Primitive omental leiomyoma: a case report.

Primitive omental leiomyomas are very rare. The primitive omental location of the leiomyoma is quite difficult to determine, with the possible presence of "parasite" myomas and of omental metastasizing myomas. Moreover, omental masses may be primitive or secondary metastasis from neoplasms. In this case report a primitive omental leiomyoma is described, and their diagnosis and management are briefly discussed, in order to improve the knowledge of this very uncommon disease.

The pathogenesis of endometrial polyps: a systematic semi-quantitative review.

UNLABELLED: The pathogenesis and natural history of endometrial polyps are not very clear. The objective of this study was to assess the opinions of international medical literature regarding the factors involved in the pathogenesis of endometrial polyps and to organize the results consistently with what is known about endometrial physiology. MATERIALS AND METHODS: A systematic review was carried out with the following search engines: PubMed, OVID, Scopus, SCIELO, and AJOL. Two hundreds forty-six abstracts were selected from the literature; of these abstracts, 58 factors were extracted and set as causative, non-causative, unclear or protective link with endometrial polyps. This relation is described through a correspondence analysis and tested with a main effect hierarchical log-linear model. RESULTS: The log-linear model resulted significant for the correspondence found with the following factors: (i) causative link (ageing, bcl-2 protein, excess weight/obesity, tamoxifen regardless of timing, relationship between estrogen receptors and prog-estinics, unbalanced estrogen therapy, estrogen-like effect, and unbalance between estrogens and progestinics), (ii) protective link (progestinics, antiestrogenic action), (iii) unclear link (menopause, ki-67 protein, angiogenesis, tamoxifen for a short time, tamoxifen for a long time, hormone replacement therapy (HRT), endometritis/inflammation), and (iv) non-causative link (none of the factors specifically). DISCUSSION: Subsequently to a review of the physiology of the endometrium, the onsetting of endometrial polyps was suggested through estrogen-related and non-estrogen related ways; the two ways can overlap. The most implied factors in the development of endometrial polyps are linked with one of these or both ways.

Behaviour of lab parameters and neonatal weight loss in relation to neonatal breathing movements and cord clamping time.

BACKGROUND: To date, delaying cord clamping two to three minutes after birth is considered effective for newborn well-being. This time does not consider the newborn's breathing movements, which may also condition neonate well-being. AIM: To investigate the behaviour of neonatal weight loss and of some umbilical vein lab parameters, in relation to timing of newborn breathing and cord clamping. MATERIALS AND METHODS: Time from birth to cord clamping and time from birth to first cry of the newborn were collected in 87 full-term healthy women. First cry is a sign of effective breathing. Birth weight loss at the first, second, and third day from birth and lab parameters were assessed in relation to: time from birth to cord clamping, time from birth to first cry, and cord clamping before or after the first cry. RESULTS: Partial pressure of carbon dioxide (pCO2) decreased if cord clamping was performed after first cry and increased if first cry occurred after cord clamping, independently from the time elapsed from birth to first cry (p = 0.012). Calcium (Ca(2+)) concentration decreased if cord clamping was performed after the first cry and increased if first cry of the baby after birth was delayed (p = 0.021). Each second of delay from birth to cord clamping resulted in an increase in Cl- concentration (p <0.001). Each second of delay in cord clamping resulted in a reduction in the percentage of weight loss at the first day (p = 0.024), at the second day (p = 0.007), and at the third day (p = 0.028) after birth. CONCLUSIONS: Neonate breathing after birth should induce umbilical vein flow from placenta to lungs, conditioning the reduction of birth weight loss after birth and umbilical lab parameters modifications.

Experience of practitioners and delivery outcome.

BACKGROUND: It is commonly believed that the experience of practitioners (time spent in delivery ward) may be helpful in aiding the spontaneous vaginal birth. AIM: To check if this opinion is true. METHODS: In 995 low-risk, full-term, pregnancies resulting in spontaneous labour, multivariate logistic regression analysis was performed, which considered the age, the years of service of the obstetrician and of the midwife, and of both as independent variables. Results The longer the obstetrician (odds ratio 0.779, C.I. 95% 0.653-0.930, p = 0.006) or the midwife has been practising (odds ratio 0.609, C.I. 95% 0.408-0.909, p = 0.015) the less likely is the occurrence of a spontaneous vaginal birth. The combined years of service of the caring doctor/midwife pair appears to have no influence on the outcome of delivery. The chances of an operative vaginal birth increase with the age of the caring obstetrician (odds ratio 1.362, C.I. 95% 1.138-1.630, p = 0.001). CONCLUSION: The experience of the staff assisting women in labour definitely does not determine the success of deliveries. The skills of each professional category are based on theoretical knowledge that is possibly not being put to use during routine duties, especially by the 'more experienced' practitioners. Additionally, it appears that there is no team work, and decisions are not taken together.

Could endometrial cytology be helpful in detecting endometrial malignancies?

This short communication assesses the concordance indexes between hysteroscopic biopsies and endometrial cytology for each endometrial pattern found in a sample of 37 women. Patients underwent endometrial cytology under sonographic guidance. The specimens were obtained with an endocervical brush and were fixed on slides (no liquid-based methods). After endometrial cytology, hysteroscopy with biopsy was performed. The best concordance index was found for endometrial malignancies, suggesting that endometrial cytology is able to detect cancers but not other endometrial diseases, as compared with endometrial hysteroscopic biopsies. Therefore, the overall concordance index suggests a fair concordance between histological and cytological findings. This leads us to conclude that usual endometrial cytology should not be recommended to screen endometrial diseases, but it may be used as an alternative diagnostic tool when hysteroscopic biopsies or other blinded procedures for endometrial sampling are unwanted, because it allows malignancies to be detected as well as hysteroscopic-guided biopsies.

Effect of epidural analgesia on labor times and mode of delivery: a prospective study.

PURPOSE: To assess changes in labor times and delivery outcome in low-risk women requesting pain relief and undergoing epidural analgesia, according to the epidural analgesia schemes. MATERIALS AND METHODS: Prospective observational study of 499 low-risk women with epidural analgesia. Speed of dilatation (SD) (centimeters of dilatation / hours), speed of lowering of the fetal head through maternal pelvis (SL) (centimeters in lowering / hours), time of active phase of labor (TA), cesarean section (CS), vacuum application (VA) were dependent variables in multivariable linear and logistic regressions. RESULTS: Dilution of ropivacain, fentanyl amount, and volume of the first dose of epidural analgesia did not seem to affect labor times. Epidural analgesia with schemes used in this study favored both the dilatation and the fetal head lowering through maternal pelvis. Every five minutes from the first dose of epidural to the last top-up, SD decreased by about 13% (p=0.002), SL decreased by about 14% (p<0.001), and TA increased by about 40% (p<0.001). Additionally, every five minutes from the first dose of epidural to the last top-up, the odds of an operative vaginal birth (vacuum) increased by 0.7% (p<0.001). Increasing of number of top-ups independently caused a reduction in odds of undergoing CS (odds ratio 0.434; C.I. 95% 0.219-0.859, p=0.017), without influencing labor times. CONCLUSION: Epidural analgesia in patients requesting pain relief favors normal course of labor if it is not discontinued or delayed.

Pain and breastfeeding: a prospective observational study.

OBJECTIVE: To demonstrate that pain affects the goodness of breastfeeding. MATERIALS AND METHODS: Seventy-nine patients were interviewed regarding satisfaction in breastfeeding, tiredness, uterine pain, nipple and other pain, and analgesic use at day three and at first, second, third, and fourth week after birth. Data regarding the mode of delivery were recorded from medical charts. Milk formula supplements, bottle use, pacifier use, and nipple shields use were considered as variables suggesting unsuccessful breastfeeding. RESULTS: At third day after delivery, it appeared that analgesic use was significantly associated with milk formula supplementing, bottle use, less satisfaction in breastfeeding, and more tiredness. At first week after delivery, the presence of pain differing from nipple and uterine pain, was more likely associated with milk formula supplementing, bottle use, pacifier use, less satisfaction in breastfeeding, and more tiredness. At third week after delivery, nipple pain was directly related to tiredness, while it increased the odds of adding milk formula and using a bottle. CONCLUSION: Pain affects the goodness of breastfeeding.

Effect of epidural analgesia on operative vaginal birth rate.

The aim of the study was to investigate if epidural analgesia may affect the operative vaginal birth rate. An observational study was carried out on 1,158 in low-risk patients who delivered vaginally; 46.9% of these patients underwent epidural analgesia using different doses and drugs. Overall, epidural analgesia enhanced the probability of vacuum delivery (OR 2.70 95% CI 1.88-3.89, p < 0.001). Vacuum application was increased about seven times by administration of fentanyl alone at the first dose, while it was reduced if ropivacaine was added to fentanyl. In patients undergoing epidural analgesia, increasing the amount of ropivacaine at the first dose reduced the probability of vacuum delivery (OR 0.82; 95% CI 0.67-1.00, p = 0.05). Moreover, increasing the number of top-ups reduced the probability of vacuum delivery (OR 0.49 95% CI 0.27-0.93, p = 0.029) and the time of the second stage of labor. On the other hand, increasing time from the first dose of epidural to the last top-up increased the risk of operative vaginal delivery (OR 1.33 95% CI 1.03-1.72, p = 0.031) and the time of the second stage of labor. Epidural analgesia seems to favor spontaneous delivery when it is properly carried on.

Impact of the medicalization of labor on mode of delivery.

AIMS: To evaluate whether routine medical interventions during labor (oxytocin augmentation, induction, amniotomy, epidural analgesia) condition the outcome of delivery independently of each other and of obstetric risk (calculated in an objective manner). Moreover, to evaluate whether there is an ideal window for initiating such interventions. METHODS: Prospective, observational study with 1,047 patients enrolled. RESULTS: Medical interventions were high, whether in low-, medium- or high-risk pregnancies. Oxytocin augmentation (odds ratio 4.678) labour induction (odds ratio 1.717) amniotomy (odds ratio 1.403) and obstetric risk (intermediate-risk odds ratio 1.889, high-risk odds ratio 2.008) increase the probability of an operative delivery. Oxytocin augmentation increases both the probability of a Cesarean delivery and vacuum extraction. Epidural analgesia reduces the probability of cesarean delivery and increases the probability of vacuum extraction. The greater the cervical dilation when oxytocin infusion is initiated, the lower the probability of an operative delivery. The more advanced the cervical dilation and the lower the station when amniotomy or epidural analgesia are carried out, the lower the probability of an operative delivery. Obstetric risk and oxytocin augmentation appear to increase the probability of operative delivery in patients who have undergone amniotomy or epidural analgesia. In addition, labor induction in patients who undergo epidural analgesia increases the risk of operative delivery. CONCLUSIONS: Medical interventions during labor are high and cause a rise in operative delivery. Therefore, practitioners should defer it as much as possible. The exception is epidural analgesia because it seems to reduce the number of cesarean sections.

Malignant transformation of uterine leiomyomata.

The malignant transformation of a uterine leiomyoma is still debated and, if it occurs, it is very rare. The case of a patient affected by three small leiomyomas, monitored by the same gynecologist over the years is described. Two of these leiomyomas were transformed into leiomyosarcoma after menopause and the patient died despite receiving therapy. The case reported here is meant to underline the need to keep all uterine myomas in check since the transition into leiomyosarcomas may occur with an evolution over a time period which has not been established so far.

Bilateral Brenner tumor with endometrial adenocarcinoma in a postmenopausal woman.

Brenner tumor is a rare ovarian neoplasm which is generally monolateral, more rarely bilateral, and often associated with endometrial disorders related to oestrogenic production. However, there is no considerable evidence that the possible oestrogenic production of this tumor may be the cause of endometrial disorders. A case of bilateral Brenner tumor with endometrial adenocarcinoma in a postmenopausal woman is presented and the features are briefly discussed, with the conclusion that hormone-producing Brenner tumors may exert their promoter effect on the development of endometrial carcinoma causing an imbalance in the oestrogen and progesterone ratio rather than producing a large amount of oestrogen.

External cephalic version for singleton breech presentation: proposal of a practical check-list for obstetricians.

OBJECTIVE: External cephalic version (ECV) for breech presentation is not routinely performed by obstetricians in many clinical settings. The aim of this work is to assess to what extent the factors involved in performing ECV are relevant for the success and safety of ECV, in order to propose a practical check-list for assessing the feasibility of ECV. METHODS: Review of 214 references. Factors involved in the success and risks of ECV (feasibility of ECV) were extracted and were scored in a semi-quantitative way according to textual information, type of publication, year of publication, number of cases. Simple conjoint analysis was used to describe the relevance found for each factor. RESULTS: Parity has the pivotal role in ECV feasibility (relevance 16.6%), followed by tocolysis (10.8%), gestational age (10.6%), amniotic fluid volume (4.7%), breech variety (1.9%), and placenta location (1.7%). Other factors with estimated relevance around 0 (regional anesthesia, station, estimated fetal weight, fetal position, obesity/BMI, fetal birth weight, duration of manoeuvre/number of attempts) have some role in the feasibility of ECV. Yet other factors, with negative values of estimated relevance, have even less importance. CONCLUSIONS: From a logical interpretation of the relevance of each factor assessed, ECV should be proposed with utmost prudence if a stringent check-list is followed. Such a check-list should take into account: parity, tocolytic therapy, gestational age, amniotic fluid volume, breech variety, placenta location, regional anesthesia, breech engagement, fetal well-being, uterine relaxation, fetal size, fetal position, fetal head grasping capability and fetal turning capability.

Sulfatides and arylsulfatase A activity in major salivary glands of hamster (Mesocricetus auratus) after adenocarcinoma induction in oral cavity.

A biochemical study of sulfatides and arylsulfatase A (ASA) was carried out in the submandibular and sublingual glands of the male and female hamster Mesocricetus auratus after experimental induction of oral adenocarcinoma by 7,12-dimethylbenzanthracene (DMBA). Hamster experimental groups included control animals, animals treated with beta-carotene, animals treated with DMBA, and animals treated with DMBA plus beta-carotene. Oral cavity treatment with DMBA induced carcinogenesis in the buccal mucosa, but not in the major salivary glands, where nevertheless, the morphology and expression of both parameters examined changed. In fact, sulfatide concentrations and enzyme activity increased significantly, while in control and beta-carotene-treated hamsters they were similar in both glands and sexes. After administration of DMBA plus beta-carotene, sulfatide concentration decreased, as did ASA activity, slightly in the submandibular gland and remarkably so in the sublingual one of female hamsters. Thin-layer chromatography (TLC) analysis of lipid patterns, after DMBA treatment, revealed considerable differences, not only in sulfatides, but also in other lipid fractions, as well as between the two glands and two sexes. These findings show that oral cavity treatment with DMBA is not able to induce carcinogenesis in the major salivary glands examined; however, it does cause considerable metabolic changes.

Expression of acidic glycosphingolipids and arylsulphatase A activity in human pathological endometrium.

Endometrium biopsic samples from women with cystic hyperplasia or adenocarcinoma were analysed by biochemical procedures to verify fluctuations in the acidic glycosphingolipid (sulphatide) concentration and arylsulphatase A (ASA) activity. Comparing the values of the considered parameters with those obtained in normal subjects, it was observed that ASA activity significantly increased in both pathologies; in contrast, sulphatide concentration underwent a non-significant decrease in hyperplasia and a statistically significant increase in neoplasia. The thin-layer chromatography (TLC) images revealed not only quantitative, but also qualitative differences in the lipid fractions. In fact, compared with controls, the sulphatides showed one more marked fraction in the neoplastic endometrium, and two fractions with different Rf values in the hyperplastic one. Moreover, two new unknown fractions also appeared in some subjects with cystic hyperplasia. The findings suggest the lipid metabolism undergoes considerable changes under the pathological conditions examined. The fluctuations observed, in particular, in the sulphatide concentration are believed to be related to changes in the biosynthetic and catabolic activities of the key enzymes directly involved in their metabolism, i.e. arylsulphatase A and sulphotransferase, which are regulated by sex hormones.

[Breast feeding. The importance of correct management]. / Allattamento al seno. L'importanza di un corretto management.

The advantages that breast-feeding still offers over bottle-feeding are widely recognized. This study has the following aims: 1) to verify how many of the women that delivered during the last biennium at the Midwifery School of Camerino breastfed their infants for a fair amount of time; 2) to evaluate the relationship between the results obtained and the protocols followed in the management of the various issues connected with breast-feeding. The research was carried out into a sample of 140 women, randomly selected. The anamnestic and clinical data obtained from the medical cards were integrated with information gathered by telephonic interviews. Less than 40% of the women of the sample gave their infants only maternal milk for a very good period. The inobservance of many WHO guidelines for the promotion of breast-feeding seems to be the main cause of the disappointing results obtained. Some groups of women proved more exposed to the risk of inadequate suckling: teenagers, the older gravidae, women that delivered prematurely, those that had children with a low birth weight, the women that had previous breast-feeding failures, smokers, women that attended a course of psychoprophylaxis, women with the lowest socioeconomic standards, mothers that were precociously separated from their babies, women that had some gestational pathology or some problems during the first days after delivery, women that had as main reference doctors without a proper breast-feeding culture.

[The role of chorionic gonadotropin in transient hyperthyroidism in hyperemesis gravidarum]. / Il ruolo della gonadotropina corionica nell'ipertiroidismo biochimico transitorio dell'iperemesi gravidica.

A possible association of hyperemesis gravidarum with biochemical transient hyperthyroidism (a significant self-limited increase in serum levels of some thyroid hormones) has long been reported. It seems there is not any causal connection between the two above mentioned conditions, but they may be both independently related to the same cause: the trophoblastic production of a large amount of human chorionic gonadotropin or, otherwise, the presence in the maternal circulation of structural variants of hCG with higher biological activity. The validity of such hypothesis, denied by some authors, encounters the verification in the peculiar clinical case described in this report. It also shows clearly the danger of considering a case of hyperemesis gravidarum as of psychological nature, without having preliminarily excluded an organic cause. For the pregnant woman, to hear of her unconscious refusal of pregnancy or of the timeliness of her removal from the environment in which some conflictual situations have likely raised or, furthermore, to hear of other common places often too easily evoked could be cause of anxiety and unjustified feelings of guilt.

[Microalbuminuria in pregnancy: effect of glucose tolerance and gestational age]. / Microalbuminuria in gravidanza: effetto della tolleranza al glucosio e dell'epoca gestazionale.

Renal hemodynamic changes and insulin-resistance are normally observed in pregnancy. This study was aimed at evaluating the presence of microalbuminuria in normotensive pregnant subjects with normal or abnormal glucose tolerance. Nineteen pregnant women have been evaluated by oral glucose tolerance test (OGTT, 100 g) and by urine testing for microalbuminuria at 10 weeks of gestation. Eighteen and 14 women have been reexamined respectively at 24 and 32 weeks of gestation. In the subjects examined there was no correlation between microalbuminuria and abnormal glucose tolerance. Microalbuminuria, however, absent when the subjects were examined at 10 weeks of pregnancy, was present in 36% of women examined at 32 weeks of gestation. In conclusion, probably due to renal hemodynamic changes, microalbuminuria appears frequently in late pregnancy.

[The role of prostaglandin E2 in cervix maturation and labor induction. Clinical experience]. / La prostaglandina E2 nella maturazione cervicale e nell'induzione del travaglio di parto. Esperienza clinica.

In obstetrics there are sometimes situations that require a prompt induction of labour. The possibility of employing prostaglandins instead of oxytocin would seem to increase the prospects of success. The aim of the present study is to strike a preliminary balance of our experience on how the use of exogenous PGE2 (dinoprostone) helps to start the labour in term pregnant women. The study considered retrospectively a sample of 40 women that underwent one or more attempts to induct labour through intracervical application of PGE2 gel during the period 01/12/1992-01/04/1994. The results of the attempts were evaluated according to numerous parameters. In addition, we tried to define the prognostic value that could be attached to the characteristics of the tocogram an hour after dinoprostone had been administered. The percentage of success (88.89%) was high, while the incidence of instrumental deliveries and/or complications proved unimportant. The results of the attempts were positively linked to the Bishop score and to the regularity of the uterine contractions an hour after the application of PGE2. The utilization of dinoprostone proved effective and free from risks, authorising its clinical employment and the experimentation of new protocols.

[Labor and delivery in a pregnancy involving fetal macrosomia]. / Travaglio e parto nella gestante con feto megalosoma.

The alleged connection between fetal magalosomia and the increased risk of maternal and perinatal morbidity justifies the lively discussion that has developed about the management problems caused by a big unborn child. The aim of this study is to offer a contribution to the definition of the more or less peculiar problems associated with labour and delivery in a pregnant women with a megalosomic fetus. The study was retrospectively carried out on a sample of 45 women who, during the period 1190-1993, delivered a fetus weighing at least 4 kg. This sample was statistically compared with a numerically identical standard sample, selected at random. The main characteristics of labour and delivery were examined in the two groups under study. The most considerable differences observed concern the length of the labour, greater in the sample than in the standard group, and the frequency of dystocic events, similarly more considerable in the pregnant women with a megalosomic fetus. Maternal and perinatal outcomes, in spite of the small number of cesarean sections performed, were anyway very good in both the examined groups. In our experience, the risks associated with fetal megalosomia were rather limited, but this is not a reason to minimize beyond measure the problem we are talking about.