PROGRESSO TECNOLOGICO IN MEDICINA PERINATALE E DECISIONI ETICHE DURANTE LA GRAVIDANZA E IL PARTO

2001/2002XIV Ciclo1962Versione digitalizzata della tesi di dottorato cartacea

Meconium-stained amniotic fluid: a risk factor for postpartum hemorrhage

Background/aim Clinical data with respect to the impact of meconium on the risk of maternal hemorrhage are scarce. Therefore, in this study, we aimed to determine whether meconium-stained amniotic fluid (MSAF) represents a risk factor for postpartum hemorrhage (PPH) after vaginal delivery in a large unselected population. Patients and methods A retrospective cohort study evaluated 78,542 consecutive women who had a vaginal delivery between 24th and 44th weeks of gestation. The women who had undergone cesarean section were excluded to avoid possible bias. Postpartum blood loss was measured with graduated blood sack. Postpartum blood loss between 1,000 and 2,000 mL and >2,000 mL were classified as moderate and severe PPH, respectively. Results A total of 74,144 patients were available for analysis. According to the color of amniotic fluid (AF), two groups of patients were identified: MSAF (n=10,997) and clear AF (n=63,147). The rates of severe and massive PPH were found to be significantly higher in the MSAF group than that of clear AF group (OR=1.3, 95% CI: 1.2\u20131.5, p<0.001 and OR=2.5, 95% CI: 1.5\u20134.2, p<0.001). Operative vaginal delivery rate was found to be higher in the MSAF group than that of clear AF group, but the difference was only borderline significant (OR=1.5, 95% CI: 1.0\u20132.2, p=0.05). There were no significant differences between the MSAF and the clear AF groups with respect to episiotomies, second- or third-degree perineal tears, vaginal\u2013perineal thrombus, cervical lacerations, vaginal births after cesarean section, twin deliveries, and placental retention rates. Conclusion To the best of our knowledge, this is the first clinical study that has investigated the role of MSAF as a risk factor for PPH after vaginal delivery in an unselected population. Our results suggest that MSAF is significantly associated with higher risk of moderate and severe PPH than clear AF

"GINEXMAL RCT: Induction of labour versus expectant management in gestational diabetes pregnancies"

<p>Abstract</p> <p>Background</p> <p>Gestational Diabetes (GDM) is one of the most common complications of pregnancies affecting around 7% of women. This clinical condition is associated with an increased risk of developing fetal macrosomia and is related to a higher incidence of caesarean section in comparison to the general population. Strong evidence indicating the best management between induction of labour at term and expectant monitoring are missing.</p> <p>Methods/Design</p> <p>Pregnant women with singleton pregnancy in vertex presentation previously diagnosed with gestational diabetes will be asked to participate in a multicenter open-label randomized controlled trial between 38+0 and 39+0 gestational weeks. Women will be recruited in the third trimester in the Outpatient clinic or in the Day Assessment Unit according to local protocols. Women who opt to take part will be randomized according to induction of labour or expectant management for spontaneous delivery. Patients allocated to the induction group will be admitted to the obstetric ward and offered induction of labour via use of prostaglandins, Foley catheter or oxytocin (depending on clinical conditions). Women assigned to the expectant arm will be sent to their domicile where they will be followed up until delivery, through maternal and fetal wellbeing monitoring twice weekly. The primary study outcome is the Caesarean section (C-section) rate, whilst secondary measurement4s are maternal and neonatal outcomes. A total sample of 1760 women (880 each arm) will be recruited to identify a relative difference between the two arms equal to 20% in favour of induction, with concerns to C-section rate. Data will be collected until mothers and newborns discharge from the hospital. Analysis of the outcome measures will be carried out by intention to treat.</p> <p>Discussion</p> <p>The present trial will provide evidence as to whether or not, in women affected by gestational diabetes, induction of labour between 38+0 and 39+0 weeks is an effective management to ameliorate maternal and neonatal outcomes. The primary objective is to determine whether caesarean section rate could be reduced among women undergoing induction of labour, in comparison to patients allocated to expectant monitoring. The secondary objective consists of the assessment and comparison of maternal and neonatal outcomes in the two study arms.</p> <p>Trial Registration</p> <p>The study protocol has been registered in the ClinicalTrials.gov Protocol Registration System, identification number <a href="http://www.clinicaltrials.gov/ct2/show/NCT01058772">NCT01058772</a>.</p

Relevance of random biopsy at the transformation zone when colposcopy is negative

As recommended by European Guidelines, the key for improving the standard of care for patients with cervical intraepithelial lesions is the skill of the colposcopist, who also has the responsibility of facilitating shared decision-making through patient information before, during, and after the examination. Recently, it has been reported that, if colposcopic examination results are normal, women with low-grade cervical cytology, even with a positive HPV test, can return to routine recall; this is surely an advantage from both a psychological and economic point of view. Our suggestion for improving the detection of high rate disease is to use a low threshold of abnormality at colposcopy (any acetowhitening); this also will favor better training for the colposcopist, rather than adding nondirected biopsies

Hysteroscopic chasing for endometrial cancer in a low-risk population: risks of overinvestigation

PURPOSE:To evaluate the appropriateness of the indications for hysteroscopy done, in fertile and postmenopausal women, for the detection of endometrial cancer. METHODS: A retrospective analysis of 2673 consecutive women who underwent office hysteroscopy chasing for endometrial cancer between January 2012 and June 2014. According to their medical history only low-risk women entered the study. RESULTS: A total of 1070 patients entered the study. The main outcome measure was the appropriateness of the indications for hysteroscopy. Appropriateness was assessed on the basis of guidelines of scientific societies and histologic report. According to the algorithm developed for appropriateness, 44 % of procedures resulted in being inappropriate. In reproductive-aged women 57 % of hysteroscopies were inappropriate. In postmenopausal women inappropriate hysteroscopies were 45 %. In reproductive-aged women, the reasons for inappropriateness were: absence of abnormal uterine bleeding (AUB) or AUB without a trial of progestin therapy. In postmenopausal women, the reasons for inappropriateness were: ultrasound report of endometrial thickening or polyp without bleeding. CONCLUSIONS: Hysteroscopy is often recommended for inappropriate indications. More evidence is needed to identify the risks of overinvestigation, overdiagnosis, and related overtreatment and to better identify the threshold beyond which benefits are likely to outweigh harms