Detection of central pelvic recurrent disease with transvaginal color Doppler ultrasound in women treated for gynecological malignancy.

OBJECTIVE: To evaluate color Doppler characteristics of small recurrent tumors detected within the central pelvis in follow-up patients treated for gynecological malignancy. PATIENTS AND METHODS: A prospective study was performed on 340 patients who were being monitored following treatment for gynecological malignancies. A selected group of 27 patients, with small pelvic masses located in the central region of the pelvis, underwent a color Doppler examination. A subjective assessment of the vascularization (vascular score), the lowest resistance index (RI), the highest peak velocity (PSV) and the highest time averaged maximum velocity (TAMXV) of the vessels detected within the lesion were analyzed. RESULTS: In 16 patients the pelvic mass was found to be benign while in 11 patients a malignant recurrence was diagnosed. Gray-scale examination could not differentiate between benign and malignant lesions. The color score of tumor recurrences was significantly higher in comparison to that in benign lesions (color score 3 in 54% vs. 0%, P < 0.005). The malignant lesions showed significantly lower mean values of RI and significantly higher mean values of PSV and TAMXV when compared with benign lesions (0.39 +/- 0.09 vs. 0.81 +/- 0.22, P < 0.0001; 19.3 +/- 4.7 vs. 10.5 +/- 5.6 cm/s, P < 0.0001; 8.9 +/- 3.7 vs. 4.3 +/- 2.7 cm/s, P < 0.005). CONCLUSIONS: Color Doppler analysis added to transvaginal gray-scale ultrasonography seems to be a helpful tool in the diagnosis of recurrent tumors in the central region of the pelvis.

Goals, benefits, and outcomes of genetic counseling: client and genetic counselor assessment.

Most studies of outcomes of genetic counseling have focused on client knowledge, reproductive plans and behavior, or satisfaction. Other measures of the "value" of genetic counseling are needed to guide research assessing the impact of genetic counseling on individuals and populations, as well as to improve the process of providing care. To obtain input from providers, we conducted telephone interviews with six experienced genetic counselors, and then we held a focus group with 10 additional genetic counselors from a variety of practice settings. To obtain input from consumers, telephone interviews were also conducted with 19 past clients of these participating counselors. We found that counselor goals focus on meeting clients' needs, usually educating and providing psychosocial support. Clients often had few goals going into a session because they were unaware of what would be discussed or how the session would be structured. They usually did not expect to receive "counseling," and when they did, it was a welcome surprise. Both clients and counselors commented that a positive interpersonal interaction and "connecting" are primary measures of success. All clients appreciated the large amount of time spent with the counselor, and the manner (clear, comprehensive, and unhurried) of providing information. Many clients said that genetic counseling resulted in improved communication with their partners and other family members. Clients view the counselor as an "expert" and value the counselor as an on-going resource for both information and support. These "outcomes"f genetic counseling need to be assessed, and new measures must be developed.

Predictive value of uterine artery velocimetry at midgestation in low- and high-risk populations: a new perspective.

OBJECTIVE: The aim of this study was to assess the value of uterine artery Doppler velocimetry performed at 18-20 and 22-24 weeks of gestation in predicting preeclampsia and adverse pregnancy outcome in low- and high-risk patients. METHODS: 865 pregnant women were evaluated: 335 and 530 pregnant women represented the high- and low-risk groups, respectively. Doppler ultrasound examination of the uterine arteries was performed at 18-20 weeks of gestation in 385 patients and at 22-24 weeks of gestation in 659 patients. Pregnancy outcome was evaluated in terms of: onset of preeclampsia; birth weight <2,500 g; birth weight <1,750 g; delivery before 36 weeks, and delivery before 32 weeks. RESULTS: At 18-20 weeks of gestation the sensitivity for the prediction of preeclampsia was 100 and 94% in low- and high-risk groups, respectively. Excellent negative predictive values towards birth weight <1,750 g (97% in low-risk and 93% in high-risk groups) and delivery prior to 32 weeks of gestation (99% in low-risk and 95% in high-risk groups) were obtained. At 22-24 weeks of gestation the sensitivity for the prediction of preeclampsia was 100 and 97% in low- and high-risk groups, respectively. Negative predictive values towards birth weight <1,750 g were 97% in low-risk and 94% in high-risk groups, whereas towards delivery prior to 32 weeks of gestation they were 98% in low-risk and 94% in high-risk groups. CONCLUSION: Doppler evaluation of the uterine artery at 18-20 and 22-24 weeks of gestation represents a useful predictive test in high-risk pregnancy and can also be used in prenatal surveillance of a low-risk population.

Pregnancy outcome and total parenteral nutrition in malnourished pregnant women.

OBJECTIVE: We evaluated pregnancy outcome and fetal growth in women requiring total parenteral nutrition (TPN). METHODS: Eleven malnourished pregnant women were treated with TPN in a single institution, starting at a mean gestational age of 20+/-8 weeks (+/- SD). Serial ultrasound evaluations of fetal growth (biparietal diameter, femur length, abdominal circumference) were performed. The paired Student t test and Wilcoxon signed-rank test were used for the statistical analysis: p values <0.05 were considered significant. RESULTS: The duration of TPN ranged from 14 to 220 days. Maternal nutritional state was well preserved and no complications were related to treatment. A gestational age of 35+/-3 weeks at delivery (mean +/- SD), birth weight of 2,251+/-670 g (mean +/- SD) and birth percentile of 29+/-16 (mean +/- SD) were observed. One intrauterine death occurred. The comparison between the sonographic findings, before and 2 weeks after starting TPN, showed a fetal percentile gain with a statistically significant increase in the abdominal circumference percentile (p < 0.05) from a median percentile of 2 (range 2-32) to 33 (range 2-78). CONCLUSIONS: TPN proved to be helpful and lifesaving in malnourished pregnant women and promoted fetal growth, as shown by the longitudinal ultrasonographic evaluations.

Ethical issues of genetic testing and their implications in epidemiologic studies.

PURPOSE: To discuss and summarize the ethical controversies related to genetic testing and screening, and their effects on the research and other professional activities of epidemiologists. METHODS: We reviewed the literature and proposed legislation to discuss the controversies related to the ethical issues of genetic testing in epidemiologic research. RESULTS: From a review of the literature and proposed legislation, we found these controversies may continue for some time and will probably add to the duties and difficulties of epidemiologists. It is important for the profession to respond to developments such as the proposed federal Genetic Confidentiality and Nondiscrimination Act of 1996 (Senate Bill 1898), which is summarized here; changes in research protocols and informed-consent forms as well as inclusion of other professionals from many disciplines will be necessary. In addition to revising training, and expanding their ethical code, epidemiologists should respond to public concerns about genetic information by disseminating knowledge about freedom to conduct clinical research, protection of the individual, and the limits of genetic information. CONCLUSIONS: The possibility of genetic discrimination may complicate epidemiological research unless the public, employers, insurers, physicians, and researchers reach a consensus on the meaning of, and need for, genetic information. Although ethical concerns are appropriate, they will make accrual of study subjects and tissue samples more difficult.

[Urinary tract infections: risk factors and therapeutic trends]. / Infezioni urinarie: fattori di rischio ed orientamenti terapeutici.

Urinary tract infections (UTIs) are very common in medical practice. Women have a high prevalence of UTIs, approximately 50 times higher than men. A large proportion of this prevalence is probably caused by anatomic and physical factors Chemical analysis of urine composition, examination of the urinary sediment and the bacterial colony counts are of great value for diagnosis and therapy. The patients may be benefit from antibiotic doses. In addition to trimethoprimsulfamethoxazole (TMP/SMZ), amoxicillin and cephalosporins, the authors observed a new drug: fluoroquinolones. These drugs derived by nalidixic acid and included: ciprofloxacin, enoxacin, lomefloxacin, norfloxacin, pefloxacin and rufloxacin. They are sinergistic against most Gram positives and negatives including Pseudomonas aeruginosa and Proteus mirabilis. Fluoroquinolone is an antibacterial agent that is effective in treating urinary tract infections. It is usually administered orally and is well absorbed after oral ingestion. Quinolones are preferable to TMP/SMZ because of their greater antibacterial activity that occurred in about 82% of women. A dose of quinolones (400 mg daily for 3 days) has been particularly effective in the treatment of UTIs. The amoxicillin-clavulanic acid can be used for treatment even if increased antibiotic resistance. The efficacy, relative safety and low cost of quinolones predispose to utilize its like the first treatment choice.

[Mycotic vulvovaginitis]. / Vulvovaginiti micotiche.

Vulvovaginitis is the most common clinical manifestation of fungal infections causing human mycoses; the incidence occurs in 10% of women, during pregnancy the incidence achieves 30% of cases. Candida albicans has resulted to be the most commonly isolated agent in patients with fungemia. In fact, Candida appears to be the species recovered in as many as 90% of cases. They are mainly the sexual activity, hormonal contraception and several pathologies such as diabetes mellitus and thyroiditis responsible for the pathogenesis of infection. The first symptom of this infection is usually pruritus associated to leukorrhea, dyspareunia and vulvovaginal irritation. Antifungal therapy may be required in more severe cases of vulvovaginal candidiasis. Candida species can be identified on isolation culture media including agar and on direct examination. Diagnosis can also be made through san immunologic examination. However, the authors confirm that the risk factors together with a correct diagnosis of the Candida etiological agent in the different species (albicans, glabrata, tropicalis, krusei) should be accurately investigated in order to give the correct therapeutical approach.

Double shunt in a case of fetal low-level obstructive uropathy.

This report describes a pregnant woman at 22 weeks of gestation examined for fetal bilateral dilated renal pelvis and oligohydramnios. Ultrasound evaluation confirmed the diagnosis of low-level obstructive uropathy. At 26 weeks of gestation, the increase in hydronephrosis prompted us to introduce a vesicoamnionic shunt. Because of unusual intraperitoneal dislocation of the shunt and an increase in ascites and hydronephrosis, we had to insert a peritoneoamnionic shunt at 30 weeks of gestation. The patient underwent cesarean section at 31 weeks for obstetric complications. The infant, at 15 months of age, showed mild renal failure.

Chronic hypertension in pregnancy: color Doppler investigation of uterine arteries as a predictive test for superimposed preeclampsia and adverse perinatal outcome.

To determine if uterine artery Doppler velocimetry is useful in identifying chronic hypertensive pregnancies at risk for superimposed preeclampsia and adverse perinatal outcome. Resistance index (RI) was assessed by color velocimetry at the level of uterine arteries at 23-24 weeks of gestation in 42 women with chronic hypertension. The "lowest", the "highest" and the "average" values were compared to select the most predictive index for superimposed preeclampsia, intrauterine growth retardation (IUGR), birth weight lower than 2500 g and gestational age at delivery less than 36 weeks. Nine patients developed superimposed preeclampsia (21%) and 15 delivered before the 36th week of gestation (36%); 4 babies were IUGR (10%) and in 18 cases birth weights were below 2500 g (43%). Statistical analysis of Doppler findings showed that abnormal values of "lowest RI" were significantly correlated with adverse pregnancy outcome. Color Doppler analysis of uterine arteries is able to select chronic hypertensive pregnant women at risk of superimposed preeclampsia and poor perinatal outcome.

The duration of hypertension in the puerperium of preeclamptic women: relationship with renal impairment and week of delivery.

OBJECTIVE: The purpose of the study was to determine whether the duration of hypertension in the puerperium of preeclamptic women was related to certain clinical features of disease severity. STUDY DESIGN: We studied 269 singleton pregnancies divided into two groups: 159 with gestational hypertension and 110 with preeclampsia. The normalization time of blood pressure in puerperium was estimated as the interval between the delivery day and the first day when each of two to four self-measurements per day of diastolic blood pressure was observed to be < or = 80 mm Hg for at least 3 consecutive days. RESULTS: Normalization time was shorter in gestational hypertension than in preeclampsia (6 +/- 5.5 [means +/- SD] vs 16 +/- 9.5, respectively, p < 0.0001). Normalization time of gestational hypertension showed a significant correlation with uric acid (r = 0.20, p < 0.025); normalization time of preeclampsia displayed significant correlations with the week of delivery (r = -0.34, p < 0.005), uric acid (r = 0.34, p < 0.025), and urea nitrogen (r = 0.29, p < 0.025), respectively. After stratification by parity, in both groups the correlations of normalization time with renal data were observed only among multiparous women, whereas in preeclampsia the link of normalization time with the week of delivery remained highly significant in both subgroups. CONCLUSIONS: The differences observed between gestational hypertension and preeclampsia suggest that distinct mechanisms or a different maternal answer to the same mechanism(s), in maintaining high blood pressure in puerperium, are present in the two groups. Normalization time might reflect the recovery time of the endothelial damage in preeclampsia.

Drug addiction in pregnancy: the HIV infection.

From January 1986 to December 1990 70 HIV-seropositive pregnant women were seen at the Department of Obstetrics and Gynecology, Rome, Italy. All of them delivered in our Hospital Center and their babies were enrolled in pediatric follow-up. Sixty-five patients (93%) were drug-addicted, only 6 of them showing signs of HIV infection (lymphoadenopathy). The authors report the results of a clinical study demonstrating that asymptomatic HIV infection did not affect the regular course of pregnancy. Moreover, they show that there was no progression of disease during pregnancy, vertical transmission was 24%, the infected babies were of low birth weight (2,586 +/- 527 vs. 3,100 +/- 470 g) and the incidence of premature delivery was higher (30 vs. 8%) than in noninfected controls.

Drug addiction in pregnancy: 13 years of experience.

In this retrospective study, we review our data on 203 drug-addicted pregnant patients, considering two different aspects of the question: maternal and fetal. We report the findings relative to maternal metabolic, endocrinological, neuroendocrinological and immunological studies performed in our department over the past 13 years. Moreover, we study fetal involvement in drug-addicted pregnancy and report the findings of our fetal behavior and urodynamic studies. The last section of this study deals with perinatal outcome. In particular, we report a high incidence of small-for-gestational-age fetuses and premature deliveries.

Immune thrombocytopenic purpura and percutaneous umbilical blood sampling: an open question.

We performed a retrospective study of 26 pregnancies with chronic immune thrombocytopenic purpura (ITP) or incidental ITP. Thirteen pregnancies were followed without the use of percutaneous umbilical blood sampling (PUBS) and 13 were followed sampling PUBS at 36-40 weeks of gestation. The overall prevalence of neonatal thrombocytopenia was 27%: 50% in chronic ITP, 12.5% in incidental ITP. Symptomatic thrombocytopenia occurred only in infants born to mothers with chronic ITP. Without the use of PUBS, 2 symptomatic thrombocytopenic fetuses were vaginally delivered and there was a high rate of cesarean sections in normal fetuses. Owing to PUBS, a decrease of the cesarean section rate in normal fetuses was observed, but one fetal bradycardia (due to the technique) was encountered. PUBS resulted helpful to indicate the best route of delivery and reducing unnecessary cesarean sections in women with chronic ITP, but in presence of incidental ITP the use of PUBS remains an open question.