Anna Locatelli

Risk factors for pulmonary hypoplasia in second-trimester premature rupture of membranes

OBJECTIVE Our purpose was to determine the independent contribution of gestational age at rupture of membranes, latency period, and severity of oligohydramnios to the prediction of pulmonary hypoplasia in patients with second-trimester premature rupture of membranes. STUDY DESIGN All women with premature rupture of membranes at < 28 weeks diagnosed between January 1982 and December 1990 were managed conservatively with a consistent protocol until intrauterine death or spontaneous or induced delivery. The diagnosis of pulmonary hypoplasia was made by strict pathologic and radiographic criteria. RESULTS A total of 63 patients fulfilled the inclusion criteria. Pulmonary hypoplasia was present in 15 cases: two of nine stillborns, 12 of 25 neonatal deaths, and one of 24 survivors. All fetuses with pulmonary hypoplasia had oligohydramnios. Univariate analysis showed that the occurrence of pulmonary hypoplasia was significantly associated with gestational age at premature rupture of membranes (p = 0.002), oligohydramnios during the latency period (p = 0.005), and duration of the latency period (p = 0.02). However, logistic regression analysis showed that only the first two variables were independent predictors of pulmonary hypoplasia. CONCLUSION Gestational age at premature rupture of membranes and oligohydramnios are independent predictors of the occurrence of pulmonary hypoplasia.

Delivery delay with neoadjuvant chemotherapy for cervical cancer patients during pregnancy: A series of nine cases and literature review

OBJECTIVE Treatment of locally invasive cervical cancer diagnosed during pregnancy in women who desire to retain their pregnancy is a major challenge to physicians. Neoadjuvant chemotherapy followed by radical hysterectomy has been reported to be an attractive option to delay delivery until fetal viability has been reached. METHODS Between 1994 and 2009 9 patients were treated at San Gerardo Hospital (Monza, Italy) for cervical cancer during pregnancy. RESULTS FIGO stage was IB1 in four patients and IB2 in five. Tumor diameter ranged between 20 and 70 mm. After neoadjuvant platinum-based chemotherapy partial response was achieved in 5 patients, while 4 had a stable disease. One patient received a second-line chemotherapy during pregnancy due to progressive disease, achieving a partial response. Median duration of therapy delay until cesarean section was 16 weeks. Between 30 and 36 weeks of gestation all patients underwent cesarean section. Piver II radical hysterectomy with pelvic lymphadenectomy was performed. Two children had mild perinatal morbidities and were discharged in good conditions after 14 and 40 days. Three patients received adjuvant therapy for pathological risk factors. Four patients relapsed (44%) and two of them (23%) died because of tumor progression. CONCLUSION During pregnancy, the oncological outcome of cervical cancer patients is similar to non-pregnant ones. Chemotherapy does not seem to affect fetal health and development, even if longer follow-up is required. Therefore, neoadjuvant chemotherapy for the treatment of locally invasive cervical cancer during pregnancy seems to be a reasonable option for delay definitive treatment until fetal viability is obtained.

Neonatal morbidity after cesarean section before labor at 34(+0) to 38(+6) weeks: a cohort study

Abstract Objective: To describe morbidity in neonates born by cesarean section (CS) before labor between 34+0 and 38+6 weeks, stratified by gestational age. Methods: Cohort study from five Italian tertiary care hospitals. Consecutive singleton pregnancies delivered by CS before labor between 34+0 and 38+6 weeks of gestation from January 2010 to August 2011 were included. Women in labor, with premature rupture of membranes, or with previous administration of steroids were excluded. The incidence of neonatal complication by gestational week was calculated. Results: A total of 1135 cases were analyzed. Composite adverse neonatal outcomes, respiratory distress syndrome, transient tachypnea and use of continuous airway positive pressure decreased from 50%, 28%, 5% and 22% at 34 weeks of gestation, to 4.7%, 1.0%, 0.9% and 0.3% at 38 weeks of gestation. Multivariate analysis showed that the only variable independently associated with composite adverse neonatal outcome was gestational age at delivery (adjusted odds ratio 0.49; 95% confidence interval 0.39–0.61). Conclusions: The prevalence of neonatal complications in newborns delivered by CS before labor halves at each week of gestation from 34 to 38 weeks. Nonetheless complications, and mainly respiratory problems, are still present at early term gestation.

Trial of labor after myomectomy and uterine rupture: a systematic review

There is concern about the risk of uterine rupture in the subsequent pregnancy after myomectomy. This risk is reported in literature to be around 0.7–1%. The aim of this study was to evaluate the incidence of uterine rupture and associated risk factors in women who had a trial of labor after prior myomectomy.

Progestogens for Maintenance Tocolysis in Women With a Short Cervix: A Randomized Controlled Trial

OBJECTIVE To assess the efficacy of progestogens for maintenance tocolysis in women undelivered after their first preterm labor episode. METHODS Women with singleton pregnancies between 22 0/7 and 31 6/7 weeks of gestation with arrested preterm labor and a cervical length 25 mm or less at hospital discharge were eligible. Patients with a previous preterm birth were excluded. In a randomized controlled trial conducted in five university hospitals, women were randomized to receive vaginal progesterone (200 mg per day) or intramuscular 17α-hydroxyprogesterone caproate (341 mg per week) or to an observation groups (control group). The primary outcome was the proportion of women with preterm birth at less than 37 weeks of gestation. A sample size of 160 per group (n=480) was planned to compare vaginal progesterone and 17α-hydroxyprogesterone caproate groups with those in the control group. The sample size estimation was based on the hypothesis that the risk of experiencing preterm birth in the control group would be 30% and that 17α-hydroxyprogesterone caproate or progesterone would decrease this risk to 15%. A P value of <.025 was defined as statistically significant. At planned interim analysis (n=254), the trial was stopped for futility. RESULTS Between July 2010 and June 2015, 257 women were eligible and 254 were subsequently randomly assigned to vaginal progesterone (n=86), 17α-hydroxyprogesterone caproate (n=87), or observation (n=81). Nineteen (8%) were excluded from the analysis because they either dropped out or information was missing, leaving 235 women available for analysis. Demographic characteristics were similar across groups. The preterm birth rate did not differ significantly between groups: 23% in the 17α-hydroxyprogesterone caproate group, 39% in the vaginal progesterone group, and 22% in the women in the control group (P=.949 for 17α-hydroxyprogesterone caproate compared with the women in the control group and P=.027 for vaginal progesterone compared with women in the control group). CONCLUSION The use of progestogens for maintenance tocolysis in women with a short cervix did not reduce the rate of preterm birth. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT01178788.

Threatened premature delivery with prolapsed amniotic sac leading to neonatal limb gangrene

Congenital limb gangrene has been reported as secondary to early premature rupture of the membranes, maternal diabetes, abnormal presentation of the fetus in utero, emboli from closure of ductus arteriosus, protein C, S, and antithrombin III deficiency, sepsis, congenital heart disease (1,2), and hyperviscosity of the recipient partner in twin-to-twin transfusion cases (3). We report a case of threatened premature delivery with a fetus partially prolapsed into the vagina. Conservative management led to intra-uterine lower limb ischemia.

Re to: Tale of rudimentary horn pregnancy and literature review

Sir, We have read with great interest the manuscript of Yassin et al. [1] about rudimentary horn pregnancy (RHP), which presents the cases that makes a point for diagnosis and treatment of these rare conditions. We reported a case of 18 weeks ruptured rudimentary horn pregnancy who had come to the emergency room (ER) after blackout episodes at home. The patient was a 31-year-old woman, secondipara with a previous first trimester miscarriage. Pathological and surgery histories were silent. Of interest, a doubt of ectopic pregnancy (EP), not confirmed by serial evaluation, was posed during the routine scan at the beginning of the pregnancy. When the patient arrived to the ER, she was pale with hypotension and tachycardia and mild pelvic pain was reported. Vaginal examination was normal and obstetrical ultrasound showed a bradycardic fetus with normal amniotic fluid; no signs of placenta abruption were reported. The blood examination revealed mild anaemia (hemoglobin of 10.2 g/dL) and hyperglycemia; general and cardiological evaluations were normal. Complete abdominal ultrasound at last revealed the presence of hemoperitoneum, but no lesions of major arterious vessels were found. Therefore, the patient was carried to the operating room. Her hemoglobin had fallen to 7.9 g/dL. Laparoscopy access was performed, but conversion to laparotomy was necessary for the presence of massive hemoperitoneum. After abdominal toilette, a complete rupture of the left cornus of the uterus was revealed, with partial expulsion of the amniotic sac with a died fetus inside. Spontaneous rupture of the amniotic sac with fetus expulsion in the peritoneal cavity occurred during the surgery and the uterine malformation was diagnosed: a right unicornual uterus with ruptured communicating rudimentary left horn in which there was placenta. Rudimentary horn and ipsilateral fallopian tube were excised. After achieving hemostasis, abdomen was closed in layers after keeping a drain. The patient received four units packed red blood cells and four units of plasma. The postoperative recovery was uneventful and she was discharged after 3 days, with indications of further imaging to study the urinary tract. Diagnosis of the implantation site in early pregnancy is mandatory when a pregnant woman comes to observation for abdominal pan and/or vaginal bleeding, nevertheless diagnosis of ectopic pregnancy (EP) may be challenging, particularly when the doubt is to locate the exact localization inside the uterus. In these cases, vaginal ultrasound and serial evaluation of serum b-human chorionic gonadotropin (bhCG), should not be thorough while three-dimensional ultrasound (3DUS) or magnetic resonance imaging (RMI) provide additional informations, such as an accurate evaluation of uterine morphology and urinary tract, and also a measure of the thickness of the myometrium surrounding the gestational sac [2]. With respect to the clinical presentation, abdominal pain is known to be present in more than 90% of cases of EP rupture, related to peritoneum irritation. Both in our and Yassin’s case, abdominal pain was mild and associated with blackout episodes and vomiting, respectively. We could explain the mild pain with the fact that the rupture did not occurr suddenly but there was a stepwise rupture, which made a quick fix and this permits the late diagnosis. So, it is crucial considering that clinical manifestation could be insidious and abdominal pain with or without other symptoms needs careful evaluation by clinicians. Anomalous site of pregnancy should be considered in case of unprovoked hemoperitoneum, in different diagnosis with spleen rupture or haemorrhage by decidualized endometriosis or others rare conditions. MRI in these case could represent a valid instrument whose use needs to be implemented, considering the high risk of mortality for the woman in case of uterine rupture. The surgical treatment consists of the excision of rudimentary horn and ipsilateral fallopian tube, as reported in literature.

Prognosis of Patients with cervical cancer diagnosed during pregnancy

Ovarian cancer is the most common cause of gynaecological cancer death, with an overall 5-year relative survival of 43%. Impaired physical wellbeing and overall quality of life (QoL) represent major concerns for women during and following ovarian cancer treatment, predict survival and are amenable to change through interventions. Exercise, now considered an important part of overall management of a number of cancers, improves short-term outcomes (e.g., function, fatigue, QoL) during chemotherapy...