Alessandro Svelato

Microplastics are particles smaller than five millimeters deriving from the degradation of plastic objects present in the environment. Microplastics can move from the environment to living organisms, including mammals. In this study, six human placentas, collected from consenting women with physiological pregnancies, were analyzed by Raman Microspectroscopy to evaluate the presence of microplastics. In total, 12 microplastic fragments (ranging from 5 to 10 μm in size), with spheric or irregular shape were found in 4 placentas (5 in the fetal side, 4 in the maternal side and 3 in the chorioamniotic membranes); all microplastics particles were characterized in terms of morphology and chemical composition. All of them were pigmented; three were identified as stained polypropylene a thermoplastic polymer, while for the other nine it was possible to identify only the pigments, which were all used for man-made coatings, paints, adhesives, plasters, finger paints, polymers and cosmetics and personal care products.

The widespread use of plastics determines the inevitable human exposure to its by-products, including microplastics (MPs), which enter the human organism mainly by ingestion, inhalation, and dermal contact. Once internalised, MPs may pass across cell membranes and translocate to different body sites, triggering specific cellular mechanisms. Hence, the potential health impairment caused by the internalisation and accumulation of MPs is of prime concern, as confirmed by numerous studies reporting evident toxic effects in various animal models, marine organisms, and human cell lines. In this pilot single-centre observational prospective study, human breastmilk samples collected from N. 34 women were analysed by Raman Microspectroscopy, and, for the first time, MP contamination was found in 26 out of 34 samples. The detected microparticles were classified according to their shape, colour, dimensions, and chemical composition. The most abundant MPs were composed of polyethylene, polyvinyl chloride, and polypropylene, with sizes ranging from 2 to 12 µm. MP data were statistically analysed in relation to specific patients' data (age, use of personal care products containing plastic compounds, and consumption of fish/shellfish, beverages, and food in plastic packaging), but no significant relationship was found, suggesting that the ubiquitous MP presence makes human exposure inevitable.

To evaluate the efficacy and feasibility of thermo-ablative fractional CO2 laser for the treatment of symptoms related to vulvo-vaginal atrophy (VVA) in post-menopausal women.From April 2013 to December 2013, post-menopausal patients who complained of one or more VVA-related symptoms and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment (T1), vaginal status of the women was evaluated using the Vaginal Health Index (VHI), and subjective intensity of VVA symptoms was evaluated using a visual analog scale (VAS). At T1, treatment satisfaction was evaluated using a 5-point Likert scale.During the study period, a total of 48 patients were enrolled. Data indicated a significant improvement in VVA symptoms (vaginal dryness, burning, itching and dyspareunia) (P<0.0001) in patients who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Moreover, VHI scores were significantly higher at T1 (P<0.0001). Overall, 91.7% of patients were satisfied or very satisfied with the procedure and experienced considerable improvement in quality of life (QoL). No adverse events due to fractional CO2 laser treatment occurred.Thermo-ablative fractional CO2 laser could be a safe, effective and feasible option for the treatment of VVA symptoms in post-menopausal women.

Microplastics (MPs) are defined as plastic particles smaller than 5 mm. They have been found almost everywhere they have been searched for and recent discoveries have also demonstrated their presence in human placenta, blood, meconium, and breastmilk, but their location and toxicity to humans have not been reported to date. The aim of this study was twofold: 1. To locate MPs within the intra/extracellular compartment in human placenta. 2. To understand whether their presence and location are associated with possible structural changes of cell organelles. Using variable pressure scanning electron microscopy and transmission electron microscopy, MPs have been localized in ten human placentas. In this study, we demonstrated for the first time the presence and localization in the cellular compartment of fragments compatible with MPs in the human placenta and we hypothesized a possible correlation between their presence and important ultrastructural alterations of some intracytoplasmic organelles (mitochondria and endoplasmic reticulum). These alterations have never been reported in normal healthy term pregnancies until today. They could be the result of a prolonged attempt to remove and destroy the plastic particles inside the placental tissue. The presence of virtually indestructible particles in term human placenta could contribute to the activation of pathological traits, such as oxidative stress, apoptosis, and inflammation, characteristic of metabolic disorders underlying obesity, diabetes, and metabolic syndrome and partially accounting for the recent epidemic of non-communicable diseases.

•After conization, HPV vaccine shows 80% clinical effectiveness in disease relapse prevention. •Clinical benefits of vaccination are demonstrated up to 4 years. •HPV vaccine has no therapeutic effect on prevalent HPV infection or disease. •HPV vaccination is beneficial as an adjuvant additional to surgical treatment.

Abstract Background The experience of childbirth crucially impacts a mother’s psychological well-being and the mother-infant relationship. It is recognised that negative births can be linked to different forms of discomfort, both for the mother as well as for the infant. This prospective longitudinal study aimed to study the effect of obstetric and psychological variables on women’s subjective experience of childbirth. Methods 111 primiparous Italian women completed a set of questionnaires at 38–40 weeks of pregnancy (Time 1) and 1–5 days after childbirth (Time 2). Sociodemographic and obstetric information were collected. Data about the childbirth were obtained from the mother’s ward birth records. Women completed the Wijma Delivery Expectancy/Experience Questionnaire both before and after childbirth. Results The subjective experience of birth was significantly predicted by the duration of the expulsive phase (β = .26; p &lt; .05), the use of epidural analgesia (β = .21; p &lt; .05) and by fear of birth (β = .21; p &lt; .05). The effect of mode of birth and duration of the dilatation phase on women’s birth experience was not found. Conclusions In our study, neither instrumental childbirth nor caesarean section have a significant effect on women’s birth experience. Instead, both a longer expulsion phase and epidural analgesia contribute to the negative experience. Moreover, the higher the fear of birth, the worse the women’s emotional experience. These findings confirmed the role of obstetric and psychological variables on birth experience. More investigation about this topic could be useful to develop specific interventions to prepare women for birth.

The primary aim of the study was to analyze the endometrioma recurrence rate in patients who underwent laparoscopic excision followed by postoperative long-term regimen of oral contraceptives (OCs). 168 patients who underwent a conservative laparoscopic surgery for endometrioma, during the period between September 2009 and August 2010 in three university hospitals were studied. A long-term OCs therapy was offered to all women following surgery. Patients were randomly divided into three groups according to different progestins used (desogestrel, gestodene, dienogest). Women who refused a postoperative hormonal therapy served as control. Follow-up visits and transvaginal scan were planned at 1, 3, 6, 12, and 24 months after surgery. All patients who showed an ultrasound persistence of the endometrioma at 1 month follow-up were excluded from clinical analysis. Of the 168 patients, 131 completed the 24 months follow-up. Endometrioma recurrence was found in 21 (12.5 %) of all patients, it was unilateral in 17 cases while bilateral in 4 cases. The rate of recurrent endometrioma was statistically significant in non-users compared to the long-term OCs treated patients. The current data suggest the usefulness of long-term OCs regimen after conservative surgery for the prevention of ovarian endometrioma recurrence. As a statistical significant difference could not be observed between OCs groups, further study on the individual molecules is required in order to really understand the effect of each of them.

Abstract In healthcare, the patient safety system which has been developed following the study of the various phases necessary for its determination, supplies strategies to avoid the repetition of circumstances that originally has led an individual to make mistakes. In fact, the culture of risk management, starting from the consideration that the errors are not eliminable, is based on the belief that they need to be properly analyzed, implementing intervention strategies that avoid its repetition, in order to become good learning opportunities.

To describe transfusion management during post-partum haemorrhage (PPH) and the usefulness of standard or point-of-care (POC) laboratory tests for guiding haemostatic management.PPH is the leading cause of maternal mortality and severe maternal morbidity worldwide. Despite the efforts made in recent years, PPH is often burdened by preventable death. Recent data from the active Italian Obstetric Surveillance System (ItOSS) highlighted the following main critical issues: inadequate communication between healthcare professionals, inability to correctly and promptly assess the severity of haemorrhage, delays in diagnosis and treatment, failure to request blood promptly and inappropriate monitoring post-partum.Data in the literature have been compared with the rotational thromboelastometry (ROTEM)- and the thromboelastography (TEG)-guided algorithms applied in the authors' departments.PPH transfusion therapy may have an empirical approach based on the standard use of blood products or a targeted approach based on coagulation monitoring by laboratory or POC tests. Here, the authors describe how they manage PPH in their departments, according to the Italian guidelines, along with the addition of a ROTEM- and a TEG-guided algorithms developed by themselves.Although the proposed algorithms have not been validated by trials or observational studies conducted in our departments, we believe that these indications could be useful for supporting clinical practice. Furthermore, we deem it appropriate to emphasise the importance of a multidisciplinary approach and the need for standardised and shared protocols to support the decisions of healthcare professionals.

The aim of this study is to assess whether the touch of osteopathic manipulative treatment (OMT) can affect the endogenous production of oxytocin in full-term pregnant women and the assessment of well-being following the treatment.In this study have been enrolled 57 pregnant women at full-term pregnancy (37th-41st week) for evaluation of the concentration of salivary oxytocin 2 minutes before and 2 minutes after a single session of OMT by an osteopath lasting for 30 minutes. Pre-OMT and post-OMT saliva samples were collected with the use of Salivette® salivary swabs. 7 salivary swabs were excluded from the analysis. 50 samples were analyzed with an appropriate ELISA kit.The mean OT salivary concentration pre-OMT was 89.98±16.39, and post-OMT was 100.60±19.13 tends to increase with p=0.0000051. In multivariate analysis, two subgroups show interesting data in the mean difference in OT salivary concentration post-OMT: women with painful contractions (p=0.06) and women under 35 years (p=0.09).The results of this study demonstrate that the effectiveness of OMT-increasing endogenous oxytocin is statistically significant in full-term pregnant women. The sensation of well-being found in most women indicates that there has been a predominantly central rather than peripheral oxytocin release after OMT.

Abstract Background The continue increase of interventions during labour in low risk population is a controversial issue of the current obstetric literature, given the lack of evidence demonstrating the benefits of unnecessary interventions for women or infants’ health. This makes it important to have approaches to assess the burden of all medical interventions performed. Methods Exploiting the nature of childbirth intervention as a staged process, we proposed graphic representations allowing to generate alternative formulas for the simplest measures of the intervention intensity namely, the overall and type-specific treatment ratios. We applied the approach to quantify the change in interventions following a protocol termed Comprehensive Management (CM), using data from Robson classification, collected in a prospective longitudinal cohort study carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy. Results Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments. Conclusions The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

Postpartum hemorrhage (PPH) is one of the most frequent causes of mortality and morbidity in the obstetric population globally, causing about a quarter of maternal deaths yearly, and is the leading cause of maternal death worldwide. The management of PPH remains a topic of great debate, even in view of new diagnostic and therapeutic possibilities in recent years, for which, however, the body of evidence available thus far is still scarce, as the standard values are lacking. The protocol hereby presented was developed after a literature review and during several meetings of an Italian multidisciplinary task group of specialists adopting a modified Delphi method, and is the result of the synthesis of therapeutic operational protocols for the treatment of PPH applied by the different specialties within the team. This protocol is intended to represent a practical proposal to support clinicians in the management of a particularly complex event that requires the intervention of a multidisciplinary team and the implementation of dedicated management protocols.

We read with great interest “Avoiding the first cesarean section – results of structured organizational and cultural changes” by Blomberg 1. We understand Blomberg's attention to the complex issue of dystocia, and we would like to ask the author some questions: How long did labor last in patients who were subject to augmentation of labor and for those who were not subject to augmentation? Was there a difference in the duration of the labor for the two groups? Did they use a partogram? When did they start partogram compilation? In which percentage of patients were oxytocin and amniotomy used? We have just concluded an analysis on 419 nulliparous women with a single fetus in cephalic presentation, in spontaneous labor at term or induced labor post term, delivered at our Department 2. These corresponded to Robson Group 1 and 2a, based on the Ten-Group Classification System 3. We focused our attention on teamwork improvement and dystocia management. We introduced a series of meetings between medical and midwifery staff with the aim of standardizing the clinical activity of doctors and midwives and enforcing the commitment to change. Our comprehensive management of dystocia showed a decrease in the percentage of use of cesarean sections for dystocia, falling from 9.3 to 2.5% (p = 0.0035), in the use of oxytocin from 33.3 to 13.8% (p < 0.0005) and from 41.7 to 7.4% (p < 0.0005) for amniotomy. This is why we agree completely with Blomberg's view that “the obstetric round” is essential for a change in attitude among midwives and doctors in favor of normal vaginal deliveries. We changed the views regarding dystocia and partograms. The partogram was, in fact, conceived as a screening tool and when individual cervimetric curves remained unchanged and went beyond the action line, we formulated the diagnosis of suspected dystocia and attempted to comprehend and diagnose the underlying possible causes of this lagging, without routinely performing amniotomy or administering oxytocin. This new management was aimed at carrying out, as precisely as possible, a diagnosis of “dystocia” to be able to treat the specific cause, thus avoiding useless and possible dangerous interventions such as oxytocin and amniotomy 2. In this way, dystocia is conceived as a syndrome, not as disease, and it is represented as a “closed box” that, when opened, by identifying a presumptive etiology, allows us to make a diagnosis and consequently act on the probable causes 4. We are therefore very interested in Blomberg's idea of dystocia management, called “wheelbarrow”, and we think that it could be interesting and probably very close to our own idea. We would therefore like to know more about this method, and we would like to ask Blomberg to explain and give us details regarding the metaphors used for dystocia.

Shoulder dystocia is a rare but severe obstetric complication associated with an increased risk of brachial plexus palsies, fractures of the clavicle and humerus, hypoxic-ischemic encephalopathy and, rarely, neonatal death. Here we describe a fatal case of shoulder dystocia in a term newborn, although labor was uneventful, fetal heart rate tracing was normal until the delivery of the head and the head-to-body delivery interval (HBDI) occurred within 5 min. Full resuscitation was performed for 35 min without success. Hemoglobin concentration evaluated on the umbilical cord still attached to the placenta was within normal range, while neonatal venous hemoglobin concentration blood gases at 9 min of life showed severe metabolic acidosis and anemia. As previously described by others, our case supports the hypothesis of a hypovolemic shock as the cause of neonatal death, probably due to acute placental retention of fetal blood. The death of the newborn following shoulder dystocia is an event that still presents numerous gaps in knowledge. Further research should focus on: Performing neonatal resuscitation with an intact umbilical cord. Milking the umbilical cord before clamping. Clamp the umbilical cord leaving a long portion attached to the newborn and squeeze its content simultaneously with the first resuscitation maneuvers. Consider postdelivery volume replacement therapy sooner than expected from resuscitation algorithm.

Sir, We would like to bring to general attention the case of a 44-year-old woman who came to our clinic because of spotting and occasional periods of amenorrhea. She had had menarche at the age of 14 years, followed by regular menstrual cycles. Her medical history revealed that she had one living child, and had subsequently experienced two miscarriages. The patient was human immunodeficiency virus (HIV) and hepatitis C virus positive. In addition, she was suffering from HIV-related chronic renal failure, HIV-related neuropathy and hepatitis C virus-related chronic hepatopathy. Physical and pelvic examinations were unremarkable. Transvaginal ultrasound examination revealed a hyperechogenic area in the uterine cavity measuring 14 mm × 6 mm. The patient underwent a diagnostic hysteroscopy, which showed a 20 mm × 10 mm white meshwork of bony spicules arising from the posterior wall, with a hard tactile consistency (Figure 1). A resectoscopic excision was then performed. The histological examination showed trabeculae of woven bone, and was consistent with osseous metaplasia of the endometrium. Concomitant endometrial histology showed a secretory endometrium. Two weeks after surgery, the patient again underwent a second transvaginal ultrasound examination, which revealed no trace of the original, abnormal ultrasound finding. Hysteroscopic aspect of osseous metaplasia of the endometrium. Osseus metaplasia is rarely encountered, with less than 100 cases reported in the international literature (1). There is controversy regarding the pathogenic mechanisms related to the histogenesis of heterotopic bone in the endometrium. A number of theories have been proposed, as follows: continuous and strong endometrial estrogenic stimulation; osteogenesis in the surrounding endometrium, which is promoted by retained fetal bones; implantation of embryonic parts without pre-existing bone after early-stage abortions; dystrophic calcification of retained and necrotic tissues, usually after an abortion; chronic endometrial inflammation, such as endometritis or pyometra; and metastatic calcification and metabolic disorders, such as hypercalcemia, hypervitaminosis D or hyperphosphatemia (1-3). The most recent and accepted theory is metaplasia of the endometrial stromal cells, usually fibroblasts, which change into osteoblasts and thus produce bone in the endometrium. A previous history of abortion is present in most of the reported cases, with osseous changes in the endometrium. Usually, the reproductive age group (between 20 and 40 years of age) is involved, although it has also been reported in the menopausal years (1). In the few reported cases in the literature, the time between the antecedent abortion and discovery of the endometrial ossification varies from eight weeks to 23 years (4). Chronic renal failure is a known cause of abnormal calcium–phosphorous metabolism with metastatic calcifications; this may be the pathway of osseous metaplasia observed in our patient. Ultrasound examination plays a primary role in the diagnosis of patients with osseous metaplasia. The characteristic hyperechogenic pattern is strongly suggestive of osseous tissue within the uterus and should be confirmed by hysteroscopic examination (2). Today, hysteroscopy is accepted as the gold standard for diagnosis and treatment. Bone formation in the endometrium is rare, but can be seen in malignant mixed Müllerian tumors and in teratomas, which should be considered in the differential diagnosis (1). Clinicians and pathologists should bear this chance in mind, particularly in light of the fact that an erroneous diagnosis may well result in unnecessary hysterectomy.

We read with great interest your case of postpartum symphysis pubis separation 1. We would like to present a case of pubic symphysis diastasis that we diagnosed with a different approach. A 36-year-old gravida 1 para 0 at 39.6 weeks' gestation was admitted with the onset of spontaneous contraction. After three hours and 18 min she delivered a 3170 g baby without complications. Three hours after delivery, she complained of severe pain in the symphysis pubic region. On examination, there was local tenderness in that region. We performed an ultrasound examination, which revealed a 15.2-mm gap in the region of the symphysis pubis (Figure 1), diagnosed as pubic symphysis diastasis. She was given analgesics and advised bed rest. The patient was discharged six days after delivery and advised to maintain active ambulation and start physiotherapy. Three months later she was seen at the outpatient clinic. She was able to walk independently and was no longer experiencing any pain. Although the case presented is not particularly impressive in severity, it still offers the opportunity to inform all clinicians about the possibility of diagnosing this condition with the use of the ultrasonography alone. The reported incidence of pubic symphysis diastasis varies widely in the literature, from 1 in 300 to 1 in 30 000 deliveries 2, 3. Generally, it is a rare complication and for this reason it is very difficult to perform randomized controlled trials to compare different diagnostic tools. The diagnosis is based primarily on clinical findings. The most consistent finding is pain in the symphyseal region that radiates to the lower back and thighs and is exacerbated by leg movement 4. In addition, many women will have difficulty walking, in fact the gait is described as waddling, or potentially be unable to stand or walk due to pain 3. Symptoms may be noted during labor and up to 48 h postpartum. Often the first diagnostic test used to identify the pubic diastasis is antero-posterior radiography. However, we think that ultrasound might be a good choice as an initial imaging study, rather than x–ray, due to absence of exposure to ionizing radiation and its ease of operation, and as it presents an optimal assessment of the extent of symphysis separation 3-5. We performed ultrasonography in the following way: we placed the probe in transverse orientation on the pubic symphysis (identified by palpation) with an approximately 30° caudal scanning plane, with the purpose of measuring the width of the symphyseal joint at its upper margin. Pubic symphysis diastasis is an uncommon injury that should be considered when evaluating patients in the peripartum period who are experiencing suprapubic, sacroiliac or thigh pain. In addition we would like to bring to the general attention the usefulness of ultrasound in the diagnosis and management of this rare condition. The literature is inconsistent on this topic, due to the lack of randomized controlled trials, but good suggestions are present 3-5. In our experience, ultrasound is simple, reproducible and without side effects, and should be used as an initial imaging study because the accuracy is at least as good as that of x-rays for estimating the width of the symphysis pubis diastasis.

Spinal epidural hematoma is a rare but serious complication of epidural anaesthesia and neurological impairment. Epidural hematoma usually becomes evident within a few hours of the procedure. Delayed clinical presentation of spinal epidural hematoma is even rarer and insidious.We reported a case of a 44-year-old woman who underwent a caesarean section for a twin pregnancy during which a delayed dorsal spinal epidural hematoma occurred. Symptoms were reported 5 days after surgery and 72 h after removal of the epidural catheter. An MRI scan showed a dorsal epidural hematoma. The patient was moved to the Neurosurgical Department and underwent decompression surgery.The possibility of the delayed onset of a spinal epidural hematoma in a pregnant woman who undergoes epidural anaesthesia in labour must always be taken into consideration. In order to achieve the best clinical result, we stress the importance of a timely diagnosis and prompt surgical treatment.

Fetomaternal hemorrhage (FMH) was reported more than 60 years ago for the first time defined by the transfer or transfusion of fetal blood into the maternal circulation before or during delivery. The transfused volume is usually very small but when this value exceeds, it may be clinically significant. Antenatal diagnosis of severe FMH is difficult and it can be suspected in case of reduction of fetal movements, abnormal cardiotocography and ultrasound. FMH is associated to different adverse outcomes and admission to neonatal intensive care. The low incidence of FMH limits the studies, thus being able to rely only on diagnosis and retrospective studies. We present case series of FMH and analyze the steps with the purpose of defining a flow-chart for early diagnosis and management of FMH.

Since operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure. This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled. Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure.Overall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable.Decision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation. Operative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.

The placenta is a crucial interface between the fetus and the maternal environment. It allows for nutrient absorption, thermal regulation, waste elimination, and gas exchange through the mother's blood supply. Furthermore, the placenta determines important adjustments and epigenetic modifications that can change the phenotypic expression of the individual even long after birth. Polyethylene glycol (PEG) is a polyether compound derived from petroleum with many applications, from medicine to industrial manufacturing. In this study, for the first time, an integration of ultra-high-performance liquid chromatography (UHPLC) coupled with mass spectrometry (MS) was used to detect suites of PEG compounds in human placenta samples, collected from 12 placentas, originating from physiological pregnancy. In 10 placentas, we identified fragments of PEG in both chorioamniotic membranes and placental cotyledons, for a total of 36 samples.

Summary paragraph Microplastics are particles smaller than five millimetres obtained from the degradation of plastic objects abandoned in the environment. Microplastics can move from the environment to living organisms and, in fact, they have been found in fishes and mammals. Six human placentas, prospectively collected from consenting women with uneventful pregnancies, were analyzed by Raman Microspectroscopy to evaluate the presence of microparticles. Detected microparticles were characterized in terms of morphology and chemical composition. 12 microparticles, ranging from 5 to 10 μm in size, were found in 4 out of 6 placentas: 5 in the foetal side, 4 in the maternal side and 3 in the chorioamniotic membranes. All the analyzed microparticles were pigmented: three of them were identified as stained polypropylene, while for the other nine it was possible to identify only the pigments, which are all used for man-made coatings, paints and dyes. Here we show, for the first time, the presence of microparticles and microplastics in human placenta. This sheds new light on the impact of plastic on human health. Microparticles and microplastics in the placenta, together with the endocrine disruptors transported by them, could have long-term effects on human health.

Synthetic oxytocin (synOT) is a commonly used drug in labor and it can be applied in all stages of labor. SynOT has been increasingly used over the years, and is currently one of the most common drugs employed in obstetrics. The goal of synOT administration is to cause the augmentation of labor; unfortunately, guidelines for the administration of this drug are often non-specific, although synOT is the drug most commonly associated with preventable adverse perinatal outcomes. Approximately half of all paid obstetric litigation claims in the United States involve allegations of injudicious use of oxytocin, and the association between oxytocin use, hyperstimulation, fetal distress and adverse neonatal outcome are well know. Furthermore, synOT and oxytocin have some extragenital effects that should be known by obstetricians. This review will present the viewpoint of the authors on this topic.

This cross-sectional study aimed at evaluating the impact of different modalities of induction of labour (IOL) and delivery on levels of woman' satisfaction. All women aged 18 years or older, who underwent IOL for at-term pregnancy (≥41 weeks of gestation) in randomly selected days during the study period in 6 participating centres were eligible for the study. The questionnaire investigated women's opinion regarding information about induction, pain control, length of induction, their experience about induction, labour and delivery and their attitude towards induction in a subsequent pregnancy. Women were also asked to fill in the Italian version of the Birth Satisfaction Scale-Revised (BSS-R). A total of 300 women entered the study. The answer to the question about a "positive attitude towards induction in a subsequent pregnancy was "absolutely yes" or "yes" respectively in the 77.8%, 52.8% and 48.6% of women who were induced with oral drugs, vaginal drugs and Cook balloon (heterogeneity chi-square p = 0.05). The corresponding values for women who delivered vaginally or by caesarean section (CS) were 63.3% and 36.4% (chi-square p = 0.0009). The mean BSS-R total score was higher among women who underwent IOL with oral drugs than with vaginal drugs (p < 0.0001) or Cook Balloon (p < 0.0001), and among women who delivered vaginally than in those who delivered by CS (p < 0.0001). Women were asked "What do you think is important for a method of induction?": 47.3% (95% CI 41.7%-53.0%) of women answered that "should make the induction as painless as possible", 47.0% (95% CI 41.4%-52.7%) "should induce labour quickly", 44.3% (95% CI 38.8%-50.0%) "should be safe for baby". This study showed that vaginal delivery was associated with a higher rate of satisfaction among induced women. Considering mode of induction, oral drugs were associated with a higher level of satisfaction. Control of pain and quick induction were the most appreciated characteristics.

OPINION article Front. Public Health, 05 June 2023Sec. Environmental health and Exposome Volume 11 - 2023 | https://doi.org/10.3389/fpubh.2023.1145240

To understand the role of fetal spine position in determining a fetal head position at the time of birth and modality of delivery.This was a multicenter prospective observational study. Fetal occiput and spine position were evaluated by intrapartum ultrasound. Eighty-six women were eligible for inclusion in the study. Occiput rotational movements and modality of delivery in relation to the fetal spine position were investigated.At the beginning of labor, fetal occiput was in a posterior position in 52.3% of cases and, in 81.5% of cases the spine was in an anterior transverse position. At birth, occiput and spine were both in an anterior position in 90.4% of cases. The rate of cesarean sections in the SP group was significantly higher than the rate in the SAT group (50% vs. 8%, p < 0.0007). Instead, the rate of vaginal deliveries without intervention in the SP group was significantly lower than the rate in the SA group (14% vs. 71%, p < 0.0001).Fetal spine position could have an important role in determining fetal occiput position at birth. Spine position might play a crucial role in the outcome of delivery.

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs).Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge.Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052).Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

We read with concern the recent “Association of abnormal first stage of labor duration and maternal and neonatal morbidity.”1Blankenship S.A. Raghuraman N. Delhi A. et al.Association of abnormal first stage of labor duration and maternal and neonatal morbidity.Am J Obstet Gynecol. 2020; 223: 445.e1-445.e15Abstract Full Text Full Text PDF Scopus (12) Google Scholar The question is about the authors’ choice to compare a variable (in this case labor duration) with outcomes related to a complex event, such as childbirth. Because of the retrospective nature of the study, classifying first stage of labor duration as an independent variable may lead to incorrect considerations.2Vassar M. Holzmann M. The retrospective chart review: important methodological considerations.J Educ Eval Health Prof. 2013; 10: 12Crossref PubMed Google Scholar In fact, the association between the duration of first stage of labor and maternal morbidity is namely an association and does not mean a causal relationship. It is obvious that if we select a population of women with a longer labor, such as in this group, we would find a greater number of maternal or neonatal adverse outcomes. However, the point is we should not mistake causes for effects, as the pathologic outcomes are probably not due to the longer duration of labor. It is rather a longer length of labor that, conversely, has an underlying cause that should be identified, which results in a prolonged labor progression and leads to the complications observed. This logical problem suggest that the conclusions reached by Blankenship et al1Blankenship S.A. Raghuraman N. Delhi A. et al.Association of abnormal first stage of labor duration and maternal and neonatal morbidity.Am J Obstet Gynecol. 2020; 223: 445.e1-445.e15Abstract Full Text Full Text PDF Scopus (12) Google Scholar that “[the] benefit of expectantly managing a prolonged first stage of labor with duration above the 90th percentile in anticipation of vaginal delivery must be weighed against the increased risk of composite maternal and neonatal morbidity” are wrong. We have previously shown3Svelato A. Ragusa A. Manfredi P. General methods for measuring and comparing medical interventions in childbirth: a framework.BMC Pregnancy Childbirth. 2020; 20: 279Crossref PubMed Scopus (7) Google Scholar,4Ragusa A. Gizzo S. Noventa M. Ferrazzi E. Deiana S. Svelato A. Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term.Arch Gynecol Obstet. 2016; 294: 753-761Crossref PubMed Scopus (16) Google Scholar that if the emphasis is on the diagnosis of the causes of slowdown in labor and not on the duration of labor per se, obstetricians can intervene to correct the probable etiologic causes. Furthermore, we reported that adverse outcomes remained unchanged. (ie, they do not depend on time) and that iatrogenicity was greatly reduced (cesarean deliveries, vaginal operative births, oxytocin augmentation). Essentially, cervimetric curves should be used as a screening test for dystocia in labor and not as a diagnostic tool. The groups discussed in the above definition, 90th and 10th percentiles, represent the levels of the independent variable, whereas the variable examined across the groups is known as the dependent variable. The problem is that waiting cannot be considered a therapy per se; time must be used to make a diagnosis instead, even if only a presumptive one, and to develop an etiologic therapy. In this way, as we have shown, we can reduce iatrogenicity without worsening birth outcomes by allowing women to express their potential to give birth and achieve a positive childbirth experience. Association of abnormal first stage of labor duration and maternal and neonatal morbidityAmerican Journal of Obstetrics & GynecologyVol. 223Issue 3PreviewContemporary guidelines for labor management do not characterize abnormal labor on the basis of maternal and/or neonatal morbidity. Full-Text PDF Awareness of time in labor does not preclude investigation of other factors contributing to maternal and neonatal morbidityAmerican Journal of Obstetrics & GynecologyVol. 224Issue 4PreviewWe appreciate the comments of Ragusa et al regarding our recent publication.1,2 With our retrospective study design, we do not suggest causality but rather demonstrate an association of abnormal first stage of labor duration with maternal and neonatal morbidity. Full-Text PDF

A productive debate is needed about the use of dinoprostone in labor induction.

The placenta is a crucial interface between the fetus and the maternal environment. It allows for nutrient absorption, thermal regulation, waste elimination and gas exchange through the mother's blood supply. Furthermore, the placenta determines important adjustments and epigenetic modifications that can change the phenotypic expression of the individual even long after birth.Polyethylene glycol (PEG) is a polyether compound derived from petroleum with many applications, from medicine to industrial manufacturing. In this study, for the first time, a combination of UHPLC followed by Mass Spectrometry was used to detect suites of polyethylene glycol (PEG) compounds in human placenta samples, collected from 12 placentas, originating from physiological pregnancy. In all but two placentas, we identified fragments of PEG in chorioamniotic membranes, and in placental cotyledons, for a total of 36 samples.

obiettivi.L'obiettivo primario della nostra ricerca è quello di valutare l'efficacia e la sicurezza del trattamento chirurgico laparoscopico nelle pazienti affette da adenomiosi cistica, rara causa di dismenorrea severa, caratterizzata dalla scarsa responsività al trattamento farmacologico

We read with great interest the recent article titled “Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean: a randomized trial.”1Rozenberg P. Sénat M.V. Deruelle P. et al.Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean delivery: a randomized trial.Am J Obstet Gynecol. 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (10) Google Scholar The authors conclude that “ultrasound measurements of the lower uterine segment (LUS) thickness did not result in a statistically significant lower frequency of maternal and perinatal adverse outcomes than standard management.” Although this conclusion is true, other studies have concluded that “LUS thickness measured by ultrasound during the third trimester of pregnancy is inversely correlated with uterine scar rupture/dehiscence at delivery”2Jastrow N. Vikhareva O. Gauthier R.J. Irion O. Boulvain M. Bujold E. Can third-trimester assessment of uterine scar in women with prior cesarean section predict uterine rupture?.Ultrasound Obstet Gynecol. 2016; 47: 410-414Crossref PubMed Scopus (28) Google Scholar; a conclusion arrived at without demonstrating the practical utility of the method, which has too many false-positives, and above all, false-negative results. However, we completely disagree with the final advice of this study.1Rozenberg P. Sénat M.V. Deruelle P. et al.Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean delivery: a randomized trial.Am J Obstet Gynecol. 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (10) Google Scholar In fact, the authors recommended that “because this study was underpowered, further research should be encouraged.” We are aware that knowing about the risk of uterine rupture causes anxiety to the physicians about the potential adverse outcomes that could be a challenge to manage.3Affronti G. Agostini V. Brizzi A. et al.The daily-practiced post-partum hemorrhage management: an Italian multidisciplinary attended protocol.Clin Ter. 2017; 168: e307-e316PubMed Google Scholar Nevertheless, we believe that further studies on the subject are totally useless, as after a cesarean delivery, the muscle tissue of the LUS is partially replaced by fibrous tissue4McIntyre D. Kerr M. Histological studies of various uterine scars.Proc R Soc Med. 1924; 17: 131-156PubMed Google Scholar and not only by muscle tissue. It is known that the strength of muscle tissue is proportional to its thickness; this is not necessarily true of fibrous tissue, which can break despite its thickness. For this reason, we believe that studies relating the thickness of the LUS with any kind of rupture of the uterus have no biological, and consequently, no clinical sense. Reply: Search for a predictive relationship between ultrasound thickness of the lower uterine segment and rupture of the uterus in women with a prior cesarean does not make biological senseAmerican Journal of Obstetrics & GynecologyVol. 226Issue 2PreviewWe would like to thank Drs Ragusa and Svelato for their comments regarding our recent article titled “Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean: a randomized trial.”1 Full-Text PDF

The aim of the pilot randomized controlled field trial is to assess if a midwifery intervention is able to increase the maternal self-efficacy and reduce the stress level during the first six months after birth.The study was conducted in two different hospitals in Rome, Italy, involving women delivering at or beyond term, aged >18 years old and with normal APGAR scores of the infant. The participants were randomly divided into two groups: "Individual Intervention Group" (they received home midwifery assistance for one month after birth, I) and the "Control Group" (C). A self-administered questionnaire was administered four times: at the baseline about one week after the hospital delivery (T0), after the intervention about one month after the delivery (T1), and at three months (T2) and at six months after birth (T3). The questionnaire included different validated scales needed to assess maternal perceived self-efficacy (KPCS), parental stress scale stress (PSS) and maternal depressive risk symptoms (EPDS).The study population counted 51 mothers: 28 women in the "C" group and 23 women in the "I" group. The PSS score was statistically higher in the "C" than "I" group at T1 (p = 0.024); whereas the KPCS score was statistically higher in the "I" (p = 0.039) group; EPDS score did not show significant difference between the two groups in the follow-up period. An inverse significant correlation between KPCS and PSS was found during the study window time (p < 0.0001).These results potentially give the opportunity to explore this area of focus further, in order to better address maternal individual needs for the successful transition to motherhood. More research in this area is required.

Our organism and the expression of our genetic inheritance are conditioned by the environment. This is demonstrated by experimental models on animals, but more and more evidence shows similarities also in humans. Evidence now supports that neonatal and maternal health also depends on the interactions between the environment and the DNA itself. Even though the DNA sequence remains the same over the years, some genetic traits of human beings can be affected by the silencing or activation of some nucleotide sequences, for example by DNA methylation. Today, epigenetics is much more important than we used to think in 1942 when Waddington used the word “epigenetics” for the first time. The environment can modify DNA sequence methylation, affecting protein production and the phenotype. Examples of how epigenetics affects childbirth phenomenon are given and mechanisms are discussed. Four biological mechanisms of epigenetics are presented: genomic imprinting and silencing of the paternal set of chromosomes, the unpredictable “on/off” expression patterns of wild type genes, paramutations, and alternative states of protein folding. Some genes are triggered by stress, maternal nutrition, drugs (namely oxytocin, fentanyl), childbirth modalities, labor, environmental behavior, microorganism colonization. Imprinting theory is a good scientific basis, to explain the permanence of some biological effects at a considerable time after birth. Imprinting is an important mechanism of DNA expression, and different types of imprinting are described. The consequences of antibiotic use in the childbirth period are discussed, along with the importance of awareness in the use of antibiotics for maternal prophylaxis. Prenatal antibiotics and cesarean sections do affect neonatal microbiome considerably and, therefore, may be the causes of inflammatory intestinal disorders, asthma, obesity, diabetes. Mode of delivery, labor, breastfeeding, and skin-to-skin practice are strictly related to future neonatal health, and the effects are shown here. One of the most important factors to explain the diseases mentioned above is probably the lack of “bacterial contamination” through the birth canal. However, this mechanism cannot be the only one to act, and, in fact, here we also discuss other mechanisms that contribute to the development of future pathologies. Last but not least, the culture and education of the operators, as well as maternal and providers’ attendance behavior during childbirth,  can change the relative outcomes of children’s long-term health.

Objective.Dystocia in labour is the most common indication for primary caesarean sections.We have investigated how Italian midwives are informed and aware of the diagnosis of dystocia in labour, which strategies they implement and how their culture can affect clinical decisions.Methods.Purpose-built questionnaire using convenience sampling on a voluntary basis.The research was carried out on a population of Italian midwives.The questionnaire was divided into three macro-areas: socio-demographic information; a clinical case with decision questions; operators' knowledge and clinical choices.Results.300 questionnaires were collected, and 289 were analysed.60% of midwives would have not diagnosed active labour before 6 cm of dilation and would have adopted conservative management.81% would adopt methods such as change of maternal posture, movement, and emotional support to solve dystocia rather than oxytocin and artificial rupture of membranes.76% is aware that there is no single definition of dystocia, 80% do not know the definition of latent phase.The discussion on dystocia is rarely addressed in a context such as an audit.Conclusions.Culture considered as experience, knowledge, and work context, could affect clinical practice.Most midwives showed interest in the subject by tackling it with a view that was mainly physiological.The need for training and structured discussion meetings is, in any case, important. SOMMARIOObiettivo.La distocia in travaglio è la più comune indicazione al taglio cesareo primario.Abbiamo indagato quanto le ostetriche italiane siano informate e consapevoli della diagnosi di distocia in travaglio, quali strategie gestionali mettano in atto e quanto la loro cultura possa influenzare le decisioni cliniche.Metodi.Indagine conoscitiva mediante questionario costruito ad hoc utilizzando un campionamento di convenienza su base volontaria.La ricerca è stata condotta su una popolazione di ostetriche.Il questionario è stato suddiviso in tre macro aree: informazioni socio-demografiche; caso clinico con domande decisionali; conoscenze degli operatori e loro scelte cliniche.Risultati.Sono stati raccolti 300 questionari e ne sono stati analizzati 289.Il 60% delle ostetriche non avrebbe fatto diagnosi di travaglio attivo prima dei 6 cm di dilatazione e avrebbe adottato un management di attesa.L'81% adotterebbe metodi come il cambio di postura, il movimento e il supporto emotivo per la risoluzione della distocia a sfavore dell'ossitocina e dell'amnioressi.Il 76% è consapevole che non vi sia una definizione univoca di distocia, l'80% non conosce la definizione di fase latente.La discussione sulla distocia è raramente affrontata in un contesto come l'audit.Conclusioni.La cultura intesa come esperienza, conoscenza e contesto lavorativo potrebbe influenzare la pratica clinica.La gran parte delle ostetriche ha mostrato interesse verso la tematica affrontandola in un'ottica prevalentemente di normalità.È comunque rilevante il bisogno di formazione e la necessità di incontri di discussione strutturati.

Synopsis Ultrasonography is very useful for the diagnosis of umbilical cord entanglements and for counseling with parents.