Persistent Postpartum Urinary Retention: A Case Report and Review of Literature.

This case report describes persistent urinary retention lasting over 30 days postpartum in a 23-year-old primiparous female after an otherwise uncomplicated vaginal delivery at 37 weeks gestation. Notable risk factors present included epidural anesthesia, episiotomy, third-degree perineal laceration, and inability to void spontaneously before leaving the delivery room. Despite initial catheterization draining a large volume, the patient experienced recurrent failed voiding trials requiring ongoing intermittent catheterization during her admission. One month after delivery, voiding trials were finally successful, and she regained normal spontaneous voiding without catheterization. This case highlights persistent postpartum urinary retention (PUR) as an uncommon but potentially serious obstetric complication requiring prompt diagnosis and appropriate management to prevent adverse events and optimize outcomes. Although most cases are self-limited, a high index of suspicion is needed to institute timely treatment with intermittent catheterization given the morbidity associated with sustained bladder overdistension postpartum.

Peripartum Ηysterectomy: A Four-Year Obstetric and Anesthetic Experience in a Tertiary Referral Hospital in Greece.

Background Although peripartum hysterectomy (PH) is a life-saving procedure in cases of abnormal placentation and postpartum hemorrhage, it can be associated with major obstetric and anesthetic complications. This retrospective study aimed to evaluate the incidence, etiology, perioperative anesthetic and obstetric management, complications, and fetal outcomes in women undergoing PH in a single tertiary referral hospital in Greece. Methodology This was a retrospective analysis of medical records of women who underwent emergency or elective PH in our hospital between January 2015 and December 2018. Results During the study period, 69 women who underwent a PH were identified. The incidence rate of elective and emergency PH was 4 and 1.2 per 1,000 deliveries, respectively. The main indication for PH was abnormal placentation (81.2%), followed by uterine atony (13%). Conversion to general anesthesia (GA) was performed in 21 (30.4%) cases. Conclusions This study showed a high prevalence of PH in our hospital compared to high-income countries. A neuraxial-only technique may be a safe alternative in individual cases of abnormal placentation. Conversion to GA can be reserved for complex surgical cases when massive hemorrhage is anticipated and, if possible, after the neonate has been delivered.

Effectiveness of maternal vaccination with quadrivalent inactivated influenza vaccine in pregnant women and their infants in 2019-2020.

OBJECTIVES: Influenza is associated with an increased risk for serious illness, hospitalization, and death in pregnant women and young infants. Our aim was to estimate the effectiveness of a quadrivalent inactivated influenza vaccine (QIV) in pregnant women and their infants during 2019-2020. METHODS: A QIV vaccine was offered to pregnant women followed in a maternity hospital. Women were contacted weekly during the influenza season and asked about symptoms. Polymerase chain reaction testing in pharyngeal samples was offered to pregnant women and infants with influenza-like illness. A Bayesian beta-binomial model was used. RESULTS: We studied 636 pregnant women (406 vaccinated and 230 unvaccinated) and 474 infants (281 of mothers vaccinated in pregnancy and 193 of unvaccinated mothers). Using a Bayesian beta-binomial model, it was estimated that influenza vaccination of pregnant women reduced their logit to develop laboratory-confirmed influenza by -4.2 (95% CI -3,7 - 4,7) and the logit of their infants to develop laboratory-confirmed influenza by -4.2 (95% CI -3.6, -4.9). The QIV effectiveness against laboratory-confirmed influenza was 43.5% in pregnant women and 31.4% in infants. CONCLUSION: Maternal influenza vaccination with QIV in pregnancy reduced the odds of pregnant women and their infants to develop influenza. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov identifier is NCT04723771.

Cervical Twin Heterotopic Pregnancy: Overview of Ectopic Pregnancies and Scanning Detection Algorithm.

Background: Ectopic pregnancy is the leading cause of gestation-related deaths during the first trimester. Cervical twin heterotopic pregnancies, when ectopic, constitute a small and rare part of gynecological surgery. Case Presentation: A 30-year-old pregnant woman (gravida 3, para 2) presented with mild pain in the lower abdomen and traces of bleeding per vaginum for three days. Transvaginal ultrasonography revealed a balloon-shaped cervical canal with a visible gestational sac measuring 3.5 × 3.9 cm. A second gestational sac was seen in the uterine cavity. The measurements of the gestational sacs corresponded to 7 + 4 weeks' pregnancy. A decision for medical abortion with mifepristone and misoprostol was made. However, due to an incomplete abortion and continuous bleeding, a curettage was performed. Conclusions: Spontaneous heterotopic pregnancy with the ectopic pregnancy located in the cervix is an extremely rare clinical condition requiring urgent treatment in order to reduce maternal mortality and morbidity and preserve fertility.

The Relevance of Notch Signaling in Cancer Progression.

The Notch signaling pathway controls normal embryonic development and tissue homeostasis of many cell types. It regulates cell proliferation, fate, differentiation, and cell death by short-range signaling between nearby cells that come in contact. The Notch pathway has also been critically involved in the pathobiology of a variety of malignancies, regulating cancer initiation and development, as well as early stages of cancer progression, by adjusting conserved cellular programs. Fibroblasts, an essential for tumor growth component of stroma, have also been affected by Notch regulation. Sequencing Notch gene mutations have been identified in a number of human tumors, revealing information on the progression of specific cancer types, such as ovarian cancer and melanoma, immune-associated tumors such as myeloid neoplasms, but especially in lymphocytic leukemia. Activation of the Notch can be either oncogenic or it may contain growth-suppressive functions, acting as a tumor suppressor in other hematopoietic cells, hepatocytes, skin, and pancreatic epithelium.

Effect of dietary myo-inositol supplementation on the insulin resistance and the prevention of gestational diabetes mellitus: study protocol for a randomized controlled trial.

BACKGROUND: Gestational diabetes mellitus (GDM) is defined as impaired glucose tolerance with onset or first recognition during pregnancy, which is characterized by an increased insulin resistance. Gestational diabetes mellitus is associated with pregnancy-related maternal and fetal morbidity (both antenatal and perinatal). Myo-inositol has been suggested to improve insulin resistance in women with polycystic ovary syndrome. The aim of this study is to examine the impact of myo-inositol supplementation during pregnancy on the incidence of gestational diabetes mellitus. METHODS: We will conduct a single-center, open-label, randomized controlled trial. A total of 160 healthy pregnant women with singleton pregnancy at 11-13+6 weeks of gestation will be randomly allocated in two groups: intervention group (N = 80) and control group (N = 80). The intervention group will receive myo-inositol and folic acid (4000 mg myo-inositol and 400 mcg folic acid daily) from 11 to 13+6 weeks of gestation until 26-28 weeks of gestation, while the control group will receive folic acid alone (400 mcg folic acid daily) for the same period of time as intervention group. The primary outcome will be gestational diabetes incidence rate at 26-28 weeks of gestation, according to the results of a 75 g oral glucose tolerance test held at 26-28 weeks of gestation. The secondary outcomes will include fasting blood glucose levels, glycated hemoglobin levels, insulin resistance level (evaluated by homeostasis model assessment of insulin resistance and Matsuda Index), and incidence rate of diet-treated gestational diabetes and diabetes requiring insulin therapy at 26-28 weeks of gestation. DISCUSSION: This trial will provide evidence for the effectiveness of myo-inositol supplementation during pregnancy in reducing the incidence of gestational diabetes mellitus. TRIAL REGISTRATION: ISRCTN registry: ISRCTN16142533 . Registered on 9 March 2017.

Effectiveness of quadrivalent influenza vaccine in pregnant women and infants, 2018-2019.

Influenza is associated with an increased risk for serious illness, hospitalization and/or death in pregnant women and young infants. We prospectively studied the effectiveness of a quadrivalent inactivated influenza vaccine (QIV) in pregnant women and their infants during the 2018-2019 influenza season. A QIV was offered to pregnant women cared in a maternity hospital in Athens. Women were contacted weekly by telephone during the influenza season and PCR test was offered to women or infants who developed influenza-like illness (ILI). We studied 423 pregnant women and 446 infants. Unvaccinated pregnant women had a 7.5% probability to develop laboratory-confirmed influenza compared to 2.1% among vaccinated women (Odds ratio: 3.6; confidence intervals: 1.14-11.34, p-value = 0.029). Infants whose mothers were not vaccinated had a 7.9% probability to develop laboratory-confirmed influenza compared to 2.8% among infants of vaccinated mothers (Odds ratio = 2.849, confidence intervals: 0.892-9.102, p-value = 0.053). Cox regression analyses showed that QIV vaccination was significantly associated with a decreased probability for laboratory-confirmed influenza, ILI, healthcare seeking and hospitalization among pregnant women and a decreased probability for laboratory-confirmed influenza, healthcare seeking and prescription of antibiotics among infants. The effectiveness of QIV against laboratory-confirmed influenza was 72% among pregnant women and 64.5% among infants during the 2018-2019 influenza season. Vaccination of pregnant women with the QIV was associated with a lower risk for laboratory-confirmed influenza for them and their infants during the influenza season. Our findings strongly support the World Health Organization recommendations for vaccinating pregnant women against influenza.

Routine immunizations during pregnancy, doctors' compliance and patient hesitancy: A two stage study on vaccination uptake.

OBJECTIVE: To evaluate the compliance of healthcare professionals with national guidelines and the hesitancy of pregnant women to be immunized against influenza and pertussis. STUDY DESIGN: We conducted a two-stage study. The first stage of our study included all women (n = 197) who gave birth in Alexandra Maternity Hospital in Athens, Greece during a 3-month period (April-June) 2018. They completed a questionnaire regarding their immunization status against influenza and pertussis. If pertinent, they detailed their reasons for not getting immunized. During the second stage of our study, we actively recommended both vaccines to the outpatients of Alexandra Maternity Hospital (n = 195) between September 2018 and January 2019. RESULTS: The majority of women (92.9%) were immunized during childhood according to Greek national immunization guidelines. Almost all the women (98%) stated that they will vaccinate their children. More than half (65.5%) responded that they would have been vaccinated during pregnancy if their doctor had recommended it, but in 73.6% of cases, their doctor did not do so. Only a small proportion of women (16.2%) were immunized against influenza during pregnancy while none of them (0%) received the Tdap vaccine. In most cases (65%), study participants stated they were not immunized because their doctor did not recommend vaccination. Additionally, 9.7% of participants feared possible side effects. During the second stage of our study 94.9% out of 195 women agreed to get vaccinated against influenza and 92.8% against pertussis. CONCLUSIONS: It is apparent that the compliance with the immunization guidelines during pregnancy is surprisingly low. However, health professionals appear to be reluctant to recommend vaccination during pregnancy. Women appear to trust their doctors and usually agree with their recommendations.

Immunizations during pregnancy: How, when and why.

Maternal immunization during pregnancy provide protection for the mother and the fetus against certain pathogens. Immunizations during pregnancy are divided to routine immunizations recommended for all pregnant women, immunizations for certain medical indications and vaccines that are potentially harmful during pregnancy and should be avoided. We conducted a comprehensive review of the literature regarding immunizations during pregnancy. The search terms used were immunization, vaccine, pregnancy, influenza, pertussis, safety and efficacy. We gathered all available guidelines on vaccination during pregnancy. Generally, vaccines are allowed during pregnancy when the benefits outweigh the risks. Tdap and inactivated flu vaccines are routinely recommended during pregnancy. Vaccines containing live attenuated viruses are contraindicated during pregnancy. These are LAIV influenza, MMR, Varicella, Zoster, BCG and smallpox pre-exposure. All other vaccines are given when medically indicated and the possible benefits outweigh the risks. Obstetricians and gynecologists should be familiar with the indications of vaccination during pregnancy. Vaccination coverage of pregnant women with routinely recommended vaccines has increased but further efforts are needed. Our aim is to review vaccination practices during pregnancy, demonstrate the benefits and dangers of different vaccines, evaluate their effectiveness and define the proper timing of vaccination.

Assessment of Uterocervical Angle Width as a Predictive Factor of Preterm Birth: A Systematic Review of the Literature.

BACKGROUND: Uterocervical angle (UCA) has been recently proposed as a potential marker that could accurately predict preterm birth (PTB). The purpose of the present systematic review is to accumulate current evidence and provide directions for future research. MATERIALS AND METHODS: We used the Medline (1966-2018), Scopus (2004-2018), Clinicaltrials.gov (2008-2018), EMBASE (1980-2018), Cochrane Central Register of Controlled Trials CENTRAL (1999-2018), and Google Scholar (2004-2018) databases in our search. RESULTS: Eleven studies were finally included in the present systematic review that evaluated data from 3,018 women. The significant heterogeneity in terms of outcome reporting and outcome reporting measures (use of optimal cut-off values) precluded meta-analysis. However, existing data support that second trimester UCA measurement might be used as a predictive factor of PTB <34 weeks, as at least two studies in unselected singleton pregnancies and two studies in pregnancies with an ultrasonographically shortened cervix seem to support this hypothesis. The most commonly reported cut-off values were 105° and 95°. CONCLUSIONS: UCA measurement during the second trimester of pregnancy may be a useful method of determining women at risk of delivering preterm. However, more studies are needed to assess the reproducibility of these findings and reach conclusive evidence.

Fetal loss following second trimester amniocentesis. Who is at greater risk? How to counsel pregnant women?

OBJECTIVE: The purpose of this retrospective observational cohort study was to determine the impact of certain risk factors on fetal loss, after mid-trimester amniocentesis. MATERIAL AND METHODS: Six thousand seven-hundred and fifty-two (6752) consecutive amniocenteses with known pregnancy outcome performed during a 7-year period (2004-2010) were included in this study. Different maternal-, fetal- and procedure-related factors were evaluated in this study. RESULTS: During this 7-year period, 6752 cases who underwent amniocentesis, with complete data available were evaluated for the outcome and risk factors mentioned. Total fetal loss rate (FLR) up to the 24th week was 1.19%. Risk factors associated with increased risk of fetal loss after amniocentesis were maternal age (OR:2.0), vaginal spotting (OR:2.2) and serious bleeding (OR:3.5) during pregnancy, history of 2nd trimester termination of pregnancy (OR:4.0), history of more than three spontaneous (OR:3.0) or surgical first trimester abortions (OR:2.1), fibromas (OR:3.0) and stained amniotic fluid (OR:6.1). CONCLUSIONS: Amniocentesis is a safe-invasive procedure for prenatal diagnosis with total FLR of 1.19% in our institution during the study period. The present study has emphasized the significance of certain risk factors for adverse outcome and therefore the need to individualize the risk.

Risk for fetal loss and prematurity after 12,413 second trimester amniocenteses in a single center.

OBJECTIVES: The purpose of this retrospective controlled study is to estimate the risk for fetal loss and preterm delivery attributed to second trimester amniocentesis from a single tertiary center. METHODS: The study group consists of 12,413 singleton pregnancies with consecutive amniocenteses, performed in a single tertiary center during a 15-year period (1996-2010) with known pregnancy outcome. The control group consisted of 6993 pregnancies with negative second trimester screening for aneuploidies during the same period who did not have any invasive test. The two groups were compared in terms of fetal loss rate up to 24 weeks and premature deliveries. RESULTS: Total fetal loss up to 24 weeks in the study group, excluding terminations of pregnancy, was estimated at 1.25% (1.05%-1.45%, confidence interval [CI]: 95%). In the control group the loss rate was 0.65% giving a procedure related fetal loss rate of 0.6% which was not found to be a statistically significant difference. Delivery before the 28th, 32nd, 34th, and 37th week in the study group was reported in 0.2%, 0.8%, 1.2% and 8.1% respectively, and it was not statistically different from controls. CONCLUSION: The present study has shown that the risk of miscarriage that can be attributed to amniocentesis in our institution is 0.6%, and this is not statistically significant when compared with cases without any invasive procedure during pregnancy. Similarly, the risk for preterm labor was not statistically significant when compared with controls.

Trends in twin pregnancies and mode of delivery during the last 30 years: inconsistency between guidelines and clinical practice.

AIM: To investigate the characteristics of twin pregnancies and their mode of delivery over a 30-year period, in order to define the current trends in clinical practice regarding twin deliveries and the factors that influence these practices. MATERIALS AND METHODS: A retrospective study of twin deliveries at ≥24 weeks of gestation between January 1st, 1981 and December 31, 2010. Data concerning number of twin deliveries, mode of delivery, maternal age, use of ART techniques, parity, gestational age at delivery, birth weight and Apgar scores were collected from labor ward records. RESULTS: Over the years there has been a statistically significant increase in the number of twin deliveries, twins after IVF, cesarean section rate, maternal age, nulliparity and a statistically significant reduction in term deliveries, mean birth weight and assisted vaginal deliveries. Maternal age, gestational age, parity and conception after IVF are factors related to the risk of performing a cesarean section. CONCLUSIONS: Despite the lack of adequate scientific evidence concerning the optimal route of delivery in twin pregnancies it seems that over time cesarean section has become the standard of care in most of twin pregnancies. Changes in the demographic characteristics contribute among other factors to this practice.

Management options and prognosis of pancreatic adenocarcinoma at 16 weeks' gestation: a case report.

BACKGROUND: Antepartum diagnosis of pancreatic adenocarcinoma is extremely rare, with only 9 cases previously reported in the literature. We report on such a case and review the literature for management options and prognosis of this unfortunate condition. CASE: A 33-year-old woman, gravida 1, para 0, was referred at 16 weeks' gestation due to weakness, weight loss and anemia. Comprehensive investigation followed and a final diagnosis of pancreatic adenocarcinoma was made after pancreatic fine needle aspiration biopsy during endoscopic ultrasound of the upper abdomen. At 19 weeks' gestation fetal demise occurred. CONCLUSION: While early diagnosis may not alter long-term outcome, it may provide the patient with an earlier opportunity to evaluate decisions related to pregnancy. The two most important factors determining management options for pancreatic cancer during pregnancy are disease stage and gestational age. Prognosis is extremely poor, with 5-year survival after surgery being 20% versus 3-5% in unresectable disease. Prognosis depends on disease stage and on the interval between diagnosis and surgery. Delay for even one month may render the disease metastatic. Participation of a multidisciplinary team is critical in the management of such cases since, due to the rarity of the disease during pregnancy, there are no evidence-based data to guide decisionmaking.

Cervical cone measurements and residual disease in LLETZ conisation for cervical intraepithelial neoplasia.

AIM: To investigate the oncologically safe limits of excision in large loop excision of the transformation zone (LLETZ) conisation performed for cervical pathology. PATIENTS AND METHODS: A retrospective study conducted at the Colposcopy Unit in a University Hospital setting. Three hundred and sixty-one cases of LLETZ conisation were conducted in a 2-year period. Data concerning age, cone dimensions, lesion types and excision margins were recorded. RESULTS: The mean age of women was 36.7 years, with 181 (50.5%) low-grade squamous intraepithelial lesion cases, 166 (45.7%) high-grade squamous intraepithelial lesion, and 14 (3.8%) with stage-IA1 cervical carcinoma. Mean conisation depth and cone volume were 10.9 mm and 2.2 ml, respectively. Incomplete removal of lesions occurred in 25% of women and correlated to severity of cervical intraepithelial neoplasia and conisation depth. The higher the grade of the lesion, the greater the percentage of residual disease. Conisation depth exceeding 10 mm, in our cohort, led to significantly less residual disease. CONCLUSION: Results indicate that a conisation depth of <10 mm may be a risk factor predicting positive resection margins, while cone volume is an inappropriate clinical marker.

Prenatal diagnosis of prune-belly syndrome at 13 weeks of gestation: case report and review of literature.

We present a case report of a foetus with Prune-Belly syndrome (PBS) which was diagnosed sonographically during the 13th week of gestation and review of the literature. Sonographic diagnosis was based on abnormally distended urinary bladder and abdomen and absence of 'keyhole sign'. Termination was performed on parental request and post-mortem examination revealed absence of abdominal wall musculature and the distended urinary bladder in a male foetus. Prenatal diagnosis of PBS is based on ultrasound and is usually diagnosed in the second trimester. In the first trimester there are very few reports to date. Prognosis and possible treatment options are herein discussed as well as the underlying mechanisms that may explain the clinical presentation of the syndrome.

Ruptured ectopic pregnancy: risk factors for a life-threatening condition.

INTRODUCTION: Ectopic pregnancy is a significant cause of maternal morbidity and mortality. The widely used features to establish the diagnosis of ectopic pregnancy are not always sufficient to predict rupture. PROBLEM: To determine the risk factors for rupture of an ectopic pregnancy to help physicians identify those women who are at greatest risk. MATERIALS AND METHODS: The study group comprises the cases of ectopic pregnancy who were treated in the gynecologic department of the General Hospital "George Gennimatas" in Athens, Greece, from January 1988 to December 2006. The following parameters were retrospectively examined: rupture status, past history of pelvic infection or ectopic pregnancy, use of IUCD, operations for infertility treatment/tubal surgery, parity and gestational age. The study group was divided into two subgroups: ruptured ectopic pregnancies and unruptured ectopic pregnancies. Where appropriate, Student's t test, Mann-Whitney-Wilcoxon test for independent samples, Pearson's chi-square and Fisher's exact test were applied. Statistical analysis was performed with STATA 8.0 statistical software. RESULTS: Two hundred and twenty-three cases of ectopic pregnancy were retrieved in the studied period. One hundred and forty-four (65%) of them were cases with ruptured ectopic pregnancies and 79 (35%) were cases with unruptured ectopic pregnancies. Fifty-five of the 144 patients (38.2%) with ruptured ectopic pregnancy and 18 of the 79 (22.8%) patients with unruptured ectopic pregnancy had a past history of ectopic pregnancy (P = 0.019, Pearson's chi-square). Moreover, there was a statistically significant positive association between rupture and parity (1.19 +/- 1.02 for ruptured cases vs. 0.85 +/- 0.89 for unruptured cases; P = 0.015, Mann-Whitney-Wilcoxon test for independent samples). A positive association of borderline significance existed between rupture and gestational age (53.9 +/- 4.7 vs. 52.9 +/- 4.9 days; P = 0.093, Mann-Whitney-Wilcoxon test for independent samples). No statistically significant associations were found concerning past history of pelvic infection, use of IUCD and operations for infertility treatment-tubal surgery. CONCLUSIONS: Previous history of ectopic pregnancy and parity seem to be significant risk factors for rupture of an ectopic pregnancy.

The HPV Cellular Transactivator Brn-3a Can Be Used to Predict Cervical Adenocarcinoma and Squamous Carcinoma Precancer Lesions in the Developed and Developing Worlds.

The cellular transactivator Brn-3a has previously been shown to be expressed at elevated levels in the cervix of women with squamous cell carcinoma of the cervix (SCC) and to activate the expression of HPV E6 mRNA. In this study, we show that common and rare cervical precancer lesions, including those of adenocarcinoma (AC), which are usually difficult to diagnose using classical procedures, also expressed high levels of Brn-3a and can be diagnosed by measuring the levels of Brn-3a and E6 mRNAs.