Pietro Litta

Elective Cesarean Delivery: Does It Have a Negative Effect on Breastfeeding?

BACKGROUND Cesarean delivery has negative effects on breastfeeding. The objective of this study was to evaluate breastfeeding rates, defined in accordance with World Health Organization guidelines, from delivery to 6 months postpartum in infants born by elective and emergency cesarean section and in infants born vaginally. METHODS Delivery modalities were assessed in relation to breastfeeding patterns in 2,137 term infants delivered at a tertiary center, the Padua University School of Medicine in northeastern Italy, from January to December 2007. The study population included 677 (31.1%) newborns delivered by cesarean section, 398 (18.3%) by elective cesarean, 279 (12.8%) by emergency cesarean section, and 1,496 (68.8%) delivered vaginally. RESULTS Breastfeeding prevalence in the delivery room was significantly higher after vaginal delivery compared with that after cesarean delivery (71.5% vs 3.5%, p < 0.001), and a longer interval occurred between birth and first breastfeeding in the newborns delivered by cesarean section (mean ± SD, hours, 3.1 ± 5 vs 10.4 ± 9, p < 0.05). No difference was found in breastfeeding rates between the elective and emergency cesarean groups. Compared with elective cesarean delivery, vaginal delivery was associated with a higher breastfeeding rate at discharge and at the subsequent follow-up steps (7 days, 3 mo, and 6 mo of life). CONCLUSIONS   Emergency and elective cesarean deliveries are similarly associated with a decreased rate of exclusive breastfeeding compared with vaginal delivery. The inability of women who have undergone a cesarean section to breastfeed comfortably in the delivery room and in the immediate postpartum period seems to be the most likely explanation for this association.

STEROID HORMONES AND BDNF

Brain-derived neurotrophic factor (BDNF) is a neurotrophin abundantly expressed in several areas of the central nervous system (CNS) and is known to induce a lasting potentiation of synaptic efficacy, to enhance specific learning and memory processes. BDNF is one of the key molecules modulating brain plasticity and it affects cognitive deficit associated with aging and neurodegenerative disease. Several studies have shown an altered BDNF production and secretion in a variety of neurodegenerative diseases like Alzheimers and Parkinsons diseases but also in mood disorders like depression, eating disorders and schizophrenia. Plasma BDNF is also a biomarker of impaired memory and general cognitive function in aging women. Gonadal steroids are involved in the regulation of several CNS processes, specifically mood, affective and cognitive functions during fertile life and reproductive aging. These observations lead many scientists to investigate a putative co-regulation between BDNF and gonadal and/or adrenal steroids and their relationship with gender difference in the incidence of mental diseases. This overview aims to summarize the current knowledge on the correlation between BDNF expression/function and both gonadal (progesterone, estrogens, and testosterone) and adrenal hormones (mainly cortisol and dehydroepiandrosterone (DHEA)) with relevance in clinical application.

First-trimester exposure to metformin and risk of birth defects: a systematic review and meta-analysis

BACKGROUND Metformin is generally considered a non-teratogenic drug; however, only a few studies specifically designed to assess the rate of congenital anomalies after metformin use have been published in the literature. The objects of the present study were to review all of the prospective and retrospective studies reporting on women treated with metformin at least during the first trimester of their pregnancy and to estimate the overall rate of major birth defects. METHODS Databases were searched for English language articles until December 2013. Inclusion criteria for the meta-analysis were: a case group of women with PCOS or pre-pregnancy type 2 diabetes and first-trimester exposure to metformin; a disease-matched control group which was not exposed to metformin or other oral anti-diabetic agents; and a list of the major anomalies in both the study and the control groups. A random effects model was used for the meta-analysis of data, using odds ratios. Studies not fulfilling the inclusion criteria for the meta-analysis but reporting relevant data on major malformations in women diagnosed with PCOS were then used to estimate the overall birth defects rate. RESULTS Meta-analysis of nine controlled studies with women affected by PCOS detected that the rate of major birth defects in the metformin-exposed group was not statistically increased compared with the disease-matched control group and that there was no significant heterogeneity among the studies. The metformin-exposed sample was composed of 351 pregnancies and the OR of major birth defects was 0.86 (95% confidence interval: 0.18-4.08; Pheterogeneity = 0.71). By evaluating all of the non-overlapping PCOS studies reported in the literature, even those without an appropriate control group, the overall rate of major anomalies was 0.6% in the sample of 517 women who discontinued the therapy upon conception or confirmation of pregnancy and 0.5% in the sample of 634 women who were treated with metformin throughout the first trimester of their pregnancy. Regarding type 2 diabetic women, we did not identify a sufficient number of studies with metformin exposure during the first trimester to proceed with the meta-analysis. CONCLUSIONS There is currently no evidence that metformin is associated with an increased risk of major birth defects in women affected by PCOS and treated during the first trimester. However larger ad hoc studies are warranted in order to definitely confirm the safety and efficacy of this drug in pregnancy.

Outpatient operative polypectomy using a 5 mm-hysteroscope without anaesthesia and/or analgesia: Advantages and limits

OBJECTIVE To assess the predictors of office-based operative hysteroscopic polypectomy using a 5.2mm continuous flow office hysteroscope without anaesthesia and/or analgesia for the treatment of endometrial and/or isthmic polyps and to define procedure limits. STUDY DESIGN Women with hysteroscopic diagnosis of endometrial or isthmic polyps were offered to proceed in the same session with operative hysteroscopy after 15 min without anaesthesia and/or analgesia. All procedures were performed using a 5.2 mm continuous flow office hysteroscope. Patient procedure compliance was assessed by means of a visual analogue scale (VAS) using a rating scale with 11 categories. A VAS < or = 4 was considered as patient procedure compliance. Regression analysis was performed to correlate the following variables: time required, size and number of polyps with VAS. A ROC analysis was performed to assess the cut-off of the strongest predictors. The influence of previous vaginal delivery and menopausal status was correlated with the VAS. RESULTS A total of 217 women underwent the office-based hysteroscopic procedure and 253 polyps were removed, among them 170 were endometrial and 83 isthmic polyps. There were 181 women with single polyps and 36 women presented multiple polyps. The size of polyps ranged from 0.5 to 5 cm. Median time of the procedure was 10 min (range 3-30 min). Regression analysis showed a statistical significative correlation between VAS and size of polyps and between VAS and operating time independent to the number of polyps. Using the ROC analysis a VAS < or = 4 was obtained when polyps were < or = 2 cm and/or time of the procedure lasted < or = 15 min. Menopausal status and previous vaginal deliveries were not significantly correlated to the VAS. CONCLUSIONS Office-based hysteroscopic polypectomy is a safe and feasible procedure and should be addressed in patients with endometrial or isthmic polyps < or = 2 cm in diameter, and the procedure limits in terms of patient procedure compliance are size of polyps and operating time, independent from menopausal status and previous vaginal delivery.

Uterine Fibroids: Pathogenesis and Interactions with Endometrium and Endomyometrial Junction

Uterine leiomyomas (fibroids or myomas) are benign tumors of uterus and clinically apparent in a large part of reproductive aged women. Clinically, they present with a variety of symptoms: excessive menstrual bleeding, dysmenorrhoea and intermenstrual bleeding, chronic pelvic pain, and pressure symptoms such as a sensation of bloatedness, increased urinary frequency, and bowel disturbance. In addition, they may compromise reproductive functions, possibly contributing to subfertility, early pregnancy loss, and later pregnancy complications. Despite the prevalence of this condition, myoma research is underfunded compared to other nonmalignant diseases. To date, several pathogenetic factors such as genetics, microRNA, steroids, growth factors, cytokines, chemokines, and extracellular matrix components have been implicated in the development and growth of leiomyoma. This paper summarizes the available literature regarding the ultimate relative knowledge on pathogenesis of uterine fibroids and their interactions with endometrium and subendometrial myometrium.

Comparison between transvaginal sonography, saline contrast sonovaginography and magnetic resonance imaging in the diagnosis of posterior deep infiltrating endometriosis

To compare clinical evaluation, transvaginal sonography (TVS), saline contrast sonovaginography (SCSV) and magnetic resonance imaging (MRI) in the diagnosis of posterior deep pelvic endometriosis (DPE).

A randomized controlled study comparing harmonic versus electrosurgery in laparoscopic myomectomy

OBJECTIVE To compare the effectiveness and safety of harmonic scalpel versus electrosurgery to reduce blood loss during laparoscopic myomectomy. DESIGN Prospective randomized controlled study. SETTING Tertiary referral centers for gynecological care. PATIENT(S) One hundred sixty consecutive premenopausal women with symptomatic uterine leiomyomata who were assigned to one of the two treatment groups (a total of 80 patients in each group): treatment with electrosurgery devices with a vasoconstrictive solution (50 mL of saline solution and 0.5 mL of epinephrine [1/2 vial of 1 mg/mL]; group A) or harmonic scalpel (group B). INTERVENTION(S) Laparoscopic myomectomy. MAIN OUTCOMES MEASURE(S) The global operative time, the time spent for myoma enucleation and for suturing uterine wall defects, and intraoperative blood loss as well as the surgical difficulty degree and postoperative pain at 24 and 48 hours after the laparoscopic procedure. RESULT(S) No relevant intra- or postoperative complications were observed in either group. The degree of pain 24 hours after surgery was significantly lower in patients in whom the harmonic scalpel was used. The degree of surgical difficulty did not differ between groups, but the global operative time was significantly shorter in the harmonic scalpel group. CONCLUSION(S) The use of the harmonic scalpel for laparoscopic myomectomy is associated with low total operative time, low intraoperative blood loss, and low postoperative pain, with no increase in surgical difficulty.

Eutopic Endometrium From Women With Endometriosis Shows Altered Ultrastructure and Glycosylation Compared to That From Healthy Controls—A Pilot Observational Study

Endometrial curettings from a cohort of 24 women with endometriosis were compared with matched biopsies from 14 healthy, fertile women and examined for ultrastructural changes and the secretion of glycans bound by the lectin from Dolichos biflorus. Ultrastructural analysis of glandular endometrial tissue from women with stages I to III endometriosis showed heterogeneous responses to the disease, biopsies often showing a mixture of features, combining delays in the maturation sequence with characteristics of later phenotypes particularly in the mid-late secretory phase of the menstrual cycle. Expression of glycans bound by Dolichos biflorus agglutinin was very variable in these cases but generally matched the observed ultrastructure. Biopsies from women with stage IV endometriosis showed immature gland morphology later in the cycle and also failed to express Dolichos biflorus agglutinin—binding glycans, suggesting an association between histological and biochemical function in advanced disease states. These findings may explain in part endometriosis-associated subfertility as blastocyst attachment is intimately associated with appropriate glycosylation and gland morphology.

Resectoscope or Versapoint for hysteroscopic metroplasty

To assess the feasibility, safety, and reproductive outcome of hysteroscopic metroplasty using the Versapoint device compared with the resectoscope using the Collins loop.

Anti-Müllerian hormone trend after laparoscopic surgery in women with ovarian endometrioma

Abstract Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to investigate the extent of the ovarian reserve damage after stripping technique of unilateral endometriomas, by dosing the Anti-Müllerian Hormone (AMH). This prospective study was conducted at the Center of Minimally Invasive Pelvic Surgery of the Department of Health of Woman and Child, University of Padua, from October 2010 to June 2012. Twenty-five women underwent excision of monolateral endometriosis ovarian cyst by stripping without accessing a bipolar coagulation and performing an intracortical suture. The AMH serum levels were estimated in the early proliferative phase of the cycle, before surgery (time 0), 24 h after surgery (time 1), the first menstrual cycle after surgery (time 2) and the third menstrual cycle after surgery (time 3). We found a nonstatistically significant decreases in serum AMH levels after surgical excision of the cysts. Our results suggest that an appropriate surgical technique, without the use of the bipolar coagulation of ovarian border, does not determine a significant reduction of ovarian reserve.