The Effect of Chorionicity on Maternal Cardiac Adaptation to Uncomplicated Twin Pregnancy: A Prospective Longitudinal Study.

OBJECTIVE: The objective of this study was to longitudinally evaluate maternal echocardiographic findings in uncomplicated twin gestations according to chorionicity. METHODS: Healthy women with twin pregnancy were assessed with transthoracic echocardiography across the first, second, and third trimesters. Cardiac findings were compared within each group and between monochorionic (MC) and dicho-rionic (DC) pregnancies. RESULTS: Overall, 19 MC and 48 DC uncomplicated twin pregnancies were included. In the MC group, no significant maternal haemodynamic changes were documented across gestation, with the exception of a decrease in ejection fraction. Compared to DC pregnancies, in the MC set lower cardiac output (second and third trimester, p = 0.001 and p = 0.006, respectively) and higher total vascular resistance (first trimester, p = 0.032) were observed. Regarding the diastolic function in MC twins, significantly higher values were observed for mitral E/A ratio (third trimester, p = 0.014), septal mitral E1/A1 ratio (third trimester, p = 0.030), lateral mitral E1 (second and third trimester, p = 0.014 and p = 0.029, respectively), and E1/A1 ratio (third trimester, p = 0.006). CONCLUSIONS: Maternal cardiac adaptation in twin pregnancy seems to differ significantly according to chorionicity. In particular, in MC pregnancies the impairment of diastolic function is less pronounced, presumably due to the lower circulating volume.

Self-Amputation of the Extra Digit in a Fetus with Polydactyly: First Ultrasound Demonstration.

We herein report the first ultrasound evidence of the self-amputation of an extra digit in case of fetal polydactyly. The prenatal evidence of fetal polydactyly is not always followed by postnatal confirmation. This is not always due to ultrasound misdiagnosis, but often to an in utero self-amputation phenomenon. We demonstrate that there is the detachment of part of the digit, leading to the evidence of a neonatal bump on the site of the prenatal extra digit. This demonstration has been possible by the direct visualization of the remnant by ultrasound.

The "occiput-spine angle": a new sonographic index of fetal head deflexion during the first stage of labor.

BACKGROUND: Fetal head "attitude" (relationship of fetal head to spine) in the first stage of labor may have a substantial impact on labor outcome. The diagnosis of fetal head deflexion traditionally is based on digital examination in labor, although the use of ultrasound to support clinical diagnosis has been recently reported. OBJECTIVES: The aims of this study were: (1) to quantify the degree of fetal head deflection via the use of sonography during the first stage of labor; and (2) to determine whether a parameter derived from ultrasound examination (the occiput-spine angle) has a relationship with the course and outcome of labor. STUDY DESIGN: This was a prospective multicentric, cross-sectional study conducted at the Maternity Unit of the University of Bologna and Parma from January 2014 to April 2015. A nonconsecutive series of women with uncomplicated singleton pregnancies at term gestation (37 weeks or more) were submitted to transabdominal ultrasound during the first stage of labor. If fetal position was occiput anterior or transverse, the angle between the fetal occiput and the cervical spine (the occiput-spine angle) was sonographically obtained on the sagittal plane. The measurements of the occiput spine-angle were performed offline by 2 operators who were blinded to the labor outcome. The intra- and interobserver reproducibility and the correlation between the occiput-spine angle and the mode of delivery were evaluated. RESULTS: A total of 108 pregnant women were recruited, 79 of which underwent a spontaneous vaginal delivery and 29 were submitted to obstetric intervention (19 cesarean delivery and 10 instrumental vaginal deliveries). The mean value of the occiput-spine angle measured in the active phase of the first stage was 126° ± 9.8° (SD). The occiput-spine angle measurement showed a very good intraobserver (r = 0.86; 95% confidence interval [95% CI] 0.80-0.90) and a fair-to-good interobserver (r = 0.64; 95% CI 0.51-0.74) agreement. The occiput-spine angle was significantly narrower in women who underwent obstetric intervention (cesarean or vacuum delivery) due to labor arrest (121° ± 10.5° vs 127° ± 9.4°, P = .03). Multivariable logistic regression analysis showed that narrow occiput-spine angle values (OR 1.08; 95% CI 1.00-1.16; P = .04) and nulliparity (OR 16.06; 95% CI 1.71-150.65; P = .02) were independent risk factors for operative delivery. A larger occiput-spine angle width (i.e., >125°) showed to be significantly associated with a shorter duration of labor (hazard ratio = 1.62; 95% CI 1.07-2.45; P = .02). CONCLUSION: We described herein the "occiput-spine angle," a new sonographic parameter to assess fetal head deflection during labor. Fetuses with smaller occiput-spine angle (<125°) are at increased risk for operative delivery.

Quality of life in patients affected by endometrial cancer: comparison among laparotomy, laparoscopy and vaginal approach.

The aim of this study is to verify if the surgical approach (laparoscopy/laparotomy/vaginal) in stage-I endometrial cancer treatment, may have effects on intra- and post-operative outcomes and on the patient's quality of life. The study group consisted of patients with histological diagnosis of type-I endometrial adenocarcinoma, stage-I. They were divided into three groups according to surgical approach chosen (laparotomic/laparoscopic/vaginal). Every patient answered a telephone health survey (SF-36) at 30 and 180 days post-surgery. Surgical-operating times, hospitalization length and short/long-term complications after surgery were also compared. The SF-36 survey revealed a better performance status in patients who underwent laparoscopy as compared to those who received laparotomy or vaginal surgery. We found significantly better results considering General Health, Physical Functioning, Role-Physical and Bodily Pain in the laparoscopy group after 30 and 180 days. Patients who underwent laparoscopy had significantly shorter hospitalization and less post-operative complications even if laparoscopy required significantly longer surgical-operating times compared to vaginal surgery. Our data confirm the superiority of the laparoscopic approach respect to the laparotomic and vaginal ones both in term of hospitalization length and post-operative complications.

Assessment of tumor size as a useful marker for the surgical staging of endometrial cancer.

Accumulating evidence suggests that the estimation of tumor size may improve endometrial cancer treatment. We conducted an observational study aimed at elucidating the association between tumor size and other universally accepted prognostic factors in order to identify suitable preoperative parameters which can guide surgery in a subgroup of early corpus endometrial cancer. We found that when tumor size increased, both stage and grading were significantly increased. Tumor size was correlated with CA 125 serum values, node metastasis and peritoneal cytology status. Patients who have grade 1 or 2 endometrioid corpus cancer, myometrial invasion < 50% and ≤ 3 cm largest tumor diameter can only be treated with hysterectomy. The tumor largest diameter should be evaluated as a preoperative parameter that indicates patients who do not require lymphadenectomy.

Impact of Highly Active Antiretroviral Therapy on the Natural History of Cervical Precancerous Lesions: A 17-Year Institutional Longitudinal Cohort Study.

We performed an observational cohort study in order to assess the correlation between precancerous cervical lesions (cervical intraepithelial neoplasia [CIN]) and immunological state in human immunodeficiency virus (HIV)-positive women treated by highly active antiretroviral therapy (HAART). We analyzed 194 HIV-infected women referred to the Parma-Universitary Hospital for early detection of human papilloma virus-induced CINs. We analyzed cytology, colposcopy, and CIN degree according to HAART: group A untreated and group B treated. We compared the CD4+ count and viral load at the time of CIN onset and the time interval between diagnosis of HIV and the onset of CIN. Group A and group B showed homogeneous results for general features, CD4+ count, viral load, and Papanicolaou test features. Differences were not found in terms of histology and CD4+ value, viral load count, pharmacological treatment, years since the diagnosis of HIV, age, smoking, sexual promiscuity, previous intravenous narcotics abuse, prostitution, sexually transmitted diseases, ethnicity, and age at diagnosis. Histology and the clinical stage of HIV showed significant concordances between the high degree of cervical dysplasia and advanced stage of HIV disease.

Risk of preterm delivery associated with prior treatment of cervical precancerous lesion according to the depth of the cone.

The aim of this study was to evaluate the impact of the surgical excisional procedures for cervical intraepithelial neoplasia (CIN) treatment both on subsequent fertility (cervical factor) and pregnancy complication (risk of spontaneous preterm delivery). We retrospectively analyzed 236 fertile women who underwent conization for CIN. We included in the study 47 patients who carried on pregnancy and delivered a viable fetus. Patients were asked about postconization pregnancies, obstetrical outcomes, and a possible diagnosis of secondary infertility caused by cervical stenosis. We evaluated the depth of surgical excision, the timing between cervical conization and subsequent pregnancies, surgical technique, and maternal age at delivery. We recorded 47 deliveries, 10 cases of preterm delivery; 8 of them were spontaneous. The depth of surgical excision showed a statistically significant inverse correlation with gestational age at birth. The risk of spontaneous preterm delivery increased when conization depth exceeded a cut-off value of 1.5 cm. Our data do not demonstrated a relation between conization and infertility due to cervical stenosis.

Can the impact of pelvic inflammatory disease on fertility be prevented? Epidemiology, clinical features and surgical treatment: evolution over 8 years.

OBJECTIVE: To assess the epidemiological features and the trend of care of patients diagnosed with pelvic inflammatory disease (PID) and to assess most predictive parameters of severe disease, for which surgical management is warranted, in particular when surgery is certain to cause permanent infertility. STUDY DESIGN: The study population was divided into 3 groups: medical therapy only, conservative surgery, and destructive surgery (surgical procedures that impaired fertility). Data from the 3 groups were compared with respect to general and medical history data, clinical signs on admission, laboratory tests, and ultrasound findings. The p value was considered significant when < 0.05. RESULTS: The non-Italian women in the study appeared to be more at risk of developing PID and were overrepresented in the surgically treated groups. C-reactive protein (CRP) and D-dimer values most likely correlated with disease severity. Ultrasound evidence of ovaritis generally led to medical therapy. Conversely, when sonography revealed pyosalpinx or tuboovarian abscesses, surgery was performed. CONCLUSION: Clinical presentation is fundamental in diagnostic counseling but should be supplemented with further laboratory tests to detect inflammation and sonograms. The latter, along with CRP and D-dimer assays, may represent useful parameters to consider when planning patient management because they appear indicative of the need for surgical treatment.

A prospective, case-control study on the lipid profile and the cardiovascular risk of menopausal women on oestrogen plus progestogen therapy in a northern Italy province.

PURPOSE: To evaluate the effects of oestrogen plus progestogen therapy (EPT) on the lipid metabolism of menopausal patients. METHODS: We conducted a prospective study on 223 patients with clinical and blood chemistry diagnosis of menopause, who were eligible for hormone therapy and a follow-up period lasting at least 5 years. We selected a control group. Patients attended annual or 6-monthly visits for the duration of the 5-year follow-up period. For each patient, total-cholesterol, HDL-cholesterol, LDL-cholesterol and triglyceride values were considered at the first visit and after 5 years. We compared these values of the above parameters in relation to time and EPT and the repercussions that the presence/absence of replacement therapy had in terms of lipid profile alteration between the groups studied. RESULTS: Of the 223 patients eligible for enrolment, 178 made up the study group (EPT Group) and 45 made up the control cohort (N-EPT-Group). At the first visit, median value was (EPT-Group vs. N-EPT-Group): cholesterol was 240 versus 226 mg/dL, LDL-cholesterol 169 versus 174 mg/dL, HDL-cholesterol 60 mg/dL in both groups, triglyceride 125 versus 92 mg/dL (p:n.s). Five years later, median value was (EPT-Group versus N-EPT-Group): cholesterol 225 versus 236 mg/dL (p < 0.001), LDL-cholesterol 125 versus 184 mg/dL (p < 0.001), HDL-cholesterol 64 versus 68 mg/dL (p:n.s.), triglyceride 72 versus 94 mg/dL (p:n.s.). No adverse effects of EPT were observed. CONCLUSIONS: Thorough risk/benefit assessment, associated with initially low doses and without rigid cutoffs, particularly when started early, EPT can be made a valid means of cardiovascular prevention, specifically because it positively alters the lipid profile of menopausal women.

Total laparoscopic hysterectomy: our experience from 2008 to 2012.

OBJECTIVES: Nowadays total laparoscopic hysterectomy (TLH) is a surgical procedure increasingly adopted for the treatment of benign and malign uterine disease. The aim of our study is to revise our recent experience of TLH. METHODS: This is a retrospective observational study conduced on 101 patients between 2008 and 2012. The surgical procedure has been performed by the same surgeon and with the same surgical technique. Patients with benign disease and I-II stage endometrial cancer (FIGO 2009) were considered eligible for the study. Data collected were concering weight, height, BMI, age; kind of disease; type of surgery performed and possible variants; surgery duration; intra-operative and post-operative complications. RESULTS: In 80 patients TLH was performed for benign disease, in 42 cases uterine fiboids; salpingo-oophorectomy has been performed in 37 patients; the mean surgical time was 81 minutes for benign disease and 112 minutes for malign disease. In 1 case conversion to laparotomy was required; in 5 patients we recorded post-surgical fever; in 1 patients we recorded deiscence of vaginal vault. None of the considered factors (age, BMI, kind of surgery) was significantly associated with increased frequency of intra- and post-operative complications. CONCLUSIONS: Our clinical experience on TLH is increasing as years pass by, and our results are in line with those reported by other Centers. On the basis of our experience, in agreement with recently published data, we believe that vaginal vault closure should be performed through vaginal access.

[Rhabdomyoma of the vagina. Case report and short literature review]. / Rhabdomyome du vagin. Revue de la littérature à partir d'un cas clinique.

The differential diagnosis of vaginal polypoid masses should take rhabdomyoma into consideration even it is an extremely rare tumor. The present report describes a vaginal cystic mass located in the anterior wall of an asymptomatic, 38-year-old, Caucasian, nulliparous woman. Local excision and subsequent pathological examination were performed. The final diagnosis was vaginal rhabdomyoma. The literature is reviewed and differential diagnosis are discussed.

Extragenital Müllerian adenosarcoma with pouch of Douglas location.

BACKGROUND: Of all female genital tract tumors, 1-3% are stromal malignancies. In 8-10% of cases, these are represented by Müllerian adenosarcoma an extremely rare tumor characterized by a stromal component of usually low-grade malignancy and by a benign glandular epithelial component. Variant that arises in the pouch of Douglas is scarcely mentioned in the medical literature. CASE PRESENTATION: A 49-year-old para-0 woman, was seen at our OB/GYN-UNIT because she complained vaguely of pelvic pain. She had a mass of undefined nature in the pouch of Douglas. A simple excision of the mass showed low-grade Müllerian adenosarcoma with areas of stromal overgrowth. One and a half year after surgery, at another hospital, a mass was detected in the patient's posterior vaginal fornix and removed surgically. Six months later she came back to our observation with vaginal bleeding and mass in the vaginal fornix. We performed radical surgery. The pathological examination showed recurrent adenosarcoma. Surgical treatment was supplemented by radiation therapy. CONCLUSIONS: The case of Müllerian adenosarcoma reported here is the third known so far in the literature that was located in the pouch of Douglas. To date, only two other such cases have been reported, including one resulting from neoplastic degeneration of an endometriotic cyst.

CA 125 serum values in surgically treated endometriosis patients and its relationships with anatomic sites of endometriosis and pregnancy rate.

Endometriosis is a benign gynecologic disease defined as the presence of functional endometrial glands and stroma outside the uterine cavity, causing dysmenorrhea, dyspareunia, menstrual irregularities, and infertility. Serum CA-125 measurement is now a consolidated method for diagnosing this condition, and its interpretation has posed a number of problems, particularly regarding utility in diagnosing minimal-mild endometriosis, whereas its value as a diagnostic aid in moderate-severe stages is well recognized. In our cohort, serum CA-125 values were significantly elevated in patients with ovarian and mixed endometriosis lesions (median levels 48 U/mL), compared with those who had exclusively extraovarian foci (median levels 27 U/mL), and so the correlation between this marker and the surgical and pathologic finding of ovarian and deep endometriosis was found to be statistically significant; however, the location did not affect the fertility rate.

Role of D-dimer testing in severe pelvic inflammatory disease: a new usable marker to assess the need for fertility-impairing surgery?

Pelvic inflammatory disease (PID), like many other inflammatory diseases, can be characterized by an inflammation-induced activation of the coagulation cascade, resulting in the production of D-dimers. In this study it is demonstrated how high levels of D-dimers, assayed at the time of hospitalization, are encountered in patients diagnosed with PID and how the levels of this parameter are significantly higher in patients, which due to the severity of the disease, needed surgical treatment. Therefore the d-dimer is shown to be an important parameter to be considered in the therapeutic counseling of severe forms of PID.