Postpartum contraception: A matter of guidelines.

The postpartum period is the perfect time to access family planning services. WHO guidelines contraindicate combined hormonal contraceptives postpartum in breastfeeding patients between 6 weeks and 6 months after delivery (Medical Eligibility Criteria category 3). On the contrary, the Faculty of Sexual and Reproductive Healthcare and the Centers for Disease Control and Prevention guidelines do not contraindicate their use in women who breastfeed from 6 weeks to 6 months postpartum. New combined hormonal contraceptives with natural estrogens have never been studied in this setting. Guidelines agree on the prescription of the progestin-only pill postpartum in non-breastfeeding women (category 1). Differences are found in women who breastfeed. In non-breastfeeding women, an implant is considered safe (category 1) by all guidelines, without any distinction in time. Regarding postpartum breastfeeding women, the guidelines for implants give quite different indications but are still permissive. Intrauterine devices are viable options for postpartum contraception but guidelines give different indications about the timing of insertion. Postplacental intrauterine device placement can reduce the subsequent unintended pregnancy rate, particularly in settings at greatest risk of not having recommended postpartum controls. However, it has yet to be understood whether this approach can really have an advantage in high-income countries. Postpartum contraception is not a 'matter of guidelines': it is the best customization for each woman, as early as possible but at the ideal timing.

Long-term outcomes of patients with preeclampsia, a review of the literature.

Hypertensive pregnancy disorders affect up to 10% of all pregnancies and are associated with an increased future risk of heart disease, chronic hypertension, kidney dysfunction, diabetes, and thromboembolism. Although mechanisms are not yet well understood, endothelial dysfunction, pro-inflammatory and procoagulant states seem to persist in women with a history of preeclampsia many years after a pregnancy complicated by HDP. Moreover, the number and severity of these complications differs according to the type of disorder developed during pregnancy. Lifestyle modifications and long-term follow-up are essential to reduce the risk of developing a disease later in life. [Figure: see text].

A Rare Ovarian Tumor: The Sclerosing Stromal You Do Not Expect-A Case Series in the Adolescent Population and a Literature Review.

Sclerosing stromal tumor (SST) is a rare ovarian tumor arising from the sex cord-stromal cells that occurs mainly in young adults during the second and third decades of life and rarely in pediatric and adolescent populations. The objective of this study is to report three illustrative cases of SST in young girls who had undergone surgery at our clinic in or after 2009, and to perform a literature review of this rare ovarian tumor. A retrospective chart review of female patients aged <18 years with a diagnosis of SST treated in a tertiary pediatric hospital was performed. Furthermore, a 10-year review of the SST literature was completed. Three cases of SST at our institution were outlined. After reviewing the literature, 18 SST cases were identified. The mean age at diagnosis was 13.4 years, and the reported clinical presentations were abdominal or pelvic pain and menstrual irregularity. Seven patients had abnormal hormone tests or CA-125 levels. In approximately 30% of cases, conservative surgery was performed, preserving residual ovarian tissue. In conclusion, some preoperative findings may help in suggesting the presence of SST. However, definitive diagnosis can only be made by histopathological examination. It is important to consider this tumor because, given its benign behavior, a conservative approach is preferred, particularly in this age group.

Systemic Oxidative Stress in Women with Ovarian and Pelvic Endometriosis: Role of Hormonal Therapy.

This study was performed to evaluate the systemic oxidative stress balance in women with either ovarian or deep infiltrating endometriosis (DIE) and any alterations of the same during hormone therapy. Free oxygen radicals (FORT) and free oxidant radical defense (FORD) were measured in the capillary blood of 24 women without endometriosis, 26 women with endometrioma, and 26 women with DIE with or without endometrioma. Endometriosis was diagnosed by clinical and ultrasound assessment. Dietary factors, lifestyle habits, and intake of any substances interfering with the oxidative status were recorded. Women were prescribed contraceptive hormones, and the baseline assessments were repeated at the 3rd month of use, revealing a higher oxidative stress balance (FORT/FORD) in women with endometriosis than in controls (4.75 ± 4.4 vs. 2.79 ± 2.2; p = 0.05). The highest values were found in women with DIE (5.34 ± 4.6; p = 0.028 vs. controls). Regression analysis revealed an independent link between FORT/FORD and endometrioma (b 2.874, 95% CI 0.345, 5.403; p = 0.027) and DIE (b 4.419, 95% CI 1.775, 7.064; p = 0.001) but a negative correlation with HDL-cholesterol (b -0.063, 95% CI -0.125, -0.002; p = 0.043). In controls, the hormone therapy increased FORT (p = 0.003), but also FORD (p = 0.012), with the FORT/FORD balance remaining stable (2.72 ± 2.2 vs. 2.73 ± 1.8; p = 0.810). In women with endometriosis, FORT remained unchanged, but FORD increased (p = 0.004), and the FORT/FORD ratio significantly decreased (4.75 ± 4.4 vs. 2.57 ± 1.76; p = 0.002) to values similar to the control levels. These data indicate that systemic oxidative stress balance increased in women with endometriosis, particularly in those with DIE. The hormonal therapy did not change the oxidative stress balance in control women but significantly improved it in women with endometriosis, particularly those suffering from DIE.

First-Line Therapy for Vaginal Atresia. Conservative Treatment vs Surgical Techniques: Quandaries Looking at Numbers.

Although it has been clearly stated that vaginal dilation must be considered the first-line treatment for clinical conditions characterized by an absent or hypoplastic vagina, mainly Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a great number of scientific papers on surgical vaginal reconstructions are reported every year. This wide variety of surgical techniques (more than 10) are recognized and performed worldwide, making it difficult to compare results and define an evidence-based approach. Standardized treatment should be considered even more important in the pediatric and adolescent population for the implications offered by the uterus transplantation scenario.

In vitro fertilization is associated with placental accelerated villous maturation.

OBJECTIVE: Accelerated placental maturation is regarded as a sign of vascular malperfusion and is often interpreted as a compensatory response by the placenta. In vitro embryo culture affects placental development. This study assessed placental maturation in spontaneous conceived and in vitro conceived pregnancies. METHODS: Retrospective cohort study on a single center between 2014 and 2017. For this study, preterm placentas of singleton pregnancies between 24 and 36 weeks were considered. Routine placental examinations were retrospectively reviewed. RESULTS: During the considered period, 423 placentas of singleton pregnancies were assessed. Three hundred ninety-six placentas were from spontaneous conception and 20 from in vitro fertilization and embryo transfer (IVF/ET). IVF/ET was significantly associated with accelerated villous maturation (AVM) and distal villous hypoplasia (DVH) (P<0.05). CONCLUSIONS: Placental AVM and DVH were significantly associated with in vitro fertilization in singleton pregnancies. This result supports the hypothesis that AVM is a compensatory response by the placenta to improve its transport capacity in specific settings such as in vitro fertilization.

Hormone Replacement Therapy in Endometrial Cancer Survivors: A Meta-Analysis.

The purpose of this study is to investigate the effect of hormone therapy (HT) on the oncological outcomes of endometrial cancer (EC) survivors. A systematic literature review was conducted in July 2021 to identify studies detailing the effect size for the relationship between HT use in EC and oncological outcomes (survival and disease recurrence). This included studies that evaluated the different recurrence rates among women treated for EC who subsequently underwent HT and those who did not. The collected studies were evaluated for quality, heterogeneity, and publication bias, and a pooled odds ratio (OR) or hazard ratio (HR) was calculated with a confidence interval of 95% (95% CI). In total, 5291 studies were collated, and after the review process, one randomized trial and seven observational studies were included, comprising 1801 EC survivors treated with HT and 6015 controls. The time-dependent analysis could be conducted for four studies, and considering the disease-free survival, the pooled HR of 0.90 (95% CI 0.28 to 2.87) showed no significant differences. However, among Black American women treated with continuous estrogen HT, the HR was 7.58 (95% CI 1.96 to 29.31), showing a significantly increased risk of recurrence for women in this ethnic group. Considering the pooled OR of all included studies 0.63 (95% CI 0.48 to 0.83), a significantly reduced risk of recurrence was found among EC survivors treated with HT. Considering the type of HT, the most risk-reducing was combined estrogen and progestin therapy and the cyclic regimen. Although supporting evidence is based mainly upon observational studies, evidence of no increased risk or even decreased risk was generally found, apart from in Black American women where a significantly increased recurrence risk was evident. The data are rather reassuring for the short-term administration of HT to symptomatic EC survivors. Future studies with a longer follow-up are necessary to better clarify the long-term effects of HT.

Relation of Birthweight and Ovarian and Uterine Size Prior to Menarche.

During pregnancy, supply of nutrients and exposure of the mother to environmental factors can influence fetus phenotype, possibly modifying growth of fetal tissues and organs. Few studies inconsistently reported that fetuses exposed to an insufficient energy supply, as those born small for gestational age, may have a reduced volume of uterus and ovaries. A retrospective analysis was performed on ultrasound data performed between 2012 and 2018 in 69 young premenarchal girls, 5 to 9 years of age, attending our endocrine-gynecologic clinic for a suspect of early puberty. Length of pregnancy and birthweight was also retrieved. When corrected for age, and presence of ovarian follicles, ovarian volume was positively (R2 = 0.210; p = 0.001) related to percentiles of birthweight (beta coefficient 0.012; 95% CI, 0.002-0.021). Similarly, uterine volume was positively (R2 = 0.237; p = 0.005) related to percentiles of birthweight (beta coefficient 0.067; 95% CI, 0.021-0.114). Ovarian (p = 0.034) and uterine (p = 0.014) volume was higher in the upper 3rd distribution of birthweight percentiles. In conclusion, development of ovarian and uterine volume increases progressively with the increase of birthweight percentiles. The data indicate an association between birthweight and the volume of uterus and ovary at 5-9 years of age.

First Trimester Uterine Rupture: A Case Report and Literature Review.

The aim is to report a case of spontaneous uterine rupture in the first trimester of pregnancy and to review the literature on the topic. METHODS: A literature search was performed using PubMed and Scopus. Relevant English articles were identified without any time or study limitations. The data were aggregated, and a summary statistic was calculated. RESULTS: A 35-year-old gravida 5, para 2 was admitted at our department because of fainting and abdominal pain. The woman had a first-trimester twin pregnancy and a history of two previous cesarean sections (CSs). Suspecting a uterine rupture, an emergency laparotomy was performed. The two sacs were completely removed, and the uterine rupture site was closed with a double-layer suture. The patient was discharged from hospital four days later in good condition. On the basis of this experience, a total of 76 case reports were extracted from PubMed and included in the review. Fifty-three patients out of 76 (69.74%) underwent previous surgery on the uterus. Most women (67.92%) had a CS, and in this group a cesarean scar pregnancy (CSP) or a placenta accreta spectrum (PAS) disorder was found to be the etiology in 77.78% of cases. Furthermore, 35.85% of the women had hysterectomy after uterine rupture. Twenty-three patients out of 76 (30.26%) had an unscarred uterus. Of this group, most women presented a uterine anomaly (43.48%). Moreover, 17.39% of these women had a hysterectomy. CONCLUSION: According to the literature, the current pandemic use of CS explains most cases of first-trimester uterine rupture.

Misoprostol administration prior to intrauterine contraceptive device insertion: a systematic review and meta-analysis of randomised controlled trials.

Objectives: Misoprostol has been used before intrauterine contraceptive device (IUCD) insertion to prime the cervical os. As the literature about this topic is controversial, we aimed to evaluate IUCD insertion failure, women's pain perception, use of cervical dilators and prevalence of side effects following the administration of misoprostol.Methods: Trials published in MEDLINE, Scopus, the Cochrane Library and ClinicalTrials.gov were searched (last search on 23 October 2019). The primary outcome was IUCD insertion failure; secondary outcomes were women's pain perception, use of cervical dilators to facilitate insertion, and prevalence of side effects.Results: Fourteen studies were eligible for inclusion. Misoprostol premedication reduced IUCD insertion failure rates and the use of cervical dilators but significantly increased the prevalence of side effects. The risk of IUCD insertion failure with misoprostol premedication was reduced among women who had undergone previous caesarean section and among women who had experienced previous IUCD insertion failure. Nulliparas did not benefit from misoprostol premedication. Buccal misoprostol administration did not seem to be effective in reducing IUCD insertion failure. Visual analogue scale pain scores were increased with both sublingual and buccal misoprostol administration if IUCD insertion was performed ≤2.5 h after misoprostol premedication.Conclusion: Our data demonstrate reduced IUCD insertion failure among women with previous caesarean section and those with previous IUCD insertion failure, suggesting that misoprostol may be a reasonable choice in these groups of women. Although misoprostol premedication reduced insertion failures, it significantly increased side effects and had a heterogeneous pattern of efficacy; thus, its routine use is not supported by the evidence.