Is it time for midwives to do intrapartum ultrasound in the delivery ward?

n

Effectiveness of diagnosis and early treatment of ocular motility alterations in premature infants

Objective: Prematurity often results in important developmental sequelae of brain structures, particularly those involved in processing visual information, such as the optic nerve, primary visual cortex and visuomotor integration areas. The aim of this study is to analyse the functionality of the sensory and motor pathways of the visual system by means of an orthoptic-ophthalmological assessment. Materials and methods: In this retrospective study, 151 records were examined, covering a period from 2000 to 2020, of preterm patients with gestational age < 32 weeks and birth weight ≤ 1,500 g up to an average age of about 8 years, referred to the Centre for Paediatric Ophthalmology and Strabology of the Ophthalmology Clinic of the Policlinico Umberto I, La Sapienza University of Rome, who underwent a complete ophthalmological and orthoptic assessment including the following tests measurement of ocular deviations according to the Hirschberg method, Lang I-II test, Titmus Stereotest, objective convergence assessment and ocular motility examination. Results: From the charts reviewed, 24.5% (37/151) of patients had Retinopathy of the Premature (ROP); while 38% of the whole sample (57/151) had strabismic amblyopia, of the latter only 31.5% (18/57) had ROP. In 8% of patients (12/151) the stereoscopic sense was absent, in 45% (8/151) stereopsis was gross (> 60 seconds of arc). In addition, 20.52 % (31/151) had a manifest eye deviation. 7.28% (11/151) had hypermetropia in the right eye (RE); 7.95% (12/151) hypermetropia in the left eye (OS); 3.31% of the patients (5/151) had myopia in the RE; 2% (3/151), myopia in the left eye (LE). In addition, the study of ocular motility revealed varying degrees of alteration poorly correlated with prematurity status. Conclusion: It was found that amblyopia, stereopsis and objective convergence are more affected by ROP than strabismus, refractive defects and ocular motility, indicating that premature children are particularly susceptible to ophthalmological and orthoptical alterations

Intravitreal injections primary prevention: a case-control study

OBJECTIVE: Intravitreal injec tions (IVI) of therapeutic substances are one of the most common procedures in ophthalmol ogy and, for sure, the most feared complica tion of them is endophthalmitis. Nowadays, a precise prophylactic protocol does not exist to avoid these infections, and the role of new anti septic drops is an interesting field of research in this regard. In this article we are going to dis cuss the tolerability and the efficacy of a new antiseptic drop based on a solution of hexam idine diisethionate 0.05% (Keratosept®; Brus chettini Srl, Genoa, Italy). PATIENTS AND METHODS: This was a sin gle-center, case-control study, comparing the in vivo effect of hexamidine diisethionate 0.05% with povidone iodine 0.6% solution during IVI program. Ocular bacterial flora composition was analyzed with a conjunctival swab on day 0. After injection patients underwent antibac terial prophylaxis with Keratosept for 3 days or povidone iodine 0.6%. A second conjunctival swab was collected on day 4 and patients were asked to fulfill a questionnaire based on the OS Di model, to investigate the ocular tolerability of the drug administered. RESULTS: Efficacy was tested on 50 patients, 25 of whom received hexamidine diisethionate 0.05% drops and the other 25 received povidone iodine 0.6% solution drops, 100 total conjuncti val swabs, 18 positive swabs before and 9 after treatment for the first group and 13 before and 5 after for the second one. Tolerability was tested on 104 patients, 55 underwent Keratosept thera py and 49 povidone iodine one. CONCLUSIONS: Keratosept demonstrated a good efficacy profile with better tolerability against povidone iodine in the analyzed sample

Does episiotomy always equate violence in obstetrics? Routine and selective episiotomy in obstetric practice and legal questions

OBJECTIVE: The study’s main goal is to figure out whether episiotomy, a widely applied invasive procedure, may constitute a determining factor of liability for practitioners according to the standards of obstetric violence. MATERIALS AND METHODS: The authors have aimed to analyze laws and documentation issued on the matter by sovereign states, statements and remarks from International health organizations, in addition to scientific article available on the main search engines (PubMed, Scopus, Google Scholar) and legal databases (Lexis, Justia). RESULTS: The body of research has highlighted the existence of a wide-ranging agreement as to routine episiotomy, deemed to be a scientifically unfounded procedure, and which should, therefore, be avoided. By virtue of that, routine episiotomy might easily give rise to charges and liability for doctors and midwives alike; likewise to claims may stem from a failure to perform an episiotomy when it was actually needed. CONCLUSIONS: Unlike routine episiotomy, selective episiotomy is far more unlikely to cause charges of obstetric violence against operators. Unfortunately, the criteria in order to establish when a selective episiotomy is indicated are far from consistent and would require an additional effort on the part of scientific societies towards a more clearly defined and shared description

Should the visceral peritoneum at the bladder flap closed at caesarean sections a post partum sonographic and clinical assessment?

Objective. To compare cesarean section (CS) using open or closed visceral peritoneum of the bladder flap (BF) in relation to fluid collection in vesico-uterine space (VUS) by ultrasound (US) and clinical outcome. Material and methods. A prospective cohort of repeat CS in 474 in advanced first and second stage of labor was studied. All women underwent a Misgav Ladach CS, in local combined anesthesia. These were divided into two groups by surgical management of the BF at the time of CS: Group I (n?262), with visceral peritoneum left open and Group II (n?212), with visceral peritoneum closed. An US check for the fluid collections in the VUS was done in the third post-operative day. The two groups were also clinically compared for: intra-operative estimated blood loss, the need for post-CS pain killers, febrile morbidity and duration of hospital stay. Results. Visceral peritoneum (VP) closure resulted in a significant increase blood collections in the VUS (p50.05). VP closure resulted in a significantly higher morbidity in all the following parameters. Rate of BFHs, post-operative fever, need for post-operative analgesia, require antibiotic administration and prolonged hospitalisation (p50.05). Conclusions. VP suturing of women requiring CS for dystocia is associated to increased rate of blood collection in the VUS, which could possibly explain the higher rate of puerperal complications in these patients. These data clearly indicate that suturing the VP of the BF in women undergoing CS for dystocia is contraindicated. This data could be probably extrapolated to all cesarean deliveries

Double hit: mantle cell lymphoma associated with squamous cell carcinoma or chalazion? A case report

A few cases of ocular adnexal neoformations related with MCL have been reported in the literature. We present a rare case of tumour duplicity: mantle cell lymphomas (MCL) associated with squamous cell carcinoma (SCC) localised at the level of the ocular adnexa, on left upper eye lid mass since two years of 18 mounth duration in a 57-year-old man who had previously been diagnosed with stage IV MCL for 14 months. The patient had been treated according to the R-DHAP scheme for 4 cycles, in anticipation of a possible autologous HSC transplant, which was not carried out due to a positive diagnosis at the end-of-cycle osteomedullary biopsy (BOM) check. Ophthalmological examination was performed, and afther surgical removal histological examination proved to be squamous cell carcinoma (SCC). The aim of this case report is to decode the signs, symptoms and factors associated with the formation, that appear to be a chalazion, at an early stage in order to prevent the overgrowth of the mass that could invade the surrounding tissues by infiltrating them, as well as negative aesthetic outcomes of the surgery due to the excessive size of the mass, which could compromise the patient's quality of life

Intrapartum sonography of fetal head in second stage of labor with neuraxial analgesia: a literature review and possible medicolegal aftermath

Intrapartum ultrasound (IU) is a valid support to obstetric management of fetal head progression in the second stage of labor in nulliparous with neuraxial labor analgesia (NLA). Nulliparous with NLA may have a prolonged the second stage of labor. The aim of this literature review was to evaluate the mode of delivery, as well as maternal and fetal morbidities associated with missed progression of fetal head detected with IU in the second stage of labor in nulliparous women with NLA.MATERIALS AND METHODS: The literature review was performed using PubMed, Cochrane, Medline, EMBASE, Scopus, Google Scholar and book chapters searches to identify relevant articles from 2001 to 2019, evaluating the mode of delivery and morbidities of the second stage of labor. Search terms used were “Intrapartum ultrasound”, “dystocia”, “prolonged labor”, “neuraxial analgesia”, “persistent occiput posterior position”, “asynclitism”, “second stage of labor”, “medico-legal aftermath”. Prolonged second stage was defined as three hours and more. Retrospective case series of women with prolonged second stage of labor with NLA were identified. The primary outcome was the incidence of operative vaginal delivery (OVD) and cesarean delivery (CS). RESULTS: The use of NLA may determine a prolonged second stage of labor (PSSL). IU when compared to the traditional vaginal digital examination (VDE) demonstrated the highest degree of diagnostic accuracy. CONCLUSIONS: The use of IU during NLA can aid in the diagnosis of fetal head progression, station or malposition and malrotation, alerts obstetrician on the possibility of dystocic labor, indicating to stop the drug administration in NLA and shift to OVD or CS. Extending the second stage of labor beyond current American College of Obstetricians and Gynecologists (ACOG) recommendations is beneficial. The ISUOG guidelines recommended the clinical application of IU to diagnose the persistent occiput posterior position (POPP) and asynclitism (A) in dystocic labor and produce photographic evidence of the case. Maternal and neonatal complications, medicolegal consequences and litigation can decrease if the IU device is used as good practice

Uterine fibroid pseudocapsule studied by transmission electronmicroscopy.

OBJECTIVE: The fibroid pseudocapsule is a structure which surrounds the uterine fibroid, separates it from the uterine tissue and contains a vascular network rich in neurotransmitters like a neurovascular bundle. The authors examined the composition of the fibroid pseudocapsule using electron microscopy. STUDY DESIGN: Twenty non-pregnant patients were submitted to laparoscopic myomectomy by the intracapsular method and samples of the removed pseudocapsules were analyzed using transmission electron microscopy. RESULTS: At the ultrastructural level the pseudocapsule cells have the features of smooth muscle cells similar to the myometrium. So, the pseudocapsules are part of the myometrium which compresses the leiomyoma. CONCLUSION: This ultrastructural feature suggests that when removing fibroids their pseudocapsules should be preserved. This study confirms preliminary evidence that pseudocapsules contain neuropeptides together with their related fibers, as a neurovascular bundle. The surgeon's behavior should be directed to carefully control and spare this muscular surrounding tissue during fibroid excision, in order to preserve the myometrium as much as possible

Caesarean Section in the World: a new ecological approach

Introduction. This study aimed to estimate the most recent caesarean section rates in the world and examine the association between these rates and old and new indicators of health care. Methods. Authors analyzed the Caesarean Section (CS) rates, also in geo-economic and economic groups, and correlated them to maternal and neonatal mortality, to births attended by skilled health personnel and to births among adolescents. Analysis of covariance and piecewise regressions were used for the statistical analysis. Results. In 47.2% of the countries, the CS rate exceeded 15%. Countries of Latin America and the Caribbean along with Europe, North America and Oceania had the highest values. The analysis showed an inverse association between CS rates and Maternal Mortality (MMR) and Neonatal Mortality (NMR) for all geographical areas except for Europe. The greatest association was observed in lower-middle-income countries. In developing countries only 50% of cases, occur in medical facilities and only half of these are seen by medical, nursing and obstetrical staff. Age of the mother appears to influence the outcome and choice of delivery type. Countries where an high ABR rate is present have low CS use. Conclusions. To best evaluate the consequences of the increasing rate of CS, it would be useful to identify the most sensitive outcome indicators