Thyroid disease in pregnancy: A review of diagnosis, complications and management

Malfunction of the thyroid gland is the second most common endocrine disorder encountered during pregnancy. It is well known that overt disease of the thyroid gland, either hyper or hypo can adversely affect pregnancy outcome. There is also an ongoing debate surrounding the issue of subclinical hypothyroidism and its effect on the cognitive development of the unborn child. The goal of this paper is to present a systematic review of the literature and the current recommendations for diagnosis and treatment of thyroid disease in pregnancy and postpartum.

Preeclampsia - What is to blame? The placenta, maternal cardiovascular system or both?

Preeclampsia (PE) is a pregnancy-specific syndrome, complicating 2%-8% of pregnancies. PE is a major cause of maternal mortality throughout the world with 60000 maternal deaths attributed to hypertensive disorders of pregnancy. PE also results in fetal morbidity due to prematurity and fetal growth restriction. The precise aetiology of PE remains an enigma with multiple theories including a combination of environmental, immunological and genetic factors. The conventional and leading hypotheses for the initial insult in PE is inadequate trophoblast invasion which is thought to result in incomplete remodelling of uterine spiral arteries leading to placental ischaemia, hypoxia and thus oxidative stress. The significant heterogeneity observed in pre-eclampsia cannot be solely explained by the placental model alone. Herein we critically evaluate the clinical (risk factors, placental blood flow and biomarkers) and pathological (genetic, molecular, histological) correlates for PE. Furthermore, we discuss the role played by the (dysfunctional) maternal cardiovascular system in the aetiology of PE. We review the evidence that demonstrates a role for both the placenta and the cardiovascular system in early- and late-onset PE and highlight some of the key differences between these two distinct disease entities.

Emergency contraception: What is new?

Unintended pregnancy rates remain high throughout the World and increase the risk of poor maternal and infant outcomes. Most of unintended pregnancies occur in women who were not using contraception or who became pregnant despite the reported use of contraception. Women who have had recent unprotected intercourse including those who have had another form of contraception fail are potential candidates for this intervention. Currently used emergency contraceptive methods are pills that contain combined estrogen-progesterone, only progestin, antiprogestins and copper intrauterine devices. The most common form of this type of contraception is oral progestin-only pills (levonorgestrel). The most effective method is copper intrauterine devices followed by anti-progestins and oral progestin-only pills. The major pathogenesis of oral emergency contraceptives is the prevention or delay of ovulation. Although conception is possible on only a few days of the cycle, emergency contraception is offered when indicated without regard to the timing of the menstrual cycle because of uncertainty in the timing of the ovulation. Levonorgestrel and E/P regimes are most effective as soon as possible after unprotected sexual intercourse. A linear relationship has been shown between effectiveness and the time of dose. The effectiveness continues for 120 h, but it is recommended to be used within 72 h after intercourse. Intrauterine devices may prevent pregnancy when 5 d after ovulation.

Use of hyaluronic acid for sperm immobilisation and selection before intracytoplasmic sperm injection: A systematic review and meta-analysis

AIM: To appraise critically the published randomised controlled trials (RCTs) reporting on the effectiveness of using hyaluronic acid (HA) for sperm immobilisation and selection before intracytoplasmic sperm injection (ICSI).

METHODS: Two authors used the PICO Method in order to perform a comprehensive literature search of the standard medical databases in June 2015. Data from the included studies was extracted independently by two authors using a predefined pro-forma. Review Manager (RevMan) was used to calculate the combined outcomes where multiple studies contributed with their results. Risk ratio (RR) with a 95%CI using the Mantel-Haenszel method was calculated for binary data variables. Heterogeneity was measured using the χ² test and quantified using I². In case of substantial heterogeneity (P < 0.10 for χ² test or I² > 50%) the combined outcome was calculated using the random effects model. The results from the meta-analysis were displayed as forest plots. The guideline of the Cochrane Collaboration was used to assess the risk of bias and it was illustrated as a risk of bias graph.

RESULTS: The systematic literature search identified 166 different studies related to sperm immobilisation and selection for ICSI. Eleven RCTs involving 13719 oocyte intracytoplasmatic injections with sperm immobilised and selected using HA or polyvinylpyrrolidone (PVP) were included in this systematic review and meta-analysis. There was low heterogeneity among the included trials (χ² = 16.86, df = 11, P = 0.11; I² = 35%). There was no statistical difference between HA and PVP groups in terms of fertilisation rate (RR = 1.01; 95%CI: 0.99-1.03; z = 0.75; P = 0.45), good embryos rate (RR = 1.01; 95%CI: 0.96-1.06; z = 0.30; P = 0.76), live birth rate (RR = 1.15; 95%CI: 0.86-1.54; z = 0.92; P = 0.36), clinical pregnancy rate (RR = 1.04; 95%CI: 0.92-1.17; z = 0.62; P = 0.53) and implantation rate (RR = 1.17; 95%CI: 0.94-1.46; z = 0.40; P = 0.16). The quality of most of the included studies was moderate to poor because of unclear randomisation technique, inadequate allocation concealment and blinding.

CONCLUSION: This systematic review and meta-analysis provides evidence of similar efficiency between using HA or PVP for sperm immobilisation and selection before ICSI.

Universal screening for hemoglobinopathies in today's multi-ethnic societies: How and when

Increasing multi-ethnicity in countries endemic or non-endemic for hemoglobinopathies has brought fundamental changes to the screening strategies for these traits. While in the past pre-screening on microcytosis was a reasonable method to economize upon follow up analysis, selecting low mean corpuscular volume means today missing all those normocytic carriers of common traits associated with severe conditions. Therefore, blood count should not be considered as a pre-selection tool but as additional information to be used for the interpretation of the provisional results, obtained by routine high throughput separation and measurement of the hemoglobin (Hb) fractions. Moreover, the moment of screening should be well planned depending on the social and cultural situation. Screening for genetic diseases in a modern multi-ethnic society should be offered to couples seeking progeny when both partners are more likely to be equally concerned with the good health of their children. In several societies screening before marriage and changing partner choice is culturally accepted. However, new generations are bound to disagree with these more or less imposed conditions and may decide not to renounce the choice of their partner asking for other preventive methods. In addition, a carrier state during pre-marital screening may in some cultures stigmatize the carrier, mostly the female with adverse social consequences. Therefore, screening for hemoglobinopathies early in pregnancy is the most sensible alternative in modern countries. Adding hemoglobinopathies to the routine rhesus screening using a simple separation of the Hb fractions on dedicated devices (high performance liquid chromatography or capillary electrophoresis) will virtually identify all female carriers of all common traits responsible for the severe conditions mainly sickle cell disease and thalassemia major in time for partner analysis, counseling and primary prevention.

Infertility and ovarian failure in celiac disease

Unexplained infertility in females may be a devastating event for the reproductive-aged female. However, infertility may be due to ovarian failure associated with celiac disease, an immune-mediated disorder that may have few or no symptoms and can be successfully treated. In some prospective serologically-based studies, over 4% of infertile females may prove to have celiac disease. Serological screening for celiac disease is relatively inexpensive and involves testing for antibodies to tissue transglutaminase. If positive, a small intestinal biopsy should be done to confirm the diagnosis. The initial treatment for this disorder is a gluten-free diet. To date, a number of reports have indicated that this treatment for celiac disease may result in successful pregnancy, in spite of prolonged periods of infertility. Celiac disease, when untreated, may also lead to several adverse events following pregnancy including increased risk of recurrent abortions, low birthweight and impaired fetal growth. Recent molecular and pathological studies from different laboratories suggest that altered placental function may be due to binding to cells in the trophoblast by tissue transglutaminase antibodies impairing embryo implantation and leading to failure of early pregnancy or retarded intrauterine growth.

Ovarian simple cysts in asymptomatic postmenopausal women detected at transvaginal ultrasound: A review of literature

AIM: To answer some questions related to the problem of ovarian simple cysts in asymptomatic postmenopausal women.

METHODS: A literature search and systematic review using MEDLINE (PubMed) database from 1980 to 2014 was performed using the following terms: “simple cyst”, “postmenopause”, “postmenopausal”, “ultrasound”, “ovary”, “ovarian”, “asymptomatic”. Papers not related to the topic, reviews, letters to editor, opinion letter, commentaries and studies published in non-English language were excluded. Two authors then reviewed the full paper of all the studies initially selected. This review does not claim to be a meta-analysis. Therefore, meta-analysis statistics were not applied and PRISMA guidelines were not strictly followed. Simple descriptive statistics were used providing absolute numbers and corresponding percentages as well as range.

RESULTS: Nine papers were ultimately included in this review, accounting for 98899 postmenopausal women. We have found that ovarian simple cysts are relatively common in asymptomatic postmenopausal women (prevalence: 8.7%). The risk of malignancy is very low (0.19%). More than 90% of these cysts were smaller than 5 cm. Bilaterality rate ranged from 3.7% to 15%. Histologically, most cysts are serous cystadenomas (61%). When managed conservatively, a significant number resolve spontaneously (46.1%) or remain unchanged (39%).

CONCLUSION: According to these data, conservative management should be the first option to offer to these women.

Outcomes of surrogate pregnancies in California and hospital economics of surrogate maternity and newborn care

AIM: To describe maternity and newborn charges for an economic analysis of surrogate pregnancies on the health care resource utilization.

METHODS: A retrospective chart review of all women identified as being surrogates and the infants born from these pregnancies was performed between January 1, 2012 and December 31, 2013. Selected maternity diagnoses, mode of delivery, duration of hospitalization, and hospital charges were collected together with infants’ birth weights, gestational age, length of hospital stay, and hospital charges. Charges associated with the in vitro fertilization cycles, artificial insemination, or embryo(s) transfer into the surrogate were not considered in the maternity charges. A ratio contrasting the maternity hospital charges for the surrogate carrier was compared as a ratio to the mean charges for 2540 infants delivered in 2013 after natural conception and adjusted to the baseline hospital charges for both maternity and newborn care.

RESULTS: Analysis of sixty-nine infants delivered from both gestational and traditional surrogate women found an increased in multiple births, NICU admission, and length of stay with hospital charges several multiples beyond that of a term infant conceived naturally and provided care in our nursery. Among singletons and twins (per infant) hospital charges were increased 26 times (P < 0.001) and in triplets charges were increased 173 times (P < 0.0001) when compared to a term infant provided care in a normal nursery at our center.

CONCLUSION: Maternity costs for surrogates exceed those of women who conceive naturally, and these costs are especially magnified in women with triplets and multiple births.

Single incision slings: Past, present, and future

Pubovaginal slings have become the gold standard to treat stress urinary incontinence. Traditionally, the sling referred to a suspensory that was placed under the urethra and brought through the retropubic space and anchored on either side of the midline. Since this original concept, there have been many materials used for the sling, and there have been many different anchoring approaches. Most agree that one of the best materials is polypropylene mesh. However, the means of anchoring the device and where best to have this anchorage placed is debatable. The options for anchoring simply include using darts vs not to hold the sling in place. The location of this anchorage, on the other hand, is much more controversial. The main locations are retropubic, transobturator, and via a single incision. The obturator and retropubic slings have become the standard of care over time. The single incision sling, on the other hand, is starting to be more acceptable which has resulted in it being used more frequently. The single incision relies on mainly anchoring the sling through the obturator internus muscle with possible inclusion of the obturator membrane. The purpose of this review article is to present the data that exists for the use of the single incision sling.

Urgent need to change clinical practices about postpartum contraception

In the United States, maternal mortality and unintended pregnancy rates are increasing. There are growing disparities in maternal health between indigent, minority women and Caucasian women of higher socioeconomic status. Family planning has long been viewed as a solution to these problems. As reliance on permanent contraception has diminished, timely access to highly effective contraceptive methods, namely long acting reversible contraceptives, which includes the contraceptive hormonal implant and intrauterine device - has become even more important. For women in the United States and abroad, the time of delivery is the one reliable opportunity for women to receive medical care. Consistently, research has shown that providing contraception in the immediate postpartum period is safe, effective, feasible and cost effective. However, misperceptions, lack of supplies, and reimbursement issues combine to defeat attempts to provide the most effective methods of contraception during that hospitalization. We believe that it is time to tackle the problem of unintended and rapid repeat pregnancy using an evidence-based, patient-centered paradigm and to eradicate systemic barriers blocking access to contraceptive methods during hospital stay. This editorial will outline some of the more compelling evidence supporting this move and will provide insights from successful programs.

Avoiding misdiagnosing an early intrauterine pregnancy as an ectopic pregnancy

In women at risk for an ectopic pregnancy, every effort should be made to exclude the presence of an intrauterine pregnancy before embarking on an irreversible treatment for ectopic pregnancy. The diagnosis of ectopic pregnancy, unless directly visualized with transvaginal ultrasound, is made with the exclusion of an intrauterine pregnancy. Measurement of human chorionic gonadotrophin and progesterone levels, and transvaginal ultrasound are the tools used to evaluate early pregnancy. In women at risk for an ectopic pregnancy, every effort should be made to exclude the presence of an intrauterine pregnancy before embarking on an irreversible treatment course. Methotrexate is an antimetabolite that inhibits DNA synthesis and repair and cell replication. It is administered to ostensible destroy a pregnancy, especially ectopic pregnancies. When administered to an intrauterine pregnancy, embryonic death and missed abortion is the most common result, but early embryos that survive this exposure are likely to have multiple anomalies. The mistaken administration of methotrexate to an intrauterine pregnancy is made because of misinterpretation of the discriminatory zone of human chorionic gonadotropin (hCG), misinterpretation of early hCG serum levels, misinterpretation of early transvaginal ultrasound images, and failure to clinically correlate hCG levels and ultrasound findings.

Value of neoadjuvant chemotherapy in advanced ovarian cancer

Data regarding the role of neoadjuvant chemotherapy (NACT) are not definitive. Several randomized trials and meta-analyses demonstrate that this chemotherapy regimen decreases the morbidity and mortality rates and increases complete cytoreduction rates. If combined with hyperthermic intraperitoneal chemotherapy (HIPEC), NACT could potentially further improve upon these already promising results. Moreover the use of NACT could help in evaluating the chemo-sensitivity of the cancer, thus preventing unnecessary HIPEC procedures in chemo-resistant patients. NACT should definitely be considered as a preferred regimen in the management of advanced ovarian cancer, especially in association with cytoreductive surgery + HIPEC procedure in the context of a multidisciplinary team management in an experienced cancer centre.

Effect of the maternal-fetal interface immunoregulation on the occurrence of intrahepatic cholestasis of pregnancy

Maternal immune tolerance of the fetus is indispensable for a healthy pregnancy. Currently, the study of the immune microenvironment of the maternal-fetal interface has been a heated topic in reproductive immunology research. More and more studies show that the immune imbalance in the maternal-fetal interface plays a very important role in the incidence of intrahepatic cholestasis of pregnancy (ICP). However, the precise etiology and mechanism of immune imbalance in the occurrence of ICP is still unknown. In order to clarify the potential immunologic mechanisms of ICP, this review summarizes the recent studies of the decidual immunology microenvironment and the potential immunologic mechanisms related to the development of ICP.

Pioneering drugs for overactive bladder and detrusor overactivity: Ongoing research and future directions

The ongoing research on pioneering drug candidates for the overactive bladder (OAB) aimed to overcome the limitations of currently licensed pharmacotherapies, such as antimuscarinics, β3-adrenergic agents, and botulinum neurotoxin, has been reviewed performing a systematic literature review and web search. The review covers the exploratory agents alternative to available medications for OAB and that may ultimately prove to be therapeutically useful in the future management of OAB patients based on preclinical and early clinical data. It emerges that many alternative pharmacological strategies have been discovered or are under investigation in disease-oriented studies. Several potential therapeutics are known for years but still find obstacles to pass the clinical stages of development, while other completely novel compounds, targeting new pharmacological targets, have been recently discovered and show potential to translate into clinical therapeutic agents for idiopathic and neurogenic OAB syndrome. The global scenario of investigational drugs for OAB gives promise for the development of innovative therapeutics that may ultimately prove effective as first, combined or second-line treatments within a realistic timescale of ten years.

Mental health of perinatal women

Pregnancy and childbirth are major stressors for some women. They can be followed by deterioration in mental health status and cause mental illnesses during perinatal period. Undetected and untreated perinatal mental illnesses can have negative unexpected impacts on parenting skills of the women and children’s development. Mentally ill mothers may not effectively attend their children’s needs in a timely manner and may experience an unfavourable mother-child attachment affecting the child’s language, social, emotional and cognitive development. The rate of pregnancy and postnatal health complications and interventions is higher among mentally ill women with some certain risk factors. The mentally ill mothers along with their partners need comprehensive support and counselling to be able to care for their infants and establish strong parent-child bond and attachment. Mental health campaigns across the world have endeavoured to increase the knowledge and awareness of the public towards perinatal mental health illnesses. To this aim, a routine screening is recommended in order to identify the women who are at risk of mood or anxiety disorder during perinatal period. The development of knowledge on perinatal mental illnesses among public and the health professionals has resulted in timely recognition and treatment of perinatal mental illnesses. Although great volumes of research show high prevalence of perinatal mental illnesses and their impacts on parenting confidence and competence as well as child’s developmental process, there is still lack of research on various aspects of perinatal mental illnesses. To enable early prevention, diagnosis and intervention, it is crucial to identify families who are at an increased risk of perinatal mental illnesses and provide support and intervention to minimise the adverse outcomes. The children’s needs may not be met by providing treatment to parental mental illnesses alone. It is also important to understand the impact of specific parenting behaviours on child outcomes which is modified by the quality of parenting.

Hepatitis B and pregnancy: An update review article

Chronic hepatitis B, as a global health problem, is a disease that begins in the prenatal period and its complications gradually become clear later in life. About 5% of women worldwide are carriers of chronic hepatitis B virus (HBV). The most common method of transmission of HBV around the world is from mother to infant. This article aims to review the unique challenges of hepatitis B in pregnancy. Data for this review were collected from our previous studies and experiences plus various data banks, such as PubMed, EMBASE, ISI Web of science, Scopus, Google Scholar and Iranian databases. A comprehensive search was performed using the combinations of the keywords to review relevant literature and higher education journals. All published data up to February 2014 have been included in this review. This article addresses several interesting aspects. First, hepatitis B in pregnancy can vary regarding prevalence, virus behavior, prenatal transmission and outcome of the pregnancy. Second, the women of reproductive age with chronic HBV remain a major source for continued spread of the virus. Finally, pregnant women need screening in prenatal care to enable early intervention when necessary.

High prevalence of post-partum depression in women with coeliac disease

AIM: To explore the prevalence of post-partum depression (PPD) in coeliac disease (CD).

METHODS: We performed a case-control study evaluating the prevalence of PPD in CD patients on gluten-free diet (GFD) compared to that of healthy subjects experiencing a recent delivery. All participants were interviewed about menstrual features, modality and outcome of delivery and were evaluated for PPD by Edinburgh Postnatal Depression Scale (EPDS).

RESULTS: The study included 70 CD patients on GFD (group A) and 70 controls (group B). PPD was present in 47.1% of CD women and in 14.3% of controls (P < 0.01; OR = 3.3). Mean EPDS score was higher in CD compared to the controls (mean score: group A 9.9 ± 5.9; group B 6.7 ± 3.7; P < 0.01). A significant association was observed between PPD and menstrual disorders in CD (69.7% vs 18.9%; P < 0.001; OR = 3.6).

CONCLUSION: PPD is frequent in CD women on GFD, particularly in those with previous menstrual disorders. We suggest screening for PPD in CD for early detection and treatment of this condition.

Hepatoma-derived growth factor expression as a prognostic marker in cervical cancer

AIM: To examine the association of hepatoma-derived growth factor (HDGF) expression with the prognosis of patients with cervical cancer of the uterus (CC).

METHODS: HDGF is a unique nuclear growth factor, and it may play an important role in the development and progression of carcinoma. HDGF expression in 88 CC patients aged 23 to 76 years (median, 54 years) was analyzed by immunohistochemistry. A rabbit polyclonal antibody against the C-terminal amino acids (aa 231-240) of the human HDGF sequence was used as primary antibody at a dilution of 1:5000. This specific anti-HDGF antibody was purified using C-terminal peptide-conjugated Sepharose columns. Staining of endothelial cells in the noncancerous areas of each specimen was used as an internal positive control. Samples with more than 80% of tumor cells showing positive immunoreactivity in both the nucleus and cytoplasm were regarded as HDGF index level 2, more than 80% positive immunoreactivity in either the nucleus or cytoplasm as level 1, and less than 80% in both the nucleus and cytoplasm as level 0. The chi-square test and Fisher’s exact probability test were used to examine the relationship between HDGF expression and clinicopathologic parameters, and statistical significance was examined by the log-rank test. Multivariate analysis of factors related to survival was performed using Cox’s proportional hazards regression model. Statistical significance was set at P < 0.05.

RESULTS: The five-year overall survival rate was 82.9%. Fourteen patients died due to tumors, nine of whom had tumor recurrence at 2-21 mo (median, 10 mo) after surgery. Tumor recurrence in five patients was determined at the time of the patients’ deaths. Nineteen cases were regarded as HDGF index level 0, 11 as level 1, and 58 as level 2. Patients with level 2 expression showed higher rates of histological classification of keratinized squamous cell carcinoma and adenosquamous carcinoma (44.8% of level 2 patients and 13.3% in levels 0 and 1), deep invasion (pT2-4 in 65.5% of level 2 patients, and 30.0% in levels 0 and 1), the presence of lymphatic invasion (50.0% in level 2, and 20.0% in levels 0 and 1), and the presence of lymph node metastasis (37.9% in level 2, and 6.7% in levels 0 and 1). Patients with an HDGF index of level 2 CC showed poorer 5-year overall survival rates than those with level 0 or 1 CC (74.0% and 100%, respectively, P = 0.0036). Univariate analysis revealed that histological classification (P = 0.04), depth of tumor invasion (P = 0.0001), vascular invasion (P = 0.004), and lymph node metastasis (P = 0.0001) were significant factors affecting overall survival in addition to HDGF expression. Multivariate analysis revealed HDGF expression level and lymph node metastasis as independent prognostic factors for overall survival (P = 0.0148 and P = 0.0197, respectively). The prognostic significance of HDGF was further analyzed in pT1 and pT2-4 patient groups, respectively. Among patients with pT1 CC, one the 39 analyzed patients died during the study, and no difference was observed among patients with HDGF index level 0, 1, or 2 CC. However, prognostic significance of the HDGF index was observed in the pT2-4 patient group, in which the mortality rates of patients with HDGF index level 2 CC and those with level 0 or 1 CC significantly differed (P = 0.0463).

CONCLUSION: The HDGF expression level is of prognostic significance in CC.

Prevention of shoulder dystocia related birth injuries: Myths and facts

Traditionally, brachial plexus damage was attributed to excessive traction applied on the fetal head at delivery. Recently, it was proposed that most injuries occur spontaneously in utero. The author has studied the mechanism of neurological birth injuries based on 338 actual cases with special attention to (1) fetal macrosomia; (2) maternal diabetes; and (3) methods of delivery. There was a high coincidence between use of traction and brachial plexus injuries. Instrumental extractions increased the risk exponentially. Erb’s palsy following cesarean section was exceedingly rare. These facts imply that spontaneous neurological injury in utero is extremely rare phenomenon. Literary reports show that shoulder dystocia and its associated injuries increased in the United States several-fold since the introduction of active management of delivery in the 1970’s. Such a dramatic change in a stable population is unlikely to be caused by incidental spontaneous events unrelated to external factors. The cited investigations indicate that brachial plexus damage typically is traction related. The traditional technique which precludes traction is the optimal method for avoiding arrest of the shoulders and its associated neurological birth injuries. Effective prevention also requires meticulous prenatal care and elective abdominal delivery of macrosomic fetuses in carefully selected cases.

Association between gamete source, exposure and preeclampsia: A review of literature

Preeclampsia complicates 3%-5% of pregnancies and is one of the major causes of maternal morbidity and mortality. The pathologic mechanisms are well described but despite decades of research, the exact etiology of preeclampsia remains poorly understood. For years it was believed that the etiology of preeclampsia was the result of maternal factors, but recent evidence suggests that preeclampsia may be a couple specific disease where the interplay between both female and male factors plays an important role. Recent studies have suggested a complex etiologic mechanism that includes genetic imprinting, immune maladaptation, placental ischemia and generalized endothelial dysfunction. The immunological hypothesis suggests exaggerated maternal response against fetal antigens. While the role of maternal exposure to new paternal antigens in the development of preeclampsia was the initial focus of research in this area, studies examining pregnancy outcomes in pregnancies from donor oocytes provide intriguingly similar findings. The pregnancies that resulted from male or female donor gametes or donor embryos bring new insight into the role of immune response to new antigens in pathogenesis of preeclampsia. The primary goal of the current review is the role of exposure to new gametes on the development of preeclampsia. The objective was therefore to provide a review of current literature on the role of cohabitation length, semen exposure and gamete source in development of preeclampsia.

Gynecological malignancies and hormonal therapies: Clinical management and recommendations

Every year in the world a large number of women receive a diagnosis of gynecological cancer and undergo a therapy such as surgery, chemotherapy and radiotherapy to the pelvic region. A large portion of these patients are already in menopause, but for younger patients therapies are responsible of early menopause. The physical and psychological symptoms due to iatrogenic menopause significantly reduce the quality of life; however hormone replacement therapy (HRT) has a high efficacy in reducing menopausal symptoms. The prescription of HRT in patients with story of gynecological cancer is debated because its safety has not been completely proven. The main criticism is based on the theory that the hormone replacement could stimulate growth of residual cancer cells increasing the risk of recurrence.

Retained placenta: Do we have any option?

Retained placenta is a known cause of post-partum haemorrhage and maternal mortality. A recent systemic review has confirmed that the incidence of retained placenta had increased all over the world, which is more common in developed countries. Failure of retro-placental myometrium contraction is the main cause of retained placenta. Maternal age greater than 35 years, grandmultipara, preterm labor, history of previous retained placenta, and caesarean section were the risk factors for retained placenta. Manual removal of the placenta has been the treatment of choice. Attempts had been made by clinician and researchers to find a safe, effective and reliable method to avoid the need for surgical intervention. The efficacy and safety of prostaglandin, nitroglycerin or acupuncture in the management of retained placenta are yet to be further evaluated. Nonetheless, till date only intra-umbilical vein oxytocin has been studied extensively but with varied success. More randomized clinical trials are needed to address this issue. However, if immediate manual placenta removal service is unavailable, a trial of intra-umbilical vein oxytocin 100 IU at a total volume of at least 40 mL while preparing for transfer to a tertiary center or theatre may result in spontaneous expulsion of the placenta.

Effect of vaginal speculum lubrication on cervical cytology and discomfort during smear examination

AIM: To evaluate the role of lubricant gel in the cytology of a Pap smear and whether it results in an improvement in the discomfort experienced by women while undergoing Pap smear screening.

METHODS: A total of 151 women were analyzed in the study. After screening for inclusion criteria, a Pap smear was taken with no lubricant in all the women and the discomfort experienced was rated on a visual analogue scale. The women underwent a second Pap smear on the next visit using a lubricant gel and were again rated on a visual analogue scale for the discomfort felt. The pathologist was blinded to the fact of whether the lubricating gel was used.

RESULTS: The number of unsatisfactory smears in the no gel group was 3 vs 5 in the gel group, P < 0.05. However, a significant difference (P = 0.00) was observed in the visual analogue pain score in both groups, suggesting that application of lubricant gel over the speculum improves the pain experienced by women.

CONCLUSION: Using a small amount of lubricant over the speculum does not impair cervical cytology but significantly improves the discomfort experienced by women while undergoing a Pap smear.

Role of minimally invasive surgery in complex adnexal tumours and ovarian cancer

Ovarian cancer is one of the most common causes of cancer-related death in women. Adnexal masses are frequently diagnosed during reproductive age and often require surgical removal. The risk of malignancy when dealing with a complex adnexal mass should be defined prior to surgery and several scoring systems may be useful for this purpose. Laparoscopic management of ovarian tumours allows a minimally invasive approach with respect to several oncological assumptions. In the last decade concerns have been raised regarding the risk of cyst rupture and tumour spillage as a consequence of the laparoscopic technique itself both in early and advanced stages of ovarian cancer. Although limited data have been reported in the literature on the use of minimally invasive techniques in ovarian cancer, the clear benefits of this approach must be balanced with the potential hazards in different clinical situations. Laparoscopic staging in borderline tumours and presumed early-stage ovarian cancer performed by a laparoscopic oncologist seems to be safe and effective when compared to laparotomy. The precise role of laparoscopy in patients with more advanced cancer is still to be defined, and the risk of suboptimal surgery should never outweigh the potential benefits of minimally invasive surgery. Thus, a tailored prediction of optimal laparoscopic debulking is mandatory in these patients.

Leiomyoma of the umbilical cord artery: A case report

A leiomyoma is a benign tumor originating from non-striated muscle that is typically found in the uterus. Intravenous leiomyomatosis is a rare form found within the veins, usually associated with uterine fibroids, and tends to recur. These masses can spread from the uterus throughout the venous system. A rare case involving a subendothelial leiomyoma found in an umbilical cord artery is presented in this article. A 21-year-old patient presented with symptoms of preterm labor, which resulted in the premature birth of a female below the 10^th percentile for 24-wk gestational age. The newborn died three days later, and microscopic analysis of the umbilical cord revealed occlusion of the artery by nodular structures. The antepartum diagnosis of intravascular leiomyoma was identified by immunohistochemistry showing that approximately 70% of all tumor cells were diffusely positive for smooth muscle markers, including desmin and smooth muscle actin. These findings indicate the possibility of a pathologic association between the umbilical cord leiomyoma, restriction of fetal growth and preterm delivery due to impaired circulation of blood in the umbilical cord.