In-utero characterization of the blood flow in the Hyrtl anastomosis.

An anastomosis between the two umbilical arteries, located approximately within 3 cm from the placental insertion, has been previously described at delivery and in utero. However, the prenatal investigation of the Hyrtl anastomosis is limited to case reports. We report a series of antenatal functional evaluations of this vessel. Forty-one women underwent a target ultrasonography to evaluate the blood flow characteristics of the Hyrtl anastomosis. The resistance index of the anastomosis and the umbilical arteries resistance indices before and after the anastomosis were obtained. The direction of the blood flow in the anastomosis was determined by color Doppler evaluation. An anastomosis between the two stems of the umbilical arteries was present in 36 cases while a fusion of the two umbilical arteries was found in the remaining five cases. The median (range) gestational age at diagnosis was 33.1 weeks (25.5-40.1). The median diameter of the anastomosis was 2.3 mm (1.3-7.1). The blood flow in the anastomosis was pulsatile with a median resistance index of 0.62 (0.45-0.85) and unidirectional toward the umbilical artery with lower resistance index. The difference between the resistance indices of the two umbilical arteries was higher after than before the anastomosis [0.07 (0-0.3) versus 0.04 (0-0.17), P=0.05]. The median diameter of the Hyrtl anastomosis was significantly higher when the anastomosis was oblique (n=8) than when it was transverse (n=28) (4.8 mm [2-7.1] versus 2.3 mm [1.3-5.3], P< 0.05). In three out of the five cases with fusion of the two umbilical arteries the placental insertion was marginal or velamentous. We conclude that the Hyrtl anastomosis may act as a pressure-equalizing system between umbilical arteries. This supports the hypothesis that the Hyrtl anastomosis plays an important role when the placental territories supplied by the umbilical arteries are different in size.

Incisional hernia in gynecologic oncology patients: a 10-year study.

OBJECTIVE: To evaluate the independent contribution of clinical and constitutional factors in the development of early and late incisional hernias in women undergoing surgery for uterine cancer. METHODS: Over 10 years, patients undergoing extended abdominal hysterectomy for cervical or endometrial malignancies through a vertical incision were followed for the identification of incisional hernias. Logistic regression and survival analyses were used for statistics. RESULTS: Four hundred fifty-five women were included in the study, 77 of whom (16.9%) developed incisional hernias. The median (range) body mass index was higher in women who developed an incisional hernia than in those who did not (28 [19--44] kg/m(2) versus 24 [16--41] kg/m(2); P <.01). The frequencies of diabetes (14.3% versus 4.8%; P <.01), wound sepsis (10.4% versus 1.3%; P <.05), and fascial closure with interrupted sutures (70.1% versus 55.6%; P <.05) were significantly higher in women with incisional hernia than in those without. Multiple logistic regression revealed that, after adjustment for confounding variables, the only factors associated with incisional hernia formation within 1 year from the operation were body mass index above 27 kg/m(2) (odds ratio [OR] 3.68; 95% confidence interval [CI] 1.38, 9.81; P <.01) and wound infection (OR 5.05; 95% CI 1.39, 18.37; P <.01), whereas the factors associated with incisional hernia formation at least 3 years after surgery were diabetes (OR 6.68; 95% CI 2.02, 22; P <.01) and wound infection (OR 8.55; 95% CI 1.54, 47.5; P <.01). For hernia developing after 5 years (OR 8.32; 95% CI 1.41, 55.65; P <.05) and 8 years (OR 49.52; 95% CI 2.72, 907.14; P <.01), the only significant association was found with diabetes. CONCLUSION: Late incisional hernia formation does not depend on conditions present at the time of operation or on surgical technique. Other factors such as diabetes seem to play an important role in the development of late incisional hernia.

Bioelectrical impedance analysis during pregnancy and neonatal birth weight.

OBJECTIVE: To generate reference ranges for bioelectrical impedance indices throughout pregnancy and to investigate whether a relationship exists between these indices and the neonatal birth weight. STUDY DESIGN: Pregnant women with a singleton gestation, gestational age lower than 12 weeks, and absence of medical diseases before pregnancy were enrolled. Patients with pregnancy complications, such as hypertensive disorders, diabetes, and antiphospholipides syndrome were excluded. Antrophometric maternal parameters and bioelectrical impedance measurements were performed during the first, second, third trimester of pregnancy, at delivery and 60 days after delivery. Height(2)/resistance (cm(2)/Omega) and height(2)/reactance (cm(2)/Omega) were utilized to estimate the total and extracellular body water amounts, respectively. Spearman rank correlations and cox proportional hazard modelling were used for statistical purposes. RESULTS: 169 patients completed all measurements. Total and extracellular water amounts significantly increase as pregnancy advances and return to the pre-pregnancy values within 60 days after delivery. After adjustment for gestational age at delivery, fetal sex, and smoking habits, height(2)/resistance at 25 weeks (hazard=1.04, 95% confidence interval (CI) 1.02-1.06, P<0.005), height(2)/resistance at 30 weeks (hazard=1.03, 95% CI 1.01-1.05, P<0.005), height(2)/reactance at 20 weeks (hazard=1.03,95% CI 1.01-1.05, P<0.005), and height(2)/reactance at 25 weeks (hazard=1.03, 95% CI 1.01-1.04, P<0.01) were found to be independent predictors of birth weight. CONCLUSION: We have provided reference ranges for bioimpedance analysis during pregnancy, an easy, fast and non invasive method to estimate the body water composition during pregnancy. Bioelectrical impedance indices during the second trimester of pregnancy are independently related to the birth weight.

Extra-amniotic Foley catheter and prostaglandin E(2) gel for cervical ripening at term gestation.

OBJECTIVE: This study evaluated the efficacy of intravaginal prostaglandin E(2) gel in comparison with that of a Foley catheter for cervical ripening and induction of labor. STUDY DESIGN: Consecutive patients with unfavorable cervix requiring preinduction cervical ripening and induction of labor at term gestation were asked to participate in the study. One hundred and two patients were assigned to treatment with intravaginal prostaglandin E(2) gel (group 1) and 122 patients underwent the placement of an intracervical Foley catheter (group 2). After a maximum of three applications of intravaginal prostaglandin E(2) gel (18h) or after 18h from Foley catheter insertion oxytocin was administered to patients not in active labor. Labor profiles and pregnancy and neonatal outcome were compared between groups. RESULTS: The groups were comparable in term of demographic characteristics, indications for induction of labor, Bishop score at admission. The induction to labor time and the induction to delivery time were similar between groups. The cesarean sections rate was higher in group 1 than in group 2 (26.5 versus 14.7%, P<0.05). This remained significant when the analysis was restricted to nulliparous patients (32.3 versus 14.2%). The incidence of urinary tract infections, chorioamnionitis, and febrile morbidity was similar between groups. CONCLUSION: For preinduction cervical ripening, the Foley catheter is a valid alternative to the application of intravaginal prostaglandin E(2) gel and it is associated with a lower cesarean rate in nulliparous women.

Adenocarcinoma of the uterine cervix.

From 1970 to 1989, 39 patients with cervical adenocarcinoma (9.3% of all cervical cancers) were treated in the Department of Gynecology - University of Pavia. Adenocarcinoma seemed to be a disease epidemiologically different from epidermoid carcinoma. Treatment included radical hysterectomy, radiotherapy, radical hysterectomy and radiotherapy. In stage I disease survival was not significantly influenced by treatment modality. However in young patients without risk factors surgery seemed to obtain the best results; in high risk patients adjuvant radiotherapy did not apparently improve survival. Prognosis for adenocarcinoma seemed to be worse than for its squamous counterpart. The main prognostic factors were grading and lymph node status. Relapse occurred also a long time after treatment. In 2 cases we observed Cervical Intraepithelial Neoplasia grade 3 (CIN 3) in association with adenocarcinoma.

Diagnostic alternatives to second look in ovarian cancer.

The accuracy of the markers CA 125, CA 15-3, CA 50 serum levels and the CT findings as alternative monitoring techniques to second look has been evaluated in 25 patients. The negative predictive value for the CA 125 was of 55% and its sensibility seems not to be increased by the association of the other markers. For the CT findings we report a diagnostic accuracy of 76%.

[HELLP syndrome. Discussion of a case]. / HELLP syndrome. Discussione di un caso.

The HELLP syndrome is the most severe variant of pre-eclampsia. A case is reported in a primigravida patient at 25 weeks of gestation. The lack of response to medical treatment and the deterioration of maternal indices necessitated a Cesarean section with intensive neonatal care at a very premature stage. The physiopathological grounds and the various methods of treating this syndrome are discussed and the paper concludes that rapid birth is the only solution capable of preventing severe maternal complications.

Cesarean section: an economic appraisal of infectious complications.

From March 1991 to April 1992, in the Dept. of Obstetrics and Gynecology, University of Pavia-Varese, 107 out of 115 consecutive patients submitted to cesarean section were evaluated for the clinical and economic evaluation of infectious complications. On the grounds of our previous experience we distinguished two groups: a high infection risk group (50 pts), because of labor and/or rupture of membranes, HIV+, diabetes; and a low infection risk group (57 pts). Our findings support the choice of these selective criteria both for the infectious event or for the use, and thence for the costs, of antibiotic treatment. In fact, based on this experience we believe that in cesarean sections with high infection risk AP is always recommended whereas in the low risk ones AP should not exceed L. 10.095 to be cost-effective.

Nomogram of Wharton's jelly as depicted in the sonographic cross section of the umbilical cord.

OBJECTIVES: To generate a nomogram for the sonographic measurement of Wharton's jelly area (WJA) during gestation and to investigate whether WJA is related to fetal biometric parameters. METHOD: The sonographic cross-sectional area of the umbilical cord and of its vessels was measured in 659 fetuses between 15 and 42 weeks of gestation. The WJA was calculated by subtracting the vascular area from the umbilical cord area. The conventional biometric parameters were measured and correlated with the WJA. Polynomial regression analysis was utilized for statistical purposes. RESULTS: The WJA increased as a function of gestational age (r = 0.63, P < 0.001). The regression equation for the mean WJA (y) according to gestational age (x) was y = -114.7 + 4.142x - 0.01x2 and for the standard deviation (y') was y' = -7.567 + 1.319x. There was a strong correlation between the WJA and the umbilical cord area (r = 0.97, P < 0.001). A significant correlation was also found between the WJA and fetal biometric parameters before 32 weeks of gestation (WJA and biparietal diameter: r = 0.82, P < 0.001; WJA and abdominal circumference: r = 0.79, P < 0.001; WJA and femur length: r = 0.81, P < 0.001) while after 32 weeks of gestation no correlations were found between WJA and fetal anthropometric parameters. CONCLUSION: A nomogram for the WJA has been generated. The WJA increases as a function of gestational age and it is correlated with fetal size up to 32 weeks of gestation.

A randomized clinical trial of two surgical techniques for cesarean section.

The Joel-Cohen incision followed by nonclosure of pelvic and parietal peritoneum has been advocated as an alternative method to the Pfannenstiel incision with peritonealization at cesarean section. A randomized trial was designed to compare intra- and postoperative morbidity between the two techniques. Women to undergo a cesarean section were randomly allocated to have either the Joel-Cohen incision with the parietal and pelvic peritoneum left open (group 1) or to have the Pfannenstiel incision with both peritoneal layers sutured (group 2). The myometrium was closed with 1-0 polyglactin 910 suture using a continuous single-layer nonlocking technique. Patients in group 2 had the peritoneum approximated with 2-0 polyglactin 910 suture. The fascia was sutured with continuous 1-0 polyglactin 910 suture in all cases. Opening time was defined as the interval from skin incision to the opening of the uterine cavity. Febrile morbidity was defined as a temperature > or =38 degrees C on two occasions 4 hours (hr) apart excluding the first postoperative day. Endometritis was defined as postpartum temperature > or =38 degrees C on two occasions 4 hr apart, with uterine tenderness and/or foul-smelling lochia. One hundred forty-nine and 150 patients were allocated to group 1 and to group 2, respectively. A shorter median (range) opening time [4 min (2-21) vs. 6 min (2-19), respectively, p < 0.01] and a shorter median (range) operative time [30 min (10-65) vs. 40 min (20-110), respectively, p < 0.01] were observed in group 1. No difference was found in terms of intraoperative complications, proportion of patients who required transfusion, endometritis, sepsis, febrile morbidity, and urinary tract infections. A higher rate of wound infections was found in group 2 than in group 1 [14 of 150 (9.3%) vs. 2 of 149 (1.3%), respectively, p < 0.01]. The Joel-Cohen incision without peritonealization resulted in a shorter opening and total operative time than the Pfannenstiel laparotomy with peritonealization. This was accomplished with a reduction of wound infections.