Challenges in the diagnosis and management of Robert's uterus: Systematic review and case presentation.

Robert's uterus is a rare Müllerian duct anomaly (MDA) characterized by complete asymmetric septum dividing uterine cavity into two non-communicating parts. This study offers insights into diagnosing and management of this condition in a young patient, and a systematic literature review. The review included 19 studies from 2013 to 2023. 11.4% of women reported a history of miscarriage and 5.7% primary infertility. Dysmenorrhea was the most frequent symptom (54.3%), and 14.3% of patients had a coexisting endometriosis. The surgical interventions most commonly combine laparoscopic and hysteroscopic techniques. Robert's uterus requires heightened clinical awareness for early diagnosis, particularly in young women.

Rate of Vaginal Cuff Dehiscence When Using Vicryl (Poliglactyn 910) Compared to PDS (Polydioxanone) for Vaginal Cuff Closure in Laparoscopic Hysterectomy.

Objective: To compare the vaginal cuff dehiscence (VCD) rates using Vicryl (Poliglactyn 910) and Polydioxanone (PDS) in patients who underwent laparoscopic hysterectomy. Materials and methods: A retrospective, monocentric study was conducted, including all patients undergoing laparoscopic hysterectomy at the Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, between January 2014 and December 2021. Patients underwent hysterectomy for benign gynecologic pathologies (endometriosis, leiomyomas, or benign pelvic pathologies) or malignant gynecologic pathologies (endometrium cancer, complex endometrial hyperplasia, ovarian cancer, cervix cancer, or uterine carcinosarcoma). The Z-score calculation was performed to find eventual statistically significant differences between the two populations regarding VCD rates. Results: Laparoscopic vaginal cuff closure was performed, with Vicryl sutures in 202 patients and PDS sutures in 184 women. Demographic and baseline characteristics were not significantly different in the two groups. VCD occurred in three patients in the Vicryl group and did not occur in the PDS group. The three cases of VCD were precipitated by intercourses that occurred within 90 days of surgery. However, there was not a significant statistical difference between the two groups regarding VCD (p = 0.09). Conclusions: Vicryl and PDS sutures seem to be similar for vaginal cuff closure in laparoscopic hysterectomy. The VCD rate was low, and the observed differences between the Vicryl and PDS groups did not reach statistical significance. Further research through prospective studies is essential.

Meningioma in the third trimester of pregnancy: A case report.

Meningiomas are rare benign tumors during pregnancy. They can put both the mother and the fetus at risk because rapid changes in size may occur. The study reports a case of olfactory groove meningioma in a 34-year-old pregnant woman with visual impairment, anosmia, and dysgeusia that increased in severity during the 29th week of gestation. Magnetic resonance imaging showed an olfactory groove meningioma. The patient underwent a preterm cesarean section to avoid the worsening of the clinical condition due to intracranial compression phenomena. A computed tomography scan of the brain supported the diagnosis. The surgical intervention occurred on the third day after delivery. The clinical course was uneventful and the chiasmal syndrome improved in the following 2 months. Meningiomas in pregnancy may present unique challenges and have a wide array of clinical presentations. Management of maternal meningiomas can be complex and requires a multidisciplinary approach. The treatment decision largely depends on the size and location of the tumor, the presence of symptoms, gestational age, and fetal well-being. Further research is needed to enhance the understanding of the underlying mechanisms and improve management approaches for this rare condition.

The Effect of Maternal Dietary Patterns on Birth Weight for Gestational Age: Findings from the MAMI-MED Cohort.

Limited evidence exists on the effects of maternal dietary patterns on birth weight, and most studies conducted so far did not adjust their findings for gestational age and sex, leading to potentially biased conclusions. In the present study, we applied a novel method, namely the clustering on principal components, to derive dietary patterns among 667 pregnant women from Catania (Italy) and to evaluate the associations with birth weight for gestational age. We identified two clusters reflecting distinct dietary patterns: the first one was mainly characterized by plant-based foods (e.g., potatoes, cooked and raw vegetables, legumes, soup, fruits, nuts, rice, wholemeal bread), fish and white meat, eggs, butter and margarine, coffee and tea; the second one consisted mainly of junk foods (sweets, dips, salty snacks, and fries), pasta, white bread, milk, vegetable and olive oils. Regarding small gestational age births, the main predictors were employment status and primiparity, but not the adherence to dietary patterns. By contrast, women belonging to cluster 2 had higher odds of large for gestational age (LGA) births than those belonging to cluster 1 (OR = 2.213; 95%CI = 1.047-4.679; p = 0.038). Moreover, the odds of LGA increased by nearly 11% for each one-unit increase in pregestational BMI (OR = 1.107; 95%CI = 1.053-1.163; p < 0.001). To our knowledge, the present study is the first to highlight a relationship between adherence to an unhealthy dietary pattern and the likelihood of giving birth to a LGA newborn. This evidence adds to the current knowledge about the effects of diet on birth weight, which, however, remains limited and controversial.

Aggressive Angiomyxoma of the Vulva: Which Is the Best Management Strategy? Description of a Case Report and Review of Literature of the Last Ten Years.

BACKGROUND: Aggressive angiomyxoma is a rare mesenchymal tumour of the genital tract with a high incidence in women of reproductive age. The aim of our work is to understand which is the best management strategy for this condition, starting from the description of a rare case report up to the performance of a narrative review of the literature. METHODS: We report a case of a 46-year-old woman who came to our attention because of the growth of a 10-centimetre pedunculated, non-soft, non-tender mass of the left labium majus. She underwent surgical excision, and the histologic diagnosis was aggressive angiomyxoma. Due to a lack of tumour-free margins, radicalization surgery was carried out after three months. A review of the literature of the last ten years was performed following the PRISMA statement on MEDLINE (PubMed). We obtained data from twenty-five studies describing thirty-three cases. RESULTS: Aggressive angiomyxoma is characterized by a high recurrence rate of between 36 and 72% after surgery. There is no universal consensus about hormonal therapy, and most studies (85%) describe surgical excision followed by only clinical and radiological follow-up. CONCLUSION: Wide surgical excision is the gold-standard treatment for aggressive angiomyxoma, succeeded by either clinical or radiological (ultrasound or MRI) follow-up.

Body Stalk Anomaly Complicated by Ectopia Cordis: First-Trimester Diagnosis of Two Cases Using 2- and 3-Dimensional Sonography.

INTRODUCTION: Body stalk anomaly is a severe defect of the abdominal wall, characterized by the evisceration of abdominal organs and, in more severe cases, thoracic organs as well. The most serious condition in a body stalk anomaly may be complicated by ectopia cordis, an abnormal location of the heart outside the thorax. The aim of this scientific work is to describe our experience with the prenatal diagnosis of ectopia cordis as part of the first-trimester sonographic screening for aneuploidy. METHODS: We report two cases of body stalk anomalies complicated by ectopia cordis. The first case was identified during a first ultrasound examination at 9 weeks of gestation. The second was identified during an ultrasound examination at 13 weeks of gestation. Both of these cases were diagnosed using high-quality 2- and 3-dimensional ultrasonographic images obtained by the Realistic Vue and Crystal Vue techniques. The chorionic villus sampling showed that the fetal karyotype and CGH-array were both normal. RESULTS: In our clinical case reports, the patients, immediately after the diagnosis of a body stalk anomaly complicated by ectopia cordis, opted for the termination of pregnancies. CONCLUSION: Performing an early diagnosis of a body stalk anomaly that is complicated by ectopia cordis is desirable, considering their poor prognoses. Most of the reported cases in the literature suggest that an early diagnosis can be made between 10 and 14 weeks of gestation. A combination of 2- and 3-dimensional sonography could allow an early diagnosis of body stalk anomalies complicated by ectopia cordis, particularly using new ultrasonographic techniques, the Realistic Vue and the Crystal Vue.

Is It Possible to Diagnose Preoperatively a Tubal Ectopic Hydatidiform Molar Pregnancy? Description of a Case Report and Review of the Literature of the Last Ten Years.

SYNOPSIS: Nowadays there are no clinical, laboratory, or ultrasound criteria to differentiate ectopic tubal pregnancy from tubal molar pregnancy, so a preoperative diagnosis is not possible. OBJECTIVE: Tubal ectopic hydatidiform moles are a rare type of gestational trophoblastic disease. The aim of our work is to understand if it is possible to diagnose, preoperatively, a tubal ectopic molar pregnancy, starting from the evaluation of a complicated case report up to performing a review of the literature. MATERIALS AND METHODS: A 27-year-old woman was referred to our department for right pelvic pain, vaginal bleeding, and positive beta-hCG (590 mUI/mL). At the ultrasound, the uterine cavity was empty and a unilocular cyst of 15 mm below the right ovary, suspicious of ectopic pregnancy, was described. Serial measurements of daily beta-hCG (2031 → 2573 → 3480 mUI/mL) and, after five days, a laparoscopic salpingectomy, were performed. The pathologist confirmed a diagnosis of "incomplete invasive vesicular mole with extrauterine implant". A review of the literature was performed, following the PRISMA statement, and searching all the articles related to this topic in the last ten years from PUBMED. We obtained data from thirteen studies, describing fourteen cases. DISCUSSION: Considering the data from the literature, the main clinical symptoms were pelvic pain (100%), vaginal bleeding (64%), vomiting (7%), and fever (7%). By ultrasound examination, left adnexal mass on ten women (72%), and right adnexal mass on four (28%), were described. An assessment of ectopic pregnancy was made in all cases, but no preoperative diagnosis of tubal molar pregnancy was made. Beta-hCG levels were the same as patients with ectopic tubal pregnancy. CONCLUSION: Nowadays there are no clinical, laboratory, or ultrasound criteria to differentiate ectopic tubal pregnancy from tubal molar pregnancy.

Uterine Rupture in Pregnancy following Two Abdominal Myomectomies and IVF.

Objective: Uterine rupture (UR) during pregnancy is an obstetric emergency that could determine poor maternal and neonatal outcomes. There are many factors that could increase the risk of UR, such as a previous myomectomy. The aim of this study is to evaluate the role of a previous myomectomy in a spontaneous UR in pregnancy. Methods: A 33-year-old primigravida comes to our obstetric emergency room for pelvic pain at 29 weeks of gestation. In her medical history, there were two previous surgical operations of abdominal myomectomy, one in 2015 and one in January 2021 (6 months before conception). After 34 minutes, a pubo-subumbilical longitudinal laparotomy was performed for pathological decelerations in the cardiotocography. In the peritoneal cavity, there was 500 mL of blood serum liquid. The right arm and shoulder of the fetus were extending out of the uterus across a breach of 5 cm near the right tubal corner. A corporal incision was performed, and a healthy baby was born and moved to neonatal intensive unit care. Results: A UR can occur at any stage of pregnancy, mostly during the third trimester of pregnancy. Risk factors that increase the incidence of a uterine rupture after myomectomy include a short period (i.e., <12 months) between the myomectomy and conception, the opening of the endometrial cavity, and large myomas (with a maximum diameter above 4 cm). Uterine rupture during pregnancy after abdominal myomectomy seems to be less frequent than after a laparoscopic one. Conclusion: Uterine rupture is an obstetric emergency; it is mandatory to consider this eventuality in pregnancy, particularly in the third trimester, if there was a previous laparoscopic myomectomy in the anamnesis of the patient.

Isolated Tubal Torsion in a Term Pregnancy: Case Report and Systematic Review of Literature of the Last 10 Years.

Objective: Isolated torsion of a fallopian tube is a rare event and it is extremely difficult to be diagnosed in pregnancy. The aim of this study is to present a clinical case report that occurred in our department and to summarize the latest evidence about tubal torsion in pregnancy. Methods: We reported data, ultrasonographic features and an intra-operative image of a case report of tubal torsion in a term pregnancy. Then a review of the literature was performed following the PRISMA statement: we searched all the articles related to tubal torsion in pregnancy in the last 10 years from the international electronic bibliographic database PUBMED. We collected data regarding population characteristics, clinical features, treatment, and feto-maternal outcomes. Results: According to our search strategy, 10 articles were included. The main clinical symptoms were abdominal pelvic pain (100%), nausea, and vomiting (30%). The mean gestational age at the diagnosis was 36 weeks after the last menstrual period in 50% of cases. Ultrasound images showed a cystic lesion in the adnexal area in 70% of cases. In most of the cases, a cesarean section with a contextual salpingectomy was performed. No cases of maternal and fetal death were respectively reported. Conclusion: Isolated torsion of the fallopian tube is a rare obstetric condition but it should be considered in case of acute lower abdominal pain presentation during pregnancy. Depending on gestational age, surgical treatment as soon as possible could prevent a salpingectomy.

Analysis of ultrasonographic and hystopathologic features of placental invasiveness in Vitro Fertilization (IVF) pregnancies: a prospective study.

PURPOSE: In Vitro Fertilization (IVF) techniques make up 1.5-5% of all births in developed countries. These pregnancies are characterized by implantation and functional alterations of the placenta, higher incidence of multiple pregnancies, higher incidence of hypertensive syndromes and pre and post partum hemorrhage (PPH). METHODS: Since January 2017 to May 2018 all single IVF pregnancies coming to San Camillo Hospital were considered prospectively for routine pregnancy checks until delivery and compared with a control group of spontaneous pregnancies. Each patient underwent to an obstetrical ultrasound of the third trimester at our clinic, with particular attention on the study of the placenta. Birth modalities, type and timing of third stage of labor, peri and post-partum complications were recorded. RESULTS: We had a higher incidence of cesarean sections in the IVF group (85% versus 25%) and peri and post-partum complications (38% versus 5%). We recorded a statistically significant difference of reduction in IVF pregnancies of VI (p = .0039) and VFI (p = .0043), while the FI index was not statistically significant in the two study groups (p = .4351). CONCLUSION: Despite the small sample size of our study, our data follow the trend of scientific literature, with an effective increase in placental anomalies in IVF pregnancies compared to healthy controls.

First trimester screening for aneuploidy: may combined test and fetal DNA work together?

INTRODUCTION: The purpose of the study was to evaluate the screening performance of combined test (based on the measurement of nuchal translucency, pregnancy-associated plasma protein A, free ß-human chorionic gonadotropin, and maternal age) and fetal DNA screening (NIPS) for trisomies 21 (T21), 18 (T18), and 13 (T13). MATERIAL AND METHODS: Women who accepted screening had a first-trimester combined test (pregnancy-associated plasma protein A, free ß-human chorionic gonadotropin, nuchal translucency interpreted with maternal age) and fetal DNA. RESULTS: Among 302 women screened (including 4 with affected pregnancies), our study demonstrated that DNA screening for trisomies 21, 18, and 13 achieved a detection rate of 100% with a false-positive rate of 0.02%, overcoming the traditional combined test with 75% of sensitivity and 4.7% of false-positive rate. In particular, fetal DNA may be useful in case of intermediate risk, in order to avoid invasive diagnostic procedures such villocentesis and amniocentesis. Because of fetal DNA costs, it can be used in clinical practice as a second step screening in case of intermediate or high risk at combined test. CONCLUSION: Fetal DNA screening may be successfully implemented in routine care, achieving a high detection rate, low false-positive rate, and, consequently, greater safety with fewer invasive diagnostic tests than other methods of screening.

A review on management of caesarean scar pregnancy.

PURPOSE OF REVIEW: To review the current literature on management of cesarean scar pregnancy. RECENT FINDINGS: Caesarean scar pregnancy (CSP) is a complex pathologic condition, which is strictly related to a previous caesarean section. It is an iatrogenic disorder, that has had an exponential increase over the last few years linked to the parallel increase in the number of caesarean sections. The Society for Maternal-Fetal Medicine (SMFM) confirmed the presence of surgical, medical, and minimally invasive therapies for caesarean scar pregnancy management but the optimal treatment is not known; the main recommendation is to avoid expectant management of CSP (GRADE 1B). The treatments for Caesarean scar pregnancy are multiple, and they include a surgical management, a medical management and a combination between these two types of treatments. Despite the recommendation of SMFM in this review, we also included some cases of conservative management published in the last months. SUMMARY: Considering all the different approaches on CSP, the management has to be individualized mainly on gestational age and it has to be discussed by a multidisciplinary team, to choose the safest clinical option.

Postpartum perineal pain: may the vaginal treatment with CO2 laser play a key-role in this challenging issue?

PURPOSE: Pregnancy and childbirth, despite being physiological events, represent a very delicate period in a woman's life, because they expose to important vulvo-perineal traumas. The pelvic pain that follows each delivery, whether spontaneous or surgical (caesarean section), does not end in the first days after birth but, depending on the studies, becomes persistent in a very variable percentage of cases. Therefore, in the present pilot study, we aimed, for the first time in literature, to assess the efficacy of CO2 laser in women affected by perineal postpartum symptoms. MATERIALS AND METHODS: Between February 2013 and June 2018, all women with late postpartum pelvic pain referred to the Department of Obstetrics and Gynecology of San Marino Hospital, were recruited and treated using the CO2 laser for three applications every 4-6 weeks. RESULTS: Between February 2013 and June 2018, according to the inclusion and exclusion criteria, 32 women with late postpartum pelvic pain were recruited in our protocol study. Mean age of patients was 34.1 years. At latest follow-up, our data demonstrated an improvement in symptoms (dyspareunia, pain at introitus, vaginal dryness, itching and vaginal burning) with a mean reduction of this symptom of 70% from baseline. CONCLUSIONS: This study has shown the effectiveness of CO2 laser treatment in postpartum perineal pain. Nevertheless, our results should be considered promising but preliminary. In fact, they need to be tested in larger cohort of patients to confirm its application in clinical practice and to evaluate the long-term duration of this treatment.

Caesarean scar pregnancy: descriptive paper of three different types of management on a series of clinical cases.

INTRODUCTION: A caesarean scar pregnancy is a complex iatrogenic pathology, which represents a consequence of a previous caesarean section. It increased in recent years due to parallel increase of cesarean sections. MATERIAL AND METHODS: We present a retrospective study on patients with caesarean scar pregnancy diagnosed in our department from June 2016 to June 2019. Stable women with an embryo (with or without cardiac activity) who accepted our experimental protocol were treated with single dose of methotrexate (50 mg administered locally intracavitary + 50 mg administered intramuscularly) and folinic acid (15 mg/day orally for 30 days). Clinically stable women with embryo (without cardiac activity) who decided to wait, were monitored by serial assays of b-hCG and clinical and ultrasonographic follow up. Women who were clinically unstable with embryo (without cardiac activity), were referred for urgent surgical treatment with dilation and curettage. RESULTS: Caesarean scar pregnancy was diagnosed in sixteen women. Among these women, seven were treated according to our experimental protocol with methotrexate and folinic acid and only one had profuse bleeding, which required a laparotomic hysterectomy. Four women were treated urgently with dilatation and curettage. Five women chose to wait: they were monitored and all spontaneously had a miscarriage. CONCLUSIONS: In our preliminary study, we highlighted how our experimental protocol gave encouraging results in the first 10 weeks of caesarean scar pregnancy. However, caution is needed in patients with advanced gestational age, a gestational sac with large diameter, higher CRL and presence of embryonic cardiac activity.

Hysteropexy with single-incision vaginal support system associated with a modified culdoplasty for enterocele prevention.

Our study assessed the safety and clinical outcomes of hysteropexy with a single-incision mesh associated with a modified culdoplasty, for the surgical management or prevention of enterocele, in women with pelvic organ prolapse (POP). We carried out a 1-year prospective single-cohort study, including 51 women with symptomatic, multi-compartmental POP. Anatomical outcome was assessed with a POP-Q system and the subjective outcomes were assessed using ICSQ-SF and PGI-I. One-year follow-up data were available for 48 out of 51 patients. The POP-Q cure rate was 91%, 83% of patients were satisfied or very satisfied (PGI-I ≤ 2). No major complications occurred; the most common minor complications were mesh erosion (6%) and pelvic pain (8%). Lower urinary tract dysfunctions arose in 16% of the patients. Anatomical prolapse recurrence (POP-Q stage ≥2) in anterior or apical compartments occurred in four patients (8%). No case of de novo prolapse occurred in the posterior compartment. None of the patients required further surgery for recurrent prolapse. This standardised procedure provided satisfactory 'restitutio ad integrum' of the vaginal anatomy and symptom relief.Impact statementWhat is already known on this subject? The post-surgical evidence of de novo prolapse in untreated compartments is well-known, especially in prosthetic surgery. The insertion of polypropylene mesh causes a vigorous support, consequently the forces on the pelvic floor are transmitted to the least consolidated vaginal compartment. A lack of simultaneous repair of all the segments involved in the POP increases the risk of surgical recurrence even in those areas that did not appear to be pre-operatively affected by the uterine descensus.What the results of this study add? Our prospective study showed that hysteropexy with a single-incision vaginal support system plus a modified culdoplasty was able to prevent the enterocele and the occurrence of prolapse in the posterior compartment, by closing the Douglas pouch and restoring the connection of the rectovaginal septum with the apical support.What the implications are of these findings for clinical practice and/or further research? This study may be relevant for clinicians in selecting the technique for pelvic floor surgery, and it may be of interest for researchers investigating the reasons for de novo occurrence of posterior segment prolapse.

Difficult diagnosis of hemoperitoneum in a patient with a pelvic mass of large size.

INTRODUCTION: Intraperitoneal hemorrhage caused by a uterine myoma is rare (Tajima et al., 2015). PRESENTATION OF CASE: A 47-year-old woman was admitted to the emergency room for worsening abdominal pain. Ultrasound revealed fluid filled almost the entire abdominal cavity as well as the presence of a mass of about 20cm near the uterus. It was not easy to understand the nature of the fluid by ultrasound. It appeared to be ascites with a tumoral pelvic neoformation. On TC there was extravasation of contrast material, but the bleeding site was not identifiable. An emergency operation was performed. Bleeding was from a subserosalmyoma on the anterior wall of the uterus; myoma measured approximately 20cm in maximum diameter. Pathological assessment of the resected specimen revealed bleeding from ruptured tortuous veins on a serosal-type uterine myoma. DISCUSSION: Spontaneous rupture of a vein or an artery overlying a myoma has been documented in English literature on the subject, although it is extremely rare (Tajima et al., 2015). CONCLUSION: The differential diagnosis between ascites and hemoperitoneum is sometimes not easy. Ultrasound is a helpful instrument in expert hands to make a diagnosis of hemoperitoneum. The aid of other diagnostic methods as TC help the clinician to arrive at the correct diagnosis quickly.