SARS-CoV-2 Infection in the Second Trimester of Pregnancy: A Case Report of Fetal Intraventricular Hemorrhage After Critical COVID-19 Infection and a Brief Review of the Literature.

More than three and a half years have passed since the start of the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and there have been several studies in the literature about the different damage and symptom patterns related to the condition; particular attention has been paid to the transmission of the disease from pregnant mothers to fetus. In this report, we present the case of a 36-year-old patient with a history of two cesarean sections (CS), two miscarriages, and hypothyroidism on replacement therapy, who contracted COVID-19 during the 15th week of gestation. Ultrasound (US) examination at 22 weeks revealed regular fetal biometry and bilateral ventriculomegaly, highly suggestive of massive intracerebral hemorrhage. The patient opted for the interruption of pregnancy. Given the critical maternal COVID-19 complications, especially tracheoesophageal fistula and the patient's two previous cesareans, we decided on an abortive CS at 23 weeks of gestation, and the samples were sent to the Pathology Department. Histologic analysis showed massive intervillous deposition of fibrin and inflammatory infiltration with hotspots of necrotic deciduitis and confirmed massive cerebral hemorrhage in the fetus. This morphological appearance was consistent with COVID-19 infection and probable fetal oxygenation compromise related to deciduitis. Immunoexpression of anti-SARS-CoV-2 S1 antibody was almost entirely positive at the level of syncytiotrophoblast cells and maternal leukocytes in the absence of a clear signal in the fetal circulation. Conversely, in the brain, immunoexpression of angiotensin-converting enzyme 2 (ACE2) and the S1 subunit of the spike protein of SARS-CoV-2, detected by a monoclonal antibody, was almost entirely negative, suggesting that there was no infection in the brain and that the massive intraventricular hemorrhage was probably a secondary effect of placental damage.

Endometrial Osseous Metaplasia: An Hysteroscopic Incidental Finding - An Overview.

Endometrial osseous metaplasia (EOM) is an uncommon clinical entity with the presence of bone in the endometrium which requires clinical and therapeutic framework. It is also described by various other names such as endometrial ossification, ectopic intrauterine bone, and heterotopic intrauterine bone. Ossification could have various locations as the cervix the ovary, and the vagina. This overview highlights the attention on the actual pivotal points of EOM.

"The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature.

The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.

Cornual Pregnancy.

Cornual pregnancy (CP) is a subtype of ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube which is defined as the tubal section crossing uterine muscular tissue. Widely recognized risk factors for CP are endometriosis, uterine leiomyomata, or pelvic inflammatory disease; all these diseases can cause tubal anatomic changes and consequently alter embryo physiological implant process. Many treatment options are available for this condition each one must be tailored according to patient and operating scenario. The incidence of uterine ruptures in the scarred uterus appears to be low, but the fear of it remains and therefore medical treatment might be favored over cornual wedge resection. The actual risk of uterine rupture after medical treatment is unknown. Multiple testing strategies exist to diagnose CP, but caution needs to be used to avoid a false diagnosis.

Intrapartum ultrasound and mother acceptance: A study with informed consent and questionnaire.

Introduction: Intrapartum ultrasound (IU) is used in the delivery ward; even if IU monitors the labouring women, it could be perceived as a discomfort and even as an" obstetric violence", because it is a young technique, not often well "accepted". A group of clinicians aimed at obtain an informed consent from patients, prior to perform a translabial ultrasound (TU). The aim of this study was to evaluate the acceptance of both translabial and transabdominal IU. Methods: In this study, performed at the University Hospital of Bari (Unit of Obstetrics and Gynecology), were enrolled 103 patients in the first or second stage of labor in singleton cephalic presentation. A statistical frequency and an association analysis were performed. As a significant result, we consider the peace of mind/satisfaction and the" obstetric violence". IU was performed both transabdominal and translabial to determine the presentation, head positions, angle of progression and head perineum distance. During the first and second stage of labor, the ASIUG questionnaires (Apulia study intrapartum ultrasonography group) were administered. Results: 74 (71, 84%) patients underwent IU and 29 had a vaginal examination (28, 15%). Significant less "violence" has been experienced with a IU (73 out 74/98, 65%) and only one person (1 /1, 35%) recorded that. On the contrary, 10 patients (10/29) perceived that "violence" (34, 48%) while 19 (65, 52%) did not respond on a similar way, after a vaginal examination (VE). More patients felt satisfaction (71 out 74/95, 95%) with the use of IU and only 3 (3/4, 05%) felt unease. A different picture was evident in the vaginal examination group. Only 17 patients (17 out 29/58, 62%) felt comfort while 12 (41, 38%) felt unease. Conclusions: In our study, IU use is well accepted by most of patients, because it could reassure women about their fetal condition. Moreover, they can see the fetus on the screen, while the obstetrician is performing the US and this is important for a visual feedback, in comparison with the classical VE.

Pregnancy by Oocyte Donation: Reviewing Fetal-Maternal Risks and Complications.

Oocyte donation (OD) has greatly improved over the last three decades, becoming a preferred practice of assisted reproductive technology (ART) for infertile women wishing for motherhood. Through OD, indeed, it has become possible to overcome the physiological limitation due to the ovarian reserve (OR) exhaustion as well as the poor gamete reliability which parallels the increasing age of women. However, despite the great scientific contribution related to the success of OD in the field of infertility, this practice seems to be associated with a higher rate of major risky events during pregnancy as recurrent miscarriage, infections and placental diseases including gestational hypertension, pre-eclampsia and post-partum hemorrhage, as well as several maternal-fetal complications due to gametes manipulation and immune system interaction. Here, we will revisit this questioned topic since a number of studies in the medical literature focus on the successful aspects of the OD procedure in terms of pregnancy rate without, however, neglecting the risks and complications potentially linked to external manipulation or heterologous implantation.

A Study of Repair Mortars for Restoration of Wall Painted Plasters in a Hypogeum Rock-Cut Church of Matera (Southern Italy).

Several lime mortars for the repair of painted plasters of the rock-cut church of Ss. Pietro and Paolo in Matera were studied. They were designed taking into account both aesthetic criteria that need to be fulfilled in the field of paintings restoration, and physical-mechanical compatibility with the original materials on site, i.e., the pre-existing plasters and the supporting rock. Mixes with calcareous and silica aggregates, based on different grain size proportions, were prepared to fill missing portions of the original painted plaster. The effects of the mineralogical nature and size of the aggregates on the characteristics and properties of the mixes were investigated in relation to the microstructure, physical-mechanical features and resistance to salt ageing. At the end of the experimental campaign, the overall performance was evaluated.

Office intrauterine morcellation for retained products of conception.

OBJECTIVE: Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs). DESIGN: Prospective analysis. SETTING: A teaching and university hospital. PATIENTS: Women with RPOC. INTERVENTIONS: Office -HM with 'Truclear 5 C'. MATERIAL AND METHODS: Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed. RESULTS: Mean procedure time was six minutes (SD ± 5). Tissue samples had a mean collection size 2.5 cm3+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any de novo IUAs in any of the enrolled patients. CONCLUSIONS: In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.

Thrombosed Arteriovenous Malformation of Umbilical Cord.

Background: Arteriovenous malformation of umbilical cord is an extremely rare congenital malformation. Causes of this condition are unknown. AVM of umbilical cord can cause significant complications in the developing fetus. Methods: We report our management of the case with accurate ultrasound study that could improve and facilitate the approach to this pathology due to the lack of literature and with an overview of the available literature. Results: There are only two cases of umbilical AVM diagnosed in the prenatal period with associated pathology. The mainstay of prenatal detection is the accurate study of umbilical cord also even if it is not requested from the actual guide lines in a way to improve the perinatal morbidity and mortality.

Management of a rare case of placenta trophotropism.

There are several variations of placental shape or implantation. Multilobed placentas are thought to arise due to implantation in areas of decreased uterine perfusion. An example is represented by lateral implantation in between the anterior and posterior walls of the uterus. Other local factors leading to multilobation are implantation over leiomyomas, in areas of previous surgery, in the cornu, or over the cervical os. After implantation, there is preferential growth in areas of superior perfusion and atrophy in areas of poor perfusion. This is called trophotropism. We described a singular case of uterine synechia, where is laid the succenturiate lobe from the anterior to the posterior wall, obstacles fetal head descent in the pelvis. Due of that synechia, a cesarean section is necessary for fetal transverse situation with reverse breech extraction.

Cost analysis of minimally invasive radical hysterectomy for cervical cancer performed by a single surgeon in an Italian center: an update in gynecologic oncological field.

The objective of this study is to perform an economic analysis and examine the influence of procedural volume of our hospital, evaluating the accounting systems of Robotic radical hysterectomy (RRH) vs Laparoscopic radical hysterectomy (TLRH) in patients with cervical carcinoma, due to the costs widely variable and lack in literature. Costs were collected prospectively, from March 2010 to March 2016. Direct costs were determined by examining the overall medical pathway for each type of intervention. 52 patients with cervical carcinoma, which were matched by age, body mass index, tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, comorbidity, previous neoadjuvant chemotherapy, histology type, and tumor grade to obtain homogeneous samples. Surgical time was similar for both the groups. RRH was associated with a significantly less (EBL) estimated blood loss (P = 0.000). The overall median length of follow-up was of 59 months. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of an RRH was €5650,31 with an hospital stay (HS) of 3.58 days (SD ± 1) vs €3750.86 for TRLH, with an HS of 4.27 days (SD ± 1.79). Our results are similar to Finnish data; the costs of robot-assisted hysterectomies were 1.5 times higher than TLRH. The main drivers of additional costs are robotic disposable instruments, which are not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. RRH resulted less expensive than robotic simple hysterectomy for benign conditions.

Robotic approach using simple and radical hysterectomy for endometrial cancer with long-term follow-up evaluation.

BACKGROUND: Feasibility and outcome of robotic-assisted laparoscopy (RAL) for endometrial cancer was evaluated with a mean follow-up of 4 years. METHODS: Robotic hysterectomy (RH) and type B robotic radical hysterectomy (RRH), with or without pelvic lymphadenectomy (PLH), was performed on 51 consecutive patients. Records were reviewed for demographic data, medical/surgical history and comorbidities, perioperative findings and outcomes, as well as long-term complications and recurrences. Regarding stage, according to 2009 FIGO, 25% of cases were IA, while 20%, 53% and 2% of cases were, respectively, IB, II and IIIA stage. RESULTS: Twenty-eight patients underwent RRH + PLH (54.9%), four patients underwent RH with concurrent nodal sampling (NS) (7.8%); a total of 32 PLH were performed (62.6%).The median operative time for RRH + PLH was 255 min (range: 160-435). Pathology confirmed the adequacy of the surgical specimen. CONCLUSION: Our data support the adoption of RAL staging in patients with endometrial cancer, including those with cervical involvement, and demonstrate good long-term outcomes.

Oak bark allometry and fire survival strategies in the Chihuahuan desert Sky Islands, Texas, USA.

Trees may survive fire through persistence of above or below ground structures. Investment in bark aids in above-ground survival while investment in carbohydrate storage aids in recovery through resprouting and is especially important following above-ground tissue loss. We investigated bark allocation and carbohydrate investment in eight common oak (Quercus) species of Sky Island mountain ranges in west Texas. We hypothesized that relative investment in bark and carbohydrates changes with tree age and with fire regime: We predicted delayed investment in bark (positive allometry) and early investment in carbohydrates (negative allometry) under lower frequency, high severity fire regimes found in wetter microclimates. Common oaks of the Texas Trans-Pecos region (Quercus emoryi, Q. gambelii, Q. gravesii, Q. grisea, Q. hypoleucoides, Q. muehlenbergii, and Q. pungens) were sampled in three mountain ranges with historically mixed fire regimes: the Chisos Mountains, the Davis Mountains and the Guadalupe Mountains. Bark thickness was measured on individuals representing the full span of sizes found. Carbohydrate concentration in taproots was measured after initial leaf flush. Bark thickness was compared to bole diameter and allometries were analyzed using major axis regression on log-transformed measurements. We found that bark allocation strategies varied among species that can co-occur but have different habitat preferences. Investment patterns in bark were related to soil moisture preference and drought tolerance and, by proxy, to expected fire regime. Dry site species had shallower allometries with allometric coefficients ranging from less than one (negative allometry) to near one (isometric investment). Wet site species, on the other hand, had larger allometric coefficients, indicating delayed investment to defense. Contrary to our expectation, root carbohydrate concentrations were similar across all species and sizes, suggesting that any differences in below ground storage are likely to be in total volume of storage tissue rather than in carbohydrate concentration.

Uterine rupture in a nulliparous woman with septate uterus of the second trimester pregnancy and review in literature.

INTRODUCTION: Uterine rupture (UR) in early pregnancy in nulliparous women is a rare and unpredictable occurrence with high maternal morbidity and fatal fetal outcomes. Intrauterine anomalies could be the primum movens of this dangerous condition and underestimated in the literature. PRESENTATION OF CASE: An uncommon case of uterine rupture at the 23rd week of gestation in a nulliparous woman, who became pregnant before the resection of an uterine septum. To provide more insight into the possible risk factors, a literature review was performed. DISCUSSION: Loss of pregnancy is common, despite prompt uterine repair. In all cases reviewed abdominal pain characterized by indistinct vague symptoms constitutes the initial symptom of this obstetrical life threatening condition. CONCLUSION: The current case highlights the association of curettage and septate uterus as a risk factor for UR in the second trimester of pregnancy. It's reasonable that obstetricians must take into account that common gastrointestinal tract problems might be an indicator of the initial weakness of uterine wall leading to the rupture, which is unpredictable all of cases reviewed.