Minerva obstetrics and gynecology最新文献

Background: Fetal aneuploidies, including trisomies 21, 13, and 18, represent a significant issue in prenatal care. The advent of non-invasive prenatal testing (NIPT) through the detection of cell-free DNA (cf-DNA) in maternal blood has modified screening for chromosomal abnormalities. This study evaluates NIPT adherence among pregnant of different ethnicities, addressing potential disparities in prenatal care.

Methods: This was a retrospective, single-center study conducted at a tertiary care university hospital in Italy between March 31, 2021, and September 30, 2022. Participants were categorized by ethnicity (Asian/Pacific islander, Black, Latina, White, Middle Eastern). Maternal demographic characteristics and prenatal test data were recorded. Comparative analyses were executed utilizing a One-Way Analysis of Variance (ANOVA) Test, augmented by Tukey's honestly significant difference test for post-hoc evaluation. Statistical significance was denoted by a P value (P)<0.05. A multivariate analysis through a multinomial regression model was conducted for the results to detect potential bias.

Results: Six hundred seventeen pregnancies were included: 418 White, 105 Asian/Pacific islander, 46 Black, 40 Latina, and 8 Middle Eastern. Maternal age showed no significant variation. Black ethnicity had higher prepregnancy Body Mass Index (BMI; mean: 27.5 kg/m²±SD: 5.92, P=0.02), while Asian and White pregnancies had higher nulliparity rates (63.8% and 70.8%). Black ethnicity had no NIPT uptake (0.00%). Asian/Pacific islander and Latina pregnant had lower NIPT utilization (9.5% and 7.5%, P<0.001). White ethnicity had a higher NIPT rate (27.5%). In the NIPT group, 8.9% of White and 12.5% of Middle Eastern pregnancies chose cf-DNA without a prior first-trimester ultrasound test. Considering the first-trimester screening, 30.4% of Black pregnancies had nuchal translucency, while 17.4% combined it with beta-human chorionic gonadotrophin (β-hCG) and associated plasma protein-A (PAPP-A; P<0.001). White pregnancies had high adherence: 74.6% had nuchal translucency and 53.8% had a first-trimester combined test. Overall, 69.6% of Black pregnancies skipped both tests versus 16.5% in the White group (P<0.001).

Conclusions: Significant disparities in prenatal care and NIPT adherence were observed among pregnant women of diverse ethnic backgrounds. Lower cf-DNA adhesion and limited adherence to first-trimester screening were observed among any ethnicities. These findings highlight the critical need for targeted interventions and policies to reduce barriers and facilitate access to prenatal care for all women.

Introduction: The objective of this study was to perform a systematic review to assess whether metformin therapy in patients diagnosed with gestational diabetes mellitus (GDM) in early pregnancy is associated with improved perinatal outcomes. We searched Ovid MEDLINE, Scopus, and Cochrane library (inclusive of ClinicalTrials.gov) from inception through November 29, 2023. We included all randomized trials that assessed metformin use in early GDM.

Evidence acquisition: The 3665 results produced from the database searches were imported into Covidence, a systematic review screening tool, and duplicates were removed. The remaining 2731 citations were screened by title and abstract against predetermined inclusion and exclusion criteria by 2 independent reviewers with discrepancies resolved after group discussion. After screening was completed, 46 studies underwent full text review, with 1 study eligible for inclusion.

Evidence synthesis: The included study showed no difference in a composite adverse perinatal outcome between those diagnosed with early GDM and treated with metformin (59.3%) vs. placebo (57.1%).

Conclusions: There is a paucity of data regarding the management of early GDM and the lack of standardization in its definition for this condition.

Background: In Italy, egg donation is being allowed again following the ruling by the Constitutional Court N. 162/2014. Nevertheless, the number of voluntary donors is insignificant, probably because no reimbursement is provided. Therefore, the great majority of egg donation cycles are performed by using imported cryopreserved oocytes from foreign countries. However, recent evidence has questioned the overall efficacy of this strategy in comparison with the shipment of frozen sperm and vitrified embryos.

Methods: Retrospective cohort study, conducted at ANDROS Day Surgery Clinic Palermo, Italy in the period 2016-2022, with the objective of evaluating the efficiency of each batch of vitrified oocytes, in terms of completed cycles. The cryopreserved donated oocytes came from a single Spanish clinic (Next Fertility, Valencia, Spain). The primary outcome was the cumulative live birth rate (CLBR). The secondary outcomes were the cumulative ongoing pregnancy rate (COPR), the cumulative clinical pregnancy rate (CCPR) and the miscarriage rate.

Results: The CLBR totaled 35.1%, the COPR 36.8%, the CCPR 49.2% and the miscarriage rate 24.7%. In the multivariate analysis, the probability of success was significantly higher in younger recipients, in fresh embryo transfer and in blastocyst-stage embryo transfer.

Conclusions: Our "transnational" donation program with vitrified oocytes has good success rates. The main focus of our analysis is the negative effect of advancing recipient age on success rates, outlining a possible, important role of age-related uterine factor on implantation mechanisms. This aspect should be emphasized during the counselling with couples much more than is routinely done.

Introduction: Relaxin is a hormone primarily produced by the corpus luteum during pregnancy, and it plays a critical role in various physiological processes related to pregnancy and childbirth.

Evidence acquisition: Studies have suggested a possible link between relaxin levels and preterm birth. Relaxin's effects on the cervix and pelvic ligaments suggest it could influence the mode of delivery. Higher relaxin levels have been hypothesized to facilitate vaginal delivery by promoting cervical ripening and softening of the pelvic ligaments, thereby reducing the need for cesarean sections. The involvement of relaxin in extracellular matrix remodeling suggests it could play a role in placental attachment. Some experimental studies have proposed that aberrant relaxin signaling might contribute to the development of placenta accreta by influencing the invasive properties of trophoblast cells.

Evidence synthesis: The current evidence on relaxin's role in preterm birth, mode of delivery, and placenta accreta is not definitive. While there are plausible mechanisms by which relaxin could influence these outcomes, clinical studies have yet to provide strong, consistent evidence. Future research should focus on well-designed, large-scale studies to better understand the relationship between relaxin levels and these critical pregnancy outcomes.

Conclusions: The focus of this review is to evaluate relaxin as a potential biomarker and its potential future therapeutic applications during pregnancy and consider the limitations that must be addressed in future studies.

Introduction: Uterocervical angle (UCA) is the angle between the anterior or posterior uterine wall and the cervical canal, and it has become an unique ultrasonographic marker in the recent years. The predictive role of the UCA in spontaneous preterm births (sPTB) has been examined by numerous authors, however few data are available on UCA as predictor of labor outcome at term of pregnancy. Therefore, the purpose of this review is to evaluate the effectiveness of transvaginal ultrasound measurement of UCA at term, and its clinical implications in obstetrics' practice.

Evidence acquisition: A literature search was conducted including all studies regarding the predictive role of ultrasonographic evaluation of the UCA on labor outcomes from 1990 to 2023.

Evidence synthesis: A narrative synthesis was subsequently performed dividing studies that considered posterior and anterior UCA. Five studies were included for the anterior UCA, and ten for the posterior UCA. UCA was then evaluated as predictor of prolonged latent phase and predictor of the onset and mode of delivery.

Conclusions: It is likely that the combination of multiple cervical parameters, rather than UCA assessment alone, together with clinical information, can achieve higher levels of accuracy in predicting delivery outcomes. Future prospective studies are needed to define with greater certainty the role of UCA as a useful screening tool before laboring, but, until then, the use of UCA as a screening test to predict labor outcome should remain investigational.

Background: Bevacizumab-based chemotherapies are commonly administered in the treatment of patients diagnosed with epithelial ovarian cancer (EOC). The primary aim of this study was to assess the factors that predict the objective response to bevacizumab-based therapies in cases of advanced and recurrent EOC.

Methods: The retrospective data of 264 patients with EOC from the current study were collected between 2009 and 2022 at our clinic. Survival analyses were conducted utilizing the Kaplan-Meier method and the log-rank test. Binary logistic regression analysis was employed to assess the factors predicting the objective response.

Results: A predominant subset of patients (83%) presented with serous adenocarcinoma, exhibiting a high-grade differentiation at 87%. The vast majority (80%) of the cohort experienced disease recurrence. Three-fourths of the cases received bevacizumab in combination with platinum-based doublet chemotherapy. In the multivariate analysis, clinical factors such as a disease recurrence (P=0.031), upfront tumor debulking surgery before bevacizumab (P=0.009), doublet chemotherapy (P=0.003), and the presence of malignant pleural effusion (P=0.024) emerged as significant determinants influencing the Objective Response Rate (ORR) in patients undergoing bevacizumab-based therapy. The ORR was 67.5% (N.=178), comprising 15.2% complete responses (N.=40) and 52.1% partial responses (N.=138). The median Progression-Free Survival (PFS) and Overall Survival (OS) were estimated at 10.2 months (95% CI, 8.60-11.9) and 20.1 months (95% CI, 16.0-24.2), respectively.

Conclusions: The responses to bevacizumab-based chemotherapies could be predict by the presence of malignant pleural effusion, disease recurrence, upfront tumor debulking surgery and doublet regimen of chemotherapy.

Background: Alongside health consequences, cesarean delivery (CD) has been associated with increased healthcare resource utilization (HCRU). A CD should be performed in case of placenta previa; in turn, the most appropriate mode of birth in women with a low-lying placenta (LLP) is still controversial. Since no previous data are available on the topic, the aim of this study was to evaluate the HCRU and economic impact on the Italian HC system of vaginal birth (VB) and CD in women with a LLP.

Methods: This retrospective study used patient-level real-world data of a cohort of women with a LLP confirmed at 28-30 weeks. A cost-minimization analysis (CMA) was conducted to compare VB and CD. Since Diagnosis-Related-Group payment may not reflect the actual use of hospital resources, a micro-costing analysis (MCA) was performed to more comprehensively evaluate the economic impact of VB and CD.

Results: The study included 86 women with a LLP at the third trimester scan, of which 49 (57%) had a VB and 37 (43%) underwent a CD. The CMA showed an economically marginal difference between VB and CD, especially when considering opportunity costs associated with the resources needed to look after women. However, the MCA identified charges for each VB being about half of those for each CD.

Conclusions: The use of patient-level real-world data allowed to generate basic information to assess the value of available interventions in case of LLP. A VB should be promoted in women with LLP, avoiding further burden on the HC system's limited resources.

Background: Inducing labor by ensuring a good maternal-fetal outcome is a challenge. The aim of the study was to evaluate the success rate, safeness, and time to delivery after the induction of labor (IOL), with the alternately first use of dinoprostone or Foley balloon, in high-risk pregnancy nulliparous women with unfavorable Bishop Score (BS).

Methods: This is a retrospective study of high-risk nulliparous women who underwent the IOL, either with dinoprostone or the Foley balloon method. In the former case, if the labor has not started after dinoprostone removal, oxytocin infusion started. In Foley group, the BS was re-evaluated after Foley removal, and IOL continued with the use of dinoprostone (if BS<6) or oxytocin (if BS>6). Here, too, if no labor occurred after dinoprostone removal, Oxytocin was administered. Delivery mode, fetal and maternal complications were recorded. The time to delivery was tracked.

Results: A total of 261 women were enrolled in the study. The CS rate was similar between groups (37.56% vs. 35.93%; P=0.81). Time to delivery was statistically lower in dinoprostone group (26.82h), as opposed to Foley (47.4h) (P<0.0001). Body Mass Index (BMI) of women who underwent Cesarean section (CS) was significantly higher than women who gave birth by vaginal delivery (VD), 26.80 vs. 27.40, P=0.012.

Conclusions: IOL in high-risk pregnancy nulliparous women resulted in equal rate of CS between the two groups. Dinoprostone first use resulted in a shorter time to delivery, with no maternal-fetal side effects. There is then no need to prolong IOL and raise maternal stress, as this will not yield better outcomes.

Uterine myomas are the most common benign gynecological tumors among women of reproductive age. The laparoscopic approach, when feasible, is considered the most suitable and safe technique for intervention. Typically, uterine muscular wall defects are sutured with absorbable filaments. However, performing intra-corporeal knots during laparoscopic procedures demands significant surgical abilities and experience. While laparoscopic myomectomies are often recommended, they pose a high risk of hemorrhage. Barbed sutures may address the challenges of laparoscopic knotting due to their inherent barbs, leading to filament cohesion with tissues. This characteristic could potentially reduce the total operative time and blood loss during surgery. In consideration of the latest literature meta-analysis on the topic, published in 2018 and cited in the present work, six papers were included in this review, excluding case reports, reviews and articles without a control group. The objective of this narrative review is to explore the literature and establish the safety profile of barbed suture compared to conventional laparoscopic sutures. Additionally, given the potential for postoperative adhesion formation with the use of barbed sutures, the review also emphasizes reproductive outcomes. Consistent with previous literature, patients undergoing barbed suture laparoscopic myomectomy experienced significantly lower suturing time and blood loss. Regarding obstetric outcomes, all studies analyzing this aspect concluded that barbed sutures in myomectomy are as safe as, and represent an easier alternative to, conventional sutures. Importantly, these findings did not adversely affect pregnancy outcomes.