Magnesium intoxication in women with preeclampsia with severe features treated with magnesium sulfate

ABSTRACT

Objective

To evaluate the maternal-neonatal outcome in magnesium (Mg)-intoxicated women with preeclampsia with severe features (PESF) treated with magnesium sulfate (MgSO₄).     

Priapus is Happier with Venus than with Bacchus

IntroductionThe relationship between alcohol consumption and erectile function is still not completely clarified.AimAims of the present study are to explore a number of biological and clinical correlates of alcohol consumption in a sample of men consulting for sexual dysfunction, and to verify possible associations with the incidence of major adverse cardiovascular events (MACEs).MethodsA consecutive series of 1956 (mean age 55 ± 11.9 years old) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of the previous sample (N = 1687) was enrolled in a longitudinal study.Main Outcome MeasuresDifferent clinical, biochemical, instrumental (penile Doppler ultrasound [PCDU]), and intrapsychic (Middlesex Hospital Questionnaire [MHQ]) were evaluated. We considered alcohol abuse more than three drinks per day.ResultsAmong the patients studied 81% reported no or mild (<4 drinks/day) alcohol consumption whereas 14.3% and 3.9% declared a moderate (4–6 drinks/day) or severe (>6 drinks/day) alcohol abuse, respectively. After adjustment for confounders, both moderate or severe alcohol abuse was associated with low perceived partner's sexual desire, worse couple relationship, and smoking abuse. Furthermore, moderate and severe alcohol abuse was associated with low prolactin and thyroid-stimulating hormone levels, as well as an increase in triglycerides and total cholesterol levels. Penile blood flow was reduced in moderate and severe alcohol drinkers even after adjustment for confounders. In the longitudinal study, after adjusting for confounding factors, any kind of alcohol abuse was independently associated with a higher incidence of MACE (hazard ratio = 2.043 [1.059–3.943]; P < 0.0001).ConclusionsOur findings demonstrate that, in subjects consulting for erectile dysfunction, severe alcohol consumption is associated with a worse sexual function and a higher incidence of MACE. Boddi V, Corona G, Monami M, Fisher AD, Bandini E, Melani C, Balzi D, Sforza A, Patussi V, Forti G, Mannucci E, and Maggi M. Priapus is happier with Venus than with Bacchus. J Sex Med 2010;7:2831–2841.     

Improved survival of patients with cervical cancer treated with image-guided brachytherapy compared with conventional brachytherapy

Objective

Since the Group Européen de Curiethérapie and the European Society for Radiotherapy and Oncology (GEC–ESTRO) published recommendations for 3D MRI-based image-guided adaptive brachytherapy (IGBT) in the treatment of cervical cancer, many institutions have implemented this technique and favourable results were documented. We investigated if introduction of IGBT in our centre indeed improved treatment outcomes and reduced toxicity compared to conventional brachytherapy (CBT).

Methods

A retrospective analysis was done of outcomes of patients with stage IB-IVA cervical cancer treated with primary radiation therapy with curative intent between 2000 and 2012. Outcome measures were overall and disease-free survival, pelvic control, distant metastasis and treatment related adverse events (AE).

Results

126 patients were analysed; 43 had been treated with CBT between 2000–2007, and 83 with IGBT between 2007–2012. External beam radiation (mean; 46.6 Gy) was combined with concurrent weekly cisplatin (51.6%), or hyperthermia (24.6%); radiation alone was used in 23.8%. Median follow-up was 121.8 months for CBT patients, vs. 42.3 months for IGBT. Complete remission was achieved in 83.7% of patients in the CBT group and in 98.8% of IGBT patients (p < 0.01). Overall survival at 3 years was 51% and 86%, respectively (p = 0.001). Pelvic recurrence was found in 32% vs. 7% (p < 0.001). Most patients had low grade adverse events. High grade (3–4) AE occurred in 15.4% vs. 8.4% at 3 years (p = 0.06).

Conclusion

Introduction of IGBT for cervical cancer has led to significantly increased 3-year locoregional control and survival rates, whilst reducing late morbidity.     

Treatment with teriparatide in a patient with pregnancy-associated osteoporosis

Introduction.?The decrease of BMD during a physiological pregnancy can in rare cases be intensified and lead to dramatic microarchitectural changes, which causes an increase incidence of fractures, preferably at the spine. This dramatic clinical picture is called pregnancy-associated osteoporosis.

Case history.?We present the case of a 40-year-old woman (gravida IV, para II) with acute back pain right after delivery due to four fractures of the spine. The diagnosis was confirmed by dual-energy X-ray absorptiometry measurement result (T-score??4.1 SD (0.598?g/cm²) at the lumbar spine (L1–L4), T-score??1.5 SD (0.759?g/cm²) at the total hip). Due to the severity of symptoms, a therapy with teriparatide (20?mg daily) was started for a period of 18 months.

Results.?After end of therapy, the T-score had significantly increased at the lumbar spine as well as at the hip (T-score of??2.1 (0.813?g/cm²) and??0.6 (0.864?g/cm²), respectively. The relative increase of BMD at the spine and total hip was 36% and 13.8%, respectively.

Discussion.?Our report demonstrates the successful use of teriparatide underlined by the increase of bone mineral density and the improvement of clinical symptoms in a case of severe pregnancy-associated osteoporosis for the first time.     

Intracytoplasmic Sperm Injection with Testicular Spermatozoa in Men with Azoospermia

Purpose : The aim of the study was to gain an insight into the optimal management of the infertile couple with the husband suffering from azoospermia. Methods : One hundred and forty-two intracytoplasmic sperm injection (ICSI) cycles performed with testicular extracted spermatozoa were retrospectively analysed. The following factors were investigated for their possible influence on fertilization, cleavage, damage, pregnancy, and ongoing pregnancy rates; the use of fresh, cryopreserved, and preincubated (24 h) spermatozoa and the etiology of the husbands' azoospermia (obstructive and nonobstructive). All microinjections were performed with apparently normal spermatozoa—a head with a tail of normal length. In 116 cycles at least two embryos were available for transfer. Results : The overall fertilization, clinical pregnancy, and ongoing pregnancy rates obtained for the 116 cycles were 65.0, 30.2, and 22.4% respectively. Similar outcomes were obtained for cycles using fresh testicular and cryopreserved testicular spermatozoa. Similarly, no significant differences were obtained between the cycles using spermatozoa from obstructive or nonobstructive azoospermic patients. An increase in motility after a 24-h preincubation was observed, and although this group was relatively small (n = 17), a significant improvement in fertilization (73.7%) and pregnancy (53.9%) rate was obtained when the testicular sample was preincubated for 24 h. This improvement prevailed in the obstructive azoospermic group, but was less pronounced in nonobstructive patients. Conclusions : This study shows that the outcome of fresh and frozen–thawed testicular spermatozoa in ICSI is comparable, obstructive and nonobstructive etiologies perform the same, and that preincubation of testicular spermatozoa results in increased fertilization and pregnancy rates. All testicular biopsies are therefore performed the day before oocyte retrieval, superfluous spermatozoa cryopreserved, and the remaining testicular homogenate preincubated for the 24 h prior to oocyte retrieval. With this regime, most azoospermic patients are treated successfully, irrespective of the use of fresh or frozen–thawed spermatozoa from obstructive or nonobstructive cases.     

Findings in Patients with Postmenstrual Spotting with Prior Cesarean Section

Study ObjectiveThroughout the years, patients previously submitted to C-sections may have abnormal uterine bleeding (AUB) of the post-menstrual spotting type. This symptom has been correlated to an anatomical defect on the anterior uterine wall. The objective of the present investigation was to assess the hysteroscopy findings of women at reproductive age, previously submitted to cesarean sections and complaining of post-menstrual spotting, stressing the diagnosis of isthmocele.DesignProspective study (Canadian Task Force II).SettingState public hospital—Department of Gynecological Endoscopy.PatientsForty-three patients at reproductive age previously submitted to one or more cesarean sections, complaining of AUB of the post-menstrual spotting type, were submitted to diagnostic hysteroscopy in order to assess the presence of anterior uterine wall isthmocele.InterventionsHysteroscopic diagnoses.Measurements and Main ResultsThe mean number of previous C-sections was 2, the average time of post-menstrual spotting observation was 6 years and the mean duration of each episode was 6 days. The hysteroscopic diagnosis of isthmocele was conclusive in 38 patients (88.37%).ConclusionPatients with previous C-sections complaining of postmenstrual spotting type of AUB have a high prevalence of isthmocele, and this condition is likely diagnosed through diagnostic hysteroscopy.     

Postmenopausal women with osteoporosis may be associated with high endothelin-1

Aim. We aimed to find out if there was any difference of the endothelin-1 (ET-1) and asymmetric dimethylarginine (ADMA) levels between osteoporotic and non-osteoporotic healthy postmenopausal women and whether there were any associations between ET-1 and ADMA levels and bone mineral density (BMD).

Methods. A total of 75 healthy postmenopausal women were enrolled in the study. BMD was measured at lumbar spine (LS) and femur neck (FN). Serum ET-1 and ADMA levels were measured by ELISA. In this population, 41 (54%) women had BMD t-scores ≥ 2.5 at the LS and/or FN defined as osteoporosis and 34 (46%) of them had normal BMDs (non-osteoporotic group).

Results. The mean value of ET-1 serum level in patients was 0.42 ± 0.30, 0.28 ± 0.12 fmol/ml in osteoporotic and non-osteoporotic groups, respectively (p = 0.018). In non-osteoporotic group, there was an only significant positive correlation was found between BMD (g/cm²) and total t-scores at the lumbar region and ET-1 level. In osteoporotic group, no correlation was found between BMD and total t-scores and ET-1 levels. Serum ADMA level was not significantly different between osteoporotic and non-osteoporotic postmenopausal women (p > 0.05).

Conclusions. ET-1 may be a physiologic regulator in non-osteoporotic healthy postmenopausal women. Osteoporotic postmenopausal women had higher ET-1 levels than non-osteoporotic postmenopausal women. ADMA seems not to have effect on bone in postmenopausal women.     

Hyperhomocysteinaemia is associated with biochemical hyperandrogenaemia in women with reproductive age

Objective

Hyperhomocysteinaemia is a well-established risk factor for cardiovascular disease. This study investigated the relationship between hyperhomocysteinaemia and factors related to polycystic ovary syndrome (PCOS).

Study design

Case–control study. Three hundred and thirty-nine women were included; of these, 84 had hyperhomocysteinaemia (homocysteine >12.4 μmol/l) and 255 had normal homocysteine levels. Homocysteine, high-sensitivity C-reactive protein, insulin resistance, metabolic disturbance and PCOS-related disturbance were evaluated. The clinical and biochemical characteristics of women with hyperhomocysteinaemia and normal homocysteine levels, including insulin resistance, metabolic disturbance and PCOS-related disturbance, were compared.

Results

Correlation was found between serum homocysteine level and serum total testosterone level and diastolic blood pressure. No correlation was found between serum homocysteine level and age, body mass index, insulin resistance and lipid profile. Women with hyperhomocysteinaemia had a significantly higher risk for biochemical hyperandrogenaemia and higher serum total testosterone levels than women with normal homocysteine levels. The prevalence rates of PCOS, oligo-amenorrhoea, polycystic ovary morphology and metabolic disturbance did not differ between the two groups. The parameters of insulin resistance and lipid profiles were similar between the two groups, and signs of clinical hyperandrogenism (hirsutism and the modified Ferriman–Gallwey score) did not differ between the two groups. Logistic regression analysis found a significant association between hyperandrogenaemia and hyperhomocysteinaemia (odds ratio 2.24, 95% confidence interval 1.26–4.01).

Conclusions

For women with PCOS, an elevated serum total testosterone level is the main factor associated with hyperhomocysteinaemia. The association between biochemical hyperandrogenism and hyperhomocysteinaemia may contribute to cardiovascular risk for women with PCOS.     

Assistance with decision-making

Objective. Various psychosocial interventions have been recommended for infertile persons, but it remains unclear what their implications are, and if some of them might even be harmful under certain circumstances.

Methods. A survey is given of papers concerning the usefulness of psychosocial support in infertility.

Results. Providing procedural information concerning the technical aspects of infertility investigation probably facilitates coping with infertility and with assisted reproductive techniques. This information can be given in the form of booklets or educational films. Using the Internet is a fast and easy way to obtain information on infertility and its treatment, but with the risk of getting wrong or misleading information. Telephone counseling can be helpful in providing specific information about the infertility workup but it cannot replace face-to-face counseling on distressing psychosocial issues. Attendance at support groups can be recommended to strengthen coping abilities. Psychosocial counseling and psychotherapy are definitely effective in reducing negative affect, mostly within a short period of time (less than 10 sessions). Pregnancy rates are unlikely to be affected by psychosocial interventions.

Conclusion. Infertility counseling and support groups seem to be the most efficient psychosocial interventions in infertility. Therefore, infertility counseling should be available at all stages of medical therapy, and it should be free of charge for the persons attending it. Course, content and goals of the infertility counseling should be made transparent. The efficacy of support groups has to be evaluated more systematically. Several methodological questions have to be solved yet, and the generalizability of these results is still restricted.     

Factors Associated with Uterine Artery Doppler Anomalies in Patients with Preeclampsia

Uterine artery Doppler anomalies are associated with unfavorable outcomes in women with preeclampsia.?Objectives:?To examine the association between abnormal uterine artery Doppler and severity of preeclampsia.?Study Design:?Retrospective analysis of a population of 287 patients with preeclampsia who underwent a uterine artery Doppler velocimetric examination at the onset of preeclampsia, between 1996 and 2002. The population was classified into three groups: Group I had normal uterine artery Doppler findings; Group II had a high uterine artery resistance index; and, Group III had both high uterine artery resistance index and bilateral notches.?Results:?Compared to Group I, preeclampsia occurred earlier in Group II (76.3%) (p < 0.001), and HELLP syndrome was most frequent in Group III. The frequency of fetal growth restriction (£ 3^rd percentile) was different between groups (19.1, 32.4 and 49.7% in groups I, II and III, respectively). The perinatal death rate was significantly higher in group III than the other two groups (12.8% vs 2.9%, p < 0.01).?Conclusions:?In patients with preeclampsia, the presence of uterine artery Doppler anomalies (high resistance index with or without bilateral notches) was associated with unfavorable pregnancy outcomes.     

Outcome of IVF in Patients with Endometriosis in Comparison with Tubal-Factor Infertility

Purpose: The aim of this retrospective study was to compare the outcome of in vitro fertilization and embryo transfer in women with endometriosis and a control group with tubal-factor infertility. Methods: Forty-eight patients with endometriosis underwent 65 cycles of in vitro fertilization and embryo transfer at Huddinge University Hospital. The matched control group with tubal-factor infertility consisted of 98 cycles in 98 patients. These groups were retrospectively analyzed regarding stimulation, fertilization, embryo development, implantation, and pregnancy outcome. Results: The fertilization rate was significantly lower in women with endometriosis, but the cleavage, implantation, and pregnancy rates did not differ. Conclusions: Our results show that women with endometriosis have a lower fertilization rate compared with women with tubal-factor infertility. However, once the oocyte is fertilized, it seems that the preembryo has a normal chance of implantation, leading to similar pregnancy rates.     

Menstrual suppression with the levonorgestrel intrauterine system in girls with developmental delay

Study ObjectiveTo describe the experiences of 21 girls with developmental delay accompanied by multiple other medical problems, seen over a 3-year interval, who underwent insertion of the levonorgestrel intrauterine system (LNG-IUS) for menstrual suppression.Study DesignRetrospective chart review.SettingA referral pediatric and adolescent gynecology clinic within a tertiary care medical center with referrals from community pediatricians, pediatric subspecialists including developmental and behavioral pediatricians, community gynecologists, and adolescent medicine specialists.ParticipantsAdolescents and young women with developmental delay and multiple comorbid conditions who were seen for consultation with their families requesting menstrual suppression.InterventionsParticipants were offered hormonal options, for menstrual suppression including the LNG-IUS.Main Outcome MeasuresSatisfaction with menstrual suppression among families electing the LNG-IUS.ResultsAdolescents and young women seen at CCHMC with developmental delay and multiple comorbid conditions with requests for menstrual suppression were offered hormonal options, including the LNG-IUS. Twenty-one families chose this option. Fifteen of 21 girls had previously used hormonal menstrual suppression. General anesthesia was required for 20 of 21 insertions, and 9 of 20 of these insertions were combined with other surgical procedures. There were no unsuccessful insertions or major complications. Mean duration of follow-up was 11 months, and families were satisfied with this option for menstrual suppression. There was 1 request for removal.ConclusionsLNG-IUS for menstrual suppression, in girls with developmental delay and multiple comorbid medical conditions for which amenorrhea is desirable and therapeutic, appears promising.     

Metabolic Syndrome in Men with Low Testosterone Levels: Relationship with Cardiovascular Risk Factors and Comorbidities and with Erectile Dysfunction

IntroductionTestosterone deficiency and metabolic syndrome (MetS) are strongly associated. Patients consulting for sexual dysfunction may have testosterone deficiency, providing a valuable opportunity to assess MetS. The identification of variables predicting MetS is of great importance.AimsTo identify cardiovascular comorbidities and risk factors, including erectile dysfunction (ED), associated with MetS in men aged ≥45 with total testosterone (TT) < 8 nmol/L (or <12 nmol/L when calculated free testosterone was <250 pmol/L) and to gain further insight into the relationship between both conditions.MethodsData were collected from a multicenter, cross‐sectional, observational study conducted in Spain among men visiting men's health‐care offices with a confirmed diagnosis of testosterone deficiency. Subjects with data for MetS assessment were included in this analysis. Other data available were anthropometrics, toxic habits, cardiovascular comorbidities, ED diagnosis, and TT values.Main Outcome MeasuresThe MetS harmonized definition was used. Waist circumference threshold was 94 cm. ED was diagnosed and classified using the International Index of Erectile Function‐5 (IIEF‐5) questionnaire. Bivariate and multivariate logistic regression analyses were performed to calculate odds ratios (ORs) for MetS.ResultsMean age was 61.2 ± 8.1 years. Prevalences of ED and MetS were 97.6% and 69%, respectively, both increasing with age. Bivariate analysis showed that moderate or severe ED, obesity, and peripheral vascular disease (PVD) were the variables associated with the greatest odds of MetS (OR = 2.672 and 2.514, respectively), followed by alcohol intake (OR = 1.911). Tobacco use, ag,e and testosterone deficiency severity had a minimal effect that disappeared on multivariate analysis. Elevated triglycerides and HDL‐cholesterol were MetS risk factors associated with a lower TT level.ConclusionThe high prevalence of MetS among men with testosterone deficiency highlights the opportunity to assess cardiovascular health in patients consulting for sexual dysfunction. Moderate to severe ED, obesity, PVD, and alcohol intake significantly increase the likelihood of MetS. García‐Cruz E, Leibar‐Tamayo A, Romero J, Piqueras M, Luque P, Cardeñosa O, and Alcaraz A. Metabolic syndrome in men with low testosterone levels: Relationship with cardiovascular risk factors and comorbidities and with erectile dysfunction. J Sex Med 2013;10:2529–2538.     

Pelvic actinomycosis with abundant ascites,pleural effusion,and lymphadenopathy diagnosed with endometrial biopsy and treated with medication only

ObjectivePelvic actinomycosis almost always presents as a “dry” type, and pelvic actinomycosis with ascites is extremely rare. We present an unusual case of pelvic actinomycosis with ascites, pleural effusion, and lymphadenopathy. Because of these atypical clinical features, a malignant process such as ovarian cancer or peritoneal carcinomatosis was suspected, but an endometrial biopsy revealed pelvic actinomycosis, which was treated without surgical intervention.Case reportA 50-year-old Korean woman presented to our clinic with a 3-month history of abdominal pain and weight loss. An abdominopelvic computed tomography scan demonstrated ascites, pleural effusion, bilateral adnexal tubular structures, several enlarged lymph nodes in the paraaortic area, and diffuse peritoneal infiltration. Ultrasonography showed fluid collections measuring 2.7 cm in the cul-de-sac, 2.42 cm in the right paracolic gutter, and 3.13 cm in the left paracolic gutter. Endometrial/endocervical specimens showed marked chronic inflammation with sulfur granules, with a colony of filamentous organisms consistent with Actinomyces infection. The patient underwent antibiotic treatment for 6 months and recovered without complications or adverse events in the 13 months of follow up.ConclusionPelvic actinomycosis should always be considered in patients with a pelvic mass and peritoneal infiltration, especially in the presence of intrauterine device use, despite the fact that abundant ascites, pleural effusion, and lymphadenopathy almost never accompany pelvic actinomycosis. Endometrial/endocervical biopsy may yield a diagnosis without an invasive procedure and should be performed. Because of the excellent response to penicillin, medical treatment alone is an effective method to eradicate pelvic actinomycosis without the need for surgical intervention.     

Increased complication rates associated with laparoscopic surgery among patients with genital tuberculosis

Objective

To compare the complications and surgical difficulties encountered during laparoscopy between women diagnosed with and without genital tuberculosis (TB).

Methods

Retrospective review of the records of women diagnosed with and without genital TB who underwent laparoscopy primarily for infertility and chronic pelvic pain from January 2006 through July 2009. Genital TB was diagnosed by laboratory studies and endoscopic findings.

Results

A total of 313 women were included in the study: 87 (27.8%) with genital TB and 226 (72.2%) without. Laparoscopy was performed in 48 (55.2%) patients with genital TB and 19 (8.4%) without; laparoscopy with hysteroscopy was performed in 39 (44.8%) with the disease and 132 (58.4%) without. Although individual complication rates were all higher in the genital TB group, significant differences were seen for inability to see the pelvis (10.3% vs 1.3%, P = 0.027), excessive bleeding requiring transfusion (2.3% vs 0%, P = 0.045), and peritonitis (8.0% vs 1.8%, P = 0.037). Other complications encountered were inability to create pneumoperitoneum, bladder injury, trocar site discharge, and need for laparotomy.

Conclusion

Laparoscopic surgery may be associated with increased complication rates in patients with genital TB compared with those without the disease.     

Placental pathologies associated with intra-uterine fetal growth restriction complicated with and without oligohydramnios

Purpose  To compare the placental pathologies and perinatal outcomes in fetal growth restriction (FGR) pregnancies with and without oligohydramnios. Methods  A retrospective cohort study, comparing placental findings in all singleton deliveries with FGR. Results  Macroscopic placental findings were available for 1,104 singleton FGR pregnancies. A total of 397 placentas were microscopically examined; of which 89 placentas were of FGR neonates who had oligohydramnios. No significant differences in placental vascular mal-perfusion were found between pregnancies with and without oligohydramnios (69.3 vs. 74.3%; P = 0.357). Likewise, no significant differences were noted between the groups regarding diffuse villous fibrosis (10.1 vs. 4.9%; P = 0.573), and amnion cell metaplasia (65.9 vs. 64.3%; P = 0.779). Cases of FGR complicated with oligohydramnios had significantly higher rates of perinatal mortality (9.9 vs. 5.9%; P = 0.028), preterm deliveries (34.9 ± 3.4 vs. 35.4 ± 3.1 weeks of pregnancy; P = 0.041), and lower birth weight (1,737 ± 542 vs. 1,845 ± 467 g; P = 0.002) compared to FGR without oligohydramnios. Conclusions  Oligohydramnios is a significant risk factor for adverse perinatal outcome in FGR pregnancies; nevertheless, no significant differences in placental pathologies were noted. Presented in part at the 29th Annual Meeting of the Society of Maternal Fetal Medicine (SMFM), San Diego, CA, USA, 26–31 January 2009.