Diagnostic, Management, and Neonatal Outcomes of Colorectal Cancer during Pregnancy: Two Case Reports, Systematic Review of Literature and Metanalysis

OBJECTIVE

Colorectal cancer (CRC) during pregnancy is a rare occurrence, with a reported incidence of 0.8 cases per 100,000 pregnancies. Managing CRC during pregnancy poses substantial challenges for clinicians: the diagnosis is often complicated and delayed due to symptom overlap with pregnancy-related manifestations, and medical imaging is constrained by safety concerns for the foetus.

METHODS

This article presents two cases of advanced CRC diagnosed and managed during pregnancy. Additionally, we conducted a systematic review of the literature to assess diagnostic and prognostic factors involved in CRC in pregnant individuals. The systematic review, with pre-registration and approval through Prospero, involved an extensive search of medical databases (Pubmed, Web of Science, Scopus and Scholar) and statistical analysis using t-test for continuous variables and chi square for dichotomous variables.

RESULTS

A total of 1058 studies were identified. After applying exclusion criteria, sixty-six studies were included. Women whose initial symptoms were severe abdominal pain not responsive to common medical treatments and constipation (acute abdomen) had a mean gestational age at delivery lower than those who presented with paucisymptomatic onset. In our study groups, women who underwent chemotherapy during pregnancy had a higher mean gestational age at delivery and did not experience worse neonatal outcomes compared to those who did not undergo chemotherapy.

CONCLUSIONS

CRC during pregnancy poses unique diagnostic and therapeutic challenges. Collaborative efforts among various medical disciplines are essential to manage CRC during pregnancy.

Analogies between HPV Behavior in Oral and Vaginal Cavity: Narrative Review on the Current Evidence in the Literature

Human genital papilloma virus infection is the most prevalent sexually transmitted infection in the world. It is estimated that more than 75% of sexually active women contract this infection in their lifetime. In 80% of young women, there is the clearance of the virus within 18-24 months. In developed countries, oral squamous cell carcinoma (OSCC) is now the most frequent human papilloma virus (HPV)-related cancer, having surpassed cervical cancer, and it is predicted that by 2030 most squamous cell carcinomas will be the HPV-related rather than non-HPV-related form. However, there are currently no screening programs for oral cavity infection. While the natural history of HPV infection in the cervix is well known, in the oropharynx, it is not entirely clear. Furthermore, the prevalence of HPV in the oropharynx is unknown. Published studies have found wide-ranging prevalence estimates of 2.6% to 50%. There are also conflicting results regarding the percentage of women presenting the same type of HPV at two mucosal sites, ranging from 0 to 60%. Additionally, the question arises as to whether oral infection can develop from genital HPV infection, through oral and genital contact or by self-inoculation, or whether it should be considered an independent event. However, there is still no consensus on these topics, nor on the relationship between genital and oral HPV infections. Therefore, this literature review aims to evaluate whether there is evidence of a connection between oral and cervical HPV, while also endorsing the usefulness of the screening of oral infection in patients with high-risk cervical HPV as a means of facilitating the diagnosis and early management of HPV-related oral lesions. Finally, this review emphasizes the recommendation for the use of the HPV vaccines in primary prevention in the male and female population as the most effective means of successfully counteracting the increasing incidence of OSCC to date.

Oxytocin augmentation and neurotransmitters in prolonged delivery: An experimental appraisal

The uterus is a highly innervated organ, and during labor, this innervation is at its highest level. Oxytocinergic fibers play an important role in labor and delivery and, in particular, the Lower Uterine Segment, cervix, and fundus are all controlled by motor neurofibers. Oxytocin is a neurohormone that acts on receptors located on the membrane of the smooth cells of the myometrium. During the stages of labor and delivery, its binding causes myofibers to contract, which enables the fundus of the uterus to act as a mediator. The aim of this study was to investigate the presence of oxytocinergic fibers in prolonged and non-prolonged dystocic delivery in a cohort of 90 patients, evaluated during the first and second stages of labor. Myometrial tissue samples were collected and evaluated by electron microscopy, in order to quantify differences in neurofibers concentrations between the investigated and control cohorts of patients. The authors of this experiment showed that the concentration of oxytocinergic fibers differs between non-prolonged and prolonged dystocic delivery. In particular, in prolonged dystocic delivery, compared to non-prolonged dystocic delivery, there is a lower amount of oxytocin fiber. The increase in oxytocin appeared to be ineffective in patients who experienced prolonged dystocic delivery, since the dystocic labor ended as a result of the altered presence of oxytocinergic fibers detected in this group of patients.

Tracking Endometrial Malacoplakia Through the Evolution of 2D and 3D Ultrasound and Histopathological Features

Malacoplakia is an uncommon disease characterized by chronic and granulomatous inflammation, which rarely involves the female genital tract. We describe the ecographic and histological evolution of the first case of a patient developing endometrial malacoplakia as a complication after a cesarean section. The patient, a 43-year-old woman, presented with pelvic pain one month after delivering by cesarean section and the initial suspicion was of retention of placental rests. We discuss the diagnostic challenges for this rare disease, highlighting the importance of considering endometrial malacoplakia as a possible diagnosis in patients with similar clinical presentations and the important role of 2D and 3D ultrasound in the diagnostic pathway. In literature, ultrasound findings in cases of endometrial malacoplakia are represented by hypoechoic thickening of the endometrial lining; hyperechoic thickening of the myometrium, and the presence of masses, nodules, cystic areas, or anechoic fluid within the endometrium. For the first time, we describe the evolution of endometrial malacoplakia through both ultrasound, 2D and 3D, and histopathological findings, from the acute to chronic stage of the disease.

Intrapartum ultrasound and mother acceptance: A study with informed consent and questionnaire

Introduction

Intrapartum ultrasound (IU) is used in the delivery ward; even if IU monitors the labouring women, it could be perceived as a discomfort and even as an" obstetric violence", because it is a young technique, not often well "accepted". A group of clinicians aimed at obtain an informed consent from patients, prior to perform a translabial ultrasound (TU). The aim of this study was to evaluate the acceptance of both translabial and transabdominal IU.

Methods

In this study, performed at the University Hospital of Bari (Unit of Obstetrics and Gynecology), were enrolled 103 patients in the first or second stage of labor in singleton cephalic presentation. A statistical frequency and an association analysis were performed. As a significant result, we consider the peace of mind/satisfaction and the" obstetric violence". IU was performed both transabdominal and translabial to determine the presentation, head positions, angle of progression and head perineum distance. During the first and second stage of labor, the ASIUG questionnaires (Apulia study intrapartum ultrasonography group) were administered.

Results

74 (71, 84%) patients underwent IU and 29 had a vaginal examination (28, 15%). Significant less "violence" has been experienced with a IU (73 out 74/98, 65%) and only one person (1 /1, 35%) recorded that. On the contrary, 10 patients (10/29) perceived that "violence" (34, 48%) while 19 (65, 52%) did not respond on a similar way, after a vaginal examination (VE). More patients felt satisfaction (71 out 74/95, 95%) with the use of IU and only 3 (3/4, 05%) felt unease. A different picture was evident in the vaginal examination group. Only 17 patients (17 out 29/58, 62%) felt comfort while 12 (41, 38%) felt unease.

Conclusions

In our study, IU use is well accepted by most of patients, because it could reassure women about their fetal condition. Moreover, they can see the fetus on the screen, while the obstetrician is performing the US and this is important for a visual feedback, in comparison with the classical VE.

Office intrauterine morcellation for retained products of conception

OBJECTIVE

Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs).

DESIGN

Prospective analysis.

SETTING

A teaching and university hospital.

PATIENTS

Women with RPOC.

INTERVENTIONS

Office -HM with 'Truclear 5 C'.

MATERIAL AND METHODS

Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed.

RESULTS

Mean procedure time was six minutes (SD ± 5). Tissue samples had a mean collection size 2.5 cm3+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any de novo IUAs in any of the enrolled patients.

CONCLUSIONS

In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.

Efficacy and safety of therapies for COVID-19 in pregnancy: a systematic review and meta-analysis

BACKGROUND

Clinical evidence suggests that pregnant women are more vulnerable to COVID-19, since they are at increased risk for disease progression and for obstetric complications, such as premature labor, miscarriage, preeclampsia, cesarean delivery, fetal growth restriction and perinatal death. Despite this evidence, pregnant women are often excluded from clinical trials, resulting in limited knowledge on COVID-19 management. The aim of this systematic review and meta-analysis is to provide better evidence on the efficacy and safety of available COVID-19 treatment in pregnant women.

METHODS

Four authors searched major electronic databases from inception until 1 st November-2022 for controlled trials/observational studies, investigating outcomes after the administration of anti-SARS-CoV-2 treatments in pregnant women affected by COVID-19. The analyses investigated the cumulative incidence of delivery and maternal outcomes in pregnant women, comparing those taking active medication vs standard care. Risk ratios (RRs) with 95% confidence intervals were calculated. Statistical significance was assessed using the random effects model and inverse-variance method. This systematic review and meta-analysis was conducted in accordance with the updated 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol has been registered in Prospero (number registration: CRD42023397445).

RESULTS

From initially 937 non duplicate records, we assessed the full texts of 40 articles, finally including ten studies. In six studies, including 1627 patients, the use of casirivimab/imdevimab (CAS/IMD), remdesivir, and IFN-alpha 2b significantly decreased the need of cesarean section ((RR = 0.665; 95%CI: 0.491-0.899; p = 0.008; I 2 = 19.5%;) (Table 1, (Fig. 1). Treatments did not decrease the risk of preterm delivery, admission to neonatal ICU, or stillbirth/perinatal loss (p-values > 0.50 for all these outcomes) and did not prevent the progression of disease towards severe degrees (k = 8; 2,374 pregnant women; RR = 0.778; 95%CI: 0.550-1.099; p = 0.15; I 2 = 0%). Moreover, the use of medications during pregnancy did not modify the incidence of maternal death in two studies (Table 2).

CONCLUSIONS

To our analysis, CAS/IMD, remdesivir, and IFN alpha 2b reduced the number of cesarean sections but demonstrated no effect on disease progression and other obstetric and COVID-19 related outcomes. The inability to evaluate the influence of viral load on illness development in pregnant women was attributed to lack of data. In our systematic review, no major side effects were reported. Though, it is essential for the medical community to focus more on clinical trials and less on episodic case reports and case series, with standardization of fetal and maternal outcomes.

Mature Triphyllic Cystic Teratoma of the Posterior Mediastinum in a Fetus: A Case Report and Literature Review

A teratoma is a neoplasm composed of cell populations or tissues that are reminiscent, in their appearance, of normal elements derived from at least two embryonic layers. Fetal mature teratomas are normally benign, cystic, and typically occur along the midline, while they are rare in the posterior mediastinum. Teratomas are frequently solitary; however, they may sometimes be associated with other congenital anomalies and/or with chromosomal abnormalities. Clinically, they are often asymptomatic but can occasionally cause compression symptoms. Prenatal diagnoses are uncommon and made with ultrasonography; differential diagnosis with other congenital conditions is mandatory. We report the case of a 21 weeks of gestational age old fetus with a mature triphyllic fetal cystic teratoma, grade 0, located in the right posterior mediastinum. The tumor presented as a 3 cm wide cystic mass that caused a contralateral shift of the surrounding structures. Histological examination later revealed the presence of derivatives of the three germ layers, such as hyaline cartilage, smooth muscle, nervous tissue, and a respiratory-type epithelium.

Treatment with valacyclovir during pregnancy for prevention of congenital cytomegalovirus infection: a real-life multicenter Italian observational study

BACKGROUND

Valacyclovir is the only treatment demonstrated to be effective for the prevention of vertical transmission of cytomegalovirus within a clinical randomized, placebo-controlled trial and has been reimbursed by the Italian National Health System since December 2020.

OBJECTIVE

This study reported the results of a real-life Italian multicenter observational study on cytomegalovirus infection in pregnancy evaluating the effect of the introduction of valacyclovir in the clinical practice for the prevention of vertical transmission of cytomegalovirus.

STUDY DESIGN

The outcomes of women who received valacyclovir treatment and their fetuses or newborns were compared with those of a retrospective cohort observed between 2010 and 2020 who did not receive the antiviral treatment. The inclusion criterion was the diagnosis of cytomegalovirus primary infection occurring in the periconceptional period or up to 24 weeks of gestation. The primary outcome was the transmission by the time of amniocentesis. The secondary outcomes were termination of pregnancy, transmission at birth, symptomatic infection at birth, and a composite outcome (termination of pregnancy or transmission at birth).

RESULTS

A total of 447 pregnant women from 10 centers were enrolled, 205 women treated with valacyclovir (called the valacyclovir group, including 1 twin pregnancy) and 242 women not treated with valacyclovir (called the no-valacyclovir group, including 2 twin pregnancies). Valacyclovir treatment was significantly associated with a reduction of the diagnosis of congenital cytomegalovirus infection by the time of amniocentesis (weighted odds ratio, 0.39; 90% confidence interval, 0.22-0.68; P=.005; relative reduction of 61%), termination of pregnancy (weighted odds ratio, 0.36; 90% confidence interval, 0.17-0.75; P=.0021; relative reduction of 64%), symptomatic congenital cytomegalovirus infection at birth (weighted odds ratio, 0.17; 90% confidence interval, 0.06-0.49; P=.006; relative reduction of 83%). The treatment had no significant effect on the rate of diagnosis of congenital cytomegalovirus infection at birth (weighted odds ratio, 0.85; 90% confidence interval, 0.57-1.26; P=.500), but the composite outcome (termination of pregnancy or diagnosis of congenital cytomegalovirus infection at birth) occurred more frequently in the no-valacyclovir group (weighted odds ratio, 0.62; 90% confidence interval, 0.44-0.88; P=.024). Of note, the only symptomatic newborns with congenital cytomegalovirus infection in the valacyclovir group (n=3) were among those with positive amniocentesis. Moreover, 19 women (9.3%) reported an adverse reaction to valacyclovir treatment, classified as mild in 17 cases and moderate in 2 cases. Lastly, 4 women (1.9%) presented renal toxicity with a slight increase in creatinine level, which was reversible after treatment suspension.

CONCLUSION

Our real-life data confirm that valacyclovir significantly reduces the rate of congenital cytomegalovirus diagnosis at the time of amniocentesis with a good tolerability profile and show that the treatment is associated with a reduction of termination of pregnancy and symptomatic congenital cytomegalovirus infection at birth.

Endometrial Osseous Metaplasia: An Hysteroscopic Incidental Finding - An Overview

Endometrial osseous metaplasia (EOM) is an uncommon clinical entity with the presence of bone in the endometrium which requires clinical and therapeutic framework. It is also described by various other names such as endometrial ossification, ectopic intrauterine bone, and heterotopic intrauterine bone. Ossification could have various locations as the cervix the ovary, and the vagina. This overview highlights the attention on the actual pivotal points of EOM.

"The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature

The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.

Uterine venous malformations in the puerperium: 2 Atypical cases and literature review

Uterine arteriovenous malformations (AVMs) is a rare but high-risk cause of uterine bleeding. The clinical management of this condition is challenging, as the ultrasound picture can sometimes be unambiguously interpreted. Moreover, in the puerperium in which acquired AVMs are most frequently formed, it is necessary to discuss the correct management in a multidisciplinary and personalized manner. We present two cases of AVMs developing in the puerperium, both with a vaginal delivery and spontaneous and complete secondment. The symptom of onset was an episode of bright red blood loss in the puerperium, on the 14th and 21st postpartum days, respectively. Transvaginal ultrasound showed a hypervascularized lesion in the myometrium with turbulent vascular flow, confirmed by transabdominal ultrasound and angiography. To date, there are no guidelines on the management of MAVs. In our cases we opted for a conservative approach, in order to preserve the fertility of the patient. These experiences reported have the purpose of enriching a literature still sparse on the subject and in the future to be able to represent a fulcrum for official recommendations.

Efficacy of Systematic Early-Second-Trimester Ultrasound Screening for Facial Anomalies: A Comparison between Prenatal Ultrasound and Postmortem Findings

Second-trimester 2D ultrasound (US) assessment of the fetal anatomy, as proposed by worldwide guidelines, allows detecting the majority of fetal malformation. However, the detection rates of fetal facial anomalies seem to still be low, mostly in cases of isolated facial malformation. The purpose of this research was to assess and analyze the concordance between the antenatal imaging findings from second-trimester US screening and the results of fetal postmortem autopsy. Between January 2010 and January 2020, there were 43 cases where fetuses with prenatal ultrasound diagnosis of a face abnormality, associated or not with a genetic syndrome or chromosomal disorder, following intrauterine death (IUD) or termination of pregnancy (TOP) after the 13 weeks of pregnancy, underwent autopsy in the Pathological Anatomy section of Bari Polyclinic specializing in feto-placental autopsies. The diagnosis of the fetal facial defects at ultrasound was compared with the findings at autopsy in all cases. A very high level of agreement between prenatal ultrasound and autopsy findings was found for facial abnormalities associated with genetic syndromes or numerical abnormality of chromosomes. A lower level of concordance was instead found in isolated facial defects or those associated with other organ anomalies, but not associated with genetic syndrome or numerical chromosome anomaly. A detailed examination of aborted fetuses led to successful quality control of early-second-trimester ultrasound detection of facial anomalies; however, it was less accurate for the isolated ones. It is, thus, reasonable to propose a systematic early-second-trimester prenatal ultrasound screening for facial anatomy by operators specialized in fetal medicine field, using 2D, 3D, and 4D techniques (two-, three-, and four-dimensional ultrasound).

How Much Is an Abortion Worth? Was a Human "Not Formed"? An Italian Proposal

INTRODUCTION

"Human capital" is defined as an integration of innate skills and knowledge acquired by investing in the formation of an individual; it is a real "capital" that pays off in the long term. In the Italian legal system, a human being is recognised as a "person" from the moment of birth. This determines the acquisition of the personal rights of an individual. Necessarily, therefore, by law, a fetus does not own such rights; nevertheless, it has an innate "potential" to acquire such rights after birth.

OBJECTIVE

In Italian jurisprudence, in general, the damage from a loss of a parental relationship is justified by the condition of existential emptiness caused in the family by the loss of a child. Compensation for this damage in the event of abortion due to third-party responsibility presents a non-uniform recognition in the judgements of the Italian courts, but in any case, it is almost always recognised with limitations since the emotional relationship with the lost individual is defined only in terms of "potential". Consequently, in this matter, at least two questions can be raised: (i) Is the economic estimate of abortion based on objective and standardised criteria, or is it heavily influenced by subjective evaluation? (ii) Is it possible to find standard criteria that may act as guidelines to quantify the loss of that human capital "in progress"?

METHODOLOGY

The authors try to answer these questions by analysing the different approaches to this issue adopted at an international level.

CONCLUSIONS

In conclusion, the authors propose homogeneous criteria to quantify the damage caused by abortion.

Cornual Pregnancy

Cornual pregnancy (CP) is a subtype of ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube which is defined as the tubal section crossing uterine muscular tissue. Widely recognized risk factors for CP are endometriosis, uterine leiomyomata, or pelvic inflammatory disease; all these diseases can cause tubal anatomic changes and consequently alter embryo physiological implant process. Many treatment options are available for this condition each one must be tailored according to patient and operating scenario. The incidence of uterine ruptures in the scarred uterus appears to be low, but the fear of it remains and therefore medical treatment might be favored over cornual wedge resection. The actual risk of uterine rupture after medical treatment is unknown. Multiple testing strategies exist to diagnose CP, but caution needs to be used to avoid a false diagnosis.

Use of Sotrovimab in a cohort of pregnant women with a high risk of COVID 19 progression: a single-center experience

Neutralizing monoclonal antibodies (mAbs) have been shown to reduce disease progression in patients with underlying predisposing conditions. Unfortunately, there is no evidence on the use of Sotrovimab in pregnant women. Herein we present a case series of pregnant women who received mAbs with Sotrovimab following the Italian Drug Agency (AIFA) indications. Since February 1, 2022 all pregnant women - regardless of gestational age - admitted to Obstetrics & Gynaecology of Policlinico University of Bari, with positive nasopharyngeal NAAT for SARS-CoV-2 were screened according to the AIFA indications for Sotrovimab and, if eligible, were proposed for treatment. Data on COVID-19, pregnancy, delivery, newborn outcomes, and adverse events were collected. From February 1 to May 15, 2022, 58 pregnant women were screened. Fifty (86%) patients were eligible, 19 of them (32.7%) denied their consent, in 18 cases (31%), the drug was temporarily unavailable, and the remaining 13 (22%) were treated with Sotrovimab. Out of these 13 patients, 6 (46%) were in the 3rd and 7 (54%) in the 2nd trimester of pregnancy. None of the 13 patients experienced adverse reactions due to Sotrovimab and all had a good clinical outcome. Furthermore, evaluating pre- and post-infusion clinical status and hematochemical profile, a reduction in D-dimers and an increase in SARS-CoV-2 antibodies (p < 0.01) during the 72 h following the infusion were observed. Our data, the first on the use of Sotrovimab in pregnant women, showed the safety and efficacy drug profile and its potential crucial role in preventing COVID-19 disease progression.

Cesarean scar pregnancy: a practical overview and our series of combined double step procedure management

BACKGROUND

Cesarean scar pregnancy (CSP), a rare iatrogenic form of ectopic pregnancy (EP), cause of severe maternal morbidity. Each subtype of CSP needs different treatment and there is no consensus about this topic. Despite improvements, the lack of universally accepted therapeutic management and discordance present in literature indicates that treatment has been mainly based on experiences reported.

METHODS

A case series of our double combined approach with methotrexate (MTX) administration followed by vacuum aspiration or resectoscopic approach was reported, with an overview of literature. Eleven patients with CSP underwent a double-step treatment: systemic MTX therapy followed by vacuum aspiration or by resectoscopy, if the gestational sac was embedded deeply in myometrium. For CSP type 1, according to Delphi sonographic classification, with minor potentially risk of complications with a myometrial thickness >3.5 mm, we preferred to adopt vacuum aspiration, while type 2-3 of CSP and myometrial thickness ≤3.5mm were managed with resectoscopy.

RESULTS

The average gestational age was 59.1±7.22 days. On the seventh day after MTX administration, the serum β hCG levels decreased in 80% of all patients. After the MTX injection, the CSP mass did not disappear in any patient. MTX therapy was followed by vacuum aspiration in six and by resectoscopy in five cases. In one case bleeding was controlled by Foley balloon treated with vacuum. In type II-III, CSP was performed UAE (uterine artery embolization) followed by resectoscopy procedure.

CONCLUSIONS

Compared with the results in previous studies, MTX administration followed by suction curettage was more effective than dilatation and curettage and systemic MTX in treatment of CSP. We consider very useful this procedure in case of slow absorption and when the camera was embedded deeply in myometrium (CSP2-3), because that hysteroscopy evaluation of uterine cavity under direct vision is highly accurate in identifying the real cleavage of the gestational camera. We have only used vacuum aspiration in CSP type 1 for minor risk of bleeding.

Upgrading Treatment and Molecular Diagnosis in Endometrial Cancer-Driving New Tools for Endometrial Preservation?

One emerging problem for onco-gynecologists is the incidence of premenopausal patients under 40 years of age diagnosed with stage I Endometrial Cancer (EC) who want to preserve their fertility. Our review aims to define a primary risk assessment that can help fertility experts and onco-gynecologists tailor personalized treatment and fertility-preserving strategies for fertile patients wishing to have children. We confirm that risk factors such as myometrial invasion and The International Federation of Gynecology and Obstetrics (FIGO) staging should be integrated into the novel molecular classification provided by The Cancer Genome Atlas (TCGA). We also corroborate the influence of classical risk factors such as obesity, Polycystic ovarian syndrome (PCOS), and diabetes mellitus to assess fertility outcomes. The fertility preservation options are inadequately discussed with women with a diagnosis of gynecological cancer. A multidisciplinary team of gynecologists, oncologists, and fertility specialists could increase patient satisfaction and improve fertility outcomes. The incidence and death rates of endometrial cancer are rising globally. International guidelines recommend radical hysterectomy and bilateral salpingo-oophorectomy as the standard of care for this cancer; however, fertility-sparing alternatives should be tailored to motivated women of reproductive age, establishing an appropriate cost-benefit balance between childbearing desire and cancer risk. New molecular classifications such as that of TCGA provide a robust supplementary risk assessment tool that can tailor the treatment options to the patient's needs, curtail over- and under-treatment, and contribute to the spread of fertility-preserving strategies.

Placental Angiodysplasia: A New Sign for Prediction of Fetal Outcome?

The study of the placenta is of great importance, not only in the attempt to understand the etiopathogenesis of various maternal-fetal pathologies, but also in the attempt to understand whether it is possible to find the cause of pathological neonatal outcomes. On the other hand, abnormalities of blood vessel formation, such as angiodysplasias, have been poorly characterised in the literature, and there is a need for more studies investigating the potential impact on the fetus. In this paper, we retrospectively analysed 2063 placentas received at the Department of Pathology of the University of Bari 'Aldo Moro', among which we identified 70 placentas affected by angiodysplasia. On these placentas, we carried out histochemical staining with Masson's Trichrome, orcein-alcian blue, and, subsequently, immunostaining with anti-CD31, CD34, and desmin and actin muscle smoothness antibodies. Finally, we performed a morphometric analysis on the allantochorionic and truncal vessels and correlated the results with neonatal outcomes. We studied the characteristics of the angiodysplasias in detail, dividing the patients into two classes (A and B) according to the morphology and histochemical characteristics of the affected vessels; statistical analysis reported a statistically significant association (p < 0.05) between the ratio of maximum thickness to maximum diameter (Tmax/Dmax) and neonatal outcome, with only 30% physiological outcome in the cohort of the placentas affected by angiodysplasia. These results shed light on a rather neglected aspect in the 2015 Amsterdam Classification, as well as in the literature, and provided strong evidence that placental angiodysplasia is predictive of an increased likelihood of the pathological fetal outcome, while other factors remain in the field. Studies with larger case series and guidelines with more attention to these aspects are mandated to further investigate the predictive potential of this pathology.

Thrombosed Arteriovenous Malformation of Umbilical Cord

Background

Arteriovenous malformation of umbilical cord is an extremely rare congenital malformation. Causes of this condition are unknown. AVM of umbilical cord can cause significant complications in the developing fetus.

Methods

We report our management of the case with accurate ultrasound study that could improve and facilitate the approach to this pathology due to the lack of literature and with an overview of the available literature.

Results

There are only two cases of umbilical AVM diagnosed in the prenatal period with associated pathology. The mainstay of prenatal detection is the accurate study of umbilical cord also even if it is not requested from the actual guide lines in a way to improve the perinatal morbidity and mortality.

"Lights and Shades" of Fertility Preservation in Transgender Men Patients: A Clinical and Pathological Review

Fertility preservation (FP) is becoming a critical issue in transgender men who desire biological offspring in the future. The prevalence of transgender individuals in the United States is increasing, and as a result, the demand for gender-affirming surgeries (GAS) and associated FP techniques is rising. Despite the growing demand, there is currently no personalized approach to FP for transgender men, and the available techniques have limitations that require further investigation. In the present review we carefully examine the existing literature on this topic to highlight the shortcomings of current methods and areas where additional research is needed to advance the field. Hormonal therapy (HT), which is an integral part of gender transition in transgender men, can have a significant impact on fertility and may increase the risk of various diseases. Moreover, GAS usually leads to permanent sterility in these patients. Therefore, it is essential to provide patients with accurate information about the benefits and potential risks of different FP techniques, taking into account the patient's reproductive goals. This review underscores the complex and multifaceted nature of FP in transgender men and emphasizes the need for further research to develop more effective and personalized approaches to FP for this population.

Total laparoscopic hysterectomy four-handed ergonomic technique: description of an original surgical procedure for the reduction of learning curve

The aim of this study was to propose the four-handed technique for total laparoscopic hysterectomy (TLH), with or without adnexectomy. From our point of view this is a more ergonomic, efficient, and effective technique that can contribute to the training of specialists in obstetrics/gynecology. In fact, teacher and learner have both an active role on the surgical field using two laparoscopic instruments each. They are alternately, mutually, and symmetrically first operator and assistant, reducing number of attempts needed for laparoscopic hysterectomy learning curve. The detailed description of all the surgical steps of TLH, "four-handed technique" (FHT), with or without adnexectomy, make sure that it can be effectively reproduced step by step safely, by transposing "FHT" surgical steps of laparotomic approach. This may allow easy access to anatomical spaces inserting trocars in different ways. By clearly knowing the steps of TLH, "FHT" it is possible to favor minimally invasive routes so that patients benefit from its multiple proven benefits. Operating this way, operative time, blood loss, use of analgesics and hospitalization can be significantly reduced. In conclusion benefits of TLH have already been widely demonstrated in literature. It is a real opportunity that young specialists become confident with this innovative "FHT," a procedure that allows them to be surgeon first assistant, and in which they can learn faster real intraoperative stereotaxis and surgical steps sequence, familiarizing with the anatomy of retroperitoneal space.

A Multi-Institutional Informed Consent Proposal as a Prevention Tool for Combined Oral Contraceptive Intake and Thrombotic Risk

Combined oral contraceptives (COC), are among the most widely used contraceptive methods in the world today. Despite the different changes in terms of estrogen/progestogen combinations and dosages, the thromboembolic risk for a woman who takes combined oral contraceptives persists to date. Methods: The review of relevant literature and international guidelines on prescription of combined oral contraceptives made it possible to create a proposal for informed consent to be used for prescribing. Results: The several sections of our consent proposal were designed according to a rationale in order to cover all the aspects presented by worldwide guidelines: how to take, adverse effects, advertisements, extra-contraceptive benefits and effects, a checklist for condition at risk of thromboembolism, the signature of the woman. Conclusions: An informed consent to standardize combined oral contraceptives prescription can improve women’s eligibility, mitigate thromboembolic risk, and assure legal protection to healthcare providers. In this systematic review in particular, we refer to the Italian medical–legal scenario, to which our group of researchers belongs. However, the model proposed was designed in the respect of main healthcare organization guidelines, and it could be easily used by any center in the world.

Ultrasound Control of Cervical Regeneration after Large Loop Excision of the Transformation Zone: Results of an Innovative Measurement Technique

The objective of this research is to evaluate cervical regeneration after large loop excision of the transformation zone (LLETZ) through the identification of a new sonographic reference point at the level of the uterine margins. In the period March 2021-January 2022, a total of 42 patients affected by CIN 2-3 were treated with LLETZ at the University Hospital of Bari (Italy). Before performing LLETZ, cervical length and volume were measured with trans-vaginal 3D ultrasound. From the multiplanar images, the cervical volume was obtained using the Virtual Organ Computer-aided AnaLysis (VOCAL™) program with manual contour mode. The line that connects the points where the common trunk of the uterine arteries reaches the uterus splitting into the ascending major branch and the cervical branch was considered as the upper limit of the cervical canal. From the acquired 3D volume, the length and the volume of the cervix were measured between this line and the external uterine os. Immediately after LLETZ, the removed cone was measured using Vernier's caliper, and before fixation in formalin, the volume of the excised tissue was evaluated by the fluid displacement technique based on the Archimedes principle. The proportion of excised cervical volume was 25.50 ± 17.43%. The volume and the height of the excised cone were 1.61 ± 0.82 mL and 9.65 ± 2.49 mm corresponding to 14.74 ± 11.91% and 36.26 ± 15.49% of baseline values, respectively. The volume and length of the residual cervix were also assessed using 3D ultrasound up to the sixth month after excision. At 6 weeks, about 50% of cases reported an unchanged or lower cervical volume compared to the baseline pre-LLETZ values. The average percentage of volume regeneration in examined patients was equal to 9.77 ± 55.33%. In the same period, the cervical length regeneration rate was 69.41 ± 14.8%. Three months after LLETZ, a volume regeneration rate of 41.36 ± 28.31% was found. For the length, an average regeneration rate of 82.48 ± 15.25% was calculated. Finally, at 6 months, the percentage of regeneration of the excised volume was 90.99 ± 34.91%. The regrowth percentage of the cervical length was 91.07 ± 8.03%. The cervix measurement technique that we have proposed has the advantage of identifying an unequivocal reference point in 3D cervical measurement. Ultrasound 3D evaluation could be useful in the clinical practice to evaluate the cervical tissue deficit and express the "potential of cervical regeneration" as well as provide the surgeon useful information about the cervical length.

"GONE WITH THE WIND": The Transitory Effects of COVID-19 on the Gynecological System

The coronavirus disease no longer seems to represent an insurmountable global problem. This is thanks to the advent of coronavirus vaccines, which have alleviated the most serious symptoms associated with this disease. On the other hand, there are still many extrapulmonary symptoms of COVID-19, and among these also those of a gynecological nature. At the moment, there are several questions in this field, one above all concerns the causal link between COVID-19, vaccines and gynecological alterations. Furthermore, another important aspect is represented by the clinical impact of post-COVID-19 gynecological alterations on the female population which, to date, would seem to be mainly due to their duration, even if the extent of these symptoms is still poorly understood. Furthermore, it is not possible to foresee eventual long-term aggravations, or more serious symptoms caused by other viral variants that may arrive in the future. In this review, we focus on this theme and attempt to reorganize the different pieces of a puzzle which, to date, does not seem to have shown us its complete picture.

Robotic sacrocolpopexy with autologous fascia lata: A case series

Objectives

Apical prolapse involves the upper vagina or vaginal vault after hysterectomy. Treatment is indicated for symptomatic women, and surgical approach is considered for women who failed or refused conservative therapy. We performed 10 pickups of autologous fascia, used for robotic sacrocolpopexy (RSCP).

Materials and Methods

We included patients between 60 and 80 years old who showed a Pelvic Organ Prolapse Quantification (POP-q) over the second stage and with symptoms related to prolapse.

Results

All of them underwent autologous fascia lata (AFL) pickup from the right leg and after to RSCP. One patient underwent also posterior colporrhaphy. The mean intraoperative time was 199.2 min (183-230 min). No intra-operatory complications were reported. POP-q assessment during follow-up showed improvements: C point gained on average 7.6 points (5-8) and mean values went from -0.6 to - 8.2 cm (-7 to -9 cm). The three women who had anterior compartment defects shows good anatomical reconstitution with a mean Aa and Ba value of - 2.83 cm (-2.5 to -3 cm) and gained 4 points (average gain: 3.5-4.5 cm). Total vaginal lenght (TVL).

Conclusion

According to these data, in our experience, AFL employment showed a good anatomical result from the first to last follow-up.

Asynclitism and Its Ultrasonographic Rediscovery in Labor Room to Date: A Systematic Review

Asynclitism, the most feared malposition of the fetal head during labor, still represents to date an unresolved field of interest, remaining one of the most common causes of prolonged or obstructed labor, dystocia, assisted delivery, and cesarean section. Traditionally asynclitism is diagnosed by vaginal examination, which is, however, burdened by a high grade of bias. On the contrary, the recent scientific evidence highly suggests the use of intrapartum ultrasonography, which would be more accurate and reliable when compared to the vaginal examination for malposition assessment. The early detection and characterization of asynclitism by intrapartum ultrasound would become a valid tool for intrapartum evaluation. In this way, it will be possible for physicians to opt for the safest way of delivery according to an accurate definition of the fetal head position and station, avoiding unnecessary operative procedures and medication while improving fetal and maternal outcomes. This review re-evaluated the literature of the last 30 years on asynclitism, focusing on the progressive imposition of ultrasound as an intrapartum diagnostic tool. All the evidence emerging from the literature is presented and evaluated from our point of view, describing the most employed technique and considering the future implication of the progressive worldwide consolidation of asynclitism and ultrasound.

Management of a rare case of placenta trophotropism

There are several variations of placental shape or implantation. Multilobed placentas are thought to arise due to implantation in areas of decreased uterine perfusion. An example is represented by lateral implantation in between the anterior and posterior walls of the uterus. Other local factors leading to multilobation are implantation over leiomyomas, in areas of previous surgery, in the cornu, or over the cervical os. After implantation, there is preferential growth in areas of superior perfusion and atrophy in areas of poor perfusion. This is called trophotropism. We described a singular case of uterine synechia, where is laid the succenturiate lobe from the anterior to the posterior wall, obstacles fetal head descent in the pelvis. Due of that synechia, a cesarean section is necessary for fetal transverse situation with reverse breech extraction.

Dystocic Labor and Adrenergic and Noradrenergic Neurotransmitters: A Morphological Experimental Study

Authors investigated the catecholaminergic neurotransmitters (chNs) quantitative modifications in pregnant uterine Lower Uterine Segment (LUS) during prolonged labor (PL) with the fetus in an occiput-posterior position (OPP), in occiput transverse position (OTP) and in fetal head asynclitism, all diagnosed by Intrapartum Ultrasonography (IU). The chNs neurotransmitters, particularly adrenaline (or epinephrine-A) and noradrenaline (or norepinephrine-N), were evaluated in LUS fragments sampled during CS of 34 patients undergoing urgent cesarean section (CS) in PL, compared to chNs fibers in the LUS of 36 women submitted to elective CS. All results were statistically analyzed to understand the differences in neurotransmitters morphological analysis by scanning electronic microscopy examination (SEM). The LUS fragments analysis revealed a reduction of A and N fibers in LUS during PL, compared with the expression of A and N fibers in LUS during elective CS. The PL for OPP, the OTP and asynclitism, all positions causing dystocia in labor lead to a reduction in neurotransmitters in LUS, with a uterine vascularization modification and a reduction in the contractility of smooth uterine cells. The A and N neurotransmitters reduction observed in PL negatively interferes with uterine contraction during labor.

Uterine rupture after previous caesarean section with hysterotomy above the lower uterine segment

Background Spontaneous uterine rupture is a severe pregnancy complication. Several risk factors have been described, especially for women with a previous caesarean section. Method We reported two cases of uterine rupture (UR) occurring outside of labour in patients with a history of caesarean section (CS) due to placenta previa. Results: The current study evaluates how a higher hysterotomy, combined with some risk factors, can increase the prevalence of UR in the subsequent pregnancy. Conclusion This study supports that a careful evaluation of risk factors can identify patients who need a specific follow up to early diagnose and treat UR and thus improve the maternal-fetal outcome.

Effects of a combination of resveratrol and alpha-lipoic acid on body weight and adipose composition in women with PCOS: a preliminary pilot study

OBJECTIVE

Polycystic ovary syndrome is associated with reproductive and metabolic dysfunction; in fact, treatment aims in PCOS focus on optimizing healthy weight, improving underlying hormonal disturbances, preventing future reproductive and metabolic complications, and improving quality of life.

PATIENTS AND METHODS

This pilot study considered 8 overweight females (BMI > 30) in reproductive age with PCOS. Patients were treated with a galenical preparation mixture containing resveratrol and alpha-lipoic acid in association with vitamin D, B and folic acid for 12 weeks, after which anthropometric assessment was conducted.

RESULTS

After 12 weeks of treatment, BMI, anthropometry and bioimpedance parameters were all reduced in the treated patients compared to baseline.

CONCLUSIONS

The present nutraceutical combination resulted beneficial for improving the metabolic profile of women with PCOS, paving the way for new nutraceutical strategies for the management of metabolic disturbances in PCOS.

SARS-CoV-2, Placental Histopathology, Gravity of Infection and Immunopathology: Is There an Association?

(1) Background: As the pandemic months progress, more and more evidence shows that the placenta acts as a “barrier” to SARS-CoV-2, although rare cases of vertical transmission have been described. (2) Methods: In an attempt to investigate whether the symptoms’ severity was related to different placental histological characteristics and the immune microenvironment, we subdivided 29 placentas from 29 mothers positive for SARS-CoV-2 into two groups, depending on the symptomatology (moderate/severe vs. asymptomatic/mild), performing immunohistochemical investigations for CD4 + and CD8 + T lymphocytes, as well as for CD68 + macrophage. We also evaluated the immuno-expression of the ACE2 receptor at the placental level. These two groups were compared to a control group of 28 placentas from 28 SARS-CoV-2-negative healthy mothers. (3) Results: The symptoms (likely to be related to viremia) were statistically significantly correlated (p < 0.05) with histopathological changes, such as maternal malperfusion, decidual arteriopathy, blood vessel thrombus of fetal relevance. Furthermore, the immuno-expression of ACE2 was significantly lower in SARS-CoV-2-positive groups vs. control group (p = 0.001). (4) Conclusions: There is still much to study and discover regarding the relationship between SARS-CoV-2 and histological changes in placentas and how the latter might contribute to various neonatal clinical outcomes, such as prematurity.

Laminar Necrosis and Hypoxic Damage of the Placenta: A Case-Control Study

The aim of this study is to verify the role of laminar necrosis (LN) in the diagnosis of hypoxic damage of the placenta. This is a retrospective case-control study in which 50 cases with laminar necrosis were compared with 100 gestational age-matched controls without laminar necrosis in a 1:2 ratio. The parameters analyzed were: the presence of other placental lesions, obstetric characteristics and neonatal outcome. For each of the 50 cases, the area affected by the lesion was detected, and the lesions were classified into three groups based on the morphology and time of onset of the lesion in order to understand whether these characteristics of the lesion had a clinical-pathology. The results showed that including the search for LN among placental lesions generally examined is useful to guide the pathologist in the diagnosis of placental dysfunction of hypoxic origin.

Obstetric outcomes in pregnant COVID-19 women: the imbalance of von Willebrand factor and ADAMTS13 axis

Background

Thrombotic microangiopathy has been invoked as one of the most important mechanisms of damage in COVID-19 patients. Protease ADAMTS13 is a marker of microangiopathy responsible for controlling von Willebrand multimers size. Von Willebrand factor/ADAMTS13 ratio has been found impaired in COVID-19 patients outside pregnancy.

Methods

We prospectively investigated 90 pregnant women admitted to two tertiary academic hospitals in Italy with a laboratory-confirmed diagnosis of SARS-CoV-2 infection. Demographic, clinical information and routine laboratory data were collected at the hospital admission and until discharge. We investigated whether vonWillebrand /ADAMTS13 axis imbalance is a predictor of adverse outcomes. Logistic regression analysis, which controlled for potential confounders, was performed to evaluate the association between laboratory parameters and clinical outcomes.

Results

Most women (55.6%) were parae, with median gestational age at admission of 39 weeks. At hospital admission, 63.3% were asymptomatic for COVID-19 and 24.4% showed more than one sign or symptom of infection. Nulliparae with group O showed Willebrand / ADA MTS-13 ratios significantly lower than non-O, whereas in multiparae this difference was not observed. Logistic regression showed that ratio von Willebrand to ADAMTS13 was significantly and independently associated with preterm delivery (OR 1.9, 95%CI 1.1–3.5).

Conclusion

This study shows an imbalance of vonWillebrand /ADAMTS13 axis in pregnant women with COVID-19, leading to a significantly higher and independent risk of preterm delivery. Monitoring these biomarkers might support decision making process to manage and follow-up pregnancies in this setting.

A rare but troublesome complication of cesarean section: the uterocutaneous fistula. Report of two cases and review of literature

Objectives

The occurrence of a uterocutaneous fistula (UCF) as an uncommon and severe complication of caesarean section (CS). The aim of this study was to describe two cases of UCFs after CS and to discuss about symptoms, diagnosis and treatment.

Case presentation

Both women few days after CS had surgical site infection, fever and elevation of lab inflammation markers. bacterial culture of the wound drainage was positive for Escherichia Coli and Enterococcus Faecalis.

Conclusions

Fistula between uterine and skin is a rare condition but should be considered with signs of inflammation after cesarean section; 2D/3D ultrasound evaluation appears to be useful for diagnosis of UCFs when combined with CT fistulography and MRI in order to obtain early diagnosis and, consequently, a conservative surgery.

COVID-19 Infection in Pregnancy: Obstetrical Risk Factors and Neonatal Outcomes-A Monocentric, Single-Cohort Study

The effects of coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 on pregnant women and neonates are mainly unknown, since limited data are available in the literature. We conducted a monocentric and cross-sectional study enrolling 122 un-vaccinated pregnant women with COVID-19 infection tested by RT-PCR nasopharyngeal swab. Only 4.1% of the patients had severe COVID-19 symptoms together with major respiratory symptoms and intensive care unit admission, whereas 35.25% of women had comorbidities and two-thirds of them were overweight or obese. COVID-19 was detected mainly in the third trimester (98.36%) and multiparous women (59.02%). The mode of delivery was influenced by mild-severe COVID-19 symptoms, with a higher number of urgent or emergent cesarean sections than spontaneous or operative vaginal births. Preterm births were associated with high BMI, mode of delivery (higher among cesarean sections), nulliparity, and severe COVID-19 symptoms. In cases of severe COVID-19 symptoms, there was a higher rate of respiratory distress syndrome among newborns. In the end, only the presence of a severe COVID-19 infection worsened the obstetrical and neonatal outcomes, with higher rates of urgent or emergent cesarean section, preterm births, and neonatal respiratory distress syndrome.

Novel artificial intelligence approach for automatic differentiation of fetal occiput anterior and non-occiput anterior positions during labor

OBJECTIVES

To describe a newly developed machine-learning (ML) algorithm for the automatic recognition of fetal head position using transperineal ultrasound (TPU) during the second stage of labor and to describe its performance in differentiating between occiput anterior (OA) and non-OA positions.

METHODS

This was a prospective cohort study including singleton term (> 37 weeks of gestation) pregnancies in the second stage of labor, with a non-anomalous fetus in cephalic presentation. Transabdominal ultrasound was performed to determine whether the fetal head position was OA or non-OA. For each case, one sonographic image of the fetal head was then acquired in an axial plane using TPU and saved for later offline analysis. Using the transabdominal sonographic diagnosis as the gold standard, a ML algorithm based on a pattern-recognition feed-forward neural network was trained on the TPU images to discriminate between OA and non-OA positions. In the training phase, the model tuned its parameters to approximate the training data (i.e. the training dataset) such that it would identify correctly the fetal head position, by exploiting geometric, morphological and intensity-based features of the images. In the testing phase, the algorithm was blinded to the occiput position as determined by transabdominal ultrasound. Using the test dataset, the ability of the ML algorithm to differentiate OA from non-OA fetal positions was assessed in terms of diagnostic accuracy. The F₁ -score and precision-recall area under the curve (PR-AUC) were calculated to assess the algorithm's performance. Cohen's kappa (κ) was calculated to evaluate the agreement between the algorithm and the gold standard.

RESULTS

Over a period of 24 months (February 2018 to January 2020), at 15 maternity hospitals affiliated to the International Study group on Labor ANd Delivery Sonography (ISLANDS), we enrolled into the study 1219 women in the second stage of labor. On the basis of transabdominal ultrasound, they were classified as OA (n = 801 (65.7%)) or non-OA (n = 418 (34.3%)). From the entire cohort (OA and non-OA), approximately 70% (n = 824) of the patients were assigned randomly to the training dataset and the rest (n = 395) were used as the test dataset. The ML-based algorithm correctly classified the fetal occiput position in 90.4% (357/395) of the test dataset, including 224/246 with OA (91.1%) and 133/149 with non-OA (89.3%) fetal head position. Evaluation of the algorithm's performance gave an F₁ -score of 88.7% and a PR-AUC of 85.4%. The algorithm showed a balanced performance in the recognition of both OA and non-OA positions. The robustness of the algorithm was confirmed by high agreement with the gold standard (κ = 0.81; P < 0.0001).

CONCLUSIONS

This newly developed ML-based algorithm for the automatic assessment of fetal head position using TPU can differentiate accurately, in most cases, between OA and non-OA positions in the second stage of labor. This algorithm has the potential to support not only obstetricians but also midwives and accoucheurs in the clinical use of TPU to determine fetal occiput position in the labor ward. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Perinatal Transmission and Outcome of Neonates Born to SARS-CoV-2-Positive Mothers: The Experience of 2 Highly Endemic Italian Regions

INTRODUCTION

COVID-19 is the disease caused by the novel coronavirus SARS-CoV-2, responsible of the pandemic declared in March 2020 and still ongoing. COVID-19 affects all ages but presents less complications and fatalities in children. Neonatal infections have rarely been reported worldwide, and vertical transmission is uncertain.

METHODS

We conducted a prospective cohort study of all infants born to SARS-CoV-2-positive mothers admitted to 2 hospitals in South (Bari) and North (Varese) of Italy from April to December 2020. A molecular nasopharyngeal swab for SARS-CoV-2 using a reverse transcriptase polymerase chain reaction was made at birth for all enrolled newborns to evaluate vertical transmission of infection. We also evaluated postnatal transmission with a second nasopharyngeal swab made at 1 month of life and described maternal and neonatal clinical findings and short-term outcomes.

RESULTS

176/179 (97%) newborns were SARS-CoV-2 negative at birth and 151/156 (97%) infants were still negative at 1 month of life. All newborns were asymptomatic. Seventy percent of newborns were breastfed during hospitalization. At 1 month of life, 76% of infants were breastfed.

CONCLUSION

According to our results, vertical and perinatal infection is very rare. Breastfeeding does not increase the risk of COVID-19 and should be encouraged.

Uterine rupture during pregnancy: The URIDA (uterine rupture international data acquisition) study

OBJECTIVE

To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients.

METHODS

Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR.

RESULTS

Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy.

CONCLUSION

Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies.

Prenatal diagnosis of Pfeiffer syndrome and role of three-dimensional ultrasound: case report and review of literature

Purpose/aim of the study: We report a rare case of autosomal dominant genetic syndrome "Pfeiffer", which is part of the group of acrocephalosyndactyly, with an annual incidence <1/100,000. Three forms are known. Type I is the less common form and it is characterized by moderate-severe mediofacial hypoplasia usually with normal cognitive development. Conversely, types 2 and 3 are more common and they are associated with more severe signs and complications with a more unfavorable prognosis. The type 3 form due to the presence of a cloverleaf skull distinguishes type 2.Materials and methods: Thirty-eight-year-old primigravida was referred to our center, at 28 weeks of gestation due to borderline ventriculomegaly, macrocrania, and a short femur. First trimester screening for chromosomopathies and CF-DNA was low risk; II trimester screening ultrasound showed the presence of "short femur" and macrocrania.Result: Our ultrasound evaluation, assisted by 3D ultrasound, showed cloverleaf skull, turricephaly, moderate ventriculomegaly (13 mm), hypertelorism and exophthalmos, low ear implantation, mild rhizomelia. Ultrasound depicts Pfeiffer syndrome or other acrocephalosyndactyly syndromes (Apert syndromes, Saethre-Chotzen) or other syndromic forms of craniosynostosis like Crouzon syndrome. The NGS panel for molecular analysis of genes involved in skeletal dysplasias showed the mutation of the FGFR2 gene, de novo.Conclusions: Using three-dimensional (3D) ultrasound, it is easier to distinguish rare syndromes characterized by facial dysmorphisms such as exophthalmos, mediofacial hypoplasia, and craniosynostosis.

Is the First of the Two Born Saved? A Rare and Dramatic Case of Double Placental Damage from SARS-CoV-2

The current coronavirus pandemic has affected, in a short time, various and different areas of medicine. Among these, the obstetric field has certainly been touched in full, and the knowledge of the mechanisms potentially responsible for placental damage from SARS-CoV-2 occupy a certain importance. Here we present here a rare case of dichorionic twins born at 30 weeks and 4 days of amenorrhea, one of whom died in the first few hours of life after placental damages potentially related to SARS-CoV-2. We also propose a brief review of the current literature giving ample emphasis to similar cases described.

SARS-CoV-2 and Placenta: New Insights and Perspectives

The study of SARS-CoV-2 positive pregnant women is of some importance for gynecologists, obstetricians, neonatologists and women themselves. In recent months, new works have tried to clarify what happens at the fetal-placental level in women positive for the virus, and different pathogenesis mechanisms have been proposed. Here, we present the results of a large series of placentas of Coronavirus disease (COVID) positive women, in a reference center for COVID-positive pregnancies, on which we conducted histological, immunohistochemical and electron microscopy investigations. A case-control study was conducted in order to highlight any histopathological alterations attributable to SARS-CoV-2. The prevalence of maternal vascular malperfusion was not significantly different between cases and controls (54.3% vs. 43.7% p = 0.19), whereas the differences with regard to fetal vascular malperfusion (21.1% vs. 4.2% p < 0.001) were significant. More frequent in cases with respect to controls were decidual arteriopathy (40.9% vs. 1.4% p < 0.0001), decidual inflammation (32.4% vs. 0.7% p < 0.0001), perivillous fibrin deposition (36.6% vs. 3.5% p < 0.0001) and fetal vessel thrombi (22.5% vs. 0.7% p < 0.0001). No significant differences in the percentage of terminal villous hyperplasia and chorioamnionitis were observed between the two groups. As the pandemic continues, these studies will become more urgent in order to clarify the possible mechanism of maternal-fetal transmission of the virus.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk

BACKGROUND

The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri.

OBJECTIVE

Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy.

METHODS

From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group.

RESULTS

The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors.

CONCLUSION

In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

Prevalence, Correlates and Outcomes of Smoking in Pregnant Women with HIV: A National Observational Study in Italy

Background: Few studies have evaluated in pregnant women with HIV the prevalence of smoking and its associations with maternal and neonatal outcomes. Objectives: to assess the prevalence of smoking among women with HIV in early pregnancy and the association between smoking and pregnancy outcomes in this particular population. Methods: We used data from a multicenter observational study to define the prevalence of smoking in women with HIV in early pregnancy, and the role of smoking status and intensity as risk factors for adverse maternal and neonatal outcomes. Main outcome measures were fetal growth restriction [FGR], preterm delivery [PD] and low birthweight [LB], evaluated in univariate and multivariate analyses. Results: The overall (2001-2018) prevalence of reported smoking (at least one cigarette/day) was 25.6% (792/3097), with a significant decrease in recent years (19.0% in 2013-2018). Women who smoked were less commonly African, had lower body mass index, older age, a longer history of HIV infection and higher CD4 counts. In univariate analyses, smokers were significantly more likely to have PD, LB, FGR and detectable HIV viral load at third trimester. Multivariable analyses confirmed for smokers a significantly higher risk of LB (adjusted odds ratio [AOR]: 1.69, 95%CI 1.22-2.34) and FGR (AOR 1.88, 95%CI 1.27-2.80), while the associations with detectable HIV and PD were not maintained. Conclusions: The common prevalence of smoking among pregnant women with HIV and its association with adverse outcomes indicates that smoking cessation programs in this population may have a significant impact on neonatal and maternal health.

Pregnancy and neonatal outcomes in women with HIV-1 exposed to integrase inhibitors, protease inhibitors and non-nucleoside reverse transcriptase inhibitors: an observational study

PURPOSE

Recommended regimens for pregnant women with HIV-1 are composed of two nucleoside reverse transcriptase inhibitors (NRTI) plus either a ritonavir-boosted protease inhibitor (PI) or an integrase strand transfer inhibitor (ISTI), with non-nucleoside reverse transcriptase inhibitors (NNRTI) representing an alternative drug class. The study's purpose was to compare these three options in terms of pregnancy outcomes.

METHODS

Data from a national observational study of pregnant women with HIV-1 were used. The analysis included all pregnancies reported between 2008 and 2018, ending in live births and exposed within 32 weeks of gestation to three-drug regimens composed of a NRTI backbone plus a PI, a NNRTI or a ISTI, without class switching during pregnancy. Clinical and laboratory outcomes were evaluated in univariate and multivariable analyses.

RESULTS

Overall, 794 exposed pregnancies were analyzed (PI 78.4%, NNRTI 15.4%, ISTI 6.2%). Almost all outcomes had similar rates in the three groups. Women who received PI in pregnancy were less likely to be virologically suppressed at third trimester. PI use was associated with higher bilirubin and triglyceride levels, and ISTI use with a lower rate of low birthweight. The differences in viral suppression at third trimester and in low birthweight were not maintained in multivariable analyses that were adjusted for confounders.

DISCUSSION

We found no major differences in a wide range of outcomes relevant for pregnant women with HIV. Such results are reassuring, and this information may be helpful in a context of preconception counseling when therapeutic choices for pregnancy are discussed between women and care providers.

Congenital toxoplasmosis and proposal of a new classification for the likelihood of primary maternal infection: analysis of 375 cases in Southeast Italy

Objective: The aim of this study was to propose a classification in order to stratify the probability of an acute Toxoplasma infection in pregnancy and to estimate the risk of vertical transmission.Study design: We evaluated the likelihood of a primary maternal infection according to the Lebech classification and to the modified-Lebech classification proposed for our group of 375 patients referred for a suspected primary maternal infection. Fetal diagnosis included the examination of amniotic fluid by PCR to detect Toxoplasma DNA as a confirmation test.Results: Differences between the old and new classification resulted statistically significant for old classes defined as probable and unlikely with a clear shift of cases from the unlikely to the probable class in the new classification. Transmission rate showed a significant (p < .05) increase of the transmission rate in the probable class in our new classification as compared with the Lebech one.Conclusions: Results obtained in the present study suggest that the new IgG avidity-based classification herein proposed could estimate more precisely the likelihood of a primary maternal Toxoplasma infection as well as the risk of fetal infection, when compared with the historical Lebech Classification.

A phase II study: dose-dense carboplatin and paclitaxel as neoadjuvant chemotherapy in locally advanced cervical cancer

This study evaluates the efficacy and toxicity of dose-dense weekly paclitaxel and carboplatin as neoadjuvant chemotherapy in locally advanced cervical cancer (LACC). We collected 23 cases of LACC treated with weekly paclitaxel and carboplatin for nine cycles: 20 patients had complete or partial response to chemotherapy and were submitted to surgery, 3 with poor response received chemoradiation therapy. Pathologic examination showed complete response in four patients, myometrial invasion <50% in nine and >50% in seven patients, parametrial involvement in two, vaginal metastasis in one and lymphovascular space invasion, with positive margins, in another case. Despite seven patients had radiological evidence of lymph nodes involvement at diagnosis, only one had nodal metastases. Five patients showed grade 3-4 of hematologic toxicity.

Tunneling nanotubes evoke pericyte/endothelial communication during normal and tumoral angiogenesis

BACKGROUND

Nanotubular structures, denoted tunneling nanotubes (TNTs) have been described in recent times as involved in cell-to-cell communication between distant cells. Nevertheless, TNT-like, long filopodial processes had already been described in the last century as connecting facing, growing microvessels during the process of cerebral cortex vascularization and collateralization. Here we have investigated the possible presence and the cellular origin of TNTs during normal brain vascularization and also in highly vascularized brain tumors.

METHODS

We searched for TNTs by high-resolution immunofluorescence confocal microscopy, applied to the analysis of 20-µm, thick sections from lightly fixed, unembedded samples of both developing cerebral cortex and human glioblastoma (GB), immunolabeled for endothelial, pericyte, and astrocyte markers, and vessel basal lamina molecules.

RESULTS

The results revealed the existence of pericyte-derived TNTs, labeled by proteoglycan NG2/CSPG4 and CD146. In agreement with the described heterogeneity of these nanostructures, ultra-long (> 300 µm) and very thin (< 0.8 µm) TNTs were observed to bridge the gap between the wall of distant vessels, or were detected as short (< 300 µm) bridging cables connecting a vessel sprout with its facing vessel or two apposed vessel sprouts. The pericyte origin of TNTs ex vivo in fetal cortex and GB was confirmed by in vitro analysis of brain pericytes, which were able to form and remained connected by typical TNT structures.

CONCLUSIONS

None of the multiple roles described for TNTs can be excluded from a possible involvement during the processes of both normal and pathological vessel growth. A possible function, suggested by the pioneering studies made during cerebral cortex vascularization, is in cell searching and cell-to-cell recognition during the processes of vessel collateralization and vascular network formation. According to our results, it is definitely the pericyte-derived TNTs that seem to actively explore the surrounding microenvironment, searching for (site-to-site recognition), and connecting with (pericyte-to-pericyte and/or pericyte-to-endothelial cell communication), the targeted vessels. This idea implies that TNTs may have a primary role in the very early phases of both physiological and tumor angiogenesis in the brain.