Arrigo Fruscalzo

Reliability of quantitative elastography of the uterine cervix in at - term pregnancies

Abstract Aims: To evaluate the intra-operator reliability of tissue Doppler imaging-based quantitative cervical elastography in at-term pregnancies. Methods: Three series of two cycles of manual gentle compression-relaxation of the cervix were performed by one gynecologist in 11 consecutive at-term pregnancies through the vaginal probe. The compression movements should be sufficient to obtain the maximal compression of the anterior portion of the cervical tissue, until the posterior portion begins to be dislocated. Strain values were assessed on the entire thickness of the anterior cervical lip. The influence of strain type (Lagrangian vs. natural) and the extent of compression exerted (difference among the two cycles of compression-relaxation) were evaluated. Results: Strain measurement was influenced by the extent of compression, as well as by the strain type. The strain measured during the cycle with larger cervical compression, using the natural strain preset, showed a superior reliability [mean strain among patients: 0.68±0.18; mean of differences among three measures: 0.07±0.06; intraclass correlation coefficient (ICC) consistency: 0.90]. The strain measured using the Lagrangian strain preset showed overall a low reliability (ICC consistency: 0.04). Conclusions: Quantitative cervical elastography performed in at-term pregnancies, under standardized conditions, has a high reliability.

Morbus Paget der Vulva: Remission durch Lokalbehandlung mit Imiquimod – Fallbericht und Literaturübersicht

Der Morbus Paget ist eine seltene Erkrankung der Vulva, welche weniger als 1% aller Neoplasien der Vulva ausmacht. Die übliche Therapie besteht in der lokalen chirurgischen Entfernung. Während die invasive Form des Morbus Paget selten ist, stellen die häufigen Lokalzrezidive, welche nicht mehr chirurgisch behandelt werden können, ein bedeutendes klinisches Problem dar. Bei einer 71-jährigen Patientin wurde ein solches Rezidiv erfolgreich mit Imiquimodsalbe behandelt. Die Juckreizsymptome bildeten sich nach kurzer Zeit zurück. Nach 4 Wochen waren die kolposkopisch sichtbaren Hauterscheinungen rückläufig. Innerhalb von 8 Wochen kam es zu einer kompletten klinischen Remission. Die Lokalbehandlung mit Imiquimod ist demnach nicht nur bei der vulvären intraepithelialen Neoplasie erfolgversprechend, sondern stellt auch bei ausgewählten Patientinnen mit rezidivierendem Morbus Paget der Vulva eine konservative Behandlungsalternative dar.

Menstrual abnormalities and predisposition to pregnancy-related hypertensive disorders: a retrospective study

Objective. Pregnancy-related hypertensive disorders (PRHDs) are a leading cause of maternal and perinatal morbidity and mortality in developed countries. This study investigated a possible association of PRHDs with menstrual abnormalities. Materials and Methods. We contacted all women with PRHDs who delivered in our clinic between 2004 and 2007 as well as a random control cohort without pregnancy complications and asked them about their menstrual cycle characteristics. Statistical analyses were performed using R, with significance set at p < 0.05. Results. We collected data for 237 women with normal pregnancies and 255 women with PRHDs, among whom 143 had gestational hypertension and 70 had mild and 41 severe preeclampsia. By monovariate analysis, PRHDs correlated with dysmenorrhoea, hypermenorrhoea and menstrual irregularity (p < 0.05). By multivariate analysis, the occurrence of PRHDs was influenced by dysmenorrhoea and menstrual irregularity (p < 0.05). Conclusions. PRHDs usually affect women with painful or irregular menstrual cycles, perhaps due to metabolic syndrome or molecular pathways involving vasoactive substances, with clear vascular implications.

New and old predictive factors for breech presentation: our experience in 14 433 singleton pregnancies and a literature review

Abstract Objective: Breech presentation represents a common indication for primary cesarean section in women presenting for parturition. This study aims to investigate the presence of new and old risk factors for breech presentation and to provide a literature review. Method: In this population-based retrospective cohort study, we collected data from 14 433 consecutive singleton deliveries occurred in a 3rd level hospital setting of northeast Italy between January 2001 and July 2009. Related risk factors and trends in breech presentation prevalence were also considered. Results: Mean maternal age was 31.78 years (±5.17) and mean gestational age at delivery 38.67 weeks (±2.54). Breech presentation prevalence in nullipara and pluripara was respectively 5.36% (415/7743) and 3.53% (236/6689; p < 0.05), and was significantly lower among Sub-Saharan-African women 2.62% (14/535) versus 4.51% (651/14432; p < 0.05). Also advanced maternal age, early gestational age at delivery, neonatal female gender and low weight at delivery resulted associated with a higher prevalence of breech presentation. By multivariate logistic regression, the breech presentation resulted independently predicted by maternal age, ethnicity, parity, gestational age and neonatal weight MoMs at delivery, and neonatal gender. Conclusions: Advanced maternal age, early gestational age, low neonatal weight MoMs at delivery and female gender resulted to be risk factors for fetal breech presentation at delivery, while multiparity and Sub-Saharan-African ethnicity resulted to be protective.

High placental index and poor pregnancy outcomes: a retrospective study of 18,386 pregnancies.

Abstract Introduction: Our aim was to state the correlation between placental index and pregnancy outcomes or in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) pregnancies. Materials and methods: We included in this retrospective study all singleton births in a third level clinic during the period 2001–2011 (n = 18 386). We divided placental index into quartiles and analyzed the differences between the groups in term of pregnancy outcomes. Then, we estimated crude and adjusted odds ratios (ORs) for placental index over the third centile of the distribution to correlate with pregnancy outcomes. We also analyzed the correlation between IVF/ICSI conceived pregnancies and placental index. Results: Poor pregnancy outcomes were overrepresented in the highest quartile of placental index distribution. Thus, placental index was higher in pregnancies characterized by pregnancy-related hypertensive disorders (PRHDs), small for gestational age infants, newborn needing cardiopulmonary resuscitation or hospitalization in neonatal intensive care unit. These findings were independent of maternal age, length of gestation at delivery, IVF/ICSI conception and ethnicity. For IVF/ICSI pregnancies, the OR for being over the third quartile of placental index distribution was 2.01 (CI.95 1.40–2.90) after adjustment for maternal age, length of gestation, ethnicity, birth weight, parity, fetal sex, alteration of glucose metabolism in pregnancy and PRHDs. Conclusions: We found a high placental index among pregnancies characterized by poor outcomes and conceived by IVF/ICSI.

Impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study

BackgroundThe role of episiotomy as a protective factor against pelvic floor disorders postpartum has been debated for many years, but its routine use has been hitherto discouraged in the literature. Comparisons between restrictive and routine use of episiotomy in existent literature, however, fail to include any consideration relating to quality of life. The aim of this study, therefore, is to state the role of episiotomy in preserving the perineum from damage, in order to prevent the influence of pelvic floor disorders on womens psycho-physical wellness after the sixth month postpartum.MethodsA follow-up telephone interview was performed among 377 primiparous and secondiparous Caucasian women who had a child by spontaneous or operative vaginal delivery in 2006 using a self-created questionnaire and Kings Health Questionnaire (KHQ).ResultsThe mean age at delivery was 35.26 (±4.68) years and episiotomy was performed in 59.2% of women. Multivariate linear regression shows episiotomy associated to higher quality of life after the sixth month postpartum by correlating with inferior values of Kings Health Questionnaire (p < 0.05).ConclusionsEpisiotomy appears to be a protective factor for womens wellness. Women who had episiotomy and who experienced perineal symptoms have a better psycho-physical health status in the 12.79 months (±3.3) follow-up.

Retinol binding protein as early marker of fetal growth restriction in first trimester maternal serum.

Abstract Background: Serum retinol binding protein (RBP4) is the binding protein for retinol, being delivered into the circulation through the carrier protein transthyretin (TTR) together with thyroxin (T4). RBP4 has also been recently indicated as a new adipokine implicated in insulin resistance and metabolism regulation. Objective: To investigate the role of RBP4 as early markers of fetal growth restriction (FGR) and preeclampsia (PE) in maternal serum during the first trimester of pregnancy. Materials and methods: Retrospective case control study in patients between the 12th and the 14th week of gestation. RBP4, TTR and T4 concentration was assessed in maternal serum of three groups of women: 15 and 14 patients later developing respectively FGR and PE were compared with 11 patients having a normal pregnancy. Results: All women were Caucasian and the mean maternal age was 33.62 years (±5.50). RBP4 resulted lower in the FGR than in the control group (11.00 versus 16.00 µg/ml, p < 0.05) and than in the PE group (15.00 µg/ml, p = 0.075), both in bivariate and multivariate analysis. No difference was observed in TTR and T4 concentration. Conclusions: RBP4 seems to play a role as early marker of FGR but not PE in first trimester maternal serum.

Prevalence and risk factors for dyspareunia and unsatisfying sexual relationships in a cohort of primiparous and secondiparous women after 12 months postpartum.

ABSTRACT Dyspareunia is a common short-term pregnancy complication, rarely lasting longer than 1 year after delivery. Our study aims to determine postpartum dyspareunia prevalence and its impact on womens sexual health. In this retrospective study, we asked 602 women about dyspareunia and the quality of sexual intercourse through telephone interviews. The influence of dyspareunia on the quality of sexual intercourse and couple relationship is scored on a 4-point verbal scale according to its severity. Data were analyzed by R (version 2.8.0), considering significant p < .05. Nearly 100% of women (99.9%) resumed their sexual activity; 16.2% of them reported dyspareunia significantly compromising their sexual intercourse and couple relationships. In univariate analysis, severe perineal tears are associated with persistent dyspareunia (p < .05). By multivariate analysis, postpartum dyspareunia results independently influenced by operative delivery, previous dyspareunia, recurrent urogenital infections and urge incontinence (p < .05), as well as by the Kristeller maneuver and partoanalgesia (p = .084) in the case of women who had a vaginal delivery. Dyspareunia significantly compromises womens sexual health postpartum, mostly caused by perineal trauma by means of delivery management and recurrent urogenital infections.

Introducing routine trial of labour after caesarean section in a second level hospital setting

Objective: We analysed the impact on caesarean section (CS) rate of introducing a routine trial of labour (TOL) for patients with a previous CS. Study design: During 2007 and 2008, we offered a TOL to all women with one previous CS planning to give birth in our hospital. The adherence to the procedure, success of vaginal delivery, overall CS rate, incidence of symptomatic uterine rupture and other complications were evaluated. Labour induction was allowed only using castor oil or Amniotomy. Results: One hundred and ninety-four women were considered eligible for TOL. A total of 87.6% of them agreed to undergo the procedure (78.7% in the first year versus 95.2% in the second year, p < 0.05). Of these, 63.5% delivered successfully (42.3% in the first year versus 78.8% in the second year, p < 0.05); 10.6% underwent a primary CS because of failed spontaneous labour or failed labour induction and 25.9% a secondary CS during labour. The CS rate decreased significantly from 19.6% (in 2003–2006) to 14.9% (iN 2007–2008) (p < 0.05). One case of symptomatic uterine rupture occurred, while no difference for other complications was observed. Conclusions: The CS rate decreased dramatically through introducing a TOL programme for patients with one previous CS. The possibility of symptomatic uterine rupture should be however considered and patients adequately informed.

First trimester concentrations of the TTR-RBP4-retinol complex components as early markers of insulin-treated gestational diabetes mellitus.

Abstract Background: The objective of the study was to investigate the relationship between first trimester maternal serum levels of the TTR-RBP4-ROH complex components and the later insurgence of an altered glucose metabolism during pregnancy. Methods: Retrospective case control study including 96 patients between the 12th and 14th week of gestation, 32 that developed gestational diabetes mellitus (GDM), respectively, 21 non-insulin-treated (dGDM) and 11 insulin-treated (iGDM), 20 large for gestational age fetuses (LGA) without GDM and 44 patients with normal outcome as control. Serum concentrations of RBP4 and TTR were assessed by ELISA; serum concentration of ROH by reverse-phase high performance liquid chromatography (rpHPLC). The molecular heterogeneity of TTR and RBP4 was analyzed after immunoprecipitation by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS). Results: iGDM patients were characterized by reduced TTR, RBP4 and ROH compared to controls (respectively, iGDM vs. controls, mean±SD: TTR 3.96±0.89 μmol/L vs. 4.68±1.21 μmol/L, RBP4 1.13±0.25 μmol/L vs. 1.33±0.38 μmol/L and ROH 1.33±0.17 μmol/L vs. 1.62±0.29 μmol/L, p<0.05). TTR containing Gly10 in place of Cys10 was lower in the iGDM group (p<0.05) compared to controls. In the final logistic regression model ROH significantly predicted the diagnosis of iGDM (OR 0.93, 95% CI 0.87–0.98, p<0.05). Conclusions: First trimester maternal serum ROH, RBP4 and TTR represent potential biomarkers associated with the development of iGDM.