Martina Derme

Imaging of stone disease in pregnancy

Renal colic is the most frequent non-obstetric cause for abdominal pain and subsequent hospitalization during pregnancy. Intervention is necessary in patients who do not respond to conservative treatment. Ultrasound (US) is widely used as the first-line diagnostic test in pregnant women with nephrolithiasis, despite it is highly nonspecific and may be unable to differentiate between ureteral obstruction secondary to calculi and physiologic hydronephrosis. Magnetic resonance imaging (MRI) should be considered as a second-line test, when US fails to establish a diagnosis and there are continued symptoms despite conservative management. Moreover, MRI is able to differentiate physiologic from pathologic dilatation. In fact in the cases of obstruction secondary to calculi, there is renal enlargement and perinephric edema, not seen with physiological dilatation. In the latter, there is smooth tapering of the middle third of the ureter because of the mass effect between the uterus and adjacent retroperitoneal musculature. When the stone is lodged in the lower ureter, a standing column of dilated ureter is seen below this physiological constriction. MRI is also helpful in demonstrating complications such as pyelonephritis. In the unresolved cases, Computed tomography remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women, but it involves ionizing radiation. Nephrolithiasis during pregnancy requires a collaboration between urologists, obstetricians, and radiologists.

Impact of mTOR-I on fertility and pregnancy: state of the art and review of the literature

Successful transplantation should lead to improvements in sexual function and sex hormone disturbances in both men and women, but immunosuppressive drugs may interfere with hormone metabolism. In this regard, several studies have showed a potential negative effect of mTOR inhibitors (mTORi) on male gonadal function, while their role in the female patients is not well documented in the literature. Successful pregnancy is possible after solid organ transplantation. The fetal effects of mTORi are still poorly defined but they seem not to represent an absolute contraindication for pregnancy. The aim of our study would be to review the impact of mTORi on fertility and pregnancy in order to have a clearer picture about their possible use after organ transplantation.

Quality of Sexual Life in Women with Primary Sjögren Syndrome

Objective. To assess the quality of sexual life of women with primary Sjögren syndrome (pSS) and to identify its correlations with disease activity and damage, quality of life, and mood disorders. Methods. The quality of sexual life of 24 women with pSS was assessed with the Female Sexual Function Index (FSFI). Twenty-four healthy women, matched by age and hormonal status, were enrolled as controls. Mood disorders and quality of life were investigated using the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study Short Form-36. Patients underwent a gynecological visit with vaginal pH measurement, cervicovaginal swabs, and Pap smears. Disease activity and damage were assessed by the European League Against Rheumatism Sjögren syndrome disease activity and damage indexes. Results. Patients with pSS showed a pathological mean FSFI score (19.1 ± 7.33) significantly different from controls (p = 0.004), both in menstruating women (p = 0.006) and in menopausal women (p = 0.03). Major differences between the 2 groups were detected in dyspareunia (p < 0.005), lubrication (p = 0.006), desire (p = 0.004), and arousal (p = 0.018). The FSFI score was inversely correlated with age (p = 0.008) and anxiety HADS (p = 0.031). No early anatomical changes, swabs, and Pap smear alterations were revealed in patients with pSS; however, vaginal pH was higher than normal in premenopausal patients (6.0 ± 0.77). Conclusion. Both premenopausal and postmenopausal women with pSS have a worse sexual quality of life. We reported a greater prevalence of dyspareunia that is statistically significant when compared with controls. The FSFI could be a useful tool to assess this topic, but has been neglected in the care of patients with pSS heretofore.

Stone disease in pregnancy: imaging-guided therapy

AbstractRenal colic is the most frequent nonobstetric cause for abdominal pain and subsequent hospitalization during pregnancy. The physio-anatomical changes in the urinary tract and the presence of the fetus may complicate the clinical presentation and management of nephrolithiasis. Ultrasound (US) is the primary radiological investigation of choice. Magnetic resonance urography (MRU) and low-dose computed tomography (CT) have to be considered as a second- and third-line test, respectively. If a study that uses ionizing radiation has to be performed, the radiation dose to the fetus should be as low as possible. The initial management of symptomatic ureteric stones is conservative during pregnancy. Intervention will be necessary in patients who do not respond to conservative measures. Therefore, it is crucial to obtain a prompt and accurate diagnosis to optimize the management of these patients. Teaching Points • In pregnancy, renal colic is the most frequent nonobstetric cause for abdominal pain and hospitalization. • Magnetic resonance urography should be considered when ultrasound is nondiagnostic. • Low-dose CT should be considered as a last-line test during pregnancy.

Evaluating the Acute Abdomen in the Pregnant Patient

Acute abdominal pain in pregnancy presents diagnostic and therapeutic challenges. Ultrasound remains the primary imaging investigation of the pregnant abdomen because of its availability, portability, and lack of ionizing radiation. MR imaging has been shown to be useful in the diagnosis of gynecologic and obstetric problems and in the setting of acute abdomen during pregnancy. MR imaging is often used when ultrasound is inconclusive. Computed tomography is the investigation of choice when there is a life-threatening situation and in case of traumatic injuries, when a rapid diagnosis is required.

Breast cancer or metastasis? An unusual case of metastatic malignant pleural mesothelioma to the breast

BackgroundMetastases to the breast from extramammary malignancies are very rare, and ruling out the diagnosis of primary breast tumor is important in order to decide on clinical management and predict prognosis.Case presentationClinical examination revealed in a 49-year-old hairdresser a 3-cm hard lump adherent to the underlying layers in the right breast. Trucut biopsy was performed. Histology showed a solid proliferation of medium-sized neoplastic polygonal cells. Immunohistochemical analysis showed tumor cells diffusely positive for cytokeratin 8/18 and calretinin and focally positive for cytokeratin 5/6 and Wilms’ tumor 1, e-cadherin, and human bone marrow endothelial-1. Estrogen receptors and progesterone receptors were negative. The final diagnosis was metastatic epithelioid malignant pleural mesothelioma.ConclusionsImmunohistochemistry is an important tool for a conclusive diagnosis of malignant pleural mesothelioma. Owing to the degree of histological and immunohistochemical overlap, a high level of clinical suspicion is essential in order to avoid unnecessary mutilating surgery.

Transabdominal ultrasound‐guided injection of methotrexate in the treatment of ectopic interstitial pregnancies

In a retrospective observational study, we evaluated the feasibility and safety of medical therapy with transabdominal ultrasound‐guided injection of methotrexate (MTX) into the gestational sac (GS) in patients with interstitial ectopic pregnancies.

Placental, Lipid, and Glucidic Effects of Mammalian Target of Rapamycin Inhibitors: Impact on Fetal Growth and Metabolic Disorders During Pregnancy After Solid Organ Transplantation

BACKGROUND Mammalian target of rapamycin inhibitors (mTORi) are a promising new family of immunosuppressive drugs. No teratogenic effects have been reported to date. Their lipid and glucidic effects should not be underestimated, however, especially during pregnancy. Moreover, mTORi may affect fetal growth by mTOR placental activity. OBJECTIVE Our purpose was to highlight mTORi placental impact and metabolic implications to detect possible maternal or fetal effects and define management guidelines in pregnant women after solid organ transplantation. METHODS A literature search was performed for articles from the Medline and Pubmed databases with the use of the following keywords: mTOR inhibitors, pregnancy, placental transport, lipid metabolism, glucose metabolism. RESULTS mTOR works as a positive regulator of system A, system L, and taurine placental amino acid transporter activity, which are critical for the transport of amino acids to the fetus. Exposing trophoblast cells to rapamycin reduces system L activity; therefore, treatment with rapamycin in human pregnancies could alter fetal growth with intrauterine growth restriction (IUGR). Regarding the metabolic effects mTORi increase lipolysis, impair insulins antilipolytic effect and reduce lipid storage, which may potentially contribute to dyslipidemia. Chronic rapamycin treatment reduces adipose tissue size and β-cell mass/function, causes hyperlipidemia, severe insulin resistance, and glucose intolerance, and promotes hepatic gluconeogenesis. CONCLUSIONS The studies on mTORi treatment in transplanted pregnant women have not focused to date on the potential metabolic and placental effects. Selection of women at high risk for metabolic disorders could be needed and consideration of switching to another immunosuppressive drug required if diabetes and abnormal blood lipids have been diagnosed in prepregnancy counseling. It seems to be mandatory to encourage prompt reporting of any additional cases of pregnancy during mTORi exposure to provide a better understanding of the placental effects and safety profile of these immunosuppressive drugs.

To evaluate the feasibility of magnetic resonance imaging in predicting unusual site ectopic pregnancy: a retrospective cohort study

ObjectiveTo evaluate the accuracy of pelvic MRI in the diagnosis of unusual ectopic pregnancy (EP), when ultrasound (US) examination is inconclusive.MethodsWe retrospectively reviewed the medical records of 150 patients with suspected EP. Clinical, US and MRI features of 15 unusual EPs were analysed. Two radiologists independently reviewed each case resolving by consensus any diagnostic discrepancy. Interobserver agreement was assessed using the Cohen κ test.ResultsMRI displayed a gestational sac-like structure surrounded by a thick wall in all cases. The thick wall displayed hyperintensity in 41 %, isointensity in 35 % and hypointensity in 24 % of cases on T1-weighted images. Diffusion- and fat saturation T1-weighted images were the most accurate sequences, as they enabled identification of 15/15 and 14/15 patients, respectively. Although US was false negative in detecting cervical and uterine infiltration underlying the caesarean scar, MRI was able to identify the invasion. Interobserver agreement was very good for all sequences (κ=0.892–1.0).ConclusionsMRI plays an important role in the early diagnosis of unusual EP. It should be considered after negative US findings, providing accurate evaluation of the site and the possible infiltration of these lesions, which help in the management of these patients.Key Points• MRI is being increasingly used as a problem-solving modality in ectopic pregnancy.• MRI plays an important role in early diagnosis of unusual ectopic pregnancy.• Knowledge of MRI features in EP is essential to determinate appropriate management.

Acute Abdominal Pain in Pregnant Patients

Acute abdominal pain in pregnancy presents diagnostic and therapeutic challenges. Prompt diagnosis and treatment are crucial for the well-being of the mother and the fetus, and imaging is often required to clarify the clinical picture. Ultrasound (US) remains the primary imaging modality for the pregnant abdomen and pelvis because of its availability, portability, and absence of ionizing radiation. US can often be used to elucidate the cause of abdominal and pelvic pain, particularly if the pain is due to an obstetric or gynecologic abnormality. However, evaluation of the bowel, pancreas, ureters, and mesenteric vasculature may be limited on US because of patient body habitus, a small field of view, and the presence of overlying structures, especially in the later stages of pregnancy. Magnetic resonance imaging (MRI) has been shown to be highly useful in the diagnosis of acute gynecological and obstetric disorders, and particularly in the setting of an acute abdomen during pregnancy. MRI is often used when US is inconclusive. Computed tomography (CT) is the imaging examination of choice when there is a life-threatening situation, and in patients with trauma, when a rapid diagnosis is required, and US is not diagnostic.