Circulating tumor DNA as a biomarker for predicting progression-free survival and overall survival in patients with epithelial ovarian cancer: a systematic review and meta-analysis

OBJECTIVES

Circulating tumor DNA (ctDNA) is emerging as a potential prognostic biomarker in multiple tumor types. However, despite the many studies available on small series of patients with ovarian cancer, a recent systematic review and meta-analysis is lacking. The objective of this study was to determine the association of ctDNA with progression-free-survival and overall survival in patients with epithelial ovarian cancer.

METHODS

An electronic search was conducted using PubMed (MEDLINE), Embase, CENTRAL (Cochrane Library), and CINAHL-Complete from January 2000 to September 15, 2023. To be included in the analysis the studies had to meet the following pre-specified inclusion criteria: (1) evaluable ctDNA; (2) progression-free-survival and overall survival reported as hazard ratio (HR); and (3) the patient population had epithelial ovarian cancer at the time of ctDNA detection. We evaluated the association of ctDNA with progression-free survival and overall survival. Secondary outcomes focused on sub-group analysis of genomic alterations and international Federation of Gynecology and Obstetrics (FIGO) stage.

RESULTS

A total of 26 studies reporting on 1696 patients with epithelial ovarian cancer were included. The overall concordance rate between plasma-based and tissue-based analyses was approximately 62%. We found that a high level of ctDNA in epithelial ovarian cancer was associated with worse progression-free survival (HR 5.31, 95% CI 2.14 to 13.17, p<0.001) and overall survival (HR 2.98, 95% CI 1.86 to 4.76, p<0.0001). The sub-group analysis showed a greater than threefold increase in the risk of relapse in patients with positive HOXA9 meth-ctDNA (HR 3.84, 95% CI 1.57 to 9.41, p=0.003).

CONCLUSIONS

ctDNA was significantly associated with worse progression-free survival and overall survival in patients with epithelial ovarian cancer. Further prospective studies are needed.

PROSPERO REGISTRATION NUMBER

CRD42023469390.

Effect of Physical Activity during Pregnancy on the Risk of Hypertension Disorders and Gestational Diabetes: Evidence Generated by New RCTs and Systematic Reviews

Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are the most common medical complications in pregnancy. Physical exercise is considered to be safe and beneficial during pregnancy. Moreover, pregnancy could be considered as an opportunity for healthcare providers to promote positive lifestyle behavior and optimize the well-being of pregnant women. Since there are few up-to-date reviews evaluating the role of exercise and the risks of developing obstetrical complications, we performed a review to investigate the effects of physical activity and exercise during pregnancy compared to a control group, focusing on the risk of development of HDP and GDM. We searched Medline and Web of Science, including only randomized controlled trials (RCTs) and systematic reviews. This review supports a beneficial effect of exercise and provides evidence that it significantly decreases the risk of HDP and GDM.

Simple hysterectomy versus radical hysterectomy in early-stage cervical cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage cervical cancer.

METHOD

We systematically searched databases including PubMed, Embase and Cochrane to collect studies that compared oncological and surgery-related outcomes between SH and RH groups in patients with stage IA2 and IB1 cervical cancer. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4.

RESULT

Seven studies comprising 6977 patients were included into our study. For oncological outcomes, we found no statistical difference in recurrence rate [OR = 0.88; 95% CI (0.50, 1.57); P = 0.68] and Overall Survival (OS) [OR = 1.23; 95% CI (0.69, 2.19), P = 0.48]. No difference was detected in the prevalence of positive LVSI and lymph nodes metastasis between the two groups. Concerning surgery-related outcomes, the comprehensive effects revealed that the bladder injury [OR = 0.28; 95% CI (0.08, 0.94), P = 0.04] and bladder disfunction [OR = 0.10; 95% CI (0.02, 0.53), P = 0.007] of the RH group were higher compared to the SH group.

CONCLUSION

This meta-analysis suggested there are no significant differences in terms of both recurrence rate and overall survival among patients with stage IA2-IB1 cervical cancer undergoing SH or RH, while the SH group has better surgery-related outcomes. These data confirm the need to narrow the indication for RH in early-stage cervical cancer.

Telemedicine in the treatment of gestational diabetes: An observational cohort study on pregnancy outcomes and maternal satisfaction

AIMS

Gestational diabetes treatment requires several outpatient consultations from diagnosis until delivery in order to prevent hyperglycaemia, which is associated with maternal and fetal complications. There is limited evidence in the literature about telemedicine superiority in improving pregnancy outcomes for women with gestational diabetes. The primary aim of the study was to evaluate maternal and fetal outcomes, while the secondary aim was to estimate the degree of satisfaction with gestational diabetes treatment, comparing telemedicine versus outpatient care.

METHODS

This observational cohort study involved 60 consecutive women with gestational diabetes treated at the Diabetology Unit of Ferrara: 27 were followed up through a weekly remote control method (telemedicine group) and 33 in ambulatory clinics every 2 or 3 weeks (conventional group). After giving birth, 56 women responded to the modified Oxford Maternity Diabetes Treatment Satisfaction Questionnaire to assess their satisfaction with diabetes care.

RESULTS

No statistically significant differences were found in most of the maternal and neonatal parameters evaluated in both groups. The questionnaire scores were positive in all areas investigated. Telemedicine follow-up made women feel more controlled (p = 0.045) and fit better with their lifestyle (p = 0.005). It also emerged that almost all women treated with telemedicine would recommend this method to a relative or a friend.

CONCLUSIONS

Telemedicine follow-up proved to be safe both in terms of metabolic control and pregnancy outcomes; furthermore, it significantly decreased the need for outpatient consultations and increased women's satisfaction. Studying the impact of telemedicine is also necessary, considering the current difficulties associated with the Sars-COV-2 pandemic.

Corrigendum: Serum IgG antibodies from pregnant women reacting to mimotopes of Simian virus 40 large T antigen, the viral oncoprotein

[This corrects the article DOI: 10.3389/fimmu.2017.00411.].

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) with cisplatin and doxorubicin in patients with ovarian cancer: A systematic review

BACKGROUND

PIPAC consists in delivering normothermic chemotherapy solution directly into the peritoneal cavity as an aerosol under pressure. Currently PIPAC is considered as a palliative treatment for patients suffering from non-resectable peritoneal carcinomatosis. We performed a SR to assess tolerance and response of this novel method among patient with OC.

METHODS

We searched electronic database PubMed, Embase, Web of Science, Clinical Trials.gov. We only included clinical studies reporting PIPAC with cisplatin and doxorubicin in patients with ovarian cancer.

RESULTS

This systematic review included 4 studies. In 3 studies all patients were pretreated with cytoreductive surgery, in 1 study surgery was performed in 8/34 (23 %) patients. Mean PCI at first PIPAC procedure ranged from 16.3 to 19.6. All studies reported the proportion of patients with ascites at the first PIPAC with a pooled rate of 48,3 %. Pooled rate of CTCAE Grade 3 toxicity calculated on the total number of PIPAC was 6 % and Grade 4 was 0.9 %. One study reported two cases of small bowel perforation related or potentially related to PIPAC. On study reported a cumulative survival after 400 days of 62 % and a mean actuarial survival time of all patients who underwent PIPAC of 442 days. In another study the mean time to progression was 144 days (95 % CI 122-168 days).

CONCLUSION

This systematic review demonstrated that PIPAC with cisplatin and doxorubicin appear to have a good safety profile with low toxicity and encouraging trend in terms of overall survival.

Safety of misoprostol vs dinoprostone for induction of labor: A systematic review and meta-analysis

OBJECTIVE

Pharmacological agents such as prostaglandins (dinoprostone and misoprostol) are commonly used to reduce the duration of labor and promote vaginal delivery. However, key safety considerations with its use include an increased risk of uterine rupture, tachysystole and hyperstimulation of pregnant women, which could potentially lead to a non-reassuring fetal heart rate and to fetal hypoxemia. The aim of this systematic review was to assess maternal and fetal outcomes between misoprostol group (PGE1) and dinoprostone group (PGE2) STUDY DESIGN: We search on MEDLINE (PubMed), CINHAL (EBSCOhost), EMBASE, Scopus (Ovid), CENTRAL (January 1, 1998, to December 31, 2022). Patients were eligible if they presented at greater than 36 weeks gestation with an indication for induction of labor and a single live cephalic fetus. We conducted a meta-analysis of data for both primary (cesarean section rate, instrumental deliveries rate, tachysystole, uterine rupture, post-partum haemorrage; chorionamiositis) and secondary outcomes (Apgar at 5 min <7, meconium-stained liquor, NICU admission, infant death) using odds-ratio (OR) as a measure of effect-size. Risk of bias assessment was performed with RoB-I. We performed statistical analyses using Cochrane RevMan version 5.4 software.

RESULTS

We found 39 RCTs comparing the outcomes of interest between misoprostol and dinoprostone. The pooled effect showed no statistically significant difference between the two groups in terms of cesarean section rate [OR: 0.94; 95% CI 0.84-1.05], instrumental deliveries rate [OR: 1.04; 95% CI: 0.90-1.19; p = 0.62], tachysystole [OR: 1.21; 95% CI: 0.91-1.60; p = 0.19], post-partum hemorrhage [OR: 0.85; 95% CI: 0.62-1.15p = 0.30], chorioamnionitis [OR: 0.94; 95% CI: 0.76-1.17p = 0.59], Apgar at 5 min < 7 [OR: 0.83; 95% CI: 0.61-1.12, p = 0.21], meconium-stained liquor [OR: 1.11; 95% CI: 0.97-1.27p = 0.59], NICU admission group [OR: 0.91; 95% CI: 0.77-1.09], infant death [OR: 0.57; 95% CI: 0.22-1.44]. After performing a sub-group analysis based on the type of prostaglandins administrations (oral, vaginal gel, vaginal pessary), results did not change substantially.

CONCLUSIONS

This systematic review and meta-analysis demonstrate that misoprostol and dinoprostone appear to have a similar safety profile.

Oxidative Stress Markers in Human Brain and Placenta May Reveal the Timing of Hypoxic-Ischemic Injury: Evidence from an Immunohistochemical Study

During pregnancy, reactive oxygen species (ROS) serve as crucial signaling molecules for fetoplacental circulatory physiology. Oxidative stress is thought to sustain the pathogenesis and progression of hypoxic-ischemic encephalopathy (HIE). A retrospective study was performed on the brains and placentas of fetuses and newborns between 36-42 weeks of gestation (Group_1: Fetal intrauterine deaths, Group_2: Intrapartum deaths, Group_3: Post-partum deaths, Control group sudden neonatal death); all groups were further divided into two subgroups (Subgroup_B [brain] and Subgroup_P [placenta]), and the study was conducted through the immunohistochemical investigations of markers of oxidative stress (NOX2, 8-OHdG, NT, iNOS), IL-6, and only on the brain samples, AQP4. The results for the brain samples suggest that NOX2, 8-OHdG, NT, iNOS, and IL-6 were statistically significantly expressed above the controls. iNOS was more expressed in the fetal intrauterine death (Group_1) and less expressed in post-partum death (Group_3), while in intrapartum death (Group_2), the immunoreactivity was very low. IL-6 showed the highest expression in the brain cortex of the fetal intrauterine death (Group_1), while intrapartum death (Group_2) and post-partum death (Group_3) showed weak immunoreactivity. Post-partum death (Group_3) placentas showed the highest immunoreactivity to NOX2, which was almost double that of the fetal intrauterine death (Group_1) and intrapartum death (Group_2) placentas. Placental tissues of fetal intrauterine death (Group_1) and intrapartum death (Group_2) showed higher expression of iNOS than post-partum death (Group_3), while the IL-6 expression was higher in the fetal intrauterine death (Group_1) than the post-partum death (Group_3). The AQP4 was discarded as a possible marker because the immunohistochemical reaction in the three groups of cases and the control group was negative. The goal of this study, from the point of view of forensic pathology, is to provide scientific evidence in cases of medical liability in the Obstetric field to support the clinical data of the timing of HIE.

Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis

OBJECTIVE

Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques.

DATA SOURCE

A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO.

METHODS

The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020.

RESULTS

Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD =  - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78).

CONCLUSION

There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.

Three-dimensional vision versus two-dimensional vision on laparoscopic performance of trainee surgeons: a systematic review and meta-analysis

Laparoscopic surgery underwent great improvements during the last few years. This review aims to compare the performance of Trainee Surgeons using 2D versus 3D/4 K laparoscopy. A systematic review of the literature was done on Pubmed, Embase, Cochrane's Library and Scopus. The following words and key phrases have been searched: "Two-dimensional vision", "Three-dimensional vision", "2D and 3D laparoscopy", "Trainee surgeons". This systematic review was reported according to the PRISMA statement 2020. PROSPERO registration No. CRD42022328045. Twenty-two randomized controlled trials (RCTs) and two observational studies were included in the systematic review. Two trials were carried out in a clinical setting, and twenty-two trials were performed in a simulated setting. In studies involving the use of a box trainer, the number of errors in the 2D laparoscopic group was significantly higher than in the 3D laparoscopic group during the performance of FLS skill tasks: peg transfer (MD: -0.82; 95% CI - 1.17 to - 0.47; p < 0.00001), cutting (MD: - 1.09; 95% CI - 1.50 to - 0.69 p < 0.00001), suturing (MD: - 0.48; 95% CI - 0.83 to - 0.13 p = 0.007), However, in clinical studies, there was no significant difference in the time taken for laparoscopic total hysterectomy (MD: 8.71; 95% CI - 13.55 to 30.98; p = 0.44) and vaginal cuff closure (MD: 2.00; 95% CI - 0.72 to - 4.72; p = 0.15) between 2D group and 3D group. 3D laparoscopy facilitates learning for novice surgeons and shows improvements in their laparoscopic performance.

Effect of SARS-CoV-2 infection in pregnancy on CD147, ACE2 and HLA-G expression

INTRODUCTION

Recent studies reported a differential expression of both ACE2 and CD147 in pregnant women associated to SARS-CoV-2 placental infection. The aim of this study is to further investigate the placental SARS-CoV-2 infection and the potential effect on protein expression (ACE2, CD147, HLA-G and CD56).

METHODS

The study was on three subgroups: i) 18 subjects positive for SARS-CoV-2 swab at delivery; ii) 9 subjects that had a positive SARS-CoV-2 swab during pregnancy but resulted negative at delivery; iii) 11 control subjects with physiological pregnancy and with no previous or concomitant SARS-CoV-2 swab positivity. None of the subjects were vaccinated for SARS-CoV-2 infection. The placenta samples were analyzed for SARS-CoV-2 NP (Nucleocapsid protein) positivity and the expression of ACE2, CD147, HLA-G and CD56.

RESULTS

We observed a higher percentage of SARS-CoV-2 NP positive placenta samples in the group of SARS-CoV-2 PCR positive at delivery in comparison with SARS-CoV-2 PCR negative at delivery. The localization of SARS-CoV-2 NP positivity in placenta samples was mainly in syncytiotrophoblast (ST) of SARS-CoV-2 PCR positive at delivery group and in extra-villous trophoblast (EVT) of SARS-CoV-2 PCR negative at delivery group. CD147, HLA-G positivity was higher in ST of SARS-CoV-2 PCR positive at delivery group, while CD56-expressing immune cells were decreased in comparison with control subjects.

DISCUSSION

We confirmed the ability of SARS-CoV-2 to infect placenta tissues. The simultaneous SARS-CoV-2 swab positivity at delivery and the positivity of the placenta tissue for SARS-CoV-2 NP seems to create an environment that modifies the expression of specific molecules, as CD147 and HLA-G. These data suggest a possible impact of SARS-CoV-2 infection during pregnancy, that might be worthy to be monitored also in vaccinated subjects.

Effectiveness and safety of COVID-19 vaccine in pregnant women: A systematic review with meta-analysis

BACKGROUND

There are limited data regarding COVID-19 vaccination during pregnancy.

OBJECTIVES

To evaluate the effects of COVID-19 vaccination received during pregnancy on SARS-CoV-2 infection, COVID-19-related hospitalisation, COVID-19-related intensive care unit (ICU) admission and maternal-fetal complications.

SEARCH STRATEGY

MEDLINE, CINHAL, Embase, Scopus and CENTRAL databases, as well as ClinicalTrials.gov, reference lists, related articles and grey literature sources.

SELECTION CRITERIA

Randomised controlled trials, non-randomised studies of interventions, pregnant women, COVID-19 vaccination during pregnancy.

DATA COLLECTION AND ANALYSIS

Study selection, risk-of-bias assessment, data extraction and assessment of the certainty of evidence using the GRADE method were performed independently by two authors. Meta-analyses were performed using Cochrane RevMan 5.4. PROSPERO registration number: CRD42022308849.

MAIN RESULTS

We included 14 observational studies (362 353 women). The administration of a COVID-19 vaccine during pregnancy resulted in a statistically significant reduction in SARS-CoV-2 infection (OR 0.46, 95% CI 0.28-0.76) and COVID-19-related hospitalisation (OR 0.41, 95% CI 0.33-0.51). The effect appeared to be greater in fully vaccinated women, for both infection (OR 0.31, 95% CI 0.16-0.59) and hospitalisation (OR 0.15, 95% CI 0.10-0.21). However, the certainty of evidence was very low. The difference in COVID-19-related ICU admission between vaccinated and unvaccinated individuals did not reach statistical significance (OR 0.58, 95% CI 0.13-2.58). Finally, there were no statistically significant differences in any of the maternal-fetal complications considered in the included studies.

CONCLUSIONS

COVID-19 vaccination administered during pregnancy seems to reduce SARS-CoV-2 infection and COVID-19-related hospitalisation, with no significant effects on maternal-fetal complications.

Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: A systematic review and meta-analysis

AIM

The endoscopic approach for early-stage endometrial cancer (EC) treatment is considered gold standard. Some authors expressed their concern regarding uterine manipulator (UM) as a risk factor for tumor spillage and dissemination allowing peritoneal or lympho-vascular spaces invasion (LVSI). This meta-analysis aimed to evaluate the effect of UM on the presence of LVSI, recurrence rate and presence of atypical or malignant peritoneal cytology in patients with endometrial cancer.

METHODS

We searched electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO, Google Scholar, and ClinicalTrials.gov. The pooled results were used to evaluate the association between the use of UM and oncological outcomes. This systematic review was reported according to PRISMA statement 2020. Statistical meta-analysis was performed using Review Manager software.

RESULTS

This systematic review included 18 studies (3 prospective studies, 13 retrospective studies, and 2 RCT). The pooled results showed no significant difference (RR: 0.86, 95% CI, 0.69 to 1.08) in the incidence of LVSI between manipulated hysterectomy and total abdominal hysterectomy (TAH) and between UM group and non-UM group in minimally invasive surgery (RR: 1.18, 95% CI, 0.76 to 1.85), no significant difference in the rate of recurrence (RR: 1.11, 95% CI, 0.71 to 1.74), in the incidence of positive peritoneal cytology between manipulated and non-manipulated hysterectomies in minimally invasive surgery (RR: 1.89, 95% CI, 0.74 to 4.83) and before and after the use of uterine manipulator (RR: 1.21, 95% CI, 0.68 to 2.16). We found a positive association between malignant cytology and hysterectomies in which a uterine manipulator had been used in a sub-group analysis where LH/LAVH were compared to TAH. (RR = 2.26, 95% CI, 1.08-4.71. P = 0.03).

CONCLUSIONS

This meta-analysis supports that the use of uterine manipulator for minimally invasive treatment of endometrial cancer does not increase the rate of recurrence and LVSI. Therefore, the opportunity of any other studies on its use in endometrial cancer women should be questioned.

Is There a Role for SARS-CoV-2/COVID-19 on the Female Reproductive System?

Coronavirus disease (COVID-19) has emerged as a very serious pandemic caused by the rapidly evolving transmission of the coronavirus SARS-CoV-2. Since its outbreak in 2020, the SARS CoV-2 has represented an important challenge for the physicians due to its well known respiratory sequelae. To date, the role of SARS-CoV-2 infection on organs and systems other than lungs and respiratory tract remains less clear. In particular, it remains to be investigated whether the reproductive system can be affected by the SARS-CoV-2 in the long term-period or, in alternative, drugs used to treat COVID-19 might impact the reproductive systems and, in turn, fertility. What is known is that SARS-Cov-2 binds to target cells of host through different receptors including angiotensin-converting enzyme 2 (ACE2), neuropilin-1, AXL and antibody-FcɣR complexes. ACE2 physiologically regulates both the expression of angiotensin II (Ang II) as well as Ang-(1-7) to exerts its physiological functions. The reproductive system abundantly expresses ACE2 and produces Ang-(1-7), starting from precursors which are locally generated or derived from systemic circulation. Ang-(1-7) plays an important role of stimulus to the growth and maturation of ovarian follicle as well as to ovulation. Also human endometrium expresses Ang-(1-7), mainly during the post-ovulatory phase. Animal and human observational studies demonstrated that Ang-(1-7) is involved in the maternal immune response to pregnancy and its deficiency is associated with a defective placenta development. In our manuscript, we review the current knowledge about whether SARS-CoV-2 may impact the female reproductive system. We further explain the possible molecular mechanism by which SARS-CoV-2 might affect ovarian, endometrial and female genital tract cells.

Recurrent pneumothorax after cesarean delivery in the critically ill pregnant with severe COVID-19 ARDS: a case report

OBJECTIVE

Few data are available on the ICU management and on the possible respiratory complications of invasively ventilated pregnant patients affected by COVID-19 pneumonia, especially in the early phase of pregnancy. Tension pneumothorax has been previously described as a rare cause of respiratory failure after delivery, but its occurrence in the postpartum of COVID-19 patient has not been reported yet. We hereby describe the ICU management of a 23rd gestational week pregnant woman who underwent invasive mechanical ventilation, prone positioning, and cesarean delivery during her ICU stay for COVID-19 related pneumonia. Moreover, we focused on the occurrence and management of recurrent tension pneumothorax after the cesarean delivery.

CASE REPORT

A 23rd gestational week pregnant woman was admitted to the ICU for a COVID-19 bilateral pneumonia and underwent invasive mechanical ventilation and prone positioning. Cesarean delivery was planned during the ICU stay, while the patient was receiving invasive mechanical ventilation. After delivery, the patient experienced a recurrent pneumothorax that required the positioning of multiple chest drains.

CONCLUSIONS

In pregnant critically ill COVID-19 patients, mechanical ventilation management is particularly challenging, especially in the postpartum period. Prone positioning is feasible and can improve oxygenation and respiratory system compliance, while tension pneumothorax must be suspected if the respiratory function suddenly deteriorates after delivery.

Preservation of the inferior mesenteric artery in laparoscopic nerve-sparing colorectal surgery for endometriosis

Laparoscopic rectosigmoid resection for endometriosis is usually performed with the section of the inferior mesenteric artery (IMA) distal to the left colic artery (low-tie ligation). This study was to determine outcomes in IMA-sparing surgery in endometriosis cases. A single-center retrospective study based on the analysis of clinical notes of women who underwent laparoscopic rectosigmoid segmental resection and IMA-sparing surgery for deep infiltrating endometriosis with bowel involvement between March the 1st, 2018 and February the 29th, 2020 in a referral hospital. During the study period, 1497 patients had major gynecological surgery in our referral center, of whom 253 (17%) for endometriosis. Of the 100 patients (39%) who had bowel endometriosis, 56 underwent laparoscopic nerve-sparing rectosigmoid segmental resection and IMA-sparing surgery was performed in 53 cases (95%). Short-term complications occurred in 4 cases (7%) without any case of anastomotic leak. Preservation of the IMA in colorectal surgery for endometriosis is feasible, safe and enables a tension-free anastomosis without an increase of postoperative complication rates.

Hypoxic events during non-obstetric abdominal surgery in pregnant women

OBJECTIVE

Every year 0.5-2% of women undergo non-obstetric surgery in pregnancy. Hypoxic events with short-term and long-term consequences are one of the most frequent complications in surgery. There is only limited data available regarding the impact of these events. This review aims to analyze the current literature on hypoxic events occurring in non-obstetric abdominal surgery in pregnant women, focused on maternal and fetal outcomes.

MATERIALS AND METHODS

We performed a non-systematic review of the literature, through a PubMed search using the key words "hypoxemia", "non-obstetric surgery", "surgical procedures", "pregnancy", "pregnant women" and "outcome".

RESULTS

There is little data available regarding maternal and fetal outcomes after hypoxic episodes during non-obstetric surgery in pregnancy. In these cases, conservative intrauterine resuscitation maneuvers or immediate delivery should be taken into account. Perimortem cesarean section can be lifesaving for both mother and fetus when maternal collapse is non responsive to resuscitation procedures. Inaccurate information regarding maternal and fetal outcomes is due to the lack of robust data and the heterogeneity of the causes underlying maternal respiratory complications during surgery.

CONCLUSIONS

Non-obstetric surgery during pregnancy must be performed when indicated. An expert multidisciplinary team, composed of obstetricians, surgeons, and anesthesiologists need to be included, giving appropriate attention to the physiological changes of respiratory, cardiovascular, and gastrointestinal system that occur during pregnancy. The shortest operative time and peri-operative assistance should be ensured. Complications, such as hypoxic events in pregnant patients need adequate assistance. Multidisciplinary cooperation, continuous training and simulation for anesthesiology and resuscitative procedures can guarantee this.

Fetal disseminated intravascular coagulopathy, hydrops and massive umbilical vein thrombosis consequence of a rare placental condition: multifocal chorangiomatosis

Purpose: Villous capillary lesions are rare abnormal placental developmental conditions which include chorangiosis, chorangiomatosis, chorangioma and a rare variant of the latter called multiple chorangioma syndrome. The causes of villous capillary lesion are not completely clear but appear to involve excessive angiogenesis.

MATERIALS AND METHODS

In this paper we start illustrating our experience of multifocal chorangiomatosis with the newborn affected by massive umbilical vein thrombosis, disseminated intravascular coagulopathy and hydrops, going to a literature review of cases available.

Results: Two other similar cases have been previously published in literature. Comparing clinical characteristics and fetal outcomes, we confirm the association with unfavorable neonatal outcome mentioned in literature. Our case is the first characterized by severe hemolytic anemia, thrombocytopenia, heart congestion with the overlap of disseminated intravascular coagulopathy and massive umbilical vein thrombosis and congenital anomalies.

CONCLUSIONS

Our clinical case and the review of literature highlight how multifocal chorangiomatosis, within the three subgroups identified, is the rarer form with distinct placental features and the worst outcomes for neonates. No cases of multifocal chorangiomatosis have never been described prenatally and, for further studies, could be reasonable investigate the involvement of some growth factors like vascular endothelial growth factor and placental growth factor that could lead to a detection of a subgroup of patient at higher risk to manifest placental vascular lesions and the follow fetal and maternal complications.

Biomolecular basis related to inflammation in the pathogenesis of endometrial cancer

OBJECTIVE

Endometrial cancer (EC) is a complex gynecological neoplasm with several clinical, histopathological and genetic features. Different hormonal, metabolic and biochemical axes are involved in pathogenesis. Obesity is a well-known risk factor for this disease and the role of local and systemic effects of adipose tissue, especially in the promotion of subclinical chronic inflammation, is an important issue. Indeed, inflammation is related to the pathogenesis of different tumors, including EC. This review aims to remark the role of obesity and inflammation in the pathogenesis of EC cancer through an exploration of the current literature.

MATERIALS AND METHODS

We performed a comprehensive review of the literature through a PubMed search using key words and including English language papers looking at this topic.

RESULTS

Only few authors analyzed the role of inflammatory cytokines released by adipose tissue in visceral abdominal fat depots. Tumor Necrosis Factor-α, Interleukin-6, Interleukin-1 Receptor Antagonist, Nuclear Factor-kB, Leptin, Adiponectin and C Reactive Protein were studied for cancer risk prediction models, risk stratification or targeted therapies. Furthermore, genetic studies evaluated the effect of inflammatory cytokines secreted by visceral adipocytes in the modulation of angiogenesis and signaling pathways such as PI3K/AKT/mTOR, that result altered in the pathogenesis of EC.

CONCLUSIONS

The identification of inflammatory biomarkers released by adipose tissue, in the pathogenesis of EC, could be useful in improving diagnostic accuracy, identifying targets of therapy, suggesting useful lifestyle behaviors. A deeper knowledge of the genetic background of alterations in inflammatory pathway genes could better define the population exposed to a higher susceptibility to EC due to genetic polymorphisms. Future studies are needed to better understand this field.

Data on correction of pelvic organ prolapse by laparoscopic lateral suspension with mesh: A clinical series

This DIB article provides additional data on laparoscopic lateral suspension with mesh for correcting pelvic organ prolapse. Data come from a multicentric sample of Italian women (https://doi.org/10.1016/j.ejogrb.2019.07.025). Data are collected retrospectively. Descriptive and raw data on surgery and descriptive and raw data on symptoms of pelvic organ prolapse pre-surgery and post-surgery are provided. Kaplan-Meier curves and scores of 7-items King's Health Questionnaire for quality of life assessment are also reported.

Correction of pelvic organ prolapse by laparoscopic lateral suspension with mesh: A clinical series

OBJECTIVE

Illustrating the outcomes of laparoscopic lateral suspension by mesh for pelvic organ prolapse repair.

STUDY DESIGN

A retrospective observational study was conducted collecting medical records of 48 patients treated between May 2016 and April 2018 in two different centers in Italy. Pre- and post-operative clinical evaluations as well as patients' satisfaction scores were considered. Patients were followed for two years. Statistical analysis was determined using the chi-square test in intention-to-treat and per-protocol analyses, while Kaplan-Meier curves were built for assessing the prolapse recurrence and the symptoms recurrence. The Steel-Dwass test for pairwise comparisons was used to compare median scores from the King's General Health Perception Questionnaire answers.

RESULTS

Regarding the anatomical result, the outcome was either optimal or satisfactory (PoP-Q ≤1) at 12 months in 92% of patients for anterior compartment, in 100% for apical compartment, and in 75% for posterior compartment (intention-to-treat). Kaplan-Meier curves depicted a repair of prolapse in 70% of cases, with better outcomes for the anterior and the apical compartment. Patient self-perception of health was over 80% at each follow-up evaluation.

CONCLUSION

Laparoscopic lateral suspension is a reasonable technique for treatment of pelvic organ prolapse. Further studies are needed to prove such a technique versus alternative surgeries.

Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis

OBJECTIVE

To evaluate the potential benefit of interventional radiology (IR) in improving the outcome of women undergoing surgery for a placenta accreta spectrum (PAS) disorder.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for studies comparing outcomes of women with a prenatal diagnosis of PAS who underwent an IR procedure before surgery vs those who did not, using a robust collection of terms relating to PAS. The primary outcome was intraoperative estimated blood loss (EBL). Secondary outcomes were the number of transfused units of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets and cryoprecipitate, operation time, length of hospital stay, EBL ≥ 2.5 L, PRBC transfused ≥ 5 units, surgical complications, bladder or ureteral injury, relaparotomy, infection, disseminated intravascular coagulation, and complications related to endovascular catheter placement. Only studies reporting on the incidence of, or the mean difference in, the observed outcomes in women affected by a PAS disorder who had vs those who did not have an IR procedure before surgery were considered for inclusion. All outcomes were explored in the overall population of women with a prenatally diagnosed PAS disorder and in those undergoing hysterectomy. Quality assessment of each included study was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence.

RESULTS

Fifteen studies (958 women with PAS) were included. In women who underwent IR before surgery, compared with those who did not, mean EBL (mean difference (MD), -1.02 L; 95% CI, -1.60 to -0.43 L; P < 0.001) and the risk of EBL ≥ 2.5 L (odds ratio (OR), 0.18; 95% CI, 0.04-0.78; P = 0.02) were significantly lower. There was no significant difference between the two groups in the other outcomes explored. On subgroup analysis of pregnancies complicated by PAS undergoing hysterectomy, EBL (MD, -0.68 L; 95% CI, -1.24 to -0.12 L; P = 0.02) and the number of transfused FFP units (MD, -1.66; 95% CI, -2.71 to -0.61; P = 0.02) were significantly lower in women who had an endovascular IR procedure compared with controls. Furthermore, women undergoing IR had a significantly lower risk of EBL ≥ 2.5 L (OR, 0.10; 95% CI, 0.02-0.47; P = 0.004). Overall, complications related to the placement of an endovascular catheter occurred in 5.3% (95% CI, 2.6-8.9; I² , 65.3%) of pregnancies undergoing IR. Overall quality of evidence, as assessed by GRADE, was very low.

CONCLUSIONS

The current available data provide encouraging evidence that IR procedures may be associated with lower EBL and need for transfusion in pregnancies undergoing surgery for a PAS disorder. However, given the overall very low quality of the evidence, further large studies are needed in order to confirm the beneficial role of IR in improving the outcome of these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Post-abortion long-acting reversible contraception in a sample of Italian women: intrauterine device versus subdermal implant

Long-acting reversible contraceptives (LARC) represent an especially effective kind of post-abortion contraception. We aimed at assessing satisfaction, discontinuation, efficacy, and tolerability associated with either levonorgestrel intrauterine device (L-IUCD), the copper intrauterine device (C-IUCD) and implant (IMP) after termination of pregnancy (TOP). We recorded baseline data about the patients and performed phone surveys at 3, 6 and 12 months after insertion to assess the bleeding profile. Furthermore, women were inquired about possible adverse events, satisfaction, and discontinuation at 12 months after insertion. LARC continuers (>12 months after TOP) were divided into three groups: L-IUCD (n = 47), C-IUCD (n = 6) and IMP (n = 36). Satisfaction rates among L-IUCD users were higher than among IMP users (100% vs. 72.2%, p < .05). A higher, yet not significant, share of patients decided to withdraw contraception in IMP group (3.6% in IUCD group and 12.2% in IMP group). The bleeding profile was significantly more favorable among L-IUCD users than among IMP users. Finally, the reported rate of treatment-associated adverse events did not differ significantly among the groups. L-IUCD insertion after TOP is associated with higher satisfaction and lower discontinuation rates than IMP. Such pattern could be attributed to a more favorable bleeding profile.

Isthmocele: From Risk Factors to Management

OBJECTIVE

 The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition.

METHODS

 A comprehensive review of the literature was performed to identify the most relevant studies about this topic.

RESULTS

 Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data.

CONCLUSION

 Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

Management of Transverse Vaginal Septum by Vaginoscopic Resection: Hymen Conservative Technique

Transverse vaginal septum is a rare female genital tract anomaly, and little is described about its surgical treatment. We report the case of a patient who wished to preserve hymenal integrity due to social and cultural beliefs. We performed a vaginoscopic resection of the septum under laparoscopic view, followed by the introduction of a Foley catheter in the vagina, thus preserving the hymen. After 12 months of follow-up, no septal closure was present, and the menstrual flow was effective. Vaginoscopic hysteroscopy is an effective method of vaginal septum resection, even in cases in which hymenal integrity must be preserved due to social and cultural beliefs.

Fetal Noncompaction Cardiomyopathy and Histologic Diagnosis of Spongy Myocardium: Case Report and Review of the Literature

Noncompaction cardiomyopathy (NCCM) and left ventricular noncompaction (LVNC), in their isolated form, are rare cardiomyopathies. They are characterized by a thickened myocardium due to the presence of deep trabeculae recesses, and to thick trabeculae. This condition is associated with a variable clinical phenotype including heart failure, thromboembolism, and sudden death. We report a case of LVNC at 26 weeks and 4 days of gestation revised on the basis of what is currently reported in the literature. A review of the literature was performed to better describe this rare condition. Left ventricular noncompaction is a rare fetal condition and it should be suspected in case of cardiomyopathy.

Correlation between umbilical arterial pH values and fetal vertebral artery Doppler waveforms at the beginning of the second stage of labor: a pilot prospective study

Objective: The aim of this study was to evaluate the association between umbilical arterial pH and fetal vertebral artery Doppler velocimetry waveforms measured at the beginning of the second stage of labor in physiological term pregnancies. Methods: This was a prospective cohort study of 250 pregnancies. The resistance index, pulsatility index, and peak systolic velocity were measured. The relationship between the fetal Doppler and the umbilical arterial pH was evaluated. A simple linear regression and a general linear model were used to explore possible correlations of Doppler parameters with fetal and neonatal outcome adjusted for confundents. Results: Umbilical arterial pH values were directly associated with vertebral artery pulsatility index. Fetuses with lower pulsatility index values were at increased risk of a subsequent diagnosis of pathological fetal heart rate tracing patterns (presence of decelerations or reduced variability according to FIGO criteria during the second stage of labor). We estimated a decrease in pulsatility index of 10% in those fetuses destined to show a pathological fetal heart rate tracing. Conclusion: Vertebral artery Doppler waveforms correlates with umbilical pH in normal pregnancies and is also a function of fetal heart rate patterns. If this proportional association would be demonstrated also for abnormal pH values, vertebral artery pulsatility index might be useful to evaluate fetal wellbeing in those cases of suspected hypoxia/academia.

Pro-inflammatory M1/Th1 type immune network and increased expression of TSG-6 in the eutopic endometrium from women with endometriosis

OBJECTIVE

The study aimed to explore the type 1 and type 2 cytokines expression in the endometrium from women affected by endometriosis compared to controls. The expression of TSG-6, a multifunctional protein involved in several inflammatory disease, was also evaluated. Study Design SETTING: Experimental clinical study.

PATIENTS

10 patients affected by endometriosis and 11 controls.

INTERVENTIONS

Patients underwent to an ultrasound transvaginal examination and a diagnostic hysteroscopy in order to exclude any uterine abnormality. All patients underwent endometrial biopsy using a Novak's curette.

MAIN OUTCOME MEASURES

The endometrial expression of type 1 (IL- 1 β TNF-α, IL-8) and type 2 (IL-10) cytokines, and of TSG-6 was evaluated by immunohistochemistry and by real time PCR. The expression of TSG-6 was confirmed by western blot.

RESULTS

Results of PCR analysis and of immunohistochemistry revealed an increased expression of IL-1β, TNF-α, IL-8 and of TSG-6 in the endometrium of endometriosic patients. IL-10 expression did not show any difference.

CONCLUSIONS

An increased expression of pro-inflammatory type 1 cytokines was demonstrated in the endometrium from endometriosic patients, suggesting an endometrial environment harmful for implantation due to the prevalence of Th1 related immunity. An increased expression of TSG-6 was also demonstrated for the first time. Our findings concur to better define the inflammatory imbalance and the abnormal endometrial receptivity, reported in literature, of the eutopic endometrium of women affected by endometriosis.

Outcome of endometrial cancer after lymphadenectomy: a single center retrospective analysis with long-lasting follow-up

BACKGROUND

Role of lymphadenectomy in endometrial cancer is unclear. Our objective is to assess the role of lymphadenectomy in endometrial cancer.

METHODS

The study reviewed retrospectively 829 cases of endometrial cancer from a single non-oncological center from 1981 to 2014. Multivariable Cox regression analyses were performed. Independent variables were: 2009 FIGO stage, histological type of endometrial cancer (non-endometrioid, endometrioid, grading 1, 2 and 3), radicality on parametria, lymphatic dissection (any kind) (yes/no), any kind of chemotherapy, any kind of radiotherapy, brachytherapy, patients' age. Dependent variable was death for endometrial cancer and first relapse. Time variable was the semester of follow-up. P value for significance was set <0.05.

RESULTS

Many data about the extension of node dissection were missing. Pelvic node dissection or sampling seem the more common procedure performed. At the 10-semester of follow-up, at the 20-semester of follow-up and at the 30 semester of follow up, lymphadenectomy does not improve overall survival at a p value of less than 0.05. Lymphadenectomy reduces the risk of relapse at the 10 semester and 20-semester of follow-up.

CONCLUSIONS

Lymphadenectomy plays a role in preventing relapses but it is not proved that non-aggressive lymphadenectomy in endometrial cancer improves overall survival at p level of 0.05. Therefore, it cannot be excluded that a very small improvement in long lasting survival in few cases of endometrial cancer could be due to node dissections.

Serum IgG Antibodies from Pregnant Women Reacting to Mimotopes of Simian Virus 40 Large T Antigen, the Viral Oncoprotein

Simian virus 40 (SV40) large T antigen (LT) coding sequences were revealed in different human samples, whereas SV40 antibodies (Ab) were detected in human sera of cancer patients and healthy individuals, although with a lower prevalence. Previous studies carried out by the neutralization assay gave a SV40 seroprevalence, in the general population, up to 8%, although higher rates, 12%, were detected in kidney transplant children, in a group of HIV-positive patients, and in healthy females. In this study, serum samples from pregnant women, together with those from non-pregnant women, were analyzed to check the prevalence of IgG Ab reacting to SV40 LT antigens. Serum samples were collected from pregnant and non-pregnant women, with the same mean age. Women were in the range of 15-48 years old. Samples were assayed by an indirect ELISA employing specific SV40 LT mimotopes as antigens, whereas functional analysis was performed by neutralization of the viral infectivity in cell cultures. As a control, sera were analyzed for Ab against BK polyomavirus (BKPyV), which is a human polyomavirus homologous to SV40. Statistical analyses employed chi-square with Yates' correction, and Student's t tests. Indirect ELISAs indicated that pregnant women tested SV40 LT-positive with a prevalence of 17% (23/134), whereas non-pregnant women had a prevalence of 20% (36/180) (P > 0.05). Ab against BKPyV were detected with a prevalence of 80% in pregnant women and with a prevalence of 78% in non-pregnant women. These data indicate that SV40 infects at a low prevalence pregnant women. We may speculate that SV40, or a close human polyomavirus still undetected, could be transmitted from mother to fetus.

Sonographic Cervical Shortening after Labor Induction is a Predictor of Vaginal Delivery

Objective Analyzing if the sonographic evaluation of the cervix (cervical shortening) is a prognostic marker for vaginal delivery.

Methods Women who underwent labor induction by using dinoprostone were enrolled. Before the induction and three hours after it, the cervical length was measured by ultrasonography to obtain the cervical shortening. The cervical shortening was introduced in logistic regression models among independent variables and for calculating receiver operating characteristic (ROC) curves.

Results Each centimeter in the cervical shortening increases the odds of vaginal delivery in 24.4% within 6 hours; in 16.1% within 24 hours; and in 10.5% within 48 hours. The best predictions for vaginal delivery are achieved for births within 6 and 24 hours, while the cervical shortening poorly predicts vaginal delivery within 48 hours.

Conclusion The greater the cervical shortening 3 hours after labor induction, the higher the likelihood of vaginal delivery within 6, 24 and 48 hours.

Cesarean section on maternal request: should it be formally prohibited in Italy?

BACKGROUND

Cesarean section on maternal request (CSMR) could represent an avoidable quota of cesareans. In Italy, this is a topical problem of health-policy, involving ethical, juridical and medical issues.

AIM AND METHODS

A 5-questions questionnaire to quantitatively assess the perspectives of medical, juridical and ethical issues of planned CSMR was administered to obstetricians and gynecologists, midwives, lawyers and pregnant women. It was assessed to what extent those issues matter on the final decision of planning a CSMR.

RESULTS

Non-homogeneous answers of stakeholders suggest different perspectives about issues on CSMR. The juridical issue seems to have the greatest impact on the final decision.

CONCLUSION

Planning a CSMR associates overall with juridical issues in each group of respondents. Therefore, an obstetrician and gynecologist is unable to counsel a patient on CSMR from a medical point of view. The most direct way for reducing cesareans in Italy could be the formal prohibition of CSMR.

Classification of stillbirths is an ongoing dilemma

AIM

To compare different classification systems in a cohort of stillbirths undergoing a comprehensive workup; to establish whether a particular classification system is most suitable and useful in determining cause of death, purporting the lowest percentage of unexplained death.

METHODS

Cases of stillbirth at gestational age 22-41 weeks occurring at the Department of Gynecology and Obstetrics of Foggia University during a 4 year period were collected. The World Health Organization (WHO) diagnosis of stillbirth was used. All the data collection was based on the recommendations of an Italian diagnostic workup for stillbirth. Two expert obstetricians reviewed all cases and classified causes according to five classification systems.

RESULTS

Relevant Condition at Death (ReCoDe) and Causes Of Death and Associated Conditions (CODAC) classification systems performed best in retaining information. The ReCoDe system provided the lowest rate of unexplained stillbirth (14%) compared to de Galan-Roosen (16%), CODAC (16%), Tulip (18%), Wigglesworth (62%).

CONCLUSION

Classification of stillbirth is influenced by the multiplicity of possible causes and factors related to fetal death. Fetal autopsy, placental histology and cytogenetic analysis are strongly recommended to have a complete diagnostic evaluation. Commonly employed classification systems performed differently in our experience, the most satisfactory being the ReCoDe. Given the rate of "unexplained" cases, none can be considered optimal and further efforts are necessary to work out a clinically useful system.

Predicting pelvic visceral hypersensitivity from the discomfort of Lugol' test during colposcopy

OBJECTIVE

Assessing the pelvic visceral hypersensitivity after Lugol' staining during colposcopy.

PATIENTS AND METHODS

On an unselected sample of 91 patients, pelvic discomfort and discomfort during menstruation, sexual intercourse, defecation, urination were assessed (numeric rating score from 0 to 10) before colposcopy. Few minutes after Lugol' staining, it was assessed the discomforting perception provoked by iodine by using the same numeric rating scale. All those scores were increased by 1 to allow regression models (linear, logarithmic, inverse, cubic, quadratic, exponential).

RESULTS

The only significant models were the linear, logarithmic and inverse ones for pelvic discomfort overall score and the linear one for sexual intercourse score. A discomfort score of 4.5 or less after Lugol' staining should be a normal reaction to iodine nociception in the vagina.

CONCLUSIONS

Lugol' staining during colposcopy causes discomfort related with visceral nociception. The rise in numeric rating score after colposcopy can be used for screening pelvic visceral hypersensitivity.

Correlations between sonographically measured and actual incision site thickness of lower uterine segment after repeated caesarean section

AIM

The aim of the present study was to verify how much the sonographically measured thickness of the lower uterine segment caesarean-section (LUS-CS) scar correlates with incision site thickness in a repeated caesarean section after uterotonic administration.

METHODS

Sixty-three obstetric patients at term undergoing repeated caesarean section. LUS-CS thickness was measured sonographically before the repeated caesarean. Some seconds after delivery of the fetus and placenta and administration of an institutional, standard uterotonic, LUS was measured on the site of surgical incision (upper side and lower side) using Castroviejo's caliper. Multiple measurements were taken and averaged for improving accuracy. Mean measurements were used for calculations (unilinear correlations and multilinear regression analyses.).

RESULTS

Poor correlation was found between sonographically measured scar thickness and lower uterine side incision thickness (r 0.311; C.I. 95% 0.068-0.519; P=0.013) and between sonographically measured scar thickness and uterine scar overall incision thickness (mean of upper side and lower side measurements) (r 0.254; C.I. 95% 0.007-0.472; P=0.045). Sonographically measured scar thickness was smaller in patients with two or more previous caesareans (P=0.045) and greater in patients who had undergone the last of the previous caesarean sections longer than two years earlier (P=0.043). Patients with two or more previous caesareans had smaller upper-side incision thickness (P=0.005); smaller lower-side incision thickness (P=0.038); smaller incision site overall thickness (P=0.006).

CONCLUSION

Sonographically measured thickness and incision site thickness of the LUS-CS scar are poorly correlated (about 25%), despite the fact that patients most at risk for uterine rupture have thinner LUS, both sonographically and when measured during surgery.

The role of hysteroscopy in the diagnostic work-up of infertile asymptomatic patients

PURPOSE OF INVESTIGATION

To demonstrate that office hysteroscopy has a key-role in the diagnostic work-up of infertile couples.

MATERIALS AND METHODS

The entire database of hysteroscopies performed in 572 menstruated women from 2008 to 2011, was retrospectively analyzed. A two-dimensional correspondence analysis among endometrial patterns, age ranges, and indication for hysteroscopies was made. A main-effect hierarchical log-linear model was built to assess the goodness of the correspondences found.

RESULTS

A clear cluster of aggregation appears in case of both primary and secondary infertility, with and without other indications for hysteroscopy, as well as in case of primary infertility with irregular menstrual bleeding. In such patients, chronic endometritis, normal pattern, and uterine malformations were frequently found. The most significant correspondence was found for normal pattern and chronic endometritis in case of secondary infertility and primary infertility, respectively.

CONCLUSIONS

Office hysteroscopy should be reconsidered in the diagnostic work-up of infertile couples. It is able to assess or rule out endometrial factor for female infertility.

Effectiveness of vaginal adelmidrol for treating pelvic visceral discomforts and anxiety: a prospective observational study

AIM

The aim of this paper was to show that self-assessed anxiety in patients with pelvic visceral discomforts is reduced after the intravaginal administration of adelmidrol.

MATERIAL AND METHODS

Twenty-four patients who described themselves as anxious (scoring 5 or more in a 1 to 10 scale in a self-assessment test) and who suffered from pelvic visceral discomfort (during defecation, urination, sexual intercourse and menstruation) were enrolled in the study. Pelvic visceral discomforts were assessed using a questionnaire in which patients were asked to assign a score between 1 and 10 according to intensity. The patients were offered intravaginal adelmidrol therapy (2%, 4.5 mL twice a day for 30 days). The patients were interviewed again and asked to self-assess anxiety and pelvic visceral discomfort at the end of therapy.

RESULTS

12 patients underwent adelmidrol therapy. With the exception of urinary discomfort, all the median scores of pelvic visceral discomforts had improved after 30 days, with significant values achieved for menstruation (P=0.013) and sexual intercourse (P=0.013). Anxiety had also decreased after 30 days (P=0.025), regardless of changes in discomfort levels.

CONCLUSION

Adelmidrol could selectively modulate the visceral nociceptive pathways (interoception), relieving pelvic discomfort. This action should have an independent effect on anxiety responses.

Primary ovarian pregnancy and its management

The authors suggest that with ultrasonographic advances, the diagnosis of primary ovarian pregnancy can be made earlier enough for conservative treatment and preservative surgery.

Primary ovarian ectopic pregnancy, i.e., the implantation of the gestational sac in the ovary, is one of the rarest forms of ectopic pregnancy. Its incidence after natural conception ranges from 1 in 2000 to 1 in 60 000 deliveries and accounts for 3% of all ectopic pregnancies. The diagnosis is intricate and based on surgical and histopathological observations. The management is, in spite of medical improvement, based on surgery.

We present a case of a 10-wk ectopic ovarian pregnancy managed laparoscopically, and we describe, through a review of the literature, the specific symptomatology, diagnostic criteria, and treatment of this particular pathology.

Cervical pregnancy treated by uterine artery embolisation combined with office hysteroscopy

OBJECTIVE

To evaluate the safety and efficacy of uterine artery embolisation in conjunction with hysteroscopic resection of trophoblast in the conservative treatment of cervical ectopic pregnancies.

STUDY DESIGN

Five women diagnosed with cervical pregnancies at University Hospital of Foggia, Italy, between May 2009 and February 2012 underwent uterine artery embolisation followed by office hysteroscopic resection of trophoblast. Data on operating time, blood loss, blood transfusion, conversion to other techniques, complications related to surgery, change of serum β-hCG level, hospitalisation days and outcome of the women after discharge were collected.

RESULTS

The mean hysteroscopic operative time was 9.8 min, and the blood loss was negligible in all cases. Blood transfusion was not needed for any of the women. None of the women required conversion to other techniques. In all cases the operations were uneventful. The serum β-hCG level in all the cases declined to normal within 15 days of surgery. The total hospitalisation time was 4 days in all the cases. No vaginal bleeding or other side effects were observed throughout and after the treatment, all women recovered without complications.

CONCLUSIONS

Uterine artery embolisation with office hysteroscopic resection is an effective option in treatment of cervical ectopic pregnancy.