Preterm delivery and premature rupture of membranes after conization in 80 women. Preliminary data.

AIM: Cervical intraepithelial neoplasia is most frequently in young women in reproductive age. Cold knife conization, laser ablation, laser conization and large loop excision are conservative methods of treatment to remove the transformation zone and preserve the cervical function. Previous studies have shown conflicting results on the outcomes of pregnancy following these therapies that might increase the risk of preterm delivery. The purpose of this study was to evaluate the outcome of pregnancy after conization and its role as predictive risk factor. METHODS: A retrospective study was performed. The study group comprised 80 women who had a conization and that had a subsequent singleton pregnancy. Variables considered includes maternal excision date, surgery procedure, previous surgery treatments, time interval between excisional procedure and subsequent pregnancy; duration and week of pregnancy, mode of delivery, histological grading (no cervical intraepithelial neoplasia [CIN], CIN 1, CIN 2-3) and cone excised depth. RESULTS: In group study 45 women underwent loop electrosurgical excision procedure (LEEP) conization, 32 cold knife conization and 3 laser CO2. The authors found 11 cases of cone tissue depth<1 cm, and remaining one>1 cm. Eight preterm delivery have been reported to data: 5 between 28 and 34 weeks, 2 lower than 28 weeks and 1 between 34 and 37 weeks. CONCLUSION: In these preliminary data the percentage of preterm birth appears as 10% and in range 6-15% evaluated for women not submitted to excisional procedures.

[Intraepithelial cervical carcinoma and HIV. Prevalence, risk factors and prevention strategies]. / Carcinoma cervicale intraepiteliale ed HIV. Prevalenza, fattori di rischio e strategie di prevenzione.

BACKGROUND: The present study analyses cervical dysplastic lesions associated with HIV infection by means of cytological, colposcopic and histologic examinations, and the diagnostic accuracy of the Pap test. METHODS: Cross-sectional study. We have studied colposcopic and histologic findings of 115 HIV-positive women. In 86 patients a cytological examination was also carried out. The results were compared with those of a control group consisting of 127 HIV-negative women in pre-menopause age. RESULTS: The prevalence of cervical dysplastic lesions present at colposcopic/bioptic examination was 3.2 times greater in HIV+ women than in HIV- women (38% vs 12%, p<0.001) and that of lesions of a higher degree 7 times greater. Compared to non-HIV+ women, patients who were positive presented more severe dysplastic lesions, a higher frequency of HPV-derived lesions and inflammatory pictures. There was also a correlation between high incidence of dysplastic cervical lesions and advanced stage of immunodepression. The negative predictive value of the Pap test was higher in the seronegatives (95%) than in the seropositives (83%, p<0.01). The overall agreement between cytology and colposcopy/histology was greater in the seronegati-ves than in the seropositives (87% vs 74%, p<0.05). CONCLUSIONS: Cervical dysplastic lesions in seropositive patients are more frequent and aggressive than in HIV negatives and are related both to the degree of immunodepression and to the HPV infection. Further, the diagnostic value of the Pap test in association with HIV is reduced. These results suggest that in HIV+ patients careful combined cytological-colposcopic screening should be adopted, together with an attentive cyto-colposcopic follow-up in treated patients.

[Bacterial vaginosis. Prevention of recurrence]. / Vaginosi batterica. Profilassi delle ricorrenze.

Bacterial vaginosis (BV) is the main cause of vaginitis. The condition is characterised by an abundant and odorous vaginal loss, but more than half the patients with demonstrable signs of BV do not report symptoms at all. Gardnerella vaginalis (Gv) is often associated with BV, but it is not the sole factor responsible, as is shown by the fact that it can be isolated in the vagina of women withBV. In 1992 and 1993, 2630 patients, 1460 of them gynaecological and 1170 obstetric, were admitted to the Obstetrics and Gynaecology Clinic of Parma University. Amsel criteria were adopted for diagnosing BV. Cases of BV were treated with 5 mg/die 2% clindamycin vaginal cream for 7 days. In the event of recurrences, 250 mg tablets of metronidazol were added: 8 tablets in 4 administrations in a single day, treatment also being extended to the partner. Patients admitted in 1993 received a protocol of hygienic and behavioural standards, stress being laid on prophylaxisa measures even after the end of therapy. BV proved to be present in 12.3% of cases, of whom only half were symptomatic. The situation was practically stationary if the 2 years are considered separately. Recurrences of symptomatic bacterial vaginosis were 15% in the absence of protocol application and 8.3% after the protocol. Recurrences were less frequent in the asymptomatic forms. Compared to the total number od cases of BV, recurrences were significantly low (12.1% p < 0.001).

Methods of contraception and rates of genital infections.

Bacterial vaginosis, trichomoniasis and candidiasis are the most common genital infection. The aim of this study was to evaluate the various methods of contraception with regard to the prevalence of bacterial vaginosis and vulvo-vaginitis over a period of four years. We also evaluated in the same period the rates of trichomoniasis, candidiasis, bacterial vaginosis and vulvo-vaginitis between users and non users of contraceptional methods and the relationship between ages of patients and types of contraceptives. Finally we considered the change of contraceptive use with regard to age among two different periods. The IUD users showed a significant increase of B.V., T.v. and other bacteria and a decrease of the negatives compared to OC users. Barrier contraceptive users had a reduction (0.01 > p > 0.001) of B.V. and an increase (p < 0.001) of the negatives compared to IUD users. OC users had a significant (p < 0.05) increase in candidiasis, B.V. together with a reduction of the negatives compared to non users group. IUD users had a significant (p < 0.001) increase of B.V. and vulvo-vaginitis from other bacteria, and the reduction of the negatives. Teenagers use OC much more than adults, but less IUD (p < 0.001). The use of OC has increased and the use of IUD decreased among adults (p < 0.001). The barrier methods were seen to be statistically reduced.

PIP: During 1985-1986 and 1991-1992 in Italy, clinicians recruited 2387 patients attending the Centre for Sexually Transmitted Diseases (STDs) at the University of Parma with symptoms of genital infections. The study aimed to examine the various types of contraceptive methods in connection with the most common genital infections. Over the 4-year period, among patients with vulvo-vaginitis, IUD users had a higher rate than oral contraceptive (OC) users of bacterial vaginosis [BV] (24.9% vs. 15.7%; p 0.05), of trichomoniasis (1.7% vs. 1.3%), and of other infections (31.6% vs. 20%; p 0.05). They had a lower negative rate than OC users (23.9% vs. 43.4%; p 0.001). Patients using barrier methods (diaphragm and condom) had a lower rate of BV and a higher negative rate than IUD users (11.5% vs. 24.9%, p 0.01 and 49.6% vs. 23.9%, p 0.001, respectively). OC users had a higher rate of candidiasis and BV and a lower negative rate than the nonusers (19.6% vs. 14.8% and 15.7% vs. 11%; p 0.05 and 43.4% vs. 52.9%; p 0.001, respectively). IUD users had a higher rate of BV and vulvo-vaginitis from other bacteria and a lower negative rate than nonusers (24.9% vs. 11%, p 0.001; 31.6% vs. 20.4%, p 0.05; and 23.9% vs. 52.9%; p 0.001, respectively). Teenagers used OCs more often than did adults (29.3% vs. 15.6%) and were less likely to use the IUD (0.3% vs. 5.5) and no method (62.2% vs. 73.5%) (p 0.001). Between 1985-1986 and 1991-1992 among adults, OC use increased (9.9% vs. 17.9%; p 0.001) and IUD use and barrier method use decreased (8.9% vs. 4.1% and 9.3% vs. 3.9%, respectively; p 0.001).

[Vaginitis and vaginosis. Comparison of two periods]. / Vaginite e vaginosi. Due periodi a confronto.

Vaginitis is the most frequent gynecological disease. It is characterized by objective and subjective signs of inflammation and differs from bacterial vaginosis (BV) which is an abnormal condition of the vaginal ecosystem caused by the excessive growth of aerobic and anaerobic flora normally present in the vagina with an increased risk of pelvic inflammatory disease (PID). The authors report the results of a study carried out at the Centre for Gynecological Infections at the Clinic of Obstetrics and Gynecology of the University of Parma. 828 patients were enrolled in the study during the period 1985-86 and 1559 patients during the two-year period 1991-92. The aim of the study was to evaluate variations in epidemiological data for vaginitis and bacterial vaginosis in the two periods examined. No significant changes were observed (p > 0.05) with regard to the prevalence of Ca, Tv and BV forms. On the other hand, there was a significant reduction (p < 0.001) in the forms sustained by other microorganisms (above all, streptococcus and enterobacteria) between the first and second periods with a parallel increase in the number of negative cases. The analysis of the age distribution of vaginitis and BV showed a reduction of other microorganisms and an increase in negative vaginal swabs in adults (> 20 years old).

[Labor in patients previously subjected to cesarean section: maternal and fetal aspects. Review of the literature]. / Il parto nella paziente precesarizzata: aspetti materni e fetali. Rassegna bibliografica.

In the present study the authors, on the basis of the existing literature, analyse the delivery problem in previous cesarean section patient, especially about maternal mortality and morbidity. After cesarean section vaginal delivery may occur only in selected patients, with precautionary measures and continuous monitoring in labor. The maternal mortality is lower in vaginal delivery patients after cesarean section than in iterative cesarean section patients; also the post operating complications are more frequent after iterative cesarean section. Perinatal mortality is in relation to uterine rupture, perinatal morbidity to iatrogenic prematurity and neonatal respiratory adaptation.

[Current trends in the therapy of C.I.N. (cervical intraepithelial neoplasia)]. / Attuali orientamenti nella terapia delle C.I.N. (cervical intraepitelial neoplasia).

The Authors examine the epidemiological data on cervical intraepithelial neoplasia (C.I.N.) and review the various therapeutic methods available for it's treatment, paying special attention to the outpatient treatment of these precancerous portio lesions.

[Cesarean section: incidence, indications and early maternal morbidity (comparison of 2 periods: 1970-1972 and 1980-1982)]. / Taglio cesareo: incidenza, indicazioni e morbilità materna precoce (due periodi a confronto: 1970-72 e 1980-82).

In this study the authors compared cesarean section rate and post-operative maternal morbidity occurred during the period 1970-72 with the period 1980-82. The data showed an increased cesarean section rate from 8% to 24% but no difference about number of maternal post-operative complications and fever. Particularly post-operative maternal morbidity in emergency cesarean section fold down till to reach the already low morbidity found in elective cesarean section, besides febrile urinary tract infections are reduced in period 1980-82. No reduction was instead noted in post-cesarean endometrities and bronchopulmonary complications.

[Short- or long-term antibiotic prophylaxis in obstetric and gynecologic laparotomy?]. / Profilassi antibiotica a breve o a lungo termine nella laparochirurgia ostetrica e ginecologica?

This clinical trial was conducted to test the effectiveness of short-term prophylaxis (1 hour before, 8 and 16 hours after surgery) and long-term prophylaxis (8 hour a part 5 days long post-operatively) in preventing morbidity related to obstetrics and gynecological abdominal surgery. Short-term prophylaxis was always performed by cefuroxime meanwhile gynecological long-term prophylaxis was performed by ampicillin plus oxacillin and by cefuroxime in case of obstetrical surgery. The results showed that long-term prophylaxis is unnecessary and short-term prophylaxis is preferable because of decreased toxicity, a smaller hospital dispensary cost and a real prophylactic action because tha antibiotic is in the tissue before exposure to the infective agents.

[Breech presentation: cesarean section or vaginal delivery?]. / Presentazione podalica: taglio cesareo o parto vaginale?

The Authors studied breech presentation rate occurred in the Institute of Obstetrics and Gynecology of University of Parma during 1983. Perinatal morbidity and mortality occurred after vaginal delivery was also compared with those occurred after both emergency and elective cesarean section. Breech presentation delivery vaginally in 12,91% and by cesarean section in 87,09%. Only one case of perinatal death occurred in 1983 and it was not related to breech presentation. Breech delivery showed the 31,18% of neonatal morbidity with an higher rate in case of vaginal delivery (66,66%). In conclusion the Author's opinion is that vaginal breech delivery should be explained in a few cases according to all possible hazards.

[Pregnancy, labor and perinatal outcome: comparison between an obstetric-pediatric multi center study of the Perinatal Preventive Medicine subproject of the National Research Council and clinico-statistic study in the second semester 1981 at the Obstetrics and Gynecology Clinic of Parma]. / Gravidanza, parto ed esiti perinatali: confronto fra indagine policentrica ostetrico-pediatrica del sub-progetto di medicina preventiva perinatale del C.N.R. e studio clinico-statistico del secondo semestre 1981 nella Clinica Ostetrica e Ginecologica di Parma.

The data collected from women who delivered in the Institute of Obstetrics and Gynecology of the University of Parma since 1/7/81 till 31/12/81 were compared to those of the Obstetric-Pediatric Policentric Study of the Subproject of Perinatal Medicine sponsored by N.R.C. (National Research Council) collected since 1973 to 1977. The maternal wish of pregnancy and the total number of obstetrical controls during pregnancy were higher in the data of Parma than in the data of N.R.C. No differences between the two groups were noted in the obstetrical pathological patterns. Spontaneous labor and elective cesarean section are more frequent in Parma meanwhile there is a minor incidence of low weight newborn and perinatal mortality. No difference was noted in the preterm labor incidence.

Postpartum glycosylated hemoglobins (HbA1): an index of glucose control in pregnancy?

Postpartum HbA1 levels were studied in 114 mothers with a normal pregnancy. HbA1 levels were correlated with neonatal anthropometric parameters and with maternal metabolic parameters. A strong positive correlation was found between weight gain during pregnancy and postpartum HbA1 levels. There was also an increased frequency of infants with large thoracic circumference born to mothers with HbA1 levels above 8.6%. Thus, postpartum HbA1 levels in mothers in whom the serial HbA1 determination is not possible, may be a useful index of glucose control during the gestational period.

Short-term versus long-term cefuroxime prophylaxis in patients undergoing emergency cesarean section.

A prospective randomized clinical trial was conducted to test the effectiveness of long-term and short-term prophylaxis with cefuroxime in preventing morbidity after cesarean section. Sixty patients who required emergency cesarean section were randomly assigned to one of three treatment groups: a control group of 20 patients receiving no prophylactic antibiotics; a group of 20 patients receiving 24 hours of cefuroxime prophylaxis (0.75 gm 30 to 60 minutes before surgery and at 8 hours and 16 hours after surgery); and a group of 20 patients receiving five days of cefuroxime prophylaxis (0.75 gm three times a day, the first dose being given postoperatively). The short-term and long-term prophylaxes were equally effective in reducing morbidity, assessed by postoperative temperatures, presence or absence of endometritis, and duration of postoperative hospital stay.

[Blood levels of maternal glycosylated hemoglobin (HbA1) in the 3d day of the puerperium and neonatal anthropometric parameters]. / Livelli ematici di emoglobina glicosilata (HbA1) materna in 3a giornata di puerperio e parametri antropometrici neonatali.

In the present study the Authors considered some neonatal anthropometric parameters such as head and chest circumference besides the neonatal weight and placental weight that may be more expressive of the fetal growth. All these parameters were correlated separately and jointly with maternal HbA1 levels of the third day of the post partum period. All mothers spent a pregnancy without any clinical and metabolic disorder. The data show a significant higher HbA1 mean value, than the controls, in mothers whose newborn showed one or more parameters like/superior the 90th centile. This finding may suggest that the evaluation of all the parameters together, the maternal HbA1 value can give more informations about the fetal growth.

Comparative efficacy of two different regimens of antibiotic prophylaxis in total abdominal hysterectomy.

A randomized, prospective study of 44 women undergoing total abdominal hysterectomy was conducted to compare cefuroxime short-term prophylaxis and ampicillin plus oxacillin long-term prophylaxis. Cefuroxime was given peri-operatively for 1 day only, whereas the penicillins were given post-operatively for 5 days. The results showed that both regimens were equally effective in providing prophylaxis. It is suggested, therefore, that the use of antibiotics after the first day of surgery is unnecessary and short-term prophylaxis is preferable because of fewer potential disadvantages.

[Glycosylated hemoglobin (HbA1) in chemical gestational diabetic and diabetic pregnancy (author's transl)]. / L'emoglobina glicostilata (HbA1) nella gravidanza con diabete chimico gestazionale e diabete clinico.

The authors have determined, by ionic resin exchange chromatographic method, HbA1 values in 16 chemical gestational diabetic pregnant, in 4 case with insulin dependent diabetes and 34 normal pregnant women. Statistical differences were found between normal's HbA1 mean values and clinical diabetics' but not with chemical gestational diabetics. HbA1 mean values in chemical gestational diabetics with diabetic familiarity were found statistically higher than normal subjects' values. Mothers with chemical gestational diabetic, who delivered newborn with less than 50th centile had HbA1 values significantly elevated.

[Adolescent pregnancy (author's transl)]. / La gravidanza nell'adolescente.

The Authors have studied 456 pregnancies on young women under the age of eighteen; this record was on 27.215 deliveries in ten years (1970-1979) at the Department of Obstetrics and Gynecology of the University of Parma. From 1970 to 1979 the number of adolescent in pregnancy has triplicated. It has been found that obstetric pathology was 45,25%: this was more in premature rupture of membranes, preeclampsia, premature delivery and urinary infections. The spontaneous delivery has been 90,35% of the total; premature delivery has ben 9,15%; low birthweight has been 9,19%. The incidence of malformations was 2,84%, while the perinatal mortality was 26,31%: the majority of this mortality was recorded after delivery.

[The pregnancy in women above 40 years (author's transl)]. / La gravidanza nella paziente attempata.

The Authors have studied 272 pregnancies in women above 40 years. This record was on 27.215 deliveries in ten years (1970-1979) at the Department of Obstetrics and Gynecology of the University of Parma. From 1970 to 1979 this phenomenon has decreased by 50%. The incidence of obstetric pathology has been elevated (38,87%): this percentage has been more in premature rupture of membranes, pre-eclampsia and uterine inertia. Of these 272 pregnancies, the 37,35% had pathologic cases before pregnancy: these cases were hypertension, heart troubles and diabetes. Cesarean section was elevated (38,98%), so also premature delivery (12,86%) and low birthweight (12,68%). The incidence of malformations was 10,50%. The perinatal mortality was elevated (49,05%0): the majority of this mortality was recorded before delivery.