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To assess labour characteristics in relation to the occurrence of Composite Adverse neonatal Outcome (CAO) within a cohort of fetuses with metabolic acidaemia.Retrospective cohort study.Three Italian tertiary maternity units.431 neonates born with acidaemia ≥36 weeks.Intrapartum CTG traces were assigned to one of these four types of labour hypoxia: acute, subacute, gradually evolving and chronic hypoxia. The presence of CAO was defined by the occurrence of at least one of the following: Sarnat Score grade ≥2, seizures, hypothermia and death7 days from birth.To compare the type of hypoxia on the intrapartum CTG traces among the acidaemic neonates with and without CAO.The occurrence of a CAO was recorded in 15.1% of neonates. At logistic regression analysis, the duration of the hypoxia was the only parameter associated with CAO in the case of an acute or subacute pattern (odds ratio [OR] 1.3; 95% CI 1.02-1.6 and OR 1.04; 95% CI 1.0-1.1, respectively), whereas both the duration of the hypoxic insult and the time from PROM to delivery were associated with CAO in those with a gradually evolving pattern (OR 1.13; 95% CI 1.01-1.3 and OR 1.04; 95% CI 1.0-1.7, respectively). The incidence of CAO was higher in fetuses with chronic antepartum hypoxia than in those showing CTG features of intrapartum hypoxia (64.7 vs. 13.0%; P 0.001).The frequency of CAO seems related to the duration and the type of the hypoxic injury, being higher in fetuses showing CTG features of antepartum chronic hypoxia.This study demonstrates that in a large population of neonates with metabolic acidaemia at birth, the overall incidence of short-term adverse outcome is around 15%. Such risk seems closely correlated to the duration and the type of hypoxic injury, being higher in fetuses admitted in labour with antepartum chronic hypoxia than those experiencing intrapartum hypoxia.

Tranexamic acid (TA) has been proposed for preventing or treating primary postpartum haemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. We conducted a systematic literature search to the TA role in managing PPH in vaginal and caesarean delivery. Twenty-seven randomised controlled trials (RCTs) (33,302 women) were identified. Three RCTs investigated TA for preventing PPH after vaginal delivery and 22 after caesarean section. None demonstrated a preventive effect on secondary clinical outcomes related to blood loss. Two trials evaluated TA for treating PPH after vaginal and caesarean delivery. Only the WOMAN trial showed that 1 g of TA is effective. In conclusion, TA is considered useful and is recommended or advised for treating PPH. Conversely, available evidence on the prophylactic role is still limited, and this use is not supported. Further investigation is recommended. In this regard, stronger and more reliable outcomes than blood loss should be considered.

A multicenter cross-sectional survey study involving four Italian University Hospitals was performed to test the hypothesis that negative affect and positive affect (affective dimensions) mediate the association between risk perception (perceived risk of infection and death; cognitive dimensions) and the feeling of work exhaustion (WE) among obstetrics healthcare providers (HCPs) during the Coronavirus Disease 2019 (COVID-19) pandemic. Totally, 570 obstetrics HCPs were invited to complete the 104-item IPSICO survey in May 2020. A theoretical model built on the tested hypothesis was investigated by structural equation modelling. The model explained 32.2% of the WE variance. Only negative affect mediated the association between cognitive dimensions and WE and also the association between WE and psychological well-being before the pandemic, experiences of stressful events, female gender, and dysfunctional coping. Non-mediated associations with WE were observed for work perceived as a duty, experience of stressful events, support received by colleagues, and the shift strategy. Only previous psychological well-being, support by colleagues, and shift strategies were inversely associated with WE. Based on study results, monitoring negative than positive affect appears superior in predicting WE, with practical implications for planning psychological interventions in HCPs at the individual, interpersonal, and organizational levels.

Transvaginal extraction is a feasible method to remove surgical specimen. In this study, we aim to report our experience with in-bag transvaginal specimen retrieval after laparoscopic myomectomy over the past 15 years.Single-center retrospective analysis.Academic hospital.Women who underwent laparoscopic myomectomy from January 2005 to April 2021.Posterior colpotomy and in-bag transvaginal extraction of the surgical specimen.We collected and analyzed data about patients' characteristics, main indication for surgery, and intra- and postoperative (within 30 days) complications.A total of 692 women underwent transvaginal specimen retrieval after laparoscopic myomectomy (mean largest myoma diameter: 6.64 ± 2.21 cm; mean specimen weight: 177 ± 140 g; mean operative time: 84.1 ± 37.1 minutes; mean blood loss: 195 ± 191 mL). Within 30-days, we reported the following colpotomy-related complications: a total of 4 cases (0.6%) of vaginal bleeding, 3 of which resolved spontaneously (1 case required readmission with new colporrhaphy under general anesthesia), and 2 cases (0.3%) of vaginal pain, with no underlying cause identified on physical examination and pelvic ultrasound. Specimen weight was positively correlated with longer operative time, intraoperative blood loss, and length of hospital stay.Posterior colpotomy and in-bag transvaginal extraction can be considered a feasible option for retrieval of surgical specimens after laparoscopic myomectomy.

Objective To assess characteristics, incidence, risk factors, and reporting rate of needlestick injuries (NSIs) among Obstetrics and Gynecology trainees. Study design We performed a nationwide cross-sectional survey study. The 40-items survey Obstetrics Needlestick Injury Questionnaire (ONSI-Q) was used to investigate the prevalence of NSIs, participant attitudes, associated factors, and the NSI reporting rate among trainees in Obstetrics and Gynecology. The target responders were all trainees of Obstetrics and Gynecology training programs in Italy. The trainees were invited between September 2018 and December 2018 via a web-based platform. Results Among 1049 trainees, 1041 (99.2%) completed the survey. Out of 1041 trainees, 639 (61.4%) had at least one NSI, and 90.9% (581/639) experienced at least one during obstetric surgery. The number of NSIs increased with the year of training, with 2.48 NSIs per trainee in the fifth year. 90.6% (579/639) reported details about the most recent NSI, which was during obstetric surgery in 95.3% (552/579) of cases. 57.1% (315/552) experienced the most recent NSI during cesarean section, which was mainly inflicted by someone else (72.4%; 228/315). 42.9% (237/552) of NSIs were during perineal suture, and 84% (199/237) of them were self-inflicted. 77.9% (417/535) of trainees did not report the NSI. Associated factors were non-high-risk patients, self-inflicted NSI, and the first NSI. Conclusions NSIs are frequent among Obstetrics and Gynecology trainees but not reported, and obstetric surgery is the primary source. These data support the European efforts to improve working practices' safety. The education about protective strategies and reporting should be a priority.

Pharmacotherapy has a key role in the management of endometriosis. However, a significant proportion of patients gains only intermittent or limited benefits. In this regard, alternative and novel drug delivery methods are of paramount importance to improve efficacy and compliance of available treatments and develop alternative medical approaches.This review aims to provide the reader with a complete overview of available evidence about alternative and novel drug delivery methods for endometriosis pharmacotherapy and highlight new research lines.Progestins and estroprogestins, which represent the first-line therapy, are already available in different formulations, being employed for contraception. Nevertheless, evidence on their adoption is still limited for some drug delivery methods, such as vaginal rings, patches, and subcutaneous implants. Further research is needed to define better their clinical utility in patients with endometriosis. Nanotechnologies have been investigated as novel drug delivery methods able to target the drug at the disease level. However, data are very limited and preliminary, and further research is needed to consider a possible clinical application in endometriosis.

Study Objective: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. Design: Secondary analysis of a prospective randomized controlled trial. Setting: Three academic research centers. Patients: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included. Interventions: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. Measurements and Main Results: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (

We investigated menstrual irregularities after the first and second doses of the COVID-19 vaccine. Women answered a customised online questionnaire (ClinicalTrial.gov ID: NCT05083065) aimed to assess the vaccine type, the phase of the menstrual cycle during which the vaccine was administered, the occurrence of menstrual irregularities after the first and second doses, and how long this effect lasted. We excluded women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as those who had irregular menstrual cycles in the last 12 months before vaccine administration. According to our data analysis, approximately 50–60% of reproductive-age women who received the first dose of the COVID-19 vaccine reported menstrual cycle irregularities, regardless of the type of administered vaccine. The occurrence of menstrual irregularities seems to be slightly higher (60–70%) after the second dose. Menstrual irregularities after both the first and second doses of the vaccine were found to self-resolve in approximately half the cases within two months. Based on these results, we suggest to consider these elements during the counselling of women who receive the COVID-19 vaccine, letting them know about the potential occurrence of temporary and self-limiting menstrual cycle irregularities in the subsequent month(s).

Introduction: To date, there is no robust evidence suggesting whether transvaginal retrieval (TVSR) or port-site specimen retrieval (PSSR) after laparoscopic myomectomy (LM) may lead to better surgical outcomes. Considering this element, we aimed to compare surgical outcomes of TVSR versus PSSR after LM. Methods: A search (PROSPERO ID: CRD42020176490) of international databases, from 1980 to 2020, in English language, was conducted. We selected studies that included women who underwent LM with TVSR compared with PSSR. Results: We did not find significant differences for operative time (MD = −8.90; 95% CI: 30.00, 12.20; I2 = 87%), myoma retrieval time (MD = −1.85; 95% CI: 13.55, 9.85; I2 = 98%), blood loss (MD = −27.62; 95% CI: 178.68, 124.43; I2 = 91%), intra-operative complication rate (OR 0.51; 95% CI: 0.01–23.09; I2 = 69%), and hospital stay (MD = −0.14; 95% CI: 0.43, 0.15; I2 = 64%); we found a significant lower postoperative rescue analgesics utilization in the TVSR group compared with the PSSR group (OR 0.31; 95% CI: 0.16–0.61; I2 = 0). Conclusion: TVSR and PSSR after LM showed comparable results for operative time and surgery-related complications. However, the need of postoperative rescue analgesics was lower in women who underwent TVSR.

Background: The efficacy and safety of a cervical ripening balloon (CRB) in women with a previous cesarean section (CS) and unfavorable Bishop score are still controversial. Methods: A retrospective cohort study was performed across six tertiary hospitals from 2015 to 2019. Women with one previous transverse CS, singleton cephalic term pregnancy and BS < 6 were included if submitted to labor induction with a CRB. The main outcome was the rate of vaginal birth after cesarean (VBAC) after CRB ripening. Secondary outcomes were abnormal composite fetal and maternal outcomes. Results: Of the 265 women included, 57.3% had successful vaginal birth. Augmentation improved vaginal delivery (32.2% vs. 21.2%). Intrapartum analgesia was associated with an increased VBAC rate (58.6% vs. 34.5%). Maternal BMI ≥30 and age ≥40 years increased emergency CS rate (11.8% vs. 28.3% and 7.2 vs. 15.9%). Composite adverse maternal outcome occurred in 4.8% of CRB group women and increased to 17.6% when associated with oxytocin. Uterine rupture occurred in one case (0.4%) in the CRB–oxytocin group. Poorer fetal outcome occurred after emergency CS, if compared to successful VBAC (12.4% vs. 3.3%). Conclusions: In women with a previous CS and unfavorable Bishop score, induction of labor with a CRB can be considered safe and effective.

The impact of Coronavirus disease 2019 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Therefore, a survey was conducted among all Italian Gynaecological Units Directors in April 2020. The response rate was 90% (135/150). 77.8% of centres performed surgery only for oncologic or not deferrable pathologies, and 9.6% was closed. 68.7% of directors were at least moderately satisfied by published guidelines/recommendations, but 94.8% of respondents identified limitations, mainly (83%) the absent definition of benign non-deferrable pathology. Responders considered as non-deferrable severe endometriosis (69.6%), endometriosis with organ failure/dysfunction (74.1%), and unresponsive symptomatic fibroids (89.6%). Despite guidelines/recommendations, respondents treated ovarian (77%) and endometrial (71.6%) cancer as usual. Only a minority of respondents reduced the laparoscopic approach (11.2%) and adopted all recommended surgical precautions (9.6%). Compliance with available guidelines/recommendations appears incomplete. Reconsidering guidelines/recommendations regarding oncological cases and specify non-deferrable benign pathologies would improve guidelines/recommendations compliance.Impact statementWhat is already known on this subject? The SARS-CoV-2 pandemic has profoundly influenced medical routine practice worldwide. Surgery units have been forced to reduce or even completely restrict their activity to re-allocate human resources. Many major international gynaecological societies have released statements and guidelines, providing various recommendations to guide practice changes. However, the impact of the SARS-CoV-2 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown.What do the results of this study add? Study results provide evidence showing how the SARS-CoV-2 pandemic has changed surgical activity in the Italian Gynaecological Units. Most centres reduced surgical activity, limiting surgery only for oncologic or not deferrable pathologies. Moreover, our research shows the level of compliance and satisfaction with available guidelines/recommendations and where they need to be improved. Most directors were at least moderately satisfied but identified different limitations. Guidelines/recommendations do not provide enough details, such as the absent definition of benign non-deferrable pathologies.What are the implications of these findings for clinical practice and/or further research? The limited compliance with available guidelines/recommendations and identified limitations suggest reconsidering guidelines/recommendations focussing on identified gaps. Provide more details, such as specifying non-deferrable benign pathologies, would improve guidelines/recommendations compliance.

Objectives To evaluate the strength of association between maternal and pregnancy characteristics and the risk of adverse perinatal outcomes in pregnancies with laboratory confirmed COVID-19. Methods Secondary analysis of a multinational, cohort study on all consecutive pregnant women with laboratory-confirmed COVID-19 from February 1, 2020 to April 30, 2020 from 73 centers from 22 different countries. A confirmed case of COVID-19 was defined as a positive result on real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens. The primary outcome was a composite adverse fetal outcome, defined as the presence of either abortion (pregnancy loss before 22 weeks of gestations), stillbirth (intrauterine fetal death after 22 weeks of gestation), neonatal death (death of a live-born infant within the first 28 days of life), and perinatal death (either stillbirth or neonatal death). Logistic regression analysis was performed to evaluate parameters independently associated with the primary outcome. Logistic regression was reported as odds ratio (OR) with 95% confidence interval (CI). Results Mean gestational age at diagnosis was 30.6±9.5 weeks, with 8.0% of women being diagnosed in the first, 22.2% in the second and 69.8% in the third trimester of pregnancy. There were six miscarriage (2.3%), six intrauterine device (IUD) (2.3) and 5 (2.0%) neonatal deaths, with an overall rate of perinatal death of 4.2% (11/265), thus resulting into 17 cases experiencing and 226 not experiencing composite adverse fetal outcome. Neither stillbirths nor neonatal deaths had congenital anomalies found at antenatal or postnatal evaluation. Furthermore, none of the cases experiencing IUD had signs of impending demise at arterial or venous Doppler. Neonatal deaths were all considered as prematurity-related adverse events. Of the 250 live-born neonates, one (0.4%) was found positive at RT-PCR pharyngeal swabs performed after delivery. The mother was tested positive during the third trimester of pregnancy. The newborn was asymptomatic and had negative RT-PCR test after 14 days of life. At logistic regression analysis, gestational age at diagnosis (OR: 0.85, 95% CI 0.8–0.9 per week increase; p Conclusions Early gestational age at infection, maternal ventilatory supports and low birthweight are the main determinants of adverse perinatal outcomes in fetuses with maternal COVID-19 infection. Conversely, the risk of vertical transmission seems negligible.

To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease.An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications.Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p 0.001) were found as independent risk factors for major postoperative complications.Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events.

Endometriosis is a chronic inflammatory gynecologic disease characterized by the presence and growth of endometrial-like tissue outside the uterine cavity, with an estimated prevalence of 10% in re...

WOS:000613461600006 PubMed ID: 32926494 Objectives To evaluate the maternal and perinatal outcomes of pregnancies affected by SARS-CoV-2 infection. Methods This was a multinational retrospective cohort study including women with a singleton pregnancy and laboratory-confirmed SARS-CoV-2 infection, conducted in 72 centers in 22 different countries in Europe, the USA, South America, Asia and Australia, between 1 February 2020 and 30 April 2020. Confirmed SARS-CoV-2 infection was defined as a positive result on real-time reverse-transcription polymerase chain reaction (RT-PCR) assay of nasopharyngeal swab specimens. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit (ICU), use of mechanical ventilation and death. Results In total, 388 women with a singleton pregnancy tested positive for SARS-CoV-2 on RT-PCR of a nasopharyngeal swab and were included in the study. Composite adverse maternal outcome was observed in 47/388 (12.1%) women; 43 (11.1%) women were admitted to the ICU, 36 (9.3%) required mechanical ventilation and three (0.8%) died. Of the 388 women included in the study, 122 (31.4%) were still pregnant at the time of data analysis. Among the other 266 women, six (19.4% of the 31 women with first-trimester infection) had miscarriage, three (1.1%) had termination of pregnancy, six (2.3%) had stillbirth and 251 (94.4%) delivered a liveborn infant. The rate of preterm birth before 37 weeks' gestation was 26.3% (70/266). Of the 251 liveborn infants, 69/251(27.5%) were admitted to the neonatal ICU, and there were five (2.0%) neonatal deaths. The overall rate of perinatal death was 4.1% (11/266). Only one (1/251, 0.4%) infant, born to a mother who tested positive during the third trimester, was found to be positive for SARS-CoV-2 on RT-PCR. Conclusions SARS-CoV-2 infection in pregnant women is associated with a 0.8% rate of maternal mortality, but an 11.1% rate of admission to the ICU. The risk of vertical transmission seems to be negligible. (C) 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To report safety and efficacy of interventional radiology procedures in the treatment of gynecologic iatrogenic urinary leaks. Methods: A retrospective analysis of iatrogenic ureteral lesions treated between November 2009 to April 2019 was performed. Under ultrasound (US) and fluoroscopy guidance, an attempt to place a ureteral stent and nephrostomy was carried out in the same session using an anterograde percutaneous approach. At the end of any procedure, a fluoroscopic control and a cone-beam CT scan (CBCT) were performed to check the correct placement and functioning of the nephrostomy and DJ stent. In cases of difficult ureteral stent placement via the single anterograde approach, the collaboration of urologists was requested to perform a rendezvous technique, combined with the retrograde approach. Results: DJ stent placement was achieved using the anterograde approach in 12/15 (80.0%) patients and using the retrograde approach in 3/15 cases (20.0%). Moreover, in 3/15 (20.0%) patients, surgical treatment was needed: in one case because of the persistence of ureteral stenosis at 6 months, and in the other two cases due to ureter-vaginal fistula. No major complications were recorded; overall, minor complications occurred in 4/8 patients. Conclusion: Percutaneous minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery is a safe and effective option.

STUDY OBJECTIVE To investigate the factors associated with poorer oncologic outcomes in patients undergoing laparoscopic radical hysterectomy (LRH) for early stage cervical cancer. DESIGN Multicenter retrospective study. SETTING Three gynecologic oncology referral centers. PATIENTS Patients with International Federation of Gynecology and Obstetrics 2009 stage IA (positive lymphovascular space invasion)-IB1 cervical cancer between January 2006 and June 2018. INTERVENTIONS LRH (Piver type II-III hysterectomies). Lymph-node dissection was accomplished according to the tumor characteristics. MEASUREMENTS AND MAIN RESULTS Surgical and oncologic outcomes were analyzed. Overall, 186 patients met the inclusion criteria, 16 (8.6%) experienced a recurrence, and 9 (4.8%) died of the disease (median follow-up period 37.9 months). Surgery-related complications did not influence disease-free survival. All the recurrences (16/16; 100%) occurred in patients with stage IB1 disease (p = .02), and 15 (93.7%) in cases involving tumors ≥2 cm. No association between positive lymph node and recurrence was detected (p =.82). Patients who had a preoperative diagnosis through conization (93; 50%) had a significantly lower rate of recurrence than those who underwent cervical biopsy (93; 50%): 1/93 (1.1%) vs 15/93 (16.1%); p

Objective: To assess the psychological distress of healthcare providers (HCPs) working in the field of obstetrics during the coronavirus disease 2019 (COVID-19) pandemic and to identify factors associated with psychological distress at the individual, interpersonal, and organizational level.Design: Cross-sectional survey study.Setting: Four University hospitals in Italy.Participants: HCPs working in obstetrics, including gynecologists, residents in gynecology and obstetrics, and midwives.Methods: The 104-item survey Impatto PSIcologico COVID-19 in Ostetricia (IPSICO) was created by a multidisciplinary expert panel and administered to HCPs in obstetrics in May 2020 via a web-based platform.Main Outcome Measures: Psychological distress assessed by the General Health Questionnaire-12 (GHQ-12) included in the IPSICO survey.Results: The response rate to the IPSICO survey was 88.2% (503/570), and that for GHQ-12 was 84.4% (481/570). Just over half (51.1%; 246/481) of the GHQ-12 respondents reported a clinically significant level of psychological distress (GHQ-12 ≥3). Psychological distress was associated with either individual (i.e., female gender, stressful experience related to COVID-19, exhaustion, and the use of dysfunctional coping strategies), interpersonal (i.e., lower family support, limitations in interactions with colleagues), and organizational (i.e., reduced perception of protection by personal protective equipment, perceived delays on updates and gaps in information on the pandemic) factors in dealing with the pandemic.Conclusions: Results confirm the need for monitoring and assessing the psychological distress for HCPs in obstetrics. Interventions at the individual, interpersonal, and organizational level may relieve the psychological distress during the COVID-19 pandemic and foster resilience skills in facing emotional distress.

Pharmacotherapy has a key role in endometriosis treatment and management, however, a significant proportion of patients have only intermittent or limited benefits with current treatment options. Therefore, novel therapeutic approaches are necessary.This systematic review provides an overview of the efficacy and safety of aromatase inhibitors (AIs) as monotherapies and combination therapies for endometriosis. A systematic literature search was performed from January 1990 to April 2020 in the electronic database MEDLINE, EMBASE, The Cochrane Library, and Web of Science.Based on the critical role of estrogens and the rate-limiting step in the production of the estrogens represented by the aromatase enzyme, AIs are a potential therapeutic option for women affected by endometriosis. Nevertheless, further research is needed to clarify the efficacy of AIs in this setting. Adverse effects need to be investigated to clarify the preventive role of add-back therapy. On that basis, AIs should be adopted only as second-line therapy in patients who are refractory to standard treatments in the setting of scientific research. Further studies should define best dosages, appropriate add-back therapies, administration routes, treatment length, and which patients may benefit more from AIs.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a global health emergency [1, 2], with Lombardy being the epicenter of this outbreak in Italy [3].

Interstitial cystitis or bladder pain syndrome (IC/BPS) is a chronic pelvic pain syndrome related to the urinary bladder. The ideal treatment should match as much as possible with the pathophysiologic causes of the IC/BPS, but the scarcely available evidence limits this approach, with the majority of available treatments that are primarily targeted to the control of symptoms. The treatment strategies have traditionally focused on the bladder, which is considered the primary end-organ and source of pain. Nevertheless, the growing body of evidence suggests a multifaceted nature of the disease with systemic components. In general, guidelines recommend the personalized and progressive approach, that starts from the more conservative options and then advances toward more invasive and combined treatments. The behavioral changes represent the first and most conservative steps. They can be combined with oral medications or progressively with intravesical instillation of drugs, up to more invasive techniques in a combined way. Despite the multiple available options, the optimal treatment is not easy to be found. Only further investigation on the etiopathogenetic mechanisms, taking into account the differences among subgroups, and the interaction between central and peripherical factors may allow providing a real improvement in the treatment and management of these patients.

Over the last decade, there has been growing interest in the psychophysical integrity of surgical patients in the context of healthcare events. In the present study, we aimed to evaluate the incidence rate of postoperative distress symptoms, namely post-traumatic stress disorder (PTSD), following total hysterectomy for benign disease. We also investigated possible associations between sociodemographic characteristics, clinical outcomes, anxiety, depression, and PTSD. We prospectively enrolled 100 consecutive patients who underwent total hysterectomy for benign disease between 01/01/2019 and 15/04/2019. Demographic and surgical-related characteristics have been registered. The Hospital Anxiety and Depression Scale (HADS) questionnaire was administered preoperatively (Time1), postoperatively (Time2), and at follow-up clinical evaluation, between two and three months after surgery (Time3). PTSD was defined based on the results of the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) at Time3. At Time3, the median PCL-5 score was 12,8 (0–70), and 16.4% of patients had PTSD symptoms (PCL-5 > 33). No correlation between sociodemographic or gynecologic characteristics and PTSD was detected. A significant association between depression (HADS > 8) at Time2 (p = 0.002) and Time3 (p Hysterectomy for benign disease is associated with a non-negligible risk of PTDS; the use of the HADS questionnaires might be useful to select patients who might benefit from dedicated psychological support.

Importance To date, a comprehensive review on the safety and effectiveness of hysteroscopic metroplasty for T-shaped uterus is still missing. Objective To provide a robust synthesis of the available studies investigating reproductive outcomes after hysteroscopic metroplasty for T-shaped uterus. Evidence acquisition We performed a systematic review and meta-analysis (CRD42019143291), using the proportion method with 95% confidence interval (CI). Statistical heterogeneity was assessed by Higgins test (I2). Results We included 11 cohort studies embedding 937 women who underwent hysteroscopic metroplasty. After surgery, the pooled percentage of live birth was 44.54% (95% CI, 36.12%-53.12%; I2 = 46.22%) and 56.88% (95% CI, 46.48%-66.98%; I2 = 36.38%) in women with primary infertility and recurrent miscarriage, respectively. In women with recurrent miscarriage, the pooled proportion of miscarriage was 21.46% (95% CI, 15.09%-28.61%; I2 = 30.18%). The pooled clinical pregnancy proportion in women with primary infertility was 57.19% (95% CI, 43.83%-70.03%; I2 = 77.81%). The pooled rate of surgical complications was 0.65% (95% CI, 0.20%-1.33%; I2 = 11.44%). Conclusions The hysteroscopic correction of T-shaped uteri was associated with high live birth rate and low miscarriage rate, both in case of primary infertility and recurrent miscarriage. Relevance Hysteroscopic metroplasty can be considered a safe and effective strategy to improve reproductive outcomes in case of T-shaped uterus.

Ovarian cancer with complete clinical response recurs with a high rate. Recurrence is observed in almost 25% of cases with early-stage diseases and in more than 80% with more advance stages. Based on a platinum-free interval cut-off of 6 months, the first recurrence is usually classified in platinum-sensitive versus platinum-resistant, reflecting the biological characteristics underlying the clinical behavior. After this first recurrence, the patients are rarely cured, but second-line therapy can provide significant clinical responses, particularly in first platinum-sensitive recurrence. The approach to secondary and tertiary recurrence follows the same general principles applied in the first recurrence. Platinum-sensitivity based on the treatment-free interval defines the available chemotherapeutic regimens, whit less therapeutic options and a generally worse prognosis in platinum-resistant recurrent disease. Nevertheless, in this scenario, the introduction of new targeted therapies changed the prognosis of patients with both platinum-sensitive and platinum-resistant recurrence. The first introduced antiangiogenic therapy resulted able to improve prognosis in recurrent disease both as a single-agent and combined therapy, although the growing adoption in the first line therapy requires further investigation to prove their efficacy after repeated use. More recently, the approach to secondary, tertiary, and later recurrence has been changed by the introduction of PARP inhibitors, which resulted effective as maintenance monotherapy in both platinum-sensitive and platinum-resistant recurrence when the genetic background of the tumor allows their application with a significant improvement of oncological outcomes. Overall, although the growing body of promising therapeutic options to approach recurrent ovarian cancer, all the available evidence suggests that the best unique management of secondary and tertiary recurrence does not exist but should be personalized based on the disease characteristics, previous treatments, patient characteristics, and patient preference. On that basis, in this review, we report a general and complete overview of the approach at the secondary and tertiary ovarian cancer recurrence with the aim to provide a wide vision on the multiple available therapeutic options.

The widespread SARS-CoV-2 implies the application of procedures aimed to detect, isolate, and appropriately manage affected patients in the setting of obstetrics and gynaecologic emergency room and in inpatient setting, such as during labour, delivery, and postpartum Here we report specific recommendations for the management of suspected and confirmed gynaecologic and obstetrics patients with COVID-19 The checklist developed by the Societa Italiana di Malattie Infettive e Tropicali (SIMIT-2, available in English, Italian, Chinese) represents the first step to clas-sify patients who need to be managed following the SIMIT-1 flowchart, applying all the appropriate infection control procedures In this scenario, the management of pregnant women needs to follow the same procedures as the general population Nevertheless, as for other potentially severe respiratory infections, pregnant women could be more vulnerable In this regard, the maternal and foetal interests can be conflicting, such as the choice of the time and mode of delivery or the use of steroids for foetal maturation More-over, available evidence suggests a maternal-foetal transmission via contact with respiratory secretions and seems to exclude in utero transmission Therefore, the appropriate management of breastfeeding is unclear, and the temporary separation of the infant from the mother could be an option Finally, in general, delivery represents a moment of a high risk of infection for healthcare providers, and specific behaviours are mandatory

Objective To summarize available evidence on clitoral reconstruction after Female genital mutilations/cut (FGM/C). Study design Systematic review of the literature to identify studies on clitoral reconstruction after previous FGM/C with at least 6 months of follow-up. The literature search was performed in the following databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. The period considered was from the database inception to June 30th, 2020. Main outcome measures Post-operative vulvar pain or dyspareunia, changes in sexual activity or orgasm, and the impact on self-image. Results We identified 8 studies; four used the same “Foldes technique”, and four adopted similar techniques based on the downward mobilization of the clitoral stump, with different reconstructions of glans and prepuce. The postoperative complication rate was reported at 5.3%. Sexual function is the only outcome investigated by all studies, which consistently suggest that clitoral reconstruction appear effective to improve clitoral pleasure/orgasm. Almost all studies assessed self-image, which appears improved. Only 2 studies provided data about pain and/or dyspareunia, which were improved by clitoral reconstruction. However, the risk of bias is high. Most patients were lost at follow-up, and validated instruments to assess outcomes were used only in a minority of studies. Conclusions Although clitoral reconstructive surgery for FGM/C appears safe and effective, caution is required to interpret available evidence due to significant limitations. Further studies are required to compare the proposed techniques and to confirm the effectiveness in terms of vulvar pain and/or dyspareunia, sexual activity and/or orgasm, and self-image improvement.

Background Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event. Objective The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial. Study Design Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy. Results After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16–6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43–3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence. Conclusion Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.

Objective To systematically evaluate pregnancy and labor course, obstetrical complications, and maternal and neonatal outcomes in women with endometriosis, stratifying according to the specific location of the disease. Study Design We retrospectively analyzed our prospectively maintained obstetrical database from January 2011 to August 2014 to identify all women with a previous histological diagnosis of endometriosis who delivered at our institution (cases). We divided the cases according to the specific location of the disease (deep infiltrating endometriosis, ovarian endometriosis, and peritoneal endometriosis). As controls, we identified all unaffected women who delivered in the year 2013. To avoid the confounding effect of parity, we limited our analysis to nulliparous women. Results A total of 118 nulliparous women with endometriosis and 1,690 nulliparous controls were identified. Women with endometriosis were significantly older, had a lower body mass index, and had a higher incidence of assisted reproductive technology. The duration of pregnancy was significantly shorter among women with endometriosis. A higher incidence of placenta previa (3.4 vs. 0.5%; p = 0.006), hypertension (11 vs. 5.9%; p = 0.04), cesarean section (41.5 vs. 24.2%; p Conclusion Women with endometriosis have a higher incidence of vacuum delivery, cesarean section, and placenta previa compared with unaffected women. The higher risk of placenta previa is attributable exclusively to women with deep endometriosis. Neonatal outcomes are unaffected by the presence of the disease.

Introduction: In the present study, perioperative outcomes of laparoscopy (LPS) were compared to open surgery (OS) for the treatment of large adnexal masses (AM).Material and methods: Retrospective...

Cesarean section is one of the most commonly undertaken operations worldwide, and its rate is constantly increasing in recent years both in middle- and high-income countries, despite several scient...

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.

Objective To determine if breastfeeding outcomes differ between mothers who conceived spontaneously compared with those who conceived with assisted reproductive technology (ART). Design Matched case-control study. Setting Teaching hospital. Patient(s) Ninety-four women having a singleton baby conceived with ART, matched by maternal age, parity, mode of delivery, and gestational age to controls who conceived spontaneously. Intervention(s) Cases and controls were interviewed using a standardized, structured questionnaire, to obtain information on lactation. Exposure to maternity care practices contributing to breastfeeding success was investigated. Main Outcome Measure(s) Initiation, exclusivity, and continuation of breastfeeding. Result(s) Cases were as likely as controls to initiate breastfeeding (89.4% vs. 90.4%), but by 6 weeks postpartum, a greater proportion of mothers who conceived through ART has ceased breastfeeding (20.2% vs. 5.3%). The percentage of mothers who exclusively breastfed their child for 6 months was similar among the 2 groups. On univariate conditional logistic regression, a history of using ART was the only predictor of early breastfeeding cessation (odds ratio=65.3 [95% confidence interval: 1.5–2889.3]). Conclusion(s) Women who have conceived with ART should be regarded as being at higher risk for early breastfeeding cessation. This study serves as a first step in the investigation of potential modifiable factors that contribute to breastfeeding failure among women who give birth after using ART, and may help in efforts to customize breastfeeding support strategies.

Objective To describe the technique and report perioperative outcomes of transvaginal contained extraction of surgical specimens at laparoscopic myomectomy. Design Retrospective analysis of prospectively collected data. Setting Two Italian referral centres for gynaecological minimally invasive surgery. Population Consecutive patients who underwent laparoscopic myomectomy. Methods Tissue extraction was accomplished following laparoscopic myomectomy in a specimen retrieval bag via a posterior colpotomy incision. If morcellation was necessary, this was performed extracorporeally, using a scalpel within the specimen retrieval pouch, whose edges were exteriorised through the vaginal introitus. Main outcome measures Intra- and postoperative complications. Results A total of 316 women underwent transvaginal specimen retrieval with enclosed manual morcellation. The mean myomectomy specimen weight was 154 ± 128 g, and the mean operative time was 79 ± 26 minutes. No intraoperative complications occurred related to the specimen extraction or morcellation technique, or from rupture of the retrieval bag. Two (0.6%) women had a haemoperitoneum that spontaneously resolved and 16 (5.1%) had fever postoperatively. The final pathological diagnosis was benign in all cases. At the 30-day follow-up, no pelvic infection, vaginal dehiscence, or complaints of dyspareunia were recorded. Conclusions Contained transvaginal extraction of fibroid specimens can be performed safely and efficiently in most women undergoing laparoscopic myomectomy. This technique represents a valuable minimally invasive alternative to intracorporeal morcellation. Tweetable abstract Transvaginal contained morcellation at laparoscopic myomectomy is a valuable alternative to intracorporeal morcellation.

To identify factors predicting for recurrence in vulvar cancer patients undergoing surgical treatment. We retrospectively evaluated data of consecutive patients with squamous cell vulvar cancer treated between January 1, 1990 and December 31, 2013. Basic descriptive statistics and multivariable analysis were used to design predicting models influencing outcomes. Five-year disease-free survival (DFS) and overall survival (OS) were analyzed using the Cox model. The study included 101 patients affected by vulvar cancer: 64 (63%) stage I, 12 (12%) stage II, 20 (20%) stage III, and 5 (5%) stage IV. After a mean (SD) follow-up of 37.6 (22.1) months, 21 (21%) recurrences occurred. Local, regional, and distant failures were recorded in 14 (14%), 6 (6%), and 3 (3%) patients, respectively. Five-year DFS and OS were 77% and 82%, respectively. At multivariate analysis only stromal invasion >2 mm (hazard ratio: 4.9 [95% confidence interval, 1.17-21.1]; P=0.04) and extracapsular lymph node involvement (hazard ratio: 9.0 (95% confidence interval, 1.17-69.5); P=0.03) correlated with worse DFS, although no factor independently correlated with OS. Looking at factors influencing local and regional failure, we observed that stromal invasion >2 mm was the only factor predicting for local recurrence, whereas lymph node extracapsular involvement predicted for regional recurrence. Stromal invasion >2 mm and lymph node extracapsular spread are the most important factors predicting for local and regional failure, respectively. Studies evaluating the effectiveness of adjuvant treatment in high-risk patients are warranted.

This article aimed to determine sexual behaviors among female and male adolescents in northern Italy. An anonymous self-administered questionnaire evaluating sexual attitudes was distributed in middle and high schools in northern Italy. Adolescents between 13 and 19 years of age were asked to participate at the survey. The study group included 664 participants. Overall, 164 (25%) adolescents had had at least one sexual intercourse. Among adolescents who have had sexual intercourse, 90 (55%) use condoms, 25 (15%) use hormonal contraception, and 49 (30%) do not use any contraception method. A total of 559 adolescents (84%) participated in school-based sexual education programs. This group had better knowledge on sexually transmitted diseases and contraception methods in comparison with adolescents who have never participated in such educational programs (p.05), and no difference in high-risk sexual behaviors was observed (p = 1.0). School-based sexual education programs improve knowledge of sexual transmitted diseases and contraception methods. However, this knowledge does not correlate to high-risk sexual behaviors reduction.