Donato D'Antona

Doppler, cardiotocography, and biophysical profile changes in growth-restricted fetuses.

OBJECTIVE: To assess from diagnosis to delivery the Doppler studies of the umbilical artery, middle cerebral artery, umbilical vein, ductus venosus, and amniotic fluid index of fetuses with idiopathic growth restriction. METHODS: A total of 145 singleton growth-restricted fetuses with abnormal umbilical artery pulsatility indexes were studied. Cesarean delivery was performed because of abnormal biophysical profile or nonreassuring fetal heart rate pattern. RESULTS: There were 4 fetal and 50 neonatal deaths. Two growth-restricted groups were identified: Group A (n = 44) included fetuses in whom all measures became abnormal preceding an abnormal biophysical profile or nonreassuring nonstress test. Group B (n = 101) included fetuses in whom 1 or more measures were normal at the time of cesarean delivery. There was no statistically significant difference in perinatal morbidity and mortality between the 2 groups. Neonatal death was increased in fetuses with umbilical artery reversed flow (odds ratio 2.34, 95% confidence interval 1.16–4.73; P < .05) and ductus venosus reversed flow (odds ratio 4.18, 95% confidence interval 2.01–8.69; P < .05). A significant correlation was also found between low birth weight and adverse perinatal outcome. CONCLUSION: In fetuses with idiopathic growth restriction, 1) low birth weight, 2) umbilical artery reversed flow, and 3) ductus venosus absent or reversed flow are associated with an increased perinatal morbidity and mortality. LEVEL OF EVIDENCE: II-2

Radical trachelectomy: The first step of fertility preservation in young women with cervical cancer (Review)

Radical trachelectomy (RT) can be performed vaginally or abdominally (laparotomic, laparoscopic or robotic). The aim of this systematic review was to compare all techniques in terms of surgical complications, disease recurrence and subsequent fertility/pregnancy outcomes. A total of 1293 RTs were analyzed (FIGO-stage: IA1–IIA). The most frequent surgical complications do not differ from the ones of radical hysterectomy. The recurrence risk is approximately 3% (range 0–16.8%). The majority of women conceive spontaneously: 284 pregnancies with 173 live births. The most frequent pregnancy complication was miscarriage and chorioamnionitis. RT appears to be a safe option for eligible women who intend to maintain their future pregnancy desire.

Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature

OBJECTIVE To investigate the most appropriate surgical technique for optimizing hemostasis and preservation of subsequent fertility after postpartum hemorrhage (PPH). DESIGN Systematic review of the literature. SETTING Not applicable. PATIENT(S) None. INTERVENTION(S) Review of MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library. MAIN OUTCOME MEASURE(S) Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications. RESULT(S) Compressive sutures and vessel embolization may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation. CONCLUSION(S) Pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies, even if the former is burdened by an increased rate of placental disorders and fetal growth restriction and the latter by an increased risk of cesarean deliveries and PPH recurrence. Randomized trials would be desirable to define the best management of PPH.

Association study of AMH and AMHRII polymorphisms with unexplained infertility.

OBJECTIVE To investigate the association of AMH and AMHRII polymorphisms with reproductive abilities in a sample of women with idiopathic infertility. DESIGN Case-control study. SETTING University Department of Obstetrics and Gynecology, and University Unit of Clinical Genetics. PATIENT(S) 76 women with idiopathic sterility and 100 fertile women as controls. INTERVENTION(S) Genotyping was performed by high-resolution melt analysis. MAIN OUTCOME MEASURE(S) Genotype distribution and allele frequency of AMH and AMHRII polymorphisms. Reconstruction of haplotype alleles to evaluate the linkage disequilibrium between single nucleotide polymorphisms. RESULT(S) Allele frequencies of -482 A>G, IVS 5-6 C>T, IVS 10+77 A>G, 146T>G polymorphisms are statistically significantly different in infertile patients compared with controls. CONCLUSION(S) Genetic variants of AMH and AMHRII genes seem to be associated with infertility, suggesting a role in the pathophysiology of normo-estrogenic and normo-ovulatory infertility. A clearer understanding of their function in ovarian physiology may help clinicians to find a role for antimüllerian hormone measurement in the field of reproductive medicine.

Levonorgestrel Intrauterine System in Adjuvant Tamoxifen Treatment Balance of Breast Risks and Endometrial Benefits—Systematic Review of Literature

Levonorgestrel intrauterine system (LNG-IUS) is used in patients with breast patients taking tamoxifen (TAM) to prevent endometrial proliferation. The benefits (on endometrium), the side effects (on breast), and the patients suitable for this treatment are not still clear. Aim of this systematic review is to define the breast risks and endometrial benefits in TAM-treated women using Mirena and to define which patients could benefit from LNG-IUS use. In all, 3 studies on LNG-IUS effects on endometrium in TAM-treated women and 4 studies on breast cancer recurrence were selected for the study. All studies described a reduction in benign endometrial pathologies among Mirena users, but controversial data showed malignant disease and breast cancer recurrence. So it is mandatory to define hormonal status before TAM treatment. In selected patients Mirena was proven to protect endometrium. Perspective clinical trials on Mirena pharmacological features are necessary to establish whether systemic levels of progesterone could increase breast cancer recurrence in such patients.

Routine second trimester ultrasound screening for prenatal detection of fetal malformations in Sassari University Hospital, Italy: 23 years of experience in 42,256 pregnancies.

OBJECTIVE To establish, for a determined period of time, the effectiveness of a program of ultrasound screening in detecting fetal malformations in prenatal time. To assess the sensitivity, the specificity, the positive and the negative predictive value of the ultrasound screening. To examine the trend of such indexes of diagnostic accuracy in a long time period. STUDY DESIGN The patients admitted to the study had effected at least one ultrasound examination within the second trimester of pregnancy (< or =23 gestational weeks). The examined pregnant women were 42,256 and the period of reference ranged from January 1981 to December 2004. All patients delivered in Gynecologic and Obstetric Clinic of Sassari University, Sassari, Italy. RESULTS In the considered period were reported 1050/42,256 (2.48%) cases of fetal malformations, of which 974 single and 76 multiple malformations. The cases of malformations diagnosed in prenatal period were 578/1050 (55.05%), of which 65/578 (11.24%) multiple anomalies. The overall sensitivity was 55.05% (95% confidence interval: 52-58%), with a variability from the 32.95% (cardiovascular system) to 81.05% (central nervous system) in relationship to the typology of the examined apparatus. The overall specificity was 99.88% (95% confidence interval: 98-99.9%), the predictive positive value 91.89% (95% confidence interval: 89-93%) and the negative predictive value 98.87% (95% confidence interval: 95-99%). CONCLUSION The sensitivity of the ultrasound screening undoubtedly appeared to be satisfactory. We believe that, for the examination of some apparatuses, as for the cardiovascular apparatus, with the extension of the standard examination (four-chamber view) to further plans of scanning, sensitivity could subsequently be improved.

Middle cerebral artery peak systolic and ductus venosus velocity waveforms in the hydropic fetus.

The purpose of this study was to assess whether Doppler assessment of the middle cerebral artery (MCA) peak systolic velocity (PSV) and ductus venosus (DV) velocity waveforms during sonography of hydropic fetuses may specify the cause of fetal hydrops.

Conservative treatment for complex neonatal ovarian cysts: A long-term follow-up analysis

OBJECTIVE We aimed to investigate safety and effectiveness of a conservative approach for complex neonatal ovarian cysts and its long term impact on fertility. STUDY DESIGN Neonates with congenital complex ovarian cysts were conservatively managed and followed from the perinatal period to adolescence. Statistical analysis included Students t-test, Mann-Whitney U-test, the Kaplan-Meier method, and the receiver operating characteristic curve. RESULTS The post-natal progressive dimensional reduction of diagnosed ovarian cyst was statistically significant. The Kaplan-Meier survival curves revealed the probability of persistence of the cyst was up to 5% at the age of 25 months. Long term follow-up revealed both ovaries visible at US in 60% of adolescent patients. CONCLUSION Conservative management of asymptomatic complex neonatal ovarian cysts can be safely undertaken. As far as the chances of the ovarian tissue to survive conservative treatment are concerned, the results are not encouraging.

Umbilical Artery Pulsatility Index in Pregnancies Complicated by Insulin-Dependent Diabetes mellitus without Hypertension

Objective: In a group of diabetic pregnant women, the umbilical artery pulsatility index (PI) was compared with both pregnancy complications and perinatal outcomes. Method: We evaluated 67 women with pregnancies complicated by insulin-dependent diabetes mellitus (IDDM), without hypertension. For the study we took the last umbilical PI value before delivery into consideration. Doppler results were not used for patient management. Umbilical artery PI was correlated with the route of delivery and the following perinatal complications: intrauterine growth retardation; cesarean sections for acute fetal distress; respiratory distress syndrome (RDS); neonatal hyperbilirubinemia; hypocalcemia; hypoglycemia; macrosomia, and neonatal intensive care unit (NICU). Results: Among the 67 diabetic patients enrolled in this study, 44 (66%) had umbilical PIs ranging from the 5th to the 95th percentile (PI mean ± SD = 1.2 ± 0.3), while 23 (34%) had PIs above the 95th percentile (PI mean ± SD = 1.6 ± 0.3). Among the group with pathologic umbilical PIs, analysis of the data revealed a significantly higher incidence of both cesarean sections for acute fetal distress and perinatal complications: RDS; hyperbilirubinemia; hypoglycemia, and the need for NICU, respectively. Conclusion: In 34% of the diabetic pregnant women without hypertension, we found increased vascular resistances. Among these patients the incidence of perinatal complications was higher, and both closer maternal metabolic control and stricter care of fetal conditions are needed.

Effective anatomical and functional status of the lower uterine segment at term: estimating the risk of uterine dehiscence by ultrasound

OBJECTIVE To define the role of lower uterine segment (LUS) evaluation at term. DESIGN Observational case-control study. SETTING University hospital. PATIENT(S) Ninety-four patients were divided into two groups. Group A consisted of 45 multiparous single fetus pregnant women with up to two previous cesarean sections (CS). Group B consisted of 49 multiparous pregnant women with up to three vaginal deliveries and no uterine scars. INTERVENTION(S) Total LUS and myometrial thickness were measured by sonogram in all patients before undergoing a CS. MAIN OUTCOME MEASURE(S) The primary outcome is a correlation between echographic measurements and features of the LUS at the time of CS. The secondary outcome is a definition of a correlation between the number of previous CS, interdelivery interval time, and features of the LUS (grades I-IV). RESULT(S) Sonographic measurements revealed significant differences in LUS size and myometrial thickness between the two groups. Grades III and IV of LUS were only observed in group A. An interdelivery interval <18 months, LUS thickness ≤ 3.0 mm, and myometrial thickness < 1.5 mm were statistically significant predictors of LUS grades III and IV. Number of previous CS showed no correlation with surgical LUS status. CONCLUSION(S) Sonographic evaluation of the LUS may be a noninvasive, reproducible, and safe technique for defining the risk of uterine dehiscence, with a sensitivity of 100% and specificity of 85% (positive predictive value, 45%; negative predictive value, 100%).