Asynclitism and Its Ultrasonographic Rediscovery in Labor Room to Date: A Systematic Review.

Asynclitism, the most feared malposition of the fetal head during labor, still represents to date an unresolved field of interest, remaining one of the most common causes of prolonged or obstructed labor, dystocia, assisted delivery, and cesarean section. Traditionally asynclitism is diagnosed by vaginal examination, which is, however, burdened by a high grade of bias. On the contrary, the recent scientific evidence highly suggests the use of intrapartum ultrasonography, which would be more accurate and reliable when compared to the vaginal examination for malposition assessment. The early detection and characterization of asynclitism by intrapartum ultrasound would become a valid tool for intrapartum evaluation. In this way, it will be possible for physicians to opt for the safest way of delivery according to an accurate definition of the fetal head position and station, avoiding unnecessary operative procedures and medication while improving fetal and maternal outcomes. This review re-evaluated the literature of the last 30 years on asynclitism, focusing on the progressive imposition of ultrasound as an intrapartum diagnostic tool. All the evidence emerging from the literature is presented and evaluated from our point of view, describing the most employed technique and considering the future implication of the progressive worldwide consolidation of asynclitism and ultrasound.

Altis® Adjustable Single Incision Sling System for Treatment of Intrinsic Sphincteric Deficiency: A 3-Year Follow-up Observational Study.

IMPORTANCE: This article is a long-term follow-up study on the Altis adjustable single incision sling (Coloplast Corp.) in patients with isolated intrinsic sphincteric deficiency (ISD). OBJECTIVES: The primary end-points were to evaluate the subjective and objective outcomes of the Altis for the treatment of ISD, with a 3-year follow-up. The secondary end-point was to evaluate the safety of this surgical procedure. STUDY DESIGN: This is a retrospective single-arm study. A total of 123 consecutive patients with ISD were selected from our database among women who underwent an Altis implantation for ISD from March 2015 to June 2017, after unsuccessful previous conservative treatment. Of the 123 included patients, 16 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using a standardized cough stress test and urodynamics, and subjectively using the Patient Global Impression of Improvement. Complications were assessed intraoperatively, perioperatively, and postoperatively. Six, 12, and 36 months of follow-ups were analyzed for the study. RESULTS: The 3-year objective cure rate was 86.9%, and the subjective cure rate was 81.5%. We observed no intraoperative complications. No women were obstructed. Ten patients reported postoperative complications, although most of them were Clavien-Dindo grade I and self-limited. CONCLUSIONS: Altis system could be considered an effective and safe alternative to traditional midurethral slings as treatment for women with ISD.

Myomectomy during pregnancy: an obstetric overview.

INTRODUCTION: Uterine fibroids (UFs) are the most common benign disease affecting female reproductive system, and occurring in 20-40% of women, and in 10% of pregnancies. The aim of the investigation was to summarize evidence about the management and treatment of UFs and related complications in pregnancy. EVIDENCE ACQUISITION: A literature review was performed using scientific databases, including all case report and case series, using a combination of key words related to the problem exposed. Data about gestational age at diagnosis, maximum fibroids diameter, type of surgery and gestational age at surgery, delivery and perinatal outcome were collected. Two clinical cases were also included. EVIDENCE SYNTHESIS: Sixty-six articles were selected, and 199 patients were included. In 76% of patients the gestational age at myomectomy was lower than 20 weeks, in 85% laparotomic surgery was chosen, in 41% of cases the maximum fibroid diameter was between 7-20 cm, in 41% of pregnancies the route of delivery was the Cesarean section. In the eight percent of cases there was a complication given by miscarriage, fetal demise or neonatal death. CONCLUSIONS: Myomectomy is a feasible procedure in those pregnancies complicated by symptomatic fibroids, though surgery in pregnancy is associated with an increased risk of obstetric complications.

Analysis of relation between placental lesions and perinatal outcome according to Amsterdam criteria: a comparative study.

BACKGROUND: To verify the correlation between histological examination of the placenta (HP), classifying the lesions according to the Amsterdam criteria (AC), and the main neonatal pathological patterns. METHODS: This prospective study carried out at the University of Bari between May 2015 and May 2017,enrolled 350 pregnant women. Complete obstetric history and HP was collected. 380 newborns were also enrolled. The analysis was also carried out by comparing the incidence of the various placental pathologies in the sample of physiological pregnancies (PP), represented by 142 cases, with the incidence of the group with placental anomalies (PA). The statistical software used was STATA MP11. RESULTS: Respiratory disorders (61 cases) are significantly correlated with generic PA (p=0.006). Neonatal sepsis (15 cases) was significantly correlated with placental inflammation (p=0.035) and villitis of unknown origin (p=0.039).Twin pregnancies (50 cases) were correlated with generic PA (p=0.00001) and late maternal malperfusion (p=0.00001). Congenital cardiopathies (50 cases) were correlated with the villitis of unknown origin and PA (p=0.0000). Preterm birth (145 cases)was correlated with the premature malperfusion (p=0, 0011) and PA (p=0.0000); SGA (low weight in relation to the gestational age - 75 cases) neonates were correlated with the early malperfusion (p=0.00000) and the generic PA (p=0.00000). CONCLUSIONS: The present study has therefore verified whether in reality the HP can be of great help to the neonatologist in the nosological and therapeutic setting of the pathological newborn. The pathological examination of the placenta is nevertheless essential to clarify the causes of the stillbirths and that these causes are particularly important for the obstetric and neonatal outcome of subsequent pregnancies.

Outcomes of robotic surgery performed in patients with high BMI class: experience by a single surgeon.

BACKGROUND: Advanced laparoscopic procedures have been shown to be safe in patients with high Body Mass Index (BMI), but conversion rates remain high. This analysis aimed to evaluate the feasibility and clinical outcomes in terms of long- and short-term complications, pain relief of robotic surgery in morbidly obese patients. METHODS: Patients with BMI class I-II-III with endometrial cancer or hyperplasia were treated with robotic hysterectomy (RH). Patients' characteristics, operating room time (OT), type of surgery, length of hospital stay, and incidence of complications were recorded. Records were reviewed for demographic data, medical/surgical history and comorbidities, perioperative findings and outcomes, as well as long-term complications and recurrences. Regarding stage, according to 2009 FIGO, 26 of cases were IA, while eight and five of cases were, respectively, IB, II stage. RESULTS: A total of 87 consecutive RH were analyzed. The more frequent comorbidity was hypertension. Twenty percent of the patients had multiple comorbidities (>2). The mean age was 63±10 years, with a mean BMI of 36±8.2 kg/m2. The more frequent BMI group treated was II class. The median OT was 114 minutes (range: 49-270). According to the Dindo Classification, there were no differences in major or minor complications between the 3 BMI classes. This series had a median follow-up of 60 months (range: 8-96) with an overall survival rate of 100%. The RRH+PLH was feasible and pathology confirmed the adequacy of the surgical specimen, with a median count of 20 nodes. CONCLUSIONS: Our data support the adoption of the surgical management of the morbidly obese patient. Although short term complication rates are higher with increasing obesity (II-III class), a majority of procedures can still be completed with minimally invasive approach.