[Placental insufficiency and intrauterine growth retardation]. / Insufficienza placentare e ritardo di crescita fetale.

AIM: Placental insufficiency is a pathological condition consisting of a placental functional deficit with multifactorial etiology; it can cause maternal complications such as edema, proteinuria, hypertension, etc. Our study aims to establish if placenta analysis after birth can lead to the identification of basic morphological alterations which can be easily documented and useful for the diagnosis of feto-neonatal pathologies. METHODS: We examined 60 pregnant women (45 primipara, 15 multipara). They were hospitalized in the period from March 1998 to March 2004 in different pregnancy periods because of fetus growth delay. After birth, a careful examination of the placenta has been carried out soon after spontaneous birth (weight, thickness, possible morphological alterations which could be macroscopically observed) and it was followed by an anatomo-pathological examination carried out at the Anatomopathology Unit of Ospedali Riuniti in Foggia. RESULTS: Macroscopic examination, in the group of women at the first pregnancy, showed that there were no morphological alterations in the placenta in all the cases, but the weight was normal (400- 500 g) in 8 cases and it was less than 400 g in the other 37 cases. In the group of multipara, placenta did not shown morphological alterations in all the cases, but the weight was normal in only 3 cases and it was lower in the remaining 12 cases. The placental microscopic examination pointed out: infarct focus in 34 cases (60%), 12 (35%) of which were recent and 22 (65%) were old infarct focuses; immaturity of chorionic villus in 15 (30%) of the examined placentas; increase in the cytotrophoblast mitotic index in 49 cases (90%) and placenta with normal histological appearance in 11 cases (10%). CONCLUSION: Placental examination, both with macroscopic and microscopic techniques, can lead to the identification of basic morphological alterations which can be easily documented and useful for the diagnosis of feto-neonatal pathologies. A good placental functionality influences both fetal life and postnatal life. Thus, a greater attention to the placental examination in obstetric practice is suggested, especially for maternal and fetal pathologies.

[Intraepithelial cervical squamous lesions: comparison between PAP-test, colposcopy, phase contrast microscopy and histology; usefulness of their synergic use]. / Lesioni intraepiteliali squamose cervicali: raffronto tra il PAP-test, la colposcopia, la microscopia a fresco e l'esame istologico; utilità di un loro uso sinergico.

AIM: In the last 10 years the tumors of cervix have showed a significant reduction in incidence, while the preneoplastic lesions are increased (linked often to human papilloma virus [HPV] infection), and so it is enhanced the role of early diagnosis. METHODS: The Authors have examined 124 patients at colposcopy showing transformation zone anomalies and/or HPV infections. The patients have submitted to PAP-test, phase contrast microscopy and to biopsy. RESULTS: The analysis of our cases show oneself better sensitivity of colposcopy than cytologic exam, in particular in the diagnosis of low grade intraepithelial lesions (LSIL), corresponding to CIN 1 and HPV lesions. CONCLUSIONS: Phase contrast microscopy, by search of possible preneoplastic elements in the smear, is a complementary technique, and if performed systematically and by qualified operators allows to reduce furthermore false negative rate. The synergic use of tools allows to increase of number of intrecervical neoplasia diagnosis. The following cost's increase cannot be considered an obstacle and it is not should be necessary to counsel always the colposcopy in case of anomalous PAP smear revealed during screening.

[Preeclampsia and high serum levels of homocysteine]. / Preclampsia ed elevati livelli sierici di omocisteinenia.

AIM: Preeclampsia, a syndrome that can arise in the second half of pregnancy and that is characterised essentially by the presence, alone or variously combined, of three symptoms, oedemas, proteinuria and hypertension, has an incidence which varies between 5-7% and 25%. It seems that the element which determines the start and the continuation of the syndrome is located in the placenta and, in particular, in structural and functional changes of the trophoblast syncytium. In addition, the literature contains numerous studies that have evidenced endothelial damage as a key element to the pathogenetic mechanism in EPH-gestosis and recently an important role is attributed to a condition of hyperhomocysteinaemia. METHODS: Blood samples obtained from 30 primigravidas with term pregnancies and physiological course were taken within 1 week of delivery and from the same number of primigravidas hospitalised for preeclampsia. RESULTS: The homocysteine levels observed were significantly higher in women with preeclampsia (8.8+/-2.7 mol/l compared with the control group (4.1+-1.8 mol/l) (P<0.05). Haematocrit values measured on the day the sample was taken did not present any particular differences in the two groups. CONCLUSIONS: Our research, carried out on gravid patients at term of a physiological pregnancy and without intercurrent diseases and on primigravidas with preeclampsia who came to our observation at the moment of delivery and with a negative history for chronic hypertension, diabetes or other, showed a high concentration of homocysteine in the primigravidas with preeclampsia close to childbirth.

[Recurrent spontaneous miscarriages and hyperhomocysteinemia]. / Aborti spontanei ricorrenti e iperomocisteinemia.

AIM: Recurrent fetal loss is defined as the number of consecutive miscarriages which is not less than 2 occurred within the 16th week of gestation and it is a very interesting pathology of pregnancy. Further to thrombophilia, very important causes have been identified, since the damage of the vascular system supporting the placenta may cause a deficiency of placenta functions and development, leading to a loss of the conception product, also in a condition of hyperhomocystinemia, causing a damage to the vascular endothelium. Hyperhomocystinemia seems to be a risk factor for artero-venous thrombotic diseases, even not in pregnancy. METHODS: We have examined 40 patients referred to our Institute for unexplained fetal loss (at least 2 consecutive miscarriages within the 16th week of gestation) and the same number of patients who had at least 1 spontaneous delivery with a healthy and alive newborn and none abortion nor fetal death nor abruptio placentae. RESULTS: The mean levels of homocystinemia observed were significantly different in the 2 groups (p = or < 0.05). In the control group the values of plasmatic homocysteine were 10+/-4 micromol/L, corresponding to normal range, while in the other group the values of plasmatic homocysteine were 21+/-6 micromol/L, values certainly elevated, also because during the 1st trimester of pregnancy the levels of homocysteine decrease, reaching the lowest value during the 2nd trimester of pregnancy. In particular, high levels of homocysteine have been found in 25% (10) of women with unexplained early fetal loss. CONCLUSION: Hypercystinemia, as a consequence of an interaction between a primary genetic defect and a nutrition condition (folate deficiency), may be a cause of recurrent miscarriages. Therefore, in these cases, a possible hypercystinemia should be searched and an association of folic acid and vitamin B6, a non teratogenic treatment, should be useful to restore the metabolic picture and to favour the pregnancy outcome.

[Outcome of pregnancy in patient with cloacal dysgenesis]. / Outcome di una gravidanza in paziente con disgenesia cloacale.

The cloacal dysgenesis or persistent cloaca is an anomaly included in urogenital tract malformations (UGM) and, in particular, in anomalies due to a missed development of the urogenital septum. The UGM occur during 6-11th weeks of gestation owing to a stop and/or alteration of the normal development and subdivision process of the cloaca, the embryonic structure from which gives origin to the ano-rectal segment of midgut, bladder, ureters, vagina and uterus. The case of a patient submitted to many surgical treatments for urogenital tract congenital malformations is described; when pregnant, she carried other pregnancy until the 34th week of gestation, giving birth a newborn by cesarean section. The patient was checked constantly for her general conditions and, in particular, her renal functions by an active collaboration between internist, nephrologist and gynecologist.

[Factor V Leiden mutation. Successful outcome of a pregnancy after heparin therapy]. / Mutazione del fattore V di Leiden. Esito positivo di una gravidanza dopo terapia con eparina.

Several reports have highlighted the significant correlation between maternal thromboembolism pathologies, such as factor V Leiden mutation, and the occurrence of gestational pathologies. The main causes of thromboembolism pathologies are the inherited coagulopathies. The most common genetic predispositions include autosomal dominant inheritance coagulative factors deficiencies, such as antithrombin III (AT III), C protein (CP), S protein (SP), G20210A mutation, hyperomocystinemia and the activated C protein resistance, caused by factor V Leiden mutation. Maternal thromboembolism as an inherited coagulopathy expression, may be associated with high fetal-maternal morbidity and mortality rate. Nowadays, a wide screening is not possible, but the patients with previous or familiar deep venous thrombosis episodes should at least undergo very careful examinations. In the present case the patient's knowledge of her own status as a factor V Leiden mutation carrier , the prophylactic therapy performed, and the frequent fetal and maternal monitoring allowed us to avoid the recurrence of the dramatic events occurring during her first pregnancy.

Electrocardiographic patterns in acute inferior myocardial infarction with and without right ventricle involvement: classification, diagnostic and prognostic value, masking effect.

BACKGROUND: In acute inferior myocardial infarction (AIMI), the ST depression from V1 to V4 has been the subject of many papers, while the ST changes in other leads, their association, and the right ventricular (RV) involvement have been studied less. HYPOTHESIS: This study was performed to contribute to the meaning of the ST changes and RV involvement in AIMI. METHODS: Seventy-one patients, admitted within 6 h from symptom onset, all thrombolysed, were enrolled. We classified them according to ST patterns and RV involvement. We divided the right coronary artery into three segments, considering the origin of RV branch and the crux as dividing points. We established a coronary score attributing 2 points to each terminal branch. Comparisons were performed between the electrocardiographic (ECG) findings at onset, the creatine phosphokinase (CPK) peaks, the radionuclide ejection fractions, and the coronary angiographies. RESULTS: We found that the ST changes give indications regarding the site, extension, and extent of AIMI; RV involvement can mask posterior extension, points to the right coronary as the culprit vessel (100%), and, with high probability, indicates the proximal segment as the site of the lesion; the ECG signs of isolated AIMI indicate a peripheral obstruction; and a collateral circulation may appear relatively early. CONCLUSIONS: Our findings prove the diagnostic and prognostic value of the ST changes and RV involvement at the onset of AIMI and suggest that the higher in-hospital mortality and complication rates found with RV involvement and reported in the literature are related more to posterior extension, masked by RV involvement than to this involvement per se. Furthermore, these findings prove the clinical value of our classification of the AIMIs and distinction in segments of the right coronary artery.

Role of family history in patients with myocardial infarction. An Italian case-control study. GISSI-EFRIM Investigators.

BACKGROUND: A family history of heart disease has been reported to increase the risk of coronary heart disease. We examined the relation between family history of myocardial infarction (MI) and risk of acute MI to establish the independency of this association, the degree of risk in relation to the number and age of relatives affected, and the possible interaction between family history and other major risk factors for MI. METHODS AND RESULTS: In a case-control study conducted in Italy within the framework of the GISSI-2 Trial, 916 cases of newly diagnosed MI and 1,106 hospital controls were identified. Using a structured questionnaire, data were collected on the history of MI in first-degree relatives and the age at which the event occurred. Compared with subjects without family history of MI in first-degree relatives, the relative risk (RR) of MI was 2.0 (95% confidence interval, CI, 1.6-2.5) in those with one and 3.0 (95% CI, 2.0-4.4) in those with two or more relatives affected (chi 2(1) test for trend, 54.1; p less than 0.001). Such an increase was not substantially affected by allowance for recognized risk factors. The risk related to family history involving at least two relatives was higher for early MI (less than 55 years) (RR, 20.0; 95% CI, 3.3-121.2) compared with later MI (less than or equal to 65 years) (RR, 3.5; 95% CI, 1.8-6.6). When known risk factors were considered for their interaction with family history, the effect on RR was approximately multiplicative for several variables, including smoking, serum cholesterol, hypertension, and hyperlipidemia but not for diabetes and body mass index. Thus, the presence of both family history and smoking and cholesterol levels greater than or equal to 226 mg/dl led to an RR of 14 (95% CI, 3.7-50.0) and 8.3 (95% CI, 1.8-38.7), respectively. CONCLUSIONS: This study indicates that a family history of MI is an independent risk factor for MI, and that the number of relatives and the age at which they were affected is related to the strength of the association. There is a multiplicative effect on RR between family history and several major risk factors for MI.

Fibronectin levels in pregnancy and puerperium.

Fibronectin levels were serially assayed during the third trimester of pregnancy and puerperium in a group women with uncomplicated pregnancies, and two groups with mild/severe hypertensive disorders of pregnancy. The values were found increased in the complicated pregnancies, with extremely elevated levels in cases of severe preeclamptic fits.

Hepatitis A virus and non-A, non-B virus superinfections in HBsAg chronic carriers.

Clinical course, morphologic changes, immunohistochemical localization of HBV-associated markers (HBsAg, HBcAg), and serum HBV-DNA production are described in 2 chronic HBsAg carriers superinfected with HAV and hepatitis non-A, non-B virus. Our data suggest that the superinfections do not cause more severe disease and do not influence the clinical course of the HBsAg chronic carriers. Our observations indicate that a careful diagnosis of hepatocytolysis is necessary in HBV chronic infection, in order to discriminate causes that are able to induce severe damage in underlying disease.

[Specificity of systolic anterior motion of the mitral valve in the echocardiographic diagnosis of hypertrophic cardiomyopathy (author's transl)]. / Specificità del movimento sistolico anteriore della mitrale nella diagnosi ecocardiografica delle cardiomiopatie ipertrofiche.

In order to determine the prevalence of sistolic anterior motion (SAM) of the mitral valve, we evaluated the echocardiographic records of 229 consecutive patients with a variety of cardiovascular conditions. SAM was present in all the 9 patients of this series with hypetrophic cardiomyopathy and in additional 4 patients with other conditions. Their diagnosis were: arterio-venous fistula of the forearm, tetralogy of Fallot, Prinzmetal angina and idiopatic hypercynetic cardio-circulatory state. Thus SAM without hypertrophic cardiomyopathy is not a rare event in patients undergoing echocardiography. The wide variability of conditions associated with SAM suggests that it represents a functional and aspecific abnormality and does not involve peculiar anatomic factors.