Primary hyperparathyroidism in pregnancy treated with cinacalcet: a case report and review of the literature.

BACKGROUND: The efficacy and safety of various modes of medical treatment for primary hyperparathyroidism in pregnancy are largely unknown. CASE PRESENTATION: We report the case of a 34-year-old white woman with primary hyperparathyroidism symptomatic for nephrolithiasis. Her serum calcium was 3.15 mmol/l and parathyroid hormone was 109.0 ng/L. Neck imaging found no pathological parathyroid tissue. Cinacalcet and cholecalciferol were started. She became pregnant 17 months later. The calcimimetic was stopped. During pregnancy, she was admitted for hydration administered intravenously two to three times per week. In her 24th week of pregnancy, cinacalcet was restarted. In her 32nd week, a cesarean section was carried out as planned. CONCLUSIONS: Only three cases of primary hyperparathyroidism in women on cinacalcet therapy in pregnancy have been published in the literature. In the present case, hydration was useful in controlling serum calcium. Cinacalcet therapy helped to control serum calcium.

Receptor modulation and functional activation of human CD34+ Lin- -derived immature NK cells in vitro by Mycobacterium bovis Bacillus Calmette-Guerin (BCG).

It is not yet clear whether immature NK (iNK) cells are bystanders to or rather participate in immune responses to pathogens that may colocalize in areas of NK-cell maturation such as bone marrow or lymph nodes. Mycobacteria, including Bacillus Calmette-Guerin (BCG), have been shown to interact with peripheral NK cells and in vivo may colocalize in areas of iNK-cell development. We studied infection with BCG of human cord blood CD34(+) Lin(-)-derived cultures containing myelomonocytes and iNK cells in vitro. Increased iNK-cell DNAM-1 expression, transient natural cytotoxicity receptor modulation, and production of IFN-γ were observed. Transcriptional receptor modulation was associated to BCG challenge, which determined increased iNK-cell cytotoxic activity against tumor cell lines and also increased killing of immature dendritic cells (iDCs). No requirement for cell contact was recorded for BCG-induced iNK-cell activation, while cytokine production including IL-18, IL-10, GM-CSF, and TGF-ß contributed to the observed effects. Thus, iNK cells are affected by mycobacteria in vitro and may contribute to shaping of adaptive mature innate responses through iDC-iNK cross-talk. In addition, iNK-cell activation by BCG may represent a novel additional mechanism contributing to the effects observed upon BCG administration in vivo.

Defective placental adhesion in voluntary termination of second-trimester pregnancy and risk of recurrence in subsequent pregnancies.

OBJECTIVE: To evaluate the prevalence of defective placental adhesion (DPA) in voluntary termination of second-trimester pregnancy and the risk of DPA recurrence in subsequent pregnancies. METHODS: We retrospectively reviewed the records of all patients who underwent voluntary second-trimester pregnancy termination in the period between January 2000 and December 2009. In all cases, the fetus and the placenta were submitted to pathological examination accordingly to our clinical protocol. RESULTS: Four hundred twenty-seven cases of voluntary termination of second-trimester pregnancy were included in the study. Ten histologically confirmed cases of placenta accreta were observed (2.3%). Two patients with histological diagnosis of placenta accreta were lost at follow-up. Among the eight remaining patients, six had further pregnancies. Overall, nine pregnancies were recorded, and placenta accreta recurred in one patient. CONCLUSIONS: This study shows that DPA occurs in 2.3% of second-trimester voluntary termination of pregnancy; these patients should have an accurate ultrasound examination of the placenta in subsequent pregnancies.

Evaluation of patients' satisfaction of cervical ripening using dinoprostone by either intravaginal gel or pessary: an open-label, randomized, prospective study.

OBJECTIVE: To evaluate patient satisfaction of cervical ripening using dinoprostone (PGE2) by either intravaginal gel or pessary. STUDY DESIGN: A group of 173 nulliparous women requiring cervical ripening were recruited in the study and randomized to receive either intravaginal gel (Prepidil, Upjohn, Milan, Italy [group A]) or intravaginal pessary (Propess, Ferring Pharmaceuticals, Malmö, Sweden [group B]). Before administration of PGE2 and after delivery, the patients answered a questionnaire investigating the anxiety and discomfort caused by cervical ripening. RESULTS: Of the group, 22 women did not adequately complete the questionnaire; therefore 151 women were included in the study. Before cervical ripening, anxiety and discomfort did not significantly differ between the two study groups; more patients in group A than in group B declared they would have preferred the other form of application. The intensity of pain experienced during the application of PGE2 was higher in group B than in group A. For the future opportunity to choose the application necessary for cervical ripening, more patients in group B than in group A would change the form of application. CONCLUSION: Patient satisfaction with the two forms of treatment appears to be equally good. The application of the intravaginal pessary causes more discomfort than the vaginal gel.

Peripartum cardiomyopathy.

According to current definition, peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the last month of pregnancy. It has been reported that the incidence of PPCM is 1 in 3,000-4,000 live births. The pathogenesis is poorly understood, however, infectious, immunologic, and nutritional causes have been hypothesized. Clinical presentation includes usual signs and symptoms of heart failure, and unusual presentations such as thromboembolism. Diagnosis is based upon the clinical presentation of congestive heart failure and the objective evidence of left ventricular systolic dysfunction. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Patients with systolic dysfunction during pregnancy are treated similar to patients who are not pregnant. The mainstays of medical therapy are digoxin, loop diuretics, sodium restriction and afterload reducing agents (hydralazine and nitrates). Due to a high risk for venous and arterial thrombosis, anticoagulation with subcutaneous heparin should be instituted. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided during pregnancy because of severe adverse neonatal effects. Effective treatment reduces mortality rates and increases the number of women who fully recover left ventricular systolic function. The prognosis is poor in patients with persistent cardiomyopathy. Subsequent pregnancies are often associated with recurrence of left ventricular systolic dysfunction.

Myasthenia gravis during pregnancy.

Myasthenia gravis (MG) affects women in the second and third decades of life, overlapping with the childbearing years. During pregnancy, the course of this disease is unpredictable; worsening of symptoms occurs more likely during the first half of pregnancy and postpartum. MG can be well managed during pregnancy with relatively safe and effective therapies. Cesarean section is recommended only for obstetric reasons; epidural anesthesia is advised to reduce physical and emotional stress. Anticholinesterase drugs are the mainstay of treatment, when MG symptoms are not satisfactorily controlled, corticosteroids, azathioprine and in some cases cyclosporin A may be used. Life-threatening conditions (e.g., respiratory insufficiency) may occur during pregnancy; therefore, intensive check-ups by a gynecologist and a neurologist are necessary.

Adenomyosis in a patient with mosaic Turner's syndrome.

BACKGROUND: Few case reports describing endometriosis in patients with gonadal dysgenesis have been published, but none has reported the presence of adenomyosis in a patient with Turner's syndrome. CASE: A 31-year-old woman with mosaic Turner's Syndrome (45,X/46,XX/47,XXX) was referred to us because of severe iron deficiency anaemia due to hypermenorrhea and persistent lower abdominal pain for more than six months. She presented normal secondary sex development, normal breast, normal pubic and axillary hair. The external genitalia were also normal. Laboratory examination showed normal gonadotropin, 17beta-estradiol, plasma androgens and cortisol levels. At transabdominal ultrasound a myoma (15 x 8.5 x 8 cm) arising from the posterior uterine wall was suspected. The mass was removed during laparotomy. Histologic examination confirmed the presence of the myoma and revealed the presence of focal adenomyosis. CONCLUSION: Adenomyosis and leiomyomata are separate entities but they share a common pathology in that they develop primarily in women of reproductive age and their growth is oestrogen dependent. To our knowledge, this is the first case report in the literature of adenomyosis in a woman who had the Turner's syndrome.

Post-operative complications after caesarean section in HIV-infected women.

This retrospective study evaluated complications associated with caesarean section in HIV-infected women. For each HIV-positive patient ( n=45) a control group of ten seronegative women ( n=450) was matched for age, number of foetuses, gestational age, indication for caesarean section, status of the membranes and kind of anaesthesia. All women delivered in the same hospital using a uniform protocol. We evaluated the duration of stay in hospital after operation, the need for antibiotics after caesarean section, the incidence of minor postoperative complications (mild anaemia, mild temperature or fever 24 h after surgery, wound haematoma or infection, urinary tract infection, endometritis) and major postoperative complications (severe anaemia, pneumonia, pleural effusion, peritonitis, sepsis, disseminated intravascular coagulation, thromboembolism). Most HIV-positive women (64.5%) had a complicated recovery after surgery. A higher incidence of major and minor postoperative complications were observed in the HIV-positive group than in the control group. There was a statistically significant greater incidence of mild anaemia, mild temperature or fever, urinary tract infection and pneumonia in the HIV-positive group. HIV-positive women with less than 500x10(6) CD4(+) lymphocytest/l had higher post-caesarean section morbidity than HIV-positive women with more than 500x10(6) CD4(+) lymphocytest/l. The median duration of hospital stay was significantly higher in the HIV-positive group (median 7 days) than in the HIV-negative group (median 4 days). The rate of HIV vertical transmission was 8.8%. Higher post-caesarean section morbidity was found in HIV-positive women than in controls. Unfortunately, the HIV-positive women (with low CD4 lymphocytes counts), whose infants theoretically will benefit most from caesarean delivery, are also the women who are most likely to experience post-operative complications.

Prospective study of mother-to-infant transmission of hepatitis C virus: a 10-year survey (1990-2000).

BACKGROUND: The purpose of this study was to determine the rate of vertical transmission of hepatitis C virus (HCV). We also aimed to analyze the time of clearance of maternal antibodies in the serum of non-infected babies. METHODS: Between March 1990 and March 2000, 170 consecutive anti-HCV-positive women and their 188 babies entered this prospective study. All women were analyzed for HCV-RNA using polymerase chain reaction (PCR). The babies were followed-up until HCV-antibody clearance or until the diagnosis of HCV infection. RESULTS: The vertical transmission rate was 2.7% overall, and it was higher in HIV co-infected women (5.4%, 2/37) than in HIV-negative women (2.0%, 3/151). All infected infants were born to mothers who had HCV viremia at delivery. The transmission rate was influenced by maternal levels of viremia. 37.2% of uninfected children became HCV-antibody negative by 6 months and 88.0% by 12 months. Babies born from HCV-RNA-positive mothers lost anti-HCV antibodies later (9.21 +/- 3.72 months) than babies born from HCV-RNA-negative mothers (7.47 +/- 3.46 months) ( p < 0.05, Kolmogorov-Smirnov test). CONCLUSIONS: The risk of HCV vertical transmission is very low in HCV-positive/HIV-negative women and it is restricted to infants born to HCV viremic mothers. High maternal viral load is predictive of the vertical transmission. The clearance time of antibodies in non-infected babies is significantly longer if the mother is viremic.

Role of amniotic membrane transplantation for conjunctival reconstruction in ocular-cicatricial pemphigoid.

PURPOSE: To evaluate the role and the effectiveness over time of amniotic membrane transplantation (AMT) as a first-step procedure to treat conjunctival reconstruction in late-stage ocular-cicatricial pemphigoid (OCP). DESIGN: Prospective interventional noncomparative case series. PARTICIPANTS: Nine eyes (9 patients) with advanced OCP. METHODS: Preoperatively, the ocular surface conditions were evaluated by immunohistochemistry of conjunctival biopsy and impression cytology specimens. The amniotic membrane was obtained during cesarean section from women who were 39 weeks pregnant and seronegative for human immunodeficiency virus, hepatitis B and C, and syphilis; it was processed, histologically tested, and stored at -80 degrees C. After scar tissue was removed, the preserved amniotic membrane was placed over the cornea, the bulbar, and tarsal conjunctiva, and was secured with 8-0 Vicryl sutures to the conjunctival edges and the deep fornices with double-armed 6-0 silk sutures. In 2 cases a double layer of amniotic membrane was transplanted. All patients received immunosuppressive systemic therapy and preservative-free tear substitutes and steroids topically for at least 6 months. During follow-up (average, 48 weeks; range, 28-96 weeks), a new standardized method was used to evaluate the fornix depth, and impression cytology testing was performed and conjunctival inflammation recorded and used as parameters for monitoring disease activity. MAIN OUTCOME MEASURES: Symblepharon, increased inferior fornix depth, presence of conjunctival goblet cells, and the degree of conjunctival inflammation. RESULTS: The conjunctival surface was free from symblepharon in all subjects for the first 16 weeks. At the week 28 examination, a small area of symblepharon was present in four eyes (44.4%). The depth of the fornix was significantly (P < 0.0001, analysis of variance) improved at weeks 4, 16, and 28. The normal conjunctival epithelium with goblet cells was restored in 6 of 9 eyes (66.7%) at the week 4 examination and in 4 eyes (44.4%) at the week 28 examination. Conjunctival inflammation was clinically but not statistically reduced. The visual acuity improved in 5 subjects. CONCLUSIONS: AMT can be a first-step procedure for ocular surface reconstruction in OCP, but its effectiveness deteriorates slightly over time.