External cephalic version for singleton breech presentation: proposal of a practical check-list for obstetricians.

OBJECTIVE: External cephalic version (ECV) for breech presentation is not routinely performed by obstetricians in many clinical settings. The aim of this work is to assess to what extent the factors involved in performing ECV are relevant for the success and safety of ECV, in order to propose a practical check-list for assessing the feasibility of ECV. METHODS: Review of 214 references. Factors involved in the success and risks of ECV (feasibility of ECV) were extracted and were scored in a semi-quantitative way according to textual information, type of publication, year of publication, number of cases. Simple conjoint analysis was used to describe the relevance found for each factor. RESULTS: Parity has the pivotal role in ECV feasibility (relevance 16.6%), followed by tocolysis (10.8%), gestational age (10.6%), amniotic fluid volume (4.7%), breech variety (1.9%), and placenta location (1.7%). Other factors with estimated relevance around 0 (regional anesthesia, station, estimated fetal weight, fetal position, obesity/BMI, fetal birth weight, duration of manoeuvre/number of attempts) have some role in the feasibility of ECV. Yet other factors, with negative values of estimated relevance, have even less importance. CONCLUSIONS: From a logical interpretation of the relevance of each factor assessed, ECV should be proposed with utmost prudence if a stringent check-list is followed. Such a check-list should take into account: parity, tocolytic therapy, gestational age, amniotic fluid volume, breech variety, placenta location, regional anesthesia, breech engagement, fetal well-being, uterine relaxation, fetal size, fetal position, fetal head grasping capability and fetal turning capability.

Primitive omental leiomyoma: a case report.

Primitive omental leiomyomas are very rare. The primitive omental location of the leiomyoma is quite difficult to determine, with the possible presence of "parasite" myomas and of omental metastasizing myomas. Moreover, omental masses may be primitive or secondary metastasis from neoplasms. In this case report a primitive omental leiomyoma is described, and their diagnosis and management are briefly discussed, in order to improve the knowledge of this very uncommon disease.

Experience of practitioners and delivery outcome.

BACKGROUND: It is commonly believed that the experience of practitioners (time spent in delivery ward) may be helpful in aiding the spontaneous vaginal birth. AIM: To check if this opinion is true. METHODS: In 995 low-risk, full-term, pregnancies resulting in spontaneous labour, multivariate logistic regression analysis was performed, which considered the age, the years of service of the obstetrician and of the midwife, and of both as independent variables. Results The longer the obstetrician (odds ratio 0.779, C.I. 95% 0.653-0.930, p = 0.006) or the midwife has been practising (odds ratio 0.609, C.I. 95% 0.408-0.909, p = 0.015) the less likely is the occurrence of a spontaneous vaginal birth. The combined years of service of the caring doctor/midwife pair appears to have no influence on the outcome of delivery. The chances of an operative vaginal birth increase with the age of the caring obstetrician (odds ratio 1.362, C.I. 95% 1.138-1.630, p = 0.001). CONCLUSION: The experience of the staff assisting women in labour definitely does not determine the success of deliveries. The skills of each professional category are based on theoretical knowledge that is possibly not being put to use during routine duties, especially by the 'more experienced' practitioners. Additionally, it appears that there is no team work, and decisions are not taken together.

The pathogenesis of endometrial polyps: a systematic semi-quantitative review.

UNLABELLED: The pathogenesis and natural history of endometrial polyps are not very clear. The objective of this study was to assess the opinions of international medical literature regarding the factors involved in the pathogenesis of endometrial polyps and to organize the results consistently with what is known about endometrial physiology. MATERIALS AND METHODS: A systematic review was carried out with the following search engines: PubMed, OVID, Scopus, SCIELO, and AJOL. Two hundreds forty-six abstracts were selected from the literature; of these abstracts, 58 factors were extracted and set as causative, non-causative, unclear or protective link with endometrial polyps. This relation is described through a correspondence analysis and tested with a main effect hierarchical log-linear model. RESULTS: The log-linear model resulted significant for the correspondence found with the following factors: (i) causative link (ageing, bcl-2 protein, excess weight/obesity, tamoxifen regardless of timing, relationship between estrogen receptors and prog-estinics, unbalanced estrogen therapy, estrogen-like effect, and unbalance between estrogens and progestinics), (ii) protective link (progestinics, antiestrogenic action), (iii) unclear link (menopause, ki-67 protein, angiogenesis, tamoxifen for a short time, tamoxifen for a long time, hormone replacement therapy (HRT), endometritis/inflammation), and (iv) non-causative link (none of the factors specifically). DISCUSSION: Subsequently to a review of the physiology of the endometrium, the onsetting of endometrial polyps was suggested through estrogen-related and non-estrogen related ways; the two ways can overlap. The most implied factors in the development of endometrial polyps are linked with one of these or both ways.

Behaviour of lab parameters and neonatal weight loss in relation to neonatal breathing movements and cord clamping time.

BACKGROUND: To date, delaying cord clamping two to three minutes after birth is considered effective for newborn well-being. This time does not consider the newborn's breathing movements, which may also condition neonate well-being. AIM: To investigate the behaviour of neonatal weight loss and of some umbilical vein lab parameters, in relation to timing of newborn breathing and cord clamping. MATERIALS AND METHODS: Time from birth to cord clamping and time from birth to first cry of the newborn were collected in 87 full-term healthy women. First cry is a sign of effective breathing. Birth weight loss at the first, second, and third day from birth and lab parameters were assessed in relation to: time from birth to cord clamping, time from birth to first cry, and cord clamping before or after the first cry. RESULTS: Partial pressure of carbon dioxide (pCO2) decreased if cord clamping was performed after first cry and increased if first cry occurred after cord clamping, independently from the time elapsed from birth to first cry (p = 0.012). Calcium (Ca(2+)) concentration decreased if cord clamping was performed after the first cry and increased if first cry of the baby after birth was delayed (p = 0.021). Each second of delay from birth to cord clamping resulted in an increase in Cl- concentration (p <0.001). Each second of delay in cord clamping resulted in a reduction in the percentage of weight loss at the first day (p = 0.024), at the second day (p = 0.007), and at the third day (p = 0.028) after birth. CONCLUSIONS: Neonate breathing after birth should induce umbilical vein flow from placenta to lungs, conditioning the reduction of birth weight loss after birth and umbilical lab parameters modifications.

Effect of epidural analgesia on labor times and mode of delivery: a prospective study.

PURPOSE: To assess changes in labor times and delivery outcome in low-risk women requesting pain relief and undergoing epidural analgesia, according to the epidural analgesia schemes. MATERIALS AND METHODS: Prospective observational study of 499 low-risk women with epidural analgesia. Speed of dilatation (SD) (centimeters of dilatation / hours), speed of lowering of the fetal head through maternal pelvis (SL) (centimeters in lowering / hours), time of active phase of labor (TA), cesarean section (CS), vacuum application (VA) were dependent variables in multivariable linear and logistic regressions. RESULTS: Dilution of ropivacain, fentanyl amount, and volume of the first dose of epidural analgesia did not seem to affect labor times. Epidural analgesia with schemes used in this study favored both the dilatation and the fetal head lowering through maternal pelvis. Every five minutes from the first dose of epidural to the last top-up, SD decreased by about 13% (p=0.002), SL decreased by about 14% (p<0.001), and TA increased by about 40% (p<0.001). Additionally, every five minutes from the first dose of epidural to the last top-up, the odds of an operative vaginal birth (vacuum) increased by 0.7% (p<0.001). Increasing of number of top-ups independently caused a reduction in odds of undergoing CS (odds ratio 0.434; C.I. 95% 0.219-0.859, p=0.017), without influencing labor times. CONCLUSION: Epidural analgesia in patients requesting pain relief favors normal course of labor if it is not discontinued or delayed.

Could endometrial cytology be helpful in detecting endometrial malignancies?

This short communication assesses the concordance indexes between hysteroscopic biopsies and endometrial cytology for each endometrial pattern found in a sample of 37 women. Patients underwent endometrial cytology under sonographic guidance. The specimens were obtained with an endocervical brush and were fixed on slides (no liquid-based methods). After endometrial cytology, hysteroscopy with biopsy was performed. The best concordance index was found for endometrial malignancies, suggesting that endometrial cytology is able to detect cancers but not other endometrial diseases, as compared with endometrial hysteroscopic biopsies. Therefore, the overall concordance index suggests a fair concordance between histological and cytological findings. This leads us to conclude that usual endometrial cytology should not be recommended to screen endometrial diseases, but it may be used as an alternative diagnostic tool when hysteroscopic biopsies or other blinded procedures for endometrial sampling are unwanted, because it allows malignancies to be detected as well as hysteroscopic-guided biopsies.

Pain and breastfeeding: a prospective observational study.

OBJECTIVE: To demonstrate that pain affects the goodness of breastfeeding. MATERIALS AND METHODS: Seventy-nine patients were interviewed regarding satisfaction in breastfeeding, tiredness, uterine pain, nipple and other pain, and analgesic use at day three and at first, second, third, and fourth week after birth. Data regarding the mode of delivery were recorded from medical charts. Milk formula supplements, bottle use, pacifier use, and nipple shields use were considered as variables suggesting unsuccessful breastfeeding. RESULTS: At third day after delivery, it appeared that analgesic use was significantly associated with milk formula supplementing, bottle use, less satisfaction in breastfeeding, and more tiredness. At first week after delivery, the presence of pain differing from nipple and uterine pain, was more likely associated with milk formula supplementing, bottle use, pacifier use, less satisfaction in breastfeeding, and more tiredness. At third week after delivery, nipple pain was directly related to tiredness, while it increased the odds of adding milk formula and using a bottle. CONCLUSION: Pain affects the goodness of breastfeeding.

Effect of epidural analgesia on operative vaginal birth rate.

The aim of the study was to investigate if epidural analgesia may affect the operative vaginal birth rate. An observational study was carried out on 1,158 in low-risk patients who delivered vaginally; 46.9% of these patients underwent epidural analgesia using different doses and drugs. Overall, epidural analgesia enhanced the probability of vacuum delivery (OR 2.70 95% CI 1.88-3.89, p < 0.001). Vacuum application was increased about seven times by administration of fentanyl alone at the first dose, while it was reduced if ropivacaine was added to fentanyl. In patients undergoing epidural analgesia, increasing the amount of ropivacaine at the first dose reduced the probability of vacuum delivery (OR 0.82; 95% CI 0.67-1.00, p = 0.05). Moreover, increasing the number of top-ups reduced the probability of vacuum delivery (OR 0.49 95% CI 0.27-0.93, p = 0.029) and the time of the second stage of labor. On the other hand, increasing time from the first dose of epidural to the last top-up increased the risk of operative vaginal delivery (OR 1.33 95% CI 1.03-1.72, p = 0.031) and the time of the second stage of labor. Epidural analgesia seems to favor spontaneous delivery when it is properly carried on.

Impact of the medicalization of labor on mode of delivery.

AIMS: To evaluate whether routine medical interventions during labor (oxytocin augmentation, induction, amniotomy, epidural analgesia) condition the outcome of delivery independently of each other and of obstetric risk (calculated in an objective manner). Moreover, to evaluate whether there is an ideal window for initiating such interventions. METHODS: Prospective, observational study with 1,047 patients enrolled. RESULTS: Medical interventions were high, whether in low-, medium- or high-risk pregnancies. Oxytocin augmentation (odds ratio 4.678) labour induction (odds ratio 1.717) amniotomy (odds ratio 1.403) and obstetric risk (intermediate-risk odds ratio 1.889, high-risk odds ratio 2.008) increase the probability of an operative delivery. Oxytocin augmentation increases both the probability of a Cesarean delivery and vacuum extraction. Epidural analgesia reduces the probability of cesarean delivery and increases the probability of vacuum extraction. The greater the cervical dilation when oxytocin infusion is initiated, the lower the probability of an operative delivery. The more advanced the cervical dilation and the lower the station when amniotomy or epidural analgesia are carried out, the lower the probability of an operative delivery. Obstetric risk and oxytocin augmentation appear to increase the probability of operative delivery in patients who have undergone amniotomy or epidural analgesia. In addition, labor induction in patients who undergo epidural analgesia increases the risk of operative delivery. CONCLUSIONS: Medical interventions during labor are high and cause a rise in operative delivery. Therefore, practitioners should defer it as much as possible. The exception is epidural analgesia because it seems to reduce the number of cesarean sections.

Malignant transformation of uterine leiomyomata.

The malignant transformation of a uterine leiomyoma is still debated and, if it occurs, it is very rare. The case of a patient affected by three small leiomyomas, monitored by the same gynecologist over the years is described. Two of these leiomyomas were transformed into leiomyosarcoma after menopause and the patient died despite receiving therapy. The case reported here is meant to underline the need to keep all uterine myomas in check since the transition into leiomyosarcomas may occur with an evolution over a time period which has not been established so far.

Bilateral Brenner tumor with endometrial adenocarcinoma in a postmenopausal woman.

Brenner tumor is a rare ovarian neoplasm which is generally monolateral, more rarely bilateral, and often associated with endometrial disorders related to oestrogenic production. However, there is no considerable evidence that the possible oestrogenic production of this tumor may be the cause of endometrial disorders. A case of bilateral Brenner tumor with endometrial adenocarcinoma in a postmenopausal woman is presented and the features are briefly discussed, with the conclusion that hormone-producing Brenner tumors may exert their promoter effect on the development of endometrial carcinoma causing an imbalance in the oestrogen and progesterone ratio rather than producing a large amount of oestrogen.

Sulfatides and arylsulfatase A activity in major salivary glands of hamster (Mesocricetus auratus) after adenocarcinoma induction in oral cavity.

A biochemical study of sulfatides and arylsulfatase A (ASA) was carried out in the submandibular and sublingual glands of the male and female hamster Mesocricetus auratus after experimental induction of oral adenocarcinoma by 7,12-dimethylbenzanthracene (DMBA). Hamster experimental groups included control animals, animals treated with beta-carotene, animals treated with DMBA, and animals treated with DMBA plus beta-carotene. Oral cavity treatment with DMBA induced carcinogenesis in the buccal mucosa, but not in the major salivary glands, where nevertheless, the morphology and expression of both parameters examined changed. In fact, sulfatide concentrations and enzyme activity increased significantly, while in control and beta-carotene-treated hamsters they were similar in both glands and sexes. After administration of DMBA plus beta-carotene, sulfatide concentration decreased, as did ASA activity, slightly in the submandibular gland and remarkably so in the sublingual one of female hamsters. Thin-layer chromatography (TLC) analysis of lipid patterns, after DMBA treatment, revealed considerable differences, not only in sulfatides, but also in other lipid fractions, as well as between the two glands and two sexes. These findings show that oral cavity treatment with DMBA is not able to induce carcinogenesis in the major salivary glands examined; however, it does cause considerable metabolic changes.

[PGF2 and the induction of the trial of labor. The prognostic value of uterine contractions]. / PGE2 e induzione del travaglio di parto. Valore prognostico delle contrazioni uterine.

BACKGROUND: Uterine contractions during the first hour following intracervical application of dinoprostone would show the myometrial sensitivity to prostaglandins E2 (PGE2) and could be a good practical marker of the real prospects of success of an attempt to induce labor according to the above mentioned modalities. The verification of such an hypothesis is the principal aim of this work. METHODS: The study was carried out on a group of 90 cardiotocograms recorded soon after a sample of pregnant women at term underwent labor induction by intracervical application of a gel containing 0.5 mg of PGE2 (dinoprostone). Special attention was paid to some characteristics of the cardiotocograms obtained during the first hour following administration of the gel: regularity of uterine contractions, total number of contractions, number of contractions having an intensity equal or superior to 50 mmHg, mean number of contractions during a period of 10 minutes, mean number of "effective" contractions during a period of 10 minutes, presence or absence of "excessive uterine activity" (tachysystole and/or hypersystole). RESULTS: Some cardiotocographic patterns were associated with a higher percentage of successful inductions, but the observed differences, not statistically significant, do not seem to be clinically interesting. CONCLUSIONS: However, it's not possible to exclude that a longer period of uterine contractions monitoring, perhaps lasting 2 hours instead of only 60 minutes, could lead to more useful information for the management choices.

[Collection of autologous blood during pregnancy and fetal safety. Computer analysis of fetal heart rate]. / Predonazione di sangue autologo in corso di gravidanza e sicurezza fetale. Analisi computerizzata dell'attività cardiaca fetale.

BACKGROUND: This study aims at objectively evaluating the impact on the fetus of a sudden maternal blood withdrawal, through a computer analysis of the various aspects of the cardiotocographic pattern before and after one autologous blood unit predonation from near term pregnant women. METHODS: For the collection of cardiotocographic data, a Sonicaid Team fetal monitor was used; it is a monitoring system which uses Doppler ultrasound impulses and autocorrelates the received Doppler signals with varied signals of frequency, connected to Sonicaid System 8000, a program for "objective" cardiotocographic analysis according to the so-called Dawes-Redman criteria. RESULTS: From the statistic comparison of Non Stress Tests preceeding and following predonation, some statistically significant differences have sometimes emerged on the level of specific parameters. CONCLUSIONS: In particular, the general variation of fetal heart frequency and fetal reactivity resulted higher after predonation, even though they were within absolute normality, justifying the suspicion that the stress of autologous predonation practice might produce some indefinite disturbance to fetal activity/rest rhythm.

[Predictive factors of fetal macrosomia]. / Fattori predittivi di megalosomia fetale.

BACKGROUND: Fetal macrosomia is a condition which may increase the risk of mechanical and/or dynamic problems for the parturient. In the past, we have demonstrated that in more than half of the cases it is not possible to exclude a contribution of maternal pathology to the determination of fetal-macrosomia. The aim of this work is to verify whether our more recent experience regarding predictive factors of fetal macrosomia shows some noteworthy novelty. METHODS: The study was retrospectively carried out on pregnant women who, during the period January 1994-February 1996, delivered babies weighing at least 4 kg at the Midwifery School of Camerino. With regard to the frequency of the main risk factors of fetal macrosomia described in scientific literature, the sample was compared with a control group randomly selected. RESULTS: Advanced gestational age at the time of delivery, parental tallness, maternal overweight/obesity, gestational glucidic dysmetabolism, a distance between pubis and uterine fundus of at least 34 cm, male sex of the unborn child have proved to be predictive factors of fetal macrosomia. CONCLUSIONS: The differences in comparison with the past, on the other hand altogether negligible, are the consequence of changes in the management of some obstetric situations.

[The role of chorionic gonadotropin in transient hyperthyroidism in hyperemesis gravidarum]. / Il ruolo della gonadotropina corionica nell'ipertiroidismo biochimico transitorio dell'iperemesi gravidica.

A possible association of hyperemesis gravidarum with biochemical transient hyperthyroidism (a significant self-limited increase in serum levels of some thyroid hormones) has long been reported. It seems there is not any causal connection between the two above mentioned conditions, but they may be both independently related to the same cause: the trophoblastic production of a large amount of human chorionic gonadotropin or, otherwise, the presence in the maternal circulation of structural variants of hCG with higher biological activity. The validity of such hypothesis, denied by some authors, encounters the verification in the peculiar clinical case described in this report. It also shows clearly the danger of considering a case of hyperemesis gravidarum as of psychological nature, without having preliminarily excluded an organic cause. For the pregnant woman, to hear of her unconscious refusal of pregnancy or of the timeliness of her removal from the environment in which some conflictual situations have likely raised or, furthermore, to hear of other common places often too easily evoked could be cause of anxiety and unjustified feelings of guilt.

[PGE2 and induction of labor. Authors' experience]. / PGE2 e induzione del travaglio di parto. Nostra esperienza.

BACKGROUND: The aim of this work is to contribute to the evaluation of the dinoprostone clinical value (PGE2) in labor induction. Special attention is paid to the evaluation of the effectiveness and safety of the method employed, as well as to the singling out of possible predictive factors of success. METHODS: The study was carried out on a sample of 85 women, who underwent labor induction by intracervical application of a gel containing 0.5 mg of dinoprostone. The following parameters were evaluated: 1) percentage of spontaneous deliveries within 24 hours from the administration of dinoprostone; 2) kind of delivery (comparison with women who delivered without labor induction); 3) characteristics of the cardiotocogram performed soon after the application of the gel; 4) prognostic value of some factors (maternal age, parity, gestational age, Bishop score). RESULTS: The difference between the two categories compared according to susceptibility of a positive answer to the treatment with PGE2 is mainly the consequence of different Bishop scores. The Bishop score was the only examined having an autonomous prognostic value and a real indicator of success prospects of an attempt to induce, labor by administration of PG. CONCLUSIONS: In personal experience, the una tantum intracervical application of dinoprostone is an effective method and, at the same time, it is free from any major risk.

Muscarinic cholinergic receptors and acetylcholinesterase activity in umbilical artery and vein in pregnancy-induced hypertension (pre-eclampsia).

The influence of pregnancy-induced hypertension (pre-eclampsia) on muscarinic cholinergic receptors and on acetylcholinesterase (AChE) activity was investigated using frozen sections of the umbilical artery and vein. Pre-eclamptic patients undergoing Caesarean delivery and normotensive pregnant control woman undergoing Caesarean delivery with similar parity, gestation length and age were examined. Muscarinic cholinergic receptors were assayed in frozen sections of the umbilical artery and vein by a radioligand binding assay technique, using [3H]-N-methyl scopolamine (NMS) as a ligand. AChE was demonstrated with a histochemical technique associated with microdensitometry. [3H]-NMS was specifically bound to sections of both umbilical artery and vein in a manner consistent with the labelling of muscarinic cholinergic receptors. The affinity of the radioligand was similar in the two vessels, whereas the maximum density of binding sites (Bmax) was higher in the umbilical vein than in the artery. A faint AChE reactivity was observed in the tunica media of both umbilical artery and vein. In pre-eclampsia, a loss of [3H]-NMS binding sites not accompanied by changes in the affinity of radioligand was found. The decrease of muscarinic cholinergic receptors involved to a greater extent the umbilical artery than the vein. No differences in AChE activity were found at the level of umbilical artery and vein between control and pre-eclamptic subjects. These findings suggest that pre-eclampsia is characterized by a loss of muscarinic cholinergic receptors in the umbilical circulation not accompanied by changes of the acetylcholine catabolizing enzyme AChE. It is possible that the decreased density of vascular muscarinic cholinergic receptors in pregnancy-induced hypertension contribute to the increased resistance of the umbilical circulation occurring in pre-eclampsia.