Browsing by Author "Malvasi, Antonio (15045047100)"

This narrative review aimed to summarize all adverse outcomes of pregnancy in advanced maternal age (AMA) to assess the age of the mother as a potentially crucial risk factor. AMA refers to women older than 35 years. While expectations and the role of women in society have undergone significant changes today, the biology of aging remains unchanged. Various pathologic changes occur in the human body with age, including chronic noncommunicable diseases, as well as notable changes in reproductive organs, that significantly affect fertility. Despite substantial advancements in technology and medicine, pregnancy in AMA remains a formidable challenge. Although there are some advantages to postponing childbirth, they primarily relate to maternal maturity and economic stability. However, regrettably, there are also many adverse aspects of pregnancy at advanced ages. These include complications affecting both the mother and the fetus. Pregnants in AMA were more prone to suffer from gestational diabetes mellitus, preeclampsia, and eclampsia during pregnancy compared to younger women. In addition, miscarriages and ectopic pregnancies were more prevalent. Delivery was more frequently completed via cesarean section, and postpartum complications and maternal mortality were also higher. Unfortunately, there were also complications concerning the fetus, such as chromosomal abnormalities, premature birth, low birth weight, admission to the neonatal intensive care unit, and stillbirth. © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2024.

Asynclitism, a misalignment of the fetal head with respect to the plane of passage through the birth canal, represents a significant obstetric challenge. High degrees of asynclitism are associated with labor dystocia, difficult operative delivery, and cesarean delivery. Despite its clinical relevance, the diagnosis of asynclitism and its influence on the outcome of labor remain matters of debate. This study analyzes the role of the degree of asynclitism (AD) in assessing labor progress and predicting labor outcome, focusing on its ability to predict intrapartum cesarean delivery (ICD) versus non-cesarean delivery. The study also aims to assess the performance of the AIDA (Artificial Intelligence Dystocia Algorithm) algorithm in integrating AD with other ultrasound parameters for predicting labor outcome. This retrospective study involved 135 full-term nulliparous patients with singleton fetuses in cephalic presentation undergoing neuraxial analgesia. Data were collected at three Italian hospitals between January 2014 and December 2020. In addition to routine digital vaginal examination, all patients underwent intrapartum ultrasound (IU) during protracted second stage of labor (greater than three hours). Four geometric parameters were measured using standard 3.5 MHz transabdominal ultrasound probes: head-to-symphysis distance (HSD), degree of asynclitism (AD), angle of progression (AoP), and midline angle (MLA). The AIDA algorithm, a machine learning-based decision support system, was used to classify patients into five classes (from 0 to 4) based on the values of the four geometric parameters and to predict labor outcome (ICD or non-ICD). Six machine learning algorithms were used: MLP (multi-layer perceptron), RF (random forest), SVM (support vector machine), XGBoost, LR (logistic regression), and DT (decision tree). Pearson’s correlation was used to investigate the relationship between AD and the other parameters. A degree of asynclitism greater than 70 mm was found to be significantly associated with an increased rate of cesarean deliveries. Pearson’s correlation analysis showed a weak to very weak correlation between AD and AoP (PC = 0.36, p < 0.001), AD and HSD (PC = 0.18, p < 0.05), and AD and MLA (PC = 0.14). The AIDA algorithm demonstrated high accuracy in predicting labor outcome, particularly for AIDA classes 0 and 4, with 100% agreement with physician-practiced labor outcome in two cases (RF and SVM algorithms) and slightly lower agreement with MLP. For AIDA class 3, the RF algorithm performed best, with an accuracy of 92%. AD, in combination with HSD, MLA, and AoP, plays a significant role in predicting labor dystocia and labor outcome. The AIDA algorithm, based on these four geometric parameters, has proven to be a promising decision support tool for predicting labor outcome and may help reduce the need for unnecessary cesarean deliveries, while improving maternal-fetal outcomes. Future studies with larger cohorts are needed to further validate these findings and refine the cut-off thresholds for AD and other parameters in the AIDA algorithm. © 2024 by the authors.

Asynclitism, a misalignment of the fetal head with respect to the plane of passage through the birth canal, represents a significant obstetric challenge. High degrees of asynclitism are associated with labor dystocia, difficult operative delivery, and cesarean delivery. Despite its clinical relevance, the diagnosis of asynclitism and its influence on the outcome of labor remain matters of debate. This study analyzes the role of the degree of asynclitism (AD) in assessing labor progress and predicting labor outcome, focusing on its ability to predict intrapartum cesarean delivery (ICD) versus non-cesarean delivery. The study also aims to assess the performance of the AIDA (Artificial Intelligence Dystocia Algorithm) algorithm in integrating AD with other ultrasound parameters for predicting labor outcome. This retrospective study involved 135 full-term nulliparous patients with singleton fetuses in cephalic presentation undergoing neuraxial analgesia. Data were collected at three Italian hospitals between January 2014 and December 2020. In addition to routine digital vaginal examination, all patients underwent intrapartum ultrasound (IU) during protracted second stage of labor (greater than three hours). Four geometric parameters were measured using standard 3.5 MHz transabdominal ultrasound probes: head-to-symphysis distance (HSD), degree of asynclitism (AD), angle of progression (AoP), and midline angle (MLA). The AIDA algorithm, a machine learning-based decision support system, was used to classify patients into five classes (from 0 to 4) based on the values of the four geometric parameters and to predict labor outcome (ICD or non-ICD). Six machine learning algorithms were used: MLP (multi-layer perceptron), RF (random forest), SVM (support vector machine), XGBoost, LR (logistic regression), and DT (decision tree). Pearson’s correlation was used to investigate the relationship between AD and the other parameters. A degree of asynclitism greater than 70 mm was found to be significantly associated with an increased rate of cesarean deliveries. Pearson’s correlation analysis showed a weak to very weak correlation between AD and AoP (PC = 0.36, p < 0.001), AD and HSD (PC = 0.18, p < 0.05), and AD and MLA (PC = 0.14). The AIDA algorithm demonstrated high accuracy in predicting labor outcome, particularly for AIDA classes 0 and 4, with 100% agreement with physician-practiced labor outcome in two cases (RF and SVM algorithms) and slightly lower agreement with MLP. For AIDA class 3, the RF algorithm performed best, with an accuracy of 92%. AD, in combination with HSD, MLA, and AoP, plays a significant role in predicting labor dystocia and labor outcome. The AIDA algorithm, based on these four geometric parameters, has proven to be a promising decision support tool for predicting labor outcome and may help reduce the need for unnecessary cesarean deliveries, while improving maternal-fetal outcomes. Future studies with larger cohorts are needed to further validate these findings and refine the cut-off thresholds for AD and other parameters in the AIDA algorithm. © 2024 by the authors.

Objective: Although the first report on cesarean myomectomy (CM) was a century ago, the management of a myomectomy during a cesarean section (CS) remains controversial. The objective of this study is to provide the latest data on this topic regarding the techniques and complications of CM. Methods: The authors consulted the most important scientific databases investigating the indications and contraindications for CM, the operational techniques, benefits and complications. Results: CM provides the benefits of two surgeries in one laparotomy, avoiding the risks of repeated anesthesia and relaparotomy. Nevertheless, in some patients, CM may be associated with increased morbidity and, in such cases, an interval myomectomy might be a safer option. Myomas compromising fetal extraction and uterine incision and/or suturing should be preferably enucleated during CS. CM is generally considered relatively safe in cases of anterior wall myomas, subserous and pedunculated myomas, particularly if a myomectomy is feasible without additional hysterotomy. Multiple myomas, deep intramural, fundal and cornual myomas and posterior uterine wall myomas are associated with more surgical complications during CM. Conclusions: With increasing reports in favor of CM, the risk–benefit ratio should be still evaluated with randomized controlled trials, in order to achieve more data on CM. © 2016 Informa UK Limited, trading as Taylor & Francis Group.

Up to 70–80% of women of reproductive age may be affected with the most common uterine tumors, known as fibroids or myomas. These benign tumors are the second most prevalent cause of surgery among premenopausal women. Predictions show that the occurrence of myomas in pregnancy will increase, and that the risk of having myomas during pregnancy increases with advanced maternal age. Although most women with fibroids do not experience any symptoms during pregnancy, up to 30% of women experience problems during pregnancy, childbirth, and the puerperium. The viability of myoma excision during cesarean surgery (CS) is a contentious issue raised by the rising incidence of myomas in pregnancy and CS rates. A new surgical procedure for removing fibroids using a trans-endometrial approach, which involves making an incision through the decidua itself, has put into doubt the long-standing practice of cesarean myomectomy (CM) with a trans-serosal approach. Some authors have recently advocated for this last approach, highlighting its advantages and potential uses in real-world situations. The purpose of this paper is to critique the present approach to cesarean myomectomy by analyzing the clinical and surgical distinctions between the two approaches and providing illustrations of the CM methods. © 2024 by the authors.

This article focuses on the anatomy, literature, and our own experiences in an effort to assist in the decision-making process of choosing between an umbilical or vaginal port. Umbilical access is more familiar to general surgeons; it is thicker than the transvaginal entry, and has more nerve endings and sensory innervations. This combination increases tissue damage and pain in the umbilical port site. The vaginal route requires prophylactic antibiotics, a Foley catheter, and a period of postoperative sexual abstinence. Removal of large specimens is a challenge in traditional laparoscopy. Recently, there has been increased interest in going beyond traditional laparoscopy by using the navel in single-incision and port-reduction techniques. The benefits for removal of surgical specimens by colpotomy are not new. There is increasing interest in techniques that use vaginotomy in multifunctional ways, as described under the names of culdolaparoscopy, minilaparoscopy-assisted natural orifice surgery, and natural orifice transluminal endoscopic surgery. Both the navel and the transvaginal accesses are safe and convenient to use in the hands of experienced laparoscopic surgeons. The umbilical site has been successfully used in laparoscopy as an entry and extraction port. Vaginal entry and extraction is associated with a lower risk of incisional hernias, less postoperative pain, and excellent cosmetic results. © 2017 by the Turkish-German Gynecological Education and Research Foundation.

Uterine rupture constitutes a critical obstetric emergency that presents substantial risks to both the maternal and fetal populations. This investigation evaluated the surgical interventions available for uterine rupture, emphasizing laparoscopic repair subsequent to uterine rupture. Laparoscopic repair serves as a fertility-sustaining alternative to conventional laparotomy, demonstrating comparable operative durations of 80 min (interquartile range [IQR] 60–114) for laparoscopic procedures versus 78 min (IQR 58–114) for laparotomy interventions. Nevertheless, laparoscopic approaches confer significant advantages, including a reduced incidence of intensive care unit (ICU) admissions (14.2% vs. 40% for laparotomy), a diminished requirement for blood transfusions (14.2% vs. 60%), and abbreviated hospital stays (median of 3 days vs. 5 days for laparotomy). The investigation explored the contentious discourse surrounding single-layer versus double-layer suturing methodologies, noting that barbed sutures significantly decrease uterine closure times (224 ± 46 vs. 343 ± 75 s for traditional sutures). Single-layer suturing is advocated as sufficient for maintaining uterine integrity in suitably selected cases. The necessity of meticulous postoperative monitoring, particularly concerning the assessment of recurrence in subsequent pregnancies, is emphasized, with recurrence rates varying from 4.8% to 19.4%. Finally, authors also proposed a feasible laparoscopic technique to repair a uterine rupture (the “CHEESE” method [closure of hemodynamically stable, early uterine rupture, via endoscopic surgery after spontaneous delivery]), appropriate for hemodynamically stable patients with minor ruptures. This review underscores the progressive role of minimally invasive techniques in the management of uterine rupture and seeks to optimize clinical outcomes for both maternal and neonatal health. © 2025 International Federation of Gynecology and Obstetrics.

[No abstract available]

Myomas are the most common disorder of the female genital organs, occurring more frequently throughout women's reproductive years. Myomas are a major health issue all over the world. They develop as a monoclonal tumor from cells influenced by ovarian steroids, and mediated by surrounding myometrial cells by paracrine mechanisms. During its growth, a myoma compresses the surrounding tissue, causing the formation of a pseudocapsule, encapsulating the myoma. The mechanical properties of myomas are a key factor which can contribute to their growth. While myomas are essentially rigid, their pseudocapsule is more elastic, and this allows uterine adaptation to the growing myoma. Hence, the pseudocapsule induces displacement on the myometrium, which is not destructive since the integrity and contractility of uterine structure is maintained. Extensive research conducted on the myoma and its pseudocapsule has produced important data. Scientific research is still trying to clarify some of the evidence regarding the influence of myomas on infertility, especially in the case of intramural myomas. During fertility-sparing myoma surgery, data suggest that during myoma removal the pseudocapsule should be preserved. However, unsolved issues still exist on the cesarean myomectomy technique, since the age of pregnancy has been increasing in the new millennium, so patients present with myomas which should be removed before and during the cesarean section, or prior to applying for medically-assisted reproduction. © 2016 Edizioni Minerva Medica.

Purpose: To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals. Materials and methods: 40 years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables. Results: 202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups. Conclusion: Patients aged over 40 years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management. © 2023, The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

[No abstract available]

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Purpose: Polycystic ovary syndrome (PCOS) is the most common endocrine-reproductive disease linked not just to infertility but also to serious comorbidities. There is a reported association between low vitamin D levels and multiple health conditions including PCOS. This narrative review aims to analyze the role of vitamin D in PCOS development, use of the vitamin D in the treatment of PCOS, and the molecular basis of these observations. Methods: A Medline and PubMed research was performed, during the years 1990–2023, using a combination of keywords on such topic. According to the author's evaluation and target, papers were identified and included for a narrative review. Results: There are associations between lower levels of vitamin D and PCOS, as well as with insulin resistance, metabolic syndrome, hyperandrogenemia, metabolic and endocrine disorders as well as the onset of oxidative stress and pro-inflammatory milieu, in PCOS women. Conclusion: Vitamin D has a role in pathologic changes linked to PCOS. Molecular and clinical investigations which give new information about the role of vitamin D in the development of PCOS and related endocrine and metabolic disturbance are further needed. © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023.

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Objective: Cesarean myomectomy (CM) is a safe procedure in selected cases. Nevertheless, literature lacks clear guidelines on patient selection. We aimed to evaluate CM safety in patients with single anterior wall and lower uterine segment (LUS) myomas. Methods: The authors selected pregnants at term, scheduled for CSs, with single anterior wall or LUS myomas. All their clinical, demographic, obstetric, and surgical parameters were recorded. Results: Thirty-six women had a CM (study group), and 17 had a CS without myoma removal (control group). No significant differences were detected in the socio-demographic and clinical findings between the groups. The average size of myomas in the study and control group (p =.873), was 55.44 mm and 47.25 mm, respectively. The average surgery duration was 62.5 min in the study and 53.82 in the control group (p =.058). Intraoperative hemorrhage was more frequent in the study group (p =.045). Nevertheless, neither the number nor the volume of intraoperative transfusions was significantly different. None of the major CM complications were recorded, and the duration of hospitalization was similar in both groups. Conclusions: CM in patients with single anterior wall and LUS myomas does not cause increased perioperative morbidity, and, therefore, can be considered safe in such cases. © 2017 Informa UK Limited, trading as Taylor & Francis Group.

Purpose: To determine the incidence of and risk factors for perioperative complications in women with a single uterine fibroid, who had a cesarean myomectomy (CM). Methods: This was a retrospective study of women who had a CM between 2015–2016. They were compared versus women who had a cesarean section (CS) alone and nonpregnant women who had a laparotomic myomectomy (LM). Results: We identified 44 CM women, 51 CS patients, and 44 LM women. Those with a CM in most cases had subserosal at the anterior uterine wall and near the lower uterine segment (LUS), as most frequent fibroids; moreover, they had, on average, 18 min longer surgery duration versus CS alone. CM did not affect the Apgar scores and the incidence of minor and major complications was 36.4% and 29.5%, with the most frequent being postoperative anemia (36.4%) and intraoperative hemorrhage (29.5%). No significant differences were reported on both minor and major complications in the three groups. The following variables were found to be significant predictors in univariate logistic regression analysis for the occurrence of major complications in women who had a CM: the fibroid size (OR = 1.040, 95%CI: 1.014–1.066, p =.002), and duration of surgery (OR = 1.059, 5%CI:1.012–1.108, p =.013). The fibroid diameter cut-off was 75.0 mm (sensitivity 69.2%; specificity 90.3%), and the surgery duration was 87.5 min (sensitivity 53.8%; specificity 93.5%). Conclusion: CM appears safe, with no additional risks when compared to CS alone and LM in the women of reproductive age. © 2019 Informa UK Limited, trading as Taylor & Francis Group.

Uterine myomas or fibroids are the most common benign female tumors of the reproductive organs, associated with significant morbidity and quality of life impairment. Several epidemiological risk factors for their occurrence have been identified so far, including nutrition and dietary habits. In this investigation, authors reviewed, as a narrative review, the data about diet and uterine myoma development in order to homogenize the current data. A PubMed search was conducted for the years 1990-2020, using a combination of keywords of interest for the selected topic. The authors searched the databases, selecting the randomized clinical studies, the observational studies, and the basic (experimental), clinical, and epidemiological researches. Once they collected the articles, they analyzed them according to the number of citations of each article, starting from the most cited to the least cited articles. Subsequently, authors collected the data of each article and inserted them in the various research paragraphs, summarizing the data collected. In this way, they crossed the available data regarding the association between nutrition habits and dietary components and myoma onset and growth. Many nutrients and dietary habits are associated with myoma development risk. These factors include low intakes of fruit, vegetables, and vitamin D, as well as pollutants in food. Despite the available data on the influence of some foods on the development of fibroids, further research is mandatory to understand all the nutrition risk factors which contribute to myoma growth and how exactly these risk factors influence myoma pathogenesis. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

Uterine myomas or fibroids are the most common benign female tumors of the reproductive organs, associated with significant morbidity and quality of life impairment. Several epidemiological risk factors for their occurrence have been identified so far, including nutrition and dietary habits. In this investigation, authors reviewed, as a narrative review, the data about diet and uterine myoma development in order to homogenize the current data. A PubMed search was conducted for the years 1990-2020, using a combination of keywords of interest for the selected topic. The authors searched the databases, selecting the randomized clinical studies, the observational studies, and the basic (experimental), clinical, and epidemiological researches. Once they collected the articles, they analyzed them according to the number of citations of each article, starting from the most cited to the least cited articles. Subsequently, authors collected the data of each article and inserted them in the various research paragraphs, summarizing the data collected. In this way, they crossed the available data regarding the association between nutrition habits and dietary components and myoma onset and growth. Many nutrients and dietary habits are associated with myoma development risk. These factors include low intakes of fruit, vegetables, and vitamin D, as well as pollutants in food. Despite the available data on the influence of some foods on the development of fibroids, further research is mandatory to understand all the nutrition risk factors which contribute to myoma growth and how exactly these risk factors influence myoma pathogenesis. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

[No abstract available]