The daily-practiced post-partum hemorrhage management: an Italian multidisciplinary attended protocol.

Postpartum hemorrhage (PPH) is one of the most frequent causes of mortality and morbidity in the obstetric population globally, causing about a quarter of maternal deaths yearly, and is the leading cause of maternal death worldwide. The management of PPH remains a topic of great debate, even in view of new diagnostic and therapeutic possibilities in recent years, for which, however, the body of evidence available thus far is still scarce, as the standard values are lacking. The protocol hereby presented was developed after a literature review and during several meetings of an Italian multidisciplinary task group of specialists adopting a modified Delphi method, and is the result of the synthesis of therapeutic operational protocols for the treatment of PPH applied by the different specialties within the team. This protocol is intended to represent a practical proposal to support clinicians in the management of a particularly complex event that requires the intervention of a multidisciplinary team and the implementation of dedicated management protocols.

Prophylactic arterial catheterization in the management of high risk patients for obstetric haemorrhage.

OBJECTIVES: Post-partum haemorrhage still remains one of the major causes of maternal morbidity and mortality. In case of abnormal placentation it is possible to carry out preventive and therapeutic actions. To maintain fertility in reproductive-aged women and to avoid a more radical surgery, embolization has been introduced in patients at high risk for haemorrhage. To describe a new option in the management of patients with abnormal placentation by an elective, preventive arterial catheterization and selective embolization of pelvic arteries. PATIENTS AND METHODS: A retrospective study including thirty six patients with abnormal placental invasion. All patients were prepared in the angiographic room and preventive arterial catheterization was performed before elective caesarean delivery. Materials for interventional angiography were transferred to the operating room. During surgery, selective embolization of pelvic arteries was realized in case of uncontrolled bleeding. RESULTS: Thirty-six elective arterial catheterizations were performed: 4 cases (11.1%) required embolization, haemorrhage was stopped in 2 patients. Hysterectomy was performed in two cases (5.5%). No death was reported. Two humeral thrombosis (5.5%) were registered. CONCLUSIONS: Prophylactic arterial catheterization appears to be safe. The main advantage is the reduction of the interval between the onset of bleeding and the embolization. This new option of management may contribute to reduce the risk of hysterectomy and maternal death.

Cervical ripening prior to hysteroscopy: is the application of misoprostol useful?

Cervical dilatation has to be considered a fundamental step in operative hysteroscopy. Different methods are used to facilitate cervical dilatation. The aim of this review is to evaluate the efficacy of Misoprostol in cervical ripening prior to operative hysteroscopy through the evaluation of published studies. Initially designed for the treatment of peptic ulcers caused by non-steroidal anti-inflammatory drugs, misoprostol, a prostaglandin E1 analogue, is commonly used for medical abortion in the first and second trimesters, cervical priming before vacuum aspiration or dilation and curettage, induction of labor, and the prevention and treatment of postpartum hemorrhage. Misoprostol was licensed for oral administration, but a large number of clinical studies have reported that vaginal administration is more effective in cervical ripening. Misoprostol is effective in inducing an adequate cervical dilatation prior to an operative hysteroscopy. Vaginal administration could be necessary for all conditions where cervical ripening is difficult to perform. Patients given GnRH analogue therapy before hysteroscopy may benefit from the application of Misoprostol. However, its use in postmenopausal patients may not be efficacious. As far as the application of Misoprostol prior to diagnostic hysteroscopy is concerned, the number of patients that may find an advantage in the treatment is probably very small. Misoprostol has some important advantages, such as easy application, very low price, and greater acceptability by doctors and patients.

Intra-abdominal versus free-loop portion Doppler analysis of the umbilical artery: the importance of the choice.

AIM: The aim of this study was to assess the variations in Doppler indexes along the length of the cord from the intra-abdominal portion (IAP) to the free loop portion (FLP) of the umbilical artery (UA). METHODS: UA blood flow velocities were measured at the IAP and FLP in 100 low-risk singleton pregnancies. The peak systolic velocity (PSV), end-diastolic velocity, pulsatility index (PI), resistance index (RI), PS/ED ratio and Delta value (Δ) were calculated. at each site of sampling and were compared. RESULTS: PI and RI of the IAP were greater versus the FLP. UA blood velocities increased with gestational age and the PSV at the IAP showed different development compared to other sites, increasing from 20 to 30-32 weeks and then decreasing until term. The PSV value was greater in the IAP from 20 until 36 weeks. There were not significant differences in EDV values between the two sites. The Δ PI in IAP remained constantly greater than ~0.2 at all gestational ages. CONCLUSION: UA Doppler parameters vary significantly at different locations, showing the greater value in the IAP. The IAP site is in a fixed anatomical position, therefore potentially reproducible. This potential advantage is very important in cases of severe growth restriction and in monoamniotic twins.

[Pharmacological induction of labour: benefits and risks]. / Induzione farmacologica del travaglio di parto: vantaggi e rischi.

AIM: Induction of labour is a very common practice in modern obstetrics. The most used method is based on the use of topical prostaglandins. In this study we aimed to analyse the results of pharmacological induction of labour through the use of dinoprostone, comparing the intracervical gel (Prepidil 0.5 mg) and the vaginal insert (Propess 10 mg). METHODS: An observational longitudinal study was conducted, in which all patients treated with prostaglandins from January 1, 2003 to June 30, 2006 were included, for a total of 852 cases. The intracervical gel was applied on 32.5% of pregnant women (277 patients) while the vaginal insert to 56.2% (479 patients); in 11.3% of the cases (96 patients) both preparations were administered, one after the other. RESULTS: In 2/3 of the total (568 patients), the induction led to vaginal delivery, in contrast to 284 cases in which the practice showed negative results: in 270 women (31.7%) a cesarean section was practiced. Adverse events occurred only in 1.8% of cases (16 patients); the most frequent adverse reaction was uterine hypertonus in 1.8% of cases, which was in any case resolved with removal of the vaginal insert or injection of a tocolytic drug (atosiban). CONCLUSION: Induction through prostaglandins is an effective and safe method to get cervical maturation. Its success is influenced by Bishop score. In the case of unfit cervix, vaginal insert seems to get better results than intracervical gel. The relation between risks and benefits is certainly better in the latter.

Spontaneous dissecting aneurysm of coronary artery in a pregnant woman at term.

We describe a case of spontaneous dissecting aneurysm of the circumflex coronary artery in a 44-year-old primigravida at term with no vascular risk factors. Spontaneous coronary artery dissection is a very rare condition with a greater prevalence in women, postpartum in particular. The left anterior descending artery is the most frequently affected. Histologically, the most common finding is a hematoma occupying the outer third of the media, resulting in complete compression of the true lumen. Arterial wall changes during pregnancy together with hemodynamic factors, a lytic action of protease released from eosinophils, and intimal tears are the main hypotheses considered to explain the etiology of spontaneous coronary artery dissection.

[Giant pedunculated clustered uterine fibromyoma in hyaline and cystic degeneration. Limitations of clinical and instrumental diagnosis]. / Fibromioma uterino gigante peduncolato a grappolo in degenerazione ialina e cistica. Limiti della diagnostica clinica e strumentale.

The authors report a case of a 46-year-old woman who was checked by integrated ultrasound examination, i.e. transabdominal and transvaginal, and by abdominopelvic CAT. The examinations, ascertained the presence of a probably malignant, voluminous, ovarian, multilobate abdominopelvic neoplasia. On opening the belly, it was found that the tumefaction was a voluminous, pedunculate uterine myofibroma in clusters starting from the rear isthmian wall while the adnexa were normal. The histological examination confirmed that it was a "fibromyoma in hyaline and cystic degeneration". The authors conclude that although the image diagnostics has reached an extremely high level of precision, it is not yet possible to make an absolutely certain diagnosis, either on the organ from which a pelvic neoplasia originates or on its biological nature.

[The possibility of using sulprostone during laparoscopic myomectomy in uterine fibromyomatosis. Preliminary studies]. / Possibilità d'impiego del sulprostone in corso di laparomiomectomia nella fibromiomatosi uterina. Indagini preliminari.

The authors considered sulprostone effects, PGE2 synthetic derivative, on the hematic loss during laparomyomectomy. This drug is been used by intravenous way during the operation in 84 patients affected with uterine myomatosis. The effectiveness and tolerance of the drug is thus evident in the reduction of the hematic intraoperative loss.

[Ultrasonographic monitoring of the endometrium in post-menopausal women asymptomatic or undergoing hormone replacement therapy]. / Monitoraggio ecografico dell'endometrio in donne in post-menopausa asintomatiche od in terapia ormonale sostitutiva (HRT).

This study evaluated the reliability of ultrasonography in the post-menopausal period for the screening of endometrium pathology in women who are non-symptomatic or undergoing hormone replacement therapy. A total of 152 women were examined, 76 were non-symptomatic and 76 were undergoing estro-progestational therapy. As in previous studies on the subject, we took 0.8 cm as the thickness limit for the endometrium; over this limit closer investigations are considered necessary. In the non-symptomatic women, a strong correlation between the thickness of the endometrium and hormonal state was noted; it was not possible to differentiate the proliferative-secretory endometrium from the hyperplastic one. For women under HRT ultrasonography proved to be a good method for monitoring the endometrium as it allows for an adequate evaluation of its thickness throughout the different phases of sequential hormone treatment.

[Post-menopausal metrorrhagia. Use of danazol in endometrial hyperplasia]. / Metrorragia post-menopausale. L'uso del danazolo nella iperplasia endometriale.

The Authors, after a careful examination of the literature on endometrial hyperplasias, review the results of a preliminary study on 15 patients affected with postmenopausal metrorrhagia, cured by Danazol (200 mg/die) through 90 consecutive days. Also recognizing the best tolerance to the drug and the low incidence of the side effects, they think the results obtained by Danazol need further confirmation by more protracted controls.

[Lasers and genital (cervico-vulvo-vaginal) pathology]. / Laser e patologia genitale (cervico-vulvo-vaginale).

The authors performed laser vaporization in 240/250 cases for viral pathology of the lower genital tract, obtaining recovery at the first treatment in 232/240 cases and at the second in 238/248 cases.

[Comparative study of short-term antimicrobial chemoprophylaxis in gynecologic surgery: cefotetan versus cefazolin]. / Studio comparativo di chemioprofilassi antimicrobica a breve termine in chirurgia ginecologica: cefoteta versus cefazolina.

The results obtained in 80 patients hospitalized at the University of Obstetrics and Gynecology Clinic in Perugia for abdominal and vaginal hysterectomy are reported and evaluated in a prospective and randomized study of perioperative antibacterial prophylaxis. In the 75 patients available to study a single intravenous dose of 2 g cefotetan was compared with a triple dose of 1 g intravenous cephazolin. A reduction in the incidence of post-operative infections both in abdominal hysterectomy from 24% (cephazolin group) to 11.53% (cefotetan group) and in vaginal hysterectomy from 40% (cephazolin group) to 71.4% (cefotetan group) was noted. These results show that a single intravenous dose of 2 g cefotetan can be considered a valid therapeutic support for antibacterial prophylaxis. In addition the absence of alterations in the parameters considered (haematological, biochemical and urinary) points to the safety, effectiveness and non-toxicity of the drug.