Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study.

PURPOSE: To evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy. METHODS: Cases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis. RESULTS: Three hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22-4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23-3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23-3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49-79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69-38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38-22.09). CONCLUSION: Women with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery. TRIAL REGISTRATION: Clinical trial registration number: NCT03354793.

Endometriosis: seeking optimal management in women approaching menopause.

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

Infectious morbidity after total laparoscopic hysterectomy: does concomitant salpingectomy make a difference?

The study was aimed to test the hypothesis that preservation of the fallopian tubes at the time of total laparoscopic hysterectomy (TLH) increases the risk for postoperative infection. The study group consisted of 137 consecutive women undergoing TLH with conservation of the ovaries, who had concomitant bilateral total salpingectomy at the time of TLH. The control group included 145 women who had had TLH without salpingo-oophorectomy before the study period. Women undergoing bilateral total salpingectomy at the time of TLH had a lower rate of infectious morbidity compared with those who had TLH alone (3/137 versus 14/145, P = 0.01). Multivariable analysis showed that bilateral total salpingectomy at the time of TLH and blood loss are independent predictors of infectious morbidity.

Ultrasonographic measurement of thymus size in IUGR fetuses: a marker of the fetal immunoendocrine response to malnutrition.

OBJECTIVE: To test the hypothesis that intrauterine growth restriction (IUGR) is associated with decreased thymus size in the human fetus. METHODS: The thymus perimeter was measured in 60 consecutive IUGR fetuses at prenatal ultrasound examination. IUGR was defined as an abdominal circumference (AC) <5(th) centile. Sixty controls were identified by selection of the next consecutive appropriately grown fetus of similar gestational age (+/-1 week). To exclude fetal size effects, ratios between thymus perimeter and fetal biometry measurements including biparietal diameter (BPD), AC and femur length (FL), as well as estimated fetal weight (EFW) were compared between IUGR fetuses and controls. RESULTS: The proportion of fetuses with thymus perimeter <5(th) centile for gestation was significantly higher in IUGR fetuses than in controls (58/60 vs. 7/60, P < 0.0001). The mean thymus perimeter/BPD ratio (0.87 +/- 0.20 vs. 1.13 +/- 0.13, P < 0.0001), thymus perimeter/AC ratio (0.28 +/- 0.06 vs. 0.35 +/- 0.03, P < 0.0001), thymus perimeter/FL ratio (1.18 +/- 0.26 vs. 1.51 +/- 0.19, P < 0.001) and thymus perimeter/EFW ratio (0.05 +/- 0.01 vs. 0.06 +/- 0.01, P = 0.02) were significantly lower in IUGR fetuses than in controls. There was a significant positive correlation between the observed-to-expected mean for gestation thymus perimeter ratio and the enrollment-to-delivery interval (r = 0.44, P < 0.001). CONCLUSION: IUGR is associated with a disproportionately small thymus. This supports the hypothesis that thymic involution may be part of the fetal neuroendocrine response to intrauterine starvation.

Transumbilical surgical specimen retrieval: a viable refinement of laparoscopic surgery for pelvic masses.

The purpose of this study was to evaluate the feasibility and surgical outcome of a policy of routine specimen retrieval through the umbilical port, avoiding the enlargement of ancillary port-site incisions. A total of 1116 women underwent laparoscopic surgery for the treatment of a pelvic mass with extraction of the specimen through the umbilical port site (a total of 1453 retrieval procedures). All retrieval procedures were successfully carried out with this technique. Neither intraoperative complication related to the retrieval procedure nor accidental rupture of the endoscopic bag occurred. There was an injury to the epigastric artery. Neither trocar-site hernias (both umbilical trocar insertion sites and extraumbilical sites) nor port-site metastases occurred.

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses.

OBJECTIVE: To evaluate the feasibility and safety of laparoscopic management of adnexal masses > or = 10 cm in size. DESIGN: Prospective cohort study. SETTING: Two Gynecology Departments of University Hospitals. POPULATION: All women presenting with an adnexal mass > or = 10 cm in diameter were candidates for laparoscopic management. Women were excluded from laparoscopic approach if there was evidence of ascites or gross metastatic disease. Neither the sonographic features of the cyst nor elevated serum CA125 level was used to exclude women from having a laparoscopic approach. METHODS: A single operative protocol was followed for all women. All removed specimens were sent for immediate pathological evaluation. MAIN OUTCOME MEASURES: Rate of conversion to laparotomy, incidence of cancer encountered, and operative complications. RESULTS: One hundred and eighty-six women underwent laparoscopic evaluation for an adnexal mass of 10 cm or larger in size. The average preoperative mass size was 12.1 +/- 4.9 cm. A benign pathological condition was found in 86.6% (161/186) of the women, primary ovarian cancer in 16 (8.6%) women, a metastatic tumour of gastrointestinal origin in 1 (0.5%) woman, and a low malignant potential ovarian tumour in 8 (4.3%) women. Laparoscopic management was successful for 174 (93.5%) women. Reasons for conversion to laparotomy included anticipated technical difficulty (n = 7) and malignancy (n = 5). No intraoperative complications occurred in the entire study group. CONCLUSIONS: The vast majority of large adnexal masses can be safely resected laparoscopically, provided that there is expertise in laparoscopic surgery, immediate access to frozen section diagnosis, and preparation of patient to receive an adequate cancer surgery where indicated.

Umbilical Richter's hernia after minimally invasive laparoscopy. A case report.

A case of Richter's hernia in the umbilical trocar site following laparoscopic radiofrequency thermal ablation of uterine myomas is presented. A 10-mm trocar was inserted through the umbilical site and the radiofrequency needle was introduced percutaneously into the uterine fibroid. Trocar was extracted under direct visual control after carbonic gas deflation. The fascial layer of umbilical port was not sutured. The umbilical Richter's hernia presented 13 days later required bowel resection. This case stresses the importance of suturing the fascial defects of 5-mm larger ports also in diagnostic and in minimally invasive laparoscopic procedures.

Large cross-sectional area of the umbilical cord as a predictor of fetal macrosomia.

OBJECTIVE: To determine whether a large cross-sectional area of the umbilical cord is a predictor of fetal macrosomia. METHODS: Consecutive patients of > 34 weeks' gestation, who presented for sonographic examination and who delivered within 4 weeks of the examination, were included in the study. The sonographic cross-sectional areas of the umbilical cord, the umbilical vessels and the Wharton's jelly were measured in a free loop of the umbilical cord. Logistic regression analysis was used to determine significant predictors of macrosomia (actual birth weight > 4000 g and > 4500 g). Fetal biometric parameters (biparietal diameter, abdominal circumference and femur length), sonographic estimated fetal weight and umbilical cord area > 95(th) centile for gestational age were used as covariates. RESULTS: During the study period, 1026 patients were enrolled. Fifty-three (5.2%) newborns had a birth weight > 4000 g, and 22 (2.1%) weighed > 4500 g. The proportion of cases with a large umbilical cord was significantly higher in the group of macrosomic compared with non-macrosomic infants (54.7% vs. 8.7%, P < 0.0001). Multiple regression models demonstrated an independent contribution of the large cord in the prediction of birth weight > 4000 g and > 4500 g (odds ratio (95% CI), 20.6 (9.2-45.9) and 4.2 (1.2-17.7), respectively). The sensitivity, specificity and positive and negative predictive values of a sonographic large umbilical cord were 54.7%, 91.3%, 25.4%, and 97.4%, respectively. The combination of abdominal circumference > 95(th) centile and large cord predicted 100% of macrosomic infants. The proportion of umbilical cords with a Wharton's jelly area > 95(th) centile for gestation was significantly higher in macrosomic fetuses of diabetic compared with non-diabetic mothers. CONCLUSIONS: Sonographic assessment of umbilical cord area may improve the prediction of fetal macrosomia.

Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings.

PURPOSE: The purpose of this study was to evaluate the contribution of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and local staging of endometriosis by comparing results with laparoscopic findings. MATERIALS AND METHODS: We evaluated 36 consecutive women with suspected or clinically diagnosed endometriosis. Thirty-two out of 36 patients met the following inclusion criteria: transabdominal and endocavitary (US) examination and MR imaging, followed by laparoscopy performed within 2 weeks. US and MR findings were classified based on location, number and morphology (small nodules, large nodules, laminar lesions, cystic lesions, complex lesions, adhesions, cul-de-sac obliteration). RESULTS: Laparoscopy, considered the gold standard, identified 143 lesions in 32 patients. US detected 101 lesions, and MR detected 92 lesions, which were subsequently divided by morphologic appearance. Sensitivity and specificity of the two imaging techniques in the recognition of the different locations were 58% and 25%, respectively, for US and 56% and 50%, respectively, for MR imaging. Results of the two techniques in the different locations examined were similar, with the exception of lesions in the rectovaginal septum, which were better detected by US, and for adhesions and cul-de-sac obliteration, which were more easily detected by MR. CONCLUSIONS: Both US and MR are accurate in the diagnosis of endometriosis. There are no significant differences in staging of pelvic endometriosis between US and MR. US examination is the primary evaluation in cases of suspected disease and for the rectovaginal septum. MR examination is recommended for correct classification in doubtful cases and in cases of suspected extrapelvic lesions and adhesions.

Two-trocar adnexal surgery: a "quasi" scarless operation.

BACKGROUND: This study aimed to explore the feasibility and safety of two-port abdominal cavity entry for adnexal surgery. METHODS: A series of patients undergoing laparoscopy for benign adnexal diseases requiring adnexectomy, ovariectomy, or salpingectomy were enrolled in the study. A 10-mm 0 degree umbilical operative laparoscope and one 3- or 5-mm suprapubic trocar were used. A grasping forceps was inserted through the ancillary trocar to displace medially and cranially the adnexa or the salpinx. The operation then was performed through the operative channel of the operative laparoscope. RESULTS: A total of 53 patients were enrolled. Bilateral salpingo-oophorectomy was performed in 10 cases. The median operative time was 39 min (range, 21-85 min). The median blood loss was 50 ml (range, 0-300 ml). The median size of the adnexal mass was 6 cm (range, 3-12 cm). No intraoperative complication occurred. At the 3-month follow-up visit, no extraumbilical abdominal scar was visible. CONCLUSIONS: The use of a two-trocar technique is safe and highly appreciated by the patients it leaves no visible abdominal scars.

[Update on postcoital hormonal contraception. Part 1]. / Attualita in tema di contraccezione post coitale di tipo ormonale. (Parte prima).

PIP: In recent years new protocols of post-coital hormonal contraception have been devised that cause fewer side-effects. 0.2 mg ethinyl-estradiol with 2 mg norgestrel twice within 72 hours after intercourse were among the first combinations that would utilize low doses of hormones. Other authors use even smaller doses; preparations for intramuscular injection are available if the woman vomits the tablets. Progesterone has been used alone within 12 hours following intercourse with a success rate close to estrogen-progestin combinations. Quingestanol acetate is used for 5 days, 0.9-1.5 mg/day. With danazol fewer side-effects are seen; 400 mg are taken twice within 72 hours with a good rate of success.^ieng

[Update on mechanical methods of postcoital contraception. Pt. 2]. / Attualita in tema di contraccezione post coitale di tipo meccanico (seconda parte).

PIP: Use of postcoital contraception (PC) has been suggested for women when hormonal contraceptives are contraindicated. This is achieved by means of the postcoital insertion of an IUD provided no side effects appear, such as persistent pelvic pain, recurring uterine cramps, prolonged bleeding, metrorrhagia, or expulsion of the device. This type of PC does not inhibit ovulation, but rather produces cellular and biochemical changes in the endometrial mucous membrane and effects tubal hypercontractility and hypermotility, which are responsible for the transport of the ovum into the uterine cavity. Impeding these phenomena results in the destruction of the fertilized egg. Apparently, the strong concentration of copper ions in the uterus from the IUD inhibits fetal development. The contraceptive activity also potentiates the blastocidal effect of bacteria that are inevitably introduced by the IUD. PC also has a great advantage compared to hormonal contraceptives, since it can be used 7-10 days after coitus. Other advantages are the low rate of contraindications, few side effects, and no injury to the embryo. Studies on PC IUD use indicate complete success with this method if CU 7, T-Cu 200, or ML Cu 250 devices are used 1 week or up to 10 days after unprotected sex.^ieng