[Prevention of postoperative adhesions]

Postoperative adhesions represent a common consequence in patients who underwent abdominal or pelvic surgery. Such adhesions can be asymptomatic, but they can cause complications such as chronic abdomino-pelvic pain, secondary infertility, an increase in bowel obstruction risk and more complexity for future surgery, including longer surgery times and an increase in morbidity. Normally, adhesions appear after offences against the peritoneum, causing flogosys, and develop both in new sites, previously not involved, and in sites already interested in adhesiolysis. Previous laparotomy is an important risk factor, as after laparatomy a minimum of 93% of patients present adhesions during a following surgery. Furthermore, the rate of recurrence after adhesiolysis is 85%. Among several strategies employed, valid prevention methods are: using minimally invasive surgery techniques, reducing the incision area, containing tissue dehydration during surgery and an accurate hemostasis. Also, for preventing and reducing adhesions, the usage of NSAIDs, fibrinolytics and anticoagulants, as well as the application of substances acting as a physical barrier, have been proposed. Recently, crystalloid solutions have been introduced, using the hydro-flotation principle for intraperitoneal organs. This research aims to analyze causes and epidemiology for postoperative adhesions, with particular regard to gynecological operations and to describe and compare the means available to prevent them.

[Current role of bed-rest in threarened abortion]

BACKGROUND

The aim of this study was to evaluate the efficacy of bed-rest in the treatment of threatened abortion. This is based on the extensive use made today of this practice, although there are no studies that suggest or prove its therapeutic success, and on the contrary many of them demonstrate its possible risks.

METHODS

The efficacy of bed-rest is evaluated by comparing the abortion rate in patients treated with bed-rest those who received no treatment. A retrospective study was made on data obtained from interviews with 226 patients with previous threatened abortion hospitalised for pregnancy-related reasons at the Obstetrics and Gynecology Clinic of Policlinico Umberto I in Rome between October 1998 and June 1999.

RESULTS

The following results were obtained: 84% of the 146 patients treated with bedrest continued pregnancy beyond week 20, whereas 16% aborted before week 20. Of the 80 patients who were not treated, 80% continued pregnancy beyond week 20 and 20% aborted before week 20. These results do not show statistically significant differences between the two groups (c2=0.4 p=NS).

CONCLUSIONS

These results suggest that bed-rest does not improve the prognosis of threatened abortion.

[Current role of progesterone therapy in the prevention of spontaneous abortion and in the treatment of threatened abortion]

Progesterone therapy is often used to prevent spontaneous abortion. In this paper the most significant studies on the benefits and risks of this treatment over the last 30 years are analyzed. None of these studies about the effects of progesterone as non-specific therapy in abortion risk and recurrent miscarriage, proved a reduced pregnancy wastage in treated patients compared with patients who received no treatment. The results concerning the use of progesterone in recurrent miscarriage for luteal phase inadequacy are more controversial, but they are still inadequate to encourage progesterone supplementation. To obtain a definitive conclusion about progesterone therapy real effectiveness, it is necessary to carry out randomized double-blind prospected trials. As regards the risks of using progesterone therapy during pregnancy, even if a possible teratologic role has certainly been reduced, it cannot be excluded completely yet. Moreover a high incidence of respiratory problems has been noticed in newborns from patients treated with progesterone, compared with control groups.

[The creation of a neovagina with laparoscopic technique]

Vaginal agenesis is sometimes found isolated but more frequently as a part of a malformative syndrome, such as the Rokitansky-Küster-Hauser or the Morris syndrome. In our department the technique of choice for surgical creation of a neovagina is that described by Vecchietti. A pelviscopic approach for this technique has recently been described. Two cases of vaginal atresia are described; one with Rokitansky-Küster-Hauser and the other with Morris syndrome, in which the laparoscopic technique was attempted. Due to the aetiopathogenetic and anatomical differences of the two syndromes, the laparoscopic technique resulted easy in the first case but very difficult in the Morris syndrome case, needing laparotomic conversion. We therefore believe that in choosing the surgical approach, a decisive issue is the type of malformation. Indeed in the Morris syndrome, the contiguity between rectum and bladder makes the laparoscopic technique more difficult.

[Deep venous thrombosis in pregnancy: diagnostic difficulties and therapeutic indications. Discussion of a clinical case]

Pregnancy is a risk factor for deep and superficial venous thrombosis because of hemodynamic changes and modifications of the coagulation and fibrinolitic systems. In case of a patient suffering from a congenital or acquired thrombophilia, risk of severe and recurrent thrombosis becomes much higher, with the possibility of a life threatening complication as pulmonary embolism. Recently a number of congenital thombophilic syndromes have been described, in particular congenital hereditary deficit of coagulation inhibitors. Among the acquired pathologies, the antiphospholipid syndrome has been recently object of studies. Diagnostic and therapeutic options are still controversial. The authors present a case of recurrent deep vein thrombosis in pregnancy treated with positioning of a caval filter for the prophylaxis of pulmonary embolism. Diagnostic difficulties are discussed, as the patient presented with low levels of the coagulation inhibitor protein S, and also circulating antibodies anticardiolipin.