Alessandro Svelato

Vulvo-vaginal atrophy: A new treatment modality using thermo-ablative fractional CO2 laser

OBJECTIVE To evaluate the efficacy and feasibility of thermo-ablative fractional CO2 laser for the treatment of symptoms related to vulvo-vaginal atrophy (VVA) in post-menopausal women. METHODS From April 2013 to December 2013, post-menopausal patients who complained of one or more VVA-related symptoms and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment (T1), vaginal status of the women was evaluated using the Vaginal Health Index (VHI), and subjective intensity of VVA symptoms was evaluated using a visual analog scale (VAS). At T1, treatment satisfaction was evaluated using a 5-point Likert scale. RESULTS During the study period, a total of 48 patients were enrolled. Data indicated a significant improvement in VVA symptoms (vaginal dryness, burning, itching and dyspareunia) (P<0.0001) in patients who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Moreover, VHI scores were significantly higher at T1 (P<0.0001). Overall, 91.7% of patients were satisfied or very satisfied with the procedure and experienced considerable improvement in quality of life (QoL). No adverse events due to fractional CO2 laser treatment occurred. CONCLUSION Thermo-ablative fractional CO2 laser could be a safe, effective and feasible option for the treatment of VVA symptoms in post-menopausal women.

Chronic renal failure and endometrial osseous metaplasia: a hypothetical pathway.

Sir, We would like to bring to general attention the case of a 44year-old woman who came to our clinic because of spotting and occasional periods of amenorrhea. She had had menarche at the age of 14 years, followed by regular menstrual cycles. Her medical history revealed that she had one living child, and had subsequently experienced two miscarriages. The patient was human immunodeficiency virus (HIV) and hepatitis C virus positive. In addition, she was suffering from HIV-related chronic renal failure, HIV-related neuropathy and hepatitis C virus-related chronic hepatopathy. Physical and pelvic examinations were unremarkable. Transvaginal ultrasound examination revealed a hyperechogenic area in the uterine cavity measuring 14 mm 9 6 mm. The patient underwent a diagnostic hysteroscopy, which showed a 20 mm 9 10 mm white meshwork of bony spicules arising from the posterior wall, with a hard tactile consistency (Figure 1). A resectoscopic excision was then performed. The histological examination showed trabeculae of woven bone, and was consistent with osseous metaplasia of the endometrium. Concomitant endometrial histology showed a secretory endometrium. Two weeks after surgery, the patient again underwent a second transvaginal ultrasound examination, which revealed no trace of the original, abnormal ultrasound finding. Osseus metaplasia is rarely encountered, with less than 100 cases reported in the international literature (1). There is controversy regarding the pathogenic mechanisms related to the histogenesis of heterotopic bone in the endometrium. A number of theories have been proposed, as follows: continuous and strong endometrial estrogenic stimulation; osteogenesis in the surrounding endometrium, which is promoted by retained fetal bones; implantation of embryonic parts without pre-existing bone after early-stage abortions; dystrophic calcification of retained and necrotic tissues, usually after an abortion; chronic endometrial inflammation, such as endometritis or pyometra; and metastatic calcification and metabolic disorders, such as hypercalcemia, hypervitaminosis D or hyperphosphatemia (1–3). The most recent and accepted theory is metaplasia of the endometrial stromal cells, usually fibroblasts, which change into osteoblasts and thus produce bone in the endometrium. A previous history of abortion is present in most of the reported cases, with osseous changes in the endometrium. Usually, the reproductive age group (between 20 and 40 years of age) is involved, although it has also been reported in the menopausal years (1). In the few reported cases in the literature, the time between the antecedent abortion and discovery of the endometrial ossification varies from eight weeks to 23 years (4). Chronic renal failure is a known cause of abnormal calcium–phosphorous metabolism with metastatic calcifications; this may be the pathway of osseous metaplasia observed in our patient. Ultrasound examination plays a primary role in the diagnosis of patients with osseous metaplasia. The characteristic hyperechogenic pattern is strongly suggestive of osseous tissue within the uterus and should be confirmed by hysteroscopic examination (2). Today, hysteroscopy is accepted as the gold standard for diagnosis and treatment. Bone formation in the endometrium is rare, but can be seen in malignant mixed M€ ullerian tumors and in teratomas, which should be considered in the differential diagnosis (1). Clinicians and pathologists should bear this chance in mind, particularly in light of the fact that an erroneous diagnosis may well result in unnecessary hysterectomy.

The reduction of first cesarean sections: a cultural issue.

Sir, We read with great interest “Avoiding the first cesarean section – results of structured organizational and cultural changes” by Blomberg (1). We understand Blomberg’s attention to the complex issue of dystocia, and we would like to ask the author some questions: How long did labor last in patients who were subject to augmentation of labor and for those who were not subject to augmentation? Was there a difference in the duration of the labor for the two groups? Did they use a partogram? When did they start partogram compilation? In which percentage of patients were oxytocin and amniotomy used? We have just concluded an analysis on 419 nulliparous women with a single fetus in cephalic presentation, in spontaneous labor at term or induced labor post term, delivered at our Department (2). These corresponded to Robson Group 1 and 2a, based on the Ten-Group Classification System (3). We focused our attention on teamwork improvement and dystocia management. We introduced a series of meetings between medical and midwifery staff with the aim of standardizing the clinical activity of doctors and midwives and enforcing the commitment to change. Our comprehensive management of dystocia showed a decrease in the percentage of use of cesarean sections for dystocia, falling from 9.3 to 2.5% (p = 0.0035), in the use of oxytocin from 33.3 to 13.8% (p < 0.0005) and from 41.7 to 7.4% (p < 0.0005) for amniotomy. This is why we agree completely with Blomberg’s view that “the obstetric round” is essential for a change in attitude among midwives and doctors in favor of normal vaginal deliveries. We changed the views regarding dystocia and partograms. The partogram was, in fact, conceived as a screening tool and when individual cervimetric curves remained unchanged and went beyond the action line, we formulated the diagnosis of suspected dystocia and attempted to comprehend and diagnose the underlying possible causes of this lagging, without routinely performing amniotomy or administering oxytocin. This new management was aimed at carrying out, as precisely as possible, a diagnosis of “dystocia” to be able to treat the specific cause, thus avoiding useless and possible dangerous interventions such as oxytocin and amniotomy (2). In this way, dystocia is conceived as a syndrome, not as disease, and it is represented as a “closed box” that, when opened, by identifying a presumptive etiology, allows us to make a diagnosis and consequently act on the probable causes (4). We are therefore very interested in Blomberg’s idea of dystocia management, called “wheelbarrow”, and we think that it could be interesting and probably very close to our own idea. We would therefore like to know more about this method, and we would like to ask Blomberg to explain and give us details regarding the metaphors used for dystocia.

Oxytocin and customization of assistance in labor

Synthetic oxytocin (synOT) is a commonly used drug in labor and it can be applied in all stages of labor. SynOT has been increasingly used over the years, and is currently one of the most common drugs employed in obstetrics. The goal of synOT administration is to cause the augmentation of labor; unfortunately, guidelines for the administration of this drug are often non-specific, although synOT is the drug most commonly associated with preventable adverse perinatal outcomes. Approximately half of all paid obstetric litigation claims in the United States involve allegations of injudicious use of oxytocin, and the association between oxytocin use, hyperstimulation, fetal distress and adverse neonatal outcome are well know. Furthermore, synOT and oxytocin have some extragenital effects that should be known by obstetricians. This review will present the viewpoint of the authors on this topic.

Is x-ray compulsory in pubic symphysis diastasis diagnosis?

SirWe read with great interest your case of postpartum symphy-sis pubis separation (1). We would like to present a case ofpubic symphysis diastasis that we diagnosed with a differentapproach.A 36-year-old gravida 1 para 0 at 39.6 weeks’ gestation wasadmitted with the onset of spontaneous contraction. After threehours and 18 min she delivered a 3170 g baby without compli-cations.Three hours after delivery, she complained of severe pain inthe symphysis pubic region. On examination, there was localtenderness in that region. We performed an ultrasound exami-nation, which revealed a 15.2-mm gap in the region of the sym-physis pubis (Figure 1), diagnosed as pubic symphysis diastasis.She was given analgesics and advised bed rest. The patient wasdischarged six days after delivery and advised to maintain activeambulation and start physiotherapy. Three months later she wasseen at the outpatient clinic. She was able to walk independentlyand was no longer experiencing any pain.Although the case presented is not particularly impressive inseverity, it still offers the opportunity to inform all cliniciansabout the possibility of diagnosing this condition with the useof the ultrasonography alone. The reported incidence of pubicsymphysis diastasis varies widely in the literature, from 1 in 300to 1 in 30 000 deliveries (2,3). Generally, it is a rare complica-tion and for this reason it is very difficult to perform random-ized controlled trials to compare different diagnostic tools. Thediagnosis is based primarily on clinical findings. The most con-sistent finding is pain in the symphyseal region that radiates tothe lower back and thighs and is exacerbated by leg movement(4). In addition, many women will have difficulty walking, infact the gait is described as waddling, or potentially be unableto stand or walk due to pain (3). Symptoms may be noted dur-ing labor and up to 48 h postpartum. Often the first diagnostictest used to identify the pubic diastasis is antero-posterior radi-ography. However, we think that ultrasound might be a goodchoice as an initial imaging study, rather than x–ray, due toabsence of exposure to ionizing radiation and its ease of opera-tion, and as it presents an optimal assessment of the extent ofsymphysis separation (3–5). We performed ultrasonography inthe following way: we placed the probe in transverse orientationon the pubic symphysis (identified by palpation) with an approx-imately 30° caudal scanning plane, with the purpose of measuringthe width of the symphyseal joint at its upper margin.Pubic symphysis diastasis is an uncommon injury that shouldbe considered when evaluating patients in the peripartum periodwho are experiencing suprapubic, sacroiliac or thigh pain. In addi-tion we would like to bring to the general attention the usefulnessof ultrasound in the diagnosis and management of this rare condi-tion. The literature is inconsistent on this topic, due to the lack ofrandomized controlled trials, but good suggestions are present (3–5). In our experience, ultrasound is simple, reproducible and with-out side effects, and should be used as an initial imaging studybecause the accuracy is at least as good as that of x-rays for esti-mating the width of the symphysis pubis diastasis.Alessandro Svelato