Alessandro Favilli

Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study

OBJECTIVE To estimate the prevalence and the characteristics of intrauterine adhesions after cold loop resectoscopic myomectomy. DESIGN Retrospective study. SETTING Endoscopic gynecologic center. PATIENT(S) 688 women with one or more G1-G2 myomas. INTERVENTION(S) Cold loop resectoscopic myomectomy and diagnostic hysteroscopy in all patients 2 months after surgery. MAIN OUTCOME MEASURE(S) Integrity of the uterine cavity and prevalence of intrauterine synechiae. RESULT(S) A total of 806 myomas were removed, ranging from a minimum of one to a maximum of five fibroids removed for each surgical procedure. Complications were reported in eight cases (1.16%). No hemorrhage, intravasation clinical syndrome, or perforation with the thermal loop were registered. Synechiae were found in 29 patients (4.23%): in 2 patients a new surgical hysteroscopic treatment was required to remove fibrous synechiae, and in 27 patients light adhesions were removed with the tip of the instrument in outpatient hysteroscopy. Neither intrauterine device nor anti-adherence mixtures were used at the end of surgery. CONCLUSION(S) The cold loop hysteroscopic myomectomy is a safe and effective procedure that seems to be associated with a lower rate of intrauterine adhesions in comparison with the reported literature. The issue appears to be of notable importance for fertility patients.

Pregnancy outcome in women aged 40 years or more

Objective: The study aimed to analyze the pregnancy outcome of women aged 40 years or more. Methods: A matched retrospective cohort study comparing women aged 40 years or more with a control group aged 20 to 30 years is described. Multivariate logistic regression models were fitted for the prediction of preterm birth and cesarean delivery. Results: Pregnancy-induced hypertension, preeclampsia and placenta previa were similar in both groups, but a higher rate of gestational diabetes was found in elderly patients (odds ratio [OR] 3.820, 95% confidence interval [CI] = 1.400–10.400; p < 0.0001). Preterm delivery was significantly more frequent in elderly women (OR 1.847, 95% CI = 1.123–3.037; p = 0.020). Gestational diabetes and pregnancy-induced hypertension were strongly associated with preterm delivery and advanced maternal age was not an independent risk factor for preterm delivery. The cesarean delivery rate was significantly higher in the study group (OR 3.234, 95% CI = 2.266–4.617; p < 0.0001). The variables most influencing the cesarean delivery rate were maternal age, analgesia, parity, premature rupture of the membranes and gestational hypertension. No significant differences were detected in neonatal birth weight and Apgar score. Conclusions: Patients aged 40 years or more have been demonstrated to carry a favorable pregnancy and neonatal outcome, similar to younger patients. The risk of cesarean delivery was higher in patients with advanced maternal age, in nulliparous and in women with a previous cesarean section. The risk of preterm delivery was not related to age but it was strongly associated with gestational diabetes and pregnancy-induced hypertension.

Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures

STUDY OBJECTIVE To assess the safety and efficacy of cold loop hysteroscopic myomectomy in a large series of cases. DESIGN Retrospective study (Canadian Task Force Classification III). SETTING Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy. PATIENTS A total of 1215 patients with 1 or more G1-G2 submucous myomas. INTERVENTION Cold loop hysteroscopic myomectomy. MEASUREMENT AND MAIN RESULTS A total of 1690 myomas were removed. A minimum of 1 to a maximum of 5 fibroids for each surgical procedure were totally removed. Out of 1215 patients, 1017 (83.7%) were treated with a single surgical procedure. Twelve intraoperative complications occurred (0.84%). No cases of uterine perforation with the thermal loop or clinical intravasation syndrome were reported. CONCLUSION Cold loop hysteroscopic myomectomy seems to represent a safe and effective procedure for the removal of submucous myomas with intramural development, while at the same time respecting the anatomic and functional integrity of the myometrium. The use of a cold loop in resectoscopic myomectomy is associated with a low rate of minor intraoperative complications and an absence of major complications. This could be of primary relevance with a view to fertility and future pregnancies.

Single indication of labor induction with prostaglandins: is advanced maternal age a risk factor for cesarean section? A matched retrospective cohort study

Abstract Objective: The aim of this study is to investigate if advance maternal age is an independent risk factor for cesarean section in women induced with prostaglandins. Only patients with a single indication for induction of labor were considered. Methods: A matched retrospective cohort study was conducted. A study group of 112 women aged 35 or older was enrolled. The control group included 216 women aged 34 or younger. Multivariate logistical regression models were fitted for the prediction of the cesarean section. Results: There were no statistically significant differences in characteristics of the patients in the study and control groups. However, a higher prevalence of nulliparous women was found in control group (p = 0.002). The indications of labor induction were homogeneous in the two groups. No significant differences were found in the route of delivery. The median time of labor was significantly shorter in the study group (p = 0.002), and the birth weight and the placental weight were significantly lower in the study group. Advanced maternal age and newborn weight were directly related, whereas time of labor, Bishop score and parity were inversely related to a higher cesarean rate. Conclusions: When single indication of induction of labor with prostaglandins is considered, advanced maternal age represents a significant independent risk factor for cesarean delivery.

Effect of epidural analgesia on labor and delivery: a retrospective study

Two groups of women have been retrospectively compared: 155 women who received analgesia and 1355 women who delivered without analgesia. The duration of the first stage, second stage, and total duration of labor was longer in epidural group, however epidural analgesia was not demonstrated as an independent risk factor for a prolonged labor. The variable most influencing the total duration of labor and the duration of the first stage was nulliparity; the variables most influencing the duration of the second stage were the older age, a reduced body mass index, a high newborn weight and nulliparity.

Early serum markers of pre-eclampsia: are we stepping forward?

Abstract Pre-eclampsia (PE) is a multisystemic disorder of human pregnancy, clinically characterized by hypertension, proteinuria, oedema and platelet aggregation; the syndrome includes vasoconstriction, resulting in maternal hypertension, reduced uterine blood flow, impairment of placenta–vascular endothelial integrity with increased permeability and activation of the coagulation cascade. The aetiopathogenesis of PE remains still unknown, although the central role played by the placenta seems to be crucial. To date, increasing efforts are trying to create an unique and robust biochemical pattern in serum to predict PE. Although the recent data, the definition of an early biochemical pattern in serum to predict PE is still far from reaching the final shape. This stalemate could be due, at least in part, to lack of robust and reproducible methodology (inclusion/exclusion criteria during enrolment, period and type of sample collection, type of sample analysis and interpretation of results) across the different studies. Considering these assumptions, the aim of the current paper is to review the available data about early serum markers of PE.

Pain in diagnostic hysteroscopy: a multivariate analysis after a randomized, controlled trial

OBJECTIVE To study which variables are able to influence womens experience of pain during diagnostic hysteroscopy. DESIGN Multivariate analysis (phase II) after a randomized, controlled trial (phase I). SETTING Endoscopic gynecologic center. PATIENT(S) In phase I, 392 patients were analyzed. Group A: 197 women with carbon dioxide (CO2); group B: 195 women with normal saline. In phase II, 392 patients were assigned to two different groups according to their pain experience as measured by a visual analogue scale (VAS): group VAS>3 (170 patients); group VAS≤3 (222 patients). INTERVENTION(S) Free-anesthesia diagnostic hysteroscopy performed using CO2 or normal saline as distension media. MAIN OUTCOME MEASURE(S) Procedure time, VAS score, image quality, and side effects during and after diagnostic hysteroscopy. RESULT(S) In phase I the median pain score in group A was 2, whereas in group B it was 3. In phase II the duration of the procedure, nulliparity, and the use of normal saline were significantly correlated with VAS>3. A higher presence of cervical synechiae was observed in the group VAS>3. The multivariate analysis revealed an inverse correlation between parity and a VAS>3, whereas the use of normal saline, the presence of synechiae in the cervical canal, and the duration of the hysteroscopy were all directly correlated to a VAS score>3. CONCLUSION(S) Pain in hysteroscopy is significantly related to the presence of cervical synechiae, to the duration of the procedure, and to the use of normal saline; conversely, parity seems to have a protective role. CLINICAL TRIAL REGISTRATION NUMBER NCT01873391.

Pain during diagnostic hysteroscopy: what is the role of the cervical canal? A pilot study.

OBJECTIVE To evaluate whether a correlation exists between the pain perceived during diagnostic anesthesia-free hysteroscopy and the characteristics of the cervical canal. STUDY DESIGN Prospective observational pilot study of 255 women undergoing diagnostic hysteroscopy. Data analysis included characteristics of the patient and the cervical canal, and the pain experience during the procedure, assessed by visual analog score (VAS). A multiple logistic regression was then carried out in order to exclude confounding factors. RESULTS The degree of pain during hysteroscopy was equal to a median VAS score of 2 (range 0-10). Bivariate analysis between patients with VAS>3 and patients with VAS≤3 demonstrated a significant correlation between pain and the presence of synechiae in the cervical canal (P=0.022), the patients age (P=0.003) and parity (P=0.001). Multivariate analysis revealed that the presence of cervical synechiae (P=0.0001) [OR=4.99 (95% CI 2.13-11.70)] and parity (P=0.014) [OR=0.42 (95% CI 0.21-0.83)] were significantly correlated with pain. There was no significant correlation with the different angles of the cervical canal. CONCLUSION Cervical synechiae appear as a major factor influencing pain during hysteroscopy. While parity acts as a protective factor, the angle of the cervical canal does not seem to play an important role for pain during diagnostic hysteroscopy.

Single indications of induction of labor with prostaglandins and risk of cesarean delivery: A retrospective cohort study

To determine the risk of cesarean delivery after induction of labor with prostaglandins and to establish if this is influenced by a single indication of induction of labor or any intrinsic characteristic of the woman or labor.

Is ‘cold loop’ hysteroscopic myomectomy a better option for reproduction in women with diffuse uterine leiomyomatosis? A case report of successful repeated pregnancies

Diffuse uterine leiomyomatosis (DUL) is a rare clinical entity with important reproductive consequences. To date, only four pregnancies have been reported after hysteroscopic myomectomy. Here we describe the case of a 28‐year‐old infertile woman with diffuse uterine leiomyomatosis, who presented infertility and metrorrhagia lasting for 2 years. A countless number of subserous, intramural and submucous myomas were ultrasonographically revealed. Diagnostic hysteroscopy described a uterine cavity completely subverted by the presence of myomas. A two‐step ‘cold loop’ hysteroscopic myomectomy was performed following the technique previously described. One month after the treatment, there were no submucous myomas. A regular uterine cavity free of synechiae was endoscopically confirmed. After the treatment, the patient carried to term three consecutive, uneventful pregnancies. This is the first report of repeated successful pregnancies following the ‘cold loop’ hysteroscopic technique in DUL. We believe that ‘cold loop’ resectoscopic myomectomy may provide new advantageous perspectives for women with DUL seeking pregnancy.