A uterus soaked in blood with low haemoglobin in a case of unrecognized uterine sarcoma

INTRODUCTION

Uterine sarcomas are rare and aggressive tumors. In some cases they can cause rupture of the uterus with or without clinical and radiological symptoms. Therefore, it is important to observe patients with clinical and/or radiological suspicion of sarcoma, even when there are no clinical manifestations.

CASE REPORT

A 71-year old woman, who was under the authors' observation for pain in the right iliac fossa. The US and the CT scan showed an abdominal-pelvic mass.Laboratory tests showed a slight but progressive reduction of haemoglobin, which could not be explained by the clinical symptoms and by the results of the imaging tests. During the surgical intervention, a small amount of peritoneal fluid, an increased uterine volume, and a subverted anatomy were observed A haematoma was found in the uterus and this could explain the progressive reduction of haemoglobin and the very low presence of peritoneal effusion.

CONCLUSION

The rupture of the uterus could not have been suspected as the patient did not have any type of symptoms, except for the slow and progressive reduction in the haemoglobin value. Therefore, it is important to observe patients with clinical and/or radiological suspicion of sarcoma, even when there are no clinical manifestations.

Endometriosis allergic or autoimmune disease: pathogenetic aspects--a case control study

PURPOSE OF INVESTIGATION

The aim of this study was to evaluate the correlation between endometriosis and pathologies on an immune basis for the possible involvement of the immune system in the pathogenesis of endometriosis.

MATERIALS AND METHODS

In this retrospective study, data of 304 patients with endometriosis and 318 without endometriosis were collected in a uniform manner for both groups and inserted into two databases, respectively, for patients with and without endometriosis. The authors calculated the percentages of patients with allergies, autoimmune diseases, asthma in both groups, and later statistical analysis were performed with two different chi-square tests.

RESULTS

The results obtained have shown that patients with endometriosis have a higher prevalence of allergies (p = 0.0003) and coexistence of both allergies and autoimmune diseases (p = 0.0274), compared to those without.

CONCLUSIONS

The present study seems to support the possible association between endometriosis and allergic diseases.

Ovarian transposition in young women and fertility sparing

OBJECTIVE

Ovarian transposition is a highly effective surgical procedure used to preserve ovarian function in premenopausal patients with cancers requiring postoperative or primary pelvic radiotherapy. Pelvic irradiation determines severe damage of ovarian DNA and iatrogenic ovarian failure with premature menopause, necessity of long-term hormone replacement therapy and infertility.

MATERIALS AND METHODS

We conducted an extensive research of the literature in Medline between January 2000 and April 2015 using the key-words "ovarian transposition radiotherapy", "radiotherapy gonadal function", radiotherapy fertility sparing". The population included young women with normal ovarian function affected by cancers that required pelvic radiotherapy. We have examined 32 articles reporting on 1189 women undergoing ovarian transposition. Median age was 32.5 years, follow up was median 48 months. The procedure has been performed in patients less than 40 years of age. Surgery has been achieved by laparotomy or laparoscoy. We have analyzed effects of radiotherapy on ovarian function.

RESULTS

The proportion of women treated by ovarian transposition preserved ovarian function was 70%. About 86% of patients did not develop ovarian cysts and in 98-99% of cases did not occur any metastatic disease.

CONCLUSIONS

Ovarian transposition is associated with significant preservation of ovarian function and a low frequency of complications as cysts and metastasis. In 31% of cases the procedure can fail. Further studies are needed to evaluate the efficacy of ovarian transposition and the follow up. Ovarian transposition should be discussed at the time of cancer diagnosis in every premenopausal woman requiring pelvic radiotherapy.

Occurrence of malignancy in endometrial polyps during postmenopause

OBJECTIVE

To evaluate the occurrence of endometrial polyp malignancy in pre- and postmenopausal women with or without symptoms.

MATERIALS AND METHODS

A retrospective study was performed on 351 patients with endometrial polyps diagnosed by hysteroscopy.

RESULTS

Histological findings of biopsies obtained by operative hysteroscopy confirmed the presence of a simple endometrial polyp in 179 cases, polyps with typical simple hyperplasia in 42 cases, polyps with typical complex hyperplasia in 24 cases, polyps with atypical complex hyperplasia in three cases; carcinomatous polyps in seven cases; atrophic polyps in 17 cases; functional polyps in 56 cases; and inadequate sample in 23 cases. All seven patients with adenocarcinoma were symptomatic; six out of seven patients with adenocarcinoma were in postmenopause and one was in premenopause. The association between menopausal status and symptoms, and the presence of a malignant lesion was statistically significant (p < 0.001).

CONCLUSIONS

This study revealed that prevalence of endometrial polyp malignant transformation was < or = 2.84% in postmenopausal and symptomatic patients.

Adjuvant chemotherapy versus radiation therapy after radical surgery in high-risk positive node stage IB/IIA cervical cancer

OBJECTIVE

The aim of this study was to evaluate whether the addition of adjuvant chemotherapy will improve the outcomes of high-risk patients with Stage IB, IIA squamous cervical carcinoma with positive pelvic and/or aortic nodes.

MATERIALS AND METHODS

127 patients with Stage IB and IIA cervical carcinoma treated with radical hysterectomy and systematic pelvic/aortic lymphadenectomy (RS) and who had lymph node involvement, confirmed at the final histological examination were enrolled from January 1987 to December 2001. All the patients received three cycles of adjuvant chemotherapy (AC) with cisplatin, bleomycin and vinblastine. The median patient age was 47.3. Seventy-seven patients had FIGO Stage IB1, 26 IB2 and 24 IIA. The results were compared with those obtained from a group of 136 patients with comparable age, stage and lymph node involvement, on whom radical surgery, systematic pelvic/aortic lymphadenectomy (RS) and adjuvant radiotherapy (RT) was performed on period 1971-1984. The followup period ranged from 7-13 years.

RESULTS

Overall survival rate of the two groups (RS+AC) vs (RS+RT) at seven years was 69.3% and 59.5%, respectively (chi2 = 2.70; p = .10). Progression-free survival was 59.8% vs 50.0% (chi2 = 2.56; p = .10 ns). The best results were however obtained with the common iliac and over two lymph node metastases.

CONCLUSIONS

Adjuvant chemotherapy in high-risk patients for lymph node positivity did not produce statistically significant results in terms of overall and disease-free survival vs adjuvant radiotherapy; however, a group of these patients, approximately 10%, could receive benefit from the treatment.

Reliability of oupatient endometrial brush cytology vs biopsy in postmenopausal symptomatic women

OBJECTIVE

To compare outpatient endometrial sampling cytology with conventional biopsy in postmenopausal women with abnormal uterine bleeding and/or abnormal endometrial thickness at ultrasound.

METHOD

Between December 2003 and December 2009 a group of 1,056 postmenopausal women was referred to the Department of Gynecological Sciences, Perinatology an Child Health II Faculty of Medicine, University of Rome, S.Andrea Hospital. Four hundred and eighty-two patients (45.6%) had abnormal uterine bleeding and 602 (57.0%) showed an endometrial thickness > 5 mm at ultrasound. Patients on hormonal therapy (n = 194) including hormonal replacement therapy (HRT) or tamoxifen (TMX), were enrolled in the study. Endometrial cytologic sampling was performed using a brush device (EBC) while endometrial histological sampling was retrieved using a Novak curette. Histologic evaluation showed: a) malignant neoplasia b) atypical hyperplasia c) benign pathology d) normal or atrophic endometrium. The following points were investigated: a) failure in performing a procedure for cervical stenosis or pelvic pain; b) nondiagnostic specimens; c) diagnostic accuracy.

RESULTS

Evidence in score pain differences between brush and curette endometrial samples were observed: 50% of patients undergoing brush cytology had lower pain scores (chi-square = 288.33; p = .001), whereas 60% of patients undergoing endometrial biopsy had higher pain scores (chi-square = 264.84; p = .001). The failure rate in performing procedures was 8.0% vs 4.1%, and the results were statistically significant on the McNemar test, respectively p = .01 and p = .001. A nondiagnostic specimen was obtained in 3.9% of cases by EBC, and 10.3% of cases by the Novak curette (p = .001). Cytological evaluation had a sensitivity of 100%, specificity of 99%, positive and negative predictive value of 97% and 100% for diagnosing malignant neoplasia. Cytology had high diagnostic accuracy for atypical hyperplasia: sensitivity 100%, specificity 99%, positive and negative predictive value 83% and 100%, respectively.

CONCLUSIONS

EBC is a reliable, well tolerated outpatient diagnostic tool for endometrial sampling in detecting early-stage cancer in postmenopausal patients at high risk for endometrial cancer.

Follow-up in a long-term randomized trial with neoadjuvant chemotherapy for squamous cell cervical carcinoma

OBJECTIVE

To assess the role of neoadjuvant chemotherapy to achieve radical surgery in a larger number of patients with locally advanced/or bulky Stage IB cervical carcinoma. We conducted a trial to determine whether neoadjuvant chemotherapy would improve disease-free survival and overall survival in Stage IB-III cervical cancer.

DESIGN

Prospective randomized clinical study with long-term follow-up.

SETTING

Department of Gynecology, Perinatology and Child Health, II Faculty University of Rome "La Sapienza".

METHODS

288 patients with squamous cell carcinoma of the uterine cervix, FIGO Stage IB-IIIB were randomized to one of the following treatments: three courses of neoadjuvant chemotherapy with cisplatin, vincristine, bleomycin (NACT arm; n = 159); conventional surgery or exclusive radiotherapy (CONV arm; n = 129). There was no difference in age, FIGO stage, tumor size and lymph node involvement between the two groups (p = ns). Two hundred and thirty-four patients in Stage IB-IIb (n = 129 NACT arm and n = 105 CONV arm) and 24 patients in Stage III (NACT arm) who proved to be chemosensitive underwent radical hysterectomy. Six Stage III patients, non responders to chemotherapy, and 24 patients, Stage III of the CONV arm, underwent radiotherapy. Follow-up extended for seven years.

RESULTS

The study was performed on disease-free survival related to several prognostic factors: age, FIGO stage, tumor size, grading, parametrial involvement, lymph node status and surgical margins. Recurrence of disease occurred in 49 (32.1%) patients of the NACT arm (n = 153) and in 39 (37.1%). patients of the CONV arm (n = 105). Statistically significant differences in the recurrence of the disease were related to FIGO stage (p < 003), grading (p < .05), parametrial involvement (p < .002) lymph node status (p < .0001) and tumor size (p <.002). No statistical significance was related to age and surgical margins (p = ns). Disease-free and overall survival in the two groups were, respectively, 65.4% vs 53.5% (p = ns) and 70.4% 65.9% (p = ns).

Transcervical hysteroscopic myomectomy: long-term effects on abnormal uterine bleeding

OBJECTIVE

To evaluate the effectiveness of hysteroscopic myomectomy in the treatment of symptomatic submucous leiomyomas and long-term outcomes.

STUDY DESIGN

A total of 107 patients with abnormal uterine bleeding (n = 84) and/or infertility (n = 23) were submitted to hysteroscopic resection.

MAIN OUTCOME MEASURES

control of menorrhagia and reproductive outcome.

RESULTS

Abnormal uterine bleeding was controlled in 68 out of 84 patients with one procedure; 15 needed a second procedure for incomplete resection. Five patients had menorrhagic pathology relapse. Among 23 patients with associated infertility pregnancy was achieved in eight cases, seven went to term and one miscarried; one patient needed a second procedure. The mean follow-up was 36 months (24-60). Three patients were lost at follow-up.

CONCLUSIONS

Transcervical hysteroscopic resection of submucous myomas is effective for control of abnormal uterine bleeding. Further studies are needed to define the value of such procedure in the treatment of infertility. Short and long-term results are strictly correlated to the possibility of obtaining a complete resection, which is conditioned by degree (0, 1, 2) and number of myomas.

Antiestrogenic therapy in breast cancer and endometrial modifications

The aim of this retrospective study was to detect endometrial lesions in tamoxifen breast cancer users (menopausal state related). The meaning of genital bleeding during the treatment and the actual incidence of benign and malignant pathology of the endometrium related to length of treatment was also evaluated. Tamoxifen (TMX) is a nonsteroidal triphenylene derivate with clear antiestrogenic properties on the breast which is used as adjuvant treatment for breast cancer; potential adverse effects include endometrial lesions. Three hundred and sixty-six breast cancer patients were enrolled in this study; 292 patients were treated with 20 mg/daily of TMX as adjuvant therapy and the remaining 74 did not receive therapy. All patients were subdivided in premenopausal and postmenopausal, asymptomatic and symptomatic groups. All patients underwent ultrasound scans (to examine endometrial thickness) and hysteroscopic examinations before treatment and after one, three and five years. Endometrial biopsy under direct hysteroscopic vision was systematically performed. The pathological histology reports were classified under polyps, simple hyperplasia, complex hyperplasia, atypical hyperplasia, and carcinoma. A higher incidence of endometrial pathology was found only in symptomatic postmenopausal TMX treated patients (27.2% vs 19.5%) between the third and fifth year of treatment.

Breast density changes associated with hormone replacement therapy in postmenopausal women. Effects on the specificity and sensitivity of mammographic screening

Postmenopausal HRT use is associated with an increase of mammographic density and reduction of sensitivity and specificity of mammography results and an increase of false-positive and false-negative outcomes. The increased density does not allow a good evaluation of the exam. Mammographic density is an independent risk factor for breast cancer, but the link between changes in breast density and difference in breast cancer risk, remain uncertain. On the other hand, today specific guidelines and protocols to optimize the screening of neoplastic breast pathology in HRT users do not exist and it is unknown if short-term suspension of therapy improves mammographic sensitivity. More information is required to define this important risk factor.

Microsurgery versus laparoscopy in distal tubal obstruction hysterosalpingographically or laparoscopically investigated

OBJECTIVE

To compare pregnancy rates after laparotomic microsurgical or laparoscopic distal tuboplasty.

DESIGN

Two hundred and twenty-four women with infertility due to distal tubal occlusion were randomized to be treated with either laparotomy or laparoscopy from 1987 to 2001 at the Institute of Gynaecology and Obstetrics, University of Rome, "La Sapienza".

RESULTS

The results were evaluated taking into account the type of surgical approach, the severity of tubal damage and of adhesions. After a 24-month follow-up period, the overall pregnancy rate obtained with microsurgery was 43.7%, of which 33.3% were term pregnancies, 5.0% abortions, and 5.0% ectopic pregnancies. After laparoscopy, the overall pregnancy rate was 41.6%, of which 29.1% were term pregnancies, 8.3% abortions and 3.9% ectopic pregnancies. No significant differences was observed between the two groups in terms of fertility rate (chi-square 0.016, p = 0.9003).

CONCLUSIONS

Laparotomy plus microsurgery and laparoscopy were equally effective in restoring fertility in women with comparable tubal damage. The severity of the damage is a critical factor for the results.

[Hyperemesis gravidarum--etiology and treatment]

Hyperemesis gravidarum is a common pathology encountered by the obstetrician in 0.1-2% of all pregnancies. The purpose of our review, along with other literature, is to report general outline of the syndrome, with etiology, complications and some guidelines about conventional and newer therapy.

Does adjuvant chemotherapy improve the prognosis of cervical carcinoma with lymph-node metastasis? A long-term follow-up

OBJECTIVE

to verify the efficacy of adjuvant therapy in the prevention of neoplastic recurrence in patients at high risk for lymph-node involvement on surgical examination.

METHODS

72 patients, suffering from squamous cell cervical carcinoma Stage IB-IIB (FIGO) who underwent radical hysterectomy with lymph-node involvement confirmed at the final histological examination, were enrolled. All the patients were treated with adjuvant chemotherapy (AC), which included cisplatin, bleomycin and vinblastine, and were followed for a minimum period of six years. The results were compared with those obtained with a historical group of 78 patients, with comparable age, stage and lymph-node involvement, on whom only radical surgery (RS) was performed.

RESULTS

the average total survival rate of the two groups (RS + AC vs RS) at five years was 63.9% and 55.1%, respectively (chi2 = 1.191; p = NS). The disease-free interval was 55.6% vs 46.2% (chi2 = 1.324; p = NS). The best results were obtained in cases where the common iliac lymph-nodes were affected, with the highest survival rate of 16.9% in the RS+AC group, out of a total of 25 cases.

CONCLUSIONS

adoption of adjuvant chemotherapy in patients at high risk for lymph-node positivity did not produce statistically significant results in terms of overall and disease-free survival; however, a small number of these patients, approximately 9%, could receive benefit from the treatment.

The role of neoadjuvant chemotherapy for squamous cell cervical cancer (Ib-IIIb): a long-term randomized trial

OBJECTIVE

to verify whether a regimen of preventive chemotherapy in the treatment of cervical carcinoma allows surgical treatment in a larger number of patients and whether cases treated with this combined neoadjuvant polychemotherapy/surgery regimen improves overall and disease-free survival rates.

DESIGN

prospective randomized clinical study.

SETTING

Department of Gynaecology and Obstetrics, University of Rome "La Sapienza".

METHODS

192 patients suffering from squamous cell carcinoma of the uterine cervix in Stages Ib-IIb were randomized to one of the following treatments: three courses of neoadjuvant chemotherapy with cisplatin, vincristine, bleomycin (NACT arm; n = 106); conventional surgery or radiotherapy alone (CO arm; n = 86). One hundred and fifty-six patients in Stage Ib-IIb (n = 86, NACT arm and n = 70, CO arm) and 16 patients in Stage III (NACT arm) who proved to be sensitive to the neoadjuvant chemotherapy, underwent radical hysterectomy. Four Stage III patients not sensitive to chemotherapy and 16 patients, Stage III, of the CO arm underwent radiotherapy.

RESULTS

the 5-year overall survival rates for the NACT and CO arm, respectively, were 78.6% and 73.2% in Stages Ib-IIa (p = NS), 68.7% and 64.3% in Stage IIb (p = NS). A 5-year disease-free survival rate for the NACT arm and CO arm, respectively, of 77.1% and 64.3% in Stages Ib-IIa (p < .05), 56.2% and 57.1% in Stage IIb (p = NS) was found.

CONCLUSIONS

the responsiveness of cervical cancer to neoadjuvant chemotherapy allows surgical treatment in a larger number of patients and results in longer overall and disease-free survival.

[Laparoscopically assisted vaginal hysterectomy Gasless. Retrospective study in patients with uterine fibroids]

PURPOSE

To evaluate the feasibility to perform laparoscopically assisted vaginal hysterectomy in patients who were not suitable for vaginal hysterectomy.

PATIENTS AND METHODS

LAVH Gasless was carried out on 31 patients with uterine fibroids. Uterine weight ranged of 420-800 gr.

RESULTS

There were 2 laparotomy conversion (6%) for uterus 800 gr; median operating time was 79 +/- 18 minutes (range 75-89); the average haemoglobin drop was 1.7 +/- 0.9 g/dl; the mean in postoperative stay was 3.7 +/- 0.7 days (range 3-5). Febrile morbidity > 38 degrees C were found in 3 cases.

CONCLUSIONS

Laparoscopic assistance has advantages in performing transection of round and infundibolo-pelvic ligaments in vaginal steps and in controlling post-operative blood loss.

[Effects of tamoxifen and estrogen replacement therapy on lipid metabolism and some other cardiovascular risk factors. A prospective study in hysterectomised women]

BACKGROUND

The aim of this clinical study was to evaluate the relationship of tamoxifen and the risk factors of cardiovascular disease in hysterectomised women.

METHODS

Between 1992 and 1998, 93 women were recruited for a prospective study with follow-up at 0, 12 and 24 months. All women had an increased risk of breast cancer and they were hysterectomised and ovariectomised for a benign pathology. They were divided according to the following categories: Group A was constituted of 26 (28%) symptomatic patients (hot flushes, depression) who had received tamoxifen and oral conjugated estrogens. Group B was constituted of 27 (29%) symptomatic patients who had received tamoxifen and transdermal 17B-estradiol. Group C was constitued of 19 (21%) asymptomatic patients who had received only tamoxifen. Group D (control) was constitued of 21 (22%) asymptomatic patients who had not received any therapy. A venous blood sample for total cholesterol levels (T-C), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglycerides (TRG), fibrinogen (FBR), platelets (PLT) and antithrombin III (AT III) was taken during follow-up. ANOVA (repeated measures) was used to assess statistical significance: p<0.05 was considered significant (95% CI).

RESULTS

The patients who received tamoxifen with or without estrogen replacement therapy showed after 24 months, a reduction of T-C, LDL-C and FBR (p<0.01); the HDL-C levels did not vary significantly compared to the control group (p=NS); the 26 patients of group A showed an increase of HDL-C (p<0.02). We reported an increase of TRG in the patients of group A and C (p<0.05); on the contrary, we obtained a significant reduction of TRG (p<0.01) in the patients who received tamoxifen and transdermal 17B-estradiol (group B). There was no interaction on plateled count (p=NS).

CONCLUSIONS

These results suggest the administration of tamoxifen in hysterectomised women with a high risk of breast cancer and without climateric symptoms. In these patients, tamoxifen could reduce coronary heart disease and incidence of breast cancer. The symptomatic patients are suggested to receive tamoxifen and transdermal 17B-estradiol because of the better effects on lipid metabolism.

Laparoscopic surgery in treatment of stage IIb cervical cancer after neoadjuvant chemotherapy. A case report and review of the literature

BACKGROUND

A detailed operative procedure of laparoscopic radical hysterectomy (type III) with pelvic and aortic lymphadenectomy after neoadjuvant chemoterapy in treatment of Stage IIb cervical cancer is described.

CASE REPORT

A 50-year-old patient with Stage IIb squamous cell carcinoma of the uterine cervix, who initially was not surgically resectable, received three courses of neoadjuvant chemotherapy that included ifosfamide 5 g/m2, cisplatin 50 mg/m2 and paclitaxel 175 mg/m2 (TIP). Following a partial clinical response to chemotherapy, the patient underwent laparoscopic type III radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy. The surgical procedure lasted 250 minutes. Blood loss was 310 ml. The patient was discharged on postoperative day 4. The mean length of the resected parametria and paracolpia was 4.1 cm and 2.0 cm, respectively. The number of dissected lymph nodes was 48:29 pelvic and 19 paraaortic nodes. No major intraoperative or postoperative complications occurred. The patient also underwent adjuvant radiation therapy. Follow-up was performed at six months so far.

CONCLUSIONS

This experience suggests that such a surgical procedure is safe. Laparoscopic radical hysterectomy potentially allows for decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results. Large studies with long term follow-up are needed to confirm that this approach may be proposed as an alternative to conventional surgery.

Hormonal replacement therapy and evaluation of intrauterine pathology in postmenopausal women: a ten-year study

BACKGROUND

To evaluate the role of hormonal replacement therapy (HRT) in determining: a) abnormal uterine bleeding (AUB); b) increased endometrial thickness at transvaginal sonography (TVS); c) the correct indication for outpatient hysteroscopy (HS) and biopsy in diagnosing intrauterine pathology.

METHODS

Between April 1991 and April 2001 a group of 3,400 postmenopausal women was referred to the Department of Obstetrics and Gynecology of Rome University "La Sapienza"; 16.7% of them had received HRT. 587 out of the 3,400 women were recruited for a comparative study, including four groups. To assess statistical significance of HRT in determining AUB, and/or endometrial thickness related to malignant disease the chi-square test was used; p < 0.05 was considered significant. Histology was considered the true result (control).

RESULTS

An increase in the endometrial thickness occurred significantly more often in women on HRT (p < 0.03); as well as the percentage of AUB (p < 0.0001). No difference in the incidence of endometrial adenocarcinoma was reported between the HRT and the non HRT groups.

CONCLUSIONS

In postmenopausal women using HRT we can confirm that a higher incidence of signs (AUB, endometrial thickness > or = 5 mm) does not coincide with a higher incidence of malignant pathology. The data obtained from the recruited patients was arranged and evaluated by the most suitable methods for screening endometrial adenocarcinoma. According to our experience, we believe a cut-off point of 8 mm to be significant (p < 0.001) to perform an hysteroscopy and biopsy except for asymptomatic patients on HRT.

[The role of copper-releasing intrauterine device or levonorgestrel-releasing intrauterine system on uterine bleeding and iron status (prospective study of 8 years)]

BACKGROUND

The aims of this study were the effects of copper intrauterine device (Cu-IUD) compared to progesterone (PRG-IUS) or levonorgestrel releasing intrauterine system (LNg-IUS) on menstrual bleeding, menorrhagia and dysfunctional uterine bleeding. The authors evaluated the effect of copper surface area on uterine bleeding.

METHODS

Between March 1992 and November 1999, 223 women, referred to I Institute of Obstetrics and Gynaecology University of Rome, were recruited in a prospective study with follow up at 3, 6 and 12 months to evaluate the incidence of endometrial pathology. The study includes 38 fertile women with regular menstruations and without intrauterine devices, as control group, and 185 patients with intrauterine devices, divides as follows: - 117 copper-releasing intrauterine devices: 30 with a copper (Cu) surface area =200 mm2, releasing 45 microgram Cu/24h (Nova T (R)); 27 with a copper surface area =250 mm2, releasing 50 microgram Cu/24h (Multiload 250 (R)); 25 with a copper surface area =375 mm2, releasing 65 microgram Cu/24h (Multiload 375 (R)); 20 with a copper surface area =384 mm2, releasing 100 microgram Cu/24h (No Gravid M (R)); 15 with a copper surface area =440 mm2, releasing 120 microgram Cu/24h (No Gravid 0,5 (R)). - 68 progesterone/levonorgestrel-releasing intrauterine devices: 40 progesterone-releasing intrauterine systems (Progestasert(R)); 28 levonorgestrel-releasing intrauterine systems 20 mg/24h (Mirena (R)). A total of 211 subjects had data that were valid for analysis: 12 women out of 223 (5,4%) were excluded from the prospective study lost to follow-up. A venous blood sample for serum ferritin (mg/l), iron (mg/dl), hemoglobin (g/dl), hematocrit (%), blood cell count, MCHC and MCV was taken during follow-up.

RESULTS

PRG or LNg-IUSs determined a significant reduction in menstrual blood loss and in irregular bleeding by gradually reducing endometrial fitness and vascularisation. Serum ferritin significantly increased in women inserted with LNg- IUSs already after 6 months (26+/-22 e 28+/-14 microgram/l versus 32.5+/-19 e 34.5+/-25 microgram/l). Hemoglobin significantly increased (p>0.05) 6 months after insertion. On the contrary this did not occur with the insertion of Cu-IUDs. We observed that the increased amount of copper, released by IUD, causes increasing of bleeding.

CONCLUSIONS

The LNg-IUS is a new contraceptive method combining the advantages of both hormonal and intrauterine contraception. In addition, it can be considered an alternative method in the treatment of menorrhagia and dysfunctional uterine bleeding. On the contrary, in women inserted with Cu-IUDs, the main reason of menorrhagia probably is due both to the shape of device and to copper surface area.

[A case of maternal and neonatal infection due to Listeria monocytogenes]

A Listeria monocytogenes infection may develop during pregnancy by eating sausages, fresh meats and milk products derived from infected animals. According to the period in which the infection starts, the pregnancy outcome can be abortion or pre-term or at term delivery. The infection can pass from mother to fetus and can cause a serious neonatal sepsis. Listeriosis in pregnant women can be asymptomatic or may present as an influenza-like syndrome. This case report, along with other published cases, demonstrates how hard is to make a correct diagnosis of listeriosis during pregnancy. Since this is mainly related to the aspecificity of symptoms, it is very important to have a high suspicion and to take a careful patient history.

Management of stage III and IV endometriosis: a 10-year experience

A retrospective analysis is reported of the management of 117 cases of infertility associated with Stage III and IV endometriosis. Combined medico-microsurgical treatment was selected in 75.3% of Stage III cases and in 83.3% of those on Stage IV. Medication consisted of medroxyprogesterone acetate in 26 patients and danazol in the remaining 64. Microsurgery alone was utilized in 24.7% of Stage III patients and in 16.6% of those on Stage IV. Both surgery alone and the combined therapy had a profound positive effect on subjective symptoms: dysmenorrhea, dyspareunia and pelvic pain. Following combined therapy, pregnancy was achieved in 34.4% of all women. Respective figures are 30.7% for medroxyprogesterone acetate (29.4% Stage III and 33.3% Stage IV) and 35.9% for danazol (37.7% Stage III and 27.2% Stage IV). In the group of patients treated by surgery alone, pregnancy occurred in 25.9%. Of the pregnancies in women with Stage III endometriosis, 25 were carried to term and 6 ended with a spontaneous abortion; figures for Stage IV women are 5 and 2, respectively. Second-look laparoscopy was performed in 49 of the 79 patients who failed to conceive, at 12-36 months after treatment; persistent genital pathology, to which infertility could be attributed, was found in 77.5% of them.

[Guidance for the obstetrician encountering a multiple pregnancy]

A retrospective review of multiple birth of higher order delivered at the Obstetric Clinic of University of Rome "La Sapienza" from 1982-1991 was performed. Comparison was made between this group (study group) and other published data. Since 1982 there has been more liberal use of abdominal delivery. Of the 25 multiple pregnancies, 17 were delivered by cesarean section (CS) and 8 by vaginal delivery. The corrected mortality rate in the study group was 19.2% (5/26) for vaginal delivery and 17.5% (10/57) for CS. Indication for CS was: elective (35%), fetal (18%) and maternal (47%). The main neonatal complications resulted from prematurity, and maternal noted complication were post-partum hemorrhage necessitating hysterectomy in one patient. The preferable mode of delivery cannot be stated dogmatically.

[Epidemiologic study of cervico-vaginal pathology in IUD users]

1800 intrauterine contraceptive device users, during a period of more than thirteen years, and 1800 control non-users were examined clinically, cytologically and histopathologically for cervical pathological lesions. There was an increase, but not statistically significant, in the incidence of metaplasia, dyskariosis or mild dysplasia. There was no difference in neoplastic lesions.

[Clinical evaluation of an immunological test for premature rupture of the fetal membranes (ROM check test)]

Commonly used methods for detecting amniotic fluid in the vagina include research LA cells, ferning, nitrazina paper, ultrasound and dye injection. These methods are difficult to interpret or invasive. We have tested a new method which detects a fetal isoform of fibronectin in vaginal secretion when amniotic fluid is present. Clinical trials demonstrate the sufficient reliability in detecting amniotic fluid in the vagina of women with rupture of amniotic membranes.

[Emergency ambulatory treatment of dysfunctional metrorrhagia in adolescents]

The authors compared the therapeutic efficacy of oestrogen-progestogen combinations with pure progestagen in the urgent treatment of adolescent metrorrhagia. Two groups of adolescents were studied whose haemorrhages were attributed exclusively to disfunction. Every medicine was evaluated as to: 1) effectiveness in completely spotting haemorrhage, 2) any persistence of bleeding, 3) side effects. The therapy was given during 2 consecutive menstrual cycles. Results following treatment with oestrogen-progestogen combinations were favourable, even though side effects were more noticeable.

[Treatment with danazol of breast adenosis. A comparative note]

The term "mammary adenosis" describes chronic congestion of the mammary gland, whose principle symptom is painfulness. The Authors report the results obtained during therapy, which utilised three different pharmacological treatments: danazol, progestogen vitamin compounds. Evaluations made were both subjective (pain) and objective (clinical details), classified in those levels: recovery, improvement, persistence of symptoms. Results were evaluated after 3 and months of treatment, and then at four months after suspension of treatment; these were then compared. The best results were obtained with danazol, although there was a greater number of side effects.

[Destructive cesarean section: hysterectomy for obstetric reasons and post-abortive hysterectomy. Analysis of 35 cases]

The Authors examined surgical case studies for the 20-year period from February 1968 to February 1988 concerning hysterectomies performed for obstetric reasons at the "La Sapienza" University of Rome, Obstetrics and Gynaecology Department; these numbered 35 out of 69,677 births. They also considered hysterectomies carried out during caesarean sections, during birth or the postpartum period, during the puerperium and after miscarriage. They also analyzed reasons for the action taken, the type of operation, the length of the gestation period, the mother's age, and transfusions given.

[Medium term treatment and prophylaxis of dysfunctional metrorrhagia in adolescence]

The authors compared the therapeutic effectiveness of these different pharmacological methods of preventing dysfunctional menometrorrhagia in adolescents, which were: 1) chorionic gonadotropin, 2) cyclofenil, 3) ovariostatics. Therapy was given during 2 menstrual cycles, and effects were evaluated both during the treatment and for the succeeding 2 cycles. Parameters followed were: a) clinical recovery, b) persistence of spotting, c) effectiveness in inducing ovulation. The results were equally good both in treatment with ovariostatics and ovulation inducers. The latter proved however, more effective during follow-up. Side-effects were very rare, so much so that, in no case was it necessary to suspend treatment.

[Use of low-dose danazol in adenosis of the breast]

Mammary adenosis is a very common affliction which, it has been calculated, affects between 7 and 15% of women of child-bearing age. The Authors report the results obtained during treatment of this condition with danazol in those different dosages (50, 100 and 200 mg per day). Results were evaluated at 3 and 6 months during therapy, and then 4 months after suspension of the treatment. Effects were evaluated in terms of changes in the symptomatic pain and in the actual clinical record. Side effects were also examined in terms of age and obstetric history. The therapy produced good results with all those dosages used. The lowest dosage gave the most favourable long-term effects, also in terms of the scarsity of side-effects.

[Hysterectomy in obstetrics. Analysis and comparison of a group of cases from the Italian and the international literature (536 cases)]

The Authors made a comparison between the frequency of obstetric hysterectomies carried out at the "La Sapienza" University Obstetrics and Gynaecology Departments and of those reported in international publications regarding Great Britain, USA, Australia, Saudi Arabia and Libya. Data obtained covered the 462 hysterectomies effected out of the 442,174 births from 1972 to 1895. Results were compared as under: general frequency per number of births, reasons for surgery, type of operation carried out, age of the patient, gestation period, obstetrical history and complications.

[Cefotetan in preoperative prophylaxis in gynecologic surgery]

The Authors report on the effectiveness of a 2nd generation "cephalosporin" (Cefotetan) used in preventive antibiotic treatment connected with gynaecological surgery. Two hundred hospital patients were involved in the experiment and were divided into 4 groups: 1) the first and second groups were given a "short-term" preventive antibiotic treatment (a single dose before the operation); 2) the third and fourth groups were given antibiotics continuously in the post-operative period. In those patients in groups I and III (who had operations for abdominal laparotomies) the incidence of fewerishness was 12% in those patients treated with the "short-term" therapy, and 10% in those receiving post-operative treatment. Sepsis on the suture developed in none of these cases. Urinary infection occurred in 6% of these patients in group I as compared with 2% in group III. During post-operative treatment of patients in group II and IV (who had had minor gynaecological operation) the incidence of inflammation with slight temperature was very much lower only 4% of the cases treated with "short-term" preventive antibiotics and only 2% in those patients receiving continuous preventive treatment. In no case was these sepsis of the suture. Urinary infection occurred in 4% of patients on "short-term" therapy (group II) but in none of the patients in group IV. Side effects were in all cases only slight and of brief duration, especially in group I and II who received the single pre-operative dose of the antibiotic.