Female urinary incontinence during pregnancy and after delivery: Clinical impact and contributing factors

Urinary incontinence (UI) is a common condition affecting adult women of all ages and it could have a negative influence on quality of life. The etiology of UI is multifactorial, but some of the most important risk factors are obesity and ageing, as well as adverse obstetric events. Pregnancy and delivery per se have been implicated in the etiology of UI. Although several studies have demonstrated a direct association between UI and vaginal delivery in short, medium and long-term, the role of childbirth on the risk of UI remains controversial. The mechanical strain during delivery may induce injuries to the muscle, connective and neural structures. Vaginal birth can be associated with relaxation or disruption of fascial and ligamentous supports of pelvic organs. Parity, instrumental delivery, prolonged labor and increased birth weights have always been considered risk factors for pelvic floor injury. Also genetic factors have been recently raised up but still there are not appropriate guidelines or measures to reduce significantly the incidence of UI. The role of pelvic floor muscle training (PFMT) in the prevention and treatment of UI is still unclear. However, PFMT seems to be useful when supervised training is conducted and it could be incorporated as a routine part of women’s exercise programmes during pregnancy and after childbirth.     

The pathogenesis of infertility and early pregnancy loss in polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) frequently present with reproductive dysfunction. Ovarian function might be disturbed, with resultant abnormal folliculogenesis and steroidogenesis and, although it is difficult to define the exact pathogenesis of anovulation, many possible mechanisms have been postulated. Folliculogenesis in anovulatory women with PCOS is characterized by failure of dominance and the ovary has multiple small follicles, which are arrested but capable of steroidogenesis. Abnormalities in gonadotrophin and insulin secretion and disordered paracrine function have been identified. Women with PCOS have an increased prevalence of miscarriage, both after spontaneous and induced ovulation. Hypersecretion of LH, hyperandrogenaemia and hyperinsulinaemia have all been investigated as possible causes of PCOS. It is likely that these factors are interlinked and together might result in disordered ovarian and endometrial function. Multiple other possible abnormalities have been postulated as contributory factors in the reproductive failure. These include decreased plasminogen activator inhibitor activity, endothelial dysfunction and obesity. Ideally, therapy should target the underlying disorders but at present data are inadequate and further investigations are essential before therapeutic recommendations are truly based on an understanding of the pathophysiology.     

Type 2 diabetes and the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder, affecting women in reproductive age, characterized by chronic anovulation and hyperandrogenism. The etiology of PCOS is still unknown. However, several studies have suggested that insulin resistance plays an important role in the pathogenesis of the syndrome. As a consequence of insulin-resistance, women affected by PCOS often present abnormalities of glucose metabolism and lipid profile, and have an increased risk of type 2 diabetes and cardiovascular disease over-time. Besides insulin-resistance, it has been demonstrated that some of these women also have alterations in beta-cell-function. Both disorders (insulin-resistance and beta-cell-dysfunction) are recognized as major risk factors for the development of type 2 diabetes. Long-term studies, evaluating the glucose-insulin system in women affected by PCOS, have shown a higher incidence of glucose intolerance, including both impaired glucose tolerance and type 2 diabetes, compared to age and weight matched control populations. The risk of glucose intolerance among PCOS subjects seems to be approximately 5 to 10 fold higher than normal and appears not limited to a single ethnic group. Moreover, the onset of glucose intolerance in PCOS women has been reported to occur at an earlier age than in the normal population (approximately by the 3rd-4th decade of life). However, other risk factors such as obesity, a positive family history of type 2 diabetes and hyperandrogenism may contribute to increasing the diabetes risk in PCOS.     

Metabolic Fuel and Clinical Implications for Female Reproduction

Reproduction is a physiologically costly process that consumes significant amounts of energy. The physiological mechanisms controlling energy balance are closely linked to fertility. This close relationship ensures that pregnancy and lactation occur only in favourable conditions with respect to energy. The primary metabolic cue that modulates reproduction is the availability of oxidizable fuel. An organism’s metabolic status is transmitted to the brain through metabolic fuel detectors. There are many of these detectors at both the peripheral (e.g., leptin, insulin, ghrelin) and central (e.g., neuropeptide Y, melanocortin, orexins) levels. When oxidizable fuel is scarce, the detectors function to inhibit the release of gonadotropin-releasing hormone and luteinizing hormone, thereby altering steroidogenesis, reproductive cyclicity, and sexual behaviour. Infertility can also result when resources are abundant but food intake fails to compensate for increased energy demands. Examples of these conditions in women include anorexia nervosa and exercise-induced amenorrhea. Infertility associated with obesity appears to be less related to an effect of oxidizable fuel on the hypothalamic-pituitary-ovarian axis.Impaired insulin sensitivity may play a role in the etiology of these conditions, but their specific etiology remains unresolved.Research into the metabolic regulation of reproductive function has implications for elucidating mechanisms of impaired pubertal development, nutritional amenorrhea, and obesity-related infertility. A better understanding of these etiologies has far-reaching implications for the prevention and management of reproductive dysfunction and its associated comorbidities.     

The natural course of habitual abortion

In recurrent spontaneous abortion an immunological fetal-maternal imbalance has been postulated and successes of immunotherapy have been described. A prospective study on the reproductive performance of untreated women with three abortions of unknown etiology has not been performed. The benefit of therapy can only be estimated if the natural course of the disease is known. The aim of this study was to investigate prospectively the abortion rate in a well-defined group of women with a history of habitual abortion of unknown etiology and to test the hypothesis that immunologic factors are involved. Fourty-four couples were taken into study. The overall pregnancy rate in the first subsequent pregnancy was 62%. Neither significant increased sharing of Human Leucocyte Antigens (HLA) nor an aberrant mixed lymphocyte reactivity in this group was found when compared to control random matings. The presence or absence of antipaternal antibodies did not correlate with the outcome of the subsequent pregnancy. It is concluded that the prognosis of untreated patients with habitual abortion is favourable and that no aberrant immunologic reactivity could be demonstrated by means of up-to-date diagnostic procedures.     

Dietary therapy in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common condition in women with reproductive age associated with reproductive and metabolic dysfunction. Treatment has traditionally focused on fertility and hormonal therapy. However, obesity, central obesity, and insulin resistance (IR) are strongly implicated in its etiology, and improving these factors has become a treatment target in PCOS. Lifestyle modification programs with an emphasis on behavioral management and dietary and exercise interventions have been successful in reducing the risk of diabetes and the metabolic syndrome in the general population and improving reproductive and metabolic features in PCOS, although as yet there is limited evidence for specific dietary and exercise approaches and guidelines for use in PCOS and requires further investigation. The use of antiobesity pharmacologic agents and bariatric surgery has been recently studied in PCOS and may offer additional treatment options for the future. Future research should focus on the optimal dietary strategies and exercise regimens for PCOS treatment and the relative efficacy and appropriate use of lifestyle management versus antiobesity pharmacologic agents and surgery.     

Genetic and non-genetic theories on the etiology of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder; the precise cause of it remains elusive. This review summarizes the genetic and non-genetic theories that have been postulated to explain the etiology of this enigmatic condition.     

Maternal risks for newborn macrosomia, incidence of a shoulder dystocia and of damages of the plexus brachialis

PATIENTS RESPECTIVELY AND METHODS: In the HEPE 619 242 births have been analysed (1990 - 2000) to calculate the incidence of a birthweight between 4000 and 4499 g and of a weight > or = 4500 g in relationship to maternal obesity, high maternal weight gain and of a duration of pregnancy more than 298 days. RESULTS: The risk of a macrosomia > or = 4500 g is in cases of obesity 3.4 times higher, in cases of obesity and prolongation of pregnancy 6.6 times higher and in the presence of all 3 risk factors 10 times higher. Data of the Frauenklinik Wiesbaden (HSK) (n = 6075 births) complete the results, because a correlation between macrosomia, shoulder dystocia and a damage to the plexus brachialis has been found. The incidence of a damage to the plexus brachialis is in case of a shoulder dystocia and a birth weight of < or = 4000 g 6.3%, at a birth weight between 4000-4499 g 25% and in newborns with a weight > or = 4500 g 40%. CONCLUSIONS: Because of the low sensitivity (60%) of the ultrasonic weight measurement the 3 maternal risk factors--if they exist--of a shoulder dystocia and of a damage of the plexus brachialis should be discussed with the pregnant woman to help her about the decision of an alternative cesarean section. Still one third of the newborns weigh more than 4000 g if all 3 maternal risk factors exist.     

New approach to polycystic ovary syndrome and other forms of anovulatory infertility

Anovulation can be classified in the clinic on the basis of serum hormone assays. Low gonadotropins along with low estrogen concentrations are suggestive of a central origin of the disease, whereas low estrogen levels along with elevated gonadotropins indicate a primary defect at the ovarian level. Most anovulatory patients (approximately 80%) present with serum FSH and estradiol levels within the normal range (World Health Organization class II). Polycystic ovary syndrome (PCOS) is a common but poorly defined heterogeneous clinical entity. Historically, characteristic ovarian abnormalities represented a hallmark of the syndrome. Because several etiological factors may lead to a similar end point (i.e., polycystic ovaries), the development of a clinically applicable classification of the syndrome has proven difficult. Clinical, morphological, biochemical, endocrine, and, more recently, molecular studies have identified an array of underlying abnormalities and added to the confusion concerning the pathophysiology of the disease. Despite the vast literature regarding the etiology and classification of PCOS, no consensus has been reached regarding the validity of criteria used to diagnose the syndrome. For instance, the significance of elevated serum luteinizing hormone (LH) concentrations, insulin resistance or polycystic-appearing ovaries assessed by ultrasound for PCOS diagnosis remains uncertain. In contrast, hyperandrogenism and chronic anovulation generally are believed to be mandatory diagnostic features. Patients with PCOS might visit a dermatologist for hirsutism, a generalist, or internist for complaints related to obesity or a gynecologist for irregular or absent bleeding. However, most patients seek the care of a gynecologist because of cycle abnormalities (oligomenorrhea) and infertility. In PCOS, serum FSH and estradiol (E2) levels are usually found to be within the (broad) normal ranges, whereas LH may either be normal or elevated. Because PCOS with normal or high LH does not seem to represent different clinical entities, it seems justifiable to consider this syndrome as a subgroup of WHO-II patients, although estrogen levels may be tonically elevated in these patients. This review will focus on characteristics of the heterogeneous group of WHO-II patients in an attempt to identify factors involved in the etiology and possible ovulation induction outcome of PCOS. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to outline the current classification of anovulatory infertility and to explain the characteristics and features used for classification.     

妊娠期糖尿病高危因素的研究进展

妊娠期糖尿病(gestational diabetes mellitus,GDM)是妊娠期常见的代谢并发症,严重危害母亲和婴儿健康,其患病率在过去的几十年里一直稳步上升,确切的病因和发病机制目前尚不完全清楚。通过妊娠前和妊娠早期预测GDM的高危因素并采取针对性预防措施,对控制GDM有重要意义。目前研究表明,GDM的发展涉及许多危险因素,较为公认的包括高龄、超重或肥胖等,同时越来越多的研究证明生活方式、多囊卵巢综合征史、血清维生素D水平、环境污染物以及遗传易感性与GDM发病密切相关。简要综述GDM高危因素的研究进展。     

易感基因遗传相关性及检测技术在盆腔器官脱垂的研究

盆腔器官脱垂(pelvic organ prolapsed,POP)不仅严重影响生活质量,而且会产生严重并发症。随着社会老龄化,POP患者逐渐增多,目前其病因和发病机制尚未明确。目前研究认为POP是一种具有遗传倾向性的多因素疾病,包括环境因素和遗传因素等,其中环境因素包括分娩损伤、绝经、肥胖、吸烟等高危因素,而对于遗传因素及遗传倾向性尚不明确。分析归纳盆底支持结构和细胞外基质成分的合成代谢、分解代谢、基因突变和(或)多态性等因素,同时对相关遗传基因的前沿技术和相关信号通路等分别进行概述。     

Polycystic ovary syndrome in the Indian Subcontinent

Polycystic ovary syndrome (PCOS) is a complex, multifaceted, heterogeneous disorder that affects approximately 5 to 10% of women of reproductive age. It is characterized by hyperandrogenism, polycystic ovaries, and chronic anovulation along with insulin resistance, hyperinsulinemia, abdominal obesity, hypertension, and dyslipidemia as frequent metabolic traits (metabolic syndrome) that culminate in serious long-term consequences such as type 2 diabetes mellitus, endometrial hyperplasia, and coronary artery disease. It is one of the most common causes of anovulatory infertility. However, the heterogeneous clinical features of PCOS may change throughout the life span, starting from adolescence to postmenopausal age, largely influenced by obesity and metabolic alterations, and the phenotype of women with PCOS is variable, depending on the ethnic background. The etiology of PCOS is yet to be elucidated; however, it is believed that in utero fetal programming may have a significant role in the development of PCOS phenotype in adult life. Though a woman may be genetically predisposed to developing PCOS, it is only the interaction of environmental factors (obesity) with the genetic factors that results in the characteristic metabolic and menstrual disturbances and the final expression of the PCOS phenotype. Irrespective of geographic locations, a rapidly increasing prevalence of polycystic ovarian insulin resistance syndrome, excess body fat, adverse body fat patterning, hypertriglyceridemia, and obesity-related disease, such as diabetes and cardiovascular disease, have been reported in Asian Indians, suggesting that primary prevention strategies should be initiated early in this ethnic group. In lieu of the epidemic increase in the prevalence of obesity and diabetes mellitus in most industrialized countries including China and India owing to Westernization, urbanization, and mechanization, and evidence suggesting a pathogenetic role of obesity in the development of PCOS and related infertility, active intervention to combat the malice of these disorders is warranted. Pharmacologic therapy is a critical step in the management of patients with metabolic syndrome when lifestyle modifications fail to achieve the therapeutic goals, and studies in China and India have proved to be effective.     

Diagnose PCOS – was bedeutet das für die Betroffene?

Polycystic ovary syndrome (PCOS) is a heterogeneous and multifactorial disorder which is accompanied by gynecological, reproductive and metabolic comorbidities, such as infertility, a higher prevalence of cardiovascular risk factors, such as hypertension, dyslipidemia and type 2 diabetes as well as an increased risk of the development of cancer, e.?g. endometrial cancer. There is evidence that patients with PCOS are at a high risk for reduced quality of life and psychological disturbances in comparison to women of the same age. In addition, PCOS is also associated with an increased risk for affective disorders, such as depressive episodes, dysthymic disorders and bipolar disorders as well as anxiety symptoms. Although the clinical features of PCOS (e.g. irregular cycles, infertility, hyperandrogenism and obesity) affect the health-related quality of life, there is still some debate on whether the increased prevalence of psychological disorders is due to the PCOS itself or is induced by the symptoms. To date, a general screening with respect to psychological comorbidities of all women with PCOS is not recommended; nevertheless, a psychological assessment should be considered during the gynecological consultation and if necessary interdisciplinary therapeutic measures should be initiated.     

Class III Obesity and Other Factors Associated with Longer Wait Times for Endometrial Cancer Surgery: A Population-Based Study

ObjectiveTo evaluate the impact of class III obesity (body mass index >40 kg/m²) on wait times for endometrial cancer surgery in Ontario, as well as other factors that influence wait time.MethodsWe performed a population-based cross-sectional study evaluating diagnosis-to-surgery time for women with endometrioid adenocarcinoma of the endometrium, during the period of 2006 to 2015, using linked administrative databases. Wait time differences between women with and without class III obesity were evaluated using a Wilcoxon rank-sum test. A multivariable generalized linear model under a generalized estimating equations approach was used to evaluate patient factors (i.e., obesity, age, comorbidities, marginalization, recent immigration, diagnosis year, geographic location), tumour characteristics (i.e., grade, stage), provider type (i.e., surgeon specialty), and institutional characteristics (i.e., rurality, hysterectomy volume, availability of minimally invasive surgery) that influence wait times.ResultsIn total, 9797 women met the criteria for inclusion; 2171 (22%) had class III obesity. The overall median wait time was 55 days (interquartile range [IQR] 37–77 d) and the median wait time was significantly longer for women with class III obesity (62 [IQR 43–88] vs. 53 [IQR 36–74] d, standardized mean difference, 0.30). Age <40 or >70 years, comorbidities, lower-grade disease, surgery at an urban teaching hospital, and surgery at a high-volume hospital with greater availability of minimally invasive surgery were associated with longer wait times. After adjusting for these variables, women with class III obesity waited 12% longer.ConclusionClass III obesity, comorbidities, and older age are associated with a longer diagnosis-to-surgery time. As the prevalence of obesity and endometrial cancer rise, processes are needed to promote equitable, timely access to care.     

Postpartum Obsessive‐Compulsive Disorder

ObjectiveTo synthesize the extant literature on the prevalence, phenomenology, etiology and treatment of postpartum obsessive‐compulsive disorder (OCD). A discussion of differential diagnosis between postpartum OCD and other postpartum psychiatric conditions (e.g., depression, psychosis) and nonpostpartum‐onset OCD is provided.Data Sources, Study Selection and Data extractionAll studies addressing postpartum OCD between the years 1950 and 2011 were reviewed. Data from all pertinent studies was explored as it related to postpartum OCD.Data SynthesisStudies were organized based on their empirical technique (e.g., retrospective, prospective), population studied (e.g., clinical OCD, nonclinical populations, males), and etiological or treatment theory (e.g., cognitive‐behavioral).ConclusionThe prevalence, phenomenology, etiology, and treatment of postpartum OCD are reviewed. The limited data on treatment approaches and outcomes for postpartum OCD are highlighted with a discussion of the role of nurses in the prevention and identification of postpartum OCD.     

The pathogenesis of pre-eclampsia: new aspects

The etiology of pre-eclampsia, a disorder specific to pregnancy, has not yet been clearly established. Generalized endothelial dysfunction is thought to occur. Inadequate trophoblast invasion at the feto-maternal junction has also been postulated as the cause. However, recent findings are more suggestive of an inappropriate maternal inflammatory response within the framework of placentation, the innate immune system being primarily involved. This exaggerated maternal intravascular inflammatory reaction to the invading trophoblast leads to the manifestations of pre-eclampsia in the mother and feto-placental unit. The extent of the inflammatory reaction, which is also present in normal pregnancy, is probably determined by genetic factors and any pre-existing disorder affecting the mother or fetus. The process is very complex and cannot be attributed to any one single cause.     

Background factors of ectopic pregnancy. I. Frequency distribution in a case-control study

Two hundred and five patients with ectopic pregnancy in a well-defined Swedish population were interviewed with respect to prior disease and pregnancy histories as well as various constitutional and socioeconomic factors. The results were compared with those of two control groups, i.e. 110 early pregnant women intending to continue the gestation to term as well as 101 women seeking voluntary interruption of pregnancy. The results provide evidence that several may be involved in the etiology of ectopic pregnancy, including abdominal (or pelvic) surgery, previous ectopic pregnancy and pelvic inflammatory disease. Furthermore, a history of infertility is strongly correlated to ectopic pregnancy. On the other hand, there is no evidence that uncomplicated spontaneous or induced abortion, parity or marital status are important factors.