Intraoperative adverse events associated with extremely preterm cesarean deliveries.

INTRODUCTION: At the same time as survival is increasing among premature babies born before 26 weeks of gestation, the rates of cesarean deliveries before 26 weeks is also rising. Our purpose was to compare the frequency of intraoperative adverse events during cesarean deliveries in two gestational age groups: 24-25 weeks and 26-27 weeks. MATERIAL AND METHODS: This single-center retrospective cohort study included all women with cesarean deliveries performed before 28+0 weeks from 2007 through 2015. It compared the frequency of intraoperative adverse events between two groups: those at 24-25 weeks of gestation and at 26-27 weeks. Intraoperative adverse events were a classical incision, transplacental incision, difficulty in fetal extraction (explicitly mentioned in the surgical report), postpartum hemorrhage (≥500 mL of blood loss), and injury to internal organs. A composite outcome including at least one of these events enabled us to analyze the risk factors for intraoperative adverse events with univariate and multivariable analysis. Stratified analyses by the indication for the cesarean were performed. RESULTS: We compared 74 cesarean deliveries at 24-25 weeks of gestation and 214 at 26-27 weeks. Intraoperative adverse events occurred at higher rates in the 24-25-week group (63.5 vs. 30.8%, p < 0.001). After adjustment for confounding factors, this group remained at significantly higher risk of intraoperative adverse events [adjusted odds ratio 5.04 (2.67-9.50)], even after stratification by indication for the cesarean. CONCLUSION: These results should help obstetricians and women making decisions about cesarean deliveries at these extremely low gestational ages.

Increased rate of spontaneous miscarriages in endometriosis-affected women.

STUDY QUESTION: Were spontaneous miscarriages more frequent in women with histologically proven endometriosis when compared with endometriosis-free controls? SUMMARY ANSWER: Endometriosis-affected women display a significantly higher rate of previous spontaneous miscarriages than endometriosis-free controls. WHAT IS KNOWN ALREADY: The association between endometriosis and miscarriages has long been debated without reaching a consensus. STUDY DESIGN, SIZE, DURATION: We conducted a retrospective cohort study comparing exposed women (endometriosis) and control (without endometriosis) regarding the incidence of miscarriages. All study participants underwent surgery for benign gynaecological conditions in a tertiary-care university hospital between January 2004 and March 2013. After thorough surgical examination of the abdominopelvic cavity, 870 women with histologically proven endometriosis were allocated to the endometriosis group and 981 unaffected women to the control group. Only previously pregnant women were finally included for the study analysis: 284 women in the endometriosis group and 466 in the control group. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were collected preoperatively using a structured questionnaire. Among women with at least one pregnancy before the surgery, the type and number of the different previous first trimester pregnancies outcomes were studied. Previous history of miscarriage was studied according to the existence of previous infertility history and the disease severity (revised American Fertility Society and surgical classification). MAIN RESULTS AND THE ROLE OF CHANCE: Four hundred and seventy-eight pregnancies in endometriosis-affected women and 964 pregnancies in controls were analysed. The previous miscarriage rate was significantly higher in women with endometriosis compared with the controls (139/478 [29] versus 187/964 [19%], respectively; ITALIC! P < 0.001). After a subgroup analysis, the miscarriage rates of women with endometriosis and the controls were, respectively: 20 versus 12% ( ITALIC! P = 0.003) among women without a previous history of infertility and 53 versus 30% ( ITALIC! P < 0.001) for women with a previous history of infertility. After using a random-effects Poisson regression and adjusting for confounding factors, we found a significantly increased incidence rate ratio (IRR) for miscarriages in women with endometriosis (adjusted IRR: 1.70, 95% confidence interval: 1.34-2.16). LIMITATIONS, REASONS FOR CAUTION: There is a possible selection bias due to the specificity of the study design which included only surgical patients. In the control group, certain of the surgical gynaecological conditions, such as fibroids, ovarian cysts or tubal pathologies, might be associated with higher spontaneous miscarriage rates. In the endometriosis group, asymptomatic women were less likely to be referred for surgery and might therefore be underrepresented. WIDER IMPLICATIONS OF THE FINDINGS: This study opens the doors to future, more mechanistic studies to establish the exact link between endometriosis and spontaneous miscarriage rates. STUDY FUNDING/COMPETING INTERESTS: No external funding was used for this study. The authors have no conflicts of interest to declare.

Measurement of hs-CRP is irrelevant to diagnose and stage endometriosis: prospective study of 834 patients.

OBJECTIVE: The pathogenesis of endometriosis is associated with an inflammatory process. Here, we assessed if the levels of high-sensitivity C-reactive protein (hs-CRP) in serum could constitute an effective method for detecting systemic inflammation during endometriosis. STUDY DESIGN: This was a prospective, laboratory-based study, which was carried out in a tertiary care university hospital. Patients with histologically proven endometriosis (n = 370) and unaffected women (n = 464) were enrolled from January 2005 through December 2009. We performed complete surgical excision of endometriotic lesions with pathological analysis. In addition, hs-CRP levels were determined through a particle-enhanced immunoturbidimetric method. The hs-CRP levels were measured in both controls and women with endometriosis according to the established surgical classifications of endometriosis: superficial peritoneal endometriosis, endometrioma, and deep infiltration endometriosis. Also, hs-CRP levels were evaluated according to hormonal treatment and menstrual cycle. RESULTS: The hs-CRP serum levels did not statistically differ between women with endometriosis and controls (median in ng/mL [range]: 0.82 [0.04-42.89] vs 0.9 [0.03-43.73], respectively; P = .599). Moreover, subgroup analysis revealed no difference among superficial peritoneal endometriosis, endometrioma, deep infiltration endometriosis, and controls: 0.8 (0.15-13.35), 0.81 (0.04-38.82), 0.83 (0.09-42.89), and 0.9 (0.03-43.73), respectively; P = .872. Furthermore, no effect was observed regarding hormonal treatment or menstrual cycle. CONCLUSION: Although endometriosis is an inflammatory disease, we failed to identify any systemic changes in hs-CRP serum levels. Therefore, hs-CRP analysis appears to be irrelevant to the diagnosis and staging of endometriosis.

An Unknown Renaissance Portrait of Tagliacozzi (1545-1599), the Founder of Plastic Surgery.

This article examines a recently discovered painting of a young scholar holding a reconstructed nose. Experts in ancient paintings have confirmed that the portrait is an authentic painting of the School of Bologna in Italy, from the last quarter of the Renaissance. In the 1580s, Gaspare Tagliacozzi (1545-1599), a young professor in surgery and anatomy at the University of Bologna, Italy, was the only one to carry out reconstructions of the nose and other missing parts of the face. We have looked whether different relevant components of this painting, which is presented for the first time to the medical community, could match with Tagliacozzi's life and achievements. We have also compared the portrait to another portrait of Tagliacozzi painted circa 1597, which belongs to the institute Rizzoli in Bologna, Italy. The latter depicts Tagliacozzi as an older established surgeon. He is seen presenting his illustrated book, De Curtorum Chirurgia per Insitionem (On the surgical restoration of defects), which is the first book devoted to plastic surgery. We have concluded that the young Renaissance scholar is Tagliacozzi. This portrait and the Rizzoli's portrait represent Tagliacozzi at the beginning and at the peak of his professional involvement in the field of plastic surgery. Tagliacozzi is the first medical doctor to practice plastic surgery as well as write about it. He also taught plastic surgery for the first time in a prestigious Renaissance school of medicine. Tagliacozzi's illustrated book of plastic surgery published in 1597, disrupted the contemporary medical community. For all these reasons, Tagliacozzi can be considered as the founder of plastic surgery. Unfortunately, he died at the age of 54, which put a term to the development of this field. Tagliacozzi's work was rediscovered, 2 centuries later, by the English surgeon J.C. Carpue (1764-1846) during the revival of plastic surgery.

Conservative management of an advanced abdominal pregnancy at 22 weeks.

Objective We report an uneventful conservative approach of an advanced abdominal pregnancy discovered at 22 weeks of gestation. Study Design This study is a case report. Results Attempting to extend gestation of an advanced abdominal pregnancy is not a common strategy and is widely questioned. According to the couple's request, the management consisted in continuous hospitalization, regular ultrasound scan, and antenatal corticosteroids. While the woman remained asymptomatic, surgery was planned at 32 weeks, leading to the birth of a preterm child without any long-term complications. Placenta was left in situ with a prophylactic embolization, and its resorption was monitored. Conclusion Depending on multidisciplinary cares and agreement of the parents, when late discovered, prolonging advanced abdominal pregnancy appears to be a reasonable option.