Adenomyosis: What the Patient Needs.

A panel of experts in the field of endometriosis expressed their opinions on management options in a 28-year-old patient, attempting pregnancy for 1 year, with severe cyclic pelvic pain and with clinical examination and imaging techniques suggestive of adenomyosis. Many questions this paradigmatic patient may pose to the clinician are addressed, and all clinical scenarios are discussed. A decision algorithm derived from this discussion is also proposed.

How to Manage Bowel Endometriosis: The ETIC Approach.

A panel of experts in the field of endometriosis expressed their opinions on management options in a 35-year-old patient desiring pregnancy with a history of previous surgery for endometrioma and bowel obstruction symptoms. Many questions that this paradigmatic patient may pose to the clinician are addressed, and various clinical scenarios are discussed. A decision algorithm derived from this discussion is proposed as well.

Phases I-II Matched Case-Control Study of Human Fetal Liver Cell Transplantation for Treatment of Chronic Liver Disease.

Fetal hepatocytes have a high regenerative capacity. The aim of the study was to assess treatment safety and clinical efficacy of human fetal liver cell transplantation through splenic artery infusion. Patients with end-stage chronic liver disease on the waiting list for liver transplantation were enrolled. A retrospectively selected contemporary matched-pair group served as control. Nonsorted raw fetal liver cell preparations were isolated from therapeutically aborted fetuses. The end points of the study were safety and improvement of the Model for End-Stage Liver Disease (MELD) and Child-Pugh scores. Nine patients received a total of 13 intrasplenic infusions and were compared with 16 patients on standard therapy. There were no side effects related to the infusion procedure. At the end of follow-up, the MELD score (mean ± SD) in the treatment group remained stable from baseline (16.0 ± 2.9) to the last observation (15.7 ± 3.8), while it increased in the control group from 15.3 ± 2.5 to 19 ± 5.7 (p = 0.0437). The Child-Pugh score (mean ± SD) dropped from 10.1 ± 1.5 to 9.1 ± 1.4 in the treatment group and increased from 10.0 ± 1.2 to 11.1 ± 1.6 in the control group (p = 0.0076). All treated patients with history of recurrent portosystemic encephalopathy (PSE) had no further episodes during 1-year follow-up. No improvement was observed in the control group patients with PSE at study inclusion. Treatment was considered a failure in six of the nine patients (three deaths not liver related, one liver transplant, two MELD score increases) compared with 14 of the 16 patients in the control group (six deaths, five of which were caused by liver failure, four liver transplants, and four MELD score increases). Intrasplenic fetal liver cell infusion is a safe and well-tolerated procedure in patients with end-stage chronic liver disease. A positive effect on clinical scores and on encephalopathy emerged from this preliminary study.

Brugada syndrome and pregnancy: highlights on antenatal and prenatal management.

Introduction. Brugada syndrome is characterized by a disruption of heart's normal rhythm. It is an autosomal dominant disease due to a mutation of SNC5A gene. Its prevalence is low all over the world, but it is a lethal disease. Sudden cardiac death is the result of phenotypic manifestation of Brugada syndrome. Among asymptomatic Brugada patients, arrhythmia could be provoked by physical activity, fever, or pregnancy. About obstetrical management, very few data or reports have been published since this syndrome has been diagnosed in late 1992. Case Presentation. A 20-year-old pregnant woman at 13 weeks of gestation was referred to our department because of her familial history of sudden cardiac deaths. Brothers and sisters of her mother died of Brugada syndrome in childhood or older and live components of this family were carrier of mutation in Brugada gene. The pregnancy was uneventful. The patient gave birth vaginally without any arrhythmia. Strictly cardiological monitoring was performed during labour, delivery, and 12 hours of the postpartum. Conclusion. Even though patient at low risk may never have arrhythmia, some conditions could represent a Brugada trigger. The management could be very easy and uneventful. Otherwise it could be very difficult with need of ECMO or antiarrhythmics drugs or intracardiac device. Obstetrical management of Brugada pregnant women should be very strict and multidisciplinary in cooperation with cardiologist and anaesthesiologist and should provide an informed consent to the couple.

Prophylactic use of intravascular balloon catheters in women with placenta accreta, increta and percreta.

OBJECTIVE: To evaluate outcomes of women undergoing cesarean hysterectomy for abnormal invasive placenta (AIP) with and without preoperative balloon catheter placement in internal iliac arteries. STUDY DESIGN: A prospective observational study of women with ultrasound diagnosis of AIP and a planned delivery at our institution. From January 2004 to June 2009, all AIP cases were treated with planned multidisciplinary cesarean hysterectomy alone (CHa group). From July 2009 to September 2013 a pre-operative balloon catheter protocol was introduced (BC group). Statistical analysis considered the entire sample (placenta accreta/increta and percreta) and the individual subgroups (accreta/increta vs percreta). RESULTS: Twenty-three cases of AIP (10 accreta/increta and 13 percreta) were treated with cesarean hysterectomy alone, and 30 cases of AIP (12 accreta/increta and 18 percreta) were treated with cesarean hysterectomy and pre-operative balloon catheters. For the entire sample, a significant difference in estimated blood loss and transfused blood products units was observed between CHa group and BC group. When women with placenta accreta/increta and women with placenta percreta were analysed separately, no difference in estimated blood loss and transfused blood products units was found between the BC and the CHa groups in women with placenta accreta/increta. However, in women with placenta percreta, mean estimated blood loss and transfused blood products units were higher in the CHa group compared with BC group (1507ml vs 933.33ml; 3.31 units vs 0.67 units). Postoperative recovery differed between the two groups, but no differences were observed in any other outcomes. CONCLUSIONS: Pre-operative placement of intravascular balloon catheters is a feasible treatment for AIP, and is particularly useful in cases of placenta percreta.

A randomized controlled trial comparing three single-incision minislings for stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Studies have observed a significant heterogeneity in efficacy data for single-incision minislings (SIMS) as surgical treatment for female urinary incontinence (UI). Our study aim was to test the hypothesis that different vaginal kits for SIMS have different long-term outcomes. METHODS: One hundred and twenty women with stress (SUI) or mixed (MUI) UI were enrolled in a multicenter randomized clinical trial (registration number NCT00751088) and treated with three different SIMS (Ajust, MiniArc, or TVT Secur System). Duration of follow-up was at least 24 months from surgery. The primary outcome was the subjective cure rate at 24 months from surgery; secondary outcomes were rates of total failure and reoperations for UI. RESULTS: At study end, no difference was detected between groups in terms of total subjective cure rate [21 (52.5%) vs. 26 (65.0%) vs. 21 (52.5%), in Ajust, MiniArc, and TVT Secur System group, respectively; P = 0.412] or in terms of total failure rate [24 (60.0%) vs. 22 (55.0 %) vs. 27 (67.5 %), in Ajust, MiniArc, and TVT Secur System group, respectively; P = 0.432]. The proportion of patients who received a second surgery for UI was also not significantly different between groups [13 (32.5%) vs. 10 (25.0%) vs. 13 (32.5%), in Ajust, MiniArc, and TVT Secur System, respectively; P = 0.831]. CONCLUSION: The long-term efficacy of SIMS does not differ between the vaginal kits examined.

Single-incision mini-slings versus retropubic tension-free vaginal tapes: a multicenter clinical trial.

STUDY OBJECTIVE: To compare single-incision mini-slings (SIMSs) and retropubic tension-free vaginal tape (r-TVT) in terms of the long-term efficacy and safety for the treatment of female stress (SUI) or mixed urinary incontinence (MUI). DESIGN: Prospective multicenter cohort trial (registration number NCT00751088) (Canadian Task Force II). SETTINGS: Department of Obstetrics and Gynecology, Italy. PATIENTS: Two hundred-forty women with SUI/MUI. INTERVENTIONS: SIMS or r-TVT. MEASUREMENTS AND MAIN RESULTS: The operative time and the use of analgesic tablets were significantly (p < .001) higher and lower, respectively, in the r-TVT group versus the SIMS group. After 24 months of follow-up, no difference between the study arms was observed in terms of the complication rate (30/120 [25%] vs 19/120 [15.8%] for the r-TVT and SIMS arms, respectively; relative risk = 1.58; 95% confidence interval, 0.94-2.65; p = .083), whereas the subjective cure rate was significantly lower in the SIMS arm than in the r-TVT arm (57/103 [55.3%] vs 89/106 [84.0%] for the r-TVT and SIMS arms, respectively; relative risk = 0.66; 95% confidence interval, 0.54-0.80]; p < .001). The proportion of retreated patients for SUI/MUI was significantly higher in the SIMS arm than in the r-TVT arm (37/103 [34.9%] vs 12/106 [11.3%] for SIMS and r-TVT arm, respectively; p < .001). CONCLUSION: SIMS has no advantage in terms of safety over r-TVT and was found to be less effective than r-TVT. Thus, its use in the clinical practice should be questioned.

Omental pregnancy: case report and review of literature.

Pregnancy, the implantation of a fertilized ovum outside the endometrial cavity, occurs in 1.5%-2% of pregnancies. It is one of the major causes (about 6%) of maternal death during the first trimester of pregnancy. The remaining 5% implant in the ovary, peritoneal cavity, within the cervix, and the omental pregnancy is the least common form of abdominal pregnancies. A review of the literature on Medline for the period 1958-2012 reported only 16 cases of omental pregnancy. Here we report a case of primary omental pregnancy in a nulliparous woman. A 24 year-old woman gravid 1, para 0, with lower abdominal pain. Her last menstrual period occurred 8 weeks before the visit. The physical examination revealed abdominal tenderness in the lower quadrants, she was not bleeding. Transvaginal ultrasound showed: a free anechoic/hypoechoic area of 30 x 57 mm in the pouch of Douglas and the endometrium was homogeneus with a thickness of 12 mm and no evidence of gestational sac in the uterine cavity. Laboratory data revealed a normal cell blood count and beta hcg levels of 8047 IU / L. Because of continuing abdominal pain and a diagnosis of ectopic pregnancy a diagnostic laparoscopy was performed, which showed hemoperitoneum. Further inspection of abdominal cavity revealed a bloody lesion that was tenaciously adherent to the omentum, using non traumatic laparoscopic forceps and bipolar scissors we carefully removed a friable mass of about 30 mm from the omental attachments. Histological examination showed the presence of blood clot material mixed with trophoblastic tissue. Ultrasound evaluation and and hCG assessment are important to determine the extrauterine location of the ectopic pregnancy but the early diagnosis of abdominal pregnancy requires also a laparoscopic evaluation and, as our case has highlighted, thorough abdominal exploration especially in the absence of adnexal findings when ectopic pregnancy is highly suspected. Early diagnosis of omental pregnancy is difficult but essential to reduce the high mortality risk for the mother.

A randomized controlled trial comparing three vaginal kits of single-incision mini-slings for stress urinary incontinence: surgical data.

OBJECTIVE: Single-incision mini-slings (SIMS) are new minimally invasive devices used for female stress urinary incontinence (SUI). To date, several SIMS are available, but few and uncontrolled comparative data have assessed their safety and feasibility. The aim of the present clinical study was to compare three different SIMS in an ambulatory setting. STUDY DESIGN: One hundred and twenty patients with SUI were randomized to receive three SIMS: Ajust, MiniArc, and TVT Secur System. Surgical data were compared. RESULTS: Significantly (P<0.05) lower surgical difficulty and higher patient satisfaction were detected in the MiniArc group when compared to the Ajust and TVT Secur System groups. A significantly (P<0.05) higher feasibility under local anesthesia and in ambulatory setting was also detected for the MiniArc group. The overall complication rate was significantly (P<0.05) lower in the MiniArc group than in the TVT Secur System group. CONCLUSIONS: MiniArc is simpler to insert under local anesthesia and in an ambulatory setting. It is safer than the TVT Secur System, and is related to higher patient satisfaction.