OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

POS0751 COMORBIDITY AND LONG-TERM OUTCOME IN PATIENTS WITH CONGENITAL HEART BLOCK: PRELIMINARY DATA OF THE ITALIAN REGISTRY ON THE IMMUNE-MEDIATED CONGENITAL HEART BLOCK

Background:

Congenital heart block (CHB) is due to placental transfer of maternal anti-Ro/SSA autoantibodies to the fetus. The prevalence of CHB has been estimated as 1-2% in anti-Ro/SSA women while the recurrence rate is 16-19% (1). This condition is associated with a high rate of fetal/neonatal mortality and most of the cases requires pacemaker (PM) pacing. Given the rarity of CHB, limited data are available regarding the long-term follow-up of the offspring other than the cardiovascular complications.

Objectives:

The results of the Italian Registry of the autoimmune congenital heart block were recently described (2). A peculiarity of this cohort was that most of the mothers had an established diagnosis of systemic autoimmune disease at CHB detection, in contrast with other registries where CHB was mostly incidentally detected in healthy women. Here we report an update, with the preliminary data regarding the long-term outcome of patients with CHB, their unaffected siblings and health controls born from mothers positive for Ro/SSA.

Methods:

Data regarding demography, treatment, maternal, neonatal outcome, and follow-up were collected through an online electronic datasheet. A dedicated questionnaire was created with the aim to investigate general health, cardiovascular follow-up, and frequency of autoimmune diseases.

Results:

One-hundred and five cases of CHB in 99 patients were included from 1969 to December 2020. CHB was mostly detected in utero (97 cases, 92.3%) with 8 neonatal cases. Third degree CHB occurred in 71 cases (67.6%). Child mortality was observed in 29 (27.6%) cases: 20 in utero, 7 during neonatal period and 2 during childhood. Overall, a PM was implanted in 54 out of the 85 live births (63.5%). Then, our cohort was divided into 2 subgroups: pregnancy that occurred before (N=61) and after 2010 (N=44) with the aim to evaluate possible differences among the subgroups. Whereas mortality, PM, CHB degree were similar, CHB more frequently occurred in the last 10 years among Ro/SSA asymptomatic carriers than in the group of pregnancies before 2010 (53.6% vs 32.8%, p=0.038). Questionnaires from 14 surviving CHB cases, 8 unaffected siblings 12 controls born from mothers Ro/SSA positive were collected. Among CHB cases, 6 were males and 8 females, median age 12 years (range 6-28). All presented a third degree CHB, 10 required a neonatal PM pacing and one had an implantable ECG recorder. PM was substituted at least once in 9 patients, the oldest patient had to change it four times. No dilated cardiomyopathy occurred and most of the patients maintain an annual follow-up. Two cases of autoimmune diseases were registered among CHB cases, one idiopathic juvenile arthritis and one Cogan’s vasculitis, both born from mothers with Sjogren Syndrome. Four cases of neurodevelopmental disorders occurred: three cases of learning disabilities (one in each group) and one case of speech disorder in the sibling group. In addition, a CHB case presented a stress disorder linked to frequent hospitalizations.

Conclusion:

This registry is an ongoing project aiming at collecting all Italian CHB. Moreover, here we reported the preliminary data concerning the evaluation of long-term follow-up of CHB patients. Our data, even if need to be confirmed in larger cohort, seems reassuring: no differences were reported comparing CHB patients with unaffected siblings or controls.

References:

[1]Brito-Zéron et al. Nat Rev Rheumatol 2015;11:301-312.

[2]Fredi M et al. Front Cardiovasc Med. 2019 Feb 28;6:11.

Disclosure of Interests:

None declared

Providing high-quality care remotely to patients with rare bone diseases during COVID-19 pandemic

During the COVID-19 outbreak, the European Reference Network on Rare Bone Diseases (ERN BOND) coordination team and Italian rare bone diseases healthcare professionals created the "COVID-19 Helpline for Rare Bone Diseases" in an attempt to provide high-quality information and expertise on rare bone diseases remotely to patients and healthcare professionals. The present position statement describes the key characteristics of the Helpline initiative, along with the main aspects and topics that recurrently emerged as central for rare bone diseases patients and professionals. The main topics highlighted are general recommendations, pulmonary complications, drug treatment, trauma, pregnancy, children and elderly people, and patient associations role. The successful experience of the "COVID-19 Helpline for Rare Bone Diseases" launched in Italy could serve as a primer of gold-standard remote care for rare bone diseases for the other European countries and globally. Furthermore, similar COVID-19 helplines could be considered and applied for other rare diseases in order to implement remote patients' care.

SAT0207 ANTI-SSA/RO POSITIVITY AND CONGENITAL HEART BLOCK: OBSTETRIC AND FETAL OUTCOME IN A COHORT OF ANTI-SSA/RO POSITIVE PREGNANT WOMEN WITH AND WITHOUT AUTO-IMMUNE DISEASES FROM THREE ITALIAN TERTIARY REFERRAL CENTERS

Background:

neonatal lupus syndrome (NLS) is an acquired disease caused by the trasplacental passage of anti-SSA antibodies. Congenital heart block (CHB) represents the most serious manifestation of NLS. The rate of CHB in Anti-SSA positive pregnant women ranges from 1 to 5% in different studies

Objectives:

to retrospectively assess the prevalence of CHB in a cohort of anti-SSA positive pregnant women followed in 3 Italian tertiary centers

Methods:

pregnancies of anti-SSA positive women attending the pregnancy clinic of ASST Pini CTO/Policlinico Mangiagalli, Rheumatology Division of Spedali Civili, Brescia and Rheumatology Division of Ospedale S Matteo, Pavia from 2009 to 2019 were included. Patients underwent monthly clinical examination. Fetal heart rate was assessed weekly by Doppler ultrasound from 14thto 26thgestational week. On week 14 and 26, a fetal echocardiography was performed. A EKG was performed at birth

Results:

351 prospectively followed pregnancies in 292 anti-SSA/Ro positive women were included. Table 1 reports diagnosis. None of the prospectively followed pregnancies were complicated by complete CHB. Seven additional patients were referred to our clinics after diagnosis of CHB and were subsequently found to be anti-SSA positive, reporting no symptoms of diseases. Considering the 7 additional pregnancies, the incidence of CHB was 1.9%. We observed 3 neonates (0.8%) with cutaneous NLS and 1 case of transient increase of liver enzymes. In another neonate, a 1thdegree A-V block was found after birth. A complete analysis of maternal and fetal outcome was possible in 244 cases (Table 2) and compared with 3158 unselected healthy controls. Among these 244 cases, 65% were taking hydroxychloroquine

Table 1.

patients diagnosis

n%Sjogren’s Syndrome58`20Systemic lupus erythematosus7626UCTD7425Asymptomatic Ro carriers5619Other2810292100Table 2.

maternal and fetal outcome

healthy controls N=3158Anti-SSA/Ro ptsN=244P valuePrevious CHB n (%)2 (0.8)Anti-SSB pos n (%)46 (18.8)aPL pos n (%)49 (20)PregnancyLive births3158241Preeclampsia, n (%)43 (1.1)2 (0.8)nsDeliveryDelivery <37 wks, n (%) / < 34 wks n (%)401 (12.6) /201 (6)35 (15.6) / 14 (6)ns / nsCesarean Section, n (%)897 (29.3)115 (47.5)<0.001

Conclusion:

none of the patients prospectively followed in our centers before and during pregnancy developed complete CHB. If the 7 cases of anti-SSA positivity diagnosed after CHB detection were included in the analysis, the incidence of CHB was comparable to previous reports. Our data suggest that a strict follow up and proper treatment of anti-SSA positive patients with or without an autoimmune disease before and during pregnancy can reduce the risk of NLS. Further studies are warranted to confirm a possible protective role of anti-rheumatic treatments, including HCQ

References:

[1]Fredi M. Front Cardiovasc Med. 2019

Disclosure of Interests:

Maria Gerosa: None declared, Micaela Fredi: None declared, Laura Andreoli: None declared, Cecilia Chighizola: None declared, Lorenza Maria Argolini: None declared, Davide Donzelli: None declared, Tamara Vojinovic: None declared, Véronique Ramoni: None declared, Elisa Bellis: None declared, Laura Trespidi: None declared, Federica Gazzola: None declared, Enrico Ferrazzi: None declared, Sonia Zatti: None declared, Fausta Benvenuti: None declared, Pier Luigi Meroni: None declared, Franco Franceschini: None declared, Carlomaurizio Montecucco: None declared, Rolando Cimaz: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Angela Tincani: None declared

Immune function in children born to mothers with autoimmune diseases and exposed in utero to immunosuppressants

The administration of immunosuppressive drugs during pregnancy is often necessary in women with autoimmune diseases. Teratogenicity of immunosuppressives during pregnancy has been evaluated, only few data exist about the effects on immune systems. We therefore performed a pilot study on the influence of foetal exposure to immunosuppressives on immune function of babies born to mothers with autoimmune disorders. We investigated serological and cellular parameters as indicators of immune system status. We included in the study 14 babies (mean age 11 months, range 1—24) born to mothers with autoimmune diseases and exposed in utero to different immunosuppressants and, as controls, 14 babies whose mothers had autoimmune manifestations but did not receive immunosuppressive therapy. We evaluated: (i) complete blood count, (ii) immunoglobulin levels and IgG subclasses, (iii) antibody response to hepatitis B vaccine, (iv) leukocyte subpopulations and (v) interleukin-2 and interferon γ in vitro production by resting or activated peripheral blood mononuclear cells. We did not find statistically significant differences between exposed and not exposed babies or among treatments for the tested parameters. Immunosuppressive regimens currently in use for controlling maternal autoimmune disorders do not significantly affect the immune status of the offspring. Lupus (2007) 16, 651—656.

Neonatal lupus: fetal myocarditis progressing to atrioventricular block in triplets

We report a case of neonatal lupus syndrome (NLS) in an in vitro fertilization induced triplet pregnancy. Echocardiographicsigns of myocarditiswere evident at the 21st week of gestation(w.g.) in twin I, with a subsequentdevelopmentof a complete atrioventricular(AV) block at the 25th w.g.; twin III also displayed echocardiographic signs of myocarditis at the same time. Treatment with dexamethasone (4mg/day) was started at the 25th w.g. A complete echocardiographicregression of the myocarditis signs was achieved, while AV block was unaffected.Caesarian section was performed at the 31.5 w.g. after a premature rupture of the membranes. Complete AV block was confirmed in twin I with a heart rate of 51beats/min that required a pacemaker implant 40 days after. Twin III developed a first-degree AV block that switched to a periodic second-degreeblock later, while twin II displayed only liver enzyme abnormalities.

Pregnancies in women receiving renal transplant for lupus nephritis: description of nine pregnancies and review of the literature

Background

Few data are available on pregnancy in renal transplanted women for lupus nephritis (LN).

Methods

Among 38 women with LN who received a renal transplant in our Unit, three had nine pregnancies. During the pregnancies, patients were followed by a multidisciplinary team including gynecologists and nephrologists.

Results

Two patients received a living related and one a deceased kidney transplant. The immunosuppressive therapy consisted of steroids calcinurin inhibithors and mycophenolate mofetil. The last drug was substituted with azathioprine in prevision of pregnancy. All patients had normal renal function and urinalysis. In two patients some signs of immunological activity persisted after transplantation. Five pregnancies ended in miscarriage and four in live births. Two pregnancies were uneventful. Pre-eclampsia occurred in a hypertensive patient in two pregnancies that ended in preterm delivery in one case and in a small for gestation age in both cases. And finally, follow-up graft function and urinalysis continued to be normal in all patients.

Conclusions

After renal transplantation our LN women continue to have frequent miscarriages. The other pregnancies ended in live births and, with the exception of pre-eclampsia in a hypertensive patient, no renal or extra-renal complications occurred during or after pregnancy, even in cases with active immunological tests.

Obstetric and vascular APS: Same autoantibodies but different diseases?

Beta2 glycoprotein I (β2GPI)-dependent antiphospholipid antibodies (aPLs) are the main pathogenic autoantibody population and at the same time the laboratory diagnostic tool for the antiphospholipid syndrome (APS).

These antibodies are responsible for both the vascular and the obstetric manifestations of the syndrome but the pathogenic mechanisms behind these manifestations are not the same. For example, thrombotic events do not appear to play a major role in APS miscarriages and a direct reactivity of β2GPI-dependent aPLs on decidual and trophoblast cells was reported. A local expression of β2GPI on these tissues was reported both in physiological conditions and in APS women, thus explaining the local tropism of the autoantibodies.

The two hit hypothesis was suggested to explain why the vascular manifestations of APS may occur only occasionally in spite of the persistent presence of aPLs. This is not apparently the case for the obstetric variant of the syndrome, making the difference even more striking. A different pathogenesis may also provide the rationale for the well-known fact that the vascular and the obstetric manifestations may occur independently although in a minority of cases.

Electrocardiographic abnormalities in infants born from mothers with autoimmune diseases a multicentre prospective study

OBJECTIVES

To assess the prevalence of congenital heart block (CHB) and electrocardiographic (ECG) abnormalities in infants of anti-Ro/SSA-positive women.

METHODS

Sixty anti-Ro-positive and 36 anti-Ro-negative patients were prospectively followed before/during pregnancy and underwent weekly fetal echocardiography from 18th to 26th weeks of gestational age. Infants' ECG and/or ECG-Holter were performed at 1, 3, 6 and 12 months. ECG of 200 consecutive neonates were used as a healthy control group.

RESULTS

One of 61 fetuses of anti-Ro-positive mothers developed CHB (20th week); another anti-Ro-positive baby developed second degree atrioventricular (AV) block (30th week). The prevalence of transient first degree AV block detected post-natally was significantly higher in the anti-Ro-positive group, in comparison with healthy controls (P = 0.002). No differences in corrected QT (QTc) interval prolongation prevalence (>/=440 ms) was observed between the anti-Ro-positive and -negative groups, but both were significantly higher than that of the control population (P < 0.001). ECG-Holter showed QTc prolongation in 59% of infants of anti-Ro-positive and in 60% of infants of anti-Ro-negative mothers. Holter QTc was >/=470 ms in four infants of anti-Ro-positive group and two of anti-Ro-negative group. Known acquired causes of QTc prolongation were excluded.

CONCLUSIONS

This prospective study confirms the low occurrence of CHB in newborns from anti-Ro-positive mothers. ECG abnormalities (first degree AV block and QTc interval prolongation) are frequent in infants of mothers with autoimmune diseases, independently of maternal disease, autoantibody profile and treatment during pregnancy.

Formulation study and anti-inflammatory efficacy of topical semi-solids containing a nitro ester of flurbiprofen

A new nitro-oxybutylester of flurbiprofen (NO-FP) is a promising anti-inflammatory drug in the treatment of dermatological disorders, and the feasibility of its cutaneous administration was evaluated. Four different semi-solid formulations were evaluated in order to assess the influence of the composition on the drug amount retained in the stratum corneum and epidermis (SCE). The lipophilic ointment induced the highest NO-FP amount retained in the SCE and, therefore, skin permeation enhancers (Transcutol), Lauroglycol), oleic acid and isopropyl myristate) were added to this formulation. The in vitro NO-FP amounts retained in the SCE were correlated with the solubility parameters, and a good linear correlation was found (r(2) = 0.925). The formulation of the lipophilic ointment was optimized, and the activity of this preparation was verified in methyl-nicotinate-induced contact urticaria and UV-induced erythema obtaining good results in terms of efficacy and safety.

Pregnancy complications of the antiphospholipid syndrome

Starting from their first description, antiphospholipid antibodies (aPL) were associated with repeated miscarriages and fetal losses. Other complications of pregnancy like preterm birth,with pre-eclampsia or severe placental insufficiency were also frequently reported and are included in the current classification criteria of the antiphospholipid syndrome (APS). The titre, the isotype of the antibodies or their antigen specificity may be important in the risk level determination. Some of the difference in the reported results can be explained by the poor standardization achieved in aPL testing or by the not univocal classification of pregnancy complications. The pathogenesis of pregnancy failures is linked to the thrombophilic effect of aPL but also to different mechanisms including a direct effect of antibodies on the throphoblast differentiation and invasion. The study of experimental animal models provided sound evidence of the pathogenic role of aPL both in lupus prone and naive mice. The definition of APS as a condition linked to high obstetric risk and the application of an effective therapy have completely changed the prognosis of pregnancy in these patients. In fact, despite the high number of complications and preterm delivery, today a successful outcome can be achieved in the large majority of the cases.

Fetal and maternal white cells and B- and T-lymphocyte subpopulations in pregnant women with recent infection

OBJECTIVE

To study maternal and fetal white cell counts, B- and T-lymphocyte subpopulations in pregnant women with evidence of recent infection.

METHODS

Thirty-seven pregnant women with recent infection and 38 controls were studied. All were referred for fetal blood sampling to exclude congenital infection, or to perform fetal chromosome analysis. There were 16 infected fetuses: 9 cytomegalovirus (CMV), 4 rubella, and 3 toxoplasmosis. Maternal and fetal blood was taken and white cell counts, the percentage of CD3+, CD4+, CD8+, CD56+, HLADR+CD3+ T-lymphocyte subpopulations and CD19+ B lymphocytes were measured.

RESULTS

The percentage of CD3+, CD8+, and HLADR+CD3+ lymphocytes were significantly higher in infected mothers compared to controls, while CD19+ and the CD4+/CD8+ ratio were lower. Infected mothers carrying infected fetuses had significantly lower white blood cell counts compared to those infected mothers without fetal infection. The percentage of HLADR+CD3+ T lymphocytes was significantly higher and the CD4+/CD8+ ratio lower in infected fetuses compared to controls and noninfected fetuses of infected mothers. Abnormal CD4+/CD8+ ratios and/or increased HLADR+CT3+ T lymphocytes were found in 8 of 10 fetuses with structural abnormalities and/or hematological/biochemical signs of systemic damage, and in 7 of 27 without (RR = 3.1, 95% CI = 1.5-6.3).

CONCLUSION

Both infected fetuses and their mothers have significant identifiable changes in white cell counts and T-lymphocyte subpopulations compared to controls. These tests may help in diagnosing maternal and fetal infection.

Serum beta 2-microglobulin in fetuses with urinary tract anomalies

OBJECTIVE

Our purpose was to establish a reference range of fetal serum beta 2-microglobulin, an index of glomerular filtration rate, and to compare the values obtained in fetuses with urinary tract anomalies with this range.

STUDY DESIGN

Serum beta 2-microglobulin was measured in 53 control fetuses at 18 to 39 weeks' gestation and in 14 fetuses with urinary tract anomalies, 9 of which had simultaneous urine sampling.

RESULTS

In controls fetal serum beta 2-microglobulin had a mean value of 3.4 mg/L (95% data intervals 2.0 to 4.9) and did not correlate with gestational age. In the 14 fetuses with urinary tract anomalies beta 2-microglobulin levels were increased overall compared with controls (median Z score 1.7, range -0.1 to 9.2), and this was also the case in the five fetuses with unilateral renal disorders (median Z score 1.7, range -0.1 to 3.8) and in a fetus who underwent vesicoamniotic shunting and had normal renal function at birth. Serum beta 2-microglobulin was normal in 4 fetuses with bilateral urinary tract obstruction and normal function at postnatal follow-up and also in 1 of 5 fetuses with renal failure. In fetuses with bilateral uropathy urinary sodium correlated with serum beta 2-microglobulin levels.

CONCLUSIONS

Increased values of serum beta 2-microglobulin in fetuses with urinary tract anomalies indicate an impaired glomerular filtration rate. The finding of raised concentrations in fetuses with unilateral damage suggests that the compensatory role of the normal kidney is not complete during intrauterine life. Larger series are required to ascertain whether fetal blood sampling is warranted in the antenatal investigation of renal function, especially in view of the close correlation between urinary sodium and serum beta 2-microglobulin levels in fetuses with bilateral obstruction.

Serial amniocenteses in the management of twin-twin transfusion syndrome: when is it valuable?

Serial decompressive amniocenteses were performed at 18-23 weeks of gestation in 23 pregnancies referred due to echographic signs typical of twin-twin transfusion syndrome. The procedures were repeated until delivery or permanent normalization of the amniotic fluid volume both in the donor and the recipient twin sac. The overall survival rate was 57%, but in only 39% of the pregnancies did both twins survive without handicaps. The absence of end diastolic flow in the umbilical artery of the donor twin was associated with poor chances of survival for both fetuses; in contrast, the presence of hydrops or ascites in the recipient twin did not worsen the prognosis. A policy of aggressive amniotic fluid decompression may achieve permanent resolution of the fluid in over 50% of the pregnancies complicated by twin-twin transfusion syndrome.

In fetuses with isolated hydronephrosis, urinary beta 2-microglobulin and N-acetyl-beta-D-glucosaminidase (NAG) have a limited role in the prediction of postnatal renal function

Seventy-one fetal urine samples were taken from the bladder or renal pelvis of 33 fetuses at 13-36 weeks' gestation with a diagnosis of urinary tract anomaly. Severe isolated hydronephrosis in the absence of an enlarged bladder was the indication for sampling in 12/33 fetuses (26 samples), who were retrospectively classified into three groups: normal, intermediate, and dysplastic, based on the evaluation of postnatal renal function or histology. For all samples, urinary sodium (Na+), calcium (Ca2+), creatinine, beta 2-microglobulin, and N-acetyl-beta-D-glucosaminidase (NAG) were measured. Among the 71 fetal urine samples, both beta 2-microglobulin and NAG correlated inversely with gestational age, Na+, and Ca2+, but not with creatinine concentrations. However, the correlation of urinary beta 2-microglobulin with gestational age was dependent on the Na+ and Ca2+ concentrations, whereas urinary NAG correlated significantly with urinary Na+ and Ca2+, and also with gestational age. In fetuses with isolated hydronephrosis, only Na+, and not Ca2+, was significantly related to both beta 2-microglobulin and NAG. Only Na+ and beta 2-microglobulin were significantly, and similarly, higher in both dysplastic and intermediate kidneys when compared with fetuses with normal postnatal function. If only the last urine sampled was considered, there was overlapping of all parameters in the three groups. In isolated hydronephrosis, only the most extreme forms of renal failure might be suggested by elevated levels of Na+, Ca2+, beta 2-microglobulin, and NAG, without an obvious superiority of any of these parameters.

Treatment with a gonadotrophin releasing hormone agonist before endometrial resection: a multicentre, randomised controlled trial

OBJECTIVES

To ascertain whether treatment with a gonadotrophin releasing hormone agonist before endometrial resection reduces absorption of distension fluid and operating time and facilitates the procedure.

DESIGN

A multicentre, prospective, randomised controlled study.

PARTICIPANTS

Seventy-one premenopausal women with established menorrhagia.

INTERVENTIONS

Eight weeks of goserelin depot treatment before endometrial resection of immediate surgery in the early proliferative phase of the cycle.

MAIN OUTCOME MEASURES

Irrigation fluid deficit, operating time and degree or difficulty of the procedure.

RESULTS

After randomisation eight women withdrew from the study, leaving 33 women in the goserelin arm and 30 in the immediate surgery arm. Mean (SD) operating time was 15.1 (9.0) min in the goserelin group versus 16.9 (9.5) min in the controls; mean difference + 1.8 min, 95% CI, -2.9 to + 6.4. Mean (SD) distension medium deficit was, respectively, 422 (287) ml versus 564 (291 ml); mean difference + 142 ml, 95% CI -4 to + 288. The goserelin effect was restricted to the 29 women with adenomyosis as the mean (SD) fluid deficit was considerably less in the 19 treated women than in the 10 controls (299 (206) ml versus 597 (135) ml; mean difference + 298 ml, 95% CI + 149 to + 447). The surgeons classified the intraoperative difficulties as none in 6, minimal in 20, moderate in 7, and severe in no cases in the goserelin group; corresponding figures in the group without pretreatment were 2, 14, 13, and 1.

CONCLUSIONS

Goserelin administration before endometrial resection may reduce absorption of fluid at surgery in women with adenomyosis and may facilitate intrauterine operating conditions.

Laparoscopic uterine biopsy for diagnosing diffuse adenomyosis

OBJECTIVE

To investigate the possibility of diagnosing diffuse adenomyosis with the uterus in situ.

STUDY DESIGN

Myometrial needle biopsy was performed on a prospectively evaluated series of 72 women undergoing laparoscopy for infertility and/or chronic pelvic pain. Before surgery the patients completed a questionnaire on the presence and severity of dysmenorrhea according to a linear analog and verbal rating scale. A single specimen was taken from along the median line in the upper third of the posterior uterine wall using a 14-gauge Tru-cut needle inserted through the anterior abdominal wall under laparoscopic guidance.

RESULTS

No complications occurred. Adenomyosis was diagnosed in 8 of the 42 subjects with menstrual pain and 5 of the 30 asymptomatic ones (19% versus 17%) and pelvic endometriosis in 27 and 10, respectively (64% versus 33%, P = .02). The frequency of moderate or severe dysmenorrhea was greater in women with adenomyosis than in those without adenomyosis or endometriosis, but the difference was not statistically significant. Conversely, menstrual pain was significantly more frequent and severe in patients with endometriosis as compared with women who had neither endometriosis nor adenomyosis.

CONCLUSION

Uterine needle biopsy is simple, rapid and safe, but its overall clinical importance, as well as the predictive value of a normal histologic result, requires further investigation.

Endometriosis and pelvic pain: relation to disease stage and localization

OBJECTIVES

To determine whether prevalence and severity of pain symptoms are related to endometriosis stage and site, with particular reference to deep infiltrating vaginal lesions.

DESIGN

Systematic assessment of chronic pelvic pain symptoms.

SETTING

University hospital endometriosis center.

PATIENTS

A total of 244 consecutive symptomatic patients with endometriosis diagnosed at laparoscopy or laparotomy.

INTERVENTIONS

Assessment of dysmenorrhea and nonmenstrual pain by means of a 10-point linear analog scale, a 7-point multidimensional rating scale, and a 3-point verbal scale; evaluation of deep dyspareunia with the first and third systems only.

MAIN OUTCOME MEASURES

Prevalence and severity of pain symptoms in relation to endometriosis stage and site of lesions. Correlation between revised American Fertility Society score and symptoms severity, as well as between two pain scales to assess dysmenorrhea and nonmenstrual pain.

RESULTS

Eighty-eight women had stage I and II disease and 156 had stage III and IV disease. Only ovarian endometriosis was present in 108 patients, only peritoneal implants were present in 37, combined ovarian and peritoneal lesions were present in 57, and histologically confirmed vaginal endometriosis was present in 42. The frequency and severity of deep dyspareunia and the frequency of dysmenorrhea were less in patients with only ovarian endometriosis than in those with lesions at other sites. Patients with vaginal endometriosis had a significantly increased risk of deep dyspareunia compared with those whose lesions were at other sites (odds ratio, 2.55; 95% confidence interval, 1.21 to 5.39). Stage per se, independent of lesion site, was not correlated with frequency and severity of dysmenorrhea and nonmenstrual pain. The severity of deep dyspareunia was related inversely to the endometriosis score (Spearman correlation coefficients for linear analog and verbal rating scales, respectively, -0.22 and -0.20). Kendall test by ranks revealed a correlation between linear analog and multidimensional pain scales in the rating of both dysmenorrhea and nonmenstrual pain (respectively, tau-b, 0.59 and tau-b, 0.68).

CONCLUSIONS

Endometriosis stage in the current classification was not related consistently to pain symptoms. The presence of vaginal lesions was associated frequently with severe deep dyspareunia. Dysmenorrhea and nonmenstrual pelvic pain were assessed with equal accuracy by a linear analog and a multidimensional scale.

Very low dose danazol for relief of endometriosis-associated pelvic pain: a pilot study

OBJECTIVES

To evaluate the efficacy and safety of very low dose danazol in improving pelvic pain in women with endometriosis, the benefit of preceding the treatment by a short course of a GnRH agonist, symptoms recurrence after drug withdrawal, and variations in menstrual pattern.

DESIGN

Open-label, randomized study.

SETTING

University hospital endometriosis center.

PATIENTS

Forty-two women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis.

INTERVENTIONS

Treatment with oral danazol, 50 mg/d, for 9 months (group I, n = 21) or leuprolide depot for 3 months followed by oral danazol, 50 mg/d, for 6 months (group II, n = 21), and a 6-month follow-up.

MAIN OUTCOME MEASURES

Variations in severity of symptoms during treatment and at the end of follow-up as shown by a linear analog scale and a verbal rating scale; menstrual blood loss as assessed by a pictorial chart.

RESULTS

Four patients withdrew from the study, one in each group at the fifth month of treatment (for persistent pain) and one in each group during follow-up (they requested additional therapy); one woman in group I was lost to follow-up. Significant improvements were obtained in dysmenorrhea, deep dyspareunia, and nonmenstrual pain in both treatment schedules without differences between the groups. Also menstrual blood loss was significantly reduced in both groups. A temporary fall in high and rise in low density lipoprotein cholesterol was observed in the study population. At the end of follow-up symptoms recurred without significant differences in median pain scores with respect to baseline.

CONCLUSION

Very low dose danazol may be an alternative for temporary relief of endometriosis-associated pain. Ovulation is not always inhibited and barrier contraception is needed. Side effects occur but are rarely severe. Further data are required to evaluate the influence of long-term administration on the lipid profile.

Veralipride for hot flushes induced by a gonadotropin-releasing hormone agonist: a controlled study

OBJECTIVES

To evaluate the efficacy of veralipride, a benzamide derivative, in the treatment of hot flushes induced by GnRH agonists (GnRH-a) and to study peripheral blood mononuclear cell beta-endorphin concentrations during drug administration.

DESIGN

Randomized, placebo-controlled, double-blind trial.

SETTING

Academic department of obstetrics and gynecology.

PATIENTS

Forty women of mean age 43 +/- 5 years who experienced disturbing hot flushes during a 4-month course of tryptorelin depot for myoma-associated menorrhagia.

INTERVENTIONS

Treatment with oral veralipride 100 mg/d (20 subjects) or matching placebo (20 subjects) during the third month of GnRH-a administration.

MAIN OUTCOME MEASURES

Modifications of frequency and severity of hot flushes as shown by a 0 to 6-point vasomotor scoring system and variations of beta-endorphin levels in peripheral blood mononuclear cells.

RESULTS

Two subjects in each group dropped out of the study. The median (range) vasomotor score at the end of the second month of treatment was 4 (3 to 6) in both the veralipride and placebo group. At the end of the third and fourth months the median (range) scores were, respectively, 2 (0 to 6) versus 4 (1 to 6) and 2 (0 to 5) versus 4 (1 to 6). No significant variations in mononuclear cell beta-endorphin concentrations were recorded. Serum PRL levels rose from 11.7 +/- 5.7 to 132.3 +/- 65.0 ng/mL (conversion factor to SI unit, 1.0) during veralipride administration and returned to 10.6 +/- 3.7 ng/mL after drug withdrawal.

CONCLUSION

Veralipride reduced vasomotor symptoms induced by a GnRH-a. Transient hyperprolactinemia was the main side effect observed. The mode of action of the drug in GnRH-a-treated patients and possible interactions with endogenous opioid peptides need further elucidation.

Gonadotropin releasing hormone agonist treatment before hysteroscopic endometrial resection

OBJECTIVES

To evaluate the effects of treatment with the gonadotropin releasing hormone (GnRH) agonist goserelin before endometrial resection on absorption of distension medium fluid and technical feasibility of the surgical procedure.

METHODS

Fifty-five patients reporting menorrhagia underwent endometrial resection after 2 months of goserelin depot therapy (33 cases) or during the proliferative phase of the cycle (22 controls).

RESULTS

In the cases, the mean distension medium deficit +/- S.D. was 511 +/- 196 ml versus 647 +/- 245 ml in controls (P = 0.03), and the operating times were, respectively, 14 +/- 4 versus 18 +/- 5 min (P = 0.002). The intrauterine operating conditions were considered excellent or good in 64% of the cases versus 27% of the controls (chi 2 = 5.60, P = 0.02).

CONCLUSIONS

GnRH agonists induce endometrial thinning, so that when administered before intrauterine interventions, mucus cellular debris and bleeding should be reduced during surgery and hysteroscopic visibility increased; the operating time may thus be shorter and fluid absorption decreased. However, more data are needed before considering GnRH agonists a proven effective means of facilitating endometrial resection.

A modified technique for correction of the complete septate uterus

When correcting a complete uterine septum, it is recommended that one should spare the cervical portion to avoid the possible risk of cervical incompetence. However, it may be difficult to create a communication between the uterine cavities above the internal os. In seven patients with complete septate uterus we incised the cervical portion with Metzenbaum scissors and the corporal portion with microscissors under hysteroscopic guidance. The operating times were shorter and the distension fluid deficit smaller compared with nine historical controls in whom the cervical septum was spared. No intraoperative or obstetric complications were associated with cervical septal section. This modified technique is simple, rapid, safe, inexpensive, and may be considered among the alternative treatments to correct a complete septate uterus.

Adenomyosis: a déjà vu?

Adenomyosis is a relatively frequent finding in series of hysterectomies performed for menorrhagia and dysmenorrhea. Evident selection biases of the available studies on adenomyosis have always limited the possibilities of defining the real clinical importance of the condition. Until now the only certain diagnoses have been made by histopathologists on uteri removed at surgery, but recently various sufficiently accurate techniques have been suggested which allow diagnosis on the uterus in situ. With the these methods it might be possible to obtain correct information on the epidemiologic characteristics of adenomyosis and to clarify whether it has a pathogenic role in unexplained ovulatory menorrhagia and juvenile dysmenorrhea. Furthermore, resectoscopic treatment has been proposed in some mild forms of adenomyosis to avoid hysterectomy, whereas it seems improbable that medical treatment can offer a definitive solution. The adoption of standard histologic criteria for adenomyosis seems important. Until this is done, it will be difficult to establish whether adenomyosis is really a disease or merely a paraphysiologic condition.

Abnormal uterine bleeding associated with iron-deficiency anemia. Etiology and role of hysteroscopy

We reviewed the clinical and histologic records of 61 consecutive premenopausal women with abnormal uterine bleeding and moderate to severe iron-deficiency anemia investigated in a tertiary care and referral center. Excessive bleeding was caused by benign lesions in 67% of the cases and by anovulation in 25% and was unexplained in 8%. Hysteroscopy revealed an organic intrauterine lesion (submucous myomas in 38%, endometrial polyps in 13%, submucous adenomyomas in 3%) that could be treated endoscopically in more than half the patients. In populations without nutritional deficiencies, a woman of reproductive age with sideropenic anemia and no other evident cause of blood loss or systemic disease should be considered menorrhagic until proven otherwise. Hysteroscopy should be included in evaluations of abnormal uterine bleeding.

A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis

OBJECTIVES

To evaluate the efficacy of goserelin versus a low-dose cyclic oral contraceptive (OC) in improving pelvic pain in women with endometriosis and to compare recurrence of symptoms during follow-up.

DESIGN

Open-label, randomized trial.

SETTING

University hospital endometriosis center.

PATIENTS

Fifty-seven women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis.

INTERVENTIONS

Six-month treatment with goserelin depot (n = 29) or a low-dose cyclic OC (n = 28) followed by 6-month follow-up.

MAIN OUTCOME MEASURES

Variation in severity of symptoms during treatment and at the end of follow-up as shown by a linear analog scale and a verbal rating scale.

RESULTS

At 6 months of treatment, a significant reduction in deep dyspareunia was observed in both groups, with goserelin superior to the OC at linear analog scale assessment. Nonmenstrual pain was diminished on both scales without differences between treatments. Women taking the OC experienced a significant reduction in dysmenorrhea. At the end of follow-up, symptoms reappeared without differences in severity between the groups.

CONCLUSIONS

Low-dose cyclic OCs may be a valuable alternative for the treatment of dysmenorrhea and nonmenstrual pain associated with endometriosis. Symptoms recurred in most subjects 6 months after drug withdrawal.

Hysteroscopic metroplasty with resectoscope or microscissors for the correction of septate uterus

During 1990, we performed hysteroscopic incision of uterine septum in 23 women with repeated abortion. The patients were allocated randomly to metroplasty with resectoscope (12 patients in group 1) or microscissors (11 patients in group 2) to compare surgical feasibility and anatomic results with these instruments. The uterine cavity was distended by instillation of sorbitol and mannitol solution under manometric control. Two patients in group 1 and three in group 2 had a complete septum. In group 1, the mean operating time, plus or minus standard deviation (S.D.), was 22 +/- 6 minutes compared with 17 +/- 5 minutes in group 2 (p = 0.06). The mean amount of distension medium used, plus or minus S.D., was 890 +/- 153 milliliters in group 1 versus 671 +/- 170 milliliters in group 2 (p = 0.003). One woman in group 1 with complete uterine septum had a uterine perforation that was managed conservatively. Postoperative morbidity for the entire series was negligible. At follow-up ultrasonography and hysteroscopy performed two months postoperatively, a residual fundal notch > or = 1 centimeter deep was detected and corrected in four patients in group 1 and two in group 2. Our findings indicate that, in terms of operating time and efficacy, the resectoscope and microscissors are equally valid instruments to correct a septate uterus, with a feasibility rate of 100 percent.

Does contraception modify the risk of endometriosis?

Long episodes of regular, prolonged, abundant menstrual flows are generally agreed to increase the risk of endometriosis. Since oral oestrogen-progestogen combinations reduce and intra-uterine contraceptive devices increase menstrual flow, an effect on the risk of development of endometriosis in women utilizing these forms of contraception could be expected. Analysis of the most recent epidemiological observations shows no consensus on a possible relationship between use of cyclic oral contraceptives and endometriosis, with an increase, a decrease, and no effect on the risk of developing the disease all being reported. A lower relative risk of endometriosis in previous users of the intrauterine contraceptive device was only found in two series, most of the other data suggesting a rise in risk or no effect. Further studies on the relationship between type of contraception and endometriosis are needed to demonstrate whether the risk of development of the disease could be influenced, and whether well tolerated, relatively inexpensive, long-term treatment might be available for symptomatic patients not desiring offspring.

Pregnancy at forty and over: a case-control study

We compared obstetric prognosis in 327 women > or = 40 years old (148 nulliparas, 279 multiparas) with 20-30-year-old matched controls who delivered at our department between 1988 and 1990. Gestational diabetes and chronic hypertension were the only more frequent antepartum complications in cases than controls (2.4% vs. 0.3% and 3.4% vs. 0.3%, respectively). There were more premature deliveries in cases than controls (19% vs. 8%) but no difference in postdate deliveries. Cesarean section was more frequent in cases than controls in both nulliparas (64% vs. 30%) and multiparas (43% vs. 12%). Incidence of abdominal delivery for acute obstetrical indications was not increased in older gravidas. Significant differences were observed in low birthweight (17% vs. 5%) and 5-min Apgar score < 7 (8% vs. 2%). Most of the abnormal Apgar scores were recorded after cesarean section; values for vaginally-delivered infants were comparable in older and younger women. Perinatal mortality was similar in the two groups.

Tumor necrosis factor in plasma and peritoneal fluid of women with and without endometriosis

To determine whether in vivo levels of tumor necrosis factor a in plasma and peritoneal fluid differ in infertile subjects with and without endometriosis, peripheral blood and peritoneal fluid samples were collected in 94 women undergoing laparoscopy for infertility. Quantitative determinations of tumor necrosis factor a were performed by an enzyme immunoassay test. Tumor necrosis factor a levels were below the detection limit (10 pg/ml) in plasma and peritoneal fluid of 42 (91%) and 30 (90%) patients with endometriosis and 40 (83%) and 31 (91%) subjects without the disease, respectively. In our series, plasma and tumor necrosis factor a levels were not different in infertile women with and without endometriosis.

Veralipride for hot flushes during gonadotropin-releasing hormone agonist treatment

Hot flushes are the commonest symptom induced by gonadotropin-releasing hormone agonists (GnRHa). We performed an open observational trial to evaluate the efficacy of veralipride, an antidopaminergic drug, in reducing hot flushes in 25 premenopausal women treated with a GnRHa for endometriosis (8 subjects) or menorrhagia (17 subjects). The patients received goserelin depot for 6 months and veralipride was added for the third month. Hot flushes, severe in all women at 2 months, improved in both frequency and intensity in 92% of the subjects during veralipride administration. The benefit obtained persisted until the end of the GnRHa treatment.