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Rationale and Objectives: Emergency contraceptives pills (ECPs) are described as drugs that work by either inhibiting or delaying ovulation without affecting implantation. In our opinion, as we aim at demonstrating, both EMA documents and the experimental papers indicate that they prevalently inhibit embryo-implantation. LNG-ECPs: literature: LNG-ECPs never prevent ovulation when are taken in the most fertile days (EMA-EPAR on ellaOne® p. 9, first table). Conversely, they prevent the formation of an adequate corpus luteum. When they are taken pre-ovulatory ovulations occur regularly, but pregnancies do not appear. Taken after ovulation, they seem ineffective in preventing pregnancies. UPA-ECPs: literature: EllaOne® prevents ovulation only when is taken in the first fertile day. Thereafter, its anti-ovulatory effect drops sharply and becomes insignificant (8%) 36 h before ovulation, in the most fertile days (Brache); its decreasing anti-ovulatory effect cannot explain a consistently high effectiveness in preventing pregnancies (≥80%) that does not decrease depending on which of the 5 d it is taken after unprotected intercourse. Besides, ovulation occurs regularly in 91.7% of women taking ellaOne® weekly, for eight consecutive weeks (EMA-CHMP-Assessment Report 'EMA/73099/2015': study HRA2914-554, p. 7). Lastly, Lira-Albarrán administered ellaOne® to women in the most fertile pre-ovulatory days: they had normal ovulation, but their endometrium, evaluated through samples obtained in the implantation window, became inhospitable: the expression of 1183 genes was exactly the opposite of that observed in the receptive pro-gestational endometrium. This agrees with information by EMA-CHMP-Assessment Report 'EMEA/261787/2009' (p. 8): after UPA administration 'the proteins necessary to begin and maintain pregnancy are not synthesized'.Conclusions: Emergency Contraceptives work prevalently by preventing embryo-implantation. People shall receive correct information. [ABSTRACT FROM AUTHOR]

Purpose: The influence of pregnancy on uterine fibroid size still remains an unsolved dilemma. Basing on current knowledge, physicians are not able to inform patients about the likelihood of uterine fibroids to modify their size during pregnancy. Study aim was to summarize available evidence concerning the size modifications of uterine fibroids during each trimester of pregnancy and during puerperium.Methods: The review was reported following the PRISMA guidelines and registered in PROSPERO (registration number: CRD42017071117). A literature search was conducted in electronic database (PubMed, Embase, Sciencedirect, the Cochrane library and Clinicaltrials.gov) until July 2017. All studies evaluating fibroids' changes during pregnancy and puerperium by ultrasound or magnetic-resonance-imaging were included. Descriptive characteristics of studies and patients were collected. The modifications of uterine fibroid diameter and volume were the outcome measures.Results: Concerning the first trimester of pregnancy, all authors reported a significant growth of uterine fibroids. Contradictory evidence was found about uterine fibroid modifications during the second and third trimesters, mainly supporting a slowdown during mid pregnancy and a subsequent size reduction during late pregnancy. Concerning the overall modifications during pregnancy and puerperium, poor evidence quality suggests that uterine fibroids do not modify their volume/slightly enlarge during pregnancy and subsequently reduce in size during puerperium.Conclusions: Uterine fibroids seem to be subject to a non-linear trend of modifications during pregnancy and puerperium, which may vary from myoma to myoma. Adequate evidence supports uterine fibroid systematic enlargement during the first trimester of pregnancy, while inconsistent evidence is available about the changes of uterine fibroids during second and third trimesters. In addition, the overall modifications of myomas during pregnancy and puerperium remain unclear. [ABSTRACT FROM AUTHOR]

The aim of the current study was to diagnose the concomitant presence of adenomyosis (AM) in endometrioid endometrial cancer (EEC) in order to evaluate its value as an oncological prognostic marker. A retrospective analysis of 289 patients diagnosed with EEC who underwent total hysterectomy, bilateral salpingo-oophorectomy and pelvic-lymphadenectomy was conducted. The total cohort included 37 patients in Group A (those with concomitant AM and EEC) and 252 patients in Group B (those affected only by EEC). The following factors were evaluated: Presence or absence of AM, tumor grade, depth of myometrial invasion, tumor size, lymphovascular space involvement, lymph node status, peritoneal cytology, concomitant detection of endometrial atypical-hyperplasia or polypoid endometrial features and tumor stage according to the International Federation of Gynecology and Obstetrics (FIGO) classification. Uterine examination of different sections of uterine cervix, corpus, myomas and cervical or endometrial polyps was performed. The diagnosis of AM was confirmed when the distance between the lower border of the endometrium and the foci of the endometrial glands and stroma was >2.5 mm. Parametric and nonparametric statistical tests were performed when possible; continuous variables were analyzed using a Student's t-test, and categorical variables were analyzed by the x² test or Fisher's exact test. The association between FIGO stage and group was determined to be significant: 83.8% of Group A patients were categorized as FIGO stage I, vs. 68.7% of Group B patients. In addition, Group A was associated with lower grades in FIGO stage, myometrial invasion, lymphovascular space involvement, lymph node involvement and tumor size. The findings suggest that the intraoperative evaluation of the presence of AM in patients with EEC may aid surgeons in estimating oncological risk and in selecting the most appropriate surgical treatment. [ABSTRACT FROM AUTHOR]

Controlled ovarian stimulation, using a gonadotrophin-releasing hormone (GnRH) antagonist protocol, is a potential treatment option for women with a low response to other fertility treatments as it appears to be at least as effective as GnRH agonists (long protocol). However, previous studies have indicated that the administration of GnRH antagonist may cause an excessive reduction in endogenous luteinizing hormone (LH) levels. The use of recombinant LH (rLH) supplementation during ovarian stimulation is controversial. The present article proposes a future study focused on women aged ≥ 40 years old, with the aim of identifying patients who are poor responders to GnRH-antagonist treatment that may benefit from rLH supplementation. We hypothesize that patients with suppressed hypothalamic-pituitary-axis activity may benefit from rLH supplementation, as GnRH-antagonist administration has the potential to induce a marked reduction in LH levels in such patients compared with that in patients that exhibit a regular recovery following the administration of oral contraceptive pills (OCPs). Furthermore, patients with hyper-responsive hypothalamic-pituitary-axis activity may be affected by elow-gonadotropin-responsivenessf, similar to that observed in patients with any mutation in the follicle-stimulating hormone (FSH) receptor, who are known to benefit from rLH supplementation. The proposed pilot study would include 120 women who are predicted to be poor responders to GnRH-antagonist treatment. All subjects will be allocated at random (using 2:1 computerized randomization) into two study groups: Group A (OCP-treated) and group B (control). For all patients, the serum values of FSH, LH and 17β estradiol (E2) will be detected on day 3 of the menstrual cycle preceding OCP treatment (baseline) and at day 4 following OCP treatment. The Δ-variation from baseline levels for all markers, the FSH/LH ratio and the E2/FSH ratio will be determined. Δ-variation from the baseline of the FSH and LH values will be used to further categorize group A patients into subgroups A1-4, based on respective quartile numbers (Q1-4). Patients admitted to each of the four subgroups A1-4, based on their FSH quartile, will be selected at random to receive rLH supplementation (ratio, 1:1) during ovarian stimulation. If the resulting data are able to identify women that may benefit from rLH supplementation during ovarian stimulation, a large part of inconclusive evidence regarding rLH supplementation will be clarified. If patients supplemented with rLH (according to abnormal recovery of hypothalamic-pituitary-axis activity after OCP treatment) exhibit an improved ovarian response during in vitro fertilization (IVF) and subsequent pregnancy rate, the pre-IVF OCP test could be adopted as a useful tool for improving the success rate of assisted reproductive technologies in poorly-responding patients. [ABSTRACT FROM AUTHOR]

Background and Purpose: Hyperglycaemic memory describes the progression of diabetic complications during subsequent periods of improved glycaemia. We addressed the hypothesis that transient hyperglycaemia causes aberrant COX-2 expression in HUVEC in response to IL-1β through the induction of long-lasting epigenetic changes involving microRNA-16 (miR-16), a post-transcriptional modulator of COX-2 expression.Experimental Approach: Studies were performed on HUVEC collected from women with gestational diabetes mellitus (GDM) (dHUVEC) and normal women (nHUVEC).Key Results: In dHUVEC treated with IL-1β, the expression of COX-2 mRNA and protein was enhanced and generation of prostanoids increased (the most abundant was the promitogenic PGF2α ). COX-2 mRNA was more stable in dHUVEC and this was associated with miR-16 down-regulation and c-Myc induction (a suppressor of miR expression). dHUVEC showed increased proliferation in response to IL-1β, which was prevented by a COX-2 inhibitor and PGF2α receptor antagonist. Comparable changes in COX-2 mRNA, miR-16 and c-Myc detected in dHUVEC were produced in nHUVEC exposed to transient high glucose and then stimulated with IL-1β under physiological glucose levels; superoxide anion production was enhanced under these experimental conditions.Conclusions and Implications: Our results describe a possible mechanism operating in GDM that links the enhanced superoxide anion production and epigenetic changes, associated with hyperglycaemic memory, to endothelial dysfunction through dysregulated post-transcriptional control of COX-2 gene expression in response to inflammatory stimuli. The association of conventional therapy for glycaemic control with agents affecting inflammatory responses and oxidative stress might lead to a more effective prevention of the complications associated with GDM. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the efficacy of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in recurrent disease, response to therapy, and long-term follow-up of ovarian cancer (OC) patients in relation to cancer antigen-125 (CA125) levels and the prognostic meaning of this modality in this subset of subjects. Material and Methods: Between 2005 and 2015, we retrospectively evaluated 125 patients affected by OC who underwent FDG PET/CT imaging at our institution. The indications for PET/CT were recurrence of disease in 78 patients, therapy response assessment in 29, and follow-up in 18. The results of FDG PET/CT were compared with those of histopathology and clinical and radiological progression during follow-up for at least 6 months. The median long-term follow-up was 33 months. The diagnostic accuracies for the different clinical settings were evaluated. The relationships among global survival (GS), FDG PET/CT results, and CA125 levels were evaluated by both Kaplan-Meier and Cox regression analysis. Results: CA125 results were positive (>35 UI/mL) in 62 patients and negative in 63 (49% vs. 51%). The sensitivity and specificity of CA125 were 72% and 91%, respectively. PET/CT imaging showed a sensitivity of 98.6% and a specificity of 77.8% for the assessment of recurrent disease, and a sensitivity of 72.7% and a specificity of 88.9% for therapy evaluation. Meanwhile, in 18 patients evaluated during follow-up, the specificity was 82.3%. GS was significantly higher in case of negative CA125 values at the time of FDG PET/CT, of a negative PET/CT scan and when no evidence of peritoneum recurrence and distant metastases was determined by PET. Multivariate regression analysis showed that only age and peritoneum recurrence as determined by PET were identified as independent predictors of poor prognosis. Conclusion: Metabolic imaging with FDG PET/CT proved useful in patients where OC recurrence was suspected, even when the value of tumor marker CA125 was in a normal range. A positive PET/CT scan and the presence of peritoneum recurrence at PET were associated with a poor prognosis after approximately 30 months. [ABSTRACT FROM AUTHOR]

Although it is widely accepted that patients, who are considered poor responders to in vitro fertilization (IVF) benefit from recombinant luteinizing hormone (rLH) supplementation during an in vitro fertilization cycle, particularly when gonadotropin-releasing hormone (GnRH)-antagonist (ant) treatment is used t he o ptimal a dministration t iming and daily dose of rLH remains to be elucidated. The aim of the present study was to investigate the optimal timing of rLH-supplementation to improve ovarian response, embryo quality, endometrial thickness and pregnancy rate in infertile, estimated poor responders to IVF, undergoing GnRH-ant treatment. In addition, the present study aimed to evaluate the optimal daily dose to achieve the same outcomes. A prospective-randomized-cross-matched investigation was performed on 40 patients undergoing a GnRH-ant-treatment-cycle The patients were randomly assigned to either group A (rLH-75 IU/day) or group B (rLH-150 IU/day) and further randomized into subgroup A1/B1, in which rLH was administered at recombinant follicle stimulating hormone (rFSH) administration, and subgroup A2/B2, in which rLH was administered at GnRH-ant administration. Patients who did not become pregnant during the first cycle (35 patients), were treated a second time, cross-matched for groups and subgroups. Improved ovarian response, embryo quality and pregnancy rate were achieved by administering rLH at 150 IU/day, starting from GnRH-ant administration, independently from the total rLH dose administered. Improved endometrial thickness at oocyte retrieval day was achieved by administering rLH at 150 IU from the start of rFSH administration. These data led to the hypothesis that ovarian responses are affected by the timing of administration more than the total-dose of rLH. The optimal window to administer rLH appears to be the mid-to-late follicular phase, despite the fact that rLH-supplementation in the early-follicular phase appeared to increase endometrial thickness and to enhance its morphology. Standardization of the optimal daily dose and supplementation timing of rLH may resolve the debate regarding its efficacy in increasing the number of pregnancies and neonatal survival rates. [ABSTRACT FROM AUTHOR]

One of the most frequent causes of maternal and perinatal morbidity is represented by hypertensive disorders during pregnancy. Women at high risk must be subjected to a more intensive antenatal surveillance and prophylactic treatments. Many genetic risk factors, clinical features and biomarkers have been proposed but none of these seems able to prevent pre-eclampsia onset. English literature review of manuscripts focused on calcium intake and hypertensive disorders during pregnancy was performed. We performed a critical analysis of evidences about maternal calcium metabolism pattern in pregnancy analyzing all possible bias affecting studies. Calcium supplementation seems to give beneficial effects on women with low calcium intake. Some evidence reported that calcium supplementation may drastically reduce the percentage of pre-eclampsia onset consequently improving the neonatal outcome. Starting from this evidence, it is intuitive that investigations on maternal calcium metabolism pattern in first trimester of pregnancy could represent a low cost, large scale tool to screen pregnant women and to identify those at increased risk of pre-eclampsia onset. We propose a biochemical screening of maternal calcium metabolism pattern in first trimester of pregnancy to discriminate patients who potentially may benefit from calcium supplementation. In a second step we propose to randomly allocate the sub-cohort of patients with calcium metabolism disorders in a treatment group (calcium supplementation) or in a control group (placebo) to define if calcium supplementation may represent a dietary mean to reduce pre-eclampsia onset and to improve pregnancy outcome. [ABSTRACT FROM AUTHOR]

The choice of the type of abdominal incision performed in caesarean delivery is made chiefly on the basis of the individual surgeon’s experience and preference. A general consensus on the most appropriate surgical technique has not yet been reached. The aim of this systematic review of the literature is to compare the two most commonly used transverse abdominal incisions for caesarean delivery, the Pfannenstiel incision and the modified Joel-Cohen incision, in terms of acute and chronic post-surgical pain and their subsequent influence in terms of quality of life. Electronic database searches formed the basis of the literature search and the following databases were searched in the time frame between January 1997 and December 2013: MEDLINE, EMBASE Sciencedirect and the Cochrane Library. Key search terms included: “acute pain”, “chronic pain”, “Pfannenstiel incision”, “Misgav-Ladach”, “Joel Cohen incision”, in combination with “Caesarean Section”, “abdominal incision”, “numbness”, “neuropathic pain” and “nerve entrapment”. Data on 4771 patients who underwent caesarean section (CS) was collected with regards to the relation between surgical techniques and postoperative outcomes defined as acute or chronic pain and future pregnancy desire. The Misgav-Ladach incision was associated with a significant advantage in terms of reduction of post-surgical acute and chronic pain. It was indicated as the optimal technique in view of its characteristic of reducing lower pelvic discomfort and pain, thus improving quality of life and future fertility desire. Further studies which are not subject to important bias like pre-existing chronic pain, non-standardized analgesia administration, variable length of skin incision and previous abdominal surgery are required. [ABSTRACT FROM AUTHOR]

In vitro fertilization (IVF) cycles generate abnormalities in luteal-phase sex steroid concentrations and this represent an important limiting factor to achieve a good pregnancy rate. Although there are evidences about the usefulness of luteal phase support (LPS) after IVF cycles, no consensus exist about the best dose and way of progesterone (PG) administration, the advantages of estradiol (E2) supplementation and which IVF protocol could benefit from one more than other LPS scheme. Aim of the study was to assess the best LPS (low-dose PG, high-dose PG, high-dose PG and E2 supplementation) to achieve the highest clinical/ongoing pregnancy rate according to stimulation protocol, E2 at ovulation induction, endometrial thickness at pick-up and women's age. We conducted a randomized trial on 360 women undergoing IVF (180 treated by long-GnRH agonist, 90 by short-GnRH agonist and 90 by short-GnRH antagonist protocol) and stimulated by recombinant follicle-stimulating hormone alone. Our data demonstrated that high-dose PG is better than low-dose to increase both clinical and ongoing pregnancy rate. E2 supplementation are mandatory in case of short-GnRH antagonist protocol and strongly suggested in all protocols when E2max <5 nmol/l and endometrial thickness <10 mm. In long-GnRH agonist protocols, as well as in patients >35 years, the real advantages of E2 supplementation remain debatable and require further confirmation. 在体外受精（IVF）周期中黄体期的性激素浓度会产生异常，这是获得高妊娠率的一个重要的限制因素。尽管证据表明IVF周期后的黄体支持（LPS）是有益的，但在给予孕酮（PG）的最佳剂量和给药方式，补充雌二醇（E2）的优点，以及哪种IVF方案会比其它LPS方案获得更多益处等方面，尚未达成一致意见。本研究旨在依据促排卵方案、诱发排卵时的E2浓度、取卵时的子宫内膜厚度以及患者年龄，评估可获得最高临床/继续妊娠率的最佳LPS（低剂量PG，高剂量PG，高剂量PG加补充E2）。我们对360名正在进行IVF的女性（180名进行长GnRH激动剂方案，90名给予短GnRH激动剂方案，90名给予短GnRH拮抗剂方案）实施了随机试验，仅用重组卵泡刺激素促排卵。数据显示，高剂量PG比低剂量PG更能提高临床妊娠率和继续妊娠率。短GnRH拮抗剂方案必须补充E2，在所有方案中当E2max＜5nmol/l和子宫内膜厚度＜10mm时强烈建议补充E2。对于长GnRH激动剂方案以及年龄＞35岁的患者，补充E2是否真正有益仍有争议，且需要进一步证实。 [ABSTRACT FROM AUTHOR]

Purpose: The aim of this review is to compare studies concerning female sterilization in order to define the most suitable approach and device for each patient considering timing, safety, cost-effectiveness, failure rate, complication rate and patient satisfaction. Methods: A systematic literature search was conducted in electronic databases MEDLINE-EMBASE-Sciencedirect and Cochrane Library between 2000 and 2012. All original descriptions, case reports, retrospective and review articles on tubal sterilization methods have been considered. Outcome measures were effectiveness, tolerability, procedure complications and female satisfaction. Results: The ideal female sterilization system should be a simple, safe, highly efficient, easily learned, inexpensive, one-time procedure without negative side-effects. Nowadays, the trans-cervical approach is associated with minimal postoperative pain, allowing short hospitalization and fast resumption of daily activities. Laparoscopic and laparotomic approaches are considered second choices, since, particularly in developing countries, the transcervical hysteroscopic methods will increasingly spread within gynaecological clinical practice. Conclusions: Safety issues, hospital stay, costs and surgeons' experience are important factors in decision-making of the method for female sterilization. Hysteroscopic devices should be preferred when possible. The counselling time remains a fundamental step in choice. The decision concerning method depends on the setting, the surgeon's experience, the country's economical development and the woman's preference. [ABSTRACT FROM AUTHOR]

The effectiveness of emergency contraception (EC) is usually estimated by comparing the number of observed pregnancies to that of expected pregnancies after unprotected intercourse. Second-generation selective progesterone receptors modulators have been developed and evaluated for EC use. Among these compounds, ulipristal acetate (UPA) has been proven to share the same antiprogestin activity as mifepristone, and as with mifepristone, UPA has been demonstrated to be effective up to 120 hours after unprotected intercourse. The UPA is more effective than levonorgestrel (LNG) in preventing the appearance of clinically evident pregnancies. The LNG delays ovulation only when taken at the beginning of the fertile period; taken later, it is ineffective on ovulation, while it has been proven to impair the subsequent luteal function. The effectiveness of LNG decreases as time elapses and is limited to 72 hours after unprotected intercourse. The UPA maintains consistent effectiveness for 5 days after unprotected intercourse, and this effectiveness is independent on which of these 5 days it is taken. The ability of UPA to delay ovulation decreases progressively as ovulation approaches and is null at the time of the luteinizing hormone (LH) peak: 1 to 2 days before ovulation, UPA behaves as a placebo. The persistent effectiveness of the drug cannot be due to antiovulatory action, as it decreases sharply as LH approaches its peak level. The effectiveness is most likely due to the dramatic endometrial effects of the drug that are produced regardless of when it is taken. These effects are consistently present, as the threshold for altering endometrial morphology is lower than the threshold for altering folliculogenesis. [ABSTRACT FROM AUTHOR]

Levonorgestrel intrauterine system (LNG-IUS) is used in patients with breast patients taking tamoxifen (TAM) to prevent endometrial proliferation. The benefits (on endometrium), the side effects (on breast), and the patients suitable for this treatment are not still clear. Aim of this systematic review is to define the breast risks and endometrial benefits in TAM-treated women using Mirena and to define which patients could benefit from LNG-IUS use. In all, 3 studies on LNG-IUS effects on endometrium in TAM-treated women and 4 studies on breast cancer recurrence were selected for the study. All studies described a reduction in benign endometrial pathologies among Mirena users, but controversial data showed malignant disease and breast cancer recurrence. So it is mandatory to define hormonal status before TAM treatment. In selected patients Mirena was proven to protect endometrium. Perspective clinical trials on Mirena pharmacological features are necessary to establish whether systemic levels of progesterone could increase breast cancer recurrence in such patients. [ABSTRACT FROM AUTHOR]

The aim of this report was to define the best diagnostic and therapeutic approach when secondary amenorrhea is related to undiagnosed Asherman syndrome. We present a single case of secondary amenorrhea with a previous diagnosis of alterated hypothalamic-hypophysary regulation, with a component of ovarian function in probable reduction, which was evaluated in our department and resulted affected by Asherman's syndrome IV stage. We describe step by step the diagnosis and treatment of a previously misdiagnosed case of severe Asherman's syndrome. An appropriate diagnosis and adequate treatment are mandatory to allow menses and fertility to be restored when severe Asherman's syndrome occurs. [ABSTRACT FROM AUTHOR]

Background. Childbirth medicalization has reduced the parturient's opportunity to labour and deliver in a spontaneous position, constricting her to assume the recumbent one. The aim of the study was to compare recumbent and alternative positions in terms of labour process, type of delivery, neonatal wellbeing, and intrapartum fetal head rotation. Methods. We conducted an observational cohort study on women at pregnancy term. Primiparous women with physiological pregnancies and single cephalic fetuses were eligible for the study. We considered data about maternal-general characteristics, labour process, type of delivery, and neonatal wellbeing at birth. Patients were divided into two groups: Group-A if they spent more than 50% of labour in a recumbent position and Group-B when in alternative ones. Results. 225womenwere recruited (69 in Group-A and 156 in Group-B).We found significant differences between the groups in terms of labour length, Numeric Rating Scale score and analgesia request rate, type of delivery, need of episiotomy, and fetal occiput rotation. No differences were found in terms of neonatal outcomes. Conclusion. Alternative maternal positioning may positively influence labour process reducing maternal pain, operative vaginal delivery, caesarean section, and episiotomy rate. Women should be encouraged to move and deliver in the most comfortable position. [ABSTRACT FROM AUTHOR]

Recent evidences identify Human Papillomavirus (HPV) sperm infection as a possible cause of male and couple infertility. It acts through different mechanisms at various steps of human conception and early gestational development. We performed a systematic review to assess the role o fHPV semen infection on male and couple infertility. Analysis of available and eligible data does not permit us to fund clear evidences about clinical impact of HPV infection on fertility, although sperm parameters impairment is the most widely recognized effect. Regarding biomolecular implications, the available data are often conflicting. More studies are required to define the role of HPV sperm infection in clinical practice. The great majority of evidences are obtained by in vitro studies and this fact represents a limitation for the clinical management of HPVDNA sperm infection. Understanding the biological significance of HPV-DNA semen infection could permit us to explain most of the idiopathic male and couple infertility, leading to a better management of infertile men and a better timing for sperm banking storage before ART cycles. [ABSTRACT FROM AUTHOR]

The article presents a study which focuses on the overview of the availability of uterotonics to prevent postpartum hemorrhage (PPH) in pregnancy. The study uses the early cord clamping, uterotonic agents, and controlled cord traction procedures to manage the third stage of labor. Results show that the first choice for PPH prophylaxis is oxytocin, while the second-line of uterotonic agents include ergot alkaloids, syntometrine, and prostaglandins.

To determine the role, timing and indications for endometrial hysteroscopic investigation in relation to the clinical, ultrasound and histological features of the endometrium during tamoxifen (TAM) use. We performed an observational longitudinal cohort study (years 2007-2012) that investigated the endometria of 151 TAMusers with hysteroscopy and histology. For all patients, gynaecological history, years of adjuvant treatment, ultrasound endometrial thickness measurement and indications for hysteroscopy were recorded. Hysteroscopic findings showed that 100% of patients referred for simple follow-up had no evidence of endometrial disease. We found a strong correlation between previous history of abnormal uterine bleeding (with or without endometrial thickening) and hysteroscopic suspicion of endometrial atypia that was confirmed by histology. Hysteroscopy had 83.3% sensitivity, 99% specificity, 83.3% positive predictive value (PPV) and 99% negative predictive value (NPV) in detecting endometrial atypia. No significant correlation was found between endometrial thickening to O5 mm without bleeding and histological atypia. Similarly, the duration of treatment was not related to endometrial thickening and histological atypia. Endometrial stromal hyperplasia was detected by histology in 70.5% of patients with endometrial thickness measurements ranging from 5 to 10 mm. In contrast, no atypia was detected when endometrial thickness was !5 mm. Ultrasound performed using a 5-mm cut-off threshold for endometrial thickness resulted in 100% sensitivity, 15% specificity, 4% PPV and 100% NPV in detecting endometrial atypia, while a 10-mm cut-off threshold resulted in 84% sensitivity, 69% specificity, 10% PPV and 99% NPV. Low-risk TAM users do not require different endometrial surveillance than the general population. Hysteroscopy could play a fundamental role in determining the endometrial status of patients before the initiation of TAM treatment and in assessing the endometrial status of patients when bleeding occurs. [ABSTRACT FROM AUTHOR]

Despite many highly effective methods of contraception are available nowadays, many pregnancies are unintended. Emergency contraception (EC) is the use of drug or device after unprotected intercourse to prevent an unwanted pregnancy. It is a woman's last chance to prevent unintended pregnancy. Nevertheless the confusion about mechanisms of action, side effects, clinical efficacy and controindications makes the intervention underused in every setting investigated. So far levonorgestrel (LNG) has been considered the gold standard for oral EC. Today, a new type of second generation progesterone receptor modulator, ulipristal acetate (UPA) has been proposed as a more effective drug than LNG in prevention of unwanted pregnancies by delaying or inhibiting ovulation; even if many other devices are disposable in commerce. We revised the literature to concern most of the data available on the role of EC and moreover clarifying the available methods, the action windows of the accessible devices, the adverse events and the controindications. [ABSTRACT FROM AUTHOR]

Wernicke's encephalopathy (WE) is a neuropsychiatric syndrome due to thiamine deficiency, which is potentially fatal but preventable. In Obstetrics, it can complicate hyperemesis gravidarum because of major daily requirement. Nowadays there is no consensus on early diagnosis, treatment and prevention of this disorder. We present a case report of hyperemesis gravidarum which degenerated into WE and Korsakoff's syndrome. It highlights that the clinical suspicion is necessary to recognize signs and symptoms, to apply the available effective preventive measures in situations at risk and to begin urgent treatment in presence of characteristic clinical features. [ABSTRACT FROM AUTHOR]

Background: Uterine sarcomas are relatively rare tumors that account for approximately 1-3% of female genital tract malignancies and between 4-9% of uterine cancers. Less than 8% of all cases are Mullerian adenosarcoma, a distinctive uterine neoplasm characterized by a benign, but occasionally atypical, epithelial and a malignant, usually low-grade, stromal component, both of which should be integral and neoplastic constituents of the tumor. Mullerian adenosarcoma with sarcomatous overgrowth (MASO) is a very aggressive variant, associated with postoperative recurrence, metastases, even when diagnosed in early stage. Case Presentation: We present a fourth MASO case derived from uterine cervix in a 72-year-old woman with metrorrhagia and a polypoid mass protruding through the cervical ostium. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, systematic pelvic lymph node dissection, omental biopsy and appendectomy were performed. Surgery treatment was associated with adjuvant whole-pelvis radiation (45 Gy) and adjuvant chemotherapy (cisplatin/ifosfamide). After nine months of follow up, the patient was free of tumor. Conclusions: The rarity of MASO of the cervix involves a management difficult. Most authors recommend total abdominal hysterectomy, usually accompanied by bilateral salpingo-oophorectomy. There is no common agreement on staging by lymphadenectomy during primary surgery and adjuvant chemo-radio therapy. [ABSTRACT FROM AUTHOR]

Aim. The aim of our study is to evaluate the effect of recombinant-human LH supplementation on ovarian response and pregnancy outcome, during ovarian stimulation, in down-regulated women with baseline low serum LH levels undergoing assisted reproductive technology. Study design. A prospective randomized study performed with 80 women, with serum LH levels <0.5 IU/l on cycle Day 6 of stimulation. Group-A (40): 14-days after down-regulation with leuprorelin, ovarian stimulation was initiated only with r-FSH 225 IU. Group-B (40): at the same time stimulation was initiated with rFSH 225 IU associated with rLH 75 UI on cycle Day 6 of stimulation. Results. Serum-E2 levels on the hCG-day administration were significantly reduced in the Group-A. FF-VEGF levels were higher in Group-A. We did not find significant differences in the number of retrieved oocytes. The quality of oocytes proved to be higher and more significant from a statistical point of view in Group-B. The number of embryos obtained and transferred, the pregnancy rate lower in Group-A. Conclusions. In our study, it was shown that LH supplementation seems to have a beneficial effect on the maturity and fertilizability of oocyte. Lower FF VEGF levels, found in Group B, could be an indication of a lower apoptosis rate in human cumulus cells after administration of LH. We can affirm that LH-supplementation is beneficial in patients who show a significant serum LH suppression during the receptorial down-regulation [ABSTRACT FROM AUTHOR]

The occurrence of trisomy 22 confined to the placenta is rare. We report on a patient who presented with fetal abnormal Doppler velocimetry (elevated umbilical artery pulsatility index), but serial ultrasound examinations revealed a spontaneous recovery throughout pregnancy. A healthy baby was normally delivered at 40 weeks. [ABSTRACT FROM AUTHOR]