Challenges for Midwives' Healthcare Practice in the Next Decade: COVID-19 - Global Climate Changes - Aging and Pregnancy - Gestational Alcohol Abuse.

Midwives are multifaceted healthcare professionals whose competence spectrum includes a large variety of knowledge and skills going from antenatal care to education and research. The aim of this review is to suggest the future challenges midwives are going to face in the upcoming decade of this Century. COVID-19 and other infections will reasonably impact healthcare workers all over the world. Midwives are frontline healthcare professionals who are constantly at risk of contagion as their job implies close contact with women, physical support and hand touch. Also, menstruation waste plays a large role in the pollution of waters, severely impacting hygiene in the developing countries and fueling climate change. Appropriate disposal of used menstrual material is still insufficient in many countries of the world especially because of lack of sanitary education on girls. As educators, midwives will be more involved into preventing inappropriate disposal of menstrual hygiene devices by educating girls around the world about the green alternatives to the commercial ones. Despite the evidences about the fertility decrement that occurs with aging, women keep postponing reproduction and increasing their chance being childless or suffering complications related to the advanced maternal age. Teen pregnancies are as well an important issue for midwives who will be called to face more age-related issues and use a tailored case to case approach, enhancing their family planning skills. Another crucial role of midwifery regards the information about the risk of drinking alcohol during gestation. Alcohol assumption during pregnancy is responsible for serious damage to the fetus causing a wide range of pathological conditions related to Fetal Alcoholic Spectrum Disorder, leading cause of mental retardation in children of western countries. On the whole, midwives have demonstrated their willingness to expand their practice through continuing professional development, and through specialist and advanced roles especially in preventive and educational positions.

A longitudinal study of painless and painful intercostobrachial neuropathy after breast cancer surgery.

Intercostobrachial neuropathy, often resulting in neuropathic pain, is a common complication of breast cancer surgery. In this 1-year longitudinal study, we aimed at seeking information on the frequency, clinical features, and course of painless and painful intercostobrachial neuropathy. We enrolled 40 women previously undergoing breast cancer surgery. In these patients, we collected, at 3, 6 and 12 months after surgery, clinical and quantitative sensory testing (QST) variables to diagnose intercostobrachial neuropathy, DN4 questionnaire to identify neuropathic pain, Neuropathic Pain Symptom Inventory to assess the different neuropathic pain symptoms, the Beck Depression Inventory to assess depressive symptoms, and SF36 to assess quality of life and Patient Global Impression of Change. Clinical and QST examination showed an intercostobrachial neuropathy in 23 patients (57.5%). Out of the 23 patients, five experienced neuropathic pain, as assessed with clinical examination and DN4. Axillary surgery clearance was associated with an increased risk of intercostobrachial neuropathy. Whereas sensory disturbances improved during the 1-year observation, neuropathic pain did not. Nevertheless, Beck Depression Inventory, SF36, and the Patient Global Impression of Change scores significantly improved over time. Our study shows that although intercostobrachial neuropathy is a common complication of breast cancer surgery, neuropathic pain affects only a minor proportion of patients. After 1 year, sensory disturbances partially improve and have only a mild impact on mood and quality of life.

Hypertensive disorders during pregnancy and 3 years after delivery in women with gestational hyperglycemia.

AIMS: Women with gestational hyperglycemia commonly experience hypertensive disorders during pregnancy. More information is needed about how hypertension develops in these patients over time. We investigated the prevalence of hypertension during and 3 years after pregnancy in Caucasian women with gestational hyperglycemia. We also investigated metabolic syndrome presence, glucose tolerance status, insulin sensitivity and insulin secretion levels in the follow-up period. METHODS: In a prospective longitudinal study with a 3-year follow-up, we assessed hypertension status and clinical-related characteristics of 103 consecutive women with gestational hyperglycemia sub-grouped according to their hypertensive status during and after pregnancy. RESULTS: Overall, 29 (28.1%) women had hypertension during pregnancy (24 gestational hypertension; 4 chronic hypertension; 1 preeclampsia). At follow-up 16 (15.5%) women were diagnosed as having hypertension (11 with hypertension in pregnancy; 5 with a normotensive pregnancy). Women with hypertension after pregnancy had higher BMI, metabolic syndrome rate and worse insulin resistance indexes than normotensive women. Weight increase at follow-up (OR 1.17, 95% CI 1.00-1.35) and hypertension in pregnancy (OR 6.72, 95% CI 1.17-38.64) were associated with hypertension after pregnancy. CONCLUSIONS: Women with gestational hyperglycemia should undergo regular monitoring during and after pregnancy to detect metabolic and clinical impairments and to prevent cardiovascular harm.

Placental, lipid, and glucidic effects of mammalian target of rapamycin inhibitors: impact on fetal growth and metabolic disorders during pregnancy after solid organ transplantation.

BACKGROUND: Mammalian target of rapamycin inhibitors (mTORi) are a promising new family of immunosuppressive drugs. No teratogenic effects have been reported to date. Their lipid and glucidic effects should not be underestimated, however, especially during pregnancy. Moreover, mTORi may affect fetal growth by mTOR placental activity. OBJECTIVE: Our purpose was to highlight mTORi placental impact and metabolic implications to detect possible maternal or fetal effects and define management guidelines in pregnant women after solid organ transplantation. METHODS: A literature search was performed for articles from the Medline and Pubmed databases with the use of the following keywords: mTOR inhibitors, pregnancy, placental transport, lipid metabolism, glucose metabolism. RESULTS: mTOR works as a positive regulator of system A, system L, and taurine placental amino acid transporter activity, which are critical for the transport of amino acids to the fetus. Exposing trophoblast cells to rapamycin reduces system L activity; therefore, treatment with rapamycin in human pregnancies could alter fetal growth with intrauterine growth restriction (IUGR). Regarding the metabolic effects mTORi increase lipolysis, impair insulin's antilipolytic effect and reduce lipid storage, which may potentially contribute to dyslipidemia. Chronic rapamycin treatment reduces adipose tissue size and ß-cell mass/function, causes hyperlipidemia, severe insulin resistance, and glucose intolerance, and promotes hepatic gluconeogenesis. CONCLUSIONS: The studies on mTORi treatment in transplanted pregnant women have not focused to date on the potential metabolic and placental effects. Selection of women at high risk for metabolic disorders could be needed and consideration of switching to another immunosuppressive drug required if diabetes and abnormal blood lipids have been diagnosed in prepregnancy counseling. It seems to be mandatory to encourage prompt reporting of any additional cases of pregnancy during mTORi exposure to provide a better understanding of the placental effects and safety profile of these immunosuppressive drugs.

Axillary lymph node metastasis as first presentation of peritoneal carcinomatosis from serous papillary ovarian cancer: case report and review of the literature.

Ovarian cancer usually spreads into abdominal cavity and to the loco-regional lymph nodes. Extra-abdominal metastases are less frequent and isolated axillary metastases are very rare. The authors describe the case of a 49-year-old woman who was diagnosed with a peritoneal carcinomatosis from ovarian cancer by mean of an enlarged axillary lymph node biopsy, whose histological examination identified as a ovarian cancer metastasis. Patient was treated by peritonectomy and intraperitoneal chemohyperthermic perfusion (HIPEC). Although patients with axillary lymph node metastasis from ovarian cancer are though to be metastatic (FIGO Stage IV), surgical radical treatment and adjuvant systemic chemotherapy can achieve the same prognosis of Stage IIIb-c patients, suggesting they could be a particularly good prognosis subset of patients. Early differential diagnosis between ovarian or breast cancer in axillary lymph node metastasis is crucial but not always very simple, because of the very different course and treatment of these tumours.

Is HE4 serum level a valid screening test in women candidates for kidney transplant? A case report and a review of literature.

While studying a candidate for kidney transplant it is essential to exclude active malignant diseases. Serum biomarkers help to exclude specific cancers. Tumor markers are proteins secreted by neoplastic cells that can mark their activities. HE4 is a new tumor marker used in ovarian cancer. It is an epithelium protein that appears overexpressed in ovarian cancer, but it is also present in other normal human tissues. Often in patients with kidney failure serum biomarkers are increased compared to healthy people. We report a case of a Caucasian woman suffering from kidney failure examined by our team to be included on the kidney transplantation list. Patient had a known pelvic mass. Determination of serum biomarkers, CA125 and HE4, was performed to exclude pelvic tumor, and we found high levels of HE4 with normal levels of CA125. A new transvaginal ultrasound was performed on the patient and it showed a pelvic mass near the left ovary. This mass resulted bigger than in the previous ultrasound, performed about a month before. We decided to perform a pelvic CT for improved diagnostic accuracy. The reports of this exam showed that the mass was a hematoma correlated with a previous knee prosthetic surgery. Even tough many serum biomarkers are higher in patients with renal failure, there is no study to demonstrate that HE4 blood levels are modified in these patients. This case report shows how HE4 can be elevated in people in hemodialysis in a benign situation, also in a pelvic mass not from the genital tract. There is no similar case described in literature.

Fertility following solid organ transplantation.

Fertility is usually restored in women after solid organ transplantation, and successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, and lung transplants. However, women with solid organ allografts have higher incidence of pregnancy complications like hypertension, preeclampsia, preterm delivery. Hypertension appears to be dependent on the type of immunosuppressive agents. The influence of pregnancy on the risk of rejection is poorly known on the basis of available data. Rejection rate appears to be at least similar to the nonpregnant population. In some cases, such as in liver transplant pregnant women, even higher as compared to the nonpregnant population. Maintaining appropriate blood levels of immunosuppressive drugs is currently recommended. Malformation rate in the offsprings of transplanted women appears to not be increased; long-term follow- up of children born to allograft recipients is necessary to investigate possible developmental, immunological, or oncological disorders. We followed 70 pregnancies after kidney transplantation and nine after liver transplantation. All recipients were maintained on immunosuppressive therapy during pregnancy, except one mother who refused immunosuppression and experienced transplant rejection. Hypertension was the most frequent complication during pregnancy: in 23% of kidney transplantated mothers and in one out of nine liver transplant recipients. The only malformation observed in the newborns was the dislocation of the hip in the child of a kidney transplant recipient.

[The creation of a neovagina with laparoscopic technique]. / Creazione di una neovagina con tecnica laparoscopica.

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.

Biologic prognostic factors in ovarian cancer: a review.

The need of foreseeing the prognosis of ovarian cancer beyond the limits of classical methods based on clinical and histopathological staging has recently caused great interest in a large number of biologic prognostic markers. Studies concern proliferation associated proteins, suppressor genes, abnormal expressions of growth factors, cytokins, and many more. Here some of the most recent and promising factors being studied are described together with their significance for future clinical application.

[Neoadjuvant chemotherapy in the treatment of breast cancer. Results and prospectives]. / La chemioterapia neoadiuvante nel trattamento del carcinoma della mammella. Risultati e prospettive.

Preoperative chemotherapy for breast cancer has been originally proposed in the treatment of locally advanced tumors (T3b-T4) in order to allow radiotherapy or radical mastectomy. Later, it has been employed also for less advanced stages of the disease (T2-T3), to allow conservative surgery. Personal series of 45 patients that underwent preoperative chemotherapy (FAC) for breast cancer stages T2-T3 is reported. A partial response in terms of reduction of tumor volume was obtained in 80% of these patients, a complete response in 6.6% of the cases. In 48.8% a quadrantectomy has been performed, as the lesion diameter was < 2.5 cm after chemotherapy. The survival rate was 70% at 10 years, and 80% for initially T2 tumors, compared with 50% 10 year survival rate in a group of patients with T2 tumors treated before the introduction of neoadjuvant chemotherapy at our Department. Neoadjuvant chemotherapy allows reduction of the initial volume of breast cancer and performance of conservative instead or radical surgery, with better cosmetic results. Moreover these data suggest that they may improve the plateau of the survival curve of patients with locally advanced breast cancer.

[Gn-RH analogs in the treatment of benign gynecologic diseases: current trends]. / Gli analoghi del Gn-RH nel trattamento della patologia ginecologica benigna: orientamenti attuali.

Gn-RH analogues have been recently employed for the treatment of oestrogen-dependent benign gynaecological disorders, such as uterine myomata, endometriosis or metrorrhagia. They induce a "pharmacological castration", inducing a marked reduction of serum oestrogen levels. They proved more effective than other drugs used up to now in the medical treatment of these benign gynaecological diseases. Thus they were initially employed in every case. Later it became clear that Gn-RH analogues need a selective indication. The authors herein report their series of 70 patients with benign gynaecological disorders (45 uterine fibroids, 10 endometriosis, 15 metrorrhagia), treated with a Gn-RH analogue depot for 2-3 months preoperatively. They evaluated the efficacy of the treatment in the group with uterine fibroids in terms of disappearance of metrorrhagia, better haemoglobin level in anaemic patients, reduction of fibroids size allowing for a simpler and less extensive surgery (vaginal surgery, myomectomy, hysteroscopic resection). The authors discuss those cases when preoperative treatment with Gn-RH analogues is not indicated, or should be employed only under careful surveillance (in the preparation of multiple myomectomies, big submucosal myomas). In the group of 10 patients with endometriosis we observed the disappearance of pelvic pain and dyspareunia, whereas the size of endometriomas was only minimally reduced. The authors discuss the usefulness of this treatment in case of patients with endometriosis grade I or II (minimal or mild), with desire of children. In the group of 15 perimenopausal patients with metrorrhagia, 10 became amenorrhoic after termination of treatment, thus avoiding surgery. The major benefit for the other 5 patients was a better haemoglobin level at the time of surgery.

Ondansetron-induced headache. Our experience in gynecological cancer.

Chemotherapy-induced emesis is one of the major problems in the treatment of oncologic patients. Recently, a novel class of compounds, the selective 5HT3 receptor antagonists, has been introduced, achieving a dramatic improvement in the control of emesis. The absence of extrapyramidal side effects adds to their safety and good tolerability. The Authors herein analyse their experience on 269 cycles of chemotherapy in 47 patients treated for gynaecological and breast malignancies, with particular regard to adverse events such as headache. Their most frequent side-effects are headache and constipation, that are usually mild and self-limiting. Nevertheless, in some cases, severe, rebel headache has been reported, leading in our experience in 6.4% of cases to discontinuation of the antiemetic regimen. A previous history of recurrent or severe headache or migraine is not correlated with the occurrence of ondansetron-induced headache, as severe headache occurred after ondansetron only in 28.4% of the patients with positive anamnesis, and 70% of the patients that experienced had never suffered from severe headache before. In those patients complaining of severe headache, the Authors suggest an antiemetic association, with a loading dose of ondansetron i.v., followed by metoclopramide i.m. orally for the following days.

Ondansetron in chemotherapy-induced emesis. Our experience.

UNLABELLED: Chemotherapy-induced nausea and vomiting is one of the major side effects of antiblastic treatment in cancer patients, seriously affecting both the compliance of the patient to therapy and his or her quality of life. OBJECTIVE: The Authors present their experience in the use of ondansetron in 47 patients receiving 186 cycles of chemotherapy for breast or genital neoplasms. RESULTS: Successful control of vomiting was achieved in the first 24 hours, in 74% of the cycles containing cisplatin and 82% of the cycles without cisplatin, if ondansetron was used. On delayed vomiting the difference in results was not as striking as on acute emesis. CONCLUSIONS: The major side effects with ondansetron were headaches (42.4%) and constipation (48.9%). As expected, no extra-pyramidal symptoms were observed in this group, versus 13.3% of the patients treated with metoclopramide.

Infiltrating lobular carcinoma of the breast (ILC). Diagnostic and therapeutic aspects.

Invasive lobular carcinoma of the breast (ILC) is the second most common form of mammary neoplasm after ductal carcinoma. Due to its histological features, characterised by a diffuse infiltration of the tissue by malignant cells with scarce fibrotic reaction, lobular carcinoma often presents clinical and instrumental diagnostic difficulties. The Authors present a retrospective series of 28 patients with lobular carcinoma, with special regard to the diagnostic work-up. Clinical examination misdiagnosed 10 cases, in which only a mild thickening of the breast parenchyma was present. Mammographic false negatives were 21.4% (6 cases). Ultrasonography allowed correct diagnosis in 5 out of these 6 cases. Fine needle aspiration (FNA) had low sensitivity (33% false negatives). ILC constitutes a diagnostic challenge, often requiring the combination of multiple diagnostic tools.

Complications in the surgical treatment of carcinoma of the endometrium.

The authors report their experience in medical and surgical complications after surgical treatment of endometrial carcinoma, from January 1976 to December 1992, 301 cases of adenocarcinoma were operated by abdominal or vaginal route. From 1980 onwards abdominal route was the most frequent (radical hysterectomy with bilateral adnexectomy Rutledge type II-III with pelvic and/or aortic lymphadenectomy). No lesion occurred either during surgery or later, in the urinary or intestinal apparatus or to the great abdomino-pelvic vessels. The only medical complication observed was one episode of cerebral ictus three days after operation. Two cases of adynamic ileus and five of ventral hernia occurred.

Pre-operative staging of endometrial carcinoma: magnetic resonance imaging versus ultrasounds and hysteroscopy.

Ultrasound, hysteroscopy and magnetic resonance imaging has been considerated to assess the loco-regional or extrapelvic extension of the endometrial carcinoma. Sonography has demonstrated a certain inaccuracy in predicting myometrial invasion or the involvement of the canal. Hysteroscopy allows us to characterize neoplasia and to assess its extension in the cervical canal. MR imaging is more helpful in the diagnosis of channel invasion. The assessment of ovarian metastasis requires ultrasonography or coronal planes RM imaging. As regards the involvement of the pelvic and extrapelvic lymph nodes MR is more accurate than ultrasound scan.

Considerations on the prognostic significance of bone marrow micrometastases in breast cancer.

Research of bone marrow micrometastases in patients with breast cancer was proposed as a prognostic factor in order to detect those patients at high risk for early recurrence. The Authors present a review of current literature and describe the different methods used, with particular regard to monoclonal antibodies. The biological significance and prognostic value of the presence of bone marrow micrometastases in clinically Mo patients with breast cancer are discussed.

Ovarian cysts in the postmenopause: is a conservative treatment feasible?

The incidence of epithelial ovarian cancer reaches a peak between the ages of 50 and 59 years. Therefore any ovarian enlargement in the postmenopause has been treated up to now with prompt surgical exploration. Recently the reliability of ultrasound has allowed a conservative management of small unilocular ovarian cysts even in the postmenopause. The Authors report here their experience on benign masses in postmenopausal women, and discuss the feasibility of ultrasound-guided aspiration of small, anechoic adnexal cysts.

Uterine changes during tamoxifen therapy.

Tamoxifen used for adjuvant therapy in breast cancer, has a complex and unclear action on endometrium and myometrium. Many authors demonstrated endometrial proliferous changes in peri and post menopausal women. Our study shows the development of myomas in three patients without uterine pathology before tamoxifen therapy, and the increase of a polip and a myoma after tamoxifen therapy. Moreover, we observed the development of a myoma in a patient after one year tamoxifen in association with LH-RH analogue therapy. It is necessary to continue our study with a larger number of patients to assess the hyperplasic effect of tamoxifen.