Management of the pregnant immigrant woman in the decade 1992-2001.

The study evaluates the mode of delivery and quality of care given to 1014 pregnant women not belonging to the European Union (EU) during the 10-year period, 1992-2001. The non-EU patients were delivered significantly more often by caesarean section than Italian controls, 35.0% vs. 29.3% (P<0.001, OR 1.30; 95% CI 1.13-1.49) and more often had babies of very low birth weight (VLBW), 7.2% vs. 5.4% (P<0.02; OR 1.35; 95% CI 1.04-1.74). Rates of preterm births (25.4% and 22.9 %, respectively, for non-EU and Italian patients) did not differ significantly (P=0.06). Episiotomy was practiced less frequently in non-EU patients and the difference was significant (P<0.001). Perinatal mortality in this latter group was 23.3/1000. Our observations provide a useful picture of how pregnancy, labour and delivery of immigrant women are managed in an Italian hospital setting. Understanding of different cultural approaches, linguistic communication, technical skills and medical interventions only when really necessary are keys for the appropriate management of childbirth.

[Celiac disease and spontaneous abortion]. / Malattia celiaca e abortività.

BACKGROUND: Over the last ten years it has become clear that the clinical expression of celiac disease is more heterogeneous than was thought in the past. Although celiac disease is a relatively frequent disease (1/170-200), it is only diagnosed in a small percentage of adult cases compared to the real situation because it is manifested with few symptoms or in an atypical form, or occasionally is completely silent. Gynecological problems have been reported in women with celiac disease, in particular delayed menarche, early menopause, sterility, recurrent abortion and fetal intrauterine growth retardation. The main aim of this study was to investigate the association between celiac disease and abortion, and in particular to evaluate whether patients suffering from recurrent spontaneous abortion might present an atypical or subclinical form of the disease. METHODS: During the period 1997-1998 a series of laboratory tests were carried out at the Department of Obstetrics and Gynecology and at the Institute of Medicine B of Verona University, in a sample of 184 women (149 from the Obstetrics Clinic and 35 from Internal Medicine B ). These tests included circulating anti-gliadin (AGA) and anti-endomysium (EMA) antibodies and total serum immunoglobulins. In positive cases, further diagnostic tests were performed using small bowel biopsy specimens. RESULTS: In our selected sample of cases, 5 women (2.7%) were positive for immunological screening against IgA-EMA and for bowel biopsy (confirmed diagnosis of celiac disease). Four of these women (2.1%) formed part of a group of patients with a positive history of spontaneous abortion and one (0.5%) was from the control group. CONCLUSIONS: An analysis of the cases that emerged from this study and those reported in the literature shows that tests to identify the celiac disease should be extended to the population with a risk of developing this disease. These subjects should include those with a family history or clinical symptoms, in particular women with a history of multiple abortions. In these cases, there are grounds for suspecting an atypical form of celiac disease.

[Proposal of a new test for the diagnosis of PROM based on the determination of hCG in the washing fluid of the posterior vaginal fornix]. / Proposta di un nuovo test per la diagnosi di PROM basato sul dosaggio della hCG nel liquido di lavaggio del fornice vaginale posteriore.

BACKGROUND: The objective of this study is to determine whether or not the measurement of hCG levels in the washing fluid of the posterior vaginal fornix is useful for the diagnosis of premature rupture of membranes. METHODS: Samples were analysed from 52 normal pregnant women, divided into three groups: 20 pregnant women without rupture of membranes, 21 patients with confirmed rupture of membranes, 11 patients with suspected rupture of membranes. In order to distinguish patients of the two groups we propose a hCG cut-off value of 100 mIU/ml. RESULTS: The analysis of our data reveals that there is no overlapping between the hCG levels of the group of pregnant women without rupture of membranes and the group of patients with confirmed rupture of membranes. CONCLUSIONS: The hCG levels in the washing fluid of the posterior vaginal fornix in our experience is a useful, very cheap and non-invasive diagnostic test of PROM.

[Assisted labor among non European community pregnant women at the Gynecology and Obstetrics Clinic of the Verona University]. / L'assistenza al parto per le gestanti extracomunitarie presso la Clinica Ginecologica e Ostetrica dell'Università di Verona (1992-1998).

BACKGROUND: The aim of this paper is to evaluate the role and the prevalence of the non-European Community pregnant women in our Institute during the period 1992-1998. The peculiarity of the female immigration in the world and particularly in Italy is stressed from the point of view of the different cultural, ethnic and religious problems of these women. METHODS: During the observed period 8972 women delivered; 434 of them came from non-European Community countries and their individual (age, country) and obstetric (parity, physiological or pathological evaluation of pregnancy, mode of delivery) data were observed. On the basis of the different countries of provenance these women have been subdivided into five groups (East Europe, North Africa and Middle East, Central Africa, Far East and Latin America). RESULTS: The percentages of preterm births (24.2% vs 23.1%), of < or = 1500 g newborns (6.9% vs 5.3%) and of caesarean sections (34.3% vs 27.7%) are higher in the non-European Community women that delivered in our Institute. In 222 (51.1%) cases the women delivered without induction of labour; while in 14.5% of cases it was induced. The length of labour and the genital conditions (episiotomy, tearing) were considered in all ethnic groups of women. CONCLUSIONS: On the basis of the literature and of the analysis of our data, some suggestions about the management of labour and delivery of non-European Community women in Italy are proposed. In particular, the problems of linguistic communication and of the hospital staff preparation in the assistance to labour and delivery are stressed.

Sexually-transmitted diseases and assisted reproduction techniques.

As to the correlation between sexually transmitted diseases (STD) and assisted reproduction techniques (ART) we must consider that it is necessary to collate information and start screening campaigns for all sexually active individuals with the purpose of prevention and early diagnosis of STD which may cause of sterility. Before starting any kind of ART it is mandatory to perform diagnostic tests in all couples and to apply the correct therapy for any STD: treatment must always involve both partners and results must be carefully checked. All diagnostic examinations and all ART procedures should not carry the risk of transmitting any infection. When one or both of the partners are carriers of a transmissible infection (especially AIDS) it is advisable to negate ART or to start treatment, particularly for the semen, in order to reduce the level of infection and to avoid the transmission of any infection to the fetus.

[Fatty acid composition of the cervical mucus obtained during ovulation and at the term of pregnancy]. / Composizione in acidi grassi del muco cervicale prelevato in periodo ovulatorio e al termine della gravidanza.

BACKGROUND: Aim of this work is to evaluate the different fatty acid composition of cervical mucus obtained during ovulation and at the term of pregnancy. METHODS: The fatty acid composition in cervical mucus was determined in 14 non pregnant women during expected ovulation (cervical score > 10) and in 12 at term pregnant women. Following extraction, (acidification and transesterification), the identification and quantification of fatty acids was performed by gas-chromatographic analysis, with the aid of a specific software. RESULTS: In both groups of samples, palmitic acid, stearic acid and oleic acid were the prevalent acids comprising more than half of the total amounts. Compared to non pregnant samples, in pregnant cervical mucus, elevated levels of oleic acid were pointed out, while mean levels of miristic acid and stearic acid were lower. In the samples of cervical mucus drew at the term of pregnancy, arachidonic acid levels mean values were higher when the first period of labour was started. CONCLUSIONS: The pregnancy-induced biochemical changes in fatty acid pattern could likely be correlate to the variations of the physiochemical properties and to the physical appearance that cervical mucus undergoes during pregnancy. The elevated levels of arachidonic acid, during the first period of labour, may be correlated with prostaglandin production by intrauterine tissues (amniotic fluid, amnion, chorion, decidua, myometrium) and probably by cervical mucus.

Fetal macrosomia and management of delivery.

During the period 1988-1966, 737 pregnancies, in which the infant birth weight was > or = 4000 grams were studied. During the same period there were 11,631 newborns, and 6.3% of them were infants with a birth weight > or = 4000 grams. Normal vaginal delivery occurred in 583 cases (79.1%), vacuum extraction in 24 cases (3.3%) and caesarean section in 130 cases (17.6%). Regarding the caesarean section, 38 (29.2%) of them were elective and 92 (70.8%) were done in different periods of the labour. In these macrosomic babies perinatal death never occurred, but different pathological neonatal outcomes were observed and the majority of these were clavicle abruptions (39 cases: 5.3%). Maternal morbidity observed in the 607 (82.4%) cases with vaginal delivery is characterized by: 60 cases (9.8%) of vaginal and perineal tears, 4 cases (0.6%) of cervical tears, and 2 cases (0.3%) of pubic symphysis traumatic diastasis. Shoulder dystocia is the most likely outcome in fetal macrosomic delivery; for this reason we considered the diagnostic and therapeutic management of this obstetrical complication. Because the normal outcome of neonatal births actually encourages the preference for normal vaginal delivery, we concluded that mothers with macrosomic fetuses can safely be managed expectantly unless there is a high maternal and fetal risk.

[Diphosphonates: and alternative to estrogen therapy in postmenopausal osteoporosis. Experience with alendronate]. / I bisfosfonati: un'alternativa al trattamento estrogenico nell'osteoporosi postmenopausale. Esperienza con alendronato.

The post-menopausal osteoporosis represents an important complication during the climateric period; its clinical, economic and social weight is destined to increase with the aging of the population. The lack of oestrogens is the main etiopathogenetic element; this is the reason why the substitutive therapy during the menopause represents the most appropriate approach. However, the possibility of clinical contra-indications to the oestrogenic treatment, the compliance of the patient not always adequate, the possibility of side-effects, and the doubt about the real opportunity of this treatment in the advanced years, require therapeutic alternatives. Between these, the "inhibitors of the bone reuptake" are actually the more realistic and justified approach knowing the pathogenetic aspect of the disease. In this group of drugs, the biphosphonates are particularly useful because of their pharmacologic properties: a strong affinity for the bone, a specific action only in the area of the bone rearrangement, a strong and selective inhibition of the osteoclastic activity. Because of their long half-life in the bone tissue, it seemed interesting to evaluate mineral bone density and metabolic effects using the alendronate. A double blind controlled study was performed in order to evaluate the effect of this drug: two groups of 15 women in post-menopause with vertebral bone mineral density (BMD) > 2 S.D. behind the mean peak of the adult and without vertebral fractures, were randomized to receive a 20 mg/die dose of alendronate or a placebo for six months. The first treatment significantly reduced all the bone turnover indexes (idrossiprolin, collagen cross links, phosphatase alkalin activity) in three months; another slight reduction was observed in the next three months. After the interruption of the treatment all the indexes of the bone turn over were slowly increased and reached the pre-treatment values in six-nine months. The lumbar BMD is increased of 3.7% (+/- 1.7 SD) after six months of aleandronate treatment; there were no modifications 6 and 12 months after the interruption of the treatment (respectively +4.6 +/- 2.8 and +4.7 +/- 2.67 referred to the basal values). The control group presents a slow reduction of the lumbar BMD, but this was significative only at the 18 degrees month of the study. The femoral BMD was not modified in a relevant measure in the group treated with the drug, while a significative reduction of the neck value was observed in the control group. We conclude that a short treatment with the alendronate is able to increase the lumbar BMD and to prevent the femoral reduction in the woman affected by post-menopausal osteoporosis. Finally, in our experience the alendronate represents a promising alternative to the oestrogen treatment of the post-menopausal osteoporosis; this approach however should be verified in the reduction in the incidence of fractures with larger studies.

Acute leukemia and pregnancy. Case report.

In this case report we describe a case of acute myeloid leukemia (AML; FAB M4) diagnosed in a 27-year-old female at the 20th week of gestation. After informed consent, the patient chose to undergo anti-leukemic treatment without therapeutic abortion. Complete remission was obtained following standard chemotherapy for AML (doxorubicin, cytosin-arabinoside, 6-thioguanine). The patient successively underwent an autologous bone marrow transplant (ABMT). No fetal malformation was observed. Urgent cesarean section was necessary at the 29th gestational week because of the onset of foetal sufferance. Fourteen months after diagnosis and seven months after ABMT the patient died due to relapse of AML. The child is presently 3.5 year old and well. In our opinion, the care of a pregnant woman with acute leukemia is feasible and it needs a multi-specialist effort that is easier to be achieved in a tertiary care institution.

[Obstetric prevention of neonatal infections caused by group B beta-hemolytic Streptococcus]. / La profilassi ostetrica delle infezioni neonatali da streptococco beta-emolitico di gruppo B.

While our understanding of Group B Streptococcal infections has progressed with impressive measure, their prevention has not been accompanied by an effective means. Chemoprophylaxis for selected colonized women at rupture of membranes or at onset of labour, enhances benefit and minimizes adverse effects. Two or more maternal risk factors are special circumstances for routine use of chemoprophylaxis in asymptomatic neonates. Immunoprophylaxis by IgG antibodies directed against the type-specific polysaccharide antigen of GBS may be provided by passive or active immunization. Hyperimmune i.v. globulins or vaccination of adult women with low levels of antibodies in their sera have been demonstrate to be protective in vivo.

[Autotransfusion in gynecologic surgery. Analysis of an experience]. / L'autotrasfusione negli interventi ginecologici. Analisi di una esperienza.

The autologous program is the most reliable method used in avoiding the consequences of homologous blood transfusion (particularly hepatitis and HIV) for patients who must undergo surgery. The autologous transfusion program's prerequisites are less restrictive than those concerning the homologous transfusion program. There are different modes to accomplish the autologous blood transfusion program according to the chosen technique. The risks involved in autologous blood donation are the same as these involved in a normal blood donation and they are not considered a restrictive factor. The practice of the autologous program in Gyn surgery is not different from what has been done in general surgery. Finally, shown below, is a study of the autologous transfusion experience in Gyn surgery performed in the OB/GYN service at San Daniele del Friuli Hospital, Udine for the period 1989-1993. A new method of autologous donation has been achieved in this ward since 1987.

[Experience with autologous transfusion in obstetrics]. / Esperienza di trasfusione autologa in ambito ostetrico.

The consequences of homologous blood transfusion have a remarkable impact on the obstetric population which mainly consists of young healthy women. The risk involved in possible post-transfusion complications is directly proportional to the number of homologous blood units that are being transfused. Autologous transfusion is riskless for the fetus' well being. The main obstetrical problem is that it is impossible to foresee to the maximum extent all cases in need of blood transfusion which might get either an excessive amount or an insufficient amount of autologous transfusion. Blood predonation is the most suitable method in the obstetrics service. Reported below are the findings concerning the autologous transfusion experience performed by the OB/GYN Department at the Hospital San Daniele del Friuli, Udine for the period 1989-1993, where a new method of autologous donation was performed on 44 pregnant women who delivered by C-section. The autologous program is considered an easy one in the OB/GYN field, without complications for the fetus' well being and also feasible for small hospitals.

[Fetal macrosomia and mode of delivery]. / Megalosomia fetale e modalità del parto.

During the period 1988-1993 the route of delivery in 482 infants with birth weight > or = 4000 grams was studied. Normal vaginal delivery occurred in 396 (82.1%) cases, vacuum extractor in 8 (1.6%) cases and caesarean section in 78 (16.1) cases. Elective induction of labor with oxytocin and/or amniotomy was carried out in 25 cases of macrosomia. Perinatal death and shoulder dystocia never occurred in these macrosomic babies, but clavicles abruption (27 cases), cephalohaematoma (2 cases), shoulder-bladehaematoma (1 case) and birth brachial palsy (1 case) were observed. Because, in our experience, elective induction of labor increased the operative delivery rate (caesarean section, vacuum extractor), we conclude that mothers with macrosomic fetuses can safely be managed expectantly unless there is a indication for induction or caesarean section.

[Experience in labor and delivery care in university centers]. / L'esperienza di assistenza al travaglio e al parto in alcuni centri universitari.

Some considerations about an individual experience of labour and delivery care by means of three different partograms at the university departments of Obstetrics and Gynecology of Genova, Trieste and Verona are reported. The value of partography in management of labour was stressed in connection with a better delivery care, with a systematic recording of cervicometric data and fetal maternal monitoring and in the prevention of the use of unsuitable medical and surgical treatments. The partogram is also essential for the correct communication and makes both tracking and data filing easier. By means of partography the return concept of personalized care of woman in labour is possible without that safety and technology of new obstetrics are lost.

[Preterm labor: timing and management]. / Il parto pretermine: tempi e modalità.

Premature rupture of membranes and intrauterine growth retardation are the most frequent conditions in which preterm labour and delivery may be facilitated or induced. If the membranes ruptured before 34 weeks, pregnancy may be prolonged for more than one week and premature fetus perhaps might benefit of steroid administration for the prevention of respiratory distress syndrome and of antibiotic preventive treatment. After 33 completed weeks no prolongation of gestation for more than one week seems to be particularly useful for newborn survival. Actually, intrauterine growth retardation and fetal chronic distress may be prematurely diagnosed (sonographic and Doppler diagnosis, non stress test, ecc.). Antepartum fetal evaluation and management of pregnancy with poor intrauterine growth are problems that need multidisciplinary measures, but the timing and the modality of delivery are strictly obstetric decisions. In case of fetal malformations and/or in case of extremely premature low-weight infants, management and timing of preterm labour and delivery need a particular care in observance of the well-being and of the outcome of these babies.

[Determination of cesium in human placenta 3 years after Chernobyl]. / Determinazione del cesio in placente umane tre anni dopo Chernobyl.

Three years after the nuclear reactor accident in Chernobyl, 80 human placentae were tested to determine concentrations of cesium 134 and cesium 137 radionuclides. The activities of radionuclides were measured using a low-back ground gamma-ray spectrometry system. Human placentae were obtained from normal and at term pregnancies in women who lived in rural areas of northern-Italy and north-west of Yugoslavia and who in particular used locally grown vegetables and meats. According to the data of other Authors, the low cesium isotopes 134 and 137 levels detected (inferior to 2 Bq/kg) in human placentae suggest that, in the observed geographic areas, the fetal risk following the reactor accident in Chernobyl was negligible.

[Determination of fetal pulmonary maturity using gas chromatographic analysis of fatty acids in the amniotic fluid. Statistic reliability of the method]. / Determinazione della maturità polmonare fetal mediante analisi gascromatografica degli acidi grassi nel liquido amniotico. Affidabilità statistica della metodica.

Assessment of foetal lung maturity by gas chromatographic analysis of the fatty acids in the amniotic fluid. Statistical reliability of the technique. Gas-chromatographic analysis of the fatty acids (Palmitis acid/Steric acid ratio: P/S ratio) was carried out in 432 samples of amniotic fluid obtained between the 28th and 42th weeks of gestational age. The present results from a series of normal (257) and various pathological (175) cases support the conclusions of other investigations that an amniotic fluid P/S ratio equal to or greater than 5 is a reliable indicator of attained fetal lung maturity. When correlated with gestational age the P/S ratios show regression lines that define the range of lung maturity in normal pregnancies between 32 and 33 weeks and in pathological cases around and over 36 weeks. Statistical studies stress that centrifugation in standard sample conditions before its gas chromatographic analysis is an essential step in order to avoid the serious consequences of an erroneous prediction. Finally Lecithin/Sphingomyelin (L/S) and P/S ratios were assessed in the same 100 samples of amniotic fluid: statistical analysis shows a very good correlation between the two methods and their reliability in the prediction of fetal lung maturity.

[Possible correlations between urinary cadmium and fetal growth retardation in pregnant women who smoke]. / Possibili correlazioni tra cadmio urinario e ritardato accrescimento fetale in gestanti fumatrici.

The results of a study on Ligurian women at the third day of puerperium are presented. The data obtained from the analysis of urinary cadmium levels in puerperae are related to their smoking habits and to the newborn weight. We found that women who smoked during pregnancy run the risk of giving birth to small-weight children one-and-a-half times higher than women who didn't smoke; moreover, cadmium levels in the urine of the women who smoked are higher too. The cadmium levels in urine on average are higher in women who gave birth to small-weight children, independently of smoke habits. We didn't find a significant relationship between cadmium levels in urine and newborn weight.

Birth rate and perinatal mortality in Italy during the years 1964 through 1986.

"Between 1964 and 1986 the number of births in Italy declined from over one million per year to little more than half a million per year. The perinatal mortality rate declined from 37.3/1,000 to 12.8/1,000. Using the year 1964 as [the] reference year, the total number of babies who were saved from perinatal death by socio-economic and medical improvements during the 22 years between 1965 and 1986 can be calculated as 435,005."