A primary lesion of advanced melanoma in pregnancy: case report and review of literature of the advanced cases in the last ten years.

INTRODUCTION: Pregnancy- associated melanoma (PAM) is reported between 2.8 and 5.0 per 100,000 pregnancies and approximately 35% of women with melanoma are of childbearing age. The diagnosis and treatment of melanoma during pregnancy needs a balance of risks and benefits for both maternal and fetal well-being. It is a type of malignancy, which requires a multidisciplinary approach, not limited to the obstetrician, but also to oncologists, neonatologists, pharmacists and psychologists. MATERIAL AND METHODS: We present a case of a 36-year-old pregnant woman, who was admitted to our 3rd level Unit of Obstetrics and Gynecology (ARNAS Garibaldi Nesima) at 27 weeks and 2 days of gestation, with a diagnosis of suspected infection, then diagnosed as an advanced melanoma, which caused a premature delivery. A review of the literature of the last ten years from the international electronic bibliographic databases PUBMED was performed following the PRISMA Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The search was limited to studies reported in the English language. We only included articles that followed our eligibility criteria, represented by: pregnant women with a diagnosis of advanced melanoma in pregnancy, with special reference to maternal, fetal or perinatal outcomes. RESULTS: The patient was affected by an 11 cm pregnancy-associated melanoma in the lower part back, with 2 hepatic metastasis. Due to the quickly development of general symptoms of sepsis it was decided to perform an urgent C-section. For the systematic review, we found 11 articles of advanced clinical melanoma, providing data from 12 patients. Maternal-perinatal outcomes is different depending on gestational age, general clinical condition, stage at diagnosis. CONCLUSION: Advanced melanoma is usually associated with a higher rate of termination of pregnancy, If the pregnancy continues, for the mother is associated with an higher risk of Cesarean section, sepsis, maternal progression of disease; for the baby is associated with prematurity, low birth weight, neonatal metastatic disease, neonatal morbidity and mortality. The future aim of clinicians should be the creation of an international database of the clinical cases of pregnancy-associated melanoma, to evaluate the same data, to improve treatments, to develop common protocols, and, finally, to improve the obstetric and perinatal outcomes.

Ultrasonographic evaluation of placental cord insertion at different gestational ages in low-risk singleton pregnancies: a predictive algorithm.

OBJECTIVE: To evaluate the accuracy of ultrasound in visualizing placental cord insertion (PCI) at different gestational ages in order to recommend the most feasible period during pregnancy to identify it. Secondary aim was to propose a predictive algorithm for PCI visualization. METHODS: We performed a single-center, prospective cohort study. We enrolled patients with singleton low-risk pregnancies who underwent fetal ultrasound scan at different gestational ages. We excluded patients with body mass index of 30 Kg/m2 or more, uterine fibroids larger than 5 cm, high-risk pregnancies, fetal weight lower than < 10° percentile or higher than > 90° percentile, increased ("deep pocket" > 80 mm) or decreased ("deep pocket" < 20 mm) amniotic fluid. RESULTS: Among the 468 recruited patients, the visualization of PCI was not possible in 5.77% of the cases. Furthermore, we showed that PCI visualization was lower as the gestational age increased (p = 0.049) and more difficult in case of posterior placenta (p = 0.001). CONCLUSIONS: PCI should be evaluated in the first trimester or as early as possible during the second trimester. Moreover, we propose a feasible model to predict the possibility of PCI visualization according to gestational age and uterine site of implantation.

Dental management in pregnancy: recent trends.

This review analyzes the changes that occur during normal pregnancy and describes the main odontogenic infections, suggesting the actual best approach in dental management. Several studies support the hypothesis that periodontal disease is associated with preterm labour and other conditions complicating pregnancy, such as pre-eclampsia and fetal growth restriction. Appropriate dental care and prevention during pregnancy may reduce poor prenatal outcomes and eliminating risk factors. Dental examination before pregnancy is strongly suggested in order to act early on dental and periodontal diseases. Prevention means reducing the presence of bacterial plaque through professional hygiene sessions, education, and motivation to proper oral hygiene at home, education in proper nutrition, a balanced diet, and low intake of sugars. For these reasons, it is essential to have a more intense interdisciplinary collaboration between gynecologist and dentist in order to achieve an optimal women's health, during this particular time in their lives.

Pelvic arterial embolization for postpartum hemorrhage: long term results of a single center experience in 29,091 deliveries.

PURPOSE OF INVESTIGATION: To evaluate the rate of all postpartum hemorrhages (PPHs) treated with uterine embolization in a third level delivery center. MATERIALS AND METHODS: Since January 2008 to March 2014, 29,091 deliveries were registered in the present hospital in Bergamo, Italy. Among these deliveries, 2,002 cases (6.8%) of PPHs occurred. Seventy-three patients with severe obstetric hemorrhage underwent uterine artery embolization (UAE) (47 cases, 1.61/1,000 deliveries) or hysterectomy (26 cases, 0.89/1,000 deliveries). All identified cases were followed up by telephone on January 2015 in order to evaluate long term results. RESULTS: Embolization was performed successfully in 45 patients (95.7%). Two women underwent total abdominal hysterectomy: one patient for uterine atony and one for adherent placenta. In the follow up all the women interviewed reported the return of their menstrual cycle and 95.2% of women reported regular cycles. CONCLUSIONS: Embolization showed a success rate of 95.7%. For this reason, in the authors' opinion, it is the best choice as second line treatment of PPH, when patient is hemodynamically stable.

Concomitant chemoradiation treatment in selected Stage I endometrioid endometrial cancers.

PURPOSE OF INVESTIGATION: To evaluate chemotherapy with concomitant radiotherapy (RT) in "high risk" endometrial cancer (EC) patients. Furthermore to develop a new algorithm for management and treatment. MATERIALS AND METHODS: The study included 182 Stage I endometrioid EC patients who underwent definitive surgery after a first treatment. Stage, grade, ploidy DNA index, lymphovascular space involvement (LVSI), tumor diameter (TD), and p53 were considered to identify "high-risk" patients. Twenty-seven women received adjuvant concomitant chemoradiation (CR). Toxicity related to the CR treatment, disease free interval (DFI), and status of the patients were considered. RESULTS: Twenty-seven patients according to the present algorithm treatment were considered at "high risk". Median follow up was 43 months (range 16-68). Twenty-five (92%) patients completed CR treatment. Overall, grade 3/4 hematological toxicity was 18% while gastrointestinal toxicity was 15%. Four patients relapsed with a five-year rate of 14% of recurrences. CONCLUSIONS: Adjuvant concomitant CR is well tolerated and is a feasible regimen in "high risk" patients. The authors' new algorithm treatment could be used for management and further clinical studies.

Laparoendoscopic single-site surgery for the assessment of peritoneal carcinomatosis resectability in patients with advanced ovarian cancer.

PURPOSE OF INVESTIGATION: To evaluate the feasibility, safety, and effectiveness of laparoendoscopic single site surgery (LESS) for the assessment of peritoneal carcinomatosis resectability in patients with advanced stage ovarian cancer (AOC). MATERIALS AND METHODS: The authors retrospectively reviewed the medical records of patients affected by advanced stage ovarian cancer who underwent LESS for operative work-up. A standard cytoreductive laparotomy surgery (CRS) was performed. RESULTS: Fifty-two women affected by AOC underwent LESS for operative work-up. The peritoneal cancer score was completed in 49 (94%) patients by use of LESS; 34/37 (92%) patients considered with a resectable disease were effectively optimally debulked and 15/52 (28%) patients considered with an unresectable disease received before neoadjuvant chemotherapy (NACT) and then underwent surgery. CONCLUSION: LESS is feasible, safe, and is an alternative minimally invasive procedure to assess the resectability of AOC patients.

Surgical removal of multiple mesenteric fibroids (Kg 4,500) by abdominal spread of previous laparoscopic uterine myomectomy.

INTRODUCTION: Huge and multiple mesenteric fibroids (4,500 Kg weight) are very unusual. In many cases they are mistaken for subserosal fibroids of the womb due to the proximity with uterine walls. When they have a rapid growth, the risk of becoming malignant (sarcoma) has not to be underestimated. Surgery is challenging to remove abdominal nodes. CASE REPORT: A case of a 40-year old woman, admitted to the hospital with abdominal masses occupying the entire cavity was reported. Both computerized tomography (CT) and ultrasounds (US) were not diriment for belonging of tumours. Clinical history of patient reports a laparoscopic removal of uterine fibroids, using the morcellator. Laparoscopy was performed four years before. Open surgery by means of a large transversal suprapubic laparotomy according to Pfannestiel was carried out. Multiple and huge mesenteric, peritoneal and intestinal tumours spread in the whole abdominal cavity were found, removed and examined by frozen section histology; in addition a series of small conglomerated myomas in the site of previous laparoscopic transumbilical route was taken away as well (the largest fibroid weighed Kg 3.500 and the all tumors removed 4,500 Kg); the result was benign (fibroids) and genital apparatus was preserved. Operation was challenging. Postoperative course was uneventful; after five days patient was discharged. CONCLUSIONS: This case is very interesting for many factors: A) many extra-uterine fibroids spread throughout abdominal cavity; B) considerable weight of the masses C) intraoperative and postoperative danger. Finally, due to involvement of previous laparoscopic transumbilical incision together with other findings, the hypothesis of post laparoscopic dissemination has to be considered. A case of so large extragenital abdominal fibroids following laparoscopic uterine myomectomy has never been published so far.

Diagnosis and management of fetal ductus arteriosus constriction-closure.

Pathognomonic features of in utero premature restriction/closure of the ductus arteriosus (DA) are increased right ventricular afterload, impaired right ventricular function, and consequently tricuspid regurgitation and right heart dilation. The most common reason for constriction-closure of DA is maternal administration of non-steroidal anti-inflammatory drugs (NSAIDs) during the 3rd trimester of gestation. The idiopathic form is a rare event and, maybe, an underestimated abnormality that, if it is not promptly recognized, may result in severe fetal-neonatal compromise. We describe a case of a 38-year-old woman presenting at 34+0 weeks of gestation with a normally grown male fetus whose fetal echocardiography had shown right ventricular hypertrophy, a tortuous S-shaped DA and a significant pulmonary hyperflow. All signs were consistent of an idiopathic severe constriction of DA with a significant fetal cardiac involvement. The patient was admitted to a tertiary care center equipped with Neonatal Intensive Care Unit (NICU), and delivered by cesarean section at 34+4 weeks with a good maternal and neonatal outcome. Based on our experience and a review of the Literature we propose a management algorithm to use when dealing with preterm or early term pregnancy complicated by this fetal hemodynamic malfunction.

Beta-Thalassemia major and pregnancy.

OBJECTIVE: It was studied the clinical management and the medical outcomes of 6 pregnancies in 5 women affected by Beta Thalassemia major, based on last guidelines and pharmacological treatments. BACKGROUND: Paediatric Department and Department of Obstetrics and Gynaecology of the University of Catania. METHODS: These patients were taken among a group of 116 women affected by beta-thalassemia major divided into three subgroups, according to the characteristics of their menstrual cycle: 1) women with primitive amenorrhoea, 2) women with secondary amenorrhoea and 3) women with normal menstruation. Only one woman, affected by primitive amenorrhoea, needed the induction of ovulation. An accurate and detailed pre-pregnancy assessment was effected before each conception. This was constituted by a series of essays, including checks for diabetes and hypothyroidism, for B and C hepatitis and for blood group antibodies. Moreover were evaluated: cardiac function, rubella immunity and transaminases. Other pregnancy monitoring, and cares during labour and delivery were effected according to usual obstetrics practice. RESULTS: All the women were in labour when they were 38 week pregnant, and the outcome were six healthy babies born at term. There were no complications related to the pregnancy and to the immediate outcome after delivery. CONCLUSIONS: The improvements of current treatments, especially in the management of iron deposits, the prolongation of survival rate, will result in a continuous increase of pregnancies in thalassemic women. Pregnancy is now a real possibility for women affected by such disease. Although numerous complications can occur, vigilant monitoring by both experienced obstetricians and hematologists can lead to successful pregnancy outcomes (Tab. 1, Fig. 1, Ref. 16).

Protection of ovarian tissue from radiotherapy.

Advances researches in the diagnosis and treatment of childhood, adolescent and adult cancer have greatly increased the life expectancy of premenopausal women with cancer. However, one of the serious side effects of these treatments is the risk of damage to fertility. The ovaries are very sensitive to cytotoxic and radiotherapeutic treatment. The only established method of fertility preservation is embryo cryopreservation according to the Ethics Committee of the American Society for Reproductive Medicine (2005), but this option requires the patient to be of pubertal age, have a partner or use donor sperm, and be able to undergo a cycle of ovarian stimulation, which is not possible when the radiotherapy has to be initiated immediately or when stimulation is contraindicated according to the type of cancer. For patients who need immediate radiotherapy, cryopreservation of ovarian tissue is the only possible alternative. This manuscript reports the different techniques of cryopreservation and the results of transplantation of cryopreserved ovarian tissue. The current techniques allow cryopreservation of human ovarian fragments for a long time with good follicular survival rate after thawing. Numerous studies ultimately in this field have demonstrated to improve the survival rate of the oocytes and cryopreserved follicles. Moreover this manuscript includes a case of a 17-year-old girl who had to undergo pelvic irradiation for non-Hodgkin's lymphoma and the laparoscopic treatment to preserve the fertility (Fig. 2, Ref. 47).