mark formosa | University of Malta (original) (raw)

Papers by mark formosa

Pregnancy is an altered physiological state where an organism essentially foreign to the individu... more Pregnancy is an altered physiological state where an organism essentially foreign to the individual carrying it, grows, develops and at an appropriate time probably initiates a series of signals which lead to its safe expulsion from the woman's body. The immunological changes which allow this process are unique to pregnancy. Recent work in this field has led to a further understanding of the changes which operate to adapt the woman to the pregnant state. The concept that has developed over the years is one where a number of factors exert their effect both at the systemic but mostly at the local uterine level to modulate the immune response which will then refrain from mounting an inflammatory response against the invading trophoblast. The main protagonists of this immunomodulation are embryonic factors, uterine (endometrial) NK cells and, of course, the hormone progesterone. Progress has been made from the original observations of miscarriage rates in HLA sharing couples and with the possibility of research in couples undergoing IVF cycles, factors are being identified which initiate immunomodulation. Once implantation occurs the endometrial NK cells which are abundant from the late luteal phase are activated to control trophoblastic invasion and enhance the changes in blood vessels which allow for adequate feto-maternal perfusion. The immune response is controlled by PIBF under the influence of progesterone to bias towards a humoral response and suppress a cytotoxic response. All these processes are prone to fail at times and the clinical manifestation of such a failure is miscarriage along with other obstetric complications such as intra-uterine growth retardation, pre-eclampsia and placental abruption. Progress in the understanding of the immunological processes which protect pregnancy will help in elucidating the mechanisms whereby these processes fail. A consequence of this should be the explanation of those cases as yet classified as unexplained recurrent miscarriage. The literature indicates that the prognosis for this group of patients is not as encouraging as one would hope and that progress in this area is eagerly awaited by both patients and doctors working in this field.

Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed wee... more Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed weeks. When diagnosing a case of preterm labour, problems arise because of the difficulty in defining established labour. labour is usually heralded by the onset of regular uterine contractions which produce effective cervical dilatation. Premature births account for a large fraction of perinatal mortality and morbidity. Despite major advances in neonatal care, retention of the foetus in utero is preferred in most instances.

Obstetrics & Gynecology International Journal, Mar 7, 2019

Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a... more Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a 46 year old lady was diagnosed with an infiltrative high grade small cell neuroendocrine adenocarcinoma which was infiltrating the uterus, after she presented with unprovoked vaginal bleeding. Surgery was done successfully, after which she was referred for chemotherapy. Discussion: MR imaging was essential in staging the tumour. It is also important to appreciate the rarity of such a diagnosis and the intricacies of its management Conclusion: A multidisciplinary approach in such cases is essential, as well as appropriate counselling of the patient.

International journal of gynaecology and obstetrics, 2000

Journal of Case Reports and Images in Obstetrics and Gynecology, 2019

A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopa... more A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopausal woman who was referred with an incidental finding of an asymptomatic pelvic mass. Extraovarian granulosa cell tumors are derived from ectopic gonadal tissue which is situated along the embryonal route of the genital ridge. An ultrasound revealed a heterogenic mass with increased vascularity on colour doppler.

Journal of Obstetrics and Gynaecology, Mar 17, 2022

The incidence of ectopic pregnancies has steadily increased over recent years and despite advance... more The incidence of ectopic pregnancies has steadily increased over recent years and despite advances in treatment it still remains a major cause of maternal morbidity and mortality. The objective of this audit was to assess whether diagnosis and management is occurring as per international suggested guidance and practice. This study is a retrospective one using data collected from June 2019 to June 2020. All data were password protected and kept anonymous. No patient contact occurred. The standard cross referenced was the 'April 2019 NICE Guideline on the Management of Ectopic Pregnancy'. Thirty-one ectopic pregnancies occurred between June 2019 and June 2020. Twenty-nine underwent surgical management and two medical. Six out of the 29 surgically managed patients were managed incorrectly. Twenty-four of the surgical cases were managed laparoscopically. Presence of a foetal heart rate remained undocumented in 21 out of 31 of cases. The results highlight the ease of access to emergency gynaecological services at Malta's national hospital. However, this audit did highlight the discrepancy that can occur in examination in association with ectopic pregnancy. An inconsistency was noted in documentation. Additionally, a number of cases could have been offered and benefitted from different modes of management.Impact StatementWhat is already known on this subject? Ectopic pregnancy (EP) is an important cause of morbidity and mortality in mothers of childbearing age. The diagnostic method and appropriate management for EP has been extensively studied. Concrete- and evidence-based guidelines guide clinical management and improve morbidity and mortality. Local guidelines improve clinical outcome.What do the results of this study add? This study shows the impact of clinical outcome without a national guideline to guide management on a national level. Malta has one national hospital in which the local obstetrics and gynaecology department is run. The results of this study thus comprise of nationwide statistics on EP and its management. Ectopic pregnancies are managed without a local guideline in place. It also reflects the ease of access to health care in smaller countries.What are the implications of these findings for clinical practice and/or further research? The findings of this study have resulted in the production of a local guideline for the management of EP, as well as the introduction of a protocol for obtaining methotrexate for medical management. It has introduced new ultrasound machines and staff training to aid diagnostics. Further re-auditing will be carried out to analyse the impact a local guideline has on clinical practice at a national level.

Journal of Obstetrics and Gynaecology, 2022

The incidence of ectopic pregnancies has steadily increased over recent years and despite advance... more The incidence of ectopic pregnancies has steadily increased over recent years and despite advances in treatment it still remains a major cause of maternal morbidity and mortality. The objective of this audit was to assess whether diagnosis and management is occurring as per international suggested guidance and practice. This study is a retrospective one using data collected from June 2019 to June 2020. All data were password protected and kept anonymous. No patient contact occurred. The standard cross referenced was the 'April 2019 NICE Guideline on the Management of Ectopic Pregnancy'. Thirty-one ectopic pregnancies occurred between June 2019 and June 2020. Twenty-nine underwent surgical management and two medical. Six out of the 29 surgically managed patients were managed incorrectly. Twenty-four of the surgical cases were managed laparoscopically. Presence of a foetal heart rate remained undocumented in 21 out of 31 of cases. The results highlight the ease of access to emergency gynaecological services at Malta's national hospital. However, this audit did highlight the discrepancy that can occur in examination in association with ectopic pregnancy. An inconsistency was noted in documentation. Additionally, a number of cases could have been offered and benefitted from different modes of management.Impact StatementWhat is already known on this subject? Ectopic pregnancy (EP) is an important cause of morbidity and mortality in mothers of childbearing age. The diagnostic method and appropriate management for EP has been extensively studied. Concrete- and evidence-based guidelines guide clinical management and improve morbidity and mortality. Local guidelines improve clinical outcome.What do the results of this study add? This study shows the impact of clinical outcome without a national guideline to guide management on a national level. Malta has one national hospital in which the local obstetrics and gynaecology department is run. The results of this study thus comprise of nationwide statistics on EP and its management. Ectopic pregnancies are managed without a local guideline in place. It also reflects the ease of access to health care in smaller countries.What are the implications of these findings for clinical practice and/or further research? The findings of this study have resulted in the production of a local guideline for the management of EP, as well as the introduction of a protocol for obtaining methotrexate for medical management. It has introduced new ultrasound machines and staff training to aid diagnostics. Further re-auditing will be carried out to analyse the impact a local guideline has on clinical practice at a national level.

Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed wee... more Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed weeks. When diagnosing a case of preterm labour, problems arise because of the difficulty in defining established labour. labour is usually heralded by the onset of regular uterine contractions which produce effective cervical dilatation. Premature births account for a large fraction of perinatal mortality and morbidity. Despite major advances in neonatal care, retention of the foetus in utero is preferred in most instances.

Journal of Case Reports and Images in Obstetrics and Gynecology, 2019

A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopa... more A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopausal woman who was referred with an incidental finding of an asymptomatic pelvic mass. Extraovarian granulosa cell tumors are derived from ectopic gonadal tissue which is situated along the embryonal route of the genital ridge. An ultrasound revealed a heterogenic mass with increased vascularity on colour doppler.

Journal of Case Reports and Images in Obstetrics and Gynecology, 2019

A case of xanthogranulomatous salpingitis is presented in a 36-year-old woman with a longstanding... more A case of xanthogranulomatous salpingitis is presented in a 36-year-old woman with a longstanding history of chronic pelvic pain on a background of endometriosis. The presentation of endometriosis in this case is that of hemorrhagic ascites which is a rare occurrence. Xanthogranulomatous salpingitis is a rare form of chronic inflammation involving the fallopian tube, and it is characterized by the presence of lipid-laden macrophages and other chronic inflammatory cells within the wall of the fallopian tube. There are only a few cases of xanthogranulomatous inflammation affecting the female genital tract which are reported in the medical literature.

Obstetrics & Gynecology International Journal, 2019

Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a... more Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a 46 year old lady was diagnosed with an infiltrative high grade small cell neuroendocrine adenocarcinoma which was infiltrating the uterus, after she presented with unprovoked vaginal bleeding. Surgery was done successfully, after which she was referred for chemotherapy. Discussion: MR imaging was essential in staging the tumour. It is also important to appreciate the rarity of such a diagnosis and the intricacies of its management Conclusion: A multidisciplinary approach in such cases is essential, as well as appropriate counselling of the patient.

Malta Medical …, 2004

Introduction The leading cause of morbidity and mortality during pregnancy and the puerperium is ... more Introduction The leading cause of morbidity and mortality during pregnancy and the puerperium is venous thromboembolism. Though uncommon, the risk is five times higher in a pregnant woman than in a non-pregnant woman of similar age.1,2 In pregnancy, all three underlying ...

European Journal of Obstetrics & Gynecology and Reproductive Biology, 2016

of which 59.5% held thromboprophylaxis during pregnancy until six weeks after delivery and none o... more of which 59.5% held thromboprophylaxis during pregnancy until six weeks after delivery and none of them had a thrombotic event. Of the 54 pregnant women evaluated, the existence of an inherited thrombophilia was the most common referral reason. 64.8% held thromboprophylaxis during pregnancy until six weeks after delivery. Hypertensive complications were not registered, however three women suffered some type of thromboembolic event. Conclusions: The study of thrombophilia in high risk women should be performed for the timely establishment of thromboprophyl axis to prevent adverse pregnancy and perinatal outcomes.

Pregnancy is an altered physiological state where an organism essentially foreign to the individu... more Pregnancy is an altered physiological state where an organism essentially foreign to the individual carrying it, grows, develops and at an appropriate time probably initiates a series of signals which lead to its safe expulsion from the woman's body. The immunological changes which allow this process are unique to pregnancy. Recent work in this field has led to a further understanding of the changes which operate to adapt the woman to the pregnant state. The concept that has developed over the years is one where a number of factors exert their effect both at the systemic but mostly at the local uterine level to modulate the immune response which will then refrain from mounting an inflammatory response against the invading trophoblast. The main protagonists of this immunomodulation are embryonic factors, uterine (endometrial) NK cells and, of course, the hormone progesterone. Progress has been made from the original observations of miscarriage rates in HLA sharing couples and with the possibility of research in couples undergoing IVF cycles, factors are being identified which initiate immunomodulation. Once implantation occurs the endometrial NK cells which are abundant from the late luteal phase are activated to control trophoblastic invasion and enhance the changes in blood vessels which allow for adequate feto-maternal perfusion. The immune response is controlled by PIBF under the influence of progesterone to bias towards a humoral response and suppress a cytotoxic response. All these processes are prone to fail at times and the clinical manifestation of such a failure is miscarriage along with other obstetric complications such as intra-uterine growth retardation, pre-eclampsia and placental abruption. Progress in the understanding of the immunological processes which protect pregnancy will help in elucidating the mechanisms whereby these processes fail. A consequence of this should be the explanation of those cases as yet classified as unexplained recurrent miscarriage. The literature indicates that the prognosis for this group of patients is not as encouraging as one would hope and that progress in this area is eagerly awaited by both patients and doctors working in this field.

Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed wee... more Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed weeks. When diagnosing a case of preterm labour, problems arise because of the difficulty in defining established labour. labour is usually heralded by the onset of regular uterine contractions which produce effective cervical dilatation. Premature births account for a large fraction of perinatal mortality and morbidity. Despite major advances in neonatal care, retention of the foetus in utero is preferred in most instances.

Obstetrics & Gynecology International Journal, Mar 7, 2019

Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a... more Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a 46 year old lady was diagnosed with an infiltrative high grade small cell neuroendocrine adenocarcinoma which was infiltrating the uterus, after she presented with unprovoked vaginal bleeding. Surgery was done successfully, after which she was referred for chemotherapy. Discussion: MR imaging was essential in staging the tumour. It is also important to appreciate the rarity of such a diagnosis and the intricacies of its management Conclusion: A multidisciplinary approach in such cases is essential, as well as appropriate counselling of the patient.

International journal of gynaecology and obstetrics, 2000

Journal of Case Reports and Images in Obstetrics and Gynecology, 2019

A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopa... more A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopausal woman who was referred with an incidental finding of an asymptomatic pelvic mass. Extraovarian granulosa cell tumors are derived from ectopic gonadal tissue which is situated along the embryonal route of the genital ridge. An ultrasound revealed a heterogenic mass with increased vascularity on colour doppler.

Journal of Obstetrics and Gynaecology, Mar 17, 2022

The incidence of ectopic pregnancies has steadily increased over recent years and despite advance... more The incidence of ectopic pregnancies has steadily increased over recent years and despite advances in treatment it still remains a major cause of maternal morbidity and mortality. The objective of this audit was to assess whether diagnosis and management is occurring as per international suggested guidance and practice. This study is a retrospective one using data collected from June 2019 to June 2020. All data were password protected and kept anonymous. No patient contact occurred. The standard cross referenced was the 'April 2019 NICE Guideline on the Management of Ectopic Pregnancy'. Thirty-one ectopic pregnancies occurred between June 2019 and June 2020. Twenty-nine underwent surgical management and two medical. Six out of the 29 surgically managed patients were managed incorrectly. Twenty-four of the surgical cases were managed laparoscopically. Presence of a foetal heart rate remained undocumented in 21 out of 31 of cases. The results highlight the ease of access to emergency gynaecological services at Malta's national hospital. However, this audit did highlight the discrepancy that can occur in examination in association with ectopic pregnancy. An inconsistency was noted in documentation. Additionally, a number of cases could have been offered and benefitted from different modes of management.Impact StatementWhat is already known on this subject? Ectopic pregnancy (EP) is an important cause of morbidity and mortality in mothers of childbearing age. The diagnostic method and appropriate management for EP has been extensively studied. Concrete- and evidence-based guidelines guide clinical management and improve morbidity and mortality. Local guidelines improve clinical outcome.What do the results of this study add? This study shows the impact of clinical outcome without a national guideline to guide management on a national level. Malta has one national hospital in which the local obstetrics and gynaecology department is run. The results of this study thus comprise of nationwide statistics on EP and its management. Ectopic pregnancies are managed without a local guideline in place. It also reflects the ease of access to health care in smaller countries.What are the implications of these findings for clinical practice and/or further research? The findings of this study have resulted in the production of a local guideline for the management of EP, as well as the introduction of a protocol for obtaining methotrexate for medical management. It has introduced new ultrasound machines and staff training to aid diagnostics. Further re-auditing will be carried out to analyse the impact a local guideline has on clinical practice at a national level.

Journal of Obstetrics and Gynaecology, 2022

The incidence of ectopic pregnancies has steadily increased over recent years and despite advance... more The incidence of ectopic pregnancies has steadily increased over recent years and despite advances in treatment it still remains a major cause of maternal morbidity and mortality. The objective of this audit was to assess whether diagnosis and management is occurring as per international suggested guidance and practice. This study is a retrospective one using data collected from June 2019 to June 2020. All data were password protected and kept anonymous. No patient contact occurred. The standard cross referenced was the 'April 2019 NICE Guideline on the Management of Ectopic Pregnancy'. Thirty-one ectopic pregnancies occurred between June 2019 and June 2020. Twenty-nine underwent surgical management and two medical. Six out of the 29 surgically managed patients were managed incorrectly. Twenty-four of the surgical cases were managed laparoscopically. Presence of a foetal heart rate remained undocumented in 21 out of 31 of cases. The results highlight the ease of access to emergency gynaecological services at Malta's national hospital. However, this audit did highlight the discrepancy that can occur in examination in association with ectopic pregnancy. An inconsistency was noted in documentation. Additionally, a number of cases could have been offered and benefitted from different modes of management.Impact StatementWhat is already known on this subject? Ectopic pregnancy (EP) is an important cause of morbidity and mortality in mothers of childbearing age. The diagnostic method and appropriate management for EP has been extensively studied. Concrete- and evidence-based guidelines guide clinical management and improve morbidity and mortality. Local guidelines improve clinical outcome.What do the results of this study add? This study shows the impact of clinical outcome without a national guideline to guide management on a national level. Malta has one national hospital in which the local obstetrics and gynaecology department is run. The results of this study thus comprise of nationwide statistics on EP and its management. Ectopic pregnancies are managed without a local guideline in place. It also reflects the ease of access to health care in smaller countries.What are the implications of these findings for clinical practice and/or further research? The findings of this study have resulted in the production of a local guideline for the management of EP, as well as the introduction of a protocol for obtaining methotrexate for medical management. It has introduced new ultrasound machines and staff training to aid diagnostics. Further re-auditing will be carried out to analyse the impact a local guideline has on clinical practice at a national level.

Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed wee... more Preterm labour is defined as the onset of labour before 259 days of gestation or 37 completed weeks. When diagnosing a case of preterm labour, problems arise because of the difficulty in defining established labour. labour is usually heralded by the onset of regular uterine contractions which produce effective cervical dilatation. Premature births account for a large fraction of perinatal mortality and morbidity. Despite major advances in neonatal care, retention of the foetus in utero is preferred in most instances.

Journal of Case Reports and Images in Obstetrics and Gynecology, 2019

A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopa... more A rare case of a retroperitoneal granulosa cell tumor (GCT) is presented in a 52-years-old menopausal woman who was referred with an incidental finding of an asymptomatic pelvic mass. Extraovarian granulosa cell tumors are derived from ectopic gonadal tissue which is situated along the embryonal route of the genital ridge. An ultrasound revealed a heterogenic mass with increased vascularity on colour doppler.

Journal of Case Reports and Images in Obstetrics and Gynecology, 2019

A case of xanthogranulomatous salpingitis is presented in a 36-year-old woman with a longstanding... more A case of xanthogranulomatous salpingitis is presented in a 36-year-old woman with a longstanding history of chronic pelvic pain on a background of endometriosis. The presentation of endometriosis in this case is that of hemorrhagic ascites which is a rare occurrence. Xanthogranulomatous salpingitis is a rare form of chronic inflammation involving the fallopian tube, and it is characterized by the presence of lipid-laden macrophages and other chronic inflammatory cells within the wall of the fallopian tube. There are only a few cases of xanthogranulomatous inflammation affecting the female genital tract which are reported in the medical literature.

Obstetrics & Gynecology International Journal, 2019

Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a... more Objective: To describe a case of a small cell neuroendocrine tumour of the cervix. Case report: a 46 year old lady was diagnosed with an infiltrative high grade small cell neuroendocrine adenocarcinoma which was infiltrating the uterus, after she presented with unprovoked vaginal bleeding. Surgery was done successfully, after which she was referred for chemotherapy. Discussion: MR imaging was essential in staging the tumour. It is also important to appreciate the rarity of such a diagnosis and the intricacies of its management Conclusion: A multidisciplinary approach in such cases is essential, as well as appropriate counselling of the patient.

Malta Medical …, 2004

Introduction The leading cause of morbidity and mortality during pregnancy and the puerperium is ... more Introduction The leading cause of morbidity and mortality during pregnancy and the puerperium is venous thromboembolism. Though uncommon, the risk is five times higher in a pregnant woman than in a non-pregnant woman of similar age.1,2 In pregnancy, all three underlying ...

European Journal of Obstetrics & Gynecology and Reproductive Biology, 2016

of which 59.5% held thromboprophylaxis during pregnancy until six weeks after delivery and none o... more of which 59.5% held thromboprophylaxis during pregnancy until six weeks after delivery and none of them had a thrombotic event. Of the 54 pregnant women evaluated, the existence of an inherited thrombophilia was the most common referral reason. 64.8% held thromboprophylaxis during pregnancy until six weeks after delivery. Hypertensive complications were not registered, however three women suffered some type of thromboembolic event. Conclusions: The study of thrombophilia in high risk women should be performed for the timely establishment of thromboprophyl axis to prevent adverse pregnancy and perinatal outcomes.