Donato D’Antona

Which Uterotonic Is Better to Prevent the Postpartum Hemorrhage? Latest News in Terms of Clinical Efficacy, Side Effects, and Contraindications A Systematic Review

Background: Postpartum hemorrhage (PPH) is a potentially fatal complication of vaginal and cesarean deliveries. The active management of the third stage of labor provides administration of prophylactic uterotonic drugs just before or immediately after delivery, since they reduce the risk of PPH by 60%. Objective: Overview on all available uterotonics for PPH prevention to clarify indications and contraindications in choice among drugs. Search Strategy: Systematic review of the literature. Main Results: Oxytocin is the first choice for PPH prophylaxis. Ergot alkaloids, syntometrine, and prostaglandins are second-line uterotonic agents. Misoprostol is not effective as oxytocin but it may be used when the latter is not available. Carbetocin should be used instead of continuous oxytocin infusion in elective cesarean sections for PPH prevention and to decrease the need for therapeutic uterotonics. Conclusions: Prophylactic oxytocics should be offered routinely in the third stage of labor in all women. The prophylactic use of uterotonics should be individualized.

Update on Raloxifene: Mechanism of Action, Clinical Efficacy, Adverse Effects, and Contraindications

Raloxifene is the only selective estrogen receptor modulator approved for long-term treatment in the prevention of osteoporotic fractures and for the reduction of invasive breast cancer risk in postmenopausal women. The demonstrated beneficial effects on bone and mammalian tissue led clinical and molecular research to focus mainly on these organs, giving less attention to all other systemic effects. The aim of this review was to evaluate all described systemic effects of raloxifene, investigating its molecular and tissutal mechanism of action. A literature research was carried out in electronic databases MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library in interval time between 2000 and 2012. Outcomes were considered in relation to positive/adverse effects concerning bone metabolism, lipid metabolism, coagulation pattern, menopausal symptoms, breast cancer onset, and endometrial cancer onset. Raloxifene acts as an estrogen agonist or antagonist depending on the tissue. This feature is related to specific actions on at least 2 distinct estrogen receptors, whose proportions vary according to tissue type. Raloxifene is a drug for the treatment of osteoporosis and for the prevention of estrogen receptor–positive breast cancer because it guarantees a safety profile on the endometrium. Raloxifene is furthermore an effective therapy in women with increased levels of plasma cholesterol. Raloxifene treatment shifts the coagulation pattern toward prothrombosis, and the patients should be exhaustively informed about the risks associated with therapy. Raloxifene does not show to affect memory and cognition. Finally, it is noteworthy that quality-of-life studies demonstrated some favorable effects of raloxifene. Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to identify the mechanism of action of raloxifene, treat the adverse effects of raloxifene, prescribe raloxifene for patients with osteoporosis, to prevent estrogen receptor–positive breast cancer, as effective therapy in women with osteoporosis and concomitant increased levels of plasma cholesterol, and select the appropriate patients for raloxifene treatment using the patient’s medical history and risk of thromboembolism.

Magnetic Resonance-Guided Focused Ultrasound Myomectomy: Safety, Efficacy, Subsequent Fertility and Quality-of-Life Improvements, A Systematic Review.

We performed a systematic review about studies reporting data of myomectomy performed by magnetic resonance-guided focused ultrasound (MRgFUS) technique in order to define its safety, feasibility, indications, complications, and impact on uterine fibroid symptom and health-related quality of life (UFS-QOL) and fertility. Outcomes were considered according to fibroids shrinkage, nonperfused volume (NPV), NPV ratio, and uterine fibroid symptoms assessed with UFS-QOL questionnaire (baseline 3, 4, 6, and 12 months). We analyzed 38 eligible studies reporting outcomes about 2500 patients (mean age 43.67 years). The MRgFUS results a safe, efficient, and cost-effective minimal invasive technique for treatment of uterine fibroids. Increasing experience, device improvements, and availability for a larger number of patients are enhancing the outcomes, while the obstetrical ones should be more extensively explored. The MRgFUS could be considered as a minimal invasive alternative to traditional surgical or radiological procedures for the treatment of symptomatic uterine myomas improving both QOL and subsequent fertility.

Update on best available options in obstetrics anaesthesia: perinatal outcomes, side effects and maternal satisfaction. Fifteen years systematic literature review

PurposeIn modern obstetrics, different pharmacological and non-pharmacological options allow to obtain pain relief during labour, one of the most important goals in women satisfaction about medical care. The aim of this review is to compare all the analgesia administration schemes in terms of effectiveness in pain relief, length of labour, mode of delivery, side effects and neonatal outcomes.MethodsA systematic literature search was conducted in electronic databases in the interval time between January 1999 and March 2013. Key search terms included: “labour analgesia”, “epidural anaesthesia during labour” (excluding anaesthesia for Caesarean section), “epidural analgesia and labour outcome” and “intra-thecal analgesia”.Results10,331 patients were analysed: 5,578 patients underwent Epidural-Analgesia, 259 patients spinal analgesia, 2,724 combined spinal epidural analgesia, 322 continuous epidural infusion (CEI), 168 intermittent epidural bolus, 684 patient-controlled infusion epidural analgesia and 152 intra-venous patient-controlled epidural analgesia. We also considered 341 women who underwent patient-controlled infusion epidural analgesia in association with CEI and 103 patients who underwent patient-controlled infusion epidural analgesia in association with automatic mandatory bolus.ConclusionNo significant differences occurred among all the available administration schemes of neuraxial analgesia. In absence of obstetrical contraindication, neuraxial analgesia has to be considered as the gold standard in obtaining maternal pain relief during labour. The options available in the administration of analgesia should be known and evaluated together by both gynaecologists and anaesthesiologists to choose the best personalized scheme and obtain the best women satisfaction. Since it is difficult to identify comparable circumstances during labour, it is complicate to standardize drugs schemes and their combinations.

Anti-Helicobacter pylori antibodies in cervical mucus: a new cause of infertility

OBJECTIVE The aims of our study were to determine on the one hand a correlation between the presence of anti-Helicobacter pylori (anti-H. pylori) IgG antibodies in serum and cervical mucus of women with idiopathic infertility, and on the other hand the effect of these antibodies on cervical mucus quality, in particular related to the ability of spermatozoa to penetrate it. STUDY DESIGN We analysed anti-H. pylori IgG antibodies in the serum and cervical mucus of 67 patients diagnosed with idiopathic infertility using the Quanta Lite H. pylori IgG test. The penetration of normal sperm, in 15 cervical mucus samples positive for anti-H. pylori antibodies and in 15 negative samples, was assessed using the simplified slide test. RESULTS A significant positive correlation emerged between anti-H. pylori IgG antibody concentrations in the serum and in the cervical mucus (r=0.9275; p<0.00001). In the 15 anti-H. pylori IgG mucus-positive samples the slide test showed abnormal penetration by the spermatozoa. CONCLUSIONS Our study demonstrated that the presence of anti-H. pylori antibody in the cervical mucus can be involved in female infertility, interfering with sperm progression. Considering the close correlation found between serum and cervical mucus anti-H. pylori antibody titres, measuring serum antibodies could become an additional test, in particular in couples with unexplained infertility.

High-Risk Human Papillomavirus DNA Test: Could It Be Useful in Low-Grade Cervical Lesion Triage? Five-Year Follow-Up

We conducted a retrospective, observational study in order to evaluate the role of high-risk human papillomavirus (hrHPV)-DNA test in patients with first diagnosis of low-grade squamous intraepithelial lesions (L-SILs).Patients were divided into group A, annual Papanicolaou test and hrHPV-DNA tests (167 patients) and group B, immediate colposcopy, followed by annual papanicolaou test and hrHPV-DNA tests (164 patients). We assessed sensitivity, specificity, negative predictive value (NPV), positive predictive value, positive–negative likelihood ratio of hrHPV-DNA test, and 5-year relative risk of cervical intraepithelial neoplasia grade 2 in hrHPV-DNA+. Colposcopy is still considered the best choice for women with L-SIL and hrHPV-DNA+ test. High sensitivity and NPV of hrHPV-DNA test permit to use it in the follow-up of L-SIL with a HPV-negative status, without necessity of referring to colposcopy.

Caesarean Section: Could Different Transverse Abdominal Incision Techniques Influence Postpartum Pain and Subsequent Quality of Life? A Systematic Review

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon’s experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: “acute pain”, “chronic pain”, “Pfannenstiel incision”, “Misgav-Ladach”, “Joel Cohen incision”, in combination with “Caesarean Section”, “abdominal incision”, “numbness”, “neuropathic pain” and “nerve entrapment”. Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required.

Pharmacological anti-thrombotic prophylaxis after elective caesarean delivery in thrombophilia unscreened women: should maternal age have a role in decision making?

Abstract In obstetrical practice, the best prevention strategy for pregnant women aged >35 years without known thrombosis risk factors who underwent elective caesarean delivery (CD) is controversial. We performed an observational-longitudinal cohort study on pregnant women aged >35 years who delivered at term by elective caesarean section after a physiological single pregnancy to evaluate the role of maternal age in the decision-making process of whether or not to perform low-molecular-weight heparin (LMWH) prophylaxis during the post-partum period after elective CD in healthy women with unknown inherited thrombophilia status. During the 6 post-partum weeks, we followed two groups: GROUP-A (349 women treated for 7 days with low-molecular-weight heparin) and GROUP-B (180 women not treated with LMWH treatment). The outcomes were as follows: onset of thromboembolic events during the post-partum period; non-obstetrical-linked maternal haemorrhage; blood transfusion; re-laparotomy; detection of a surgical site haematoma; length of hospitalisation; and treatment suspension because of decreased platelet count. Except for the parity number, the two groups were homogeneous with regard to general features. In both the groups, we reported no cases of thromboembolic events during the follow-up period. Maternal haemorrhage requiring transfusion occurred in 16 women in GROUP-A and none in GROUP-B. Among the GROUP-A women, 11 demonstrated a surgical site haematoma and 4 required re-laparotomy. No cases of treatment suspension were reported. Pneumatic compression stockings represent a better, low cost and safe way to prevent post-partum venous thromboembolic episodes after elective caesarean section in an unscreened population. Pharmacological prophylaxis after elective caesarean section should be performed only in case of clear and known adjunctive risk factors, independent of maternal age.

Intrauterine morcellator devices: The icon of hysteroscopic future or merely a marketing image? A systematic review regarding safety, efficacy, advantages, and contraindications

The aim of this study was to analyze all available evidence regarding the use of intrauterine morcellator (IUM), for treatment of the most prevalent intrauterine benign lesions, compared to both traditional resectoscopy and conventional outpatient operative hysteroscopy in terms of safety, efficacy, contraindications, perioperative complications, operating time, and estimated learning curve. We reported data regarding a total of 1185 patients. Concerning polypectomy and myomectomy procedures, IUM systems demonstrated a better outcome in terms of operative time and fluid deficit compared to standard surgical procedures. Complication rates in the inpatient setting were as follows: 0.02% for IUM using Truclear 8.0 (Smith & Nephew Endoscopy, Andover, Massachusetts) and 0.4% for resectoscopic hysteroscopy. No complications were described using Versapoint devices. Office polipectomy reported a total complication rate of 10.1% using Versapoint device (Ethicon Women’s Health and Urology, Somerville, New Jersey) and 1.6% using Truclear 5.0 (Smith & Nephew Endoscopy). The reported recurrence rate after polypectomy was 9.8% using Versapoint device and 2.6% using Truclear 8.0. Finally, the reported intraoperative and postoperative complication rate of IUM related to removal of placental remnants using Truclear 8.0 and MyoSure (Hologic, Marlborough, Massachusetts) was 12.3%. The available evidence allows us to consider IUM devices as a safe, effective, and cost-effective tool for the removal of intrauterine lesions such as polyps, myomas (type 0 and type 1), and placental remnants. Evidence regarding Truclear 5.0 suggests that it may represent the best choice for office hysteroscopy. Further studies are needed to confirm the available evidence and to validate the long-term safety of IUM in procedures for which current data are not exhaustive (placental remnants removal).

Impaired lactation performance following elective delivery at term: role of maternal levels of cortisol and prolactin

Objective: Lactation performance depends on stress surrounding labor and delivery, and it is likely to be different in women who underwent elective cesarean delivery (ECD) or vaginal (VD). The aim of this study was to assess the relationship between cortisol and human prolactin (hPRL), following ECD and lactation performance, from the delivery room to the 6th month of life. Methods: A total of 106 mothers were consecutively enrolled: 38 after ECD, 28 after emergency cesarean delivery (EmCD), and 40 after VD. Results: Basal stress-, lactogenic-hormones, cortisol, and hPRL were comparable on day 3 postpartum in all the women. Multivariate analysis indicated that ECD has a negative impact (OR; 95% CI) on breastfeeding prevalence on the seventh day (0.14; 0.0–0.44, p = 0.008) and at third month post partum (0.19; 0.05–0.71, p = 0.05) in comparison to VD. In addition, hPRL levels proved to have a statistically significant role in early breastfeeding (1.01; 1–1.01, p = 0.002). Conclusions: ECD is a risk factor for successful lactation performance. This information should be provided to mothers and caregivers for extra breastfeeding guidance.