Hysteroscopic Evaluation of Endometrial Changes in Breast Cancer Women with or without Hormone Therapies: Results from a Large Multicenter Cohort Study

STUDY OBJECTIVE

The primary aim of our study was to investigate the incidence of endometrial pathologies, especially endometrial cancer, in women with breast cancer treated with tamoxifen (TAM), aromatase inhibitors (AIs), or receiving no treatment (NT). The secondary aim was to identify, in this cohort, ultrasonographic findings that represent robust indications for hysteroscopy and endometrial biopsy, to avoid unnecessary second-level diagnostic procedures.

DESIGN

Multicenter retrospective cohort study (Clinical Trial ID: NCT03898947).

SETTING

Data were collected from different Italian centers: Regina Elena National Cancer Institute of Rome, Arbor Vitae Centre of Rome, Gaetano Martino University Hospital of Messina, and Villa Sofia-Cervello Hospital of Palermo.

PATIENTS

We selected and consecutively included patients with a history of breast cancer who had undergone hysteroscopy for ultrasonographic or clinical indications between January 2007 and December 2016.

INTERVENTIONS

Diagnostic hysteroscopy with endometrial biopsy or operative hysteroscopy, when clinically indicated.

MEASUREMENTS AND MAIN RESULTS

A higher percentage of patients in the TAM and AI groups had a normal endometrium compared with those in the NT group, whereas the incidence of endometrial polyps was higher in the NT group than in the others; no significant differences were observed among the 3 groups for other benign conditions or for premalignant and malignant uterine diseases, such as endometrial atypical hyperplasia and adenocarcinoma.

CONCLUSION

TAM treatment does not seem to be associated with a higher rate of endometrial cancer in women with breast cancer compared with women treated with AIs or NT.

Preterm birth: seven-year retrospective study in a single centre population

Background

Preterm birth is a health and social problem, considered the leading cause of neonatal mortality worldwide. It is associated with higher rates of neurodevelopmental morbidity, sensorineural impairments and other complications. The aim of the study was to describe the incidence and the major risk factors associated with preterm birth.

Methods

We performed a single center, observational and retrospective Cohort study in the Division of Obstetrics and Gynaecology, University Hospital “G. Martino”, Messina. Clinical records of all pregnant women who delivered from 1st January 2010 to 31 of December 2016 were collected.

Results

In the 7 years considered, a total of 7954 pregnant women were included in our study. The majority of all preterm births were due to infants born late preterm (71.83%), 26.45% were due to preterm and 1.72% to extremely preterm. The preterm cohort had a higher proportion of history of preterm delivery (p < 0.0001), and unmarried (p = 0.003) and underweight or obese patients (p < 0.0001). In addition, prematurity was associated with presence of uterine anomalies (p < 0.0001), vaginal/urinary infections (p = 0.02), poli/oligohydramnios (p < 0.0001), maternal diabetes (p = 0.004), hypertension (p < 0.0001), short cervical length (p < 0.0001).

Conclusions

We suggest prompt identification of all risk factors associated with preterm birth to apply immediate and appropriate specific interventions.

Relatively high rate of postpartum thyroiditis in the Straits of Messina area. Predictivity of both postpartum thyroiditis and permanent hypothyroidism by performing, in the first trimester of gestation, thyroid ultrasonography and measurement of serum thyroperoxidase and thyroglobulin autoantibodies

The prevalence of postpartum thyroiditis (PPT) averages 5%, with a range from 1% (Thailand) to 22% (Wales, UK, and Liguria, Italy), but 3.6% in another Italian region (Puglia). Evolution of PPT into permanent hypothyroidism (PH) occurs in approximately 50% of cases. Positive thyroperoxidase autoantibodies (TPOAb) in a pregnant woman is a strong predictor of PPT. Because in previous gestational cohorts we found an approximate 12% rate of TPOAb positivity, which compares with 15% in the Liguria cohort and 6% in the Puglia cohort, we hypothesized that the currently unknown prevalence of PPT in Sicily would approximate the said Liguria prevalence. We also explored the predictive value of serum thyroglobulin Ab (TgAb) positivity and ultrasonographic signs suggestive of thyroiditis (UST) at first trimester of gestation for PPT.

Of 412 pregnant women who were followed-up for 1 year after delivery, 63 (15.3%) developed PPT, and 54% of them had PH. Gestational rates of TPOAb positivity alone, TgAb positivity alone or UST were 11.4%, 7.8% or 35.0%, with associated PPT rates of 66%, 45% or 36%. TgAb assay allowed detection of 9/63 PPT women (14.3%) who were TPOAb-negative. However, TPOAb remained a better predictor compared to TgAb or UST (odds ratio = 32 vs 10 or 13). Lowering the positivity threshold for either Ab to ≥61 U/ml, Ab-positive were 23.8% of PPT women and 17.7% of pH women. UST was detected in 82.5% of women who developed PPT, precisely 88% of those who evolved into PH and 75.9% of those who did not.

Ours is the second study of the new millennium showing a PPT frequency >10%. The dual Ab and lowered threshold strategy correctly predicts more cases of PPT and PH compared to the sole TPOAb strategy. We confirm that half of the PPT women will have PH.

What women want? Results from a prospective multicenter study on women's preference about pain management during labour

OBJECTIVE

The aim of this study was to assess women preference about pain and duration of labour applying a standardized questionnaire.

STUDY DESIGN

A prospective multicentre large cohort study was carried out in two different University Hospitals. A standardized questionnaire was proposed before active labour and the day after delivery in order to investigate whether women preferred low pain intensity for a longer labour duration or greater pain intensity for a shorter labour duration. The studied population was divided and analysed in two groups according to Epidural Analgesia (EA) administration. A multivariable linear regression analysis was performed to assess which variables were able to influence the opinion about the pain perception after birth.

RESULTS

EA group showed an increased risk of episiotomy (p = 0.004), of longer duration of labour (Stage I, p < 0.001; Stage II, p = 0.002) and of oxytocin augmentation (P = 0.030). No statistical differences were found about the route of delivery between the two groups. Rates of pre-labour scores significantly differed from rates of post labour scores (p < 0.001). In the multivariable linear regression analysis, pre-labour score was directly related to post-labour score (p = 0.013). The EA was indirectly related to higher pain levels for a longer duration preference (p = 0.001), whereas oxytocic infusion in labour was directly related with preference for higher pain for a shorter duration (p = 0.011).

CONCLUSIONS

Patients' preferences about labour are focused on both pain relief and labour duration. The standardized questionnaire could be a useful tool to screen patients eligible for EA.

Preterm birth: incidence, risk factors and second trimester cervical length in a single center population. A two-year retrospective study

OBJECTIVE

To report the incidence and the major risk factors (RFs) associated with preterm birth (PTB), combining both maternal RFs and cervical length (CL), and to understand if cervical length measurement is really useful in all the patients.

PATIENTS AND METHODS

The study population consisted of 2048 women admitted to the Department of Obstetrics and Gynecology, University Hospital of Messina, over a 2-year period. Preterm cases represented approximately 8.64% of our total population and, exactly, 65% were late preterm, 32% were preterm, and 3% were extremely preterm.

RESULTS

An analysis of PTB sub-categories based on gestational age showed a stronger correlation between gestational age and CL among preterm and extremely preterm, while no correlation was found among late preterm. Between preterm cases and controls, there was a significant difference in pre-pregnancy weight and Body Mass Index (BMI). Moreover, a significant association between PTB and uterine anomalies, poli-oligodramnios and hypertension was found.

CONCLUSIONS

We strongly suggest adding a transvaginal ultrasound CL universal screening to all pregnant women at the time of the second trimester ultrasound. We encourage further studies to identify new RFs of PTB and to define the mechanisms by which risk factors are related to PTB.

Fertility Sparing Strategies in Patients Affected by Placental Site Trophoblastic Tumor

OPINION STATEMENT

Placental site trophoblastic tumor (PSTT) is the least common and the most ambiguous gestational trophoblastic tumor. Presentation of PSTT may occur in the course of gestation or from 1 week to 14 years after a normal or an abnormal pregnancy (mole, ectopic pregnancy, abortion). The indicators of aggressive behavior for this tumor are not well established. Due to the rarity of this disease that usually affects women of childbearing potential, we aimed to review the current literature, to identify risk factors and the best conservative therapeutic choices among the cases described. We performed a systematic literature search of articles in English language, published from 1996 to 2017 and indexed in PubMed and Scopus. Based on selective inclusion/exclusion criteria, we considered eight papers eligible for the review. Five were case reports and three were retrospective studies. We extracted and organized data into three different categories depending on the main treatment used. A total of 12 cases were treated with laparotomy; in 5 cases, the treatment was not curative. Therefore, a total abdominal hysterectomy was needed. Five cases were treated successfully with a minimally invasive approach, 2 with uterine evacuation, 2 with hysteroscopic resection, and 1 with a combined hysteroscopic/laparoscopic resection. Only 1 case treated with exclusive chemotherapy proved curative for the patient. Preservation of fertility in PSTT patients of childbearing age should be considered and as showed by the abovementioned studies, is a possible and safe therapeutic choice. Laparotomy for local uterine resection with the modified Strassman approach could be offered in patients at clinical stage 1 that are very motivated to retain fertility, extensively informing the patient of the risks and benefits related to this choice.

Thromboembolism prophylaxis in laparoscopic surgery for gynecologic benign diseases. Results of a single center experience in 922 procedures

AIM

The aim of this study is to assess the role of preoperative evaluation risk for venous tromboembolism (VTE) in patients submitted to laparoscopic surgery for gynecologic benign diseases.

METHODS

Date from nine hundred twenty-two women affected by adnexal benign diseases treated with laparoscopic procedures were collected and included in this study. VTE risk was assessed by "on line Caprini score calculator". Patients with one or more negative risk factors for Caprini's score underwent to venous thromboembolism prophylaxis (VTP). The remainign of the patients did not recived any VTP. A survey was conducted after three months from the discharge in order to collect the follow up date.

RESULTS

In our study 160 patients had a Caprini's score major than 2 and they have been subjected to VTP. A total of 762 patients were considered at low risk for VTE and they did not receive any VTP. In these patients was not registered any event of VTE.

DISCUSSION

The results of this study suggest that laparoscopic approach, when carried out in non-oncological patients and without any previous thromboembolic risk factor, is associated with a very low risk of VTE. This study also confirm what was reported by Ageno et al. 6, Nick et al. 7 and ACCP guidelines in 2012 8 in which routine thromboprophylaxis is recommended for patients with additional risk factors.

CONCLUSIONS

Laparoscopic surgery in women for gynecologic benign diseases is associated with a very low risk of thromboembolism and therefore it does not require any mechanical or pharmacological thromboprophylaxis in the absence of risk factors. The systematic evaluation of VTE risk with the help of a standard calculator is highly recommended.

KEY WORDS

Gynaecology, Laparoscopic surgery, Thromboprophylaxis.

Work load and management in the delivery room: changing the direction of healthcare policy

Nurse staffing, increased workload and unstable nursing unit environments are linked to negative patient outcomes including falls and medication errors on medical/surgical units. Considering this evidence, the aim of our study was to overview midwives' workload and work setting. We created a questionnaire and performed an online survey. We obtained information about the type and level of hospital, workload, the use of standardised procedures, reporting of sentinel and 'near-miss' events. We reported a severe understaffing in midwives' work settings and important underuse of standard protocols according to the international guidelines, especially in the South of Italy. Based on our results, we strongly suggest a change of direction of healthcare policy, oriented to increase the number of employed midwives, in order to let them fulfil their duties according to the international guidelines (especially one-to-one care). On the other hand, we encourage the adoption of standardised protocols in each work setting.

Inositol's and other nutraceuticals' synergistic actions counteract insulin resistance in polycystic ovarian syndrome and metabolic syndrome: state-of-the-art and future perspectives

The incidence of metabolic syndrome (MetS), type II diabetes (T2D) and polycystic ovarian syndrome (PCOS) has been progressively increasing. Insulin resistance (InsR) seems to play a key role in a majority of phenotypes of these conditions, altering metabolic homeostasis, within muscle, liver, adipose and other tissues. Hyperinsulinemia is often associated with InsR and causes hormonal imbalances especially within ovaries and adrenals. Inositol is a polyalcohol, naturally occurring as nine stereoisomers, including D-chiro-inositol (DCI) and myo-inositol (MI), which have prominent roles in the metabolism of glucose and free fatty acids. MI and DCI have been classified as insulin-sensitizers and seem to adequately counteract several InsR-related metabolic alterations with a safe nutraceutical profile. Based on our analysis of selected studies that investigated MI and/or DCI, we conclude that supplementation with MI and/or DCI complement each other in their metabolic actions and act in synergy with other insulin sensitizing drugs and/or nutraceuticals. Nevertheless, considering the possible severe bias due to different methodologies across published studies, we conclude that there is a need for further studies on larger cohorts and with greater statistical power. These should further clarify outcomes and suitable therapeutic dosages of MI and DCI, possibly based on each patient's clinical status.

Association between maternal serum high mobility group box 1 levels and pregnancy complicated by gestational diabetes mellitus

BACKGROUND AND AIMS

Gestational diabetes mellitus (GDM), is characterized by chronic, low-grade subclinical inflammation with altered production of cytokines and mediators. Recently, a new protein acting as a "danger signal", high mobility group box 1 (HMGB1), that migrates quickly during electrophoresis, has been identified. The aim of our study was to analyze serum levels of HMGB1 in pregnant women, with or without GDM, in the third trimester of pregnancy to evaluate correlation with insulin resistance and other risk factors for GDM.

METHODS AND RESULTS

Seventy five pregnant women positive to the 75 g oral glucose tolerance test (OGTT) were included in the study group and 48 pregnant women who were negative to the screening test, were randomly selected using a computer-generated randomisation table. A significant positive univariate correlation was observed between serum HMGB1 levels, HOMA-IR index, glycaemia values at OGTT and pre-pregnancy BMI. Moreover, logistic regression analysis showed that serum HMGB1 was independent linked to GDM.

CONCLUSION

Our study demonstrated that HMGB1, a marker of chronic inflammation, is associated to GDM and insulin resistance level, in the third trimester of pregnancy.

Does eating oily fish improve gestational and neonatal outcomes? Findings from a Sicilian study

BACKGROUND

Fish is a source of long-chain polyunsaturated n-3 fatty acids, but it may also contain a number of pollutants.

METHODS

Between April and July 2013, we selected 114 women who gave birth to living babies, and divided them according to type and frequency of the fish consumed. We evaluated both gestational and neonatal outcomes. Docosahexaenoic acid (DHA) supplementation was taken into account.

FINDINGS

One hundred and four women (91.2%) consumed fish on the average of 4.7 times/month, while 10 (8.8%) did not consume fish at all. Fifty-nine women (51.8%) were taking supplements containing DHA (200mg/day), almost all of whom (n=55) consumed fish. Pregnancy induced hypertension was more frequent in non-fish eaters than in fish eaters (20% vs 4.8%, P=0.056). Consumption of small size oily fish correlated positively with both neonatal weight (r=0.195, P=0.037) and head circumference (r=0.211, P=0.024). In contrast, consumption of lean fish or shellfish correlated negatively with neonatal head circumference (r=0.206, P=0.028, or r=0.192, P=0.041).

DISCUSSION

These data agree with previous observational studies and reinforce the protective role of small oily fish consumption on preterm birth risk, neonatal weight, length and head circumference.

CONCLUSION

Small oily fish consumption should be favored over other types of fish.

Dienogest as preoperative treatment of submucous myomas for hysteroscopic surgery: a prospective, randomized study

The aim of this single-center, prospective, randomized, parallel-group study was to compare Dienogest and Danazol as endometrial preparation in patients who have to undergo hysteroscopic surgery for submucous myomas. We enrolled 80 consecutive eligible patients, in reproductive age, affected by submucous myomas. Pre- and posttreatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 40 were treated with 2 mg of Dienogest/die, 40 with 100 mg of Danazol/die, both orally for 5 weeks, starting on day 1 of menstruation. Posttreatment comparison of endometrial patterns showed a significant more marked effect of Dienogest, respect to Danazol, in atrophying endometrium ("normotrophic non-responders" versus "hypotrophic"-"atrophic", p = 0.028). Intraoperative data showed no significant difference between the two groups for cervical dilatation time (p = 0.326), while in the Dienogest group, we found a significant reduction of operative time (p = 0.001), infusion volume (p = 0.001), and severity of bleeding (p = 0.042). Moreover, Dienogest caused less side effects (p = 0.008). According to our data analysis, Dienogest, respect to Danazol, is more effective for the preparation of the endometrium in patients who have to undergo hysteroscopic surgery for submucous myomas, and causes less side effects.

Metabolism and Ovarian Function in PCOS Women: A Therapeutic Approach with Inositols

Polycystic ovary syndrome (PCOS) is characterized by chronical anovulation and hyperandrogenism which may be present in a different degree of severity. Insulin-resistance and hyperinsulinemia are the main physiopathological basis of this syndrome and the failure of inositol-mediated signaling may concur to them. Myo (MI) and D-chiro-inositol (DCI), the most studied inositol isoforms, are classified as insulin sensitizers. In form of glycans, DCI-phosphoglycan and MI-phosphoglycan control key enzymes were involved in glucose and lipid metabolism. In form of phosphoinositides, they play an important role as second messengers in several cellular biological functions. Considering the key role played by insulin-resistance and androgen excess in PCOS patients, the insulin-sensitizing effects of both MI and DCI were tested in order to ameliorate symptoms and signs of this syndrome, including the possibility to restore patients' fertility. Accumulating evidence suggests that both isoforms of inositol are effective in improving ovarian function and metabolism in patients with PCOS, although MI showed the most marked effect on the metabolic profile, whereas DCI reduced hyperandrogenism better. The purpose of this review is to provide an update on inositol signaling and correlate data on biological functions of these multifaceted molecules, in view of a rational use for the therapy in women with PCOS.

Oxidative Stress during Ovarian Torsion in Pediatric and Adolescent Patients: Changing The Perspective of The Disease

Among the different causes of gynecological acute pelvic pain, ovarian torsion represents a surgical emergency. It is a rare case in the pediatric/adolescent aged group that must be included in the differential diagnosis of any girl with abdominal pain or pelvic/abdominal mass. Current recommendations suggest that laparoscopic detorsion should be performed in order to preserve the integrity of the ovaries and fertility, although oophoropexy may be considered in case of severe necrosis. Nevertheless, maintaining the circulation of the ovary after detorsion deteriorates the tissue injury and leads to a pathologic process called ischaemia/reperfusion (I/R) injury, which is characterized by oxidative stress. During the detorsion process, an excess amount of molecular oxygen is supplied to the tissues, and reactive species of oxygen (ROS) such as superoxide radical (O₂^-), hydrogen peroxide (H₂O₂), hydroxyl radical (OH•), as well as reactive nitrogen species (RNS) are produced in excess. ROS, RNS and their toxic products cause DNA damage and lipid peroxidation in the cellular and mitochondrial membranes, leading to cell death. In spite of attention on this topic, currently there is no shared and clear evidence about the use of anti-inflammatory and antioxidant agents to prevent I/R damage after laparoscopic ovarian detorsion. Considering this element, future research should aim to develop shared protocols for the clinical use (route of application, dosage and time of application) of antioxidants after laparoscopic management of this condition.

Analysis of the Influence of Lunar Cycle on the Frequency of Spontaneous Deliveries: A Single-centre Retrospective Study

Background Man, since ancient times, has been convinced of, and has researched scientific evidence that the barometric and gravitational forces play an important role in structural and biological variation of the planets, influencing the various forms of life. In particular, the synergistic relationships between variations in atmospheric pressure and gravitational forces on human gestation period have been the subject of rigorous observations and statistical calculations, which have not led to a universal conclusion in literature.Objectives The aim of our work was to check whether there is a higher incidence of spontaneous deliveries, during the periods of full Moon than during the other phases of the Moon.Methods We performed a retrospective analysis of 327 non-induced vaginal deliveries in a year, divided by month. We subsequently analyzed the incidence of these deliveries during periods of full Moon Vs other lunar phases.Results We evidenced a statistically significant difference between the annual total spontaneous deliveries happened in full Moon periods Vs all other Moon phases (T= 2,3946; p=0,0256). However, we reported a discordant trend of deliveries in full Moon period, depending on each considered month.Conclusion Since these differences were found both in increase and decrease, it is unacceptable the assumption of a linear correlation between periods of full Moon and increased frequency of spontaneous deliveries. For this reason, our data allow us to conclude that there is no need to increase the number of doctors and midwives in obstetric units during these periods.Kathmandu University Medical Journal Vol.12(4) 2014; 233-237

Evaluation of recovery and quality of sexual activity in women during postpartum in relation to the different mode of delivery: a retrospective analysis

AIM

Aim of the study was to assess the recovery and quality of sexual activity of women during postpartum, in relation to delivery.

METHODS

We recruited 200 women at 8 weeks after delivery. For each patient we recorded mode of delivery, age, body mass index (BMI), parity and test Female Sexual Function Index (FSFI) score.

RESULTS

Sixty-four women (32%) had spontaneous deliveries without episiotomy, 48 (24%) had it with episiotomy, 88 (44%) had caesarean sections. The analysis of variance (ANOVA) test showed no significant differences among the 3 groups for age, BMI, parity. The test FSFI evidenced 68 cases (34%) of Regular Female Sexual Function (RFSF) and 132 (66%) of Female Sexual Dysfunction (FSD). The ANOVA test showed significant differences among the 3 groups in RFSF (F [2, 14]=8.075, P=0.005), but not in FSD (F [2, 30]=2.646, P=0.087). In RFSF, FSFI score was higher in women who had vaginal delivery with episiotomy compared with the other two groups. Conversely, in FSD (both with or without resumed sexual activity at 8 weeks postpartum) we evidenced that patients who had vaginal delivery with episiotomy showed lower FSFI score than the other two groups, with a decrease in lubrication, orgasm and satisfaction scores. Furthermore, we observed that most of the RFSF patients had a job and breastfed.

CONCLUSION

Our results did not evidence a direct and significant correlation between mode of delivery and onset of female postpartum sexual dysfunction, even if FSD patients who underwent episiotomy during delivery markedly showed low FSFI scores.

Management of the second phase of labour: perineum protection techniques

The obstetric experience alongside scientific evidences in literature indicate several management techniques during the expulsive period of labour to minimize obstetric complications. Among the various methods that can be used for the protection of the perineum during the expulsive phase, some are performed prepartum (perineum massage), while most are used during childbirth. Among the second group, progressively increasing importance is assumed by the manual techniques to protect the perineum (using the "hands-on" and "hands-off") and by episiotomy. These techniques, when used in accordance to the guidelines, may favour the reduction of adverse outcomes for both the mother and the newborn, both immediately after birth and after a longer time. The midwife should be aware of the evidences in literature so that a critical analysis of the available techniques can be made and put in action during the expulsive phase in order to protect the mother and the foetus from any unfavourable outcomes. Currently, clinical evidence in literature is directing obstetric and medical staff towards a careful analysis of the maternal-foetal parameters, in order to achieve a precise assessment of the risks factors of intrapartum and postpartum outcomes. Increasingly, there is the need for close collaboration between the midwife and medical staff to ensure proper personalized assistance based on the peculiar characteristics of the woman and the fetus.

Gonadotrophin-releasing hormone analogue or dienogest plus estradiol valerate to prevent pain recurrence after laparoscopic surgery for endometriosis: a multi-center randomized trial

OBJECTIVES

To evaluate the efficacy of dienogest + estradiol valerate (E2V) and gonadotrophin-releasing hormone analogue (GnRH-a) in reducing recurrence of pain in patients with chronic pelvic pain due to laparoscopically diagnosed and treated endometriosis.

DESIGN

Multi-center, prospective, randomized study.

SETTING

Three university departments of obstetrics and gynecology in Italy.

POPULATION

Seventy-eight women who underwent laparoscopic surgery for endometriosis combined with chronic pelvic pain.

METHODS

Post-operative administration of dienogest + E2V for 9 months (group 1) or GnRH-a monthly for 6 months (group 2).

MAIN OUTCOME MEASURES

A visual analogue scale was used to test intensity of pain before laparoscopic surgery at 3, 6 and 9 months of follow up. A questionnaire to investigate quality of life was administered before surgery and at 9 months of follow up.

RESULTS

The visual analogue scale score did not show any significant differences between the two groups (p = 0.417). The questionnaire showed an increase of scores for all women compared with pre-surgery values, demonstrating a marked improvement in quality of life and health-related satisfaction with both treatments. No significant differences were found between the groups. The rate of apparent endometriosis recurrence was 10.8% in group 1 and 13.7% in group 2 (p = 0.962).

CONCLUSION

Both therapies seemed equally efficacious in preventing endometriosis-related chronic pelvic pain recurrence in the first 9 months of follow-up.

Evaluation of Maternal-Fetal Outcomes After Emergency Vaginal Cerclage Performed With Shirodkar-McDonald Combined Modified Technique

Background

Several techniques of emergency vaginal cerclage have been proposed in case of unexpected and abrupt cervical incompetence (CI), in order to prolong the pregnancy as much as possible and to reduce the adverse maternal-fetal outcomes. The aim of our study was to evaluate the effectiveness of emergency cervical cerclage, performed with the combined modified Shirodkar-McDonald technique.

Methods

We selected 12 cases of emergency vaginal cerclage, performed between January 1, 2008 and June 30, 2013. The age of the patients was between 20 and 38 years (mean 29.0 ± standard deviation (SD) 5.69), parity between 0 and 2 (mean 0.7 ± SD 0.65), and gestational age at the time of admission ranged between 17 and 26 weeks (mean 21.0 ± SD 3.44). In all these cases, we used a combined modified Shirodkar-McDonald technique to perform the procedure.

Results

The neonatal survival rate was 83.3%. The cesarean section rate was 16.7%. The average pregnancy prolongation was 89.9 days, higher than that reported for other studies in the literature.

Conclusions

We can assume that the emergency vaginal cerclage performed with the combined modified Shirodkar-McDonald technique is the best option of surgical therapy for the treatment of unexpected and abrupt CI.

High mobility group protein B1: a new biomarker of obesity in pregnant women?

Obesity is associated with an increased risk of an adverse pregnancy outcome. The aim of this study was to analyze the serum levels of high mobility group protein B1 (HMGB1) in obese pregnant women, to assess the role of this protein in the pathogenesis of this disease and to evaluate its possible function as a diagnostic marker for obesity-related complications in obese women. Study participants were randomly selected, from a cohort of pregnant women afferent to our department. A total of 120 women were enrolled in this study: 60 pregnant women had normal body mass index (BMI) and 60 women resulted obese. Pre-pregnancy BMI, weight increase and HMGB1 levels were evaluated for each pregnant woman enrolled. Matching serum HMGB1 levels in two groups, our data evidenced higher levels in the obese women, with a statistically significant difference (p = 0.0023). A significant positive univariate correlation was observed between serum HMGB1 levels and BMI in obese women. HMGB1 serum levels may therefore represent a predictive marker of disease in pregnant women (r = 20.9 and p = 0.0001). Further studies are needed in order to validate the role of this cytokine, with the aim of making it possible to use in clinical practice not only for diagnostic purposes, but especially for the early recognition of complications related to it.

Hashimoto thyroiditis onset after laparoscopic removal of struma ovarii: an overview to unravel a rare and intriguing finding

Struma ovarii is an uncommon type of ovarian tumor derived by germinal cells, characterized by the predominance of thyroid tissue (> 50%); 90-95% of these formations are benign and mainly affect the left ovary, while in 6% of the cases struma ovarii is bilateral. The malignant transformation is a rare condition that often occurs after 50 years. In most instances, diagnosis of malignant struma ovarii is made postoperatively during histological analysis. This tumor appears to derive by one germinal cell through loss of heterozygosity of the androgen receptor gene and of the X chromosome. Clinical symptoms comprise abdominopelvic mass, lower abdominal pain, abnormal vaginal bleeding, and ascites (the occurrence of this condition has been observed in one-third of the cases). The patients with struma ovarii generally do not manifest symptoms related to thyroid hyperfunction, reported only in 8% of the cases, and due to hyperstimulation of the thyroid by auto-antibodies. Thyroid tissue of the struma ovarii, often embedded in a teratoma, may be papillary, follicular or with mixed pattern and it can include elements of mucinous cystoadenomas, Brenner's tumor or carcinoid or melanomas cells. Here the authors report their experience with an unusual case of Hashimoto thyroiditis onset after laparoscopic removal of struma ovarii.

Post-partum management in a patient affected by thrombotic thrombocytopenic purpura: case report and review of literature

Thrombotic thrombocytopenic purpura (TTP) is a rare and potentially lethal syndrome characterized by severe thrombocytopenia, microangiopathic haemolytic anaemia, and aspecific neurologic symptoms. This syndrome is the result of an abnormal intravascular platelet aggregation which induces transient ischemia in various organs, especially in the central nervous system. Platelet aggregation causes also fragmentation of erythrocytes, thus leading to the characteristic anaemia. The exact cause of TTP is unknown, but a large body of evidence suggest that this syndrome might be due to acquired (immunological) or congenital ADAMTS13 deficiency. The dysregulation of ADAMTS 13 activity could promote massive release of high molecular weight multimers of von Willebrand factor (VWF) from endothelium and, as a consequence, could cause intravascular platelet aggregation. Pregnancy is commonly associated with numerous metabolic, immunological, and haemostatic changes which could increase thrombotic risk: during pregnancy, in fact, it is generally observed an increase of procoagulant activity and a decrease of fibrinolytic activity; moreover, at the end of pregnancy, it is not rare to find thrombocytopenia. All these reasons lead us to consider pregnancy itself as a triggering event for the onset of TTP. The authors describe a case of TTP occurred during puerperium, in a patient who underwent caesarean section.

Cytogenetic analysis of epithelial ovarian cancer's stem cells: an overview on new diagnostic and therapeutic perspectives

Ovarian cancer is one of the most frequent solid tumor that shows clearly biphasic behaviour in response to chemotherapy, with the majority of patients who achieved complete remission after the first cycle of chemotherapy, and subsequently present a relapse which, in most cases, leads to death. Epithelial ovarian cancer (EOC) arises as a consequence of genetic alterations that affect the cells of the ovarian surface, which leads to changes that occur through the activation of oncogenes and inactivation of tumor suppressor genes. The progression of EOC is characterized by a series of combined epigenetic aberrations, including the most important of those determined by the loss of methylation of certain regions of DNA encoding genes such as Ras-association domain-containing family 1 [(RASSF1A) tumor suppressor], death-associated protein kinase [(DAPK) protein kinase associated with the regulation of apoptosis], human sulfa- tase-I [(hSulf-1) sulfatase, which plays a key role in the regulation of apoptosis], breast cancer 1 gene [(BRCA1) tumor suppressor gene, involved in the processes of DNA repair], and HOXAI0 (gene required to promote many transcription factors). To date, accumulating evidence suggests that the initial clinical response is due primarily to the therapeutic efficacy of chemotherapy against differentiated can- cer cells that constitute the bulk of the tumor, whereas the high rate of recurrence is thought to be due to remaining drug-resistant cells, biologically distinct, identified as cancer stem cells (CSC). Current efforts are focusing on genetic and cytological definition of CSC, to guide the development of new diagnostic, and therapeutic perspectives.

Desogestrel versus danazol as preoperative treatment for hysteroscopic surgery: a prospective, randomized evaluation

The aim of this single-center, prospective, randomized, parallel-group study was to compare desogestrel and danazol as preoperative endometrial preparation for hysteroscopic surgery. We enrolled 200 consecutive eligible patients, in reproductive age, with endouterine diseases. Pre- and post-treatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 100 were treated with 75 μg of desogestrel/die, 100 with 100 mg of danazol/die, both orally for 5 weeks, starting on Day 1 of menstruation. We recorded intraoperative data (cervical dilatation time, operative time, infusion volume and severity of bleeding) and drugs' side effects. Post-treatment comparison of endometrial patterns showed a significant more marked effect of desogestrel, respect to danazol, in atrophying endometrium ("normotrophic non-responders" versus "hypotrophic"-"atrophic", p = 0.031). Intraoperative data showed no significant differences between the two groups for cervical dilatation time (p = 0.160), while in the desogestrel group we found a significant reduction of operative time (p = 0.020), infusion volume (p = 0.012), and severity of bleeding (p = 0.004). Moreover, desogestrel caused less side effects (p = 0.031). According to our data analysis, desogestrel showed most marked effect in inducing endometrial atrophy, allowed a better intraoperative management and caused less side effects during treatment.

3D sonohysterography vs hysteroscopy: a cross-sectional study for the evaluation of endouterine diseases

PURPOSE

To assess the concordance between the presumed diagnosis obtained with the 3D sonohysterography (SHG) and with the diagnostic hysteroscopy (HYS); to determine whether the 3D SHG has the accuracy needed to be considered as a diagnostic screening standard in cases of suspected endouterine pathology.

METHODS

We selected 224 patients who voluntarily decided to undergo 3D SHG from a population with suspected presence of endouterine disease at TVS. The patients underwent first 3D SHG and then diagnostic HYS. We recorded each patient's discomfort/pain during the two techniques. We used the "Bayes Theorem" to calculate the sensitivity and specificity of the 3D SHG as compared to HYS.

RESULTS

Overall the 3D SHG diagnosis was confirmed in 156/224 cases (69.64 %). Concordance for endometrial thickening was 0 %; for Asherman's syndrome was 50.00 %; for polyp was 77.78 %; and for myoma, mucus accumulation and Müllerian anomalies (arcuate uterus, septate and subseptate uterus) was 100.00 %. Furthermore, 3D SHG was better tolerated than HYS.

CONCLUSION

Despite the diagnostic accuracy and mini-invasiveness of 3D SHG, we suggest that it cannot be a substitute of HYS in endouterine disease diagnosis, but it could be considered as a good method of screening to address patients to hysteroscopic confirmation.

Behavior of tumor necrosis factor-α and tumor necrosis factor receptor 1/tumor necrosis factor receptor 2 system in mononuclear cells recovered from peritoneal fluid of women with endometriosis at different stages

During endometriosis, a breakdown occurs in endometrial and peritoneal homeostasis caused by cytokine-induced cell proliferation and dysregulation of apoptosis. We studied tumor necrosis factor (TNF)-α, TNF receptor (TNFR) 1, and TNFR2 gene expression at both messenger RNA (mRNA) and protein levels in peritoneal fluid (PF) mononuclear cells (PFMCs), the percentages of these cells bearing the same markers, and soluble TNF-α (sTNF-α) values in PF of 80 women with endometriosis. We found that TNFR1 mRNA and protein levels, the percentages of TNFR1-bearing PFMCs, and sTNF-α values decreased from minimal to severe stages of the disease. Instead, TNF-α and TNFR2 mRNA and protein levels, the percentages of membrane TNF-α (mTNF-α)- and TNFR2-bearing PFMCs increased as the disease worsened. These data allow us to hypothesize that, in early stages, the high percentages of TNFR1-bearing PFMCs and the high levels of sTNF-α could address signal toward complex I pathway, favoring the inflammatory response. With the worsening of the disease, the low percentages of TNFR1-bearing PFMCs are probably due to decreased TNFR1 mRNA transcription and protein translation rate. In early stages (minimal and mild), the percentages of both TNFR2- and mTNF-α-bearing PFMCs are so low, due to decreased mRNA transcription and protein translation rate, that subsequent cellular events may depend minimally by this interaction. The high levels of sTNF-α may be rerouted to bind TNFR1. In contrast, in the moderate and severe stages, the high percentages of TNFR2-bearing PFMCs may be saturated by high percentages of mTNF-α-bearing PFMCs, triggering death process. So, in endometriosis, each component of the TNF-α/TNFRs system may trigger opposite cellular fate.

Chronic pelvic pain in endometriosis: an overview

Chronic pelvic pain (CPP) could be considered nowadays a deep health problem that challenges physicians all over the world. This because its aetiology is still unclear, the course of the disease could vary a lot among different patients and through time in the same patient, and the response to treatments is not every time successful. Among women who underwent laparoscopy for CPP, endometriosis is found in about 1/3 of the cases, while only 25% of women with histological confirmed endometriosis are asymptomatic. A wide range of variables may exert their influence on the resulting pain syndrome in endometriosis; for example, score according to American society for reproductive medicine (rASRM), size of the sub-peritoneal and pelvic wall implants, Douglas obliteration, previous surgery. It is widely accepted nowadays that central nervous system (CNS) and peripheral nervous system (PNS) seems to influence each other and this interconnection play a key role in pain modulation. Moreover, the phenomena induced by endometriosis in the pelvis, including the breakdown of peritoneal homeostasis and the induction of the production of proinflammatory and proangiogenic cytokines, are responsible of altered innervations and modulation of pain pathways in these patients. There are many proposed medical and surgical approach to treat this painful syndrome, although there is necessity of more efforts to create new non-invasive strategies that set a more accurate diagnosis of the causes of endometriotic-related CPP, and therefore facilitate its eradication.