Extrauterine pregnancy in Mozambique.

Epidemiologic, clinical and management information was collected from the case histories of 103 women operated on for an extrauterine pregnancy at the Department of Obstetrics and Gynaecology of the Central Hospital in Maputo (Mozambique) from April 1st, 1987 to March 31st, 1988. We observed a decline in extrauterine pregnancies (9.76%), an association of pelvic schistosomiasis (3.9%), and a high percentage of women with ruptured tubes and subsequent hemoperitoneum (75.7%).

The urine stream interruption test and pelvic muscle function in the puerperium.

OBJECTIVES: This study assesses the role of the uroflowmetric urine stream interruption test (UST) in the evaluation of postpartum pelvic floor muscle function. METHOD: Two months after vaginal delivery, 492 women who underwent a digital test, vaginal manometry, and a UST were divided into two groups: continent and incontinent. Variables were subjected to the Student's t-test and to Fisher's exact test to verify the difference between the two groups. RESULTS: Digital test and vaginal manometry results were higher in the continent group, but only the UST showed significantly different values (P=0.001). All test results of incontinent puerperae who underwent rehabilitation were significantly improved after treatment. CONCLUSIONS: UST is low cost, non-invasive, and can give objective information about pelvic floor performance after a vaginal delivery. It can be used for both routine clinical use and an outcome measure for women who undergo rehabilitation treatment.

[Current trends in the therapy of bladder instability in women]. / Orientamenti attuali in tema di terapia dell'instabilità vescicale nella donna.

The authors review the different procedures used today to resolve female bladder instability and analyse the most modern trends regarding therapeutic strategy.

[Pathogenesis of uro-gynecologic disorders in post-menopausal women]. / Patogenesi dei disturbi uro-ginecologici della post-menopausa.

In the pathogenesis of uro-gynaecological complaints in post-menopausal women, the effects of aging and estrogenic deprivation operate jointly to produce complex clinical conditions where numerous different factors are involved: neurological disorders, loss of the usual support of the pelvic organs, rigid urethral wall, atrophy of urethrovesical and genital epithelium. The Authors analyse all these factors and dwell upon mechanisms by which they lead to the various genito-urinary affections of the female climacteric.

[Seasonal incidence of extrauterine pregnancy]. / Incidenza stagionale delle gravidanze extrauterine.

Ectopic pregnancy (EP) is becoming a more and more frequent problem in many developed countries, but the cause of such increase is not fully understood. Improved diagnosis certainly explains part of it, but also the changing lifestyle and sexual habits might play an important role. During the years 1990-1993, 56 women were admitted into the Divisione di Ostetricia e Ginecologia of the Istituto per l'Infanzia of Trieste because of EP diagnosed on the basis of clinical history and signs, transvaginal echography and serum HCG levels. 33 of them underwent surgical operation for the presence of severe abdominal pain, hemoperitoneum greater than 50 cc, and increases HCG level. The other 23 women were treated conservatively. Taking into account the approximate date of conception both for ectopic and other pregnancies, the monthly incidence of EP was computed and showed a statistically significant peak during the summer period (14.4%) compared to the other periods (6%). The increased frequency of EP among pregnancies started during the warmer months is interesting not only as a descriptive result, but also because it may contribute to a better understanding of the conditions under which the ectopic development of the fertilized ovum may take place.

[Postpartum perineal evaluation. Role of the Q-tip test]. / Valutazione perineale post-partum. Il ruolo del Q-tip test.

Data reported in this study concern 56 women who were subjected, 1 and 6 months after delivery, to a perineal examination including, in addition to the functional evaluation of the levator ani muscles, the "Q-tip test". A positive Q-tip test is associated with a greater incidence of stress urinary incontinence, especially when, at the same time, the score for the functional evaluation of the levator ani muscles ("Perineal Testing") is inferior to 3. The results of this study seem to indicate a greater gravity and ventral extension of obstetric perineal injuries.

[Urinary disorders in the puerperium. Study of the major risk factors]. / I disturbi urinari dell'età puerperale. Studio dei maggiori fattori di rischio.

BACKGROUND: There is a very wide range of genitourinary disorders which can follow vaginal birth, including slight and occasional problems as well as serious disorders which could affect a woman's social and sexual life, for example the effects of dyspareunia on a woman's sexual identity, social marginalization as an inevitable result of symptoms like urinary incontinence, urgency and fecal incontinence. The aim of this study was to identify elements which may be of use in understanding the pathogenetic mechanisms of these disorders. METHODS: Three weeks after birth 537 mothers underwent a clinical genitourinary evaluation including: collection of data regarding pregnancy development and birth, genitourinary history (urinary problem data collected in accordance with the proposal of the International Continence Society), an objective genitourinary examination with a PC-test and identification of possible antagonist abdominal-diaphragmatic muscular synergies, instrumental tests in cases of post-partum urinary incontinence. RESULTS: Maternal age at birth, parity, weight before pregnancy and at term, weight increase, gestational age, duration of the second stage of labour, development and characteristics of birth, perineal condition and neonatal weight were the variables considered as risk factors while genuine stress urinary incontinence, urge incontinence, frequency, urgency, dysuria and inability to interrupt urination were the disorders whose dependence on the various risk factors were to be studied. The analysis of the association of the various pairs of variables recorded both positive and negative correlations, whether the population taken was that of all puerperae or that of only primiparae. CONCLUSIONS: Maternal age at birth, parity and duration of the second stage of labour, even if not always separable from other co-existing risk conditions, are the main responsible risk factors in the pathogenesis of urination disorders in puerperium. These results once again confirm the fundamental role of birth in the pathogenesis of female pelvic statics anomalies and of the genitourinary disorders which are their most evident chemical demonstration.

[Post-partum urogenital and perineal prolapse]. / Il descensus urogenitale e perineale nel postpartum.

BACKGROUND: It is well known that vaginal birth, even under apparently normal circumstances, involves a significant mechanical straining of the various muscular connective structures which make up the pelvic floor and that an unusual strain of the perineal plates can cause morphologic-functional alterations which are not entirely reversible. The integrity of structures which make up the "pelvic floor" and the "endopelvic fascia" is the fundamental element to maintaining a normal anatomic position of the pelvic organs in the various functional conditions. Consequently prolapse of female pelvic organs can be linked back to the functional limitations of perineal plates (muscular support fascia system) and/or of the ligaments of the sub-peritoneal endopelvic connective tissue (ligament suspension system). METHODS: After birth 537 mothers underwent a urological and gynecological examinations as follows: collection of clinical data regarding pregnancy development and birth; medical history regarding the number of day- and night-time urinations, urinary volume, possible encouraging factors and pre-urinary sensations; objective urological and gynecological examination (pubo-coccygeal test, highlighting of possible agonistic and antagonistic muscular synergies, stress test, evaluation and staging of vaginal prolapse according to Baden and Walker; instrumental evaluation in cases of post-partum urinary incontinence. Simple regression analyses were carried out where prolapse of various vaginal segments were proportionately related to the various risk factors. RESULTS: Maternal age at birth, parity, weight before pregnancy and at term, weight increase, duration of second stage of labour, development and characteristics of the birth, perineal condition and neonatal weight were all variables considered risk factors while prolapse in each vaginal segment, PC-test, involuntary reflex execution of opposite command and uterine retroversion were all "response variables" whose dependence on various risk factors was studied. Analysis of the associations between the various pairs of variables showed a correlation, both positive and negative, whether the population considered was that of all mothers or that of primiparae. CONCLUSIONS: In the light of the results of this study, it can be said that there are two important pathogenetic factors: the tissue factors and the iatrogenic factor. Elevated maternal age and multiparity underline the role of the tissue factor in the pathogenesis of obstetric perineal damage. With regard to the iatrogenic factor it is interesting to note a higher concentration of symptomatic women cases where labour had been induced or birth had been achieved through instrumental delivery.

[Anthropometric skin-fold and impedance measurement assessment of the maternal nutritional status at the end of pregnancy. Comments deduced from a study of 54 cases]. / Valutazione antropoplicometrica ed impedenziometrica dello stato nutrizionale materno al termine della gravidanza. Considerazioni dedotte dallo studio di 54 casi.

BACKGROUND: It is generally accepted that an optimal maternal weight gain is indicative of a normal course of pregnancy. Nevertheless, evaluations of nutritional status should not be limited to the periodic body weight measurement alone, they should rather include the measurement of anthropoplicometric parameters more strictly associated with the variations of the different body components (fat mass, fat-free mass and body water). Therefore, it seems necessary to define standard parameters, such as to allow the attribution of a clinical value to the anthropometric variations that can be measured during pregnancy. In this study we preliminarily proposed to survey maternal nutritional status in a group of women examined in the second day after delivery. MATERIALS AND METHODS: Anthropoplicometric parameters and bioelectric impedance measurements were evaluated in order to study nutritional status of 54 puerperae within 48 hours after delivery. A linear regression analysis was carried out examining the relationship of anthropoplicometric measurements with gestational weight gain and post-partum impedance parameters. RESULTS AND CONCLUSIONS: The results of this study lead to believe that a correct examination of maternal nutritional status must necessarily include not only weight and body mass index, but also an accurate and periodic anthropoplicometric evaluation including limb circumferences and triceps plica.

[Schistosomiasis: possible cause of ectopic pregnancy. Four clinical cases]. / Schistosomiasi: possibile causa di gravidanza ectopica. Quattro casi clinici.

The Authors describe 4 cases of ectopic pregnancy associated with foci of schistosomiasis and point out the relevance of mass screening on urine, stool and vaginal secretions in those areas where schistosomiasis is endemic and frequent the involvement of female genital tract. Utilization of laparoscopy in all cases where as adnexal mass and/or a history of unexplained infertility is found is finally advocated.

[Postpartum perineal assessment]. / Valutazione perineale postpartum.

BACKGROUND: To evaluate the incidence of urogenital and anorectal dysfunctions during puerperium, verify the correlation between obstetric perineal damage observed during labour and puerperal symptoms, test the efficacy of tests to evaluate perineal function in pelvic floor dysfunctions consequent to vaginal birth. METHODS: A total of 693 consecutive puerperae were recruited two months after birth. All completed a clinical and anamnestic questionnaire and underwent clinical urogynecological examination, digital test, vaginal manometry and uroflowmetric evaluation of the voluntary capacity to interrupt micturition. From a statistical point of view, persistent urinary incontinence was identified by graphic representation on frequency tables and predictive tests, and statistical "kappa" was used to evaluate the correlation between perineal function tests. RESULTS: Stress urinary incontinence (15.1%) represents the most widespread symptom, a postpartum perineal inspection provides a sufficiently accurate estimate of posterior damage, but does not identify those puerperae who will develop urinary incontinence. None of the tests used was able to predict persistant urinary incontinence. CONCLUSIONS: Postpartum perineal inspection seems to be effective in predicting anorectal dysfunctions, but is not so useful for urethro-vesical disorders. None of the diagnostic methods examined allowed a sufficiently accurate selection of those puerperae at risk.

[Fetal bradycardia during the second stage of labor. Study of 72 cases]. / Bradicardia fetale durante il secondo stadio del travaglio. Studio condotto su 72 casi.

The Authors analyse cardiotocographic patterns characterized by a constant frequency level below 120 beats/minute during the second stage of labour. Some aspects of "terminal bradycardia" (length, amplitude of oscillations, fetal heart rate in the 30 minutes preceding the onset of bradycardia) are related with the condition of the newborn (1st and 5th minute Apgar-score). Terminal bradycardia (Fischer 3, Melchior 2, 3 and 4, 2nd and 4th of Thiery) seems to have an unfavourable prognostic value especially when prolonged (more than 20 minutes), associated with low base-line variability and when cardiotocographic pattern previous to the fall of frequency is characterized by variable and late decelerations.

[The importance and limits of laboratory tests for evaluating the transplacental passage of fetal erythrocytes into the maternal circulation]. / Importanza e limiti dei test di laboratorio per valutare il passaggio transplacentare di emazie fetali nel circolo materno.

The KBB acid elution test is used to assess the presence and extent of transplacental passage of fetal cells into the maternal circulation both as a diagnostic aid in detecting hemorrhage before birth and in monitoring pregnancies at risk for hemolytic disease of the newborn. However the technique is ineffective when an hereditary Hb-pathy with associated increase in HbF is present in the mother, like the HPFH, delta-beta thalassemia and other hereditary abnormal hemoglobins. A mother with HPFH and another mother with delta-beta thalassemia with false positive result of the acid-elution test are described and the need for an extension of the clinical and laboratory study in families with hereditary HbF disorder is stressed.

[Insulinemic response to oral glucose loading tests in screening for diabetes in pregnancy]. / Risposta insulinemica al carico orale di glucosio nei test di screening del diabete gestazionale.

BACKGROUND AND AIMS: Given that an increased peripheral insensitivity to insulin represents the primum movens of gestational diabetes, it is reasonable to suppose that the determination and evaluation of the insulinemic response to an oral glucose loading test may represent a simple, effective and low cost screenign test. A method was devised which consisted in performing two assays of insulin and glycemia in venous blood; the first while fasting, the second one hour after the ingestion per os of 50 g glucose. METHODS: A group of 79 pregnant women, aged between 20 and 41 years old (mean age 30.5), was tested in around the 23rd week of gestation. All women were attending the Obstetric and Gynecological Clinic at Trieste University. RESULTS: Based on the results obtained, insulinemic parameters appear to be significantly correlated with data for the short glycemic curve according to O'Sullivan-Mahan. CONCLUSIONS: This study appears to confirm the need to include insulinemic tests as part of the new and more efficacious glucose tolerance tests and to perform prospective studies in order to identify the most reliable screening method in terms of sensitivity and specificity, also in relation to the cost-benefit ratio.

[Static anomalies of the pelvis caused by labor. Maternal weight increase during pregnancy as a risk factor]. / Le anomalie della statica pelvica conseguenti al parto. L'incremento ponderale gravidico materno quale fattore di rischio.

In this retrospective study, the role of Gravidic Maternal Ponderal Increase (GMPI) within pathogenetic factors of perineal obstetric injuries, is analysed. TO this purpose, clinical data of 58 puerperae, who underwent a functional evaluation of perineum 30 days after delivery, were examined. The results of this study seem to indicate an autonomous pathogenetic role of GMPI, besides the indirect relation deriving from the association with other risk factors (age, parity, diabetes, fetal megalosomia, ecc).

[Monitoring of protracted pregnancy. Comparison of two methods]. / Monitoraggio della gravidanza protratta. Due metodiche a confronto.

Antepartum cardiotocographic patterns (NsT:Nonstress Test) and echographic assessments of amniotic fluid pockets were retrospectively analysed in 63 postdate pregnancies. The results of NsT (Fisher-score) and ecographic examinations were correlated with obstetric outcome (5 minutes Apgar-score). Ecographic assessments of amniotic volumes seem more effective than NsT for the lower frequency of false-positive results. Anyhow, considering the low sensibility of NsT and Echography separatedly considered, the Authors suggest a simultaneous valuation of the two tests.

[Functional evaluation of the perineum in pregnancy. Hypertonia of the levator ani muscles]. / Valutazione funzionale del perineo in gravidanza. L'ipertonia dei muscoli elevatori dell'ano.

In this study, the role of "levator ani muscles hypertonia" among pathogenetic factors of perineal obstetric injuries is analysed. For this purpose, clinical data of 142 pregnant women, who underwent functional evaluation of perineum during pregnancy and 30 days after delivery were examined. Data here reported are not sufficient to confirm the importance of this factor within the pathogenesis of postpartum perineal deficiency. Levator ani hypertonia on one hand seems to be able to obstruct fetal progression, on the other hand it presumably constitutes, as an expression of a good voluntary control of perineal muscles, a favourable prognostic factor.

[Functional evaluation of the perineum in pregnancy. Inversion of control]. / Valutazione funzionale del perineo in gravidanza. L'inversione del comando.

This study concerns clinical data of 142 women, who were subjected to functional evaluation of perineum during the last part of pregnancy. The 16 cases characterized by synergic activation, during the examination of perineal muscles ("perineal testing"), of antagonist muscles ("inverted control"), were examined taking into account data regarding evolution of labour and perineal outcome. "Inverted control" seems to influence, in this study, length of the second stage and frequency of operative deliveries whereas we can't confirm the importance of this disorder within pathogenesis of perineal obstetric complications.

[Oligoamnios in protracted pregnancy. Cardiotocographic aspects]. / L'oligoamnios nella gravidanza oltre il termine. Aspetti del cardiotocogramma.

Ecographic assessments of amniotic fluid volumes and their relationship to ante-partum cardiotocographic patterns were retrospectively analyzed in 59 postdate pregnancies. Sonographic evidence of oligoamnios is significantly related with absence of sporadic accelerations and rarity of fetal movements.

[The role of pelvic outlet dystocia in the pathogenesis of pelvic floor damage cause by obstetric intervention]. / Ruolo delle distocie dell'egresso pelvico nella patogenesi del danno perineale ostetrico.

BACKGROUND: Vaginal delivery may cause injury to the perineum even when it progresses normally. In the light of this, some authors have suggested that other factors besides obstetric trauma may be implicated in the pathogenesis of genito-urinary prolapse, such as maternal constitution, race, connective tissue characteristics, etc. The aim of this study was to investigate the role of mechanical factors in causing perineal injury. METHODS: We examined the clinical data of 250 women who underwent, 20 days after delivery, a clinical examination consisting of a semeiological study of micturition and a functional evaluation of the pelvic floor. RESULTS: Outlet dystocia seems to be associated with the higher prevalence of anteriormedian prolapse and seem to play an important role in the pathogenesis of post-partum pelvic floor deficiency. CONCLUSIONS: If valid prognostic indexes for the selection of patients at risk are found, it will be possible to carry out an effective prevention of pelvic floor damage and also to avoid an indiscriminante and unjustified increase of laparotomic deliveries.