Postpartum Hemorrage: Are There Physiological Mechanisms of Prevention?

The postpartum hemorrhage (PPH) it is one of the worst complications of the pregnant woman and the leading cause of maternal mortality in the world, as it produces potentially catastrophic effects on patients, with high morbidity and morbidity. Likewise, the reduction in maternal mortality, which is particularly high in low income countries, but rising even in developed countries (as in USA), is one of the eight primary global health current goals of the WHO. In the complex pathophysiological phenomenon of PPH, the uterine contractility and connective tissue arrangement are poorly investigated. Both topics are scantly little understood and investigated, in terms of pelvic functional anatomy and pathophysiology. The anti-version uterine posture is essential for the optimal and necessary muscle contraction in the immediate postpartum stage, to avoid PPH onset. In this review, authors analyzed the physiology of uterine contraction related to the childbirth and the PPH, identifying an anatomical system involved in the physiological post-partum uterine contraction. This biological system is the integrated pelvic myofascial system and it has a prime importance in the physiological reduction of the PPH risk and to maintain uterine contractility during and after childbirth

Analiza czynników klinicznych, biologicznych i położniczych wpływających na decyzję o usunięciu mięśniaka macicy w trakcie cięcia cesarskiego

Objectives: Myomas in pregnancy are associated with a significantly higher risk for cesarean section (CS). Cesarean myomectomy (CM), i.e. myomectomy during cesarean section, has been the source of much debate and was considered relatively contraindicated for many years. However, some authors advise to perform routine myomectomy during CS. The aim of our study was to determine factors influencing the intraoperative decision to perform CM. Material and methods: A total of 185 patients with uterine myomas, who delivered by caesarean section during a 5-year period, were included in the study - 102 patients underwent CM (study group) and 83 women underwent CS without myomectomy (control group). Clinical and obstetric data were recorded and processed for analysis. Using non-parametric correlation methods, we investigated the influence of different variables on the decision to perform CM. Results: No differences were recorded between the two groups in terms of parity, fetal presentation, gestational age, number of previous laparotomies, and previous myomectomy, presence of diabetes and hypertension, indications and type of CS. Significant differences were detected in type and location of the myomas, contrary to their number and size, where no significant differences were registered. Conclusions: The most significant predictors of CM included age, surgical experience and type of myomas. CM is generally performed by experienced surgeons and in younger women. Also, it is more often performed in patients affected by pedunculated and subserosal myomas, and less frequent in case of intramural and multiple myomas.Cel pracy: Mięśniaki macicy w ciąży są związane z istotnie wyższym ryzykiem cięcia cesarskiego (CS). Miomektomia podczas cięcia cesarskiego (CM) jest źródłem wielu debat a przez wiele lat była uznana za przeciwwskazaną. Aczkolwiek niektórzy autorzy zalecają rutynową miomektomię podczas cięcia cesarskiego. Celem naszego badania jest określenie czynników wpływających na decyzję o miomektomii podczas cięcia cesarskiego. Materiał i metoda: Do badania włączono 185 pacjentek z mięśniakami macicy, które miały wykonane cięcie cesarskie w czasie 5 letniej obserwacji – 102 pacjentki przeszły miomektomię podczas cięcia cesarskiego (grupa badana) a 83 miały wykonane cięcie cesarskie bez miomektomii (grupa kontrolna). Analizie poddano dane kliniczne i położnicze. Przy pomocy testów nieparametrycznych zbadano wpływ różnych zmiennych na decyzję o cięciu cesarskim. Wyniki: Nie znaleziono różnic pomiędzy dwiema grupami pod względem rodności, położenia płodu, wieku ciążowego, liczby uprzednio wykonanych laparotomii oraz miomektomii, obecności cukrzycy lub nadciśnienia, wskazań do cięcia cesarskiego oraz rodzaju wykonanego cięcia cesarskiego. Istotne różnice dotyczyły typu i lokalizacji mięśniaków, w przeciwieństwie do liczby i rozmiaru, które nie miały znaczenia. Wnioski: Na wykonanie miomektomii podczas cięcia cesarskiego największy wpływ miały wiek, doświadczenie operatora i rodzaj mięśniaka. CM jest wykonywana przez doświadczonych chirurgów i u młodszych kobiet. Również miomektomia podczas cięcia cesarskiego częściej jest przeprowadzana na uszypułowanych i podsurowicówkowych mięśniakach a rzadziej w przypadku śródściennych i mnogich mięśniaków

Complications of Uterine Fibroids and Their Management, Surgical Management of Fibroids, Laparoscopy and Hysteroscopy versus Hysterectomy, Haemorrhage, Adhesions, and Complications

A critical analysis of the surgical treatment of fibroids compares all available techniques of myomectomy. Different statistical analyses reveal the advantages of the laparoscopic and hysteroscopic approach. Complications can arise from the location of the fibroids. They range from intermittent bleedings to continuous bleedings over several weeks, from single pain episodes to severe pain, from dysuria and constipation to chronic bladder and bowel spasms. Very seldom does peritonitis occur. Infertility may result from continuous metro and menorrhagia. The difficulty of the laparoscopic and hysteroscopic myomectomy lies in achieving satisfactory haemostasis using the appropriate sutures. The hysteroscopic myomectomy requires an operative hysteroscope and a well-experienced gynaecologic surgeon

Episiotomy: an informed consent proposal

Purpose: Since every obstetric surgical procedure requires gaining informed consent from patient, we have set out to evaluate whether such requirement also applies to episiotomy. Material and methods: To that end, we have conducted a thorough search of relevant scientific literature on multidisciplinary databases (Scopus, PubMed, PubMed, Central, Research Gate, Google Scholar) and articles that were published from 1989 to March 2019. The search keys used were: "episiotomy," "informed consent," "complications," "malpractice." Results: The sources that we have ultimately drawn upon, whilst acknowledging the need for a targeted informed consent for episiotomy, do not deal with the specifics of what such consent should include, in terms of information provided and related aspects. Therefore, the authors have laid out an episiotomy-targeted consent form, drawing upon opinions and indications from scientific societies and institutions, in order to properly reflect and document the patient's acceptance or refusal of the procedure. Conclusions: Valid consent documentation may well prove instrumental in staving off or reducing complications, malpractice and liability, and in order to safeguard health care operators from obstetric malpractice allegations

The Increasing Trend in Cesarean Sections in South Eastern Italy: Medical and Biopolitical Analysis of Causes and Possible Mechanisms for Its Reduction

Abstract: Caesarean section (CS) rates are rising globally, though with considerable variation from country to country; in Italy the CS rate is about 38.2% and in Puglia, a region in the South-east (4 million inhabitants), the CS rate is about 47.7%, up 4.25% in the last two years. Currently, the high rate of CS and operative delivery in developed countries may be attributed to larger foetuses, an increase in the frequency of diabetes mellitus and pelvic adiposity, advanced maternal age at first pregnancy and a decrease in tissue elasticity. Moreover patients have a very low acceptance of any maternal-foetal risk in labour, and there is a significant increase of CS "on maternal request". Studies of communities with low rates of caesarean delivery may help to identify factors that lower the CS rate, such as cultural attitudes toward childbirth, design of the perinatal system,and genetic and social aspects. Also needed are biopolitical projects for the rationalisation of human and technological resources, which may lead to a reduction in legal claims and a natural decrease in defensive practices or defensive obstetrics based on doubtful diagnoses. Furthermore, the number of caesarean deliveries performed "on maternal demand" should be reduced by making sure that women are adequately informed about the safety of vaginal versus caesarean delivery. National health programs should be insttituted and extended to large populations, showing the costs and benefits of vaginal versus CS delivery. This analysis reviews the current reasons for performing CS, analyzing limitations in labour management and focusing on dystocia, in order to identify possible socio-political and medical mechanisms that may reduce the CS rate in south-eastern Italy, including promising but under-used technologie

Zloporaba gama-hidroksibutirata – farmakologija, trovanje i liječenje ovisnosti

Gamma-hydroxybutyrate (GHB) is a central nervous system depressant primarily used as a recreational drug of abuse, but also for the treatment of narcolepsy with cataplexy in adult patients and as an adjuvant for control of alcohol withdrawal syndrome. The main aim of this review is to summarise updated knowledge about GHB pharmacokinetics and pharmacodynamics, acute poisoning, and clinical features of GHB withdrawal syndrome, its diagnosis and medical treatment. The most common clinical signs and symptoms of acute poisoning include sleepiness to deep coma, bradycardia, hypotension, and respiratory failure. Therapy is essentially supportive and based on continuous monitoring of vital signs. GHB withdrawal syndrome shares patterns with other withdrawal syndromes such as alcohol withdrawal and is sometimes difficult to distinguish, especially if toxicological tests are GHB-negative or cannot be performed. There are no official detoxification protocols for GHB withdrawal syndrome, but its therapy is based on benzodiazepine. When benzodiazepine alone is not effective, it can be combined with barbiturates or antipsychotics. Information about abuse and distribution of GHB and its precursors/analogues among the general population is still limited. Their prompt identification is therefore crucial in conventional and non-conventional biological matrices, the latter in particular, to clarify all the issues around this complex molecule.Gama-hidroksibutirat (GHB) depresiv je središnjega živčanog sustava koji se ponajviše zlorabi kao rekreativna droga, ali se primjenjuje i za liječenje narkolepsije s katapleksijom u odraslih bolesnika te kao pomoćni lijek u kontroli sindroma odvikavanja od alkohola. Ljudi i endogeno proizvode GHB, budući da je on prekursor gama-aminomaslačne kiseline (GABA), jednoga od glavnih neurotransmitera s inhibicijskim učinkom na živčani sustav. GHB ima ulogu neuromodulatora u GABA sustavu i uglavnom djeluje preko GABAB receptora. Za zloporabu se čestu kupuju GBH prekursori/analozi gama-butirolakton (GBL) i 1,4-butanediol (1,4-BD) u obliku otapala namijenjenih legalnoj industrijskoj uporabi. Oni, međutim, nisu endogeni. Glavni je cilj ovoga preglednog rada bio sažeti najnovije spoznaje o farmakokinetici i farmakodinamici GHB-a, akutnom trovanju i o kliničkim značajkama sindroma odvikavanja od GHB-a, njegovoj dijagnozi i liječenju. Akutno je trovanje GHB-om donekle i dijagnostički izazov jer su znakovi i simptomi uobičajeni i za depresive središnjega živčanog sustava. Najčešći su klinički znakovi akutnoga trovanja pospanost (sve do duboke kome), bradikardija i hipotenzija te respiratorno zatajenje. Liječenje je u osnovi potporno, uz stalno praćenje vitalnih znakova. Sindrom odvikavanja od GHB-a dijeli značajke s drugim sindromima odvikavanja (npr. od alkohola ili benzodiazepina). Ponekad ih je vrlo teško razlikovati, ponajviše kada su testovi na GHB negativni ili nije moguće napraviti toksikološku analizu. Ne postoje službeni protokoli za detoksikaciju od GHB-a ili njegovih prekursora/analoga. Liječenje se temelji na primjeni benzodiazepina te, ovisno o težini simptoma, sekundarno barbituratima ili antipsihoticima

Medicolegal issues in power morcellation: cautionary rules for gynecologists to avoid unfavorable outcomes

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event

Laparoscopy and Natural Orifice Surgery: First Entry Safety Surveillance Step

Results of this study suggest that surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopic procedures may assist in recognizing complications that might otherwise be missed