Habitual abortion: causes,diagnosis, and treatment

Habitual abortion is defined as three or more consecutive pregnancy losses before 20 weeks of gestation and affects 1% of couples trying to conceive. It is a heterogeneous condition with a number of possible underlying causes: uterine, infectious, genetic, thrombophilic, endocrine, metabolic, immunologic, and environmental. Some of these causes are overdiagnosed because of the different methodologies employed. Over the past few years, attention has been paid to the role of infection (bacterial vaginosis and chlamydial infection) in the etiology of habitual abortion, but studies determining the role of intervention in improving pregnancy outcome are needed. Controversy surrounds the treatment of the different causes of habitual abortion. This is related to problems such as the size of the studies and the different methodologies that have been used in treatment and patient selection. To overcome this, large randomized controlled studies are necessary. Despite the various investigations, the etiology of recurrent abortions remains unknown in about half of all cases. For these individuals, psychologic support and reassurance, rather empirical treatment, are recommended.     

Endometrial Polyps and Subfertility

Endometrial polyps are frequently seen in subfertile women, and there is some evidence suggesting a detrimental effect on fertility. How polyps contribute to subfertility and pregnancy loss is uncertain and possible mechanisms are poorly understood. It may be related to mechanical interference with sperm transport, embryo implantation or through intrauterine inflammation or altered production of endometrial receptivity factors. Different diagnostic modalities such as two- or three-dimensional transvaginal ultrasound, saline infusion sonography or hysteroscopy are commonly used to evaluate endometrial polyps with good detection rates. The approach of clinicians towards polyps detected during infertility investigations is not clearly known, and it is quite likely that there is wide variation amongst different groups. Most clinicians suggest hysteroscopy and polyp removal if a polyp is suspected before stimulation for in vitro fertilisation or a frozen embryo transfer cycle. However, the clinical evidence and benefit of different management options during assisted reproduction technology cycles are conflicting. Currently, there is insufficient evidence to recommend one particular option over others when a polyp is suspected during stimulation for in vitro fertilisation. A properly designed randomized controlled trial is needed to determine the best treatment option. In this article, we present the available evidence and our practice related to different diagnostic modalities and management options. We also discuss the available literature relevant to the management of endometrial polyps in relation to natural conception, intrauterine insemination and in vitro fertilisation.     

Subfertility, fecundability, and the impact of laparoscopy on conception rates

Confusion is common when trying to compare the outcome of different fertility treatments. Calculation of fecundability is an excellent adjunct to reports that show cumulative conception totals after a period of observation or treatment.     

Subfertility and gastrointestinal disease: 'unexplained' is often undiagnosed

Subfertility can be more reliably explained and effectively treated with an improved understanding of the contribution of chronic medical disease to reproductive dysfunction. This review addresses several common gastrointestinal disorders which are increasingly implicated in infertility and early pregnancy loss: celiac disease, inflammatory bowel disease (ulcerative colitis and Crohn's disease), and hemochromatosis. Appreciating the reproductive impact of these comorbidities and their treatments enables clinicians to accurately counsel patients and to modify medical and fertility treatments based on etiology. Because unexplained infertility can represent the initial presentation of undiagnosed medical disease, considering these often-subclinical gastrointestinal disorders in the differential diagnosis of subfertility provides an opportunity not only to increase the probability of conception and uncomplicated pregnancy, but also to improve overall maternal health.     

Nipple pain in breastfeeding women: causes, treatment, and prevention strategies

This article identifies problems and conditions that contribute to nipple pain during lactation and that may lead to early cessation or noninitiation of breastfeeding. Signs and symptoms of poor latch-on and positioning, oral anomalies, and suckling disorders are reviewed. Diagnosis and treatment of infectious agents that may cause nipple pain are presented. Comfort measures for sore nipples and current treatment recommendations for nipple wound healing are discussed. Suggestions are made for incorporating in-depth breastfeeding content into midwifery education programs.     

Congenital toxoplasmosis: prenatal diagnosis, treatment and postnatal outcome.

We report a female patient with congenital toxoplasmosis who presented with hydrops fetalis and cerebral abnormalities, detected on fetal ultrasound. Following prenatal treatment, the hydrops fetalis resolved and at four months of age she has normal growth and development. This case emphasizes the potential good prognosis in cases with congenital toxoplasmosis detected and treated prenatally.     

Incidence,treatment and outcome of peripartum sepsis

BACKGROUND AND METHODS: Clinical and microbiological features of maternal sepsis in the peripartum period (7 days before to 7 days after delivery) were analyzed to determine possible risk factors, optimal treatment and outcome. In 43 483 deliveries during 1990-98, laboratory-confirmed bacteremia was found in 41 (5.1%) out of 798 clinically suspected septic infections. RESULTS: Preterm deliveries were associated with a crude 2.7-fold risk for peripartum sepsis as compared to term deliveries. Antepartum sepsis was associated with a crude 2.6-fold risk for cesarean section, while postpartum sepsis was 3.2 times more likely to occur after cesarean section than after vaginal delivery. A combination of cefuroxime and metronidazole was used in 80% (33/41) of all treatments. All mothers recovered well, and only one suffered from septic shock. In total, 42 bacterial strains, representing 18 different bacterial species, were isolated from the blood cultures; 37 strains (88%, 37/42) were aerobic and five (12%, 5/42) were anaerobic. The most common species were betahemolytic streptococci, Escherichia coli and Staphylococcus aureus. Most microbes (81%, 34/42) were found to be susceptible to first- or second-generation cephalosporins. CONCLUSION: Our analysis shows that peripartum sepsis is associated with preterm pregnancies and cesarean sections. Treatment of peripartum sepsis with second-generation cephalosporin is usually effective, and the outcome is good.     

Carcinosarcoma of the ovary: Natural history,patterns of treatment,and outcome

Objective

Ovarian carcinosarcomas (OCS) are rare tumors composed of both malignant epithelial and mesenchymal elements. We compared the natural history and outcomes of OCS to serous carcinoma of the ovary.

Methods

Patients with OCS and serous carcinomas registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2007 were analyzed. Demographic and clinical characteristics were compared using chi square tests while survival was analyzed using Cox proportional hazards models and the Kaplan–Meier method.

Results

A total of 27,737 women, including 1763 (6.4%) with OCS and 25,974 (93.6%) with serous carcinomas, were identified. Patients with carcinosarcomas tended to be older and have unstaged tumors (P < 0.0001). After adjusting for other prognostic factors, women with carcinosarcomas were 72% more likely to die from their tumors (HR = 1.72; 95% CI, 1.52–1.96). Five-year survival for stage I carcinosarcomas was 65.2% (95% CI, 58.0–71.4%) vs. 80.6% (95% CI, 78.9–82.2%) for serous tumors. Similarly, five-year survival for stage IIIC patients was 18.2% (95% CI, 14.5–22.4%) for carcinosarcomas compared to 33.3% (95% 32.1–34.5%) for serous carcinomas.

Conclusions

Ovarian carcinosarcomas are aggressive tumors with a natural history that is distinct from serous cancers. The survival for both early and late stage carcinosarcoma is inferior to serous tumors.     

Subfertility and the risk of low birth weight

OBJECTIVE: We evaluated the association between subfertility and low birth weight infants. DESIGN: Women in this analysis participated in a cross-sectional investigation of maternal risk factors for adverse pregnancy outcomes. SETTING: Medical and obstetric history and life style information were obtained from women who delivered at the Boston Hospital for Women, 1977 to 1980. PATIENTS, PARTICIPANTS: Our analysis was restricted to nondiabetic married women who planned their pregnancies and subsequently delivered viable singletons (3,622). The 644 "subfertile" women (no conception during a year of unprotected intercourse) were compared with 2,978 "fertile" women (conception within 1 year). MAIN OUTCOME MEASURE(S): The relative risk of low birth weight was estimated using the cumulative incidence risk ratio. RESULTS: After adjusting for confounding, the relative risk of delivering a low birth weight infant (less than 2,500 g) for subfertile women versus fertile women was 1.9 (95% confidence interval [CI], 1.3 to 2.8). The adjusted relative risk of delivering a term low birth weight (intrauterine growth retarded) infant was 2.3 (95% CI, 1.2 to 4.4). CONCLUSIONS: In these data, subfertility is a predictor for low birth weight. The association may result from endocrinological, immunological, cervical, or other factors that interfere with optimal fetal growth.     

Menopausal vasomotor symptoms: a review of causes, effects and evidence-based treatment options

Vasomotor symptoms are the most common medical complaint of perimenopausal and postmenopausal women. Frequent vasomotor symptoms can be disabling, affecting a woman's social life, psychological health, sense of well-being and ability to work. Women with hot flushes are more likely to experience disturbed sleep, depressive symptoms and significant reductions in quality of life as compared to asymptomatic women. Despite the prevalence and impact of these symptoms, the pathophysiology of hot flushes is unclear; however, estrogen withdrawal clearly plays an important role. It is postulated that declining estrogen concentrations may lead to changes in brain neurotransmitters and instability in the hypothalamic thermoregulatory center. The most effective therapy for relieving vasomotor symptoms and reducing their impact on quality of life is hormone therapy. Other options for women who decline hormone therapy include selective serotonin reuptake inhibitors and related agents. Most herbal therapies that have been evaluated in placebo-controlled trials have shown no clinically significant benefit.     

Lactation mastitis: bacterial cultivation of breast milk, symptoms, treatment, and outcome.

The aim of this prospective study was to compare serum C-reactive protein (CRP) and leukocytes, hemoglobin, clinical signs, treatment, and outcome among 41 episodes of lactation mastitis grouped by the outcome of bacterial cultivation of breast milk. Group A included 25 cases with positive cultures only for bacteria normally present on skin. Group B included 16 cases in which cultures indicated the presence of potentially pathogenic bacteria. Serious complications were observed among women in group B, including protracted illness and weaning. No complications were observed in group A. Staphylococcus aureus was the most frequently isolated bacteria in group B. Mean serum leukocytes were significantly higher in group B than in group A. Although CRP levels in both groups were elevated, no significant difference was found between groups. Rest and frequent emptying of the breast were curative in group A. Further interventions were necessary for mothers in group B.     

Nausea,vomiting, and heartburn in pregnancy: a prospective look at risk,treatment, and outcome

Objective: To examine risk factors, treatment, and outcomes for nausea/vomiting (N/V) and heartburn during pregnancy. Methods: We included 2731 women from a prospective cohort study of gallbladder disease in pregnancy. Subjects completed questionnaires at enrollment, early third trimester, and 4–6 weeks postpartum. We used logistic regression to examine independent predictors of upper gastrointestinal symptoms. Results: Ninety-five percent of pregnant women experienced either heartburn and/or N/V. Independent predictors for heartburn included prepregnancy heartburn (OR 5.28, 95% CI 3.78–7.37), multigravidity, prepregnancy body mass index, and pregnancy weight gain. Independent predictors for N/V included prepregnancy N/V (OR 2.25, 95% CI 1.52–3.31), other digestive problems prepregnancy, younger age, single gestation, and carrying a female fetus. 11% of women with N/V and 47% of women with heartburn used pharmacologic therapy. Infants born to women with heartburn had significantly higher birth weights (p?=?0.03), but gestational age at delivery was not significantly different. N/V was not associated with birth weight or gestational age at delivery. 19.7% of women with heartburn during pregnancy reported postpartum heartburn. Conclusions: Heartburn and N/V are common pregnancy symptoms, particularly among women with a history of such symptoms. Neither condition appears to adversely affect the outcome of pregnancy. Pregnancy-related heartburn predisposes to early postpartum heartburn.     

Persistence and malignant sequelae of gestational trophoblastic disease: Clinical presentation, diagnosis, treatment and outcome

Background:  The major concern in gestational trophoblastic disease is management of persistent disease and malignant sequelae. However, prediction of response to treatment is difficult and methods used controversial.
Aim and methods:  To evaluate the usefulness of clinical presentation, methods of diagnosis and categorisation of risk in determining clinical outcomes, by analysis of a database of 705 registered patients collected over 30 years.
Results:  From the database, there were 97 patients who developed persistent disease and malignant sequelae on the basis of defined criteria – 80.4% had molar pregnancy and 19.6% non-molar pregnancy. Vaginal bleeding was not a common presentation; 59.8% had no clinical symptoms. According to protocol, monitoring by serial human chorion gonadotrophin (HCG) levels followed by imaging screen was used in all patients; histology was also available in 41.2% from hysterectomy and curettage specimens. There were 16 of 76 patients with persisting disease who had metastases (21.1%), and 2 of 20 patients with choriocarcinoma who had an antecedent molar pregnancy (10.0%). Based on five risk factors, 25 patients were categorised as 'high risk' and assigned to receive multi-drug chemotherapy. There were two deaths (2.1% for all malignant sequelae); both were from molar pregnancies. One patient failed to respond and the other suffered a complication of intensive chemotherapy.
Conclusion:  Serial HCG levels remain the best monitor to determine therapeutic response. Categorisation of 'high risk' by five factors is useful in treatment. Albeit a small series, clinical outcome is favourable with a five-year survival of 89.7%.     

Deep dyspareunia: causes, treatments, and results

PURPOSE OF REVIEW: We critically review the causes and treatments of deep dyspareunia. RECENT FINDINGS: Endometriosis, pelvic congestion syndrome, and interstitial cystitis have been associated with deep dyspareunia. Although medical therapies may improve deep dyspareunia in women with endometriosis, laparoscopic excision of deep endometriotic lesions has been demonstrated to improve not only deep dyspareunia but also the quality of sex life. Deep dyspareunia related to the presence of pelvic congestion syndrome should be treated by pelvic vein embolization. Intravesical therapy may be effective in treating deep dyspareunia in women with interstitial cystitis. It remains unclear whether uterine myomas and adenomyosis are causes of deep dyspareunia. SUMMARY: Treatment of deep dyspareunia should be mainly directed to causative factors; however, clinicians should keep in mind that secondary sexual dysfunction can arise from organic pelvic pathology.