Pregnancy management in Behçet's disease treated with uninterrupted infliximab. Report of a case with fetal growth restriction and mini-review of the literature.

BACKGROUND: The mutual impact of Behçet's disease (BD) and pregnancy is variable and still unclear. Among the safe drugs administered, the newer infliximab (IFX) was rarely experienced in pregnancy, particularly in the third trimester. CASE: The authors report a pregnancy with fetal growth restriction at 36 weeks in a 31-year-old primigravida with symptomatic BD, treated with uninterrupted monthly IFX and daily enoxaparin. The patient was induced at 38 weeks and had an uneventful vaginal delivery of a healthy baby. The postpartum period and following six months were uneventful for mother in terms of BD exacerbation, and newborn in terms of potential risks of neonatal BD and/or infections due to late immunosuppressive IFX administration. CONCLUSION: Because of the inconstant mutual impact, BD pregnancies should be precautionary considered at "potential high-risk" and need a careful and close monitoring by a multidisciplinary team with specific expertise.

Nonhormonal management of postmenopausal women: effects of a red clover based isoflavones supplementation on climacteric syndrome and cardiovascular risk serum profile.

PURPOSE OF INVESTIGATION: The aim of this prospective randomized study was to evaluate a red clover based isoflavones supplementation in the treatment of climacteric syndrome and its effects on cardiovascular risk serum profile. MATERIALS AND METHODS: The study included 150 healthy postmenopausal women that were randomly assigned to receive phytoestrogens tablets, amounting in a total daily intake of 60.8 mg red clover isoflavones plus 19.2 mg soy isoflavones (n = 75), or placebo (n = 75). The authors evaluated teh following: daily number of hot flushes and Kupperman Index at baseline and after one and three months; serum total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and antithrombin III (ATIII) at baseline and after three and six months. RESULTS: One hundred twenty-eight patients completed the study: 67 in the active group and 61 in the placebo group. The treatment led to a progressive significant reduction (p < 0.05) of the number of hot flushes in the active group compared to placebo already after one month, while Kupperman Index was statistically reduced after three months. No significant variation in total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, PT, PTT, fibrinogen, and ATIII were found. CONCLUSION: The present findings suggest that a red clover based isoflavones supplementation in healthy postmenopausal women is promptly effective on climacteric syndrome, improves neurovegetative symptoms, safe on cardiovascular risk serum profile, and does not modify lipids and coagulation.

Screening for trisomy 21 by maternal age fetal nuchal translucency thickness and maternal serum sample.

AIM: The aim of this paper was to examine the performance of two-stage first-trimester combined screening based on maternal age, fetal nuchal translucency (NT) thickness and maternal serum sample "free beta-human chorionic gonadotropin (ß-hCG) and pregnancy-associated plasma protein-A (PAPP-A)". METHODS: A combined screening for chromosomal anomalies was performed in 713 singleton pregnancies. We performed a two-stage screening with the blood taken at 8+0 to 10+6 weeks and the measurement of NT performed at 12+0 to 12+6 weeks. The maternal age related risk for trisomy 21 was calculated and adjusted according to the gestational age at the time of screening to derive the a-priori risk. The measured free beta-human chorionic gonadotropin (ß-hCG) and pregnancy-associated plasma protein-A (PAPP-A) were converted into a multiple of the median (MoM) for gestational age, adjusted for maternal weight, smoking status, ethnicity, method of conception (spontaneous or IVF) and parity. The measured NT was assessed in relationship of mesasure of CRL. Finally, the risk resulting by NT thickness and biochemical markers were multiplied by the a-priori risk to derive the patient-specific risk. RESULTS: The ultrascreen was considered positive in the case where the risk was greater than 1:250. In this case it was suggested the study of the fetal karyotype through an invasive test. In our study we had 23 positive cases after the combined screening: all patients have opted for the study of fetal karyotype, and in 5 cases the result was abnormal (trisomy 21). We had 1 case where the test was negative but the fetal karyotype was abnormal (trisomy 21). We have calculated sensitivity and false positive rate of the test. CONCLUSION: In our study there were 707 cases with a normal karyotype or delivery of a phenotypically normal baby and 6 cases with trisomy 21. The detection rate of the first trimester screening for chromosomal anomalies was 83% with a false positive rate of 3,2%. The aim of the study was estimated the performance of two-step strategy screening. In our study, the performance of the screening model, based on the two-stage, was not higher than the performance of screening based on a single-step reported in literature. In our opinion, there is no potential advantage in terms of detection rate.

Alcohol sclerotherapy: a new method for Bartholin gland cyst treatment.

AIM: Bartholin gland cysts are one of the most common gynecologic problems. Around 2% of women suffer from these pathologies. Bartholin gland cyst are generally asymptomatic, but sometimes extremely painful to restrict physical activity. The treatment choice is related to the patient's age, the size of the cyst or abscess and relapses, but different approaches are possible. The aim of this study is to investigate the efficicacy and safety of the alcohol sclerotherapy versus the only aspiration to cure symptomatic cysts or abscesses of the Bartholin's gland. METHODS: Between January 2002 and June 2004, 18 patients suffering from Bartholin symptomatic unilateral cysts or with abscess are selected. These patients have been divided into 2 groups and they have been treated with alcohol sclerotherapy or aspiration. The simple aspiration removes only the cyst fluid. The alcohol sclerotherapy allows to destroy the epithelial covering of the cyst by a coagulative necrosis and then a fibrosis which covers the cavity and prevents the reformation of liquid. RESULTS: Treatment has been satisfactory for all the patients, and treatment time has been shorter with alcohol sclerotherapy. None of the patients, in both groups, presented sexual dysfunctions or dyspareunia. CONCLUSIONS: Alcohol sclerotherapy might be an ideal and safe procedure in the treatment of the Bartholin's gland or abscesses with a low percentage of relapses.

Methotrexate treatment for tubal pregnancy. Criteria for medical approach.

AIM: The purpose of this retrospective study is to underline the indications for the use of systemic methotrexate (MTX) in tubal pregnancies. METHODS: One hundred and four (n=104) consecutive women were treated in our Department for tubal pregnancy. The database analysis showed that after careful respect for inclusion criteria, the treatment chosen was the intravenous administration of MTX in 68 patients, whereas laparoscopy constituted the primary treatment in 36 patients. A single dose of MTX was intravenously administered, diluted in saline solution, with a dosage of 50 mg/m2 of body surface. Close serum beta-hCG monitoring was performed, and in the case of a short fall, a 2nd dose of methotrexate was submitted. RESULTS: The overall success rate of MTX treatment was 91%; the 2nd dose of MTX was used in 12% of patients, whereas in only 6 out of 68 patients included in the medical treatment group a surgical approach for suspected tubal rupture was necessary. CONCLUSION: Treatment with methotrexate is effective and safe in the presence of these criteria: patient hemodynamically stable, absence of tubal rupture sign and hemoperitoneum, an adnexal mass with a diameter < or = 5 cm, an amenorrhea < or = 6 weeks and HCG levels < or = 10,000 mIU/ml. Laparoscopy is indicated in diagnostic uncertainty, when MTX is not suggested, when adnexal mass is > 5 cm, or in patients in which beta-hCG levels was > 10,000 mIU/ml.

Alcohol sclerosis of endometriomas after ultrasound-guided aspiration.

AIM: We investigate the possibility to use ultrasound-guided aspiration and alcohol sclerosis in patients with endometrioma. METHODS: Ten patients with endometriotic ovarian cysts, mean diameter <70 mm, CA125 <35 UI, persistence of cyst after medical therapy and refusal of surgical therapy have been studied. The patients were submitted to ultrasound-guided aspiration of endometriomas. Fifty per cent of aspirated fluid was replaced with pure ethanol, which was left in situ for 10 to 20 minutes. No medical therapy was employed after aspiration and ethanol treatment. RESULTS: In 9 patients no recurrence was observed at ultrasound after 21.2+/-6.62 months of follow-up. In 1 case only, after 6 months, a recurrence of the endometrioma in the same site was observed. CONCLUSION: Ultrasound-guided alcoholic sclerotherapy of the endometriotic ovarian cysts is effective and safe. We speculate that this procedure could be indicated in patients refusing standard surgical therapy.

Ovarian hyperstimulation syndrome: distinction between local and systemic disease.

The ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, unpredictable and potentially life-threatening complication in patients submitted to pharmacological ovarian stimulation. Information on risk factors, etiopathogenetic mechanisms, prevention strategies and therapeutic management is continuously updated. The present study retrospectively analyzed 123 women affected by different grades of OHSS as a result of pharmacological ovulation induction. Hospital admission was suggested in 14 patients with severe OHSS, whereas patients with moderate or mild OHSS were followed in the out-patient section of our department. The results confirmed the efficacy of the therapeutic scheme adopted. The syndrome is localized to the ovaries at the time that the condition is triggered; when organs different from the ovaries become involved, OHSS assumes systemic aspects. The different clinical signs are the basis of a proposal of a local and systemic classification.

[Myomectomy during cesarean section and outside pregnancy. Different outcomes of scars]. / Miomectomia in corso di taglio cesareo e al di fuori della gravidanza. Differenti esiti della cicatriche.

BACKGROUND: The purpose of this study is the comparison between the scar of myomectomy performed during cesarean section and out of the pregnancy. METHODS: Eighteen pregnant patients were submitted to cesarean section between 37 and 39 weeks of gestation for previous myomectomy. The previous myomectomy has been performed in 8 patients during a cesarean section, in 10 patients out of pregnancy; in all patients only one subserous-intramural myoma of uterine fundus or body with a maximum diameter of 4-5 cm has been excised. RESULTS: In myomectomies performed during cesarean section the scar appeared more linear, with good well defined limits, less wide and with modest introflection in comparison to surrounding myometrium. The myometrial thickness did not present variations and was well contracted. CONCLUSIONS: Our results show substantial differences: in fact, according to personal opinion, the different evolution of the healing process is due to variations occurring in pregnancy and particularly for local immunology system which in pregnancy is hyperactive. The presence and increased synthesis of immunological substances support a better healing with an optimal functional recovery.

[Pelvic actinomycosis and sub-acute abdomen]. / Actinomicosi pelvica ed addome sub-acuto.

An interesting case of pelvic actinomycosis with paculiar clinical manifestation is presented. A 42 years-old patient came to our emergency service for an abdominal pelvic pain and fever. Past history showed IUD in situ for over 15 years. The patient was submitted to a ultrasonographic scan and a complete hematological screening was performed. The diagnosis was of subacute abdomen, and an exploratory laparotomy was carried out. During laparotomy an atypical reactive tissue and a suppurative cavity were found. The histological finding of tissue biopsy showed pelvic actinomycosis. On the basis of these findings the conclusion is drawn that a better prevention of pelvic actinomycosis is necessary of its diffusion in the last years due to sexual habit changes.

Restitutio ad integrum of myometrium after myomectomy. Different results in pregnant and non-pregnant patients.

BACKGROUND: The aim of this study is to check whether there exists a difference in restitutio ad integrum of the uterus after myomectomy performed during Caesarean section and out of pregnancy. METHODS: Two different groups are considered: Group A (n=8) that underwent myomectomy during Caesarean section; Group B (n=10) in which myomectomy was performed out of pregnancy. All patients were followed with serial scan evaluations. RESULTS: The results showed a much more complete and faster absorption of hyperplasia and hypertrophy surrounding fibroid nodules when myomectomy was performed during Caesarean section. CONCLUSIONS: A later pregnancy in patients who underwent myomectomy during Caesarean section might have a favourable outcome, possibly reaching a term gestation and vaginal delivery.

Regression of ovarian enlargement in pharmacological ovulation induction.

The aim of the present study was to determine a possible relationship between ovarian functionality and regression of ovarian enlargement according to the different categories and degree of severity of ovarian hyperstimulation syndrome (OHSS). Among a group of sterile woman (n = 111), two subgroups were studied: group A (n = 15), patients affected by severe syndrome; and group B (n = 96), patients with massive ovarian enlargement only. The protocol of ovarian stimulation was conducted in various in vitro fertilization (IVF) centers; ultrasonographic examination and hematological checks were carried out daily; patients with severe OHSS were hospitalized. In women of group A, severe symptoms disappeared in 7-11 days; in nine patients with regular cycles ovary size returned to normal in about 30-40 days, whereas in six subjects with anovulatory cycles, the resolution was recorded in about 50-60 days; serum estradiol returned to physiological levels within 20-30 days. Women of group B showed a spontaneous regression at different times: in 43 subjects that presented regular ovulatory cycles, the resolution was recorded in about 30-40 days, whereas in 36 women with anovulatory cycles before pharmacological induction, resolution occurred in 50-60 days, and in 17 cases with polycystic ovary syndrome before pharmacological ovulation, an incomplete resolution was obtained; serum estradiol levels returned to a physiological range within 20-30 days. Our results show that in patients with regular ovulatory cycles, resolution of symptoms is obtained in a shorter time than in patients with anovulatory cycles before pharmacological induction.

Ultrasound diagnosis and Doppler monitoring of a pelvic spleen in pregnancy.

We describe a patient with a pelvic spleen diagnosed during pregnancy and monitored through gestation which we believe to be the first reported case. A 40-year-old woman was referred at 8 weeks of gestation because of a chronic intense pain in the left iliac cavity which had spread to her lower back. Clinical examination revealed a poorly defined pelvic mass. Pelvic ultrasound demonstrated a gestational sac containing a viable embryo whose size was consistent with the period of amenorrhea. While the splenic area in the left hypocondrium was found to be empty, a homogeneous and elongate mass measuring 152 x 123 mm with a maximum thickness of 53.4 mm was observed in the left iliac cavity above the uterus. This mass, the ectopic spleen, was monitored by Doppler velocimetry at monthly intervals until delivery and no variation throughout gestation was observed; therefore, despite the occasional occurrence of heavy pain, it was possible to exclude circulatory complications such as thrombosis or torsion. Doppler ultrasound proved to be a useful tool for the differential diagnosis of this rare anatomical variation.

Contribution to the choice of therapy in abdominal pregnancy.

The goal of our study was to offer our contribution to the selection of the most suitable therapy to treat abdominal pregnancy. We discuss three patients affected with this pathology, which was diagnosed early by laparoscopy. The patients were treated with 50 mg/m2 of methotrexate administered intravenously. The abdominal pregnancy was terminated in all three patients. Since the outcome involved termination of the pregnancy, it is important to emphasize that methotrexate therapy, must be considered elective. Operative laparoscopy can be limited only to cases in which the ovum has not become implanted in the intestinal interstices and is not near sites susceptible to complications.