Breastfeeding education: where are we going? A systematic review article

Background: UNICEF (United Nations International Children’s Emergency Fund) and WHO estimate that if all babies were breastfed for at least the first six months of their lives, the rate of morbidity and malnutrition would sig-nificantly decrease all over the world. In this view, these two organizations promoted a worldwide campaign for breastfeeding, creating the Baby Friendly Hospital Initiative (BFHI) that encourages good practices for the promotion of breastfeeding in hospitals. The aim of our study was to review the available evidence regarding the positive effects of breastfeeding, in order to suggest to most appropriate strategy to support it. Methods: The main databases including Scopus, PubMed, MEDLINE, Google scholar and Science Direct were researched to obtain the original papers related to breastfeeding education. The main terms used to literature search were "Breastfeeding education", Breastfeeding support", and “Breastfeeding healthcare policy”. The timeframe in-cluded the obtained articles was from 1980 to 2015. Results: Our analysis confirms that healthcare providers play a pivotal role in education and encouraging mothers to begin and continue breastfeeding. In this view, the adequate training of healthcare providers seems to be mandatory in order to support this practice. Moreover, adequate facilities are needed in order to promote and support breastfeeding. Conclusion: Considering the available evidence, breastfeeding should be supported among all the mothers. Based on the positive data emerging from the public awareness campaign in different Countries of the world, we strongly en-courage an accurate training for doctors and midwives and the implementation of adequate facilities in order to sup-port breastfeeding

Data comparison between pharmacological induction of labour and spontaneous delivery. A single centre experience

Objectives: To assess the differences in the maternal and fetal outcomes between pharmacological induced and sponta­neous labour in nulliparous women. Material and methods: Observational cohort study carried out over a period of 2 years. Inclusion criteria: nulliparous sin­gleton pregnancies, with cephalic fetal presentation, elective labour induction with intra-vaginal prostaglandin E2 (PGE2) gel (Prepidil® 2 mg) at a gestational age of 41 weeks. Control group: patients who entered labour spontaneously at a gestational age of ≥ 40 weeks. The main demographic maternal characteristics and intra- and postpartum data were extracted from computer records and obstetrics diaries and were used for the analysis. Results: One hundred and three patients with induction of labour and 97 with spontaneous labour were enrolled. Cesarean delivery was performed in 18 cases (17.5%), all in the induction group. There were no differences in newborn weights between the 2 groups while both the 1-minute and 5-minute Apgar scores were significantly higher in the spontaneous group (p = 0.014 and p = 0.0003, respectively). Women in the induction group had a significantly longer duration of I stage labour in comparison with spontaneous group (p < 0.0001). Conclusions: Primiparous women whose labour was induced spent a longer time in labour than women who presented in spontaneous labour. Clinicians should keep in mind that a slow rate of dilation in a woman being induced may be normal. For this reason, an arrest diagnosis needs to be carefully considered

RISK FACTORS FOR VOLUNTARY INTERRUPTION OF PREGNANCY AND POSSIBLE PREVENTIVE PUBLIC HEALTH ACTIONS

Introduction. Voluntary interruption of pregnancy (VIP) is one of the most frequent healthcare procedures in the world and a Public Health concern in many countries, especially after liberalization of the abortion laws. The study has been carried out to identify the factors that still influence a fraction of female population towards abortion in the absence of fetal malformations.Methods. We conducted a cross-sectional study in the period 2012-2016. The survey was carried out on all VIPs performed at the Gynecology and Obstetrics Unit of the University Hospital "G. Martino" in Messina, Italy. Results. The analyzed sample consisted of 1131 women, aged between 16 and 50 years. Only 4% of VIPs was due to a diagnosis of fetal malformation. In relation to the presence or absence of fetal malformations as the possible reason for VIP, the sample was split up into two groups and the socio-demographic characteristics were considered. VIPs in the absence of malformations were significantly more frequent in younger women with a lower educational level, in unmarried and unemployed women and in women who already had children. Multivariate analysis, including as covariates education level, marital status, profession, number of children, number of previous abortions and nationality, indicated that the variables mainly related to using VIP in the absence of malformations were marital status, age and number of sons.Conclusions. Based on our results, it is crucial to further prevent requests for VIPs through information and sex education programs for adolescents in schools and consultants, and responsible procreation promotion programs

Genistein reduces angiogenesis and apoptosis in women with endometrial hyperplasia

Roberta Granese,1,* Alessandra Bitto,2,* Francesca Polito,2 Onofrio Triolo,1 Domenico Giordano,1 Angelo Santamaria,1 Francesco Squadrito,2 Rosario D'Anna1 1Department of Paediatric, Gynaecological, Microbiological, and Biomedical Sciences, 2Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Messina, Messina, Italy*These authors contributed equally to this workAbstract: Endometrial hyperplasia without cytological atypia is commonly treated with progestins, but other treatments may be available with equivalent efficacy and reduced side effects. Here, we evaluate the effect of genistein aglycone on angiogenesis and apoptosis-related markers women with endometrial hyperplasia. Premenopausals (n=38) with nonatypical endometrial hyperplasia were administered either genistein aglycone (54 mg/day, n=19) or norethisterone acetate (10 mg/day, n=19) on days 16–25 of the menstrual cycle and evaluated for 6 months. Biopsies were taken during hysteroscopy at baseline and 6 months, and symptoms including excessive uterine bleeding were assessed at baseline and 3 and 6 months following recruitment. The expression of angiogenesis (Vegf), epithelial (Egf and Tgfb), and apoptosis-related (Bax, Bcl-2, and Casp-9) molecules, were assessed in uterine biopsies at baseline and after 6 months of therapy. Follicle-stimulating hormone, luteinizing hormone, estradiol, SHBG, and progesterone levels were also measured. After 6 months, 42% of genistein aglycone-administered patients had a significant improvement of symptoms compared to 47% of norethisterone acetate subjects. No significant differences were noted in hormone levels for any treatment. Gene expression revealed a significant reduction in Vegf, Egf, and Tgfb (P<0.05 versus baseline), and an increase in proapoptotic molecules (Bax and Casp-9), with a concomitant decrease in Bcl-2 values (P<0.05) in both groups. These results suggest that genistein aglycone might be useful for the management of endometrial hyperplasia without atypia in women who cannot or do not wish to be treated with progestin.Keywords: genistein, endometrial hyperplasia, Vegf, Bcl-2, Bax, Casp-

Interplay between Misplaced Müllerian-Derived Stem Cells and Peritoneal Immune Dysregulation in the Pathogenesis of Endometriosis

In the genetic regulation of Müllerian structures development, a key role is played by Hoxa and Wnt clusters, because they lead the transcription of different genes according to the different phases of the organogenesis, addressing correctly cell-to-cell interactions, allowing, finally, the physiologic morphogenesis. Accumulating evidence is suggesting that dysregulation of Wnt and/or Hox genes may affect cell migration during organogenesis and differentiation of Müllerian structures of the female reproductive tract, with possible dislocation and dissemination of primordial endometrial stem cells in ectopic regions, which have high plasticity to differentiation. We hypothesize that during postpubertal age, under the influence of different stimuli, these misplaced and quiescent ectopic endometrial cells could acquire new phenotype, biological functions, and immunogenicity. So, these kinds of cells may differentiate, specializing in epithelium, glands, and stroma to form a functional ectopic endometrial tissue. This may provoke a breakdown in the peritoneal cavity homeostasis, with the consequent processes of immune alteration, documented by peripheral mononuclear cells recruitment and secretion of inflammatory cytokines in early phases and of angiogenic and fibrogenic cytokines in the late stages of the disease

Unus pro omnibus, omnes pro uno: A novel, evidence-based, unifying theory for the pathogenesis of endometriosis

The theory of retrograde menstruation as aetiopathogenesis of endometriosis formulated by John Sampson in 1927 shows clear shortcomings: this does not explain why retrograde menstruation is a physiological process that affects 90% of women, while endometriosis occurs in only 10% of cases; it also does not explain the endometriotic foci distant from the pelvis, nor explains the cases of endometriosis in male patients. The immunological alterations of the peritoneal fluid explains the effects of disease, such as the inhibition of the physiological processes of cytolysis, but does not explain the cause. There is evidence to support the hypothesis that ectopic müllerian remnants of the endometrium, endocervix and endosalpinx are items from the genital ridge leaked during organogenesis. It is known that tissues derived from coelomatic epithelial and mesenchymal cells have the potential to metaplastically differentiate into epithelium and stroma. In addition, the phenotype of the ectopic endometrial cells is significantly different from those ectopic. There is scientific evidence that, during organogenesis, the genes of the Homeobox and Wingless family play a fundamental role in the differentiation of the ducts of Muller and development of the anatomical structure of the urogenital tract. We present here a hypothesis that deregulation of genes and the Wnt signaling pathway Wnt/β-catenin leads to aberrations and deregulation within the mesoderm, thus, may cause aberrant placement of stem cells. In addition, immune cells, adhesion molecules, extracellular matrix metalloproteinase and pro-inflammatory cytokines activate/alter peritoneal microenvironment, creating the conditions for differentiation, adhesion, proliferation and survival of ectopic endometrial cells

Miomectomia isteroscopica: risultati a lungo termine sui pattern mestruali e sull’outcome riproduttivo

Scopo dello studio è stato quello di valutare retrospettivamente i risultati a distanza della miomectomia isteroscopica sui pattern mestruali e sull’outcome riproduttivo in 77 donne con fibromiomi sottomucosi sintomatici (sanguinamento uterino anormale, algie pelviche, infertilità). L’età media delle pazienti era di 43.9 anni; 72 (93.5%) erano in premenopausa, 5 (6.5%) erano già in postmenopausa. Le dimensioni dei miomi, erano comprese tra 1 e 5 cm di diametro (media 2.8 cm). Per il trattamento preoperatorio sono stati utilizzati, a seconda dei casi, gli analoghi del Gn-RH, il gestrinone, oppure il danazolo. In media, la durata dell’intervento è stata di 22 minuti, la quantità di soluzione impiegata 2.6 litri, quella intravasata o comunque non recuperata di 320 cc. Nel corso degli interventi non si sono avute complicanze importanti ed il decorso post-operatorio è stato regolare. Nel periodo di follow-up (media 2.8 anni), 8 pazienti sono state perse. Delle altre 69, soltanto 5 (7.2%) sono state sottoposte ad isterectomia per persistenza della sintomatologia (sanguinamento, algie pelviche), mentre in 3 su 5 con problemi riproduttivi si è ottenuta la gravidanza. In conclusione, la miomectomia isteroscopica si conferma una tecnica alquanto valida ed efficace per il sanguinamento uterino e l’infertilità da miomi sottomucosi

Epigenetic modifications of primordial reproductive tract. A common etiologic pathway for Mayer-Rokitansky-Kuster-Hauser Syndrome and endometriosis?

Dear Editor, we read with great interest the paper by Alcolado [1], published in your prestigious Journal. This work conforms ‘‘the fetal basis of adult disease’’ hypothesis, which proposes that prenatal exposure to certain forms of environmental stress can cause increased susceptibility to clinical disorders, modulating the gene expression later in life (the so-called ‘‘epigenetic imprinting”). During embryogenesis, it was already shown that homeobox (Hox) genes are strictly involved in the differentiation of the paramesonephric duct into the mature female reproductive system [2]. Two weeks after birth, Hoxa9, Hoxa10, Hoxa11 and Hoxa13 develop their characteristic spatial distribution throughout the Müllerian ducts [3]. Moreover, it was demonstrated that the loss of Hoxa10 function provokes dysregulation during decidualization and implantation, resulting in female infertility [4]. Although clear data about the role of Hoxa gene clusters in infertility remain to be elucidated, we know that Hoxa10 specifically mediates the progesterone regulation of two prostaglandin E2 receptors (EP3 and EP4) in uterine stroma [5]. Moreover, another well-known family of genes that influence remarkably the organogenesis of the Müllerian reproductive tract is Wnt (wingless-type MMTV integration site family). Failures in Wnt signaling are associated with infertility, endometriosis, endometrial cancer and gestational trophoblastic disease such as choriocarcinomas [6]. Basing on these data, it is possible that epigenetic disturbance(s) during the Müllerian reproductive tract development may lead to modified intercellular communications, dysregulation of common downstream targets and, finally, to defect of organogenesis. Considering that the dysregulation of Wnt and/or Hox genes may affect cell migration during organogenesis and differentiation of Müllerian structures of the female reproductive tract, these altered pathways can underlie the well-known Mayer-Rokitansky-Kuster-Hauser Syndrome [7], clinically characterized by a physiological development of the secondary sexual characters and by a normal female karyotype 46 XX, with a congenital aplasia of the uterus and of 2/3 superior parts of vagina. A similar etiologic machinery was already hypothesized for endometriosis [8], a gynecological condition characterized by the breakdown of peritoneal immune homeostasis [9–11] and related symptoms and signs [12–14] due to the pro-inflammatory profile of pelvic as well as intrauterine microenvironment

Work load and management in the delivery room: changing the direction of healthcare policy

Nurse staffing, increased workload and unstable nursing unit environments are linked to negative patient outcomes including falls and medication errors on medical/surgical units. Considering this evidence, the aim of our study was to overview midwives’ workload and work setting. We created a questionnaire and performed an online survey. We obtained information about the type and level of hospital, workload, the use of standardised procedures, reporting of sentinel and ‘near-miss’ events. We reported a severe understaffing in midwives’ work settings and important underuse of standard protocols according to the international guidelines, especially in the South of Italy. Based on our results, we strongly suggest a change of direction of healthcare policy, oriented to increase the number of employed midwives, in order to let them fulfil their duties according to the international guidelines (especially one-to-one care). On the other hand, we encourage the adoption of standardised protocols in each work setting