"The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature.

The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.

Uterine venous malformations in the puerperium: 2 Atypical cases and literature review.

Uterine arteriovenous malformations (AVMs) is a rare but high-risk cause of uterine bleeding. The clinical management of this condition is challenging, as the ultrasound picture can sometimes be unambiguously interpreted. Moreover, in the puerperium in which acquired AVMs are most frequently formed, it is necessary to discuss the correct management in a multidisciplinary and personalized manner. We present two cases of AVMs developing in the puerperium, both with a vaginal delivery and spontaneous and complete secondment. The symptom of onset was an episode of bright red blood loss in the puerperium, on the 14th and 21st postpartum days, respectively. Transvaginal ultrasound showed a hypervascularized lesion in the myometrium with turbulent vascular flow, confirmed by transabdominal ultrasound and angiography. To date, there are no guidelines on the management of MAVs. In our cases we opted for a conservative approach, in order to preserve the fertility of the patient. These experiences reported have the purpose of enriching a literature still sparse on the subject and in the future to be able to represent a fulcrum for official recommendations.

VBAC: antenatal predictors of success.

To determine antenatal factors that may predict successful vaginal birth after Caesarean section (VBAC), to develop a relevant antenatal scoring system and a nomogram for prediction of vaginal birth after caesarean delivery. A non recurring indication for previous Caesarean section (CS), such as breech presentation or foetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Foetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. An inter-pregnancy interval of <24 months is not associated with a decreased success of VBAC. Success rates decrease when interval increases. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases. There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases.

Prevalence of chronic endometritis in repeated unexplained implantation failure and the IVF success rate after antibiotic therapy.

STUDY QUESTION: What is the prevalence of chronic endometritis (CE) in women with repeated unexplained implantation failure (RIF) at IVF, and how does antibiotic treatment affect the reproductive outcome? SUMMARY ANSWER: Chronic endometritis, associated with infection with common bacteria or mycoplasma, is common in women complaining of RIF and antibiotic treatment significantly improves the reproductive outcome at a subsequent IVF cycle. WHAT IS KNOWN ALREADY: We have reported that CE is a frequent finding in women with repeated pregnancy loss and a significantly higher rate of successful pregnancies was achieved after adequate antibiotic treatment. Moreover, CE was identified in 30.3% of patients with repeated implantation failure at IVF and women diagnosed with CE had lower implantation rates (11.5%) after IVF cycles. In contrast, other authors reported that the clinical implication of CE should be considered minimal and that the reproductive outcome at IVF/ICSI cycles was not negatively affected by CE. STUDY DESIGN, SIZE, DURATION: A retrospective study was performed from January 2009 through June 2012 on 106 women with unexplained infertility and a history of RIF. PARTICIPANTS/MATERIALS, SETTING, METHODS: All patients underwent hysteroscopy and endometrial sampling for histology and microbiological investigations. Women diagnosed with CE underwent antibiotic treatment and the effect of treatment was confirmed by hysteroscopy with biopsy. Within 6 months after treatment all women had a further IVF attempt. The IVF outcomes were compared in women without signs of CE (Group 1) and persistent CE (Group 2) after antibiotic treatment. Clinical pregnancy rate (PR), and live birth rate (LBR) were compared at post-treatment IVF attempt. MAIN RESULTS AND THE ROLE OF CHANCE: Seventy (66.0%) women were diagnosed with CE at hysteroscopy. In 61 (57.5%) CE was confirmed by histology and 48 (45.0%) by cultures. Common bacteria and mycoplasma were the most prevalent agents. In 46 (75.4%) out of 61 women, with diagnosis of CE at hysteroscopy and histology, examinations were normal after appropriate antibiotic treatment control (Group 1) while in 15 (24.6%) cases signs of CE were still present (Group 2). At IVF attempt after treatment, a significantly higher PR and LBR was reported in women from Group 1 compared with women from Group 2 (65.2 versus 33.0% P = 0.039; 60.8 versus 13.3%, P = 0.02, respectively). LIMITATIONS, REASONS FOR CAUTION: Possible biases related to retrospective studies and to preferential referral of patients with CE, and limited number of cases. WIDER IMPLICATIONS OF THE FINDINGS: A prospective randomized clinical trial is needed to confirm our findings but in women with RIF a hysteroscopic evaluation of the uterine cavity to exclude CE should be considered and appropriate antibiotic treatment should be given before submitting the patient to a further IVF attempt.

Endometrial effects, bleeding control, and compliance with a new postmenopausal hormone therapy regimen based on transdermal estradiol gel and every-other-day vaginal progesterone in capsules: a 3-year pilot study.

In a 3-year prospective study, 30 postmenopausal women received transdermal E2 gel and every-other-day vaginal P in capsules. At study completion, endometrial thickness was significantly reduced as compared with baseline (2.7 +/- 0.5 vs. 3.4 +/- 0.9 mm), endometrial biopsy showed endometrial atrophy in all cases, and amenorrhea was achieved in 92.6% of cycles, while excellent patient satisfaction was achieved.

Blood to the cornual area of the uterus is mainly supplied from the ovarian artery in the follicular phase and from the uterine artery in the luteal phase.

BACKGROUND: The blood supply to the uterus is provided by the uterine and ovarian arteries, which form anastomoses. Yet the flow direction through this anastomoses and the primary source of blood supply to the tubes and uterine cornua remains unknown. To clarify this issue, we studied the spatial propagation of temperature changes following cooling of the upper vaginal area. METHODS: A thermocatheter with eight measurement points at 5-mm intervals was inserted into the uterus of nine women in the follicular phase and 11 in the luteal phase. The distal tip was positioned in the cornual area and temperatures were registered every 2 s. The vagina was then cooled for 7 min with 25 degrees C saline. RESULTS: The pattern of uterine cooling based on local counter-current transfer differed between the follicular and luteal phase. Cooling of the cornual area was significantly lower in the luteal phase compared with the follicular phase, indicating a shift in the prevailing source of arterial supply in that area following ovulation. CONCLUSIONS: The divide between the territories irrigated by the uterine and ovarian arteries moves between the follicular and luteal phase. This constitutes the first description of a functionally determined shift in the territorial divide of two vascular systems, and has numerous practical implications.

The vascular cast of the human uterus: from anatomy to physiology.

The blood supply to the uterus originates mainly from the uterine artery. However, the uterine and ovarian arteries form anastomoses bilaterally. Controversy exists about the direction of the flow in the anastomoses and thus the origin of the arterial supply to the tube and tubal part of the uterus. A similar arcade is formed by the vaginal and uterine arteries. We have investigated the vascular border of supply between the uterine and ovarian arteries in postmenopausal women, which was positioned in the uterus 1-2 cm from the tube. A similar result was found in younger, ovulating women. However, the border between the territories irrigated by the uterine and ovarian arteries differs between the follicular and luteal phase; more uterine tissue is perfused from the ovarian artery when a large follicle is present. This constitutes the first description of a functionally determined shift in the territorial divide of two vascular systems and has numerous practical implications. The venous system copies the arterial one with one major exception: some of the uterine veins join the ovarian outlet. The close contact between veins and arteries facilitates transfer of substances, thus forming semilocal systems of regulation; for example, the ovary locally influences the function of the ipsilateral tube and part of the uterus. From a therapeutic point of view, it has been documented that application of progesterone to the vagina creates high uterine concentrations due to local vascular transfer.