Vaginal sampling of amniotic fluid in pPROM: a new technique for early detection of subclinical chorioamnionitis?

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Could molecular assessment of calcium metabolism be a useful tool to early screen patients at risk for pre-eclampsia complicated pregnancy? Proposal and rationale.

Abstract One of the most frequent causes of maternal and perinatal morbidity is represented by hypertensive disorders during pregnancy. Women at high risk must be subjected to a more intensive antenatal surveillance and prophylactic treatments. Many genetic risk factors, clinical features and biomarkers have been proposed but none of these seems able to prevent pre-eclampsia onset. English literature review of manuscripts focused on calcium intake and hypertensive disorders during pregnancy was performed. We performed a critical analysis of evidences about maternal calcium metabolism pattern in pregnancy analyzing all possible bias affecting studies. Calcium supplementation seems to give beneficial effects on women with low calcium intake. Some evidence reported that calcium supplementation may drastically reduce the percentage of pre-eclampsia onset consequently improving the neonatal outcome. Starting from this evidence, it is intuitive that investigations on maternal calcium metabolism pattern in first trimester of pregnancy could represent a low cost, large scale tool to screen pregnant women and to identify those at increased risk of pre-eclampsia onset. We propose a biochemical screening of maternal calcium metabolism pattern in first trimester of pregnancy to discriminate patients who potentially may benefit from calcium supplementation. In a second step we propose to randomly allocate the sub-cohort of patients with calcium metabolism disorders in a treatment group (calcium supplementation) or in a control group (placebo) to define if calcium supplementation may represent a dietary mean to reduce pre-eclampsia onset and to improve pregnancy outcome

An update on maternal hydration strategies for amniotic fluid improvement in isolated oligohydramnios and normohydramnios: Evidence from a systematic review of literature and meta-analysis

open8Objective Several trials aimed at evaluating the efficacy of maternal hydration (MH) in increasing amniotic-fluid-volume (AFV) in pregnancies with isolated oligohydramnios or normohydramnos have been conducted. Unfortunately, no evidences support this intervention in routineclinical- practice. The aim of this systematic-literature-review and meta-analysis was to collect all data regarding proposed strategies and their efficacy in relation to each clinical condition for which MH-therapy was performed with the aim of increasing amniotic-fluid (AF) and improving perinatal outcomes. Materials and Methods A systematic literature search was conducted in electronic-database MEDLINE, EMBASE, ScienceDirect and the Cochrane-Library in the time interval between 1991 and 2014. Following the identification of eligible trials, we estimated the methodological quality of each study (using QADAS-2) and clustered patients according to the following outcome measures: route of administration (oral versus intravenous versus combined), total daily dose of fluids administered (2000), duration of hydration therapy: (1 day, >1 day but 1 week), type of fluid administered (isotonic versus hypotonic versus combination). Results In isolated-oligohydramnios (IO), maternal oral hydration is more effective than intravenous hydration and hypotonic solutions superior to isotonic solutions. The improvement in AFV appears to be time-dependent rather than daily-dose dependent. Regarding normohydramnios pregnancies, all strategies seem equivalent though the administration of hypotonicfluid appears to have a slightly greater effect than isotonic-fluid. Regarding perinatal outcomes, data is fragmentary and heterogeneous and does not allow us to define the real clinical utility of MH. Conclusions Available data suggests that MH may be a safe, well-tolerated and useful strategy to improve AFV especially in cases of IO. In view of the numerous obstetric situations in which a reduced AFV may pose a threat, particularly to the fetus, the possibility of increasing AFV with a simple and inexpensive practice like MH-therapy may have potential clinical applications. Considering the various strategies of maternal hydration implemented in the treatment of IO, better results were observed when treatment was based on a combination of intravenous (for a period of 1 day) and oral (for a period of at least 14 days) hypotonic fluids (≥2000ml).openGizzo, Salvatore; Noventa, Marco; Vitagliano, Amerigo; Dall'Asta, Andrea; D'Antona, Donato; Aldrich, Clive J.; Quaranta, Michela; Frusca, Tiziana; Patrelli, Tito SilvioGizzo, Salvatore; Noventa, Marco; Vitagliano, Amerigo; Dall'Asta, Andrea; D'Antona, Donato; Aldrich, Clive J.; Quaranta, Michela; Frusca, Tiziana; Patrelli, Tito Silvi

Endometrial scratch injury before intrauterine insemination: is it time to re-evaluate its value? Evidence from a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE: To assess the impact of endometrial scratch injury (ESI) on the outcomes of intrauterine insemination (IUI) stimulated cycles. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Infertile women undergoing one or more IUI stimulated cycles. INTERVENTION(S): Randomized controlled trials (RCTs) were identified by searching electronic databases. We included RCTs comparing ESI (i.e., intervention group) during the course of IUI stimulated cycle (C-ESI) or during the menstrual cycle preceding IUI treatment (P-ESI) with controls (no endometrial scratch). The summary measures were reported as odds ratio (OR) with 95% confidence-interval (CI). MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, ongoing pregnancy rate, multiple pregnancy rate, ectopic pregnancy rate, miscarriage rate. RESULT(S): Eight trials were included in the meta-analysis, comprising a total of 1,871 IUI cycles. Endometrial scratch injury was associated with a higher clinical pregnancy rate (OR 2.27) and ongoing pregnancy rate (OR 2.04) in comparison with the controls. No higher risk of multiple pregnancy (OR 1.09), miscarriage (OR 0.80), or ectopic pregnancy (OR 0.82) was observed in patients receiving ESI. Subgroup analysis based on ESI timing showed higher clinical pregnancy rate (OR 2.57) and ongoing pregnancy rate (OR 2.27) in patients receiving C-ESI and no advantage in patients receiving P-ESI. CONCLUSION(S): Available data suggest that ESI performed once, preferably during the follicular phase of the same cycle of IUI with flexible aspiration catheters, may improve clinical pregnancy and ongoing pregnancy rates in IUI cycles. Endometrial scratch injury does not appear to increase the risk of multiple pregnancy, miscarriage, or ectopic pregnancy

Uterine fibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature

PURPOSE: The influence of pregnancy on uterine fibroid size still remains an unsolved dilemma. Basing on current knowledge, physicians are not able to inform patients about the likelihood of uterine fibroids to modify their size during pregnancy. Study aim was to summarize available evidence concerning the size modifications of uterine fibroids during each trimester of pregnancy and during puerperium. METHODS: The review was reported following the PRISMA guidelines and registered in PROSPERO (registration number: CRD42017071117). A literature search was conducted in electronic database (PubMed, Embase, Sciencedirect, the Cochrane library and Clinicaltrials.gov) until July 2017. All studies evaluating fibroids' changes during pregnancy and puerperium by ultrasound or magnetic-resonance-imaging were included. Descriptive characteristics of studies and patients were collected. The modifications of uterine fibroid diameter and volume were the outcome measures. RESULTS: Concerning the first trimester of pregnancy, all authors reported a significant growth of uterine fibroids. Contradictory evidence was found about uterine fibroid modifications during the second and third trimesters, mainly supporting a slowdown during mid pregnancy and a subsequent size reduction during late pregnancy. Concerning the overall modifications during pregnancy and puerperium, poor evidence quality suggests that uterine fibroids do not modify their volume/slightly enlarge during pregnancy and subsequently reduce in size during puerperium. CONCLUSIONS: Uterine fibroids seem to be subject to a non-linear trend of modifications during pregnancy and puerperium, which may vary from myoma to myoma. Adequate evidence supports uterine fibroid systematic enlargement during the first trimester of pregnancy, while inconsistent evidence is available about the changes of uterine fibroids during second and third trimesters. In addition, the overall modifications of myomas during pregnancy and puerperium remain unclear

Extragenital Müllerian adenosarcoma with pouch of Douglas location

Background: Of all female genital tract tumors, 1-3% are stromal malignancies. In 8-10% of cases, these are represented by Mullerian adenosarcoma an extremely rare tumor characterized by a stromal component of usually low-grade malignancy and by a benign glandular epithelial component. Variant that arises in the pouch of Douglas is scarcely mentioned in the medical literature.Case Presentation: A 49-year-old para-0 woman, was seen at our OB/GYN-UNIT because she complained vaguely of pelvic pain. She had a mass of undefined nature in the pouch of Douglas. A simple excision of the mass showed low-grade Mullerian adenosarcoma with areas of stromal overgrowth. One and a half year after surgery, at another hospital, a mass was detected in the patient's posterior vaginal fornix and removed surgically. Six months later she came back to our observation with vaginal bleeding and mass in the vaginal fornix. We performed radical surgery. The pathological examination showed recurrent adenosarcoma. Surgical treatment was supplemented by radiation therapy.Conclusions: The case of Mullerian adenosarcoma reported here is the third known so far in the literature that was located in the pouch of Douglas. To date, only two other such cases have been reported, including one resulting from neoplastic degeneration of an endometriotic cyst

Emerging evidence regarding statins use as novel endometriosis targeted treatment: real "magic pills" or "trendy" drugs? Some considerations.

Dear Editors, We read with great interest the recent review by Gibran et al. concerning the evidence of pleiotropic effects of statins in conservative treatment of endometriosis disease [1]. The authors performed an exhaustive review of the literature investigating all the possible molecular mechanisms through which statins may interfere with cellular and tissue pathways involved in development, establishment and progression of endometriosis. To date, several drugs have been proposed and administered with the intention of treating endometriosis conservatively but many of these drugs are affected by time-limited administration and several side effects, with the result that they are frequently useful only for symptom reduction with little benefit on disease severity and/or on restoration of fertility [2]. Unexpectedly, from 2006 to the present, encouraging results derived from in vitro human-cell studies and in vivo murine studies seem to strongly nominate statins as \u201cmagic pills\u201d for long term conservative treatment of endometriosis, due to their low cost, safe pharmacological profile and apparent neutrality on the hormonal profile of women of childbearing age [1]. This is new exciting evidence, especially because it was collected during research on conservative treatment for a disease whose etiopathological mechanisms are not well understood and to date without any curative treatment, but it may erroneously result in a \u201creassuring and optimistic message\u201d for both scientists and clinicians. Much of the data demonstrating the dose-dependent effective reduction in number and volume of endometriotic lesions after administration of statins was collected in murine models or in vitro studies. To date only one study, by Almassinokiani et al. [3], has reported data from the in vivo human model, and the endpoint was focused on post-surgical pain reduction. The authors observed that, after adequate surgical treatment, therapy with atorvastatin (20 mg/day) was comparable to gonadotropin-releasing hormone agonists (3.75 mg/IM/month) in reducing post-surgical pain due to endometriosis. Though encouraging, however, this study was affected by several biases such as small sample size (60 patients), short term follow-up (16 weeks), and absence of an untreated control group (making it impossible to prove whether the observed benefits were due to surgical treatment or to post-operative medical therapy). In addition, Almassinokiani et al. administered statins to women who were trying to conceive, apparently underestimating the possible risks associated with the administration of therapy in the pre-conceptional and early pregnancy period. Besides the lack of evidence about possible teratogenic effects, the impact that this class of drugs may have on female fertility considering both germ line cells and somatic cells is not clearly defined. Only one in vivo study has investigated the potential adverse effect on human female gonadal function using as outcome the reduction of luteal-phase length [4]. It reported that 4 months of simvastatin administration did not result in ovarian hormonal function impairment. Contradictory data collected by an in vitro study demonstrating a pro-apoptotic effect of statins on human ovarian periovulatory granulosa cells [5] underline the not-underestimable bias of the above-mentioned in vivo study regarding the methodology used to achieve its reassuring conclusions. Further studies aimed at clarifying the safety profile of statin administration in fertile women should consider a longer time-exposure to really quantify the in vivo biological effects on ovarian reserve. Moreover, further in vitro studies will better clarify the cause\u2013effect relationship between pleiotropic effects of statins and the pathways involved in humans. Overcoming these potential limitations may be useful for evaluating the real effectiveness of statins in reducing both \u201corganic\u201d and \u201cfunctional\u201d damage caused by endometriosis onset, establishment and progression. In our opinion, while awaiting further evidence regarding the innocuousness of statins on female gonadal function and fertility, it would be appropriate to test these molecules on fertile women affected by endometriosis who do not desire pregnancy or have already completed their reproductive program