EXIT procedure in a twin gestation and review of the literature.

Prenatal diagnosis can show masses of the fetal neck, mouth, and face that can potentially cause respiratory distress at birth. To prevent such an emergency, the EXIT (ex utero intrapartum technique) is performed: it is the intrapartum intubation of the fetus at term while still connected to the placenta. The EXIT procedure was first performed in a case of cervical teratoma. Up to now a total of 34 cases are described, mostly cervical teratomas (13 cases), lymphangiomas (7), epignathus (3); babies' outcome has been successful in 25 of them, with one death related to the procedure. Among the reported cases we are aware of only one where EXIT was performed in a twin gestation, in which the normal twin was delivered first. In our case the normal fetus was posterior to the twin with cervical malformation, requiring us to work on the latter while the former was still in the uterus. After having safely secured the airway in twin A, twin B was prompt delivered with excellent general conditions. Our limited experience enlarges the possibility to perform this prenatal procedure even in "nonstandard" conditions, such as a twin gestation, and may prove useful to those who are going to deal with such issues.

[Hemolytic uremic syndrome in twin pregnancy at 32 weeks gestation with HELLP syndrome. Case report]. / Sindrome uremico emolitica in gravidanza gemellare alla 32(a) settimana con HELLp syndrome. Descrizione di un caso clinico.

Renal failure occurring in pregnancy or post partum is an unusual but well-described complication. Acute renal failure seems to be associated more often with HELLP syndrome rather than with pre-eclampsia or chronic hypertension. Probable overlapping of HELLP and hemolytic uremic syndrome in pregnancy or postpartum should be taken into consideration when treating pregnant women who show signs of proteinuria, hypertension, hematuria, increase of reticulocytes, decrease of haptoglobin with thrombocytopenia and microangiopathic hemolytic anemia. Our case refers to a 32 year old woman at 32 weeks gestation in twin pregnancy who presented with HELLP syndrome and renal failure. Immediately postpartum oliguria was noted and the laboratory analyses suggested the coexistence of HELLP and hemolytic uremic syndrome. In patients with gestosis and/or HELLP syndrome presenting oliguria combined with a decrease of hemoglobin level not due to intraoperative hematic leaks it is always necessary to ask for haptoglobin dosage. In treating hemolytic uremic syndrome it is very important to use a high dosage of plasma and sometimes plasmapheresis. HELLP syndrome contributes to various complications which are sometimes responsible for kidney or maternal mortality. In treating these patients early diagnosis combined with a specific treatment can considerably reduce kidney and maternal mortality.

[The EX-utero Intrapartum Technique (EXIT) procedure in Italy]. / Il parto ex-utero intrapartum technique (EXIT) in Italia.

Aim of the study was to present the first two Italian cases of C-section performed with the EXIT procedure (EX-utero Intrapartum Technique). Deliveries were performed at the Division of Obstetrics and Gynecology of the Hospital of Padua in cooperation with the Pediatric Surgery Department, both tertiary care centers. The first case was a twin with a huge neck mass (cystic hygroma) and the second a fetus with an oropharyngeal mass (epignathus). Airway patency could have been compromised at birth in both of them. EXIT procedure consists in securing the airway of the fetus partially delivered and still connected with the placenta. This technique leaves an intact feto-placental circulation and guarantees a normal fetal oxygenation while fetal airway patency is secured. Both the fetuses were successfully intubated and the C-section ended up in a short period of time without maternal and fetal complications. The EXIT technique, performed for the first time in 1989 and now in many centers abroad, can be considered a safe procedure as long as a multidisciplinary approach is carried out. The EXIT procedure is indicated whenever fetal airways can be compromised at birth, that is when oropharyngeal masses, laryngeal atresia, cystic hygroma and goiter are encountered during prenatal ultrasound.

[Non-invasive instrumental method in uncontrollable post-partum hemorrhage (an alternative to hemostatic hysterectomy)]. / Tecnica strumentale non invasiva nelle emorragie irrefrenabili del post-partum (in alternativa all'isterectomia emostatica).

A new non-invasive instrumental technique which is useful to stop the most severe post-partum haemorrhages is described. This technique is proposed as an alternative to more invasive methods such as the binding of uterine or hypogastric arteries, which is itself a trauma, not always effective and could promote the obstetric shock. The method proposed by the authors is not invasive, can be performed in a few minutes and performed without the help of anaesthesia. Very encouraging results were achieved and have allowed to avoid the use of the so-called "haemostatic" hysterectomy.

[Premature membrane rupture. Comparison of diagnostic tests]. / Rottura intempestiva delle membrane. Test diagnostici a confronto.

BACKGROUND: Objective of this study was to evaluate the accuracy of the vaginal pH-test, the Fern-test, the research of foetal cells and of foetal fibronectin in vaginal discharge, which are used to diagnose premature rupture of membranes. METHODS: To this aim 40 pregnant patients between 24th and 37th weeks gestation have been examined, considered at risk for sub-clinic loss of aminiotic fluid: 23 were affected by preterm labour and 17 by suspected rupture of membranes. RESULTS: Subsequently amniotic sac was confirmed to be ripped in 10 cases (25%): 2 (8.7%) in the 23 patients with preterm labour, and 8 (47%) in the 17 patients with suspected PROM. Sensibility, specificity and accuracy were respectively: 70, 97 and 90% for pH-test; 70, 100 and 93% for Fern-test; 50, 93 and 82% for foetal cells; 100, 90 and 93% for fibronectin test. CONCLUSIONS: In personal experience fibronectin test appeared to be the most sensible and accurate marker. Fern-test was the most specific, while the research of foetal cells appeared to be the least reliable.

[beta-Interferon in the therapy of cervico-vaginal papilloma virus (HPV) infection associated with cervical intraepithelial neoplasia (CIN)]. / beta-interferone ed infezioni cervico-vaginali da papilloma virus (HPV) associate a neoplasia cervicale intraepiteliale (CIN).

58 patients suffering from HPV infection associated with CIN were treated using human fibroblast interferon, via an intramuscolar route, with positive results (87.9% of cases).

[Thymopentin and cervico-vaginal HPV infection associated with CIN]. / Timopentina ed infezione cervico-vaginale HPV associata a CIN.

46 patients affected by HPV+CIN were treated with Thymopentin i.m. HPV disappeared in all cases. We also observed complete disappearance or only a partial remission of CIN in 82.6% of cases.

[Emergency surgical indications in pregnancy (3 rarely encountered cases)]. / Indicazioni chirurgiche d'urgenza in gravidanza (tre casi di raro riscontro).

The authors evaluated 3 cases of acute abdomen during pregnancy: Spontaneous rupture of splenic artery at 30th gestational week (gw). Torsion of left normal Fallopian tube at 33rd gw. Left adnexal torsion at 36th gw. The symptomatology, the etio-pathology and the anatomo-pathological characteristics of every case wore discussed. In women that are usually young, maternal and fetal exitus in the first case and salpingectomy or adnexectomy in the second and third case can be avoided only thanks to timely surgical intervention.

[Human fibroblast interferon therapy alone and human fibroblast interferon combined with thymostimulin in genital papillomavirus infection associated with cervical intraepithelial neoplasia]. / La terapia con interferone umano da fibroblasti e con interferone umano da fibroblasti più timostimolina nelle infezioni genitali da HPV associate a CIN.

Eighteen patients suffering for HPV infections associated with CIN were treated using human fibroblast interferon, via an intramuscular route, with positive results. Five cases of recurrent HPV within nine months of treatment received thymostimulin therapy, via an intramuscular route, with positive results.

Cervical intraepithelial neoplasia. Therapeutical trends.

CIN is an intraepithelial alteration of unpredictable development. Its presence may require in the case of CIN 1 only periodical colposcopy and cytology, while in the presence of CIN 2 or CIN 3 a complete removal of the lesion is necessary. Surgery must be "personalized". Sometimes when the excision is large, it may be necessary to follow with hemostatic suture in order to reconstruct the portio.

Toxoplasmosis. Two observations and a specification.

On the basis of two interesting observations of toxoplasmic disease the Authors attempt to interpret the various pathological pictures, comparing two different formulations of toxoplasmic disease: that of Sabin and that of more modern AA.

Postpartum hostility and prolactin.

In a previous study ten women with hyperprolactinemia and amenorrhea had significantly higher Symptom Questionnaire scores for depression, hostility and anxiety than patients with amenorrhea only and a matched nonpatient employees group. The hyperprolactinemic patients and employees were compared with ten women on their seventh day after childbirth who had been matched for sociodemographic variables and had similar prolactin levels. Hostility was significantly higher in postpartum patients than employees and did not differ significantly from that of women with hyperprolactinemic amenorrhea. Postpartum hyperprolactinemic women did not differ significantly from the employees for anxiety and depression, which was significantly lower than in the amenorrheic patients. In several mammals aggression occurs concurrently with lactation. The studies in humans suggest an association of high prolactin levels with hostility.