Reconstructive surgery after Female Genital Mutilation: a multidisciplinary approach.

BACKGROUND AND AIM: Female Genital Mutilations (FMGs) are all interventions involving partial or total removal of external female genital apparatus, perpetrated not for therapeutic purposes. This review aims to describe a multidisciplinary approach to clinical management of women with FGM, requiring reconstructive surgery and therapeutic deinfibulation. Furthermore, these traditional procedures are harmful to women's physical integrity, being able to result in severe psychological damage with strong inhibitions in sexual and emotive life. METHODS: Clinical management followed internal protocol implemented at the obstetric Pathology of IRCCS Burlo Garofolo of Trieste, in the framework of the regional project "Female genital mutilation and women immigrants: a draft integrated training and support person," supported by Regione Friuli Venezia Giulia, Italy. We have enrolled in our protocol 15 women that came in our Hospital spontaneously. Here, we present a case of a 38-year-old woman, who had undergone ritual FGM type III with a deep groove scar. She had suffered pain and limitations to sexual intercourses. RESULTS: We performed a reconstructive surgery of the mutilated genital tissue and a therapeutic deinfibulation. The deep groove scar was successfully removed with a multidisciplinary approach. We achieved careful evaluation, both clinical and psychological, of the patient, before surgery. CONCLUSIONS: Reconstructive surgery for women who suffer sexual consequences from FGM is feasible. It restores women's natural genital anatomy, allowing to improve female sexuality.

Soluble TRAIL is elevated in recurrent miscarriage and inhibits the in vitro adhesion and migration of HTR8 trophoblastic cells.

STUDY QUESTION: What is the potential physiopathological role of tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) in recurrent miscarriage (RM), characterized by at least three consecutive pregnancy losses. SUMMARY ANSWER: The levels of serum TRAIL immediately after miscarriage in RM patients are significantly elevated with respect to that in first-trimester normal pregnant women, and recombinant TRAIL inhibits the adhesion and migration of HTR8 trophoblastic cells in vitro. WHAT IS KNOWN ALREADY: Both TRAIL and its trans-membrane receptors (TRAIL-R1, TRAIL-R2, TRAIL-R3 and TRAIL-R4) have been documented in the placenta, but their physiopathological role is incompletely understood. STUDY DESIGN, SIZE, DURATION: The study populations consisted of RM patients (n = 80) and first-trimester normal pregnant women (n = 80). Blood samples were obtained within 24 h after abortion (RM) or at gestational 12-week (normal pregnant women). As additional controls, third-trimester normal pregnant women (n = 28) were examined before (within 72 h) and after (within 24 h) partum. PARTICIPANTS/MATERIALS, SETTING, METHODS: The concentrations of TRAIL were analysed in serum samples by ELISA. In parallel, the effect of soluble recombinant TRAIL (0.1-1000 ng/ml) was analysed on the survival of primary extravillus trophoblasts (EVTs) and on the survival, proliferation, adhesion and migration of trophoblastic HTR8 cells. MAIN RESULTS AND THE ROLE OF CHANCE: The circulating levels of TRAIL in RM women (median: 52.5 pg/ml; mean and SD: 55.5 ± 24.4 pg/ml) were significantly higher with respect to first-trimester normal pregnant women (median: 44.9 pg/ml; mean and SD: 47 ± 15.1 pg/ml) and third-trimester normal pregnant women, as assessed before (median: 45.1 pg/ml; mean and SD: 46 ± 12.4 pg/ml) and after partum (median: 35.4 pg/ml; mean and SD: 38 + 17.5 pg/ml). Both primary EVT and HTR8 cells expressed detectable levels of TRAIL death receptors, but exposure to soluble recombinant TRAIL did not induce cell death of trophoblastic cells. On the other hand, TRAIL dose-dependently inhibited the adhesion of HTR8 cells to decidual endothelial cells (DEC) as well as the migration of HTR8 in transwell assays using either fibronectin or DEC. LIMITATIONS, REASONS FOR CAUTION: Although this study suggests that TRAIL might have a pathogenic role in RM by inhibiting both the adhesion and migration capabilities of first trimester trophoblastic cells, there is a possibility that the elevated serum levels of TRAIL in RM are not cause but rather the result of RM. WIDER IMPLICATIONS OF THE FINDINGS: Our current findings together with data of other authors suggest that circulating TRAIL should be further analysed as a potential important biomarker in different physiopathological settings. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by FIRB projects (RBAP11Z4Z9_002 to Giorgio Zauli and RBAP10447J_002 to Paola Secchiero). The authors have no competing interests to declare.

Glucose plasma levels and pregnancy outcomes in women with HIV.

BACKGROUND: There is limited information on the relation between glucose levels in pregnancy and adverse perinatal outcomes in HIV-infected pregnant women. OBJECTIVE: To evaluate the potential impact of fasting glucose levels on pregnancy outcomes in a large sample of pregnant women with HIV from a national study, adjusting for potential confounders. METHODS: Data from the Italian National Program on Surveillance on Antiretroviral Treatment in Pregnancy were used. The main outcomes evaluated in univariate and multivariable analyses were birthweight for gestational age>90th percentile (large for gestational age [LGA]), nonelective cesarean delivery, and preterm delivery. Glucose measurements were considered both as continuous and as categorical variables, following the HAPO study definition. RESULTS: Overall, 1,032 cases were eligible for the analysis. In multivariable analyses, a birthweight>90th percentile was associated with increasing fasting plasma glucose levels (adjusted odds ratio [AOR] per unitary (mg/dL) increase, 1.04; 95% CI, 1.01-1.06; P=.005), a higher body mass index, and parity of 1 or higher. A lower risk of LGA was associated with smoking and African ethnicity. A higher fasting plasma glucose category was significantly associated with LGA occurrence, and AORs for the glucose categories of 90-94 mg/ dL and 95-99 mg/dL were 3.34 (95% CI, 1.09-10.22) and 6.26 (95% CI, 1.82-21.58), respectively. Fasting plasma glucose showed no association with nonelective cesarean section [OR per unitary increase, 1.00; 95% CI, 0.98-1.02] or preterm delivery [OR per unitary increase, 1.00; 95% CI, 0.99-1.02]. CONCLUSIONS: In pregnant women with HIV, glucose values below the threshold usually defining hyperglycemia are associated with an increased risk of delivering LGA infants. Other conditions may independently contribute to adverse perinatal outcomes in women with HIV and should be considered to identify pregnancies at risk.

Circulating TRAIL shows a significant post-partum decline associated to stressful conditions.

BACKGROUND: Since circulating levels of TNF-related apoptosis inducing ligand (TRAIL) may be important in the physiopathology of pregnancy, we tested the hypothesis that TRAIL levels change at delivery in response to stressful conditions. METHODS/PRINCIPAL FINDINGS: We conducted a longitudinal study in a cohort of 73 women examined at week 12, week 16, delivery and in the corresponding cord blood (CB). Serum TRAIL was assessed in relationship with maternal characteristics and to biochemical parameters. TRAIL did not vary between 12 (67.6±27.6 pg/ml, means±SD) and 16 (64.0±16.2 pg/ml) weeks' gestation, while displaying a significant decline after partum (49.3±26.4 pg/ml). Using a cut-off decline >20 pg/ml between week 12 and delivery, the subset of women with the higher decline of circulating TRAIL (41.7%) showed the following characteristics: i) nullipara, ii) higher age, iii) operational vaginal delivery or urgent CS, iv) did not receive analgesia during labor, v) induced labor. CB TRAIL was significantly higher (131.6±52 pg/ml) with respect to the corresponding maternal TRAIL, and the variables significantly associated with the first quartile of CB TRAIL (<90 pg/ml) were higher pre-pregnancy BMI, induction of labor and fetal distress. With respect to the biochemical parameters, maternal TRAIL at delivery showed an inverse correlation with C-reactive protein (CRP), total cortisol, glycemia and insulin at bivariate analysis, but only with CRP at multivariate analysis. CONCLUSIONS: Stressful partum conditions and elevated CRP levels are associated with a decrease of circulating TRAIL.

Ascites in puerperium: a rare case of atypical pseudo-Meigs' syndrome complicating the puerperium.

PURPOSE: We report the case of puerperal ascites, associated with elevated CA125 levels and secondary to a uterine myoma. The literature on pseudo-Meigs' syndrome associated with pregnancy was reviewed. CASE: A 35-year-old woman complained of abdominal distension 2 days after a spontaneous vaginal delivery. A mass of 5 cm in the right uterine corner had been detected during the first trimester ultrasound and had been diagnosed as subserosal myoma. Physical examination and ultrasound revealed massive ascites. Computed tomography confirmed ascites and laboratory investigations showed CA125 raised levels. Cytology of ascitic fluid resulted negative for malignancy. A laparotomy was performed and a large pedunculated myoma was removed. A final diagnosis of atypical pseudo-Meigs' syndrome was performed, being computed tomography and chest X-ray negative for pleural effusion. CONCLUSIONS: To the best of our knowledge, this is the first case of pseudo-Meigs' syndrome caused by a uterine leiomyoma described in puerperium and without hydrothorax. Though ascites is very rare in obstetrics, it should be considered when evaluating puerperal patients complaining of abdominal distension.

Factors influencing gestational age-adjusted birthweight in a national series of 600 newborns from mothers with HIV.

BACKGROUND: Few studies have assessed the determinants of birthweight in newborns from HIV-positive mothers in analyses that adjusted for different gestational age at delivery. METHOD: We calculated gestational age-adjusted birthweight Z-score values in a national series of 600 newborns from women with HIV and in 600 newborns from HIV-negative women matched for gender and gestational age. The determinants of Z-score values in newborns from HIV-positive mothers were assessed in univariate and multivariate regression analyses. RESULTS: Compared to newborns from HIV-negative women, newborns from HIV-positive women had significantly lower absolute birthweight (2799 vs. 2887 g; p = .007) and birthweight Z score (-0.430 vs. -0.222; p < .001). Among newborns from mothers with HIV, the maternal characteristics associated with significantly lower Z-score values in univariate analyses were recent substance use (Z-score difference [ZSD] 0.612, 95% CI 0.359-0.864, p < .001), smoking >10 cigarettes/day (ZSD 0.323, 95% CI 0.129-0.518, p = .001), absence of pregnancies in the past (ZSD 0.200, 95% CI 0.050-0.349, p = .009), no antiretroviral treatment in the past (ZSD 0.186, 95% CI 0.044-0.327, p = .010), and Caucasian ethnicity compared to Hispanic (ZSD 0.248, 95% CI 0.022-0.475, p = .032). Body mass index (BMI) at conception and maternal glycemia levels during pregnancy were also significantly related to birthweight Z scores. Glycemia, BMI, and recent substance use maintained a significant association with Z-score values in multivariate analyses. In the multivariate analysis, the only factors significantly associated with Z-score values below the 10th percentile were recent substance use (adjusted odds ratio [AOR] 3.17, 95% CI 1.15-8.74) and smoking (AOR 2.26, 95% CI 1.13-4.49). DISCUSSION: We identified several factors associated with gestational age-adjusted birthweight in newborns from women with HIV. Smoking and substance use have a significant negative impact on intrauterine growth, which adds to an independent HIV-related effect on birthweight. Prevention and information on this issue should be reinforced in women with HIV of childbearing age to reduce the risk of negative outcomes in their offspring.

Early invasive diagnostic techniques in pregnant women who are infected with the HIV: a multicenter case series.

OBJECTIVE: Studies that mostly were conducted before the widespread use of combination antiretroviral treatments have reported that antenatal invasive procedures markedly increase the risk of human immunodeficiency virus vertical transmission. We aimed to evaluate the vertical transmission rate and other maternal and neonatal complications among women who were infected with human immunodeficiency virus who underwent antenatal invasive procedures during the second trimester of pregnancy and who were delivered after the advent of antiretroviral regimens. STUDY DESIGN: We conducted a multicenter case series of women who were infected with human immunodeficiency virus who underwent amniocentesis or chorionic villus sampling or cordocentesis during the second trimester of pregnancy and who were delivered after January 1, 1997. RESULTS: Sixty-three of 775 recruited women (8.1%) had performed early invasive diagnostic techniques . This rate has improved progressively from 4% in 1997 to 14%. Two of 60 viable infants (3.3%; 95% CI, 0.6%-10.1%) were infected with the human immunodeficiency virus. This rate did not differ significantly from the transmission rate that was observed in women who did not undergo antenatal invasive techniques (1.7%; P = .30). CONCLUSION: The current risk of human immunodeficiency virus vertical transmission that is associated with early invasive diagnostic techniques is lower than previously reported.

Gestational diabetes: universal or selective screening?

OBJECTIVE: To evaluate the incidence of gestational diabetes in our population and verify costs of universal screening. To assess neonatal and obstetrical outcomes with respect to maternal epidemiological characteristics. METHODS: Eight hundred and fifty-six pregnant women between 24th and 28th weeks of gestation were examined in this observational study. Universal screening with glucose challenge test was used to screen the group for gestational diabetes. History, obstetrical and neonatal outcomes were collected and then analyzed. RESULTS: Gestational diabetes was diagnosed in 6.6% of cases. Patients with at least one risk factor had a cesarean section in 50% of cases and a spontaneous vaginal delivery in 23.59% of cases (p < 0.001). The absence of any risk factor was found in 73.7% of positive glucose tolerance test and in 62.5% of affected patients. The cost of universal screening in our study, was 57,60 Euros per case identified. CONCLUSIONS: Given the high prevalence of diabetes, the high proportion of patients potentially not identified with a selective screening in this study and the relatively low cost, universal screening for gestational diabetes seems the best way to identify patients and prevent adverse obstetrical and neonatal outcomes.