Adenomatoid tumor of the fallopian tube: A case report and a review of the literature.

INTRODUCTION: Adenomatoid tumor is a rare, benign condition, more common in males, that affects the epididymis, spermatic cord and testicular tunics, whereas in females, the uterus and fallopian tubes. This solitary tumor is commonly appearing as an incidental finding. The diverse morphological characteristics of these tumors pose challenges in differential diagnoses. PRESENTATION OF CASE: We report a case of a 33-year-old woman with a multilocular solid mass identified in a routine gynecological check-up. The cyst was removed laparoscopically, and histology analysis reported an adenomatoid tumor of the fallopian tube. Patient recovered without any additional treatment and within 2 years delivered a healthy offspring. Extensive literature search was conducted in Pubmed, Embase and Google Scholar for the identification of all relevant case reports or case series of adenomatoid tumors of the fallopian tubes. DISCUSSION: Literature search revealed other 49 cases of adenomatoid tumors in fallopian tube published. The mean age of patients was 45,6 years (ranged from 29 to 72 years) and the mean diameter of the tumor was 10 mm. CONCLUSION: Laparoscopic removal of such a rare, benign tumor is effective and safe.

Placenta Accreta Spectrum: A Comprehensive Review of Guidelines.

Importance: Placenta accreta spectrum (PAS) represents a range of disorders characterized by abnormal placental invasion and is associated with severe maternal morbidity and mortality. Objective: The aim of this study was to review and compare the most recently published major guidelines on the diagnosis and management of this potentially life-threatening obstetric complication. Evidence Acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the International Society for Abnormally Invasive Placenta, the Royal College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, and the Society of Obstetricians and Gynecologists of Canada on PAS disorders was carried out. Results: There is a consensus among the reviewed guidelines regarding the definition and the diagnosis of PAS using specific sonographic signs. In addition, they all agree that the use of magnetic resonance imaging should be limited to the evaluation of the extension to pelvic organs in case of placenta percreta. Moreover, American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynecologists, International Federation of Gynecology and Obstetrics, and the Society of Obstetricians and Gynecologists of Canada agree that screening for PAS disorders should be based on clinical risk factors along with sonographic findings. Regarding management, they all highlight the importance of a multidisciplinary team approach and recommend delivery by elective cesarean section at a tertiary center with experienced staff and appropriate resources. Routine preoperative ureteric stenting and occlusion of pelvic arteries are universally not recommended. Moreover, hysterectomy following the delivery of the fetus, expectant management with placenta left in situ, and conservative management in case of focal disease and desired fertility are all considered as acceptable treatment options. The reviewed guidelines also suggest some measures for intraoperative and postoperative hemorrhage control and recommend prophylactic administration of antibiotics. Methotrexate after expectant management is unanimously discouraged. On the other hand, there is no common pathway with regard to the optimal timing of delivery, the recommended mode of anesthesia, the preferred skin incision, and the effectiveness of the delayed hysterectomy approach. Conclusions: PAS disorders are mainly iatrogenic conditions with a constantly rising incidence and potentially devastating consequences for both the mother and the neonate. Thus, the development of uniform international practice protocols for effective screening, diagnosis, and management seems of paramount importance and will hopefully drive favorable pregnancy outcomes.

Comparison of Fetal Crown-Rump Length Measurements between Thawed and Fresh Embryo Transfer.

Background and Objectives: Neonates born from thawed embryo transfers tend to have a significantly higher birthweight compared to those from fresh embryo transfers. The aim of this study was to compare the crown-rump length (CRL) between thawed and fresh embryos to investigate the potential causes of different growth patterns between them. Materials and Methods: This was a retrospective study (July 2010-December 2023) conducted at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece. In total, 3082 assisted reproductive technology (ART) pregnancies (4044 embryos) underwent a routine scan at 11+0-13+6 gestational weeks and were included in the study. Maternal age, the type of embryo transfer (thawed vs. fresh, donor vs. their own oocytes), CRL, twin and singleton gestations were analyzed. Results: The mean maternal age in thawed was significantly higher than in fresh embryos (39.8 vs. 35.8 years, p-value < 0.001). The mean CRL z-score was significantly higher in thawed compared to fresh embryo transfers (0.309 vs. 0.199, p-value < 0.001). A subgroup analysis on singleton gestations showed that the mean CRL z-score was higher in thawed blastocysts compared to fresh (0.327 vs. 0.215, p-value < 0.001). Accordingly, an analysis on twins revealed that the mean CRL z-score was higher in thawed blastocysts (0.285 vs. 0.184, p-value: 0.015) and in oocytes' recipients compared to own oocytes' cases (0.431 vs. 0.191, p-value: 0.002). Conclusions: The difference in CRL measurements between thawed and fresh embryos may be a first indication of the subsequent difference in sonographically estimated fetal weight and birthweight. This finding highlights the need for additional research into the underlying causes, including maternal factors and the culture media used.

Antenatal Care: A Comparative Review of Guidelines.

Importance: Antenatal care plays a crucial role in safely monitoring and ensuring the well-being of both the mother and the fetus during pregnancy, ultimately leading to the best possible perinatal outcomes. Objective: The aim of this study was to review and compare the most recently published guidelines on antenatal care. Evidence Acquisition: A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Public Health Agency of Canada, the World Health Organization, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists regarding antenatal care was conducted. Results: There is a consensus among the reviewed guidelines regarding the necessary appointments during the antenatal period, the proper timing for induction of labor, the number and frequency of laboratory examinations for the assessment of mother's well-being, and management strategies for common physiological problems during pregnancy, such as nausea and vomiting, heartburn, pelvic pain, leg cramps, and symptomatic vaginal discharge. In addition, special consideration should be given for mental health issues and timely referral to a specialist, reassurance of complete maternal vaccination, counseling for safe use of medical agents, and advice for cessation of substance, alcohol, and tobacco use during pregnancy. Controversy surrounds clinical evaluation during the antenatal period, particularly when it comes to the routine use of an oral glucose tolerance test and symphysis-fundal height measurement for assessing fetal growth, whereas routine cardiotocography and fetal movement counting are suggested practices only by Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Of note, recommendations on nutritional interventions and supplementation are offered only by Public Health Agency of Canada and World Health Organization, with some minor discrepancies in the optimal dosage. Conclusions: Antenatal care remains a critical factor in achieving positive outcomes, but there are variations depending on the socioeconomic status of each country. Therefore, the establishment of consistent international protocols for optimal antenatal care is of utmost importance. This can help provide safe guidance for healthcare providers and, consequently, improve both maternal and fetal outcomes.

Diagnosis and Management of Macrosomia and Shoulder Dystocia: A Comprehensive Review of Major Guidelines.

Importance: Macrosomia represents the most significant risk factor of shoulder dystocia (SD), which is a severe and emergent complication of vaginal delivery. They are both associated with adverse pregnancy outcomes. Objective: The aim of this study was to review and compare the most recently published influential guidelines on the diagnosis and management of fetal macrosomia and SD. Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and the Department for Health and Wellbeing of the Government of South Australia on macrosomia and SD was conducted. Results: The ACOG and RANZCOG agree that macrosomia should be defined as birthweight above 4000-4500 g regardless of the gestational age, whereas the National Institute for Health and Care Excellence defines macrosomia as an estimated fetal weight above the 95th percentile. According to ACOG and RANZCOG, ultrasound scans and clinical estimates can be used to rule out fetal macrosomia, although lacking accuracy. Routine induction of labor before 39 weeks of gestation with the sole indication of suspected fetal macrosomia is unanimously not recommended, but an individualized counseling should be provided. Exercise, appropriate diet, and prepregnancy bariatric surgery are mentioned as preventive measures. There is also consensus among the reviewed guidelines regarding the definition and the diagnosis of SD, with the "turtle sign" being the most common sign for its recognition as well as the poor predictability of the reported risk factors. Moreover, there is an overall agreement on the algorithm of SD management with McRoberts technique suggested as first-line maneuver. In addition, appropriate staff training, thorough documentation, and time keeping are crucial aspects of SD management according to all medical societies. Elective delivery for the prevention of SD is discouraged by all the reviewed guidelines. Conclusions: Macrosomia is associated not only with SD but also with maternal and neonatal complications. Similarly, SD can lead to permanent neurologic sequalae, as well as perinatal death if managed in a suboptimal way. Therefore, it is crucial to develop consistent international practice protocols for their prompt diagnosis and effective management in order to safely guide clinical practice and improve pregnancy outcomes.

Ultrasonographic Evaluation of the Second Stage of Labor according to the Mode of Delivery: A Prospective Study in Greece.

BACKGROUND AND OBJECTIVES: Accurate diagnosis of labor progress is crucial for making well-informed decisions regarding timely and appropriate interventions to optimize outcomes for both the mother and the fetus. The aim of this study was to assess the progress of the second stage of labor using intrapartum ultrasound. MATERIAL AND METHODS: This was a prospective study (December 2022-December 2023) conducted at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece. Maternal-fetal and labor characteristics were recorded, and two ultrasound parameters were measured: the angle of progression (AoP) and the head-perineum distance (HPD). The correlation between the two ultrasonographic values and the maternal-fetal characteristics was investigated. Multinomial regression analysis was also conducted to investigate any potential predictors of the mode of delivery. RESULTS: A total of 82 women at the second stage of labor were clinically and sonographically assessed. The mean duration of the second stage of labor differed between vaginal and cesarean deliveries (65.3 vs. 160 min; p-value < 0.001) and between cesarean and operative vaginal deliveries (160 vs. 88.6 min; p-value = 0.015). The occiput anterior position was associated with an increased likelihood of vaginal delivery (OR: 24.167; 95% CI: 3.8-152.5; p-value < 0.001). No significant differences were identified in the AoP among the three different modes of delivery (vaginal: 145.7° vs. operative vaginal: 139.9° vs. cesarean: 132.1°; p-value = 0.289). The mean HPD differed significantly between vaginal and cesarean deliveries (28.6 vs. 41.4 mm; p-value < 0.001) and between cesarean and operative vaginal deliveries (41.4 vs. 26.9 mm; p-value = 0.002); it was correlated significantly with maternal BMI (r = 0.268; p-value = 0.024) and the duration of the second stage of labor (r = 0.256; p-value = 0.031). Low parity (OR: 12.024; 95% CI: 6.320-22.876; p-value < 0.001) and high HPD (OR: 1.23; 95% CI: 1.05-1.43; p-value = 0.007) were found to be significant predictors of cesarean delivery. CONCLUSIONS: The use of intrapartum ultrasound as an adjunctive technique to the standard clinical evaluation may enhance the diagnostic approach to an abnormal labor progress and predict the need for operative vaginal or cesarean delivery.

Combination of Mifepristone and Misoprostol for First-Trimester Medical Abortion: A Comprehensive Review of the Literature.

Importance: Several medications have been used to achieve medical abortion in the first trimester of pregnancy. The most commonly used is the combination of mifepristone and misoprostol; however, different doses and routes of administration have been proposed. Objective: The aim of this study was to summarize published data on the effectiveness, adverse effects, and acceptability of the various combinations of mifepristone and misoprostol in medical abortion protocols in the first trimester of pregnancy. Evidence Acquisition: This was a comprehensive review, synthesizing the findings of the literature on the current use of mifepristone and misoprostol for first-trimester abortion. Results: The combination of mifepristone and misoprostol seems to be more effective than misoprostol alone. Regarding the dosages and routes, mifepristone is administered orally, and the optimal dose is 200 mg. The route of administration of misoprostol varies; the sublingual and buccal routes are more effective; however, the vaginal route (800 µg) is associated with fewer adverse effects. Finally, the acceptability rates did not differ significantly. Conclusions: Different schemes for first-trimester medical abortion have been described so far. Future research needs to focus on identifying the method that offers the best trade-off between efficacy and safety in first-trimester medical abortion.

Postnatal Care: A Comparative Review of Guidelines.

Importance: Postnatal care refers to the ongoing health care provision of both the mother and her offspring and contributes to the timely identification and effective management of complications in the postpartum period, to secure maternal and infant short- and long-term well-being. Objective: The aim of this study was to review and compare the most recently published influential guidelines on postnatal care practices. Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Care Excellence, and the Public Health Agency of Canada regarding postnatal care was conducted. Results: There is a consensus among the reviewed guidelines regarding the importance of health care provision in the postpartum period, including home visits and midwifery services, the use of telemedicine for the facilitation of communication with the patient, and the appropriate preparation for discharge, as well as the discharge criteria. All medical societies also agree on the clinical aspects that should be evaluated at each postnatal visit, although discrepancies exist with regard to the contact schedule. In addition, there is consistency regarding the management of postpartum infections, perineal pain, fecal and urinary incontinence, and physical activity guidance. Mental health issues should be addressed at each postnatal visit, according to all guidelines, but there is disagreement regarding routine screening for depression. As for the optimal interpregnancy interval, the American College of Obstetricians and Gynecologists recommends avoiding pregnancy for at least 6 months postpartum, whereas the National Institute for Health and Care Excellence recommends a 12-month interval. There is no common pathway regarding the recommended contraceptive methods, the nutrition guidance, and the postpartum management of pregnancy complications. Of note, the World Health Organization alone provides recommendations concerning the prevention of specific infections during the postnatal period. Conclusions: Postnatal care remains a relatively underserved aspect of maternity care, although the puerperium is a critical period for the establishment of motherhood and the transition to primary care. Thus, the development of consistent international protocols for the optimal care and support of women during the postnatal period seems of insurmountable importance to safely guide clinical practice and subsequently reduce maternal and neonatal morbidity.

Fetal Growth Restriction: A Comprehensive Review of Major Guidelines.

Importance: Fetal growth restriction (FGR) is a common pregnancy complication and a significant contributor of fetal and neonatal morbidity and mortality, mainly due to the lack of effective screening, prevention, and management policies. Objective: The aim of this study was to review and compare the most recently published influential guidelines on the management of pregnancies complicated by FGR. Evidence Acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada (SOGC), the Perinatal Society of Australia and New Zealand, the Royal College of Physicians of Ireland, the French College of Gynecologists and Obstetricians (FCGO), and the German Society of Gynecology and Obstetrics on FGR was carried out. Results: Several discrepancies were identified regarding the definition of FGR and small-for-gestational-age fetuses, the diagnostic criteria, and the need of testing for congenital infections. On the contrary, there is an overall agreement among the reviewed guidelines regarding the importance of early universal risk stratification for FGR to accordingly modify the surveillance protocols. Low-risk pregnancies should unanimously be evaluated by serial symphysis fundal height measurement, whereas the high-risk ones warrant increased sonographic surveillance. Following FGR diagnosis, all medical societies agree that umbilical artery Doppler assessment is required to further guide management, whereas amniotic fluid volume evaluation is also recommended by the ACOG, the SOGC, the Perinatal Society of Australia and New Zealand, the FCGO, and the German Society of Gynecology and Obstetrics. In case of early, severe FGR or FGR accompanied by structural abnormalities, the ACOG, the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the Royal College of Obstetricians and Gynecologists, the SOGC, and the FCGO support the performance of prenatal diagnostic testing. Consistent protocols also exist on the optimal timing and mode of delivery, the importance of continuous fetal heart rate monitoring during labor, and the need for histopathological examination of the placenta after delivery. On the other hand, guidelines concerning the frequency of fetal growth and Doppler velocimetry evaluation lack uniformity, although most of the reviewed medical societies recommend an average interval of 2 weeks, reduced to weekly or less when umbilical artery abnormalities are detected. Moreover, there is a discrepancy on the appropriate timing for corticosteroids and magnesium sulfate administration, as well as the administration of aspirin as a preventive measure. Cessation of smoking, alcohol consumption, and illicit drug use are proposed as preventive measures to reduce the incidence of FGR. Conclusions: Fetal growth restriction is a clinical entity associated with numerous adverse antenatal and postnatal events, but currently, it has no definitive cure apart from delivery. Thus, the development of uniform international protocols for the early recognition, the adequate surveillance, and the optimal management of growth-restricted fetuses seem of paramount importance to safely guide clinical practice, thereby improving perinatal outcomes of such pregnancies.

Prevention of Early-Onset Neonatal Group B Streptococcal Disease: A Comprehensive Review of Major Guidelines.

Importance: Group B Streptococcus (GBS) colonization during pregnancy is associated with significant neonatal morbidity and mortality and represents a major public health concern, often associated with poor screening and management. Objective: The aim of this study was to review and compare the most recently published influential guidelines on the screening and management of this clinical entity during antenatal and intrapartum periods. Evidence Acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, and the Society of Obstetricians and Gynecologists of Canada on the prevention of early-onset neonatal group B streptococcal disease was carried out. Results: There is a consensus among the reviewed guidelines regarding the optimal screening specimen type, indications for intrapartum antibiotic administration such as bacteriuria during pregnancy, clinical signs of chorioamnionitis or maternal pyrexia, and history of GBS-related neonatal disease. There is also agreement on several conditions where no intervention is recommended, that is, antepartum treatment of GBS and GBS-positive women with planned cesarean delivery and intact membranes. Controversy exists regarding the optimal screening time, with the Royal College of Obstetricians and Gynecologists stating against routine screening and on management strategies related to preterm labor and preterm prelabor rupture of membranes. Conclusions: The development of consistent international practice protocols for the timely screening of GBS and effective management of this clinical entity both during pregnancy and the intrapartum period seems of paramount importance to safely guide clinical practice and subsequently improve neonatal outcomes.