Minerva obstetrics and gynecology最新文献

Background: The rapid development of the COVID-19 pandemic has altered the context of healthcare around the world. SARS-CoV-2 positive pregnant and postnatal women, being at greater risk of complications, require continuous midwifery surveillance as well as specialized medical care. Scientific literature lacks studies related to midwifery care models in hospital settings during the pandemic. The aim of this work is to describe hospitalizations in an obstetric-gynecological COVID care unit and to provide a descriptive analysis of the organizational and care model adopted.

Methods: A cohort retrospective descriptive study was carried out. The sample was stratified by COVID-related care complexity and by obstetric risk. The sample recruited pregnant women, postnatal women, and gynecological patients with confirmed SARS-CoV-2 infection admitted to the obstetric-gynecological COVID unit of a birth center in Northern Italy, from March 16, 2020, to March 16, 2022.

Results: A number of 1037 women were hospitalized, and of these, 551 were SARS-CoV-2 positive women. The 551 SARS-CoV-2 positive women included 362 pregnant women, 132 postnatal women, 9 gynecological patients with medical diagnosis while 17 with a surgical path, and 31 women undergoing voluntary interruption of pregnancy. The final sample included 536 women. 68.6% of women requested a low care complexity, 22.8% a medium one, and 8.6% a high care complexity. Among the obstetric women population, the majority (70.6%) showed a high obstetric risk.

Conclusions: The COVID-19 cohort of women required different levels of care with various care complexity and levels of obstetric risk. The model adopted allowed the acquisition of new technical and professional skills as well as the sharing of responsibilities and competences according to the care model of the Buddy System. Future studies could investigate COVID-related care models adopted internationally, but also deepen the technical and professional skills developed by midwives during the pandemic in order to enrich, improve and support midwifery profession.

A bilateral adnexal mass with suspected carcinosis could be a challenging experience for the gynecologist especially in fertile age and in patients with a desire for pregnancy. A 26-year-old patient who came to the outpatient clinical observation for bilateral, multilocular pelvic masses, with more than 4 papillary structures, color score 2, hypomobile compared to the uterus and rectum, respectively of 65 and 68mm in maximum diameter, free liquid in the abdomen and suspected of ovarian neoplasm. Positive tumor markers and a strong desire of a fertility sparing treatment (FST). A 2-step surgical approach managed to perform a diagnosis of bilateral ovarian borderline tumor with implants and a fertility sparing surgery. Harvesting and cryopreserving oocytes prior to the cytoreductive intervention was successfully performed.

Background: Obesity is a widespread pandemic and obstetric care must adapt to meet the needs of obese pregnant women. Little is known about the impact of Body Mass Index (BMI) on the induction of labor (IOL). Therefore, our objective was to evaluate if the duration of the first and second stages of IOL is affected by maternal BMI in nulliparous and multiparous women.

Methods: We included singleton pregnancies at term with cephalic presentation whose labor was induced from June 2018 to December 2019. Women were divided into two groups according to pre-pregnancy BMI in normal weight and obese women.

Results: A total of 668 women with IOL were included in the study, among them, 349 had a normal weight and 321 were obese. The first stage of labor was longer in obese multiparous than normal-weight women (normal weight 81.98±71.7 vs. obese 134.3±158.1 min, P=0.000), while the second stage resulted significantly shorter (normal weight 22.2±27.8 vs. obese 14.3±14.2 min, P=0.000). The total time elapsed from IOL beginning and delivery was significantly higher in obese nulliparous (normal weight 10.4±19.7 vs. obese 22.0±26.2 h, P=0.000). Operative vaginal deliveries, emergency cesarean section, and failed IOL resulted to be similar between the groups.

Conclusions: Obese multiparous women have longer first stages of labor while shorter second stages. The total time for induced obese nulliparous to reach delivery is higher than the normal weight. It might be reasonable to reconsider the partographs according to maternal BMI in case of induced labor for future obstetric practice.

The increased risks of various obstetric, maternal and fetal comorbidities of monochorionic twin pregnancies are widely known. However, despite its high prevalence and significance, the assessment of neurological morbidity as more commonly in selective fetal growth restriction (sFGR) is concerned with more health care. This literature review aims to provide more information about such an assessment. To this end, retrospective cases of sFGR were studied in monochorionic twins, already diagnosed, classified and who had the recommended management, published between 2001 and 2018 in 17 scientific articles. In the assessment of fetal mortality, the highest risk of death of the restricted fetus was found in type 3 of sFGR, while type 2 sFGR was responsible for the highest death rates of both fetuses and also the lowest mean gestational age at delivery, 30.9 weeks. Regarding neurological morbidity, however, studies have shown a higher risk of brain damage in the habitually growing twin compared to the restricted one in the case of sFGR. This may be due to prematurity or intermittent diastolic flow on Doppler in type 2 and 3 of sFGR, however, statements about its pathophysiology still lack further studies.

Background: To use the algorithm of the Fetal Medicine Foundation (FMF) to determine the cutoff point for prediction of preeclampsia (PE) in a Brazilian population.

Methods: Randomized clinical trial with 274 nulliparous patients at gestational age between 11 and 13 weeks and 6 days. To calculate the risk of PE, the algorithm available at the website of the FMF (http://fetalmedicine.org/research/assess/preeclampsia/first-trimester) was used. Among the patients, 138 did not use preventive measures (100 mg/day aspirin [ASA]). Youden's criteria were used to calculate the cutoff point. To test the effectiveness of 100 mg/day ASA in preventing PE, the patients were divided into two groups - at risk above and below the cutoff point.

Results: In the group comprising the 135 patients that did not take ASA, the median age was 22 years, the Body Mass Index (BMI) was 59.3 kg/m², the mean arterial pressure (MAP) was 73.3 mmHg, and the mean pulsatility index of uterine artery Doppler was 1.71. The median gestational age at delivery was 39.3 (38.1-40.3) weeks. The prevalence of PE was 11.1%. In our sample, the use of 100 mg/day ASA reduced total PE by 36.3% (prevalence of PE in the group above the cutoff point was 19% and 12.1% when ASA and placebo were used, respectively).

Conclusions: The cutoff point defined for prediction of PE was 1:155 with sensitivity of 80%, specificity of 57.5%, positive predictive value of 19.1%, and negative predictive value of 95%, which should help to select patients that will benefit from prophylactic ASA.

Background: Cervical cancer has been ranked as the fourth most common cancer in women. The role of HPV, the DNA virus identified in the 1980s, in almost all cervical cancers is undisputed. In patients scanned with smear and HPV, a cervical biopsy is performed accompanied by colposcopic examination, and the lesion is defined. The concentration of mucoproteins varies in the structure of the cervical mucus with neoplasms. The major aim of this study was to investigate the changes in the levels of cervical mucoprotein in patients at the early stages of cervical cancer and evaluate if these levels can be used in the early diagnosis of this cancer type.

Methods: The study was designed as a prospective cohort study. Samples from cervical mucus were taken and stored before colposcopy examination of human papillomavirus (HPV) positive patients (N.=100). According to the pathology results, while 36 cases constituted the precancerous group, no suspicion of cancer was found in 64 cases. To ensure standardization, colposcopy was performed immediately after the menstrual cycle and at least 0.5 mL of the cervical mucus sample was taken from all individual patients used in this study. Cervical mucus samples of the patients were analyzed for mucoproteins MUC1, MUC2, MUC5AC and MUC5B.

Results: All mucoprotein levels were found to be higher in patients with cervical intraepithelial neoplasia (CIN) than those of subjects with normal pathology for cervical neoplasia.

Conclusions: Significant relationship was obtained between cervical intraepithelial neoplasms and the levels of mucoproteins in cervical mucus. The results showed that diagnosis of neoplasia with HPV may be easily performed by utilizing any mucoprotein test.

Background: The study aimed to evaluate the rate of endometrial sampling (ES) failure, predictive factors of success, and reliability as diagnostic methods of Endosampler versus Novak.

Methods: A retrospective single-center study was carried out with all patients who underwent ES via Endosampler or Novak in 2020 and 2021. Demographic data, personal background, and histopathologic results were evaluated.

Results: Eighty-six patients underwent ES by Novak and 90 by Endosampler. The failure rate of ES was 43.2% with lower values for Endosampler (33.3% vs. 53.5%, P<0.05). Age, biopsy device, menopausal status, indication for biopsy, and amount of sample collected were predictive factors of failure. Analyzing each device, Endosampler was only affected by menopausal status. Only 50% in Novak and 62.5% in the Endosampler group of endometrial neoplasia cases were detected by these methods. Analyzing the performance for endometrial neoplasia (EN), we obtained higher values of sensitivity and accuracy for Endosampler (62.5% vs. 50.0% and 83.3% vs. 72.7%), respectively.

Conclusions: In our study, the failure rate obtained was in line with other previous studies. Menopausal status, age, type of biopsy device, indication for biopsy, and amount of sample collected affected ES performance. Analyzing diagnostic performance for EN, we found that these methods have better reliability for positive results than for negative ones, which may indicate the need for further evaluation in cases of high clinical suspicion. In short, we obtain a higher rate of success rate in Endosampler devices and better performance in diagnosing EN, which is the major objective of an ES.

Background: Breastfeeding can be challenging in neonates born between 34 ^0/7 and 36 ^6/7 weeks gestation (late preterm).

Methods: This prospective cohort study aims to evaluate exclusive breastfeeding at discharge, at three and six months of life in late preterm infants, and to identify facilitators and challenges to it. We included late preterm neonates eligible for the rooming-in. Data about breastfeeding at discharge, at three and six months of life were collected.

Results: Two hundred and fourteen late preterm infants were included in the study. At discharge 70 infants (32.7%) were fed with human milk and 144 (67.2%) were not. Non-exclusive breastfeeding was more common in women who were primiparous, had hypertension, and who underwent cesarean sections. Non-exclusive breastfeeding was associated with a low birthweight (<2500 g), ≥2 blood glucose controls, weight loss >10%, and longer hospital stay. Early first latch-on and skin-to-skin contact were more frequently associated with exclusive human milk feeding (P<0.001). Late preterm neonates born at 35 weeks showed a significant increase in exclusive human milk feeding at 3 months compared to the rate at discharge (P=0.004).

Conclusions: In this cohort, early first latch-on and immediate skin-to-skin contact resulted associated with exclusive human milk feeding. Despite formula-fed during hospitalization, infants born at ≥35 weeks gestation who were exclusively breastfed at follow-up increased.

Introduction: The relative efficacy and safety of insulin neutral protamine Hagedorn (NPH) and detemir (IDet), in the management of diabetes in pregnancy remains unclear. We sought to conduct an updated systematic review and meta-analysis to study the effect of NPH versus IDet during pregnancy on clinically relevant maternal and fetal outcomes.

Evidence acquisition: MEDLINE and Google Scholar were queried from inception till September 2022 for original studies comparing NPH with IDet for management of diabetes during pregnancy. Data was pooled using a random-effects model, to generate risk ratios (RR) for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, along with 95% confidence intervals (CIs). I² test was used to assess the magnitude of heterogeneity. Sensitivity analysis was conducted to explore the potential source of heterogeneity. As less than ten studies were included in our analysis, funnel plots were not made to evaluate publication bias. A P value of ≤0.05 was considered significant in all cases.

Evidence synthesis: Our search of the literature yielded 1087 articles initially, of which seven articles comprising 1396 patients, were included in our analysis. All included articles were of reasonably high methodological quality. Our pooled analysis demonstrates no statistically significant difference between the efficacy of insulin Detemir and insulin NPH as assessed by the HbA1c values from baseline. For safety outcomes, insulin detemir was significantly associated with a greater gestational age at delivery (WMD=0.39, 95%CI: 0.07 to 0.71, P=0.02) and lower incidence of hypoglycemic events (RR=0.64, 95%CI: 0.48 to 0.86, P=0.003) in-contrast to insulin NPH.

Conclusions: Our findings demonstrate that both, insulin IDet and insulin NPH have a similar efficacy in reducing HbA1c from baseline. However, insulin detemir was associated with lesser incidence of maternal hypoglycemic events and greater gestational age at delivery, compared to NPH.