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Few studies have investigated the features associated with pain levels during abortion. We aimed to investigate the risk factors for experiencing pain during medication abortion, focusing on women's psychological distress and anxiety levels.We carried out this observational study at two centers in Bologna, Italy. We included women aged 18 years or more with a viable intrauterine pregnancy of up to 63 days of amenorrhea, who chose medication abortion. Women received 600 mg of Mifepristone orally and after 48 hours 400 mcg of buccal misoprostol, repeated after 3 hours according to local and regional medication abortion guidelines, as well as prophylactic analgesia. We evaluated the clinical characteristics which may represent risk factors for severe pain (Visual Analogue Scale ≥ 70) through a multivariate model.Two hundred forty-two patients were included in our analysis; 92 (38.0%) reported severe pain during medication abortion. Women with higher baseline anxiety levels (General Health Questionnaire 12 score ≥ 6 and General Anxiety Disorder 7 score ≥ 10) had a higher probability of experiencing pain with a Visual Analogue Scale ≥70 (OR = 3.33, 95% CI 1.43-7.76), as well as those who reported dysmenorrhea in the past year (OR = 6.30, 95% CI 2.66-14.91). Previous vaginal deliveries were inversely correlated with pain intensity (OR 0.26, 95% CI 0.14 - 0.50).Increased baseline anxiety levels, dysmenorrhea and no previous vaginal deliveries are associated with severe pain in women undergoing medication abortion.The identification of women at risk for severe pain based on clinical and historical factors as well as the definition of an adequate analgesic regimen may help to improve women's care and pain management during medication abortion.

Study Objective To compare long-term surgical, clinical, and functional outcomes between conservative and radical surgery in patients with rectosigmoid endometriosis (RSE) and preoperative intermediate risk of segmental resection. Design Retrospective cohort study (Canadian Task Force classification II-2). Setting Endometriosis tertiary level referral center, St. Orsola Academic Hospital, Bologna, Italy. Patients Three hundred and ninety-two patients with RSE presented for complete macroscopic surgical excision between January 2004 and January 2017. Intervention Assessment of laparoscopic bowel shaving, discoid excision, or segmental resection for the treatment of RSE. Measurements and Main Results The 392 patients were divided into 3 groups according to surgical technique: shaving (n = 297; 75.8%), discoid excision (n = 33; 8.4%), and segmental resection (n = 62; 15.8%). Preoperative characteristics, surgical data, short- and long-term complications, and rates of proven and suspected recurrence were assessed. The segmental resection group had a higher rate of short-term complications compared with the discoid and shaving groups (17.7% vs 9.1% vs 5.4%, respectively; p = .004). The median follow-up time was 43 months (range, 12–163 months). Suspected and proven RSE recurrence rates showed no statistically significant differences among the 3 groups. There also were no significant differences concerning the rate of de novo chronic constipation and urinary retention. Conclusion To date, there is no consensus regarding the choice between radical (segmental resection) or conservative (shaving, discoid excision) surgical management for RSE, particularly for patients with preoperative intermediate risk of bowel segmental resection (the gray zone). Our data suggest that conservative surgery is preferred over radical surgery in patients with RSE in the gray zone risk category, resulting in similar suspected and proven RSE recurrence rates and associated with fewer short-term complications.

Background and Objectives: Hormonal replacement therapy (HRT) is effective in treating many debilitating symptoms of menopause. However, its use in women with uterine fibroids is widely debated, based on the susceptibility of these tumors to sexual steroids. This review aims to ascertain the effects of HRT on leiomyomas development and growth in postmenopausal women. Materials and Methods: Electronic databases (i.e., MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) were searched from January 1990 until May 2019. All English-written studies evaluating the impact of various HRT regimens on uterine leiomyomas were selected. Results: Seventeen papers, considering a total of 1122 participants, were included. Fifteen of these were prospective trials, of which nine were randomized controlled trials. The remaining two works were a retrospective observational trial and a retrospective case series respectively. Five studies evaluated the effects of tibolone, also comparing it with various estrogen/progestin combinations, while two were about raloxifene. Thirteen studies compared different combinations of estrogens/progestins, the most common being transdermal estrogens (used in nine studies) and medroxyprogesterone acetate at different doses (used in 10 studies). Conclusions: For women with uterine fibroids, the choice of the most appropriate HRT regimen is crucial to avoid leiomyomas growth and the symptoms possibly related to it. Available data are conflicting, but suggest that uterine fibroids might be influenced by HRT, without representing an absolute contraindication to hormonal replacement therapy. Women with uterine fibroids subjected to HRT should be periodically examined and hormonal treatment should be discontinued if leiomyomas appear to increase in size. Moreover, the minimal effective dose of progestin should be employed.

Objective To assess the impact on women’s reproductive outcomes of barbed sutures to repair uterine breaches during laparoscopic myomectomy compared with traditional smooth sutures. Design Retrospective, monocentric cohort study, with information on subsequent pregnancies prospectively acquired for some women. Setting Tertiary-level academic referral center. Patient(s) Women older than 18 years who had undergone a laparoscopic myomectomy and had sought pregnancy afterward, divided into two groups based on type of suture used to repair the uterine wall: group A (nonbarbed) and group B (barbed). Intervention(s) Laparoscopic removal of FIGO types 3, 4, 5, and 6 uterine leiomyomas by use of either only barbed sutures or only traditional smooth sutures to reconstruct the uterine defect. Main Outcome Measure(s) Pregnancy achievement rates, delivery modes, main pregnancy complications, perioperative complications for both kinds of suture, and the trend of the use of barbed sutures over time at our center. Result(s) Of 164 patients included, 83 were in group A and 81 in group B. Ninety-one patients (55.5%) experienced at least one postoperative pregnancy, with no differences between the groups (group A 60.5%; group B 50.6%). Of the 103 recorded postoperative pregnancies, 70 (68%) resulted in live births, 29 (28.1%) in first-trimester miscarriages, and 4 (3.9%) were ongoing. Conclusion(s) Barbed sutures have a similar impact on reproductive outcomes as smooth conventional threads, both in terms of pregnancy and obstetric complication rates, after laparoscopic myomectomy.

OBJECTIVES This study aimed to evaluate surgical and clinical outcomes of laparoscopic mesh-less cervicosacropexy for the treatment of uterovaginal prolapse. METHODS This single institutional review board-approved prospective cohort study enrolled 46 consecutive, sexually active symptomatic women requiring surgical correction of uterovaginal prolapse, from July 2013 to March 2016. After supracervical laparoscopic hysterectomy, the cervix was suspended to the anterior longitudinal ligament of the sacral promontory through a continuous suture with plication and shortening of the right uterosacral ligament. Pelvic organs' function was evaluated through validated questionnaires during preoperative and postoperative follow-up evaluations. The anatomical recurrences of genital prolapse with a Pelvic Organ Prolapse Quantitative stage 2 or higher, in particular of central compartment (Pelvic Organ Prolapse Quantitative score C ≥-1), were recorded. RESULTS Mean ± SD age was 55.5 ± 10.9 years. Mean ± SD operating time was 97.4 ± 25.6 (range, 60-180) minutes. Mean ± SD hospitalization length was 3.6 ± 0.9 (range, 2-6) days. No intraoperative complications were recorded. Median length of follow-up was 24 (range, 12-38) months. During the follow-up period, the objective success rates for central compartment prolapse and for all compartments were 93.5% and 89.1%, respectively. No woman presented dyspareunia at follow-up. Thirty-nine women (84.8%) reported very high satisfaction related to surgery and 6 (13%) a moderate satisfaction. Overall Female Sexual Function Index, Knowles-Eccersley-Scott Symptom, and Bristol Female Lower Urinary Tract scores improved significantly after surgery, except for incontinence score domain. CONCLUSIONS Laparoscopic mesh-less cervicosacropexy represents an effective and feasible option for the surgical treatment of uterovaginal prolapse in sexually active women, avoiding postoperative complications due to the mesh use.

Aims: The study aimed to evaluate feasibility and safety of in-bag manual morcellation compared to uncontained power morcellation during laparoscopic myomectomy. Methods: A total of 72 women undergoing laparoscopic myomectomy were randomized into 2 treatment groups: 34 patients underwent in-bag manual morcellation (experimental group) and 38 were submitted to uncontained power morcellation (control group). The primary end point was the comparison of morcellation operative time (MOT). Total operative time (TOT), rate of intraoperative complication, and postoperative outcomes in the 2 groups were regarded as secondary outcomes. Results: Mean MOT and TOT were longer in the experimental group than in the control one (MOT: 9.47 ± 5.05 vs. 6.16 ± 7.73 min; p = 0.01; TOT: 113.24 ± 28.12 vs. 96.74 ± 33.51 min; p = 0.01). No intraoperative complications occurred in either group and no cases of bag disruption or laparotomic conversion were recorded. No significant difference in hemoglobin drop, hospital stay, and postoperative outcomes was reported between groups. Conclusion: In-bag manual morcellation appears a safe and feasible procedure and, despite slightly longer operative time, could represent an alternative to uncontained power morcellation.

Study Objective To compare enucleation time, total operative time, and perioperative complications during laparoscopic myomectomy in patients pretreated with ulipristal acetate (UPA) compared with untreated patients. Design Prospective, observational pilot study. Setting Tertiary referral center of minimally invasive gynecologic surgery, Sant'Orsola Academic Hospital, Bologna, Italy. Patients Seventy-four of 108 patients scheduled for laparoscopic myomectomy from January to November 2017 were enrolled. Interventions Laparoscopic myomectomy following pretreatment with UPA or no hormonal pretreatment therapy. Measurements and Main Results Of the 74 patients who were enrolled, 29 were pretreated with UPA (UPA group), and 45 did not receive any hormonal therapy before surgery (control group). Surgeons, blinded to patient pre-operative treatment, completed a 3-item questionnaire after each procedure to evaluate surgical difficulty. Based on surgeon response, myomas in the UPA group appeared softer and more difficult to enucleate because of less clear cleavage planes than the control group. The overall difficulty of myoma detachment from the myometrium was judged considerably higher in the UPA group. Despite this, enucleation time, total operative time, and perioperative complications were not statistically different in the 2 groups. Conclusion Myomas in patients pretreated with UPA are subjectively less easy to enucleate; however, surgical times and perioperative outcomes are not affected by pretreatment with UPA.

Hormonal replacement therapy (HRT) is effective in treating the symptoms of menopause. Endometriosis is defined as the presence of functional endometrial tissue outside the uterine cavity with a tendency towards invasion and infiltration. Being an estrogen-dependent disease, it tends to regress after menopause. Nevertheless, it affects up to 2.2% of postmenopausal women. Conclusive data are not available in the literature on the appropriateness of HRT in women with endometriosis or a past history of the disease. The hypothesis that exogenous estrogen stimulation could reactivate endometriotic foci has been proposed. The aim of this state-of-the-art review was to revise the current literature about endometriosis in perimenopause and menopause and to investigate the possible role of HRT in this setting of patients. An electronic databases search (MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) was performed, with the date range of from each database’s inception until May 2019. All of the studies evaluating the impact of different HRT regimens in patients with a history of endometriosis were selected. 45 articles were found: one Cochrane systematic review, one systematic review, five narrative reviews, two clinical trials, two retrospective cohort studies, 34 case reports and case series. Some authors reported an increased risk of malignant transformation of endometriomas after menopause in patients assuming HRT with unopposed estrogen. Low-quality evidence suggests that HRT can be prescribed to symptomatic women with a history of endometriosis, especially in young patients with premature menopause. Continuous or cyclic combined preparations or tibolone are the best choices. HRT improves quality of life in symptomatic post-menopausal women, who should not be denied the replacement therapy only due to their history of endometriosis. Based on low-grade literature evidence, we recommend to prescribe combined HRT schemes; tibolone could be considered.

Objective To describe a case of spontaneous hemoperitoneum in a woman affected by deep infiltrating endometriosis (DIE). Design Technical video showing laparoscopic management of a spontaneous hemoperitoneum in a patient with DIE. Setting Minimally Invasive Gynecological Unit, Sant'Orsola Academic Hospital, Bologna, Italy. Intervention A 35-year-old nulliparous woman was admitted to our gynecologic emergency room because of pelvic pain and a fainting sensation. She had a history of DIE and had been followed for 6 months by our outpatient clinics. The patient underwent an immediate laparoscopy because of the rapid worsening of clinical conditions. After blood suction and difficult adhesiolysis, a vascular lesion with a huge blood flow, close to the left utero-ovarian ligament, was detected. Selective coagulation was performed with good results. During the follow-up visit after 1 month, the patient reported good health. Written informed consent was obtained from the patient for publication of this case report. Conclusion Spontaneous hemoperitoneum represents a rare and life-threatening complication associated with endometriosis. In patients with hemoperitoneum and a history of endometriosis, it is important to pay attention to the possible presence of uncommon bleeding localizations. Laparoscopy was useful and effective in this challenging situation, identifying the bleeding source and performing selective coagulation.

STUDY OBJECTIVE Despite the enormous impact of lateral parametrial endometriosis (LPE), only a few studies have evaluated its diagnosis, prevalence, and clinical features. Our aim was to estimate the intraoperative prevalence of LPE in patients affected by deep infiltrating endometriosis (DIE) and to analyses clinical and surgical data associated with LPE. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Endometriosis tertiary level referral center, Sant'Orsola Academic Hospital, Bologna, Italy. PATIENTS We included 1360 consecutive women submitted to surgery for DIE between 2007 and 2017. Patients were divided into 2 groups according to the presence (study group, n = 231) or absence (control group, n = 1129) of LPE. INTERVENTION We retrospectively compared data records on the demographic features, preoperative data, and surgical outcomes of the 2 groups. MEASUREMENTS AND MAIN RESULTS The intraoperative prevalence of LPE was 17%. Preoperatively, LPE patients complained of having a more severe intensity of dysmenorrhea (p

Ureteral endometriosis (UE) can be classified as severe when there is obstruction to urinary flow (ureteral compression (UC)). In this retrospective study on 205 patients, we evaluated intraoperatively the frequency of severe ureteral endometriosis (UE) in women with UE and, secondarily, risk factors associated with UC. We documented intraoperatively ureteral UC in 124 (60.5%) patients with UE. A significantly lower body mass index (BMI) was observed in women with UC than in women without UC (p = .02). A significant association was found between UC and parametrial endometriosis (p = .001). In multivariable analysis, these variables remained significantly associated with UC. Ureteral compression is common in patients with UE, especially in women with parametrial infiltration and a low BMI.

Introduction There are several published clinical trials of the use of tranexamic acid (TXA) in an obstetric setting, but no consensus on its use or guidelines for management. Material and methods The aim of this meta-analysis was to evaluate the effectiveness of TXA in reducing blood loss when given prior to cesarean delivery. We performed a systematic search in electronic databases. We included all randomized controlled trials comparing the use of TXA prior to cesarean delivery with controls (either placebo or no treatment). Results Nine trials with 2365 women were included in the analysis. Women who received TXA had significantly less postpartum blood loss, a lower drop in hemoglobin and a lower incidence of postpartum hemorrhage and severe postpartum hemorrhage compared with controls. Moreover, the number of women who needed additional uterotonic agents was significantly lower in the TXA group than in controls. The percentage of women who required blood transfusions at, or immediately after, cesareans was significantly lower in the intervention group than in the controls. There was no difference in the incidence of thromboembolic events in the two groups. Conclusions Prophylactic TXA given before cesarean skin incision in women undergoing cesarean delivery, under spinal or epidural anesthesia, significantly decreases blood loss, including postpartum hemorrhage and severe postpartum hemorrhage, in addition to the standard prophylactic oxytocin given after delivery of the neonate. The effect of TXA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further.

Historically, in the majority of judicial systems, the protection of trademarks with reputation differs from the protection of normal trademarks. It is widely recognised that reputed trademarks have an “added value” deserving wider protection. The contribution analyses the evolution of the protection of trademarks with reputation in the European Union legislation and the jurisprudence of the Court of Justice of the European Union (CJEU). The First Directive strengthened the protection of trademarks with reputation both in the field of registration and in the field of infringement. Article 5(2) of the TMD leaves to Member States the possibility to protect well-known trademarks against dilution. Third parties can be prevented by the proprietor of the trademark with reputation from using signs identical or similar to this trademark. The use must take place in the course of trade, the products or services with which it is related should be similar to those for which the trademark is registered and it must take unfair advantage of the distinctiveness of the trademark or be detrimental to it. Considering the internet features, its availability worldwide and the growing number of users, it is evident that is essential for a trademark to expand its reputation and monitor if it is used by third parties that can damage its reputation or take advance of it. The protection of reputed trademarks on the internet is very discussed and problematic. Many actions have been brought for trademark infringement by the use of similar or identical signs ad keywords in search engines. The ECJ tried to order and clarify the application of EU legislation to these particular cases (Vuitton v Google, L'Oreal v Ebay and Interflora v Marks and Spencer).Read more

The preparation of 3-substituted tetrahydropyrazinoisoquinolines using the tributyltin hydride mediated intramolecular radical cyclization of suitably protected 2-substituted 3,4-dihydropyrazines is reported. The compounds are obtained as single enantiomers, as the relative configuration of the new generated stereogenic center is driven by the stereochemistry of the 2-substituted carbon in the starting materials, which is in turn derived from naturally occurring amino acids.

OBJECTIVE: To derive a birth weight predictive equation and to compare its diagnostic value with that of ultrasound. METHODS: A longitudinal observational cohort study, including singleton pregnancies at term, was performed at St. Orsola-Malpighi Hospital, University of Bologna (Italy). A birth weight prediction formula, including symphysis-fundal height (SFH), BMI, maternal abdominal circumference (mAC) and parity was derived from a general linear model (GLM) (retrospective study). Moreover, on a new series of patients, the fetal weight was estimated by using both GLM and ultrasound using Hadlock formula (prospective study). The residual analysis and the intraclass correlation coefficient (ICC) were used to test the accuracy of methods in predicting birth weight. RESULTS: Between January and November 2012, 1034 patients were included in the retrospective study and 44 in the prospective one. The following GLM was derived: estimated birth weight (g) = 1485.61 + (SFH (cm) × 23.37) + (11.62 (cm) × mAC) + [BMI × (-6.81)] + (parity (0 = nulliparous, 1 = multiparous) × 72.25). When prospectively applied, the GLM and ultrasound provided a percentage of prediction within ±10% of the actual weight of 73% and 84%, respectively. Ultrasound estimation, as opposite of GLM one, was significantly associated with neonatal weight (R(2 )= 0.388, F = 26.607, p value

Study Objective To show a new laparoscopic technique of hysteropexy for uterine retrodisplacement (retroversion and/or retroflexion). Design Narrated step-by-step explanation of the Bologna hysteropexy technique using descriptive text and an educational video. Setting Tertiary referred center of minimally invasive gynecology, Sant'Orsola Hospital, Bologna University. Interventions The Bologna hysteropexy is proposed as an additional procedure after surgical laparoscopic interventions for benign gynecologic disease. The technique consists of 2 semicontinuous absorbable sutures (Biosyn monofilament no. 1 [Covidien, Mansfield, MA] with 2/3 inch diameter needle, 36 mm) suspending the uterus to the anterior abdominal wall, through the plication and shortening of round ligaments. A knot is tied intracorporeally between the 2 free ends of the semicontinuous sutures, drawing a V shape figure and resulting in uterine ventrosuspension. Conclusion The Bologna technique hysteropexy is simple and quick to perform. It is effective in suspending the uterus in anteverted and anteflexed positions at 6-month ultrasound follow-up. No perioperative complications were recorded. It can be done with a standard surgical suture-passer and does not add additional cost to surgery. Furthermore, an absorbable suture is desirable for fertile women.

A new class of selective NPS antagonist was developed starting from a commercially available product identified by screening activities. Experimental NMR observations and computational experiments allowed the discovery of a new class of derivatives. 5-Phenyl-2-[2-(1-piperidinylcarbonyl)phenyl]-2,3-dihydro-1H-pyrrolo[1,2-c]imidazol-1-one represents a new lead compound in the NPS antagonist field.