Alfredo Mancuso

Gestational thyroid function abnormalities in conditions of mild iodine deficiency: early screening versus continuous monitoring of maternal thyroid status

OBJECTIVE To longitudinally evaluate the timing of maternal thyroid underfunction occurrence in mildly iodine-deficient (ID) pregnant women, and ultimately assess the benefit of thyroid function testing at early gestation only in identifying maternal thyroid underfunction. PARTICIPANTS/METHODS Serum free-thyroxine and TSH were measured in 220 consecutive women once in early pregnancy (by week 12) and twice per trimester subsequently. Anti-thyroperoxidase and anti-thyroglobulin were also determined at initial and final observation. RESULTS Thyroid autoantibodies were detectable in 8.2% women. Overall, the prevalence of hypothyroidism over the course of gestation was 11.8% (26/220), with a relative risk of hypothyroidism in antibody-positive women of 5.0 (chi(2) 20.02, P<0.0005). Nonetheless, almost 70% hypothyroid women tested negative for thyroid autoantibodies. Fifteen/26 (57.7%) hypothyroid women were identified at presentation, and the remaining 11 at either early (6/11) or late (5/11) phases of the 2nd trimester. Isolated hypothyroxinemia was observed in 56/220 (25.4%) women, mostly from the 2nd trimester onwards. CONCLUSIONS In mildly ID areas thyroid function testing early in gestation seems to be only partly effective in identifying thyroid underfunction in pregnant women. Indeed, in our series more than 40% hypothyroid women would not have been diagnosed had we limited our observation to early thyroid function tests alone. Although thyroid autoimmunity carried a 5-fold increased risk of hypothyroidism, iodine deficiency seems to be a major determinant in the occurrence of thyroid underfunction. Adequate iodine supplementation should be strongly recommended to meet the increased hormone demand over gestation.

Maternal thyroid function in different conditions of iodine nutrition in pregnant women exposed to mild-moderate iodine deficiency: an observational study.

Objective  We examined the effect of different conditions of nutritional iodine intake on maternal thyroid function throughout gestation in a cohort of healthy, anti‐thyroid antibody‐negative women from a mild‐moderately iodine‐deficient (ID) area.

Thyroid Function in Women Found to Have Early Pregnancy Loss

BACKGROUND Pregnancy influences thyroid function and may bring to light mild and latent disorders. Thyroid dysfunction has been related to obstetrical complications such as premature delivery, gestational hypertension, preeclampsia, and placental abruption. The aim of our study was to evaluate whether the occurrence and timing of pregnancy loss could be related to thyroid autoimmunity or subclinical hypothyroidism (SH) per se. METHODS Two hundred sixteen apparently healthy pregnant women with no previous history of thyroid disease and with diagnosis of early miscarriage (before the 12th week of gestation) were enrolled. Miscarriages were classified as very early pregnancy loss (EPL) or embryo loss (crown rump length < or =10 mm) and EPL or fetal loss (crown rump length > 10 mm). Women were subdivided into four groups: euthyroid (ET), SH, overt hypothyroidism, and thyroid autoimmunity group. RESULTS One hundred seventy-six women had a normal thyroid function (84.6%), 24 patients were found to have positive thyroid antibodies (11.5%), 8 women (3.8%) an SH, and 8 cases were excluded. Thyroid-stimulating hormone levels were found to be higher in the very early (1.4 +/- 1.0 mU/L) than in the EPL group (1.1 +/- 0.7 mU/L) (p = 0.04), and in patients affected by SH (3.9 +/- 0.1 mU/L) compared to ET (1.0 +/- 0.5 mU/L) (p < 0.001) and autoimmune women (1.0 +/- 0.4 mU/L) (p < 0.001). Although the multivariate logistic regression analysis revealed that both autoimmunity and SH were independently correlated with the onset of very EPL, abortion was more precocious in the SH group (6.5 +/- 0.9 weeks), followed by the autoimmune (8.2 +/- 2.1 weeks) and ET groups (8.2 +/- 1.6 weeks) (p = 0.02). CONCLUSIONS Both thyroid diseases SH and autoimmune disorder are independently associated with very early embryo loss, but women suffering from SH have a lower gestational age at abortion.

Enhanced iodine concentrating capacity by the mammary gland in iodine deficient lactating women of an endemic goiter region in Sicily

Iodine balance during pregnancy and lactation was investigated by measuring iodine con-centration in the urine of 11 pregnant women, born and living in a moderately iodine deficient endemic goiter area in Northeastern Sicily, collected during the last week of pregnancy, and between the 5th and 7th day after delivery, and in their milk sampled simultaneously with the urine of their newborns. The results were compared with those obtained on similar samples from 16 euthyroid age-matched nongoitrous women and their offspring from an iodine sufficient area. Urinary iodine concentration in pregnant women from the endemic area (1.28 ± 0.13 gMg/dl, mean ± SE) was significantly lower than that of pregnant women from the iodine sufficient area (3.77 ± 0.57 gMg/dl) (t = 3.56, p < 0.005). The longitudinal measurement of iodine concentration in each nursing woman showed a marked increase (≈90%) when compared with the values obtained during pregnancy in both endemic and control groups (2.32 ± 0.36 and 7.76 ± 2.08 gMg/dl; t = 2.13 p < 0.05, respectively). The slight difference in milk iodine concentration between the endemic (3.25 ± 0.77 gMg/dl) and the control (4.33 ± 0.57 gMg/dl) group was not statistically significant (t = 1.14; p < 0.5, NS). Similarly no difference was found in urinary iodine excretion between the endemic and the control newborn groups (3.41 ± 0.76 and 4.30 ± 0.65 gMg/dl, respectively, t = 0.88 p < 0.1, NS). The similarity between milk and urinary iodine content of newborns in the two areas was in contrast with the greatly different daily iodine intake of the mothers (endemic area 45 ± 6 gMgl/24h vs control area 106 ± 23 gMgl/24h, t = 2.14 p < 0.05 estimated in general population). An explanation for this was given by the calculation of milk iodine uptake (% intake) by the mammary gland, which was higher in endemic as compared with the control group (45 ± 6% vs 34 ± 4%). Enhanced iodine uptake by the mammary gland of the lactating mothers from endemic goiter area in the presence of low iodine supply can account for the above findings. This enhanced concentrating capacity, being inversely related to daily iodine intake (r = -0.41 p < 0.05), appears to be a further effort to effectively compensate for iodine deficiency, in order to prevent congenital hypothyroidism and to correct transient hypothyroidism of the infant.

Uterine myomas during pregnancy: a longitudinal sonographic study

To evaluate volumetric changes of uterine myomas (fibroids) during pregnancy.

Adnexal torsion in pregnancy

Torsion of the adnexa is an uncommon cause of surgical emergency. Adnexal torsion (AT) may arise in women of any age, but particularly during the reproductive years. It is generally unilateral and may involve either normal or pathological adnexa. Only rarely AT complicates pregnancy occurring more frequently in the first trimester. The clinical symptoms are non-specific and consequently a prompt and correct diagnosis is not frequently made. The traditional treatment of the ischemic, twisted adnexa consists in oophorectomy or salpingo-oophorectomy; in young women, in the case of early diagnosis, a conservative approach is recommended to pursue the future fertility of these patients.

Women's preference on mode of delivery in Southern Italy

Background. Rates of cesarean section are rising worldwide and maternal requests for this kind of delivery contribute to the increase in this trend. The purpose of this study was to analyze the factors influencing maternal demand in our region and the profile of women preferring this mode of delivery. Methods. Six obstetricians (3 male and 3 female) were asked to give out a questionnaire to their patients with an uncomplicated pregnancy. Demographic data, obstetrical history, lifestyle, and physician–patient relationship were analyzed. Patients who would have preferred abdominal delivery were asked to report the motivations for their choice. A psychiatric evaluation, using the Hamilton Anxiety Scale and the Montgomery–Åsberg Depression Rating Scale, was conducted. Results. 16.9% of 390 patients enrolled preferred cesarean section. This wish was correlated with patients’ age ≥ 35 years (OR 2.43; p=0.0065), high level of education (OR 4.28, p=0.019), previous infertility (OR 3.91, p=0.0045), smoking (OR 4.25, p=0.0008), quality of information (OR 29.08, p=0.0013), and desire for more comprehension (OR 8.25, p=0.00001). The most frequent motivation for this choice was a safer childbirth (90.9%). No difference was found for the Hamilton scales score, while the Montgomery‐Asberg Scale showed a lower mean score for the cesarean section group (7.2±3.3 versus 9.4±7.3, p=0.0002). Conclusions. A high rate of women wish to give birth by cesarean section. This is probably an expression of the changes in societys attitudes. However, more careful attention to the psychological aspects and more personalized information about pregnancy and delivery could reduce this maternal demand.

General versus spinal anaesthesia for elective caesarean sections: effects on neonatal short-term outcome. A prospective randomised study

Objective. To compare neonatal short-term outcome in patients who underwent spinal, general anaesthesia and conversion from spinal to general anaesthesia. Methods. One hundred seventy-nine pregnant women undergoing elective caesarean section were allocated randomly to general (n = 89) or spinal anaesthesia (n = 90) and compared with 63 patients who required conversion to general anaesthesia. Umbilical cord artery pH, Apgar score as well as its individual parameter and need for assisted ventilation were evaluated. Results. No differences were found in pH values (p = 0.35), while the need for assisted ventilation differed significantly (p = 0.001). The rate of depressed newborns was 1.1% in the spinal group, 25.9% in the general group and 12.7% in the conversion group with a significant difference for all comparisons. At 5-min, all newborns were vigorous. At 1 min, a higher score for each parameter was found in spinal group with respect to general group, while ‘activity’, ‘grimace’ and ‘respiration’ showed a higher score in conversion group than in general group. At 5 min, a difference was found only for ‘activity’. Conclusions. All kinds of anaesthesia seem to be safe, but loco-regional blockade shows more advantages on the neonatal outcome also when a conversion is necessary.

Wound length and corticosteroid administration as risk factors for surgical-site complications following cesarean section

Objective. To evaluate the effect of some specific gestational factors and other known variables associated with poor wound healing in women who delivered by cesarean section. Design. Observational, prospective study. Setting. University Hospital of Messina. Population. A total of 212 consecutive pregnant women at term delivering by elective cesarean section. Methods. All data regarding demographic and gestational characteristics were collected at admission. The subcutaneous tissue depth was intra‐operatively measured from the fascia to the skin surface, while the incision length was measured after skin closure. Main outcome measures. Onset of wound complications such as infection, seroma, hematoma, abscess or dehiscence > 1 cm. Results. Body mass index (BMI) at term [odd ratio (OR) 1.2, 95%CI 1.03–1.38; p = 0.01], wound length (OR 1.03, 95%CI 1.01–1.05; p < 0.001) and corticosteroid administration (OR 3.4, 95%CI 1.5–7.9; p = 0.004) were found to be correlated with wound complications. The receiver operating characteristics curve analysis suggested a cut‐off of 31.1 for the BMI at term and 166 mm for the wound length with an OR of 2.28 (95%CI 1.18–4.39; p = 0.013) and 4.3 (95%CI 2.2–8.6; p < 0.001), respectively. The multivariate logistic regression model, applied to these variables and to corticosteroid administration, showed an independent correlation (at term BMI > 31.1: OR 2.04, 1.01–4.13, p = 0.047; wound length > 166 mm: OR 4.89, 2.36–10.14, p < 0.001; corticosteroid administration: OR 3.11, 1.38–6.95, p = 0.006). Conclusions. To avoid wound complications obstetricians should be careful in the administration of steroids before surgery, in the skin incision length that should be kept as short as possible and in carefully observing gestational BMI.

Struma ovarii: a rare benign pathology which may erroneously suggest malignancy

The presence of a pelvic mass with suspicious clinical and sonographic features associated with elevated levels of CA 125 may be suggestive of gynecological malignancy even in fertile women. However, there are benign conditions of the ovaries and uterus that are associated with increased concentrations of serum CA 125. Some of these conditions show an altered sonographic pattern and can mimic pelvic cancer. One such condition is struma ovarii which may lead to suspicion of an ovarian malignancy since all the signs are present.