Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe.

BACKGROUND: The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe. OBJECTIVES: The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth. DESIGN: Survey of policies. SETTING: The project was a European collaboration, with participants in 14 European countries. SAMPLE: All maternity units in 12 countries and in selected regions of two countries in Europe. METHODS: A postal questionnaire was sent to all or a defined sample of maternity units in each participating country. MAIN OUTCOME MEASURES: Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage. RESULTS: Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable. CONCLUSIONS: Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.

[Primary genital herpes infection in pregnancy]. / Infezione erpetica primaria in gravidanza.

A case report of primary genital herpes infection in a 36-years old pregnant woman during her second pregnancy is presented; the patient was treated according to American College of Obstetricians and Gynecologists guidelines. Maternal primary herpes simplex virus (HSV) genital infection arose at the 16th week of gestation and treated orally with acyclovir 400 mg 3 times a day for a period of 10 days. Nested polymerase chain reaction (PCR), positive on vaginal swab, resulted negative on the maternal serum and on the amniotic fluid (at the 21st week). The patient was monitored for the rest of her pregnancy and she received a suppressive oral acyclovir therapy (400 mg 3 times daily) from the 36th week of gestation until the vaginal delivery, occurred spontaneously at the 38th week with an HSV negative vaginal swab. The live male infant, weighing 3,050 g and with Apgar scores of 7-9 at 1 and 5 min, was delivered and in repeated clinical examinations resulted negative to HSV laboratory investigations with no evidence of herpes infection or adverse effects due to acyclovir therapy.

[Severe form of herpes gestationis]. / Herpes gestationis. Una forma severa.

We report a very severe form of herpers gestationis that arose at the 26(th) week of pregnancy and reached us for observation at the 30(th) week. Herpes gestationis in an autoimmune vesicobullous dermatosis characterised by skin eruptions, intense itching and consequent increase in fetal morbility, with delayed intrauterine growth and prematurity. Owing to its particular severity (involvement of the entire body surface including the face), between the 30th and the 32(nd) weeks we had to address a severe clinical condition characterised by anaemia, marked hypoproteinaemia, hypoalbuminaemia, hupertension and hyperglycaemia which led us to resort to the maximum dose of oral corticotherapy in association with topical therapy using clobetasol propionate. In our opinion the results obtained were highly statisfactory with the result that at the end of the 37(th) week, in consideration of the patient's obstetric history, podalic presentation and parity, we performed a Caesarean delivering a newborn of 3000 g in excellent condition. The patient was discharged symptom-free on the 6(th) day and the newborn was in full healt.

The effect of a soy rich diet on the vaginal epithelium in postmenopause: a randomized double blind trial.

BACKGROUND: A traditional asiatic phytoestrogen-rich diet is associated with a lower incidence of estrogen-dependent cancers and clinical consequences of postmenopausal estrogen deficiency. First Wilcox in 1990, showed an increase of the vaginal cell maturation with phytoestrogens on postmenopausal women, but this has not been confirmed in some subsequent studies. METHODS: In this study, we analyzed the effects of a 6-month soy-rich diet on the vaginal epithelium of asymptomatic postmenopausal women in a randomized clinical trial. 187 women were recruited for the study and divided into three groups: a phytoestrogen rich diet group; a hormonal replacement group, and a control group. A vaginal sample for hormonal cytology was taken before and at the end of the study, and sent unnamed to a cytologist. RESULTS: The karyopycnotic index (KI) increased significantly in the diet group and in the HRT group but not in the control group. The maturation value (MV) had an identical trend to the KI. CONCLUSION: We conclude that a soy rich diet is efficacious in increasing the maturation indices of vaginal cells. This effect could be a useful marker of the efficacy of a dietary intervention with phytoestrogen rich foods, and should be considered during preventive interventions against menopausal effects and vaginal atrophy.

Efficacy of a soy rich diet in preventing postmenopausal osteoporosis: the Menfis randomized trial.

OBJECTIVES: To compare the effect of a soy rich diet and hormone replacement therapy (HRT) on the main biomarkers of bone turnover and bone mineral density (BMD) at postmenopausal age. METHODS: 187 healthy asymptomatic postmenopausal women, aged 39-60, were recruited and randomized into a soy rich diet group, a HRT group, and a control group. Bone biomarkers and BMD were evaluated at baseline and after 6 months at the end of the study. RESULTS: Diet is not as effective as HRT in reducing the postmenopausal turnover; however diet stimulates bone osteoblastic activity, as evidenced by significant increase in osteocalcin concentrations. BMD decreases significantly only in the control group, but not in the intervention groups. CONCLUSIONS: Our data suggest that soy products could be effective in reducing the risk of osteoporosis in asymptomatic postmenopausal women, but our findings should be confirmed before recommending the diet as a valid alternative to HRT.

The effects of a soy rich diet on serum lipids: the Menfis randomized trial.

OBJECTIVE: To assess beneficial effects of a soy rich diet on the main biomarkers of cardiovascular health in menopause, compared with the effects of the hormone replacement therapy (HRT). METHODS: 187 healthy asymptomatic postmenopausal women, aged 39-60, were recruited and randomized into three groups: a soy rich diet group, a HRT group, and a control group. Lipid profile, body mass index, blood pressure, endometrial thickness, uterine artery resistance index (RI), were evaluated in all the participants at the baseline, after 6 months, and at the end of the study. RESULTS: After a 6-month intervention period, the lipid profile in the soy rich diet group showed a favourable outcome, similar to that observed in the HRT group, but compliance to the diet was low. CONCLUSION: Soy products may be used in the prevention of cardiovascular risk in postmenopausal women because of their efficacy in contrasting the negative effects of menopause on the cardiovascular system, but our findings should be confirmed; moreover, suitable strategies to improve the compliance have to be considered.

Postmenopausal osteoporosis and celiac disease.

Individualizing risk factors is the most important tool to prevent late consequences of menopause. Celiac disease is a predisposing condition not very considered for some postmenopausal diseases, such as postmenopausal osteoporosis. In this review the authors examine climacteric conditions that could be heightened by a celiac status especially if disregarded and untreated.

Influence of the hormonal status on somatic, psychopathological and mood symptoms in climacteric women.

OBJECTIVE: To evaluate the influence of hormonal status on somatic, psychopathological and mood symptoms in climacteric women. METHOD: 122 postmenopausal women have been evaluated by the PISA-system and P.O.M.S. (Profile of Mood States) to evaluate somatic, psychopathological and mood symptoms in a 3-intervention trial (perimenopausal women, postmenopausal women on replacement therapy, and postmenopausal women without any therapy). RESULT: We found no statistically significant difference among the three groups. A clear trend has however resulted: sex hormones seem to decrease the depressive mood, aggressiveness/anger and sexual dissatisfaction. CONCLUSION: Our results are inconclusive but they suggest that hormones influence some psychological and mood symptoms during the climacterium.

[Recruitment strategies for a randomized clinical study]. / Strategie di reclutamento per uno studio clinico randomizzato.

BACKGROUND: To value the level of acceptance of the Memphis Study, (a random clinical study suggested verifying the efficacy of a diet enriched with phytoestrogens to prevent menopausal problems), and underlining the reasons which induce the acceptance or refusal of the study. STUDY DESIGN: Prospective study. METHODS: Meeting groups have been held with 82 women needing Day Hospital treatment for Menopause at III Department of Obstetrics and Gynecology of the University of Bari. The features of women and the reasons that induce these++ acceptance or refusal of the study were valued by an anonymous questionnaire with a precoded reply. RESULTS: 92.9% of the women accepted participation in the study. The main reasons for acceptance were: 1) believing that the study was drawn up for women; 2) it was done by expert physicians; 3) it was not done for financial gain. The random standard was the main reason for refusal. CONCLUSIONS: With this method we had a very high acceptance, talking over the goals and problems that study aimed to address and to resolve. The chance offered to judge the reliability and competence of physicians is important.

[Territorial research on the availability of phytoestrogen rich foods]. / Indagine territoriale sulla disponibilità di alimenti ricchi di fitoestrogeni.

BACKGROUND: To verify the availability of foods containing phytoestrogens, the quality of available products, the degree of knowledge of these foods by dealers, the willingness of dealers to give cooperation in preparation of the MENFIS study, a study assessing the efficacy of a phytoestrogen rich diet on the long term effects of menopause. METHODS: Perspective research by questionnaires carried out in the herbalist's shops of Bari. RESULTS: For the aims of the study the herbalist's shops resulted in being the most suitable, because they were the most supplied with these products and with natural foods, with a high degree of knowledge of these foods and a helpfulness towards the users, perhaps because of the strong motivation towards this type of diet. CONCLUSIONS: The easy availability of these products, the good preparation of managers of the herbalist's shops and their good experience is a sound basis for those intending to start dietary programs with phytoestrogen rich foods.

Factors of risk for breast cancer influencing post-menopausal long-term hormone replacement therapy.

The advantages of hormone replacement therapy (HRT) are well documented in contrasting the symptomatology of climacterium and in reducing morbidity and mortality associated with coronary heart disease and osteoporotic fractures of postmenopausal age. However, growing evidence points to increased breast cancer risk in HRT long-term users, and the adverse effect would, obviously, overwhelm any other benefit. At present, the risk/benefit ratio of HRT is an object of hot debate, and we feel it necessary and urgent to select women who can safely benefit from HRT and women whose risk of breast cancer can be perilously increased by the raised hormonal levels related to HRT. We have reviewed studies on the breast cancer risk in HRT users and data on the interaction between steroid hormones and breast cancer. Reasoning that the outcome of mammary cancer can be increased by hormonal overstimulation of the breast, we have focused on those factors of risk that could be further enhanced by the exogenous hormonal stimulus of HRT, so as to cause a further significant increase in the risk of breast cancer. We conclude that some biologic and clinical markers, namely android obesity, bone density, mammographic density, androgen and estrogen circulating levels, alcohol consumption, benign breast disease, and familiarity, should be carefully considered before prescribing long-term HRT. Our analysis suggests that HRT could increase the risk of breast cancer and useless in preventing coronary heart disease and osteoporotic fractures when administered in women with positivity for one or more of these markers.

Sonographic, hysteroscopic, and histologic evaluation of the endometrium in postmenopausal women with breast cancer receiving tamoxifen.

STUDY OBJECTIVE: To evaluate the estrogenic effects of tamoxifen on the endometrium in postmenopausal women with breast cancer. DESIGN: Consecutive study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Thirty-three women. Interventions. All patients underwent transvaginal sonography (TVS) and color flow Doppler of endometrial vessels, hysteroscopy, and, if necessary, endometrial biopsy or other operative hysteroscopic procedures. MEASUREMENTS AND MAIN RESULTS: In four women the endometrium was thin on TVS and atrophic at hysteroscopic assessment. In 29 women with thick endometrium on TVS, hysteroscopy and endometrial biopsy showed atrophy (11 patients), hyperplasia (5), polyps (11), and well-differentiated adenocarcinoma (2). The two endometrial cancers were present in women with uterine bleeding. In women with positive histologic findings, the endometrium was significantly thicker (p = 0.04) and duration of tamoxifen therapy longer than in those with negative findings, although this was not statistically significant (p = 0.067). CONCLUSION: We believe regular assessment of the endometrium by TVS should be performed in postmenopausal patients at the start of the tamoxifen therapy, and hysteroscopy in women with a thick endometrium or postmenopausal bleeding. We believe that patients with thin endometrium on TVS at the beginning of tamoxifen therapy, who have no abnormal uterine bleeding should be screened with these examinations for 2 years.

Dietary phytoestrogens in the prevention of long-term postmenopausal diseases.

Phytoestrogens (PEs) are natural compounds, with a biological activity like estrogen, which comprise isoflavones, lignans and coumestans. A traditional Asiatic phytoestrogen-rich diet is associated with a lower incidence of breast cancer and postmenopausal illness, and much evidence indicates that PEs prevent bone resorption, increase bone density and reduce cholesterol. The estrogenic effects of phytoestrogens can be useful in preventing postmenopausal osteoporosis and cardiovascular disease.

[Severe preeclampsia. Appropriate management and socio-cultural factors]. / La preeclampsia severa. Adeguato management e fattori socioculturali.

BACKGROUND: Preeclampsia in its severe form is characterized by a high incidence of both maternal and fetal morbidity and mortality. Its prevention is therefore one of the fundamental goals of modern obstetrics. METHODS: Twenty-two women with severe preeclampsia have been perspectively examined and compared with 66 women without preeclampsia with the aim to evaluate the effect of the prenatal care and the influence of sociocultural variables. RESULTS: Differences between the two groups weren't observed with regard to sociocultural features, but the women with severe preeclampsia were treated later and less controlled during pregnancy. CONCLUSIONS: Preeclampsia requires a careful surveillance and an intense care, above all in its severe form, to avoid the high tribute of maternal and fetal complications that this syndrome still causes today.

[Phytoestrogen-containing food and prevention of postmenopausal osteoporosis and cardiovascular diseases]. / Fitoestrogeni alimentari e prevenzione dell'osteoporosi e della malattia cardiovascolare postmenopausale.

Food phytestrogens and prevention of postmenopausal osteoporotic and cardiovascular disease. Phytestrogens are diphenolic compounds, widely found in plants and foods, with structural and biological estrogen-like similarities. Their anti-estrogenic effects are well known and studied due to the possibility to prevent some tumors such as breast and prostate cancer. In menopause they have an estrogenic-like action on lipidic and bone metabolism. Phytestrogens rich foods can positively affect the postmenopausal osteoporotic and cardiovascular pathology.

Evaluation of nonspecific immunity and plasma levels of interferon-gamma, interleukin-6 and tumor necrosis factor-alpha in preeclampsia.

In this study we evaluated the maternal cell-mediated immune aspects of preeclampsia in terms of phagocytosis and killing of monocytes and polymorphonuclear cells. To evaluate the contribution of cytokines (Cks) in the pathophysiology of preeclampsia, we investigated the plasma levels of interferon-gamma (IFN-gamma), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), respectively, by an enzyme-linked immunosorbent assay. Data showed that phagocytic and killing activities of monocytes were depressed in preeclamptic and normal pregnancies. At the same time, IFN-gamma plasma levels were undectable in both groups. Conversely, we detected significant levels of TNF-alpha in plasma from preeclamptic and normal pregnancies. Moreover, since in three preeclamptic patients the onset of severe preeclampsia was associated with a sharp increased of TNF-alpha plasma levels, we suggest that an increased production of this CK may be implicated in the pathophysiology of preeclampsia.

Postmenopausal users of long-term hormonal replacement therapy: social-cultural features.

OBJECTIVE: To study of influence of social-cultural factors on the effects of long-term hormonal replacement therapy (HRT) in preventing cardiovascular disease and menopausal osteoporosis. METHOD: We examined, perspectively the social-cultural features of 394 postmenopausal women who attended the menopausal out-patient department and were eligible for long term HRT. RESULTS: The HRT users were thinner and younger, with earlier menopause, physically more active, healthier, with more oophorectomies and with more professional work. Data shows that, as a whole, a greater number of healthy women are selected or self-selected for HRT. CONCLUSION: Evaluating the results of long-term HRT in preventing cardiovascular disease and menopausal osteoporosis, the social-cultural features of HRT users must be carefully considered before any mass preventive interventions.

Breast cancer and replacement therapy: which women are at risk?

The fear of breast cancer is the most important concern for women who have to decide whether to take hormone replacement therapy (HRT) for the treatment and prevention of postmenopausal disturbances. A calculation of the risk for breast cancer with respect to HRT is useful to reassure women about this risk and to help them to decide. In the present report, all breast cancer risk factors have been examined and those likely worsened by increased levels of estrogens with HRT have been considered. On the basis of pathogenic, clinical and epidemiological evidence seven breast risk factors (testosterone levels, body mass index, waist-to-hip ratio, alcohol consumption, density to mammography, previous benign breast disease, familiarity) have been selected and a score has been awarded to them; then a model for the calculation of the SRR (Summary Relative Risk) has been elaborated. A simple, feasible, easy to achieve decision model for the calculation of breast cancer risk is proposed in relation to the use of HRT.