LA SESSUALITA' IN GINECOLOGIA

LIBRO DI TESTO PER STUDENTI IN MEDICIN

Lipid and lipoprotein (Low Density Lipoprotein) apheresis in pregnancy [Lipidoaferesi ed LDL-aferesi in gravidanza]

Pregnancy and delivery in a women with a severe genetically determined hyperlipidemia is a rare event, but not impossible. Increasing morbidity and mortality of both mother and child due to severe hyperlipidemia already existing, or induced by change of sex hormones concentration may occur during pregnancy. Reasonable therapeutic measures are to be undertaken to prevent complications, inevitably. However, it is also well-known that lipid lowering drugs are contraindicated during pregnancy. Notwithstanding, when critical clinical conditions occur there is the need to provide a therapeutic option. Lipid and Lipoprotein apheresis are recognized effective and reasonably safe, although invasive treatment for severe disorders of lipid and lipoprotein metabolism. Therapeutic Lipid apheresis (Plasma-exchange, Cascade Filtration) and Lipoprotein apheresis (Dextran Sulphate, H.E.L.P., and D.A.Li. Low Density Lipoprotein apheresis) offer an alternative, to be used in selected cases to reduce high LDL-cholesterol levels or insurgent elevation of Triglyceride-rich lipoproteins in plasma, during pregnancy. The existing evidence suggested that Lipid and Lipoprotein apheresis do not interfere with physiologic adaptations of lipid and lipoprotein metabolism during pregnancy in hyperlipidemic subjects, seemingly. This review is aimed at reporting existing clinical evidence on how women with severe hypercholesterolemia who became pregnant on long-term Lipid and/or Lipoprotein apheresis treatment, or affected by severe hypertriglyceridemia and hyperchylomicronemia, who were treated by therapeutic apheresis because of their acute exposure to the risk of pancreatitis during pregnancy, have been treated. Existing guidelines and reccommendations are also reviewed

Lipidoaferesi ed LDL-aferesi in gravidanza

La gravidanza e il parto in una donna con una severa dislipidemia geneticamente determinata è un evento raro, ma non impossibile. L’aumento della mortalità e morbidità sia della madre che del bambino, dovuto ad una grave dislipidemia già esistente o indotte da cambiamenti della concentrazione di ormoni sessuali, può verificarsi durante la gravidanza. Devono essere intraprese ragionevoli misure terapeutiche per prevenire le complicanze altrimenti inevitabili. Tuttavia, è anche noto che i farmaci che riducono i livelli plasmatici dei lipidi e delle lipoproteine, sono controindicati in gravidanza. Nonostante ciò, quando si verificano condizioni cliniche critiche, vi è la necessità di accedere rapidamente ad un’opzione terapeutica. L’aferesi dei lipidi e delle lipoproteine - ovvero un trattamento extracorporeo a carattere invasivo per i disturbi gravi del metabolismo lipidico e lipoproteico - è riconosciuta come metodica terapeutica efficace e ragionevolmente sicura. L’aferesi terapeutica non selettiva dei lipidi (il plasma-exchange, la filtrazione a cascata) e l’aferesi selettiva delle lipoproteine (destrano-solfato, H.E.L.P. e D.A.LI) la LDL-aferesi (Low Density Lipoprotein-Apheresis) offrono un'alternativa realistica, da utilizzare in casi selezionati per ridurre gli elevati livelli di colesterolo LDL o l’aumento delle lipoproteine ricche in trigliceridi nel plasma, così come si verifica durante la gravidanza. Le più attuali evidenze suggeriscono che l’aferesi dei lipidi e delle lipoproteine non interferisca apparentemente con gli adattamenti fisiologici del metabolismo lipidico e lipoproteico che avvengono durante la gravidanza nei soggetti con dislipidemia. Questa breve rassegna ha lo scopo di riportare le esistenti evidenze scientifiche e cliniche su come le donne con ipercolesterolemia grave ad elevato rischio cardiovascolare, che erano state sottoposte da lungo tempo ad aferesi dei lipidi e/o delle lipoproteine rimaste incinte e quelle colpite da grave ipertrigliceridemia ed iperchilomicronemia nella stessa condizione, esposte al rischio di pancreatite acuta durante la gravidanza, sono state sottoposte a trattamento mediante tecniche di aferesi terapeutica dei lipidi e delle lipoproteine. Le linee guida esistenti e le inerenti raccomandazioni sono state recensite

A Rare Case of Sudden Death Due to Hypotension during Cesarean Section in a Woman Suffering from Pheochromocytoma and Neurofibromatosis

Sudden death following acute hypotension due to an undiagnosed pheochromocytoma (PHEO) is a rare event. Moreover, histopathology of the myocardium in such cases is rarely reported. We present a case of a woman who died during delivery. A 37-year-old parturient, who was 38 weeks pregnant, suffering from neurofibromatosis underwent a cesarean section following peridural anesthesia. Acute hypotension, acute intra-operative pulmonary edema and supraventricular paroxysmal tachyarrhythmia occurred during delivery, followed by death. The autopsy revealed the presence of a PHEO, confirmed immunohistochemically with chromogranin-A (CgA), CD20 antibody (L26), anti-Keratocan antibody (KER-1) and neuron-specific enolase (NSE), and a PHEO-induced cardiomyopathy. The physiopathology of both stress-induced cardiomyopathy and PHEO-induced cardiomyopathy, as well as the role of anesthesia in provoking the death, are discussed. The association of an undiagnosed PHEO with neurofibromatosis as the cause of sudden death in pregnancy is an obstetric urgency that raises forensic pathology issues. © 2013 American Academy of Forensic Sciences

[Attitudes toward estrogen replacement therapy. Study conducted on a sample population of women attending an ambulatory care center for the treatment of menopause].

Hormonal Replacement Therapy (HRT) is the most effective treatment of menopausal disturbances and has an established role in reducing the cardiovascular risk and in preventing the postmenopausal osteoporosis. Nevertheless several reports have evidenced that compliance with hormonal replacement therapy was not as good as expected, and that physician's and women's opinions can strongly influence the HRT choice, and the continuation of HRT use. The aim of this study was to assess the opinions and the expectations of menopausal women toward HRT. PATIENT AND METHODS. We utilized a questionnaire exploring social and affective conditions, and in particular women's opinions and experiences on menopause, hormonal therapy, the possibility of information, the reasons for accepting or refusing hormonal therapy. The questionnaires were administered to 226 menopausal clinic patients (Menopausal age: 2-10 years) in spontaneous menopause. RESULTS. 28% of the women were taking HRT at the time of the survey. Worries about menopause were reported by 27.4% of the group; this percentage was similar in both user and non-user groups. 70% received information on HRT from family doctors, and 63% from mass-media or conversations. 70% believes that the main problem of menopause is osteoporosis, and its prevention represents the most frequent aim that patients feel can be achieved by HRT. 67.5% of the group is afraid that long term treatment can be dangerous, however only 57% asked for detailed information to the doctor. To the question "Are you informed that HRT can reinduce menstrual bleeding?", 57.5% of the patients answered yes; 30% considered it to be a problem. CONCLUSIONS. Our study was carried out in a menopausal clinic and this can influence the answers of the respondents. Most women received some information on HRT, but their knowledge was only partial and did not eliminate the unrational fear of hormone therapy. Although long term use of HRT is to prevent CVD and menopausal osteoporosis, many of our patients specifically asked for treatment to be as short as possible. Women expectations's towards HRT are mainly referred to osteoporosis prevention and treatment: this may be explained by the high frequency of osteoarticular pain found in our patients; nevertheless it is possible that the more rational fear of osteoporosis hides the unconscious fear of a dramatic physical breakdown caused by the menopause. Detailed information to family doctors, to specialists, and to patients along with a further improvement of therapeutic regimens will allow a greater diffusion of HRT, bringing its short and long term benefits to an increasing number of women

Breast imaging screening in a BRCA1-mutated lactating patient: a potential pitfall mimicking malignancy

Breast imaging screening during lactation poses a real clinical challenge, especially in high-risk patients. We presented the case of a 34-year-old BRCA1-mutated woman showing marked, asymmetric background parenchymal enhancement on the right breast suspicious for malignancy in the context of annual screening magnetic resonance imaging. The patient revealed that she was still occasionally breastfeeding her two-year-old child only from right side. Ultrasound evaluation reported typical benign lactational findings on the right enhancing breast. An in-depth understanding of expected/ physiologic breast changes during lactation and an accurate clinical-radiological correlation are required to appropriately guide patient management and avoid misdiagnosis

Different Hormonal Treatment In Pre- and Post-Menopausal Women: Effect on the Cardiovascular Risk

Estrogens and progestogens are associated to metabolic changes which may favour the risk of the dvelopment of Cardiovascular Disease, namely Coronary Heart Diseas