Pre-cervical ripening and hygroscopic cervical dilators in pre-labor induction

INTRODUCTION

Induction of labor (IOL) is becoming a universal topic in Obstetrics, when the risk of continuing a pregnancy outweighs the benefits. Preinduction is a more recent tool to prepare the cervix when the BISHOP-score is low. About one-third of IOL cases require cervical ripening, which is the physical softening, thinning, and dilation of the cervix in preparation for labor and birth. We report a single center experience regarding the use of hygroscopic dilators in the pre-labor phase to obtain cervical ripening before labor induction.

MATERIALS & METHODS

We conducted a retrospective observational study comparing patient records from the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital in Prato, Tuscany. The inclusion criteria for participants were women who had undergone pre-labor induction because of a BISHOP-score < 3. The gestational age of all the pregnant women was at term (> 37 weeks).

RESULTS

From January 2022 to April 2022, a total of 581 women delivered at term of gestational age at the Gynecology and Obstetrics Unit in "Santo Stefano" Hospital. Cervical ripening was necessary for 82 women with a Bishop score < 3 and hygroscopic cervical dilators were used in 35/82 (42.7%) patients. All patients showed a change in Bishop-score upon removal of the dilators. All 35 patients (100%) reported an increase in terms of consistency and dilation of the cervix but not in terms of length. None of the patients reported discomfort during the 24 h that they kept the hygroscopic dilators in place. No patients reported uterine tachysystole on cardiotocographic tracing, vaginal bleeding, rupture of membranes or cervical tears.

CONCLUSIONS

Our results are in line with those in the literature, demonstrating the validity of hygroscopic dilators in cervical maturation of pregnancies at term and their efficacy was again highlighted in terms of both maternal and fetal safety and patient satisfaction.

Case report: vertical transmission of Plesiomonas shigelloides. Is it time to strengthen information on safety concerns for raw seafood dietary exposure in pregnancy?

The consumption of raw seafood, generally considered to be a healthy food, has greatly increased worldwide. Pathogens of fish can cause foodborne illnesses in humans, especially following the consumption of raw seafood from contaminated water.Foodborne illness in pregnant women is seldom the cause of neonatal infection, but, as in the reported cases, it has been associated with a high degree of morbidity and mortality.We present the case of a newborn with septicemia and meningitis caused by Plesiomonas shigelloides acquired via the transplacental route. There was a maternal history of ingestion of raw seafood 1 week prior to delivery. A few similar cases are described in the existing literature, which reports 7 neonatal deaths.Therefore, the primary objective of this paper is to highlight the fact that the popularity of raw seafood such as sushi, sashimi, and oysters, requires an improvement in dietary advice regarding unsafe choices in pregnancy in order to avoid preventable foodborne diseases, sometimes fatal for the newborn.

Contrast Agents during Pregnancy: Pros and Cons When Really Needed

Many clinical conditions require radiological diagnostic exams based on the emission of different kinds of energy and the use of contrast agents, such as computerized tomography (CT), positron emission tomography (PET), magnetic resonance (MR), ultrasound (US), and X-ray imaging. Pregnant patients who should be submitted for diagnostic examinations with contrast agents represent a group of patients with whom it is necessary to consider both maternal and fetal effects. Radiological examinations use different types of contrast media, the most used and studied are represented by iodinate contrast agents, gadolinium, fluorodeoxyglucose, gastrographin, bariumsulfate, and nanobubbles used in contrast-enhanced ultrasound (CEUS). The present paper reports the available data about each contrast agent and its effect related to the mother and fetus. This review aims to clarify the clinical practices to follow in cases where a radiodiagnostic examination with a contrast medium is indicated to be performed on a pregnant patient.

Waterbirth: current knowledge and medico-legal issues

Water immersion during labour and birth has become increasingly popular and widespread in many countries, in particular in midwifery-led care settings. Nevertheless, there is a dearth of quality data about waterbirth, with currently available findings mostly arising from observational studies and case series. The lack of high-quality evidence and the controversial results reported by different studies determined a "behavioral gap" without clearly objective, consistent indications allowing for a sound and evidence-based decision making process. Although water immersion in the first stage of labour is generally considered a safe and cost-effective method of pain management for women in labor, concerns still linger as to the safety of immersion during the second stage of labor and delivery, particularly in terms of neonatal risks and medico-legal implications.

Fertility Sparing Treatments in Endometrial Cancer Patients: The Potential Role of the New Molecular Classification

Endometrial cancer is the most frequent gynecological malignancy, and, although epidemiologically it mainly affects advanced age women, it can also affect young patients who want children and who have not yet completed their procreative project. Fertility sparing treatments are the subject of many studies and research in continuous evolution, and represent a light of hope for young cancer patients who find themselves having to face an oncological path before fulfilling their desire for motherhood. The advances in molecular biology and the more precise clinical and prognostic classification of endometrial cancer based on the 2013 The Cancer Genome Atlas classification allow for the selection of patients who can be submitted to fertility sparing treatments with increasing oncological safety. It would also be possible to predict the response to hormonal treatment by investigating the state of the genes of the mismatch repair.

GRAd-COV2, a gorilla adenovirus-based candidate vaccine against COVID-19, is safe and immunogenic in younger and older adults

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High grade cervical intraepithelial neoplasia positive biopsy: the importance of accurate pre-operative workup

BACKGROUND

In cervical cancer screening programs, women with abnormal cytology and confirmation by biopsy are referred for colposcopy for histological evaluation.

METHODS

We characterized the presence and the genotype of HPV by Linear Array HPV genotyping assay in cytological samples collected from about 400 women undergoing conization, with reported high CIN grade after biopsy.

RESULTS

The most prevalent genotype was HPV 16, with an increasing presence depending on the severity of the CIN and with the highest incidence in the 26-35 age range. In the group of younger women (<25) we found the highest percentage of CIN3 (39.3%) and the lowest of CIN1 (17.9%). An increase of CIN1 with increasing age was observed. A different distribution of HPV presence was observed depending on CIN grade (P<0.001): CIN1 HPV negative samples were 46.3%, CIN2: 5.8% and CIN3: 1.4%. Interesting, in the analyzed cohort, we observed the presence of 30% of CIN1. Moreover, within CIN1, 85% of them were associated to negative HPV detection, this observation suggested that the detection of HPV presence may be useful to identify low CIN grade that should be reconsidered for surgical treatment.

CONCLUSIONS

These findings suggest implementing the protocol for the management of women with high risk precancer lesions, with a further HPV test before surgical treatment. The evaluation of HPV presence and genotype before conization might represent a useful tool in reducing or postpone the conization treatment.

Intravenous immunoglobulin for the secondary prevention of stillbirth in obstetric antiphospholipid syndrome: A case series and systematic review of literature

OBJECTIVE

To evaluate the efficacy and safety of intravenous immunoglobulin (IVIg) in secondary prevention of pregnancy complications for patients with obstetric antiphospholipid syndrome (APS) and history of stillbirth.

METHODS

We described three cases of obstetric APS patients with history of stillbirth treated with IVIg in four pregnancies. In addition, we conducted a systematic literature review on the use of IVIg in obstetric APS with history of stillbirth.

RESULTS

Three patients with obstetric APS and history of stillbirth were treated with prophylactic IVIg, in addition to standard treatment (hydroxychloroquine, low-dose aspirin, low molecular weight heparin, and prednisone), in four pregnancies (three singleton and one twin). All pregnancies resulted in live healthy newborns. Long-term follow-up re-evaluations (24-53 months) did not shown any sign or symptom of active systemic disease, and the children were healthy. The systematic literature review retrieved only three cases of use of IVIg in obstetric APS patients with history of stillbirth. All three cases resulted in live healthy newborns. Only in one case, mild thrombocytopenia occurred during treatment, although this event was unlikely to be related to IVIg.

CONCLUSION

Our experience suggests that IVIg as secondary prevention of APS-related stillbirth is associated with good pregnancy and long-term outcomes, with no relevant safety concerns. However, the literature evidence on this topic is limited to few isolated cases, and further studies are needed to clarify which obstetric APS patients may benefit the most from IVIg.

Pilot investigation of the mutation profile of PIK3CA/PTEN genes (PI3K pathway) in grade 3 endometrial cancer

Endometrial cancer (EC) comprises a biological and clinical heterogeneous group of tumors. Several genetic alterations are involved in the development and progression of EC, and may be used for targeted therapy, particularly in patients with advanced-stage EC. In the present study, a combined procedure was developed based on polymerase chain reaction (PCR)-high resolution melting analysis (HRMA) and Sanger sequencing for the evaluation of somatic mutations in selected phosphoinositide 3-kinase (PI3K) catalytic subunit α (PIK3CA; exons 1, 9 and 21) and phosphatase and tensin homolog (PTEN; exons 5, 6, 7 and 8) exons. This combined procedure has the specificity and sensitivity of the two techniques, and overcomes their limitations. A pilot study was performed on 18 selected homogenous EC samples, of grade 3 endometrioid subtype (G3 EEC). First, the feasibility of the combined procedure was investigated to properly identify the presence of somatic mutations on PIK3CA and PTEN, the variations identified were analyzed using Catalogue of Somatic Mutations in Cancer, PolyPhen-2 and Mutation Taster software, and the frequency of mutations/variations was determined in the selected samples. The evaluation of mutational load revealed that the majority of the G3 EEC samples exhibited PIK3CA mutations (39%) and PTEN mutations (67%), and the majority of the samples (83%) had mutations in at least one of the two genes, and 33% had mutations in the two genes. The results of the present pilot study suggested that the cost-effective combined PCR-HRMA and Sanger sequencing procedure may be suitable for identification of PTEN and PIK3CA mutations in G3 EEC and that their frequency was consistent in G3 EEC, indicating that the PI3K pathway serves a pivotal function that may have potential for defining targeted therapy for the treatment of G3 EEC.

Spontaneous Resolution of an Acquired Uterine Arteriovenous Malformation in an Elderly Primigravida

BACKGROUND Uterine arteriovenous malformation (AVM) is an uncommon lesion characterized by an abnormal connection between arterial and venous circulation that can be congenital or acquired. Acquired uterine AVMs are generally traumatic and follow delivery, abortion, curettage, or uterine surgery. CASE REPORT A 45-year-old female who was gravida 1 para 0 presented to our hospital with severe vaginal bleeding. Two weeks before, the patient underwent therapeutic abortion. At admission, a transvaginal ultrasound showed an unclear intrauterine lesion that spread out to the myometrium. Color Doppler evaluation demonstrated an elevated color score. Beta human chorionic gonadotropin (beta-hCG) levels were measured at admission and daily repeated, with a progressive decrease of values up to a negative level. A pelvic magnetic resonance imaging described an area of tubular and tortuous structures involving the myometrium. A computed tomography angiography confirmed the presence of a lesion infiltrating the endometrium and myometrium containing arteriovenous structures with a highly enhanced effect. Despite these findings, the patient was clinically stable. A diagnosis of uterine AVM was made and, after accurate counselling with the patient, she was discharged and underwent "watch and wait" management. After 35 days, the patient had a follow-up ultrasound that showed a complete resolution of the uterine lesion. CONCLUSIONS AVM should be considered in the presence of heavy and sudden vaginal bleeding in a patient with risk factors for acquired AVM. A color Doppler ultrasound scan should be performed as the first approach and an expectant management should be taken into account especially with a patient of childbearing age and hemodynamic instability.

Severe Fetal Distress and Placental Damage might be Associated with High Troponin I (cTnI) Levels in Mothers

Patient: Female, 40

Final Diagnosis: cTnI elevation of unknown etiology

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: —

Specialty: Obstetrics and Gynecology

Ability of cervical length to predict spontaneous preterm delivery in twin pregnancies using the receiver-operating characteristic curve analysis and an a priori cut-off value

In this retrospective study based on cervical length (CL) measurements between 20 and 24 + 6 weeks, we examined the ability of CL to predict spontaneous preterm birth (SPTB) in 222 twin pregnancies using the receiver-operating curve (ROC) analysis and an a priori cut-off. CL predicted SPTB before 34 weeks. Using the ROC the selected cut-off was 37.5 mm. Positive predictive value (PPV) and negative predictive value (NPV) regarding SPTB before 34 weeks for 37.5 mm were 15.7% and 5.3% respectively. Using the 5th percentile, PPV and NPV regarding SPTB before 34 weeks for 24 mm were 41.7% and 91.4%, respectively. The 5th centile of CL measurements should be employed in clinical practice. CL measurement is an adequate screening tool for SPTB since it has a high NPV. Studies on CL measurement and SPTB should explain which methodology they adopted to obtain a cut-off value and the rationale of their choice.

Vulvar melanoma: a 33 years single Italian center experience

AIM

Vulvar melanoma is a rare disease with a poor prognosis. The purpose of this study was to report our experience on vulvar melanoma.

METHODS

This is a retrospective study on patients with primary melanoma of the vulva admitted to our hospital during the last 33 years. Clinical characteristics, surgical therapy and follow-up are reported. Patients were classified following the 2009 edition of the melanoma staging system.

RESULTS

The predominant symptom was pain; five patients reported ulceration and one patient presented bleeding from the vulvar lesions. The average age at diagnosis was 61.4 years. Surgical treatment was performed: radical vulvectomy in five cases, emivulvectomy in three cases, large regional excision in one case. Average time to follow-up was 50.2 months. In four cases (44.4%), regional recurrence occurred and the patients died as a result of the tumor; one patient died of other causes; four patients were still alive at the time of the study.

CONCLUSION

Current treatment protocols have moved towards less aggressive treatment in view of the current available evidence. Sentinel lymph node biopsy and adjuvant therapy are still under debate. Our study confirms the overall poor prognosis for vulvar melanoma.

Two-team simultaneous total radical vulvectomy and inguino-femoral lymphadenectomy via separate incisions for locally advanced (FIGO stages IB ≥ 4 cm-III) squamous vulvar cancer

AIM

To describe the feasibility, safety, and oncological outcomes of a modified triple-incision total radical vulvectomy and inguino-femoral lymphadenectomy in patients with locally advanced squamous vulvar cancer.

PATIENTS AND METHODS

A modified triple-incision technique performed by two surgical teams operating simultaneously under regional anesthesia was performed on a consecutive series of 57 patients with Fédération Internationale de Gynécologie Ostétrique (FIGO) stages IB ≥ 4 cm to III squamous vulvar cancer. Adjuvant radiation therapy was delivered according to margin status and groin involvement. Surgical outcomes and follow-up data were retrospectively analyzed.

RESULTS

The mean age of patients was 75.5 ± 10.7 years and 54 (94.7%) had at least one comorbidity. Fifteen (26.3%) had disease of clinical FIGO stage I ≥ 4 cm, 7 (12.3%) had stage II, and 35 (61.4%) had a stage III. All surgical procedures were completed as planned. The mean surgical duration was 108 ± 37 min. Major intraoperative complications were observed in two cases (3.5%). Twenty-one (36.8%) patients received adjuvant radiation therapy. During a mean follow-up of 51.6 ± 50.5 months, 29 (50.9%) patients developed local, regional or distant recurrence. The disease-free survival was 39.5 ± 20.9 months. Nineteen (33.3%) patients died of primary disease. Overall survival for the entire cohort was 65.4%, with 3-year and 5-year overall survival of 60.5% and 48.6%, respectively.

CONCLUSION

Our results seem to reveal that the procedure is safe, with surgical and oncological outcomes comparable to classic sequential triple-incision technique. The shortening of surgical duration along with the use of regional anesthesia can have significant advantages for perioperative care, reducing the global burden of treatment and increasing the number of patients eligible for therapeutic surgery.

Different fate of a single reporter protein containing KDEL or KKXX targeting signals stably expressed in mammalian cells

In mammalian cells, resident luminal and type I transmembrane proteins of the endoplasmic reticulum usually contain KDEL and KKXX at the carboxyl terminus. These sequences induce retrieval from compartments located downstream in the secretory pathway. It has been suggested that the retrieval may occur from multiple sites, ranging from the intermediate compartment to the trans-Golgi network. To compare the retrieval of luminal and type I membrane proteins, we have used different forms of a single reporter, the human CD8 glycoprotein, stably expressed in FRT cells. Metabolic labeling and oligosaccharide analysis show that the mechanism based on the KDEL signal is leaky. With time, the KDEL-containing CD8 form reaches the trans/trans-Golgi network compartments, where the protein is terminally glycosylated. At this stage, the retrieval mechanism stops being effective and the protein is consequently secreted. Conversely, the mechanism based on the KKXX signal guarantees that most of the KKXX-containing CD8 form resides in the endoplasmic reticulum, little in the Golgi complex and undetectable levels at the plasma membrane. The O-glycosylation of this protein comprises for the vast majority the sole addition of peptide-bound GalNAc that occurs in an early Golgi compartment.

A soluble form of Sda-beta 1,4-N-acetylgalactosaminyltransferase is released by differentiated human colon carcinoma CaCo-2 cells

We have previously shown that human colon carcinoma CaCo-2 cells express the Sda-beta 1,4-N-acetylgalactosaminyltransferase (Sda-beta GalNAc-transferase) and that the enzyme activity correlates with the degree of enterocytic differentiation. Here we report that a large amount of this glycosyltransferase is released in soluble form, particularly when CaCo-2 cells are maintained in culture for more than 3 weeks in order to ensure an higher degree of enterocyte differentiation. The soluble enzyme was concentrated and partially purified by Blue-Sepharose and fetuin-Sepharose chromatography. The substrate specificity of the partially purified enzyme was similar to that of Sda-enzyme from epithelial cells of colon mucosa, and for its activity strictly required the presence in acceptors of NeuAc in alpha 2,3-linkage to subterminal galactose. Among the low molecular glycans tested, NeuAc alpha 2,3Gal beta 1,4GlcNAc appeared to be the best acceptor, whereas sialyl-Lewisx and sialyl-Lewisa did not serve as acceptors, indicating that the fucosylation of sub-terminal GlcNAc hindered the transferase activity. Contrary to this, the activity towards a disialylated acceptor such as di-sialyl-lacto-N-tetraose was reduced but not abolished. When CaCo-2 cells were cultured on porous membranes and the transferase activity assayed in medium collected from chambers corresponding to either the apical or basolateral face of highly differentiated CaCo-2 cells, a preferential release from the basolateral surface was found. Considering that Sda-beta GalNAc-transferase is mainly located in the large intestine, current results support the notion that colonic cells largely contribute to the presence of the enzyme in human plasma.

Effect of ethanol on human colon carcinoma CaCo-2 and HT-29 cell lines during the maturation process

The aim of the study was to ascertain whether the exposure to ethanol of human colon carcinoma CaCo-2 and HT-29 cell lines affects the differentiation process. As an index of enterocytic differentiation, the expression of sucrase, alkaline phosphatase, alpha 2,6-sialyltransferase toward the N-acetyllactosaminic sequence, and beta 1,4-N-acetylgalactosaminyltransferase (beta 1,4GalNAc-transferase) was examined. The latter enzyme is responsible for the biosynthesis of Sda carbohydrate histo-blood antigen, which mainly occurs in human colonic cells; its expression in CaCo-2 cells depends strictly on the enterocytic differentiation. The addition of ethanol in the culture medium resulted in a significant increment of sucrase and alpha 2,6-sialyltransferase activities in both cell lines, as well as the beta 1,4GalNAc-transferase activity in CaCo-2 cells and alkaline phosphatase activity in HT-29 cells. The increment was dose-dependent in the range between 50 and 200 mM ethanol and evident after 2 days of exposure in both cell systems. These results support the notion that, as occurs for cell lines of different origin, the ethanol in vitro positively affects the differentiation of intestinal cells, namely along the enterocytic lineage. The putative mechanism by which ethanol interferes with the maturation process of colonic cells is discussed.