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Vaginal birth after caesarean (VBAC) is an option to avoid major abdominal surgery and many consequences related to repeated caesarean delivery. In the last years, many efforts have been made to increase the number of patients attempting trial of labour after caesarean (TOLAC). The aim of our study was to identify the most important factors associated with the success of VBAC. A retrospective study was conducted in two Italian referral centres. Subjects included were singleton and morphologically normal pregnancy with previous C-section. Subjects with an inter-pregnancy interval shorter than 18 months, a large for gestational age baby, a pregnancy complicated with gestational diabetes and a previous unclassified uterine scar were excluded. The characteristics of the subjects were compared and a logistic regression was performed to evaluate variables associated with successful VBAC. Of the 300 patients included, 224 (74.7%) achieved VBAC while 76 (25.3%) underwent C-section after failed TOLAC. The number of previous C-sections was not significantly associated with the success of TOLAC. Factors positively associated with achievement of VBAC were previous vaginal delivery (OR of 6.88 for one and 9.68 for more than one) and oxytocin implementation (OR 3.32). No maternal and neonatal adverse events occurred. Our results show that attempting VBAC is a feasible option in referral centres after adequate evaluation of the potential factors affecting the probability of success. A careful record of obstetrical history and management of labour can provide clinicians useful information to counsel women before and during labour.

Folic acid (FA) supplementation prevents neural tube defects (NTDs), but the effects on other reproductive outcomes are unclear. While common recommendation is 0.4 mg/day in addition to regular nutrition, the most appropriate dose of FA is still under debate. We investigated the effects of a higher dose of periconception FA on reducing adverse reproductive outcomes. In this multicenter double-blind randomized controlled trial (RCT), 1060 women (aged 18–44 years and planning a pregnancy) were randomly assigned to receive 4.0 mg or 0.4 mg of FA daily. The primary outcome was the occurrence of congenital malformations (CMs). A composite outcome including one or more adverse pregnancy outcomes was also evaluated. A total of 431 women had a natural conception within 1 year. The primary outcome occurred in 8/227 (3.5%) women receiving 4.0 mg FA and 9/204 (4.4%) women receiving 0.4 mg FA (RR 0.80; 95%CI 0.31 to 2.03). The composite outcome occurred in 43/227 (18.9%) women receiving 4.0 mg FA and 75/204 (36.8%) women receiving 0.4 mg FA (RR 0.51; 95%CI 0.40 to 0.68). FA 4.0 mg supplementation was not associated with different occurrence of CMs, compared to FA 0.4 mg supplementation. However, FA 4.0 mg supplementation was associated with lower occurrence of other adverse pregnancy outcomes.

Objective To assess incidence and clinical patterns of severe maternal morbidities related to pregnancy. To determine associated feto-maternal outcomes and economic costs for the institution. Methods Observational study in a tertiary care Italian public hospital during a 10-year period. To identify severe obstetric complications, the following management-based criteria were adopted: need for intensive care unit admission, blood transfusion ≥5 units, emergency peripartum hysterectomy/laparotomy and arterial embolization. Impact of severe obstetric complications on facility resources was estimated considering length of hospital stay, need for additional surgery and transfusion. Results A total of 151 cases were identified, most frequent obstetric morbidities being major obstetric hemorrhage (50.3%) and hypertensive disorders (19.2%). Pre-term birth, caesarean section and sub-saharan African origin were factors significantly associated with severe morbidity. Maternal mortality and maternal mortality to morbidity ratios were 17 per 100,000 live births and 3:151, respectively. Stillbirth rate was 4.4%. Massive use of blood products and prolonged admissions concurred to increase hospital expenditures. Conclusion Institutional severe maternal morbidities may be effectively monitored by implementing a surveillance program and selecting a combination of management-based criteria which define the extremely morbid cases. Focusing on causes and risk factors associated with adverse obstetric situations has the potential to improve quality of care, prevent maternal life-threatening complications and perinatal mortality, reduce hospital expenditures.

Current data show that maternal mental conditions affect about 10% of pregnant women worldwide. Assessing timing and patterns of mental health illness, therefore, is critical to ensure the wellbeing of the mother, the new-born and the whole family. The aim of this review is to summarize the latest evidence linking maternal mental disorders and adverse reproductive outcomes. Following the PRISMA guidelines for systematic reviews, a literature search was conducted to ascertain the possible impact of mental health conditions on reproductive outcomes before and during pregnancy. The comprehensive strategy included cohort studies, randomised controlled trials and literature reviews on women with Primary Maternal Mental Illness (PMMI) and Secondary Maternal Mental Illness (SMMI) considering periconceptional, obstetric and foetal-neonatal outcomes. PubMed, WoS, CINAHL and Google scholar were used for the search. Cross-referencing in bibliographies of the selected papers ensured wider study capture. Evidence linking depressive disorders and infertility among PMMI is weak. Given this, women with prior mental conditions experience additional distress when undergoing fertility treatments. Primary mental disorders may also increase the risk of miscarriage and other pregnancy complications (e.g., gestational diabetes). For SMMI, there is more robust evidence correlating Preterm Birth (PTB) and Low Birth Weight (LBW) with common mental disorders which develop during pregnancy. Prevention and management of maternal mental health diseases and minor mental conditions within the first 1000 days’ timeframe, should have a place in the holistic approach to women going through reproductive decisions, infertility treatment and pregnancy.

No Abstract.Keywords: Cesarean section, peritoneal closure, parietal hematoma, hemoperitoneum

Objective(s) To assess incidence, risk factors, management, and short and long-term outcomes of unintentional transvesical caesarean section (UTV-CS) defined as any extraction of the fetus through a double full thickness bladder wall cystotomy. Study design Data about all UTV-CS between January 2013 and December 2017 were retrieved searching the diagnosis of bladder injury and bladder repair during caesarean section (CS) in our comprehensive computerized labor and delivery database and register. CS with bladder wall injury not classified as UTV-CS were excluded. Data analysis included maternal history, demographics and obstetric parameters, details regarding CSs, bladder injury location and extension, and short- and long-term maternal outcomes. Results Among 28,822 deliveries, 7,616 (26.42%) were CSs. Three cases of UTV-CS were identified with comprehensive incidence of 0.039%. We provided details of the reported cases and described bladder repair procedure. Conclusion(s) This is the first study that assessed the incidence of UTV-CS. UTV-CS risk factors are consistent with factors related to milder bladder injuries. The risk of bladder injury during CS should be always considered, despite the low incidence of this complication. Prompt diagnosis and surgical repair seem to allow avoiding severe complications and recovery of a normal urological function even in UTV-CS.

Introduction and objective The novel coronavirus outbreak has caused substantial changes in societal norms as well as adjustments in health systems worldwide. To date the impact of these pandemic-related variations has yet to be fully understood also in the field of maternal health for which continuity of care is a proven life-saving preventive measure. Design Following the PRISMA guidelines for reviews, a literature search was carried out to assess different approaches that combine quality of maternal care with the imposed social-distancing rules. Nine studies were included in the scoping review. Findings Reduction of in-person visits is the preferred overall solution. Yet, fewer consultations can still guarantee essential services and appropriate care through integration with telemedicine. Referral to epidemic-free community centres is an alternative option and new paths need to include the interdisciplinary contribution of medical consultants and IT experts, among others. In this context, delaying access for symptomatic expectant mothers is still debated since it carries the potential risk of untimely detection of pregnancy complications. Key conclusions Preliminary experiences provide an overview of the different attempts put in place to reshape health services to contain the pandemic hazards. Implications for practice These early prototypes may inspire future innovative health solutions compatible with local resources and specific population preferences and needs.

The desire for pregnancy in sickle cell disease (SCD) women has become a true challenge for hematologists, requiring a multidisciplinary approach. Erythrocytapheresis (ECP) is an important therapeutic tool in SCD, but only limited data on starting time and the effects of ECP during pregnancy are available.This is a double-center retrospective cross-sectional study on a total of 46 single pregnancies in SCD women from January 2008 to June 2017. ECP was started at 10.7 ± 5.2 weeks of gestation, and prophylactic enoxaparin (4,000 U daily) was introduced due to the reported high prevalence of thromboembolic events in pregnant SCD women.The alloimmunization ratio was 2.1 per 1,000 and the alloimmunization rate was 5.6%. In early ECP-treated SCD women, no severe vaso-occlusive crisis, sepsis or severe infection, or preeclampsia or eclampsia were observed. We found normal umbilical arterial impedance during pregnancy, suggesting an optimal uteroplacental function in early ECP-treated SCD women. This was also supported by the improvement in newborn birthweights compared to previous studies. In our cohort, three SCD women were started later on ECP (20-25 weeks), and gestation ended with late fetal loss. Placenta pathology documented SCD-related damage and erythroblasts in placental vessels, indicating fetal hypoxia.Collectively, our data generate a rationale to support a larger clinical trial of early ECP program in SCD pregnancy.

Intramural hematoma of the esophagus is a rare injury causing esophageal mucosal dissection. Forceful vomiting and coagulopathy are common underlying causes in the elderly population taking antiplatelets or anticoagulation agents. Acute retrosternal pain followed by hematemesis and dysphagia differentiates the hematoma from other cardiac or thoracic emergencies, including acute myocardial infarction or aortic dissection. Direct inspection by endoscopy is useful, but chest computed tomography best assesses the degree of obliteration of the lumen and excludes other differential diagnoses. Intramural hematoma of the esophagus is generally benign and most patients recover fully with conservative treatment. Bleeding can be managed medically unless in hemodynamically unstable patients, for whom surgical or angiographic treatment may be attempted; only rarely esophageal obstruction requires endoscopic decompression. We report an unusual case of esophageal hematoma, presenting in a young preeclamptic woman after surgical delivery of a preterm twin pregnancy, with a favorable outcome following medical management.

Objective We wanted to assess the diagnostic value of computed tomographic colonography (CTC) in recognizing bowel endometriosis in comparison with serum Ca125, transvaginal sonography (TVS), and presence of intestinal symptoms. Methods We included in this study 92 women undergoing surgery for symptomatic DIE. Preoperative evaluation included clinical history, Ca125 serum value, and TVS. CTC was performed in 37/92 patients (40.2%), and the results were compared to the other preoperative tools and to surgical exploration, considered the clinical reference standard. Results Surgery confirmed bowel endometriosis in 49/92 subjects (53.3%). Presence of intestinal symptoms, serum Ca125 values, and TVS were significantly correlated to intestinal involvement, but CTC had the highest accuracy in detecting bowel endometriosis with a sensitivity of 68%, a specificity of 67%, a PPV of 81%, and a NPV of 50% (P = 0.04). Conclusions CTC proved to be an accurate and low invasive imaging technique to detect DIE of the bowel and compared favorably with clinical evaluation, serum Ca125 determination, and TVS.

Preeclampsia is a severe disorder of pregnancy characterized by the development of hypertension and proteinuria, in which increased vascular resistance and endothelial dysfunction in the mother are often accompanied by altered placental perfusion and restricted fetoplacental growth.1,2 Little information is available concerning the release of cytochrome P450 (CYP) metabolites of arachidonic acid (AA) in pregnant women.3 Epoxyeicosatrienoic acids (EETs) are involved in vasoprotective, antiinflammatory, and renal excretory mechanisms that epitomize their critical role as endogenous antipressor agents.4–6 In addition to circulating levels of EETs, EETs are formed in the placenta, trophoblast, amnion, chorion, decidua, and myometrium of the gravid uterus.7–9 EETs, acting as endothelial-derived hyperpolarizing factors, have been proposed to support uterine blood flow during preeclampsia in the face of reduced synthesis of nitric oxide and prostaglandins.2 CYP epoxygenase expression in the rat kidney is upregulated during pregnancy,10 thereby raising renal EET levels, which have been shown to antagonize prohypertensive 20-hydroxyeicosatetraenoic acid (20-HETE) in resistance blood vessels, lessening the renal vasoconstrictor response to 20-HETE.11,12 20-HETE is systemically prohypertensive, although it exerts natriuretic effects in the proximal tubules and the medullary thick ascending limb.13 CYP monooxygenase metabolism of AA produces cis-EETs and 20-HETE, while red blood cells (RBCs) generate cis- and trans-EETs from AA by activated hemoglobin and by peroxidation of AA esterified in phospholipids.14 Hemoglobin in RBCs relieves oxidative stress in the circulation through its peroxidase activity.15 EETs of cis- and trans-configuration can also be produced by the CYP interaction with lipid hydroperoxides derived from lipoxygenases.16 RBCs are reservoirs for abundant cis- and trans-EETs, which are linearly correlated with plasma EETs.17,18 Plasma EETs circulate principally esterified to the phospholipids of lipoproteins, and free EETs account for 3% or less of plasma EETs.19 EETs are hydrolyzed by the soluble epoxide hydrolase (sEH) forming dihydroxyeicosatrienoic acids (DHETs) that have generally reduced activity. The current study was designed for cross-sectional analysis by comparing plasma, RBC, and urine content of EETs, DHETs, and 20-HETE in pregnant and nonpregnant women. We hypothesize that circulatory EETs and 20-HETE are closely associated with the development of pregnancy and preeclampsia. Comparison of the levels of these eicosanoids in maternal peripheral (brachial) venous blood and urine along with levels in the fetoplacental circulation is the first step in evaluating an antipressor function for this system during pregnancy, and its contribution to the pathophysiology of preeclampsia.

BACKGROUND Epoxyeicosatrienoic acids (EETs) derived from cytochrome P450 (CYP)-dependent metabolism of arachidonic acid are increased in the plasma of women with preeclampsia as compared with normal pregnancy and are significantly higher in fetal than in maternal plasma and erythrocytes. We hypothesized that differences in EET synthesis or metabolism in the feto-placental unit contributed to the observed differences in circulating EETs. METHOD To evaluate EETs, formation as well as the expression of relevant CYP isoforms and the metabolizing enzyme, soluble epoxide hydrolase (sEH), biopsies of placenta were collected from 19 normal pregnancy and 10 preeclampsia at the time of cesarean section delivery. EETs were extracted from tissue homogenates and analyzed by liquid chromatography coupled with tandem mass spectrometry. RESULTS Both cis-EETs and trans-EETs were detected in the placenta. Concentration of total EETs was higher in the placenta from preeclampsia compared with normal pregnancy (2.37 ± 1.42 ng/mg vs. 1.20 ± 0.72 ng/mg, mean ± SD, P

To compare pain associated with vaginal dinoprostone pessary vs. gel for induction of labor in women with an unfavorable cervix.A randomized controlled trial in a large academic public general hospital. A total of 52 nulliparous women of gestational age ≥ 38 weeks, with Bishop score ≤ 4 and intact membranes were allocated either to a controlled-release vaginal dinoprostone pessary or repeat doses of vaginal dinoprostone gel. Pain was recorded hourly from early induction until the onset of labor.Mean pain experienced by women belonging to the two groups differed significantly (p0.01). Women in the controlled-release device group were also significantly more often severe pain-free than women receiving gel (p0.05). Both methods had similar rates of oxytocin infusion and vaginal deliveries.The two induction procedures should be considered equivalent as far as ripening the cervix and initiating labor. In view of this finding, the low Bishop score should be considered an indication to prefer the controlled-release device, since it reduces pain thereby improving the physical and emotional wellbeing of the parturient.

Background/Aim: European societies are facing a wave of incoming immigrants and the needs of a new multiethnic obstetrical population. It remains controversial whether native and immigrant women have equivalent pregnancy outcomes. Methods: Perinatal indicators of the obstetric outcome were monitored in all delivering women during a 5-year period in a large academic public general hospital. We compared rates of preterm deliveries, low birth weight, cesarean section during labor, perineal tears, and fetal acidemia in the native and immigrant parturients. Results: Immigrant women experienced very low birth weight (p < 0.005) and preterm deliveries (p < 0.05), more often than natives did. Among ethnic groups, data singled out Sub-Saharan African women to be at a higher risk for very small premature babies and cesarean section during labor. Conclusions: There are differences in perinatal outcome between immigrant and Italian woman; within the large migrant population, ethnic groups show wide disparities and challenge the health provider differently. Special attention to women at a higher risk may reduce fetal-maternal morbidities.

To assess whether deep endometriosis has different risk factors compared with endometriosis at other sites. In epidemiological terms, this should be the case if deep endometriosis represents a different condition than ovarian and peritoneal endometriosis.Case-control study.University hospitals.The first group of cases included 181 women with a diagnosis of deep endometriosis. The second group of cases included 162 women with endometriosis at other sites. The control group included women younger than 55 years of age who were admitted for acute non-gynecological, non-hormonal, non-neoplastic conditions.Questionnaire.Odds ratios.The age distribution of women with cases of deep and ovarian and pelvic endometriosis was not statistically significantly different. A higher body mass index decreased the risk of both deep as well as ovarian and pelvic endometriosis: the estimated ORs for women reporting a body mass index ofor =21 vs. those reporting a body mass index of21 were 0.6 (95% confidence interval [CI], 0.3-0.8) for deep endometriosis and 0.6 (95% CI, 0.4-0.9) for pelvic and ovarian endometriosis. Parous women were at decreased risk: in comparison with nulliparae, the odds ratio for deep endometriosis was 0.1 (95% CI, 0.1-0.2) for women reporting one or more births. The corresponding value for pelvic and ovarian endometriosis was 0.1 (95% CI, 0.1-0.2).This study suggests that deep as well as ovarian and pelvic endometriosis share similar risk factors.

Background The diagnosis of inguinal endometriosis can be complex, and patients are often first operated by a general surgeon for a hernia. We present five cases of inguinal endometriosis in which primary surgery resulted in recurrence and a second correct procedure resulted in a cure. Cases Five patients with inguinal endometriosis, operated between 1996 and 2002, were seen for the recurrence of symptoms. All underwent excision of the extraperitoneal portion of the round ligament and pelvic exploration. In all cases, both pelvic and round ligament endometriosic lesions were confirmed at histology. No complications or recurrence of inguinal endometriosis occurred. Conclusion The complete excision of inguinal endometriosis must also include the extraperitoneal portion of the round ligament.

A study carried out in Mozambique sought to develop a socioeconomic profile of women being treated for illegal abortion undergoing legal abortion and receiving prenatal care and to determine the hospital and individual costs associated with each type of abortion experience. Data were collected from 103 women undergoing legal abortion (abortion is legally available on demand for up to 12 weeks of pregnancy) in Maputo Central Hospital 103 women seeking outpatient care for "miscarriage" who admitted undergoing an illegal abortion and 100 women receiving prenatal care. Statistical analysis of the data indicated that the women who resorted to illegal abortion were younger than those seeking legal abortion or receiving prenatal care and more likely to be living without a husband. Only 38 of the women with illegal abortion completed secondary school as compared to 70 of the women undergoing legal abortion and 96 of the prenatal care clients. The household income of the women seeking illegal abortion was also lower than that of the other groups (less than half that of the women undergoing legal abortion). Most of the study population was Roman Catholic including 36 women who underwent illegal abortion 59 who had legal abortions and 20 who had prenatal care. The fact that average direct cost to patients for illegal abortion (14 contos) was much less than for legal abortions (46 contos) is partly due to the 46 cases of self-induced illegal abortion. The public costs of hospital care was also higher among the illegal group. These findings imply that the availability of legal abortion should be communicated widely and that the cost of legal abortion should not create a barrier for poor women.

We tested the hypothesis that maternal peripheral blood leukocytes contribute to elevated levels of soluble TNF receptors (sTNFR) in preeclampsia (PE) with concomitant intrauterine growth restriction (IUGR). TNFR1 and TNFR2 were evaluated in a cross-sectional study comparing preeclamptic (n = 15) with or without IUGR versus normotensive pregnant women (PREG, n = 30), and non-pregnant controls (Con; n = 20). Plasma levels of sTNFR1 were higher in PE (1675.0 ± 227.1 pg/mL) compared with PREG (1035.0 ± 101.1 pg/mL) and Con (589.3 ± 82.67 pg/mL), with the highest values observed in PE with IUGR (2624.0 ± 421.4 pg/mL; n = 6). Plasma sTNFR2 was higher during pregnancy (PE: 1836.0 ± 198.7 pg/mL; PREG: 1697.0 ± 95.0 pg/mL) compared with Con (598.3 ± 82.7 pg/mL). Urinary levels of sTNFR1 and sTNFR2 were higher in PE and PREG compared with the Con group. Abundance of TNFR1 mRNA in peripheral blood leukocytes was strongly correlated with plasma levels of sTNFR1 in PE. However, TNFR2 mRNA accumulation in leukocytes did not correlate with sTNFR2 plasma levels. The level of sTNFR1 in plasma was correlated with body weight of the newborn (r = -0.56). The data suggest that maternal leukocytes contribute to sTNFR1 levels in plasma in association with decreasing newborn weight and PE with concomitant IUGR.

Objective The purpose of this study was to compare the outcome of standard extrafascial hysterectomy and tailored radical hysterectomy as a definitive treatment of recurrent deep endometriosis. Study design This was a descriptive study that comprised 38 patients who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy between 1989 and 2002 for symptomatic recurrences of deep endometriosis, after ≥1 previous surgical procedures and ovarian suppressive medical treatments. After the operation, all of the patients were given transdermal estradiol. The minimum follow-up time was 24 months. Results Twenty-six patients underwent standard extra-fascial hysterectomy (group A), and 12 patients underwent modified radical hysterectomy that included the removal of all deeply infiltrating endometriotic lesions (group B). The recurrence of pain caused by endometriosis occurred in 8 women (31%) of group A and in no patients of group B. Conclusion Definitive surgery for deep endometriosis should include the removal of the uterus, adnexa, and all surgically accessible deep lesions. As a consequence, the surgeon must be familiar with radical pelvic surgery.

Objective The purpose of this study was to evaluate the feasibility and efficacy of laparoscopic radiofrequency ablation of uterine fibroids. Study design Eighteen women with symptomatic intramural uterine myomas underwent radiofrequency ablation under laparoscopic guidance. Postoperative sonographic evaluations of the fibroids size were scheduled at 1, 3, 6 ,9, and 12 months. The impact of myoma-related symptoms on quality of life (QOL) was assessed using a validated questionnaire. Results The median number of myomas treated per patient was 1 (1-3). The median baseline volume of the dominant myoma was 67.2 cm 3 (14.8-332.8). No intraoperative or postoperative complications occurred. The median reductions in myomas volume were 41.5%, 59%, and 77% at 1, 3, and 6-months, follow-up evaluation, respectively. No further change in fibroid size was observed at 9 months and 1 year. A significant improvement in the symptoms score and QOL score was observed at 3 and 6 months, follow-up. Conclusion In this pilot study, laparoscopic radiofrequency ablation successfully reduced fibroid symptoms and fibroid volume in short-term follow-up. Additional studies are needed before its efficacy and safety can be confirmed.

Objective The purpose of this study was to observe the natural history of untreated asymptomatic rectovaginal endometriosis. Study design This was a prospective, observational study. Eighty-eight patients with untreated asymptomatic rectovaginal endometriosis were followed for 1 to 9 years. Pain symptoms and clinical and transrectal ultrasonographic findings were evaluated before and every 6 months after diagnosis. Results Two patients had specific symptoms that were attributable to rectovaginal endometriosis that was associated with an increase in lesion size and underwent surgery. In 4 other patients, the size of the endometriotic lesions increased, but the patients remained symptom free. The estimated cumulative proportion of patients with progression of disease and/or appearance of pain symptoms that were attributable to rectovaginal endometriosis after 6 years of follow up was 9.7%. For the remaining patients, the follow-up period was uneventful, with no detectable clinical nor echographic changes of the lesions and with no appearance of new symptoms. Conclusion Progression of the disease and appearance of specific symptoms rarely occurred in patients with asymptomatic rectovaginal endometriosis.

Objective The purpose of this study was to evaluate long-term results in patients who received conservative surgical treatment for rectovaginal endometriosis. Study design We analyzed the follow-up data for 83 women who underwent surgery for rectovaginal endometriosis. The inclusion criteria were age 20 to 42 years, moderate-to-severe pain symptoms, conservative treatment with retention of the uterus, and at least 1 ovary; the follow-up period was ≥12 months. Kaplan-Meier analysis and Cox regression were used to calculate recurrence rates. Results The cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment were 28%, 34%, and 27%, respectively. The younger patients had the higher risk of recurrence. Pregnancy had protective effects against the recurrence of symptoms and a need for a new treatment. Patients who underwent bowel resection had fewer recurrences. Conclusion Segmental resection and anastomosis of the bowel, when necessary, improves the outcome without affecting chances of conception. Higher recurrence rates in younger patients seems to justify a more radical treatment in this group of women.

Background Life-threatening events during pregnancy are currently used as a measure to assess quality of obstetric care. The aim of this study is to assess prevalence of near miss cases and maternal deaths, to elucidate the causes and to analyze avoidable factors based upon the three-delays approach in southern Mozambique. Methods Near miss cases comprised five categories: eclampsia, severe hemorrhage, severe sepsis, uterine rupture and severe malaria. Pregnant women surviving the event were interviewed during a 5-month period within five health facilities offering comprehensive emergency obstetric care in Maputo City and Province. Family members gave additional information and were interviewed in case of the patient’s death. Results Out of 27,916 live births, 564 near miss cases and 71 maternal deaths were identified, giving a total maternal near miss ratio of 20/1,000 live births and maternal mortality ratio of 254/100,000 live births, respectively. Near miss fatality rate was 11.2%. Among near miss cases hemorrhage accounted for the most common event (58.0%), followed by eclampsia (35.5%); HIV seroprevalence was 22.3%. Inappropriate attendance in antenatal care services (21.1%), late or wrong diagnosis (12.6%), inadequate management immediately after delivery (9.6%), no monitoring of blood pressure and other vital signs (9.2%) were the most prevalent factors contributing to the severe morbidity under study. Third delay was identified in 69.7% of the interviews. In more than one fourth of near miss cases treatment was not started immediately. Lack of blood derivates and unavailable operating room were reported in 42.0% and 35.0%, respectively. Conclusions Near miss cases were frequent and related to delays in reaching and receiving adequate care. First and third type of delay contributed significantly to the number of maternal near miss cases and deaths. Maternal health policies need to be concerned not only with averting the loss of life, but also with ameliorating care of severe maternal complications at all levels including primary care. Sexual and reproductive health services for adolescents should be prioritized to prevent adverse outcomes.

Objective : This study examines the association between dietary habits and risk of spontaneous abortion. Design : Hospital-based case-control study. Setting : Obstetric hospitals in Milan, Italy. Subjects : Cases were: 912 women admitted for spontaneous abortion (within the 12th week of gestation). Controls were: women who gave birth at term to healthy infants on randomly selected days at the same hospitals where cases had been identified. Results : The risk of spontaneous abortion was inversely and significantly related to green vegetables, fruit, milk, cheese, eggs and fish consumption. The multivariate odds ratios (OR), for highest versus lowest levels of intake, were 0.3 for fruit, 0.5 for cheese, 0.6 for green vegetables and milk and 0.7 for fish and eggs. The major type of seasoning fats have showed a direct association with risk of miscarriage. Comparing the highest with the lowest intake, the ORs were 2.0 (95% confidence interval, CI 1.1–3.6) and 1.6 (95% CI 1.1–2.3) for butter and oil, respectively. No consistent association emerged between meat, liver, ham and carrots intake and the risk of spontaneous abortion. Conclusions : This result suggests that a diet poor in several aspects, including vegetables and fruit, milk and dairy products, but rich in fats, may be a determinant or a correlate of increased risk of spontaneous abortion.

Objective: To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum. Design: Prospective therapeutic non-randomized, self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months. Setting: Tertiary referral center for treatment of deep endometriosis. Patient(s): Eleven symptomatic patients with rectovaginal endometriosis. Intervention(s): A levonorgestrel-releasing IUD was inserted and maintained for 12 months. Main Outcome Measure(s): Severity of dysmenorrhea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography. Result(s): Dysmenorrhea, pelvic pain, and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment. Conclusion(s): Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.

Objective: This study was undertaken to evaluate the effectiveness of a 6-month course of gonadotropin-releasing hormone agonist treatment for patients with symptomatic endometriosis of the rectovaginal septum. Study Design: Fifteen patients with rectovaginal endometriosis and moderate to severe pain symptoms were the subjects of the study. None of these patients had either clinical or objective evidence of ovarian endometriosis, nor was there evidence of any obstructive lesions of the intestine or ureters. All patients were given leuprolide acetate depot at 3.75 mg, 1 ampule intramuscularly every 28 days, and treatment had a planned duration of 6 months. Follow-up evaluations were set every 2 months during the treatment phase and every 3 months thereafter until the completion of 1 year after discontinuation of medical therapy. At each follow-up visit pain symptoms were recorded, and clinical exploration, transvaginal ultrasonography, and transrectal ultrasonography were performed. Results: Two patients stopped the treatment early after the second and fourth leuprolide doses; in both cases the reason was persistence of pain, and both requested a surgical solution. The other 13 patients showed a marked improvement with respect to pain during the 6-month treatment course but had early pain recurrence after drug suspension; 11 of them required further treatment within the first year of follow-up. The failure rate of gonadotropin-releasing hormone agonist therapy to produce 1-year pain relief after treatment discontinuation was 87% (13/15) on an intent-to-treat basis. The endometriotic lesions showed a slight but significant reduction in size during therapy but had returned to the original volume within 6 months after cessation of the gonadotropin-releasing hormone analog treatment. Conclusion: Our results suggest that gonadotropin-releasing hormone analogs should not be considered a real therapeutic alternative to surgical treatment for patients with symptomatic endometriosis of the rectovaginal septum, except possibly in a limited and unpredictable number of cases. (Am J Obstet Gynecol 2000;183:1462-7.)

Study objective : To compare the effect of HRT with transdermal estradiol and that of treatment with tibolone in post-menopausal women with residual endometriosis. Materials and Methods : 21 women with residual pelvic endometriosis after bilateral oophorectomy with or without hysterectomy were enrolled in the study and were randomized to HRT with transdermal estradiol 50 mg twice weekly ( n =10) associated with cyclic medroxyprogesterone acetate 10 mg daily in women who preserved uterus, and to treatment with tibolone 2.5 mg administered orally once a day ( n =11). The duration of both treatments was scheduled to last at least 12 months. Residual endometriosis was located in the bowel wall in four patients, in the rectovaginal septum in six and deeply in the retroperitoneal pelvic space in six. All women were symptomatic before oophorectomy. Results : All the women were followed for 12 months. No patient suspended therapy because of side effects. Four patients of the estradiol group experienced moderate pelvic pain during treatment compared with only one patient in the tibolone group. One patient in the estradiol group reported severe dyspareunia. Conclusion : Although our series is very small, it seems that tibolone may be a safe hormonal treatment for post-menopausal women with residual endometriosis.

PURPOSE: This study examined the association between maternal smoking before and during the first trimester of pregnancy and spontaneous abortion. METHODS: We have been conducting a hospital-based case-control study on risk factors for spontaneous abortion in the greater Milan area. We collected information from 782 cases of spontaneous abortions and 1543 controls (women who delivered at term healthy infants). RESULTS: With respect to never smokers, the odds ratio (OR) were 0.7 (95%, confidence interval (CI), 0.5–1.0) for women who quit smoking and 1.3 (95% CI, 1.0–1.6) for those who continued during pregnancy. Women who smoked more than 10 cigarettes/day in the first trimester were at increased risk of miscarriage, with an OR of 1.4 (95% CI, 1.0–2.1). No relationship was evident between the number of cigarettes smoked before conception and the risk of abortion. Likewise, no association emerged between paternal smoking and miscarriage. Moreover, no significant interaction or modification effect was obtained when strata of age and other major characteristics were investigated. CONCLUSIONS: The risk of abortion associated with cigarette smoking during the first trimester of pregnancy was measurable and noticeable in this population, and accounted for 9% (95% CI, 6–13%) of all cases. The increased risk of spontaneous abortion in women smoking during pregnancy is a further reason to encourage pregnant women to quit.

Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence in the obstetric population. Nevertheless, it is a potentially life-threatening complication. In the majority of the cases, the first clinical symptom associated with intracranial subdural bleeding is severe headache, but the clinical course may have different presentations. In this report, we describe the case of a 38-year-old woman with an acute intracranial subdural hematoma shortly after spinal anesthesia for cesarean section. Early recognition of symptoms of neurologic impairment led to an emergency craniotomy for hematoma evacuation with good recovery of neurologic functions. The possibility of subdural hematoma should be considered in any patient complaining of severe persistent headache following regional anesthesia, unrelieved by conservative measures. Only early diagnosis and an appropriate treatment may avoid death or irreversible neurologic damage.

To assess prevalence and causes of severe acute maternal morbidity cases and evaluate their impact on feto-maternal wellbeing and on facility resources.Observational retrospective study adopting management-based criteria in a tertiary care public hospital during a 5-year period. Criteria adopted were: intensive care unit admission, blood transfusion ≥ 4 units, emergency peripartum hysterectomy and arterial embolization at any time during pregnancy.A total of 80 cases were identified, most of them (97.5%) through a combination of two criteria, ICU admission and blood transfusion. Commonest severe obstetric morbidities were major obstetric haemorrhage (48.8%) and hypertensive disorders (27.5%). Immigrant status (OR 1.68, 95% CI 1.03-2.7), pre-term birth (OR 4.15, 95% CI 2.5-6.8), Caesarean section (OR 7.74,95% CI 4.2-14.3) were factors significantly associated with SAMM cases. Major abdominal surgery was necessary in 26 women (32.5%), with emergency peripartum hysterectomy in 11 (13.5%). These events led to an average blood consumption per woman of 6.5 ± 12.8 units and a mean hospital stay of 8.9 ± 5.0 days, significantly longer (p0.001) than the average duration of post-delivery care. Maternal mortality to morbidity ratio was 1:80.An integrated intervention-based approach proved to be effective in finding severe acute maternal morbidity cases. Information on underlying causes and associated risk factors may improve prevention and treatment of obstetric morbidities, thus reducing feto-maternal adverse effects and hospital expenditures.

In developed countries, 98% of all women receive prenatal care and 94% give birth under the supervision of skilled healthcare practitioners with timely access to appropriate emergency treatment if complications arise. In contrast, large numbers of pregnant women in Africa and Asia do not receive adequate prenatal care and lack skilled attendance at birth. In developing countries quality of prenatal care is often scarce: models of care adopted in the western world and exported to the developing world have not been monitored early enough to discover their weak points promptly. This blind attitude has transformed antenatal care into an empty and useless ritual, and explains why antenatal care programmes continue to be unsuccessful, being inappropriate to the specific situation. A mix of educational and cultural factors together with persistent lack of resources in a global critical situation all contribute to the poor results of antenatal care programmes. Antenatal care services should be free of charge, planned and implemented within the community, cost-effective, and should yield evidence-based quality care. They should also include information for the patient and family members, provide affordable treatment of existing conditions, and warrant referral for complications.

Objective To compare the laparoscopic excision of primary versus recurrent ovarian endometriomas. Design Descriptive study. Setting Tertiary referral center for the treatment of endometriosis. Patient(s) Between 1993 and 2002, 359 consecutive patients: 305 primary surgeries (group A) and 54 reoperations for a recurrent endometrioma in the same ovary of the primary cyst (group B). Intervention(s) Laparoscopic stripping of the cyst wall. Follow-up evaluations every 6 months, including clinical and ultrasonographic evaluations and a questionnaire for pain symptoms (mean follow-up time, ± standard deviation: 35.4 ± 27.6 months). Main Outcome Measure(s) Recurrence of pain symptoms, sonographic recurrence of endometriomas, need for a new medical or surgical treatment, and reproductive outcome. Result(s) In groups A and B, respectively, the 5-year cumulative rates were not statistically significantly different: pain recurrence 20.5% versus 17.4%; ultrasonographic recurrence 18.9% versus 15.1%; retreatment requirement 19.4% versus 17.3%; and pregnancy 40.8% versus 32.4%. Although the difference was not statistically significant, compared with patients of group A, the women of group B underwent assisted reproduction techniques more frequently (50% vs. 32.2%) and had more irregular menstrual cycles associated with follicle-stimulating hormone levels ≥ 14 IU/mL in the early follicular phase (5.5% vs. 1.3%). Conclusion(s) After laparoscopic excision of recurrent ovarian endometriomas, the recurrence of pain and the reproductive outcome are comparable with those found after primary surgery.

Study Objective To compare the functional ovarian damage associated with the use of bipolar coagulation versus ovarian suture after laparoscopic excision of ovarian endometriomas in patients with a solitary ovary. Design Retrospective study (Canadian Task Force classification II-3). Setting Tertiary care center. Patients Forty-seven consecutive women with a single ovary and regular menses who underwent laparoscopic stripping of one or more ovarian endometriomas between June 1996 and June 2001. Intervention Twenty-one patients had bipolar electrocoagulation (group A), while 26 had suturing of the ovary (group B). Plasma follicle-stimulating hormone (FSH) and estradiol levels were determined before surgery and re-evaluated at 3-, 6-, and 12-month follow-up. Measurements and Main Results At 12-month follow-up, six patients (29%) in group A had oligo-amenorrhea versus three patients (12%) in group B (p = .14). Follicle-stimulating hormone levels between 10 and 20 mIU/mL were found in five patients (24%) in group A and in three patients (12%) in group B, whereas FSH levels above 20 mIU/mL were found in three patients (14%) in group A and in no patient in group B. Eight patients (38%) in group A had FSH levels greater than 10 mIU/mL versus three patients (12%) in group B (p = .042). Overall, repeated analysis of variance showed a marginally significant difference (p = .06) in FSH values between the two groups. Conclusion Our results suggest that bipolar electrocoagulation of the ovarian parenchyma after laparoscopic stripping of an endometriotic ovarian cyst adversely affects ovarian function.

Objective To describe the long-term outcome of surgical conservative treatment of bladder endometriosis. Design Descriptive study. Setting Tertiary referral center for the treatment of endometriosis. Patient(s) Forty-seven patients with symptomatic bladder endometriosis. Intervention(s) Partial cystectomy by laparoscopy or laparotomy. Main Outcome Measure(s) Rates of recurrence at a 36-month follow-up. Result(s) All 14 patients with isolated bladder dome lesions remained symptom-free. Among the 33 patients with lesions involving the vesical base and vesicouterine septum, cumulative recurrence rates at 36 months were 24.7% and 15.5% for recurrence of symptoms and of clinical-instrumental evidence of lesion, respectively. The only factor influencing rate of recurrence was the extent of surgical excision. When the resection included both the vesical lesion and a 0.5- to 1-cm deep portion of the adjacent myometrium, recurrence was significantly less frequent compared to the removal of the bladder lesion only (7% vs. 37% for symptom recurrence and 0% vs. 26% for clinical-instrumental recurrence, respectively). Conclusion(s) Conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality.

Objective To report our experience on laparoscopic resection of the cavitated noncommunicating rudimentary horn in 10 patients with unicornuate uterus. Design Descriptive study. Setting A tertiary referral center for the treatment of female genital malformations. Patient(s) Ten consecutive patients operated between 1994 and 2002. Intervention(s) Laparoscopic removal of the rudimentary uterine horn. Main outcome measure(s) Operating time, intraoperative and postoperative complications, relief of symptoms at a 6-month follow-up. Result(s) Median operating time was 65 minutes (range 40–92 minutes) with neither intraoperative nor postoperative complications. All patients were discharged within 72 hours from the procedure. Clinical follow-up during 6 months showed a marked improvement of symptoms. Conclusion(s) Laparoscopy proves to be an effective surgical approach for the removal of the cavitated noncommunicating rudimentary horn in patients with unicornuate uterus.

Objective To present a rare case of endometrial stromal sarcoma arising in endometriosis of the rectovaginal septum. Design Case report. Setting Academic tertiary referral center for endometriosis treatment. Patient(s) A 50-year-old woman with a history of endometriosis presented with catamenial rectal pain and deep dyspareunia. Imaging findings suggested new endometriotic lesions in the rectovaginal space. Intervention(s) Total hysterectomy, salpingo-oophorectomy, and excision of the lesion in the rectovaginal septum were performed. Although extemporary pathology confirmed endometriosis, the final histologic diagnosis was extrauterine adenosarcoma in the rectovaginal septum. Two years later, recurrence of the malignancy occurred and was treated by resecting the new perirectal mass. Subsequent radiotherapy and chemotherapy were administered. Main outcome measure(s) Imaging findings at follow-up evaluation. Result(s) The patient was in good health for 2 years after the initial surgery, when she developed a new lesion at the site of the previous resection. The histologic appearance of the lesion was consistent with recurrence of the tumor. After postoperative therapy, the patient is now without evidence of disease. Conclusion(s) Malignant transformation of endometriosis should be considered in the differential diagnosis of a new pelvic lesion in a patient with a history of endometriosis.

Objective To describe the conservative treatment of diffuse uterine leiomyomatosis. Design Descriptive study. Setting Tertiary care centers. Patient(s) Three premenopausal women with diffuse uterine leiomyomatosis associated to persistent menorrhagia, two with desire of becoming pregnant and one with desire of preservation of the uterus. Intervention(s) Preoperative ultrasound showed symmetrically enlarged uteri with innumerable, poorly defined and small-sized (0.5–3 cm) myomas involving all the myometrium. An "extreme" myomectomy was performed in two cases, including the removal of a large portion of corporal myometrium. One patient was treated only medically with GnRH analogues (GnRH-a). Main outcome measure(s) Menstrual pattern and, when applicable, ability to conceive and pregnancy outcome. Result(s) Regular menses were restored in both patients who underwent surgery: one had no pregnancy desire and the other was not able to conceive after two IVF-ETs. The patient treated with GnRH-a conceived spontaneously as soon as medical treatment was discontinued; at 34 gestational weeks, an emergency cesarean section followed by hysterectomy was performed for vaginal bleeding and a healthy 2,400-g baby was born. Conclusion(s) Our experience supports the idea that a conservative approach to uterine leiomyomatosis may result in restoration of normal cycles and eventually in the birth of a viable fetus.

The study evaluates the mode of delivery and quality of care given to 1014 pregnant women not belonging to the European Union (EU) during the 10-year period, 1992-2001. The non-EU patients were delivered significantly more often by caesarean section than Italian controls, 35.0% vs. 29.3% (P

Our objectives were to compare the prevalence of sexually transmitted infections (STIs) in 103 women undergoing induced legal abortion (LA) and in 101 women with confirmed, recent illegal abortion (IA), in Maputo, Mozambique. For the purpose of this study, LA was considered the abortion provided in the Maputo Central Hospital with the approval of the Ministry of Health, and IA the one not provided through the approved facility, mentioned above. Women with IA were recruited in the outpatient gynaecology ward and women with LA in the emergency gynaecology ward in the Maputo Central Hospital, during the same time period. Serological tests for syphilis (rapid plasma reagin, ELISA-IgG and fluorescent treponemal antibody absorption), gonorrhoea (indirect haemagglutination) and chlamydia (microimmunofluorescence) were carried out. Direct immunofluorescence for detection of Chlamydia trachomatis antigen was done on endocervical smears from all the women. The prevalence of syphilis seropositivity in IA women is twice that of LA women (odds ratio [OR] 2.13; 95% confidence interval [CI] 0.55-9.95), with 10.9% and 4.9%, respectively. Exposure to gonorrhoea in these 2 groups is similar (OR 1.18; 95% CI 0.63-2.20), with seroprevalence of 31.1% in the LA and 34.7% in the IA group. The high titres are also similar in both groups. Serology findings for C. trachomatis indicate prevalence of seropositivity of 40.6% in the LA and 44.4% in the IA group with no significant difference (OR 1.17; 95% CI 0.64-2.13). In conclusion, STIs are highly prevalent in both IA and LA groups in Maputo. Urgent interventions are needed to reduce their prevalence and consequently their adverse consequences.

Objective: To evaluate the surgical feasibility and the long-term anatomic and functional results of a new procedure that uses the endoscopic approach to treat uterovaginal agenesis, known as Rokintansky syndrome. Design: Evaluation of surgical feasibility and recording of clinical data over a 12-month follow-up. Setting: Tertiary referral center for the treatment of female genital malformations. Patient(s): Fifty-two patients with vaginal agenesis. Intervention(s): The laparoscopic version of the Vecchietti method was used to create a neovagina. Main Outcome Measure(s): Anatomic success was defined as a neovagina ≥6 cm long, allowing easy introduction of two fingers, within 6 months after corrective surgery. Functional success was considered achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery. Result(s): The surgical procedure was performed with no major complications and with 100% anatomic success; functional success was obtained in 98.1% of the study population. Conclusion(s): In patients with Rokitansky syndrome, the laparoscopic approach for creating a neovagina by the Vecchietti method is simple, safe, and effective.

Objective: To evaluate the effects of two types of hormone replacement therapy, an estrogen–progestin combination and tibolone, on uterine myomas in menopausal women. Study design: Thirty-eight menopausal women with one or more uterine myomas were randomized to treatment with a transdermal system continuously releasing estradiol 50 μg/day combined with oral medroxyprogesterone acetate (MPA) 10 mg/day for 12 days/month or tibolone tablets 2.5 mg/day. The scheduled duration of both treatments was 12 months. Physical examination and abdominal/transvaginal ultrasonography were performed before entering the study and at 3, 6 and 12 months of treatment. At each ultrasonography the overall uterine volume was determined as well as the size of each myoma and the endometrial thickness and characteristics. Results: No statistically significant difference was detected between the two groups at any time during treatment. However, within-group analysis showed a significant increase of uterine volume and of myoma number and size in the estrogen–progestin group, whereas no such increase occurred in the patients treated with tibolone. Also, the mean endometrium width increased significantly from baseline to the end of treatment in the estrogen–progestin group, but not in the tibolone group. Conclusions: Tibolone seems a valid alternative in menopausal patients with uterine myomas as it provides adequate relief from menopausal symptoms and avoids volume increase of the uterus and myomas.

Objective: To assess the efficacy and diagnostic value of GnRH agonist (GnRH-a) therapy in cases of hidden sciatic nerve endometriosis. Design: Case report. Setting: Academic tertiary referral center for endometriosis treatment. Patient(s): Three patients with cyclic, catamenial sciatica associated with pelvic endometriosis who had electromyographic evidence of sciatic nerve damage but negative computed tomography and magnetic resonance imaging findings. Intervention(s): Monthly administration of the GnRH-a leuprolide acetate plus daily transdermal E 2 (25 μg). Main Outcome Measure(s): Relief of pain symptoms and improvement in motor function. Result(s): All three patients had clear decreases in pain and partial amelioration of claudication. Conclusion(s): Endometriosis of the sciatic nerve may be hard to diagnose with the use of current imaging techniques but may be proved by clinical response to GnRH analogue treatment and may be more frequent than previously thought.