Minerva obstetrics and gynecology最新文献

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: 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.

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.

Background: Considering the cervix at the climacteric period, important changes take place in the morphology of the epithelium and stroma due to hypoestrogenism. Therefore, the aim of the present study was to compare the presence of transformation zone cells in the cervix of premenopausal and postmenopausal women.

Methods: In a private laboratory in São Paulo (Brazil) a retrospective analysis of cervical cytology results was performed. A total of 1,026,671 satisfactory cytology tests were evaluated between January 2010 and December 2015.

Results: A marked decline in transformation zone cells with age was evident, with a greater decrease in the ≥50 years age groups. Only 35% of women ≥50 years of age had transformation zone cells in cytology, while in those <50 years, the figure was 67.5% (P<0.001). The prevalence of negative cytological results in these two age groups was respectively 89.9% and 95.3%; however, it was observed that the most serious cytological results occurred in the group after menopause.

Conclusions: Although cytology is the recommended screening method for cervical cancer in Brazil, the low number of transformation zone cells in cytology in menopausal patients could be less sensitive for screening of dysplasia and cancer. So, we suggest routine high-risk HPV DNA testing, when possible, given that this test is considered more sensitive for detecting cervical lesions in this group of patients. When HPV DNA testing is not possible, cytology should be collected, and for cytology sampling we suggest regular topical estrogenization and use of appropriate technique.

Fetal growth restriction includes all those fetuses that do not reach their own growth potential due to placental insufficiency and therefore at higher risk of adverse perinatal outcomes. Identification and follow-up of these fetuses is essential to decrease this additional risk. Although estimated fetal weight under the 3rd centile and pathological cerebroplacental ratio are the most accepted predictive criteria, some evidence suggests that abnormal uterine artery Doppler may be a useful prognostic parameter in late-onset growth restriction fetuses at the moment of diagnosis. However, its prediction capacity as a standalone parameter is limited. In that context, integrated models of biometric and hemodynamic ultrasound parameters including uterine Doppler have been proposed as an effective approach to stratify the risk and improve perinatal outcomes. Moreover, an association of abnormal uterine artery Doppler and histological findings of placental underperfusion due to vascular obstruction has been described. Finally, it has also been suggested that the evaluation of uterine artery Doppler at third trimester in appropriate-for-gestational-age fetuses could identify cases of subclinical placental insufficiency, but further evidence is needed to define such predictive strategies.

Background: Gynecological pathologies are an important cause of anemia in women. In this study, we aimed to evaluate women who had been hospitalized because of anemia (Hb level <10 g/dL) caused by gynecologic pathologies and treated with either intravenous iron (ferric carboxymaltose) or blood transfusion.

Methods: This retrospective cross-sectional study was performed in a tertiary care center. Women who were hospitalized with the diagnosis of anemia with Hb level<10 g/dL and abnormal uterine bleeding between March 2015- September 2017 in the gynecology clinic were enrolled in the study. Hemoglobin levels, hemoglobin changes, uterine pathology and treatment of patients were recorded and compared.

Results: One hundred and fifteen women received red blood cell transfusion and 100 women were treated with intravenous ferric carboxymaltose. The mean age of the women was 45.1±6.1 (22-57) years. Although the mean Hb levels were higher in the iv-iron replacement group at the end of the one month (P=0.001), the mean increase in Hb levels was similar between two treatment modalities (P=0.101). Among the anemic women who required surgery, iv iron replacement was the first choice in 75.9% of women; 34.1% received red blood cell transfusion in the preoperative period.

Conclusions: Gynecological pathologies are a common cause of anemia in reproductive age women and intravenous carboxymaltose treatment is a safe and cheaper alternative of blood-transfusion in appropriate cases to elevate the Hb levels in the preoperative period.

Background: Fibromyalgia women (FM) seems to get worse at menopause suggesting some influence of estrogens on its pathophysiology. We aimed to study the influence of postmenopausal hormone therapy (HT) in FM, the relationship with sleep and FM impact.

Methods: We analyzed prospectively 69 menopausal women, divided in two groups, FM group (FMG; N.=32) and comparison group (CG; N.=28) submitted to HT for twelve weeks (1.2 mg/g transdermal estradiol, 100 mg micronized natural progesterone oral/daily). Data on Utian Quality of Life Questionnaire (UQOL) and Pittsburgh Sleep Quality Index (PSQI) were obtained in both groups, at entrance and twelve weeks after HT. FM patients also completed the Fibromyalgia Impact Questionnaire - Revised (FIQ-R) and fibromyalgia severity (FS).

Results: FM patients improved significantly the FIQ-R (P=0.0001, median FIQ-R score 30% lower), mainly the severity of FM, assessed by FS (P<0.0001). Both groups had improved quality of life and sleep (UQOL: P=0.0001; P=0.001, PSQI: P<0.0001; P=0.007, respectively). Differences between first and second PSQI were greater for CG than for FMG (P=0.008).

Conclusions: HT improving sleep and quality of life in both groups; it was a significant clinical improvement seen by FIQ and FS in FM patients. These changes characterize improvement of functional status and symptoms severity.

Introduction: Ovarian endometrioma is a common subtype of endometriosis with a prevalence between 17 and 44%. The reported average recurrence of endometrioma after surgical management is 21.5% after 2 years and 40-50% after 5 years. The aim of this narrative review was to summarize the existing literature focusing on treatment options after endometrioma recurrence in order to provide an evidence-based approach for the clinical practice.

Evidence acquisition: Three electronic databases (MEDLINE, EMBASE and Cochrane) were searched until September 2022 for eligible studies.

Evidence synthesis: The available studies showed that repeated surgery has a negative impact on ovarian function, without improving the fertility outcomes. Transvaginal aspiration as an alternative option for surgery has a high rate of recurrence, which varies from 8.20 to 43.5% depending on the technique used and on the study population. Pregnancy related outcomes were similar between transvaginal aspiration groups and no intervention groups in patients with endometrioma recurrence. Regarding medical treatments, only four studies were found, showing that progestins reduce the pain and the diameter of the ovarian cyst.

Conclusions: Recurrent endometrioma is a challenging condition which could be encountered during the care of women with endometriosis. The decision about the treatment-strategy has to be individualized considering family planning status, age, ovarian reserve and transvaginal ultrasound findings. Well-designed randomized clinical trials are needed to export safer conclusions about the most appropriate treatment in each specific condition after endometrioma recurrence.