Ultrasonographic measurement of thymus size in IUGR fetuses: a marker of the fetal immunoendocrine response to malnutrition.

OBJECTIVE: To test the hypothesis that intrauterine growth restriction (IUGR) is associated with decreased thymus size in the human fetus. METHODS: The thymus perimeter was measured in 60 consecutive IUGR fetuses at prenatal ultrasound examination. IUGR was defined as an abdominal circumference (AC) <5(th) centile. Sixty controls were identified by selection of the next consecutive appropriately grown fetus of similar gestational age (+/-1 week). To exclude fetal size effects, ratios between thymus perimeter and fetal biometry measurements including biparietal diameter (BPD), AC and femur length (FL), as well as estimated fetal weight (EFW) were compared between IUGR fetuses and controls. RESULTS: The proportion of fetuses with thymus perimeter <5(th) centile for gestation was significantly higher in IUGR fetuses than in controls (58/60 vs. 7/60, P < 0.0001). The mean thymus perimeter/BPD ratio (0.87 +/- 0.20 vs. 1.13 +/- 0.13, P < 0.0001), thymus perimeter/AC ratio (0.28 +/- 0.06 vs. 0.35 +/- 0.03, P < 0.0001), thymus perimeter/FL ratio (1.18 +/- 0.26 vs. 1.51 +/- 0.19, P < 0.001) and thymus perimeter/EFW ratio (0.05 +/- 0.01 vs. 0.06 +/- 0.01, P = 0.02) were significantly lower in IUGR fetuses than in controls. There was a significant positive correlation between the observed-to-expected mean for gestation thymus perimeter ratio and the enrollment-to-delivery interval (r = 0.44, P < 0.001). CONCLUSION: IUGR is associated with a disproportionately small thymus. This supports the hypothesis that thymic involution may be part of the fetal neuroendocrine response to intrauterine starvation.

Infectious morbidity after total laparoscopic hysterectomy: does concomitant salpingectomy make a difference?

The study was aimed to test the hypothesis that preservation of the fallopian tubes at the time of total laparoscopic hysterectomy (TLH) increases the risk for postoperative infection. The study group consisted of 137 consecutive women undergoing TLH with conservation of the ovaries, who had concomitant bilateral total salpingectomy at the time of TLH. The control group included 145 women who had had TLH without salpingo-oophorectomy before the study period. Women undergoing bilateral total salpingectomy at the time of TLH had a lower rate of infectious morbidity compared with those who had TLH alone (3/137 versus 14/145, P = 0.01). Multivariable analysis showed that bilateral total salpingectomy at the time of TLH and blood loss are independent predictors of infectious morbidity.

The impact of urinary stress incontinence in young and middle-age women practising recreational sports activity: an epidemiological study.

OBJECTIVES: To evaluate the prevalence of urinary stress incontinence (USI) in menstruating women practising recreational sports activity, to detect specific sports with a stronger association with urinary incontinence (UI) and to evaluate risk factors possibly related to this condition. DESIGN: Epidemiological study. SETTING: Non-competitive sports organisations in the province of Varese, Italy. PARTICIPANTS: 679 women of fertile age, practising recreational sports activity. INTERVENTION: Anonymous questionnaire on UI. MAIN OUTCOME MEASUREMENTS: The questionnaire included questions about patients' general characteristics, occurrence of UI in relation to sport or daily general activities, time of onset of this condition, frequency of leakage episodes, correlation of incontinence with types of movements or sports, subjective impression of being limited on such occasions and/or necessity to modify the type of sport. RESULTS: UI was reported by 101 women (14.9%). Of these, 32 (31.7%) complained of UI only during sports activity, 48 (47.5%) only during daily life and 21 (20.8%) in both circumstances. Body mass index and parity were significantly associated with the risk of UI. Looking at the different sports activities, a higher rate of incontinence was found in women participating in basketball (16.6%), athletics (15%), and tennis or squash (11%). 10.4% of women abandoned their favourite sport, because of USI, and a further 20% limited the way they practised their favourite sport to reduce leakage episodes. CONCLUSIONS: Female UI affects a significant proportion of young women practising non-competitive sports activity; it can cause abandonment of the sport or limitation of its practice.

Transumbilical surgical specimen retrieval: a viable refinement of laparoscopic surgery for pelvic masses.

The purpose of this study was to evaluate the feasibility and surgical outcome of a policy of routine specimen retrieval through the umbilical port, avoiding the enlargement of ancillary port-site incisions. A total of 1116 women underwent laparoscopic surgery for the treatment of a pelvic mass with extraction of the specimen through the umbilical port site (a total of 1453 retrieval procedures). All retrieval procedures were successfully carried out with this technique. Neither intraoperative complication related to the retrieval procedure nor accidental rupture of the endoscopic bag occurred. There was an injury to the epigastric artery. Neither trocar-site hernias (both umbilical trocar insertion sites and extraumbilical sites) nor port-site metastases occurred.

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses.

OBJECTIVE: To evaluate the feasibility and safety of laparoscopic management of adnexal masses > or = 10 cm in size. DESIGN: Prospective cohort study. SETTING: Two Gynecology Departments of University Hospitals. POPULATION: All women presenting with an adnexal mass > or = 10 cm in diameter were candidates for laparoscopic management. Women were excluded from laparoscopic approach if there was evidence of ascites or gross metastatic disease. Neither the sonographic features of the cyst nor elevated serum CA125 level was used to exclude women from having a laparoscopic approach. METHODS: A single operative protocol was followed for all women. All removed specimens were sent for immediate pathological evaluation. MAIN OUTCOME MEASURES: Rate of conversion to laparotomy, incidence of cancer encountered, and operative complications. RESULTS: One hundred and eighty-six women underwent laparoscopic evaluation for an adnexal mass of 10 cm or larger in size. The average preoperative mass size was 12.1 +/- 4.9 cm. A benign pathological condition was found in 86.6% (161/186) of the women, primary ovarian cancer in 16 (8.6%) women, a metastatic tumour of gastrointestinal origin in 1 (0.5%) woman, and a low malignant potential ovarian tumour in 8 (4.3%) women. Laparoscopic management was successful for 174 (93.5%) women. Reasons for conversion to laparotomy included anticipated technical difficulty (n = 7) and malignancy (n = 5). No intraoperative complications occurred in the entire study group. CONCLUSIONS: The vast majority of large adnexal masses can be safely resected laparoscopically, provided that there is expertise in laparoscopic surgery, immediate access to frozen section diagnosis, and preparation of patient to receive an adequate cancer surgery where indicated.

Efficacy of tolterodine in women with detrusor overactivity and anterior vaginal wall prolapse: is it the same?

The aim of this study was to assess the efficacy of tolterodine in women with overactive bladder (OAB) and concomitant anterior vaginal prolapse. In this prospective study, 235 consecutive women with OAB symptoms and urodynamic diagnosis of detrusor overactivity who either had no prolapse or had pure anterior vaginal prolapse were included: 184 women (group 1) had no prolapse and 51 women (group 2) had anterior prolapse greater than and equal to stage IIa. Tolterodine 4 mg slow release once a day was prescribed. After 12 weeks, women were reassessed using a 3-point scale (no change, improvement and cured). A total of 158 (85.9%) women in group 1 and 31 (60.8%) women in group 2 reported improvement or cure (P = 0.0002). Women with OAB and significant anterior vaginal prolapse should be informed of a reduced efficacy of antimuscarinics in treating their urinary symptoms.

Cervical ripening with the Foley catheter.

OBJECTIVE: To evaluate maternal and neonatal outcomes in a large series of patients undergoing cervical ripening with a Foley catheter. METHODS: The database of the Labor and Delivery Unit of the University of a teaching hospital in Italy was used to identify consecutive patients with a Bishop score (BS) of 4 or less who underwent pre-induction cervical ripening with a Foley catheter. The main outcome measures were clinical chorioamnionitis, endometritis, and suspected and culture-proven neonatal sepsis. RESULTS: Of 602 women undergoing cervical ripening with a Foley catheter, 160 (26.6%) went into active labor without additional interventions. Oxytocin was administered immediately after removal of the Foley catheter in 188 (31.2%) of the women, and 254 (42.2%) required an application of prostaglandin E2 vaginal gel. The cesarean delivery rate was 25.6%. The median time to delivery was 1469 min (range, 94-3350 min). Of the women who gave birth vaginally, 225 (50.2%) were delivered within 24 h. Clinical chorioamnionitis and postpartum endometritis occurred in 3 (0.5%) and 6 (1.0%) of the women, respectively. Neonatal sepsis was suspected in 4 (0.7%) of the newborns but blood culture results were negative in all cases. CONCLUSION: Transcervical use of the Foley catheter is safe for pre-induction cervical ripening, and the associated risk of maternal or perinatal infections is negligible.

The Hayman technique: a simple method to treat postpartum haemorrhage.

Of the several uterine compression sutures described in more recent years to treat postpartum haemorrhage (PPH), the Hayman suture offers the potential advantages that can be applied faster and easier, avoiding the performance of a lower segment hysterotomy when PPH follows a vaginal delivery. Data on efficacy and safety are limited, and long-term follow-up information are lacking. We report our experience with the Hayman suture in 11 consecutive women with massive PPH. Of these, ten were successfully treated without further interventions. One woman ultimately required a hysterectomy. Postoperative course was uncomplicated in all the cases. The median follow-up time was 11 months (range 1-19). One woman conceived spontaneously 10 months after the procedure. Our results suggest that the Hayman suture is an effective and safe treatment for PPH.

Female psychopathologic profile during menopausal transition: a preliminary study.

OBJECTIVES: To evaluate the psychopathological profile and the incidence of major depressive disorders in consecutive women attending a Menopause Clinic. METHODS: Women attending outpatient menopause clinic at Filippo del Ponte Hospital in Varese (Italy), referring to the centre from 1 March to 30 April 2005, were invited to fill up a specific questionnaire while waiting for the visit. The questionnaire included demographics and history (e.g. current or past use of antidepressant drugs); symptoms check list (SCL-90-R); Beck depression inventory (BDI). RESULTS: Sixty-four women were enrolled to the study. On the SCL-90-R, "somatic" symptoms cluster was the most frequent. Patients diagnosed as depressed using the Beck depression inventory (BDI) were 18 (28.1%). Thirteen (70%) of currently depressed women presented a positive history of depressive disorders. The analysis of depressed women according to previous depressive disorders revealed higher scores for women with positive history in both scales. Depressed patients have a significantly lower mean age compared to non-depressed patients (53.3+/-6.2 years versus 57.33+/-4.9 years, p=0.023). CONCLUSIONS: Our preliminary data show a high correlation between a history of depressive disorder and recurrence of depression in the menopausal period. Perimenopause seems to be a higher risk period for the development of a depressive disease compared to menopausal status. The somatization cluster warrants further investigation.

The incidence of venous thromboembolism following gynecologic laparoscopy: a multicenter, prospective cohort study.

BACKGROUND: Information on the incidence of venous thromboembolism (VTE) following laparoscopic procedures is inadequate and there is currently no solid evidence to guide the use of thromboprophylaxis in this setting. Gynecologic laparoscopy is a common procedure, and is frequently performed in low-risk patients. To our knowledge, there are no clinical studies specifically designed to assess the incidence of VTE in this setting. METHODS: In a prospective cohort study, consecutive patients undergoing gynecologic laparoscopy underwent compression ultrasonography (CUS) and clinical assessment to evaluate the incidence of clinically relevant VTE. CUS was performed 7 +/- 1 and 14 +/- 1 days postoperatively. A subsequent telephone contact was scheduled at 30 and 90 days. No patient received pharmacologic or mechanical prophylaxis. Patients with malignancy or previous VTE were excluded from the study. RESULTS: We enrolled 266 consecutive patients; mean age was 36.3 years, range: 18-72. The most common indications for laparoscopy were ovarian cysts in 25.6% of patients, endometriosis in 21.0% of patients, unexplained adnexal masses in 12.4% of patients, and infertility in 7.5% of patients. The mean duration of the procedure was 60.5 min (range: 10-300 min). In particular, in 55.6% of patients the duration exceeded 45 min. There were neither episodes of CUS detected DVT (0/247; 0%, 95% CI 0-1.51%) or clinically relevant VTE after follow-up (0/256; 0%, 95% CI 0-1.48%). No patient died of fatal pulmonary embolism (0/266; 0%, 95% CI 0-1.42%). CONCLUSIONS: Gynecologic laparoscopy in non-cancer patients is a low-risk procedure for postoperative VTE.

Two-trocar adnexal surgery: a "quasi" scarless operation.

BACKGROUND: This study aimed to explore the feasibility and safety of two-port abdominal cavity entry for adnexal surgery. METHODS: A series of patients undergoing laparoscopy for benign adnexal diseases requiring adnexectomy, ovariectomy, or salpingectomy were enrolled in the study. A 10-mm 0 degree umbilical operative laparoscope and one 3- or 5-mm suprapubic trocar were used. A grasping forceps was inserted through the ancillary trocar to displace medially and cranially the adnexa or the salpinx. The operation then was performed through the operative channel of the operative laparoscope. RESULTS: A total of 53 patients were enrolled. Bilateral salpingo-oophorectomy was performed in 10 cases. The median operative time was 39 min (range, 21-85 min). The median blood loss was 50 ml (range, 0-300 ml). The median size of the adnexal mass was 6 cm (range, 3-12 cm). No intraoperative complication occurred. At the 3-month follow-up visit, no extraumbilical abdominal scar was visible. CONCLUSIONS: The use of a two-trocar technique is safe and highly appreciated by the patients it leaves no visible abdominal scars.

Postoperative complications after pelvic lymphadenectomy for the surgical staging of endometrial cancer.

OBJECTIVE: To assess whether pelvic lymphadenectomy at surgical staging for endometrial carcinoma is an independent risk factor for the occurrence of postoperative complications. METHODS: Women with uterine cancer who underwent radical abdominal hysterectomy type I or II of Piver-Rutledge with or without pelvic lymph nodes dissection were considered. The occurrence of intraoperative and early postoperative complications (deep vein thrombosis, lymphocysts, febrile morbidity, extraoperative site infections, wound dehiscence, relaparotomy, and death) was prospectively recorded. Non parametric tests, receiver characteristic curve analysis, and multiple logistic regressions were used for statistical purposes. RESULTS: Two hundred six subjects were enrolled, of whom 133 underwent pelvic lymphadenectomy. The rate of postoperative complications was 26.7% (55 of 206). Women with complications had a higher median (range) number of lymph nodes removed than those without complications (17 [3-62] versus 11 [1-74], P <.01). The performance of a type II hysterectomy (OR = 2.49, P <.05) and the removal of more than 14 lymph nodes (OR = 3.05, P <.005) were significantly associated with the occurrence of at least one complication. Multiple logistic regression revealed that, after adjustment for the type of surgery, the removal of more than 14 nodes was the only condition associated with postoperative complications (OR = 2.56, P <.01). The only variable significantly associated with the development of two postoperative complications was the removal of more than 19 nodes (OR = 9.7, P <.01). CONCLUSIONS: The extension of retroperitoneal lymph nodes (more than 14) dissection is an independent risk factor for the occurrence of postoperative complications in patients undergoing surgical staging for endometrial carcinoma.

Bioelectrical impedance analysis during pregnancy and neonatal birth weight.

OBJECTIVE: To generate reference ranges for bioelectrical impedance indices throughout pregnancy and to investigate whether a relationship exists between these indices and the neonatal birth weight. STUDY DESIGN: Pregnant women with a singleton gestation, gestational age lower than 12 weeks, and absence of medical diseases before pregnancy were enrolled. Patients with pregnancy complications, such as hypertensive disorders, diabetes, and antiphospholipides syndrome were excluded. Antrophometric maternal parameters and bioelectrical impedance measurements were performed during the first, second, third trimester of pregnancy, at delivery and 60 days after delivery. Height(2)/resistance (cm(2)/Omega) and height(2)/reactance (cm(2)/Omega) were utilized to estimate the total and extracellular body water amounts, respectively. Spearman rank correlations and cox proportional hazard modelling were used for statistical purposes. RESULTS: 169 patients completed all measurements. Total and extracellular water amounts significantly increase as pregnancy advances and return to the pre-pregnancy values within 60 days after delivery. After adjustment for gestational age at delivery, fetal sex, and smoking habits, height(2)/resistance at 25 weeks (hazard=1.04, 95% confidence interval (CI) 1.02-1.06, P<0.005), height(2)/resistance at 30 weeks (hazard=1.03, 95% CI 1.01-1.05, P<0.005), height(2)/reactance at 20 weeks (hazard=1.03,95% CI 1.01-1.05, P<0.005), and height(2)/reactance at 25 weeks (hazard=1.03, 95% CI 1.01-1.04, P<0.01) were found to be independent predictors of birth weight. CONCLUSION: We have provided reference ranges for bioimpedance analysis during pregnancy, an easy, fast and non invasive method to estimate the body water composition during pregnancy. Bioelectrical impedance indices during the second trimester of pregnancy are independently related to the birth weight.

Extra-amniotic Foley catheter and prostaglandin E(2) gel for cervical ripening at term gestation.

OBJECTIVE: This study evaluated the efficacy of intravaginal prostaglandin E(2) gel in comparison with that of a Foley catheter for cervical ripening and induction of labor. STUDY DESIGN: Consecutive patients with unfavorable cervix requiring preinduction cervical ripening and induction of labor at term gestation were asked to participate in the study. One hundred and two patients were assigned to treatment with intravaginal prostaglandin E(2) gel (group 1) and 122 patients underwent the placement of an intracervical Foley catheter (group 2). After a maximum of three applications of intravaginal prostaglandin E(2) gel (18h) or after 18h from Foley catheter insertion oxytocin was administered to patients not in active labor. Labor profiles and pregnancy and neonatal outcome were compared between groups. RESULTS: The groups were comparable in term of demographic characteristics, indications for induction of labor, Bishop score at admission. The induction to labor time and the induction to delivery time were similar between groups. The cesarean sections rate was higher in group 1 than in group 2 (26.5 versus 14.7%, P<0.05). This remained significant when the analysis was restricted to nulliparous patients (32.3 versus 14.2%). The incidence of urinary tract infections, chorioamnionitis, and febrile morbidity was similar between groups. CONCLUSION: For preinduction cervical ripening, the Foley catheter is a valid alternative to the application of intravaginal prostaglandin E(2) gel and it is associated with a lower cesarean rate in nulliparous women.

Incisional hernia in gynecologic oncology patients: a 10-year study.

OBJECTIVE: To evaluate the independent contribution of clinical and constitutional factors in the development of early and late incisional hernias in women undergoing surgery for uterine cancer. METHODS: Over 10 years, patients undergoing extended abdominal hysterectomy for cervical or endometrial malignancies through a vertical incision were followed for the identification of incisional hernias. Logistic regression and survival analyses were used for statistics. RESULTS: Four hundred fifty-five women were included in the study, 77 of whom (16.9%) developed incisional hernias. The median (range) body mass index was higher in women who developed an incisional hernia than in those who did not (28 [19--44] kg/m(2) versus 24 [16--41] kg/m(2); P <.01). The frequencies of diabetes (14.3% versus 4.8%; P <.01), wound sepsis (10.4% versus 1.3%; P <.05), and fascial closure with interrupted sutures (70.1% versus 55.6%; P <.05) were significantly higher in women with incisional hernia than in those without. Multiple logistic regression revealed that, after adjustment for confounding variables, the only factors associated with incisional hernia formation within 1 year from the operation were body mass index above 27 kg/m(2) (odds ratio [OR] 3.68; 95% confidence interval [CI] 1.38, 9.81; P <.01) and wound infection (OR 5.05; 95% CI 1.39, 18.37; P <.01), whereas the factors associated with incisional hernia formation at least 3 years after surgery were diabetes (OR 6.68; 95% CI 2.02, 22; P <.01) and wound infection (OR 8.55; 95% CI 1.54, 47.5; P <.01). For hernia developing after 5 years (OR 8.32; 95% CI 1.41, 55.65; P <.05) and 8 years (OR 49.52; 95% CI 2.72, 907.14; P <.01), the only significant association was found with diabetes. CONCLUSION: Late incisional hernia formation does not depend on conditions present at the time of operation or on surgical technique. Other factors such as diabetes seem to play an important role in the development of late incisional hernia.

Recurrence of ovarian endometriosis and anatomical location of the primary lesion.

OBJECTIVE: To investigate whether the risk of endometriosis recurrence and pregnancy rate are related to the side of the pelvis on which the primary lesion is found. DESIGN: Cross-sectional study. SETTING: Tertiary institutional hospital. PATIENT(S): One hundred and twenty-one patients with advanced-stage pelvic endometriosis. INTERVENTION(S): Conservative laparoscopic treatment. MAIN OUTCOME MEASURE(S): Endometriosis recurrence and pregnancy rate. RESULT(S): Endometriosis was localized on the left hemipelvis, right hemipelvis, and bilaterally in 47.9%, 33.9%, and 18.2% of patients, respectively. The overall rate of disease recurrence was 17.3%. The recurrence rate was higher when the left ovary was involved than when it was not (29% vs. 7.3%; P<.05). The overall rate of spontaneous pregnancy was 48.1%. The median interval between surgery and occurrence of pregnancy was shorter in patients with endometriosis limited to the right hemipelvis than in those with disease limited to the left side (21 months [range, 12-48 months] vs. 9 months [range, 6-12 months]; P<.01). CONCLUSION(S): The likelihood of disease recurrence is lower when endometriosis is located only on the right side of the pelvis than when the left side is involved. In patients who try to conceive, the time between surgery and occurrence of pregnancy seems to be shorter when the endometriosis is localized in the right hemipelvis.

Case-control study on risk factors for premature ovarian failure.

Objective of this case-control study was to investigate the potential risk factors for premature ovarian failure (POF). Seventy-three patients with secondary hypergonadotropic amenorrhea and, as control group, 144 women with acute, non-gynecological, non-neoplastic, non-hormone-related diseases were included in the study. Information was obtained on sociodemographic characteristics, gynecological and obstetric data, general lifestile habits, smoking habits and history of selected gynecological and other clinical conditions. A statistically significant association between high education level and POF was found (p = 0.03). Parity was related to a reduced risk of POF and this reduction increased with the number of live births (p = 0.02). No association emerged between POF risk and age at menarche, cycle length and oral contraceptive use. Women with POF could not be distinguished from control women by behavioral and reproductive history, except for lower fertility. The minor influence that reproductive and lifestyle factors have on the occurrence of POF suggests that genetic inheritance plays a more important role.

The idiopathic forms of premature menopause and early menopause show the same genetic pattern.

Genetic factors may influence the timing of menopause. Premature ovarian failure (POF) has recently been identified as a genetic entity, but no genetic data are available on early menopause (EM). We investigated 36 patients with EM (age of menopause between 40 and 45 years of age) using cytogenetic and pedigree analysis. In 30 patients of this study the EM was idiopathic and 15 subjects (50%) had a familial condition of EM or POF. Pedigree analysis revealed a dominant pattern of inheritance of EM through maternal or paternal relatives. Our data reveal that POF and EM patients show the same genetic features and we postulate that these conditions may be a variable expression of the same genetic disease.