Non-obstetrical indications for cesarean section: a state-of-the-art review.

PURPOSE: To propose an evidence-based review on the most frequent indications for Cesarean section (CS) given by specialists in disciplines other than Obstetrics and Gynecology, with the aim of increasing consciousness about the available data in the literature and the guidelines recommendations about topics that are not frequently managed by obstetricians and gynecologists. METHODS: We analyzed hospital discharge data regarding deliveries occurred in a 10-year study period in our department to obtain the prevalence and the list of the most recurrent non-obstetrical indications for CS. A search was performed in PubMed, the Cochrane Library, SCOPUS, Web of Science and Ovid MEDLINE and only studies published in English from 1950 to 2017 were included. For indications for which no systematic reviews existed, we included the best available evidence, including guidelines of non-obstetrics scientific societies or organizations, RCTs, non-randomized controlled clinical trials, case-control studies, cohort studies, and case series. RESULTS: The rising rate of CS registered in the recent years is not justified by reduction in maternal--fetal risk or perinatal outcomes and often reflects inappropriate clinical behaviour and a wrong tendency that assimilates CS as a defensive practice. In a relevant percentage of cases, the indication to CS is given by specialists in other disciplines, even when specific guidelines do not give clear recommendation about the route of delivery. CONCLUSIONS: To refuse non-obstetrical indications for CS, when scientific support is lacking, could be a useful and safe strategy to further reduce the rate of unnecessary CS.

DJ-1 is a reliable serum biomarker for discriminating high-risk endometrial cancer.

New reliable approaches to stratify patients with endometrial cancer into risk categories are highly needed. We have recently demonstrated that DJ-1 is overexpressed in endometrial cancer, showing significantly higher levels both in serum and tissue of patients with high-risk endometrial cancer compared with low-risk endometrial cancer. In this experimental study, we further extended our observation, evaluating the role of DJ-1 as an accurate serum biomarker for high-risk endometrial cancer. A total of 101 endometrial cancer patients and 44 healthy subjects were prospectively recruited. DJ-1 serum levels were evaluated comparing cases and controls and, among endometrial cancer patients, between high- and low-risk patients. The results demonstrate that DJ-1 levels are significantly higher in cases versus controls and in high- versus low-risk patients. The receiver operating characteristic curve analysis shows that DJ-1 has a very good diagnostic accuracy in discriminating endometrial cancer patients versus controls and an excellent accuracy in distinguishing, among endometrial cancer patients, low- from high-risk cases. DJ-1 sensitivity and specificity are the highest when high- and low-risk patients are compared, reaching the value of 95% and 99%, respectively. Moreover, DJ-1 serum levels seem to be correlated with worsening of the endometrial cancer grade and histotype, making it a reliable tool in the preoperative decision-making process.

Oocyte competence is comparable between progestin primed ovarian stimulation with Norethisterone acetate (NETA-PPOS) and GnRH-antagonist protocols: A matched case-control study in PGT-A cycles.

OBJECTIVE: To outline oocyte competence after progestin primed ovarian stimulation with Norethisterone acetate (NETA-PPOS) compared to conventional GnRH-antagonist protocol. STUDY DESIGN: Retrospective matched case-control study involving advanced-maternal-age women undergoing ICSI with PGT-A. 89 NETA-PPOS were matched with 178 control patients based on maternal age and ovarian reserve biomarkers. Both groups underwent recombinant-FSH OS with GnRH-agonist ovulation trigger and collected ≥1 MII. In the study group, NETA (10 mg/day) was administered orally starting from day2 of the menstrual cycle. Euploid blastocyst rate per cohort of metaphase-II oocytes (EBR per MII) was the primary outcome. All other embryological and clinical outcomes were reported. Gestational age, birthweight and length were also assessed. RESULTS: The EBR per MII was comparable among PPOS and control (13.9 % ± 19.3 % versus 13.3 % ± 17.9 %; the sample size allowed to exclude up to a 10 % difference). Blastocysts morphology and developmental rate were similar. No difference was reported for all clinical outcomes among the 61 and 107 vitrified-warmed euploid single blastocyst transfers respectively conducted. The cumulative live birth delivery rate per concluded cycles was also comparable (24.7 % versus 21.9 %). Neonatal outcomes were analogous. CONCLUSIONS: Oocyte competence after NETA-PPOS and standard OS is comparable. This evidence is reassuring and, because of its lower cost and possibly higher patients' compliance, supports PPOS administration whenever the patients are indicated to freeze-all (e.g., fertility preservation, PGT-A, oocyte donation). More data are required about follicle recruitment, oocyte yield, gestational and perinatal outcomes. Randomized-controlled-trials are advisable to confirm our evidence.

Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere.

OBJECTIVE: The objective of this study is to compare ovarian function and surgical outcomes between patients affected by benign uterine pathologies submitted to total laparoscopic hysterectomy (TLH) plus salpingectomy and women in which standard TLH with adnexal preservation was performed. METHODS: We retrospectively compared data of 79 patients who underwent TLH plus bilateral salpingectomy (group A), with those of 79 women treated by standard TLH without adnexectomy (sTLH) (group B). Ovarian reserve modification, expressed as the difference between 3 months post-operative and pre-operative values of Anti-Müllerian Hormone (AMH), Follicle Stimulating Hormone (FSH), Antral Follicle Count (AFC), mean ovarian diameters and Peak Systolic Velocity (PSV), was recorded for each patient. For each surgical procedure, operative time, variation of hemoglobin level (ΔHb), postoperative hospital stay, postoperative return to normal activity, and complication rate were recorded as secondary outcomes. RESULTS: According to our post-hoc analysis, this equivalence study resulted to have a statistical power of 96.8%. Significant difference was not observed between groups with respect to ΔAMH (p=0.35), ΔFSH (p=0.15), ΔAFC (p=0.09), Δ mean ovarian diameters (p=0.57) and ΔPSV (p=0.61). In addition, secondary outcomes such as operative time (p=0.79), ΔHb (p=0.41), postoperative hospital stay (p=0.16), postoperative return to normal activity (p=0.11) and complication rate also did not show any significant difference. CONCLUSIONS: The addition of bilateral salpingectomy to TLH for prevention of ovarian cancer in women who do not carry a BRCA1/2 mutations do not show negative effects on the ovarian function. In addition, no perioperative complications are related to the salpingectomy step in TLH.

Being an obstetrics and gynaecology resident during the COVID-19: Impact of the pandemic on the residency training program.

OBJECTIVE: to evaluate the impact of the COVID-19 pandemic on the obstetrics and gynecology residency training program in Italy. STUDY DESIGN: This was a cross-sectional survey study aimed to assess the impact of the COVID-19 pandemic on the obstetrics and gynecology residency training program in Italy. An online survey with 45 questions was sent and completed anonymously by residents after accepting an informed consent. The invitation to the online survey was sent to all the Italian residents in obstetrics and gynecology. Those on maternity leave at the time of the study were excluded. Residents were asked about their routinely activity before the COVID-19 pandemic, and to report the reduction in their clinical practice. They were also asked about psychological impact of COVID-19 on their clinical practice. RESULTS: 933 Italian residents in obstetrics and gynecology, were invited for this survey study. Four-hundred and seventy-six (51 %) completed the survey and were included in the study. Three-hundred and eighty-seven (81.3 %) were female, and 89 (18.7 %) were male. Residents age ranged from 25 to 42. In 71,8 % (342/476) of the cases residents work in a COVID-19 reference Hospitals. One-hundred and eighty-four out of 76 residents (38.6 %) were tested on RT-PCR assay of nasal and pharyngeal swab specimens, and of them 12/184 (6.5 %) were positive to SARS-COV-2. Regarding the use of personal protective equipment (PPE), 267 (56.1 %) reported to receive adequate device, and 379 (79.6 %) felt to be well informed about prevention and management protocols. Three-hundred and thirty-one residents (69.5 %) reported to have managed COVID-19 positive patients. For 54,7 % of respondent residents, training activity in general decreased significantly during the COVID-19 epidemic. A one-third reduction was reported in 31,4 % of the cases, whereas a total suspension of the training in 9,9 % of the cases. In 89,3 % of cases the reduction was caused by the reorganization of work. Anxiety about the professional future was reported in 84 % of the residents, and 59 % of them had the perception that their training was irreversibly compromised. CONCLUSIONS: Among Italian residents in obstetrics and gynecology, COVID-19 pandemic was associated with a significant training impairment.

Difficult caesarean section: A literature review.

BACKGROUND: Caesarean section (CS) is usually perceived as a simple and safe alternative to natural birth, but in some instances can be technically difficult with consequent health hazards for both the mother and the fetus. We have proposed an evidence-based literature review of the most common difficult CS scenarios, with the aim to provide useful information about their management, possible prevention and resolution of complications. METHODS: We identified articles through a reserch in PubMed, Scopus, Web of Science and Ovid MEDLINE for studies published between 1979 and 2019. We included the best available evidence, such as RCTs, non-randomised controlled clinical trials, case-control studies, cohort studies, and case series. About sixty articles were included in this review, four hundred and thirty-six were excluded after reviewing the title or abstract or because they weren't in English. FINDINGS: The possible causes of "difficult" caesarean sections were divided into four categories: difficult access to the lower uterine segment; complicated fetal extraction, laceration or organ damage and abnormal placentation. CONCLUSIONS: Knowing in advance the potential technical difficulties and resulting risks allows the surgeon to plan appropriate strategies.

Influence of COVID-19 pandemic on the psychological status of infertile couples.

OBJECTIVE(S): to evaluate the impact of the COVID-19 pandemic on infertile couples' emotions, anxiety and future plans. STUDY DESIGN: An observational study was perfomed by Italian ART centers and online forums. In this study, infertile couples candidate to ART and whose treatment was blocked due to the COVID-19 lockdown were enrolled through an online survey. The psychological impact of COVID-19 was measured by Impact of Event Scale-Revised (IES-R) and by a short form of the Spielberger State-Trait Anxiety Inventory (STAI); Self-perceived anxiety related either to pregnancy safety and to economic crisis measured by VAS scale. RESULTS: 627 patients completed the survey. The COVID-19 lock-down had a moderate/severe psychological impact on infertile patients (mean IES-R score 36.4 ± 16.6). The mean STAI score was 49.8 ± 15.3, with an overall incidence of STAI > 36 of 71 %. The mean VAS scale for anxiety perception was 45.3 ± 15.3. Women were more emotionally distressed, anxious and depressed than men (36.8 ± 16.4 vs 31.0 ± 18.4 for IES-R, respectively; p = 0.03). Notwithstanding the uncertainty about pregnancy safety, 64.6 % of respondents chose to maintain their reproductive programme. Economic crisis induced 11.5 % of the surveyed patients to give up their ART program. Respondents who had at least one relative affected by COVID-19 had a significantly higher IES-R score and anxiety VAS, but not higher STAI scores, than patients belonging to unaffected families. CONCLUSION(S): COVID-19 pandemic itself and the recommendation to stop ART program generated higher distress levels in infertile couples. The psychological impact of COVID-19 pandemic in infertility patients should not be underestimated, and a specific psychological support should be planned.

Novel approaches for diagnosis and management of low prognosis patients in assisted reproductive technology: the POSEIDON concept.

The management of patients with a poor ovarian response (POR) to ovarian stimulation represents a challenging issue in reproductive medicine. Apart from economic burdens, the patient with POR has poor prognosis in assisted reproductive technology (ART), which represents a common cause of drop-out from treatment. To introduce a more nuanced picture of POR, the POSEIDON group developed novel criteria to identify and classify patients with low prognosis who undergo ART. The primary goal of POSEIDON criteria is to offer clinicians a pragmatic system to guide therapeutic management with the mindset to obtain the number of oocytes needed for improving ART success. A novel marker of ART success, namely, the ability to obtain the number of oocytes required for achieving at least one euploid embryo for transfer in each patient, is aligned with the POSEIDON criteria. A novel prediction model (ART Calculator) is developed to help clinicians estimate the POSEIDON marker of success. Furthermore, the POSEIDON criteria can also be used to identify more homogeneous populations to test in interventional trials.

The Genetics of Non-Syndromic Primary Ovarian Insufficiency: A Systematic Review.

Several causes for primary ovarian insufficiency (POI) have been described, including iatrogenic and environmental factor, viral infections, chronic disease as well as genetic alterations. The aim of this review was to collect all the genetic mutations associated with non-syndromic POI. All studies, including gene screening, genome-wide study and assessing genetic mutations associated with POI, were included and analyzed in this systematic review. Syndromic POI and chromosomal abnormalities were not evaluated. Single gene perturbations, including genes on the X chromosome (such as BMP15, PGRMC1 and FMR1) and genes on autosomal chromosomes (such as GDF9, FIGLA, NOBOX, ESR1, FSHR and NANOS3) have a positive correlation with non-syndromic POI. Future strategies include linkage analysis of families with multiple affected members, array comparative genomic hybridization (CGH) for analysis of copy number variations, next generation sequencing technology and genome-wide data analysis. This review showed variability of the genetic factors associated with POI. These findings may help future genetic screening studies on large cohort of women.

Corrigendum to "The Efficacy of Inositol and N-Acetyl Cysteine Administration (Ovaric HP) in Improving the Ovarian Function in Infertile Women with PCOS with or without Insulin Resistance".

[This corrects the article DOI: 10.1155/2014/141020.].

Failure to recognize preoperatively high-risk endometrial carcinoma is associated with a poor outcome.

OBJECTIVE: To evaluate the misdiagnosis between endometrial biopsy and definitive surgical pathology and to assess whether the failure in recognizing preoperatively high-risk endometrial carcinoma (EC) can impact oncological outcomes. STUDY DESIGN: A retrospective study was conducted to evaluate patients with EC diagnosed by preoperative endometrial biopsy who subsequently underwent surgical staging between 2006 and 2013 at our institution. In patients with a surgical diagnosis of high-risk EC, histotype and grade change between the endometrial biopsy and surgical specimen (discordance diagnosis) were evaluated and correlated to survival outcomes. Cox's regression model for multivariable analysis was used to evaluate the effect of several variables (age, stage, discordance in diagnosis, co-morbidities, frozen section, extensive surgical staging and adjuvant chemotherapy) on the survival rate. RESULTS: Data from 447 patients were reviewed. Among 109 women with surgical diagnosis of high-risk EC, 35 (32.1%) were preoperatively misdiagnosed. Of these 35 women, 24 (68.6%) cases were upgraded to grade 3, and 11 (3.4%) were upgraded to serous or clear cell type in the definitive specimen. The 5-year overall survival (OS; 70.2 vs. 86.8%; p=0.029), disease-specific survival (DSS; 72.5 vs. 88.2%; p=0.039) and recurrence free survival (RFS; 62.6 vs. 82.5%; p=0.024) were significantly lower in the high-risk EC patients who were preoperatively undiagnosed in the endometrial biopsy compared with patients with an appropriate preoperative histological diagnosis. Controlling for age, stage, co-morbidities, frozen section, extensive surgical staging and adjuvant chemotherapy, multivariable analysis revealed that discordance in diagnosis was associated with poorer survival outcomes. CONCLUSION: Failure to recognize preoperatively high-risk ECs is associated with worse outcomes.

The Efficacy of Inositol and N-Acetyl Cysteine Administration (Ovaric HP) in Improving the Ovarian Function in Infertile Women with PCOS with or without Insulin Resistance.

Objective. Substances such as inositol and N-acetylcysteine (NAC) have been recently shown to be effective in treatment of PCOS patients. The aim of this prospective trial is to evaluate the efficacy of NAC + Inositol + folic acid on ovulation rate and menstrual regularity in PCOS patients with and without insulin resistance. Methods. Among the 91 PCOS patients treated with NAC + Inositol + folic, insulin resistance was present in 44 subjects (A) and absent in 47 (B). The primary endpoint was the ovulation rate/year, determined by menstrual diary, serum progesterone performed between 21° and 24° days, ultrasound findings of growth follicular or luteal cysts, and luteal ratio. HOMA-index assessment after 6 and 12 months of treatment was evaluated as secondary endpoint. Results. In both groups there was a significant increase in ovulation rate and no significant differences were found in the primary outcome between two groups. In group A, a significant reduction of HOMA-index was observed. Conclusions. The association NAC + Inositol + folic, regardless of insulin-resistance state, seems to improve ovarian function in PCOS patients. Therefore, inositol and NAC may have additional noninsulin-related mechanisms of action that allow achieving benefits also in those patients with negative HOMA-index.

Does metformin affect ovarian morphology in patients with polycystic ovary syndrome? A retrospective cross-sectional preliminary analysis.

BACKGROUND: The significance of polycystic ovarian morphology and its relation to polycystic ovary syndrome (PCOS) is unclear, but probably it is associated with higher androgen and insulin levels and lower sex hormone binding globulin (SHBG) in absence of identifiable differences in gonadotropin dynamics. The aim of this study was to evaluate ovarian morphology in patients affected by PCOS with different ovulatory responses to metformin. METHODS: In this cross-sectional analysis, we studied 20 young normal-weight PCOS patients who had received a six-month course of metformin treatment. Ten of these patients remained anovulatory (anovulatory group), whereas other ten became ovulatory, but failed to conceive (ovulatory group). Other ten age- and body mass index (BMI)-matched PCOS subjects were also enrolled as controls and observed without any treatment (control group). RESULTS: After six months of metformin, in both PCOS treated groups, a similar improvement in testosterone (T) and insulin resistance indexes was observed. Moreover, in one (10.0%) and nine (90.0%) subjects from anovulatory and ovulatory PCOS groups, respectively, ovarian morphology changed, whereas a significant reduction in ovarian dimension was observed in the PCOS ovulatory group only. CONCLUSION: PCOS patients under metformin administration demonstrate a change in ovarian morphology closely related to ovulatory response.