Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study.

OBJECTIVE: To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa. METHODS: This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms. RESULTS: A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta. CONCLUSIONS: Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Surgical morbidity of total laparoscopic hysterectomy for benign disease: Predictors of major postoperative complications.

OBJECTIVE: To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease. STUDY DESIGN: An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications. RESULTS: Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p < 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p < 0.001) were found as independent risk factors for major postoperative complications. CONCLUSIONS: Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events.

[The use of RCGO triggers in the obstetric - gynecological procedures: the impact on the reduction of adeverse events. The experience of the Lombardia Region]. / L'utilizzo dei RCOG trigger in area ostetrica - ginecologica e la riduzione degli eventi avversi. L'esperienza della regione Lombardia.

The last few weeks of pregnancy are critical to a baby's health because important organs, including the brain and lungs, are not completely developed until the end of pregnancy. The adverse events during labor and childbirth can have very serious physical, psychological and financial consequences for the child, the family, health professionals and the whole community. These events can be reduced through interventions aimed at improving the safety and quality of care, based on evidence-based knowledge, guidelines and practices that must be widely and effectively applied. This work reports the experience of the Lombardy Region on improvement actions in the obstetric and gynecological procedures for the reduction of adverse events and sentinel events through the monitoring and management of the RCGS trigger tool.

Predictors of recurrence following laparoscopic radical hysterectomy for early-stage cervical cancer: A multi-institutional study.

OBJECTIVE: To assess predictors of recurrence following laparoscopic radical hysterectomy (LRH) for apparent early stage cervical cancer (CC). METHODS: This is a retrospective multi-institutional study reviewing data of consecutive patients who underwent LRH for FIGO 2009 stage IA1 (with lymphovascular space invasion (LVSI)), IA2 and IB1(≤4 cm) CC, between January 2006 and December 2017. The following histotypes were included: squamous, adenosquamous, and adenocarcinoma. Multivariable models were used to estimate adjusted odds ratio (OR) and corresponding 95% CI. Factors influencing disease-free survival (DFS) and disease-specific survival (DSS) were also explored. RESULTS: 428 patients were included in the analysis. With a median follow-up of 56 months (1-162) 54 patients recurred (12.6%). At multivariable analysis, tumor size (OR:1.04, 95%CI:1.01-1.09, p = .02), and presence of cervical residual tumor at final pathology (OR: 5.29, 95%CI:1.34-20.76, p = .02) were found as predictors of recurrence; conversely preoperative conization reduced the risk (OR:0.32, 95%CI:0.11-0.90, p = .03). These predictors remained significant also in the IB1 subgroup: tumor size: OR:1.05, 95%CI:1.01-1.09, p = .01; residual tumor at final pathology: OR: 6.26, 95%CI:1.58-24.83, p = .01; preoperative conization: OR:0.33, 95%CI:0.12-0.95, p = .04. Preoperative conization (HR: 0.29, 95%CI: 0.13-0.91; p = .03) and the presence of residual tumor on the cervix at the time of surgery (HR: 8.89; 95%CI: 1.39-17.23; p = .01) independently correlated with DFS. No independent factors were associated with DSS. CONCLUSIONS: In women with early stage CC the presence of high-volume disease at time of surgery represent an independent predictor of recurrence after LRH. Conversely, preoperative conization and the absence of residual disease at the time of surgery might play a protective role.

Maternal intra- and postpartum near-miss following assisted reproductive technology: a retrospective study.

OBJECTIVE: To assess whether risk of severe maternal morbidity at delivery differs for women who conceived using assisted reproductive technology (ART), compared with those with a spontaneous conception. DESIGN: A cohort study using a prospectively maintained institutional database. SETTING: A tertiary university maternity hospital. POPULATION: All women delivering at Del Ponte Hospital, Italy, between 2005 and 2016. METHODS: Data from 650 ART-conceived pregnancies were compared with 22 803 spontaneously conceived pregnancies. We used multivariable analysis to estimate the odds of severe maternal morbidity at delivery associated with ART conception, adjusting for maternal demographic and health factors, gestational age, and mode of delivery. MAIN OUTCOME MEASURES: The World Health Organization criteria for potentially life-threatening conditions and near-miss maternal mortality were used. RESULTS: The incidence of near-miss in the entire cohort was 3.3 cases per 1000 births (95% confidence interval, 95% CI, 2.6-4.1). The crude prevalences of potentially life-threatening conditions and maternal near-miss were higher among ART than among non-ART deliveries (27.1 versus 5.7% and 2.6 versus 0.3%, respectively). The three most common causes of maternal near-miss cases were peripartum hysterectomy, transfusion of ≥5 units of red blood cells, and cardiovascular dysfunction requiring vasoactive drugs. The odds of a maternal near-miss at delivery were increased for ART-conceived pregnancies compared with non-ART-conceived pregnancies (adjusted odds ratio, aOR 3.61, 95% CI 1.61-8.09, for ART-conceived pregnancies with autologous oocytes; aOR 13.57, 95% CI 5.45-33.77, for ART pregnancies conceived with donor oocytes). CONCLUSION: Although we cannot exclude unmeasured confounding, we found that pregnancies conceived via ART, especially those conceived with donor oocytes, are at increased risk of maternal potentially life-threatening conditions and near-miss at delivery. FUNDING: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. TWEETABLE ABSTRACT: Conceiving through assisted reproductive technology increases the likelihood of maternal near miss.

Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort study.

OBJECTIVE: To describe the technique and report perioperative outcomes of transvaginal contained extraction of surgical specimens at laparoscopic myomectomy. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Two Italian referral centres for gynaecological minimally invasive surgery. POPULATION: Consecutive patients who underwent laparoscopic myomectomy. METHODS: Tissue extraction was accomplished following laparoscopic myomectomy in a specimen retrieval bag via a posterior colpotomy incision. If morcellation was necessary, this was performed extracorporeally, using a scalpel within the specimen retrieval pouch, whose edges were exteriorised through the vaginal introitus. MAIN OUTCOME MEASURES: Intra- and postoperative complications. RESULTS: A total of 316 women underwent transvaginal specimen retrieval with enclosed manual morcellation. The mean myomectomy specimen weight was 154 ± 128 g, and the mean operative time was 79 ± 26 minutes. No intraoperative complications occurred related to the specimen extraction or morcellation technique, or from rupture of the retrieval bag. Two (0.6%) women had a haemoperitoneum that spontaneously resolved and 16 (5.1%) had fever postoperatively. The final pathological diagnosis was benign in all cases. At the 30-day follow-up, no pelvic infection, vaginal dehiscence, or complaints of dyspareunia were recorded. CONCLUSIONS: Contained transvaginal extraction of fibroid specimens can be performed safely and efficiently in most women undergoing laparoscopic myomectomy. This technique represents a valuable minimally invasive alternative to intracorporeal morcellation. TWEETABLE ABSTRACT: Transvaginal contained morcellation at laparoscopic myomectomy is a valuable alternative to intracorporeal morcellation.

Endometrial cancer cells can express fibrinogen: Immunohistochemistry and RT-PCR analysis.

We investigated whether endometrial cancer (EC) cells can express fibrinogen. Consecutive patients treated for EC were enrolled (cases). A control group of women who had hysterectomy for benign conditions was identified in a case:control ratio of 4:1. Immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR) were performed to identify the presence of fibrinogen and the mRNA of its three chains (α, ß, γ) in the tissue specimens from both cases and controls. Sixteen EC cases and 4 benign controls were included. Immunohistochemistry failed in one case of EC. In 12/15 (80%) cases versus 0 controls, a moderate-to-intense positivity for fibrinogen was observed (p = 0.09; OR: 32.1; 95%CI: 1.4-752.9). Six (37.5%) women among the cases versus 0 controls expressed RNA for at least one chain of fibrinogen (p = 0.25). All the cases (6/6, 100%) with positive RT-PCR had moderate-to-intense positive immunohistochemistry. Molecular and immunohistochemistry show that some cases of EC have the capability to express fibrinogen and the mRNA of at least one of its chains.

Interobserver reliability to interpret intrapartum electronic fetal heart rate monitoring: Does a standardized algorithm improve agreement among clinicians?

Our aim was to investigate the accuracy in predicting intrapartum fetal acidaemia and the interobserver reproducibility of a mathematical algorithm for the interpretation of electronic fetal heart rate (FHR) monitoring throughout labour. Eight physicians (blinded to the clinical outcomes of the deliveries) evaluated four randomly selected intrapartum FHR tracings by common visual interpretation, trying to predict umbilical artery base excess at birth. They subsequently were asked to re-evaluate the tracings using a mathematical algorithm for FHR tracing interpretation. Common visual interpretation allowed a correct estimation of the umbilical artery base excess in 34.4% of cases, with a poor interobserver reproducibility (Kappa correlation coefficient = 0.24). After implementation of the algorithm, the proportion of correct estimates significantly increased to 90.6% (p < 0.001), with excellent inter-clinician agreement (κ: 0.85). To conclude, incorporation of a standardised algorithm reduces the interobserver variability and allows a better estimation of fetal acidaemia at birth.

Minilaparoscopic radical hysterectomy for cervical cancer: multi-institutional experience in comparison with conventional laparoscopy.

OBJECTIVE: To analyze the preliminary experience of three gynecologic oncology services with minilaparoscopic radical hysterectomy (mLRH) for the treatment of cervical cancer and to compare perioperative outcomes with those of conventional laparoscopic surgery (LRH). METHODS: Prospectively collected data on consecutive cervical cancer patients undergoing radical hysterectomy with a laparoscopic approach were analyzed retrospectively. Perioperative outcomes of women undergoing mLRH were compared to data from control patients who had undergone LRH with 5-mm instruments. Adjustment for potential selection bias in surgical approach was made with propensity score (PS) matching. RESULTS: The study cohort consisted of 257 patients, 35 undergoing mLRH and 222 undergoing LRH. The two groups were comparable in terms of demographic and tumor characteristics. No significant differences were observed between groups in terms of operative time, blood loss, lymph node yield, amount of parametrial or vaginal cuff tissue removed, and percentage of intra- or postoperative complications, both in the entire cohort and in the PS matched group. No conversions were needed from mLRH to standard laparoscopy or from minilaparoscopy to open surgery. Conversion from standard laparoscopy to open surgery was necessary in 2 patients. A shorter hospital stay was observed among women who had mLRH than in those undergoing LRH [2 (1-10) vs 4 (1-14) days, p = 0.005]. This difference remained significant after PS matching. CONCLUSION: Our preliminary study suggests that in experienced hands minilaparoscopy is a feasible and safe technique for radical hysterectomy and yields results that are equivalent to those of LRH.

Prediction of fetal base excess values at birth using an algorithm to interpret fetal heart rate tracings: a retrospective validation.

OBJECTIVE: To evaluate whether a standardised algorithm to interpret fetal heart rate (FHR) tracings during the entire length of labour can predict umbilical artery base excess at birth, and to investigate its inter- and intra-observer reproducibility. DESIGN: Retrospective study. SETTING: Obstetrics and gynaecology department at a tertiary referral centre in a university hospital. POPULATION: Group 1: 152 consecutive, generally low-risk, labouring women. Group 2: mixed group of 30 women who delivered a fetus with pH < 7.00 and 30 women who delivered a fetus with pH ≥ 7.00. METHODS: Intrapartum FHR tracings were retrospectively and blindly evaluated by two independent assessors using an algorithm proposed by Ross and Gala to predict fetal base excess at birth. MAIN OUTCOME MEASURES: The accuracy in predicting the base excess values of newborns was expressed as the proportion of FHR tracings in which the operator was able to correctly calculate the actual base excess at birth (approximation of ± 2 mmol/l). Inter- and intra-observer reproducibility were estimated using the Pearson correlation coefficient. RESULTS: In the group of 152 low-risk labouring women, the two assessors correctly predicted the umbilical artery base excess in 73.1 and 76.3% of cases, respectively. Inter-observer (Pearson correlation coefficient = 0.75) and intra-observer (Pearson correlation coefficient = 0.80 and 0.82 for the first and second assessor, respectively) reproducibility was very good. In the 30 fetuses that were acidemic, the first and second observers correctly predicted base excess values in 23 (76.7%) and 21 (70%) cases, respectively (inter-observer reproducibility, Pearson correlation coefficient = 0.72). CONCLUSIONS: The algorithm proposed by Ross and Gala may be a valuable tool to estimate changes in umbilical base excess during active labour, with a high inter- and intra-observer reproducibility.

Shift work and pregnancy outcomes: a systematic review with meta-analysis of currently available epidemiological studies.

BACKGROUND: Varying work schedules are suspected of increasing risks to pregnant women and to fetal wellbeing. In particular, maternal hormonal disturbance arising from sleep deprivation or circadian rhythm disruption might impair fetal growth or lead to complications of pregnancy. Two independent meta-analyses (from 2000 to 2007) reported a small adverse effect of shift work on the risk of preterm delivery (PTD). However, these reviews were based on few high-quality studies. OBJECTIVES: To provide an updated review of the associations of shift work with PTD, low birthweight (LBW), small-for-gestational-age (SGA) infants and pre-eclampsia. SEARCH STRATEGY AND SELECTION CRITERIA: We conducted a systematic search of MEDLINE using combinations of keywords and MeSH terms. DATA COLLECTION AND ANALYSIS: For each relevant paper we abstracted standard details, used to summarise design features and rate methodological quality. We calculated pooled estimates of relative risk (RR) in random-effect meta-analyses. MAIN RESULTS: We retrieved 23 relevant studies. The pooled estimate of RR for PTD was 1.16 (95% CI 1.00-1.33, 16 studies), but when five reports of poorer methodological quality were excluded, the estimated RR decreased to 1.03 (95% CI 0.93-1.14). We also observed increased RRs for LBW (RR 1.27, 95% CI 0.93-1.74) and for SGA (RR 1.12, 95% CI 1.03-1.22), which varied little by study quality. Little evidence was found on pre-eclampsia. CONCLUSIONS: These findings suggest that overall, any risk of PTD, LBW, or SGA arising from shift work in pregnancy is small.

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.

Laparoscopic colorectal resections with transvaginal specimen extraction for severe endometriosis.

INTRODUCTION: Bowel resection is now considered the "gold standard" treatment for severe endometriosis infiltrating the bowel. Laparoscopic colorectal resection can be considered a safe option in order to reduce surgical trauma and complications as well as to improve cosmetics. Transvaginal approach, used for several years to remove large specimens, can be an interesting approach also in case of colorectal resections. AIM OF THE STUDY: To present our experience on laparoscopic colorectal resection and transvaginal specimen extraction as treatment of severe endometriosis. RESULTS: Eleven patients (mean age 45+/-12 years) have been operated by a combined team of gynecologist and colorectal surgeons. There were no intra- or post-operative complications. In all cases, the transvaginal route was used to remove the specimen and prepare the bowel for anastomosis. Patients were allowed to free light diet on post-operative day 3+/-1 and discharged on day 5+/-2. The mean follow-up was 4+/-2 months and all patients are well with normal bowel function and symptoms free. CONCLUSIONS: Our preliminary experience demonstrates such approach is safe and feasible with excellent results in term of post-operative course.

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.

Efficacy of tolterodine in women with detrusor overactivity and anterior vaginal wall prolapse: is it the same?

The aim of this study was to assess the efficacy of tolterodine in women with overactive bladder (OAB) and concomitant anterior vaginal prolapse. In this prospective study, 235 consecutive women with OAB symptoms and urodynamic diagnosis of detrusor overactivity who either had no prolapse or had pure anterior vaginal prolapse were included: 184 women (group 1) had no prolapse and 51 women (group 2) had anterior prolapse greater than and equal to stage IIa. Tolterodine 4 mg slow release once a day was prescribed. After 12 weeks, women were reassessed using a 3-point scale (no change, improvement and cured). A total of 158 (85.9%) women in group 1 and 31 (60.8%) women in group 2 reported improvement or cure (P = 0.0002). Women with OAB and significant anterior vaginal prolapse should be informed of a reduced efficacy of antimuscarinics in treating their urinary symptoms.