Clinical practice evaluation of combination of atosiban, ritodrine and ketoprofen for inhibiting preterm labor.

AIM: The aim of this study was to compare the efficacy and tolerability of atosiban vs ritodrine administered as single-drug or as combination therapy with the COX inhibitor ketoprofen in the treatment of preterm labor and to investigate how frequent is the need for combination therapy with ketoprofen. METHODS: Ninety-one women with diagnosis of threatened preterm delivery at 24-33 weeks' gestation were enrolled in an observational case-control study. Forty-seven received IV atosiban (6.75 mg initial dose, 300 microg/min loading dose for 3 hours, 100 microg/min maintenance dose for 48-96 hours) and 44 IV ritodrine (0.05-0.3 mg/min). When response to the first drug in the first 2-4 hours was unsatisfactory, ketoprofen was added (100 mg loading dose IV and 100-150 mg maintenance dose every 12 hours) for a maximum of 48 hours. RESULTS: Ketoprofen was added in 51.1% of the atosiban group and 47.7% of the ritodrine group (P 0.75, not statistically significant). The percentages of women non delivered in the two groups were 85.1% vs 81.8% at 48 hours (P=0.44) and 59.6% vs 54.5% at 7 days (P=0.39). One woman treated with atosiban reported transient dyspnea at the administration of the bolus dose; 20.5% of women who received ritodrine developed tachycardia and 4.5% dyspnea (P=0.001). Neonatal mortality and morbidity were comparable in both groups and unrelated to ketoprofen exposure. CONCLUSION: Atosiban efficacy was comparable to ritodrine, but with a superior safety profile. A large proportion of women in both groups required second-line ketoprofen therapy, with comparable neonatal outcomes.

Uterine artery embolization in the treatment and prevention of postpartum hemorrhage.

OBJECTIVES: The study was conducted to evaluate the efficacy of superselective transcatheter uterine artery embolization for control of obstetric hemorrhage. METHODS: Between January 2002 and December 2005, 14 consecutive patients underwent uterine artery embolization to control postpartum hemorrhage, and two to prevent hemorrhage before second-trimester therapeutic abortion. RESULTS: Embolization was performed by transfemoral arterial catheterization. Pieces of absorbable gelatin sponge were used in all cases, with the addition of platinum coils in two cases for complete vessel occlusion. Optimal bleeding control was achieved in all cases but one--a patient who underwent hysterectomy due to embolization failure. No severe complications were observed. CONCLUSIONS: The high success rate, low morbidity rate, and possibility of preserving reproductive function have made superselective uterine artery embolization the technique of choice to control life-threatening, intractable postpartum hemorrhage in hemodynamically stable patients, provided multidisciplinary medical teams are promptly available.

[Dinoprostone: slow release vaginal insert (Propess) and intracervical gel (Prepidil) for the induction of labour with unriped cervix]. / Dinoprostone: inserto vaginale a lento rilascio (Propess) e gel intracervicale (Prepidil) nell'induzione del travaglio di parto con Bishop score sfavorevole.

AIM: The purpose of the present study is to compare the effectiveness and safety of a slow release vaginal PGE2 insert (Propess) with intracervical PGE2 gel (Prepidil gel) in the induction of cervical ripening and labour. METHODS: For the induction of labour we selected 103 single pregnancies at term presenting a Bishop score of less than 5. Fifty-one were induced with Propess, and 52 with intracervical Prepidil. RESULTS: The 2 groups were homogeneous as regards indications to induction and obstetric characteristics. The success of induction (achievement of uncomplicated vaginal delivery) was comparable in the 2 groups: Propess 67%, Prepidil 65%. The times needed to induce labour were on average longer with Propess (16 h 59 min) than with Prepidil (12 h 54 min), (p<0.05); nevertheless the time needed to achieve delivery by the vaginal route within 24 hours was comparable (49% vs 48%). The number of patients requiring more than one application of prostaglandin was less in the Propess group (5.9%) than in the Prepidil group (55.8%) (p<0.001). The times relative to dilation and expulsion did not differ significantly. Resort to cesarean section for fetal indication (cardiotocographic changes) was greater in inductions with Prepidil (8 cases) compared to Propess (2 cases), p<0.05. CONCLUSION: The systems proved equally effective, nevertheless Propess seems to be safer thanks to the lower incidence of cardiotocographic changes such as to indicate urgent cesarean section. Propess would seem to be more acceptable on the part of patients thanks to the smaller number of applications necessary.

[Epidural analgesia during labour: maternal, fetal and neonatal aspects]. / Analgesia epidurale in travaglio di parto. Aspetti materni, fetali e neonatali.

AIM: The most effective technique for eliminating labour and childbirth pain is continuous lumbar epidural analgesia. The preoccupation regarding the possible negative effects on the time taken for labour and on dystocias in general represents one of the greatest hindrances in the way of its wider use. The purpose of the present study is to monitor the effects of continuous lumbar epidural analgesia on delivery times, on the state of the fetus, on the incidence of dystocic deliveries and on neonatal outcome. METHODS: Comparative prospective study. The data relating to the deliveries of 148 nulliparas and 51 pluriparas at term, submitted to epidural analgesia at the Obstetric Clinic of the University of Parma in 1999-2000 were compared with data from 144 nulliparas in labour and 60 pluriparas without epidural analgesia, selected in random fashion out of 4251 women who delivered children in the same period. The anesthetic procedure employed consisted in an injection of 20 mg/10 ml ropivacaine and 50 mg fentanyl in the epidural space at intervals of 1-2 h. RESULTS: The duration of the dilatation period was not influenced by administration of epidural analgesia while the expulsion period was longer in the course of epidural analgesia. There were no significant differences between delivery modalities in the 2 groups either as regards vaginal operative delivery or the number of cesarean sections for dystocia. The cardiotocographic profile was similar in the 2 groups. The neonatal outcome (Apgar index at 1' and 5' and transfer to the intensive care department) did not show significant differences, confirming the absence of noteworthy side-effects even from the neonatal standpoint. CONCLUSIONS: The use of low concentrations of ropivacaine (0.2%) associated with fentanyl in the epidural space proved to be a safe and effective technique for controlling labour and delivery pain.

[Vertical transmission of HIV infection: risk factors and prevention strategies]. / Trasmissione verticale dell'infezione da HIV: fattori di rischio e strategie di prevenzione.

In this study it has been evaluated the connection between the maternal immune status and the obstetrical factors on the one hand end the perinatal transmission of HIV in the other as well as, the effects of zidovudine prophylaxis and elective caesarean section on vertical HIV transmission. From January 1987 to September 1999, 60 HIV infected pregnant women were followed with their 64 infants. From July 1995 15 women and their respective children were treated with zidovudine prophylaxis (protocol ACTG 076); from June 1997, in 8 of these patients a systematic caesarean section was performed (7 electively and 1 on an emergent basis). The transmission rare was 20.5% among the 44 children in the group without zidovudine prophylaxis, compared with 7.1% among the 14 children in the group receiving Zidovudine. As for as the mother-child pairs receiving Zidovudine therapy, the rate of vertical transmission was 0% for the 7 mothers who underwent elective cesarean section and 14.3% for the 7 mothers with other ways of delivery. The interaction between zidovudine prophylaxis and elective caesarean section was associated with the lowest rate of vertical HIV transmission.

[Pre-partum cardiotocography: comparison between the traditional and the computed systems]. / Cardiotocografia antepartum: confronto fra analisi tradizionale e computerizzata.

The objective of our study was to determine the usefulness of a computerized antepartum fetal heart rate (FHR) analysis instead of the common visual evaluation of cardiotocographic parameters. From a total of 4,000 antepartum FHR tracings performed in our institute in the years 1994-1996, and analyzed on-line by the software HP 2CTG, 100 were visually assessed by five physicians in three different moments. To each reader a qualitative and quantitative interpretation was required. With use of k coefficient, we have analyzed the differences in observer's qualitative interpretation, then, with use of the intraclass correlation coefficient (RINTRA) and the contingency table X2 we have compared the quantitative analysis with that of the computer. Our results show that variability is the most difficult parameter to interpret, so that the interobserver agreement isn't in anyway sufficient (k 0.43). The agreement between observers on the clinical judgment of the FHR traces proves to be low (k 0.54). The agreement between each of the observers and the computer readings is good for the estimation of the FHR (RINTRA between 0.96 e 0.98) and low for the mean term variability (RINTRA between 0.81 and 0.58). There is a valuable agreement with the computer for tracings with 0 or 1 large acceleration (94.7% and 97.5% respectively), but it is significantly poorer (p < 0.001) for tracings with 0 or 1 small acceleration (57.4% and 50.8% respectively). Decelerations are the most difficult pattern of interpretation. Usually observers do not identify 36% of the FHR traces having at least one deceleration according to computer analysis. Our study confirms the wide variability in fetal monitoring interpretation, a difficulty which can be overcome thanks to a computerized analysis.

[Vertical transmission of the hepatitis C virus]. / La trasmissione verticale del virus dell'epatite C.

The incidence of hepatitis C in childhood is approximately 0.4%. The mode of transmission can be parenteral, sexual, occupational and also vertical. The latter has an incidence that varies widely and it increases in the case of human immuno-deficiency virus (HIV) coinfection and high titers of HCV in the mother. The vertical transmission is not influenced by breast feeding, however, data are discrepant with regard to child delivery (cesarean section vs vaginal delivery). Ninety-seven babies born from mothers with hepatitis C from 1996 to 1999, were evaluated prospectively in the Day Hospital of the Pediatric Department of Parma. The protocol of observation established a blood sampling for titers of antibodies anti-HCV and HCV-RNA at the 3rd trimester of pregnancy and subsequent clinical and biochemical controls at 3-6-9-12-15 and 18 months. Thirty (31.2%) out of the 96 mothers evaluated were positive for antibodies anti-HCV and 66 (68.8%) were positive for antibodies anti-HCV and HCV-RNA. Five (5.15%) out of the 97 babies evaluated were infected by HCV. Of these 4 were delivered vaginally and 1 by cesarean section. Of the 3 babies born to mothers with HIV coinfection, none was infected by HIV, but 1 was infected by HCV. Vertical transmission is increased by HCV viral load or HIV coinfection in the mother. The vaginal delivery and breastfeeding do not represent an additional risk factor.

[Risk of materno-fetal transmission of the HIV infection with antiretroviral therapy and cesarean section: experience of the Parma group]. / Rischio di trasmissione materno-fetale dell'infezione da HIV mediante terapia antiretrovirale e taglio cesareo: esperienza del gruppo di Parma.

Vertical transmission of HIV is by far the most important way of infection in pediatric patients. Transmission rate of infection varies between 15-40% in the absence of antiretroviral prophylaxis. Only 2% of infected pregnant women who underwent caesarean section and zidovudine treatment transmitted the infection to their newborns. From January 1995 to September 2000 twenty seropositive pregnant women and their twenty newborns were followed at the Azienda Ospedaliera of Parma. Nine women (45%) were treated with only zidovudine according to the ACTG 076 protocol; eight women (40%) continued the treatment they were assuming before pregnancy with the eventual addition of zidovudine. 3 women (15%) were not treated because HIV infection was only detected after delivery. 15 women underwent caesarean section, in 13 cases in association to antiretroviral prophylaxis: in the remaining 2 cases no intrapartum treatment was started due to the urgency of delivery. The rate of vertical transmission among the 20 women was 5% (1/20), significantly less then that observed (20.5%) among 31 pregnant HIV women followed in Parma from January 1987 to December 1994 and not treated with antiretroviral prophylaxis and/or cesarean section (Magnani G. Personal data). The only infected baby was born by vaginal delivery. No transmission was observed in the group of pregnant women who underwent the combination of antiretroviral prophylaxis and cesarean section.

[Early discharge project appropriate for the healthy newborn]. / Progetto di dimissione precoce appropriata del neonato sano.

Recently the stay in the hospital of the pueperae and of their newborns has progressively been shortened in several Countries. A lot of reports evaluating the risks of early discharges have not shown any significant differences in the hospital readmission rates between newborn early discharged and case-controls. This phenomenon is occurring also in Italy and the early discharge after the delivery is one of the aims of the "Percorso-Nascita" in the National Health Program of 1998-2000. Since three years ago, in the Nursery of the Department of Neonatal Medicine of University of Parma we have been discharging the newborns at term in the second day of life, choosing the healthy newborns in agreement with the obstetricians. The increment of the early discharges has happened in our Department after realizing that those did not create an increment of the hospital admissions in the neonatal period. Since January 2000 in Parma the project of appropriate discharge named "around the cradle" derived from the cooperation between hospitals and territory is working. This project consists of a continuous essistential support for mothers and children throughout an organic integration between hospital and territory. The women that take part to this project have the opportunity to be discharged from the hospital between the 44 and the 56 hours after the physiological delivery, being followed at home by the local obstetrician and paediatrician. The project is divided into three parts. The first part, pre-partum, is based on the information that is delivered to all the pregnant women that are eligible; the second part, the hospital phase, implies the usual and routinary care to the pueperae and their newborns as well as the clinical neonatal and obstetrical evaluation that allows to select our cohort. In the latter phase, extra-hospital, the local paediatrician take care of the newborn and start examining him/her within 72 hours after the discharge, while the home assistance of the local obstetrician will be within 48 hours. After initial difficulties, the organization of this project is quite efficient with a constant increment of attending requests to our project by the patients. Of course this is an organizative model quite complex that needs to verify process, efficiency and results, but anyway it sees the cooperation among many professionists of different specialities: neonatologists, paediatricians, obstetricians, practitioners, all working together for a common programme.

[Childbirth preparation courses: obstetrical and neonatal evaluation]. / Corsi di preparazione al parto: valutazioni ostetriche e alla nascita.

From 1997, R.A.T. (Respiratory Autogenous Training) and "Stretching" training have been performed into the Department of Obstetrics and Gynecology University of Parma, for childbirth preparation. The aim of this study is to evaluate the obstetric characteristics of these women during labor and delivery. We compared the labour and delivery characteristics of 200 women who have completed antepartum R.A.T. and stretching training with 100 matched controls who have not. Preparation is significantly related to reduction in dystocic deliveries (operative vaginal delivery and cesarean section) and emergency cesarean section. Epidural analgesia (an obstetric procedure that is not routinely offered in the department of Parma) is more frequently performed in women prepared with ante-partum training. The neonatal outcome is good in all the three groups. "Prepared-childbirth" courses offer measurable clinical, obstetrical and neonatal advantages and psychological support, providing a useful link between prenatal ambulatory care and hospital labor and delivery care.

[Preliminary data on early discharge after delivery]. / Dati preliminari sulla dimissione precoce dopo il parto.

Puerpera and baby's early discharging falls within a bigger project that deals with the reduction of medical treatment and with the razionalization of economic resources. We can talk about early discharging when it occurs by 48 hours after a vaginal childbirth and by 96 hours after a cesarean section. When the mother and the baby have been discharged from hospital, their health will chiefly depend on the efficiency of the sanitary organization that works on the territory. If the nursing service at home is competent and specialized, the stay in hospital will get shorter and shorter. The most deepen studies about early discharging after vaginal childbirth agree upon the lack of any risk both for the mother and for the baby. Early discharging is possible without any risk for the mother's health after a cesarean section as well, but only if the woman is well-disposed, if she is at low risk, if she answers to predetermined criteria of eligibility, and if she has an adequate follow-up when she comes back home. On the basis of these evidences, we have traced a clinical outline that draws the early discharging in obstetrics that, in the last five years, has led to a progressive reduction of the stay in hospital both after vaginal childbirth and after cesarean section.

[Innovations of the Stark method for cesarean section. Comparison of techniques]. / Innovazione al metodo di stark per il taglio cesareo. Tecniche a confronto.

BACKGROUND: The evolution of surgical techniques for cesarean section have improved the neonatal outcome as well as maternal morbidity and mortality. Aim of this study is to compare the conventional technique with a personally modified Stark's technique, in order to evaluate its effectiveness. METHODS: A prospective study has been carried out on a group of patients submitted to cesarean section by two different teams. A conventional technique for cesarean section was performed by a team, while the other carried out a modified Stark's technique, at the Obstetrics and Gynecology Department of the University of Parma from May 1997 to February 1998. A total of 105 cases underwent a modified Stark's technique, while 99 were submitted to cesarean section with the conventional technique. In order to get a better reliability of results, homogeneous cases for epidemiological characteristics and indications have been enrolled in the study. Statistical analysis was performed by using Student "t"-test, chi 2 test and Wilcoxon test. The Stark's technique for cesarean section, modified by the Authors, is described. RESULTS: The parameters concerning surgical procedure, postoperative course and neonatal outcome showed statistically significant differences in favour of the modified Stark's technique. CONCLUSIONS: The conclusion is drawn that this technique leads to a remarkable reduction of blood loss and urine bacteria. Surgical drainage was never required.

Intravesicular prostaglandin E2 for the prophylaxis of urinary retention after colpohysterectomy.

The aim of this study was to assess the efficacy of PGE2 in enhancing bladder function after vaginal hysterectomy. A total of 110 women with or without urinary incontinence underwent vaginal hysterectomy and cystourethropexy surgery because of grade II or III genital prolapse. Preoperatively the patients were randomly assigned to two groups: group 1 (n = 50) received on the fourth post-operative day, before removal of the bladder catheter, an intravesicular solution of 1.50 mg PGE2 (2 x 0.75 mg); group 2 (n = 60) did not receive any prophylaxis for urinary retention. In the PGE2-treated group significantly fewer patients had urinary retention for 3 days or more (10%, P < 0.05) than in the control group (27%). The use of intravesicular PGE2 reduced the time taken to restore detrusor function.

[Term pregnancy: the review and development of fetal surveillance protocols]. / La gravidanza a termine: revisione ed evoluzione dei protocolli di sorveglianza fetale.

The authors have analyzed the reasons behind the changes in clinical and biophysical monitoring of term and post-term pregnancies. In particular, there is an assessment of the results of NST monitoring over a one-year period. Furthermore, the importance of the introduction of new methods of labour induction by means of intracervical PGE2 is also discussed and there is a reference to the results. It is clinically evident that these methods have contributed to modify the problem of term-pregnancy management. Finally, there is a presentation of the new version of up-to-date procedures based on more clinical experience and more recent statistics on the subject.

Plasma concentration, urinary excretion and renal clearance of L-carnitine during pregnancy: a reversible secondary L-carnitine deficiency.

Plasma concentration, urinary excretion and renal clearance of free, total and esterified L-carnitine were monitored monthly in 14 women during the last 6 months of pregnancy and 1 month after delivery. Plasma concentration and renal clearance measured 1 month after delivery overlapped with normal values for females of comparable age, and were considered the reference values for further comparisons. Plasma concentration of free, total and esterified L-carnitine decreased during pregnancy, reaching values as low as half of those measured 1 month after delivery, whereas urinary excretion and renal clearance, mainly of L-carnitine esters, increased, with renal clearance reaching a peak at the 16th week of pregnancy. Pregnancy thus leads to a reversible secondary deficiency of L-carnitine. The involvement of L-carnitine in the excretion of an excess of acyl-S-coenzyme A groups to prevent a possible systemic acidosis, as well as hormonal changes and a reduction of L-carnitine biosynthesis, could play a significant role in the variations in L-carnitine metabolism encountered in pregnancy. As physiological components of L-carnitine are excreted via a saturable tubular reabsorption, their threshold seems to follow plasma concentration, even when they decrease markedly, as in pregnancy.

Fetal distress: role of cardiotocography.

The FHR monitoring in 320 patients with fetal distress were randomly analyzed and revised over 16 years. The aim of our study, in so long a period, was to evaluate the role of cardiotocography in order to preserve the fetus from irreversible damage. The results show a progressive improvement of neonatal outcome, due to the development of the experience with this method, and to the improvement in interpretative criteria. However, cardiotocography showed its limits, and the moment has come to seek new integrative methods to associate cardiotocography with a continuous monitoring of the fetal status.

[Echographic diagnosis of gestational age and law 194]. / Diagnosi ecografica di epoca gestazionale e legge 194.

The authors examine the various biometrics parameters evidentiable at the 13th week of pregnancy, which is so important age for the limits imposed by the law 194, that regulates the legal abortion. These findings are studied as for their evidentiability and their diagnostic predictivity aiming to single out the most reliable. As for the results obtained examining the singular parameters, the authors conclude that the goal of the echographist is to search for the fetal CRL and BPD: they are characterised of an optimum predictivity and a good evidentiability, besides they provide direct data about the embryo dimensions. If these measurements are not evidentiable the operator can base his diagnosis on the other parameters that do not refer directly to the embryo. At last the authors sustain that who carried out the ultrasound examination should not "force" the diagnosis trying to establish the gestational age with excessive exactness; on the contrary he must limit himself to provide the evidentiable biometric values, indicating the minimum and the maximum age that is compatible with them. It is up to the physician who performs the termination of pregnancy to draw the correlations about the gestational age.

[Echographic diagnosis of fetal malformations]. / La diagnosi ecografica di alcune malformazioni fetali.

The Authors report their experience about ultrasound diagnosis of congenital anomalies, related to 15 cases from approximately 4000 gravides. They emphasize the impossibility to carry out total antenatal population screening by sonar and the usefulness to carefully select the gravidas at high risk for harboring a fetus with a birth defect. They also suggest that, in looking for physical defects, it is best to make ultrasound examination at 17a-18a weeks' gestation; at this moment, the ultrasound evaluation is particularly favorable for diagnosis and treatment.

[Thermal therapy in gynecology]. / Terapia termale in ginecologia.

The Authors consider the importance of Thermal Therapy in a large part of gynaecological diseases. They emphasize of its utility mostly in the chronic flogosis of the female genitalia. However other indications emerged from this research, such as female sterility, pelvic vascular disease, climaterie syndrome and post-operatory affects.