Rola nacięcia krocza w profilaktyce uszkodzeń podczas porodów pochwowych – wyniki z dwóch ośrodków europejskich

Objectives: There is an ongoing debate regarding the routine versus restrictive use of episiotomy. The study aim was to investigate if episiotomy during vaginal deliveries can reduce both, the number and severity of genital lacerations. Material and methods: The study included all women who gave vaginal birth at AOU. “G. Martino” Messina (n=382) and the Clinic for Ob/Gyn Clinical Center of Serbia, Belgrade (n=4221) during 2011. Lacerations during birth were recorded and divided according to location and severity. Women with lacerations were subdivided into two groups: with or without medio-lateral episiotomy. We assessed potential risk factors for laceration: maternal age, parity, use of labor stimulants and epidural analgesia, participation in antenatal classes, fetal presentation, neonatal birth weight, and duration of the second stage of labor. Results: Older women had higher grade perineum or combined lacerations. Children with higher birth weight in occipito-posterior presentation caused higher grade lacerations. Performance of episiotomy was connected with fewer perineum and labial lacerations. There were no differences in laceration grade between patients with and without episiotomy. Assessed parameters proved to be good discriminating factors between lacerations sites. According to logistic regression, laceration site was the most important risk factor for laceration grade. Combined lacerations had the highest grade. Conclusions: Episiotomy can significantly reduce the number of genital lacerations, but it does not influence laceration grade. Advanced maternal age, higher parity, occipito-posterior presentation and fetal macrosomia can cause lacerations during vaginal birth. Therefore, we suggest analysis of maternal and fetal factors to prevent widespread genital lacerations.Cel: Trwa debata w prawie właściwego stosowania nacięcia krocza: regularne kontra ograniczone. Celem badania była ocena czy nacięcie krocza podczas porodu pochwowego może zredukować zarówno liczbę jak i ciężkość uszkodzeń krocza. Materiał i metoda: Do badania włączono wszystkie kobiety, które w 2011 roku urodziły drogą pochwową w ośrodku w AOU „G.Martino” Messina (n=382) i w Klinice Położniczo-Ginekologicznej w Serbii, w Belgradzie (n=4221). Uszkodzenia krocza podczas porodu zostały podzielone względem lokalizacji i ciężkości. Kobiety z uszkodzeniami podzielono na dwie podgrupy: z nacięciem i bez nacięcia pośrodkowo-bocznego krocza. Oceniono możliwe czynniki ryzyka uszkodzeń krocza: wiek matki, rodność, użycie stymulacji porodu, znieczulenie zewnątrzoponowe, uczestnictwo w szkole rodzenia, położenie płodu, masa urodzeniowa noworodka, czas trwania drugiej fazy porodu. Wyniki: Starsze kobiety miały wyższy stopień uszkodzenia krocza i bardziej złożone pęknięcia. Urodzenie dziecka z większą masą urodzeniową w ułożeniu potylicowym-tylnym powodowało wyższy stopień pęknięć krocza. Nacięcie krocza wiązało się z mniejszą ilością pęknięć krocza i warg sromowych. Nie zanotowano różnic w stopniu uszkodzenia krocza pomiędzy pacjentkami z i bez nacięcia krocza. Oceniane czynniki są przydatne w różnicowaniu miejsca uszkodzenia. Na podstawie regresji logistycznej, miejsce pęknięcia było najważniejszym czynnikiem ryzyka stopnia uszkodzenia krocza. Złożone uszkodzenia miały najwyższy stopień. Wnioski: Nacięcie krocza istotnie zmniejszało liczbę uszkodzeń krocza, lecz nie wpływało na ich stopień. Zaawansowany wiek matki, wyższa rodność, ułożenie potylicowe-tylne i makrosomia płodu mogą powodować pęknięcia krocza w trakcie porodu. Sugerujemy analizę matczynych i płodowych czynników ryzyka celem zapobiegania szerokim uszkodzeniom krocza w trakcie porodu

Historical, morphological and clinical overview of placental site trophoblastic tumors: from bench to bedside

Placental site trophoblastic tumor (PSTT) is a form of gestational trophoblastic disease that originates from the implantation of an intermediate trophoblast. It was described for the first time by Von F. Marchand in 1895 as belonging to chorioepithelioma sui generis, a pathological condition with many variations and a progressive degree of malignancy

Fertility sparing strategies in patients affected by placental site trophoblastic tumor

OPINION STATEMENT: Placental site trophoblastic tumor (PSTT) is the least common and the most ambiguous gestational trophoblastic tumor. Presentation of PSTT may occur in the course of gestation or from 1 week to 14 years after a normal or an abnormal pregnancy (mole, ectopic pregnancy, abortion). The indicators of aggressive behavior for this tumor are not well established. Due to the rarity of this disease that usually affects women of childbearing potential, we aimed to review the current literature, to identify risk factors and the best conservative therapeutic choices among the cases described. We performed a systematic literature search of articles in English language, published from 1996 to 2017 and indexed in PubMed and Scopus. Based on selective inclusion/exclusion criteria, we considered eight papers eligible for the review. Five were case reports and three were retrospective studies. We extracted and organized data into three different categories depending on the main treatment used. A total of 12 cases were treated with laparotomy; in 5 cases, the treatment was not curative. Therefore, a total abdominal hysterectomy was needed. Five cases were treated successfully with a minimally invasive approach, 2 with uterine evacuation, 2 with hysteroscopic resection, and 1 with a combined hysteroscopic/laparoscopic resection. Only 1 case treated with exclusive chemotherapy proved curative for the patient. Preservation of fertility in PSTT patients of childbearing age should be considered and as showed by the abovementioned studies, is a possible and safe therapeutic choice. Laparotomy for local uterine resection with the modified Strassman approach could be offered in patients at clinical stage 1 that are very motivated to retain fertility, extensively informing the patient of the risks and benefits related to this choice

Uterine Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP) Treated with Conservative Surgery: Systematic Review of Reproductive Outcomes

Background: Uterine smooth muscle tumors of uncertain malignant potential (STUMPs) are a rare tumor that represent a diagnostic challenge to both clinicians and pathologists. Hysterectomy is considered the definitive treatment in women who don’t desire to conceive anymore; while myomectomy is suggested in young women who desire to preserve their fertility. The aim of this review is to evaluate the reproductive outcomes in patients submitted to fertility sparing treatment and with a diagnosis of STUMP at the definitive pathological evaluation. Methods: We searched among electronic databases from inception of them through January 2022. The research was conducted using meshes created by the combination of relevant heading term, key words, and word variants for: “uterine smooth muscle tumor of uncertain malignant potential”, “fertility”, “pregnancy”. Results: Seven retrospective studies including 80 women desirous of conceiving after a diagnosis of STUMP were included in this systematic review. Among these, 33 (41.25%) women got pregnant at least once and we recorded a total number of pregnancies of thirty-nine. Almost all deliveries were performed by caesarean section. Two (6.1%) relapses were diagnosed. Patients were submitted to hysterectomy and STUMP was confirmed as the final pathological diagnosis. The median follow-up in patients who delivered live babies was 61 months after surgery. At the last follow-up, all patients were alive without evidence of disease. Conclusions: This review shows that pregnacy seems to be possible and safe after the diagnosis of STUMP. These women should undergo rigorous follow-up and consider hysterectomy after completion of their reproductive plan. This review could be a useful tool for the counseling and the management of women with STUMP who desire to keep their fertility