study: Minimizing the time obtention of a large amount of viable dental pulp stem cells (DPSC) as critically important for stem cell banking for clinical use and to study the effect of the usual, high oxygen concentration (21% O2), compared to the physiological (3% O2), on the parameters of proliferation, oxidative stress and cell cycle regulation.


Finding: Our results showed that the ambiental oxygen tension is far not the optimal oxygen condition for in vitro stem cells culturing, as it effects negatively the adhesion, proliferation rate, differentiation, oxidative stress, cell cycle regulation and antioxidative defense parameters. We also proposed the underlying molecular mechanism behind these results.


<strong>Shaikh Zinnat Ara Nasreen</strong><br />Z H Shikder Women’s Medical College Hospital, Bangladesh

Biography

Professor Shaikh Zinnat ara Nasreen is working relentlessly for the improvement of women’s health. She has graduated from Dhaka medical college in 1984 with honours marks in Medicine and in anatomy. She obtained Gold Medal for extraordinary academic activities. Later she obtained her FCPS degree from BCPS and Mph from North South University. She also got MRCOG and FRCOG from Royal college of Obs/Gyne, UK. She is at present working as professor and Head of obs/gyne dept of ZHSikder women’s medical college and hospital, Dhaka. She has national and international publication and she had attended several international conferences. At present she is the secretary general of BMS and organizing secretary of OGSB, and Member secretary of BCPS.

Abstract

Pregnancy loss brings tremendous psychological effect. Empirical treatments are aspirin, heparin and progesterone. Progesterone from corpus luteum, placenta is the key hormone for implantation and maintenance of pregnancy. Much work is going on since 1940, removal of corpus luteum is associated with pregnancy loss but replacement with progesterone can help to maintain the pregnancy. Progesterone antagonists readily induces abortion. Deficiency of progesterone may lead to Pre term birth (PTB). The safety of progesterone was reported and showed no anomalies.

 Meta-analysis of 60 RCT (1989) showed that pregnancies reached at least 20 weeks RR =3.09 (95% CI 1.28-7.42) with progesterone and meta-analysis (2002) suggested luteal support with progesterone is superior to HCG. Level evidence 1 support, progesterone prevents PTB. On the contrary study by Mohammed reported, progesterone in any route proved to have limitation and side effects. Meta-analysis of 25 articles stated luteal support of progesterone is unnecessary for it, slow benefits, costs and side effects.  Meta-analysis of 53 publications by Leyan showed progesterone resulted increase in pregnancy rate odds (OR= I.12; p<0.01), but the study of Stephanie Castillo (PROMISE) reflected, benefit of progesterone is not proven for miscarriage. Amanda  (2017) showed that 2/3 of women who used progesterone, successfully delivered despite they had previous two miscarriages. Meta-analysis of 10 RCT by Saccon G showed progesterone in 1st trimester lowered risk for pregnancy loss (RR 0.72; 95% CI, 0.53-0.97).

Suk-Joo Choi stated, progesterone is effective in preventing PTB. Meta-analysis analysed 39 RCT showed lowered risk of PTB with progesteron. In contrast OPTIMUM and PROGRESS trials found no significant benefits but OPTIMUM study showed progesterone reduces PTB where Cervix is shortened. Progesterone is not effective for preventing PTB following PROM.

Meta-analysis of 168 articles (Salim Daya) suggested use of progesterone but efficacy has not been demonstrated. Mesen supported exogenous progesterone for Luteal phase support in ART.  Meta-analysis by Katherene 2017 concluded, progesterone as luteal support is beneficial, live birth rate (RR 1.77, 95% CI 1.30-2.42).

Conclusion

Analysis of Meta-analysis suggested, progesterone supports pregnancy. But the optimum dose, type, route, nature, duration and starting time are not been evaluated.

Speaker

Networking & Lunch

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Time: 12:30- 13:30

<strong>Networking & Lunch</strong>

Biography