G. Morosetti

May intraperitoneal irrigation with Betadine improve cesarean delivery outcomes? Results of a 6 years’ single centre experience

Abstract Purpose: Cesarean presents increased risk of adverse outcomes, such as endometritis, bacteremia, peritonitis, and maternal fever. This retrospective study aims to evaluate, for the first time in Literature, the effects Betadine washing versus normal saline washing after uterine closure in women undergoing cesarean delivery (CD) at ≥36 gestational weeks. Methods: Of the 2080 patients identified retrospectively for the analysis at Department of Obstetrics and Gynecology of San Camillo Hospital of Rome, 1042 were assigned to “Betadine group” and 1038 to “No Betadine group”. There were no differences noted for maternal and obstetric characteristics. The outcomes of the present study were to evaluate the incidence of postoperative infections or fever; the reduction of blood white cells among preoperative and postoperative exams; mean and median time of intestinal recanalization, of postoperative ambulation and of 24-h post-CD pain, evaluated using VAS scale. Results: Betadine group patients reported a statistically significant lower white cells increment, a lower mean time to ambulation and intestinal recanalization after CD and a lower 24-h post-CD pain and infections. Conclusions: Betadine intraperitoneal irrigation during CD seems to improve postoperative CD outcomes and patients’ quality of life.

Prevalence of human papillomavirus infection in Italian and immigrant women

Human papillomavirus (HPV) is the most common sexually transmitted agent worldwide. Prevalence varies according to the geographic regions, and is highest in developing countries. Geographic differences exist also in the detection rate of oncogenic types in malignant cervical lesions. In this study, the prevalence of HPV infection as well as the spectrum of HPV types was evaluated in Italian and immigrant women of the urban area of Rome. Several risk factors (age at first intercourse, number of partners, smoking, pregnancy, age at first pregnancy, contraception, education, and menarche) were taken into consideration. Overall, there was a high prevalence of HPV infection in the two groups studied. No significant differences were observed in the spectrum of HPV types detected. HPV 16 and 18 were the types detected more frequently in both groups. Interestingly, HPV 54 and 70 were found only in the immigrants. Whether this finding reflects a recent introduction of these HPV types in the population studied remains to be established. Monitoring of HPV types in the population is advisable, especially in countries like Italy which is a destination and a gateway for immigrants directed towards north and central Europe. The introduction of high risk HPV variants may have a clinical impact and affect the diagnostic procedures.

The Isolated Ovarian Endometrioma: a History between Myth and Reality

STUDY OBJECTIVE To assess the association between ovarian endometriomas detectable at transvaginal ultrasound (TVS) and other specific extraovarian lesions including adhesions, deep infiltrating endometriosis (DIE), and adenomyosis. DESIGN Retrospective observational study (Canadian Task Force classification II-2). SETTING Two university hospitals. PATIENTS Two hundred fifty-five symptomatic women with at least 1 ovarian endometrioma found on ultrasound after presentation with pain or irregular menstruation. INTERVENTIONS Patients underwent TVS followed by either medical or surgical treatment. MEASUREMENTS AND MAIN RESULTS Two hundred fifty-five women, aged 20 to 40 years, underwent TVS and were found to have at least 1 endometrioma with a diameter > 20 mm. Associated sonographic signs of pelvic endometriosis (adhesions, DIE, and adenomyosis) were recorded, and a subgroup of patients (n = 50) underwent laparoscopic surgery within 3 months of TVS. Mean endometrioma diameter was 40.0 ± 18.1 mm, and bilateral endometriomas were observed in 65 patients (25.5%). TVS showed posterior rectal DIE in 55 patients (21.5%) and a thickening of at least 1 uterosacral ligament in 93 patients (36.4%). One hundred eighty-six patients (73%) had adhesions, and 134 patients (53%) showed signs of myometrial adenomyosis on TVS. Thirty-eight patients (15%) exhibited only a single isolated endometrioma with a mobile ovary and no other signs of pelvic endometriosis/adenomyosis at TVS. CONCLUSION Ovarian endometriomas are indicators for pelvic endometriosis and are rarely isolated. Particularly, left endometriomas were found to be associated with rectal DIE and left uterosacral ligament localization and bilateral endometriomas correlated with adhesions and pouch of Douglas obliteration, whereas no correlation was found between endometrioma size and DIE. Determining appropriate management, whether clinical or surgical, is critical for ovarian endometriomas and concomitant adhesions, endometriosis, and adenomyosis in patients desiring future fertility.

OP24.09: Ulipristal acetate (UPA) therapy increased ultrasound features of adenomyosis: a good treatment given in an erroneous diagnosis of uterine fibroids

Objectives: To assess whether ulipristal acetate (UPA) improves adenomyosis-related heavy menstrual bleeding (HMB) persisting after the insertion of the levonorgestrel-releasing intrauterine device (Lng-IUD) and to evaluate the changes in the endometrium during treatment. Methods: This prospective study included patients with adenomyosis complaining persistence of HMB after at least 6 months from the insertion of the Lng-IUD. Adenomyosis was diagnosed by ultrasonography accordingly to the MUSA statement. Patients were offered a continuous treatment with UPA (5 mg/day; Gedeon Richter) for 6 months. The ultrasonographic characteristics of the endometrium were assessed before administering UPA, after 3 and 6 months of treatment. The endometrium was also evaluated by hysteroscopy after 3-month of treatment. At the end of treatment, patients rated the degree of satisfaction by using a Likert scale. The pictorial blood-loss assessment chart (PBAC) was used to estimate uterine bleeding. The intensity of pain symptoms was measured on a 100 mm visual analogue scale. Results: 23 women were included in the study; the mean (±SD) length of use of the Lng-IUD prior to the administration of UPA was 9.0 (±2.2) months. 2 patients (8.7%) interrupted the double-drug treatment before the 6-month follow-up because of pain symptoms. At the end of the 6-month treatment, 73.9% of the patients (17/23) were satisfied or very satisfied. 81.0% of the patients (17/21) were amenorrheic; 4 patients had controlled uterine bleeding (PBAC 28-days score < 75). 5 patients (4.8%) reported worsening of pain symptoms. Endometrial thickness was similar at baseline and 6-month follow-up (p = 0.150). Most of the patients (76,2%; 16/21) had a homogeneous (IETA) endometrial patter at the completion of treatment. Hysteroscopy revealed hypotrophic endometrium in 87.0% of the patients (20/23); a chicken-wire vascular pattern was observed in 30.4% of the patients (7/23). Conclusions: The administration of UPA improves HMB persisting after the insertion of the Lng-IUD.

P18.08: Bowel resection for DIE: 2D and 3D transvaginal sonographic evaluation of residual disease and associated symptoms

Objectives: Endometriosis is defined as the presence of ectopic, functioning endometrial tissue outside the uterine cavity. Abdominal wall endometrioma presents as a painful swelling resembling surgical lesions. It mostly follows obstetrical and gynecologic surgeries like Caesarean delivery (commonest), hysterectomy, tubal ligations. We are describing nine cases of scar endometriosis following Caesarean section. Varied appearance of the lesion on sonography is discussed. The importance of using high frequency linear transducer to diagnose this condition is emphasised. Methods: The study was performed on Phillips HD 11 XE and IU22 ultrasound machine using High frequency Linear 3-12 transducer. The size, location, ultrasound morphology and colour Doppler flow was evaluated. Results: 12 women (age range 28-38yrs) with 15 scar endometriomas (three women had two different nodules at scar site) were evaluated. Out of 15 lesions seven lesions were located between the subcutaneous fat and muscular sheath. In three cases both the subcutaneous and muscular planes were infiltrated. Three endometriomas were purely subcutaneous and two were entrapped in the muscular layer of the abdominal wall. Out of 15 nodules 13 were solid hypoechoic with spiculated margins, 1 was predominantly cystic and 1 was both solid, cystic. 7 lesions showed vascularity within, 6 were avascular and two showed minimal peripheral vascularity. Nine out of 12 were subsequently surgically removed and confirmed on histopathology. Two patients responded to medical line of treatment and refused surgical intervention. One was lost to follow up. Conclusions: High index of suspicion of scar endometriosis in patients with relevant clinical history always clinches the diagnosis. Use of high frequency linear transducer is strongly recommended to make the diagnosis. Judicious use of B mode Sonography and Colour Doppler to achieve this diagnosis obviates need of any further imaging modality like MRI.

OP31.08: New sonographic score of adenomyosis: interobserver reproducibility in the evaluation of type and degree of the myometrial involvement

Methods: Between 2014 and 2017 we collected three pregnant patients in which the presence of hypoechoic peritoneal tissue in addition to decidualised endometriomas was described on US. Those patients were followed up during and after pregnancy with US. MRI was performed during pregnancy in all cases. Results: The age of the patients was 29, 33 and 33 years respectively. The diagnosis was made at 16th, 15th and 14th weeks of gestation respectively. The first patient had a spontaneous delivery at 40th weeks, the second patient incurred in intrauterine fetal death at 24th weeks, and the last one is currently pregnant. No patient underwent surgery during pregnancy. On US examination, the implants appeared richly vascularised at colour Doppler, and they were quite swollen with smooth margins on dynamic evaluation. In all cases MRI, which was performed between 16th and 21st weeks of gestation, confirmed decidualised endometriomas and detected peritoneal nodules in two cases. After termination of pregnancy, in the first case the nodule disappeared, whereas in the second case the persistent nodule was smaller and not vascularised, with irregular margins. Conclusions: Endometrial ectopic tissue incurs in decidualisation during pregnancy, appearing soft and vascularised. The rich vascularisation can worries the examiner on the nature of the implants, but the smooth margins, the soft consistence and the concomitant presence of a decidualised endometrioma should reassure the examiner on the benign nature of the lesion.

Ellagic acid and Annona muricata in the chemoprevention of HPV-related pre-neoplastic lesions of the cervix

Ellagic acid is a phenolic compound naturally present in nuts and berries. Several studies have demonstrated that this bioactive compound has antioxidant, chemopreventive and antiviral activity. Annona muricata is a type of fruit tree with a long history of traditional use. A number of properties have been attributed to different parts of the plant, including anticancer and antioxidant activities. In the current study, a complex based on ellagic acid, Annona Muricata and antioxidant factors (an ellagic acid complex) was administered to a group of human papilloma virus (HPV) infected women with and without cervical lesions, for 12 months. Its effect on HPV clearance and cervical cytological outcomes was assessed and a group of women with the same clinical features who did not receive the ellagic acid complex served as a control. A positive correlation was observed between intake of ellagic acid complex and negative Pap test following 6 and 12 months of treatment (χ2 test: 0.041 and 0.014, respectively). Women treated with the ellagic acid complex were less likely to be diagnosed with an abnormal Pap smear at 6 months [Odds ratio (OR): 0.39; 95% confidence interval (CI) 0.14-1.06] and 12 months (OR: 0.35; 95% CI 0.13-0.89), compared with the control group. After adjusting for confounding factors including age and smoking habit, this association remained significant. No effect was observed on HPV clearance or viral integration. The data from the current study suggest a protective effect of the ellagic acid complex on cervical cells, possibly through apoptosis, cell cycle arrest and repair mechanisms.