Secondo Guaschino

Coagulation and fibrinolysis changes in normal pregnancy : Increased levels of procoagulants and reduced levels of inhibitors during pregnancy induce a hypercoagulable state, combined with a reactive fibrinolysis

OBJECTIVE To establish the physiologic changes in the coagulation and fibrinolytic systems during normal pregnancy and puerperium. STUDY DESIGN One hundred and seventeen normal pregnant women were investigated in a longitudinal study involving five measurements: blood samples were collected at 10, 20, 30, 36 weeks and on the second day puerperium and were assayed for prothrombin time (PT expressed in INR), activated partial thromboplastin time (PTT), fibrinogen (FBG), antithrombin III activity (AT III), protein C activity (PC), protein S activity (PS), prothrombin fragments 1+2 (F1+2), type 1 plasminogen activator inhibitor activity (PAI) and tissue-plasminogen activator antigen (t-PA). Student t-test, One Way Analysis of Variance (ANOVA) and Bonferroni test were used for statistical analysis. P<0.05 (two tails) was assumed to indicate a significant difference. RESULTS Fibrinogen concentrations were always increased with respect to controls (P<0.001), while protein S was always decreased, with values averaging 60% of those of controls from the 10th week of pregnancy onwards (P<0.001). Variance analysis showed a statistically significant increase with gestational age for procoagulant factors (INR: P<0.001; FBG: P<0.001), a reduction for anticoagulants (PC: P<0.0001; PS: P<0.0001), and a rise for F1+2 (P<0.0001). With regard to fibrinolysis, there was an increase both for t-PA (P<0.0001) and PAI-1 (P<0.0001) during pregnancy. The t-PA values were always comprised in the normal range. PAI-1 were increased with respect to control values starting from 31st week. The most significant variations in the procoagulants (expressed by PT and FBG) were recorded up to the 20th week (P<0.001); from the 30th week onwards, they remained stable until after the delivery. The same was true for protein S levels (P<0.001), except that the difference between the 10th and the 20th weeks was not statistically significant. The level of F1+2 gradually increased throughout pregnancy (P<0.001), and then fell in the puerperium (P<0.001). CONCLUSIONS The parameters showing the greatest variation during pregnancy were PT, FBG, PS, F1+2 and PAI-1. The existence of a hypercoagulable state in pregnancy was suggested by the increased levels of F1+2.

Caesarean section on request: a comparison of obstetricians' attitudes in eight European countries

Objective  To explore the attitudes of obstetricians to performe a caesarean section on maternal request in the absence of medical indication.

The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery.

OBJECTIVE: To evaluate the effect of mediolateral episiotomy on puerperal pelvic floor strength and dysfunction (urinary and anal incontinence, genital prolapse). METHODS: Five hundred nineteen primiparous women were enrolled 3 months after vaginal delivery. Puerperae were divided in 2 groups: group A (254 women) comprised the women who received mediolateral episiotomy and group B (265 women) the women with intact perineum and first- and second-degree spontaneous perineal lacerations. Each woman was questioned about urogynecological symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. Data were subjected to Student t test and Fisher exact test to assess, respectively, the difference between the mean values and the proportions within the subpopulations. Using a simple logistic regression model to test an estimate of relative risk, we expressed the odds ratios of the variables considered with respect to the control population (group B). RESULTS: No significant difference was found with regard to the incidence of urinary and anal incontinence and genital prolapse, whereas dyspareunia and perineal pain were significantly higher in the episiotomy group (7.9% versus 3.4%, P = .026; 6.7% versus 2.3%, P = .014, respectively). Episiotomy was associated with significantly lower values, both in digital test (2.2 versus 2.6; P < .001) and in vaginal manometry (12.2 versus 13.8 cm water; P < .001), but not in uroflowmetric stop test. CONCLUSION: Mediolateral episiotomy does not protect against urinary and anal incontinence and genital prolapse and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain. LEVEL OF EVIDENCE: II-2

Facts and myths on recurrent vulvovaginal candidosis-a review on epidemiology, clinical manifestations, diagnosis, pathogenesis and therapy.

Approximately three-quarters of all women will experience an episode of vulvovaginal candidosis at least once in their life and 5-10% of them will have more than one attack. Women suffering from three to four attacks within 12 months will be diagnosed with recurrent vulvovaginal candidosis (RVVC). This review covers the large number of proposed aetiological factors for RVVC. The diagnosis of the condition made by conventional means by health providers is often false and is also often misdiagnosed by the affected woman herself. The review covers various methods of diagnosing RVVC and the current knowledge on potential pathogenetic mechanisms proposed for genital candida infections. Treatment of RVVC, including local and systemic antimicrobial therapy and behaviour modification to decrease the risk of recurrences, are discussed. Recent knowledge on drug resistance in candida is also included.

An epidemiological survey of vulvovaginal candidiasis in Italy.

Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9+/-2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.

Prevalence of Bacterial Vaginosis and Vaginal Flora Changes in Peri- and Postmenopausal Women

ABSTRACT Our aim was to evaluate the prevalence of bacterial vaginosis and decrease in lactobacillus colonization in women 40 years old or older in relation to menopausal status by evaluation of Gram-stained smears. A total of 1,486 smears from Italian Caucasian women aged 40 to 79 years were examined. Women were classified as follows: fertile (regular cycles) (n = 328), perimenopausal (irregular cycles) (n = 237), and postmenopausal (n = 921), including 331 women on estroprogestinic hormone replacement therapy (HRT). The prevalences of bacterial vaginosis (assessed as a Nugent score of ≥7) in fertile (9.8%) and perimenopausal (11.0%) women were not statistically different, whereas the prevalence was significantly lower overall in postmenopausal women (6.0%) (P = 0.02). Specifically, 6.3% of postmenopausal women without HRT and 5.4% of postmenopausal women with HRT were positive for bacterial vaginosis. The Nugent score system was not adequate for evaluating the normal and intermediate vaginal flora in women over the age of 40 years. High numbers of peri- and postmenopausal women had no lactobacilli and no bacterial-vaginosis-associated microorganisms. This nonpathological absence of lactobacilli in women with a Nugent score of 4 was scored as 4∗, and this group was considered separately from the intermediate flora group. A score of 4∗ was obtained for 2.1% of fertile women, 11.4% of perimenopausal women, 44.1% of postmenopausal women without HRT, and 6.9% of postmenopausal women with HRT. The physiological reduction in lactobacillus colonization of the vagina in postmenopausal women does not cause an increase in bacterial-vaginosis prevalence. Reversion of lactobacillus flora to premenopausal levels due to HRT does not increase the prevalence of bacterial vaginosis in postmenopausal women.

Perineal ultrasound evaluation of urethral angle and bladder neck mobility in women with stress urinary incontinence

Objectives 1. To assess the reproducibility of an electronic ultrasonographic technique for the measurement of urethral angulation; 2. To test the ability of measurement of the urethral angle and bladder neck mobility to predict genuine stress incontinence; 3. To compare ultrasound variables in stress incontinent women and in controls.

Aetiology of preterm labour: bacterial vaginosis

Bacterial vaginosis (BV) is a common condition characterised by a polymicrobial disorder, with an overgrowth of several anaerobic or facultative bacteria and with a reduction or absence of lactobacillus colonisation. The prevalence of BV ranges from 4 to 64%, depending on the racial, geographic and clinical characteristics of the study population. In asymptomatic women, the prevalence varies from 12 to 25%, and similar percentages are observed in pregnant women. Although BV is associated with several adverse outcomes, such as upper genital tract infections, pelvic inflammatory disease, endometritis, preterm birth and low birthweight, many basic questions regarding the pathogenesis of BV remain unanswered. Mucosal immune system activation may represent a critical determinant of adverse consequences associated with BV. An unequal risk for BV acquisition and\or recurrence could derive from different mucosal immune host abilities and\or capability of invading microbes to produce factors that inactivate the local immune response. BV is associated with a two‐fold increased risk of preterm birth, with the greatest risk when BV is present before 16 weeks of gestation (odds ratio = 7.55). This may indicate a critical period during early gestation when BV‐related organisms can gain access to the upper genital tract and set the stage for spontaneous preterm labour later in gestation. The results of treatment trials for pregnant women with BV have been heterogeneous, with anywhere from an 80% reduction to a two‐fold increase in preterm birth among women who received treatment. For this reason, in current clinical practice significant controversy surrounds determining not only who and when to screen but also who and how to treat. Recent evidence shows that individual genetic backgrounds can affect chemokine production. This is an interesting area for future research and could lead to trials of treatment only for women genetically predisposed to preterm birth.

Correlation of Local Interleukin-8 with Immunoglobulin A against Gardnerella vaginalis Hemolysin and with Prolidase and Sialidase Levels in Women with Bacterial Vaginosis

Mucosal immune system activation may represent a critical determinant of adverse consequences associated with bacterial vaginosis (BV), such as sexual human immunodeficiency virus transmission, upper genital tract infections, postsurgical infections, and adverse pregnancy outcomes. Concentrations of sialidase, prolidase, and anti-Gardnerella vaginalis hemolysin (Gvh) immunoglobulin A (IgA) were higher in vaginal fluids of 75 fertile women with BV, compared with concentrations in vaginal fluids of 85 healthy control subjects. Interleukin (IL)-8 levels were positively associated with anti-Gvh IgA response and inversely correlated with high levels of prolidase and sialidase in women with BV. IL-8 concentration was strongly associated with leukocyte count in both healthy and BV-positive women. The absence of leukocytes in most women with BV likely is due to lack of IL-8 induction. Parallel impairment of innate and adaptive mucosal immune factors, likely through microbial hydrolytic effects, may allow for the ascent of microorganisms to the upper genital tract and may facilitate viral infections.

Postpartum urinary symptoms: prevalence and risk factors

OBJECTIVES To assess the prevalence of urinary symptoms, the relationship between urinary symptoms and vaginal descent, and the association between urinary symptoms and obstetric factors. STUDY DESIGN Five hundred and thirty-seven women were interviewed and underwent a urogynaecological evaluation 3 months after vaginal delivery. Quantitative-type variables were subjected to Students t test. Simple logistic regression analyses were carried out on the symptoms studied as a function of risk factors. RESULTS 8.2% of primiparae showed stress urinary incontinence and multiparae in 20% (P=0.0001); urge incontinence was present in 5.5% of primiparae and in 13% of multiparae (P=0.004). Significant correlations were found among operative vaginal delivery, dysuria (P=0.048) and frequency (P=0.036). Urinary incontinence appeared associated with induced labour with prostaglandins (P=0.018) and with general maternal factors, such as parity (P=0.001) and elevated weight at the beginning of pregnancy (P=0.019). CONCLUSIONS It is likely that the pathogenesis of postpartum urinary incontinence includes not only the effects of pelvic floor trauma on urethrovesical mobility under stress, but also a deficiency in urethral resistance caused by drugs, such as prostaglandins.