Breastfeeding and migraine headaches.

Migraine headaches affect 19 percent of adult women. A small group of these migraine sufferers also are breastfeeding mothers. Although a correlation has not been documented in the literature, some women have noted that the onset, frequency, or pattern of their migraine headaches changes during lactation. Lactation consultants can provide education and support to breastfeeding women suffering from migraine. They also are in an excellent position to add case studies to the scientific database about this phenomenon.     

Management of migraine headaches

With 17% to 18% of women suffering from migraine headaches, clinicians will often be asked by their patients to prescribe medication. Migraine is an episodic chronic disease that is best managed with an overall treatment plan, rather than treated as an acute illness that is managed with sporadic medications. Realistic goals for the long-term management of migraine are based on patient education and an ongoing discussion between patient and provider. This article reviews the clinical presentation of migraine and recommendations for both acute and preventive treatment, including complementary therapies. "Red flags" that could be signs of more serious neurologic illness are presented. The management of migraine in pregnancy is also reviewed.     

Cerebrospinal fluid leptin levels in preeclampsia: relation to maternal serum leptin levels

BACKGROUND: To determine whether cerebrospinal fluid (CSF) and circulating levels of leptin differ between women with preeclampsia and women who had an uncomplicated pregnancy. METHODS: Maternal serum and CSF leptin concentrations obtained in the third trimester of the gestation were compared in 16 women with mild preeclampsia and 23 normotensive pregnant women who underwent cesarean section. Before administering local anesthetic for spinal anesthesia, 2 mL CSF and 4 mL venous blood sample were taken and were stored at -30 degrees C until serum and CSF leptin levels were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: Mean CSF leptin concentrations were not significantly different between the two groups (preeclampsia 9.7 +/- 4.2 ng/mL, normotensive 13.6 +/- 4.3 ng/mL, p = 0.952). Similarly, mean serum leptin concentrations were similar between the two groups (mild preeclampsia 21.7 +/- 7.1 ng/mL, normotensive 18.3 +/- 6.7 ng/mL, p = 0.698). CSF leptin levels are inversely related to the serum leptin concentrations in preeclamptic patients (r = -0.87, p = 0.000). An inverse relationship was also detected between CSF and serum leptin levels in normotensive pregnant subjects (r = -0.66, p = 0.000). CONCLUSIONS: CSF and serum leptin levels were similar in patients with preeclampsia and normotensive pregnant women. However, the CSF leptin was negatively correlated with the serum leptin concentrations in preeclamptic and normotensive control subjects, suggesting that leptin enters the brain by a saturable transport system. Further work is needed to confirm our findings.     

Family history of hypertension and diabetes in relation to preeclampsia risk in Peruvian women

In a case-control study of 169 preeclamptics and 201 controls, we assessed maternal parental history of chronic hypertension and diabetes in relation to preeclampsia risk among Peruvian women. Participants provided information on parental history of the two conditions and other covariates during postpartum interviews. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for confounding by age, parity and prepregnancy adiposity. In this population, women were more likely to know the diabetes status of their parents than their hypertension status. Compared with women without a parental history of hypertension, women with a parental history of hypertension experienced a 20% increased risk of preeclampsia (OR = 1.2; 95% CI 0.7-2.2) that did not reach statistical significance. Women with a positive parental history for diabetes had a 3.4-fold increased risk of preeclampsia (95% CI 1.4-8.4). Women with a positive parental history of both hypertension and diabetes, as compared with those whose parents had neither condition, experienced a 4.6- fold increased risk of preeclampsia (OR = 4.6; 95% CI 0.9-23.0). Our results are generally consistent with the thesis that parental history of hypertension and diabetes reflects genetic and behavioral factors whereby women may be predisposed to an increased risk of preeclampsia.     

Risk of preterm delivery in relation to maternal low birth weight

OBJECTIVE: We examined the relationship between maternal low birth weight and preterm delivery risk. METHODS: Information concerning maternal birth weight was collected during in-person interviews. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI). Preterm delivery cases were studied in aggregate, in subgroups (spontaneous preterm labor, preterm premature rupture of membranes, medically induced preterm delivery, moderate preterm delivery [gestational age at delivery 34-36 weeks], and early preterm delivery [gestational age at delivery<34 weeks]). RESULTS: After adjusting for confounders, women weighing<2,500 g at birth had a 1.54-fold increased risk of preterm delivery versus women weighing=2,500 g (95% CI 0.97-2.44). Maternal low birth weight was associated with a 2-fold increased risk of spontaneous preterm delivery (95% CI 1.03-3.89), but weakly associated with preterm premature rupture of membranes (OR=1.44; 95% CI 0.67-3.09) and medically induced preterm delivery (OR=1.10; 95% CI 0.43-2.82). Maternal low birth weight was more strongly associated with early preterm delivery (OR=1.94) than with moderate preterm delivery (OR=1.46). Women weighing<2,500 g at birth and who became obese (pre-pregnancy body mass index, =30 kg/m2) before pregnancy had a 3.65-fold increased risk of preterm delivery (95% CI 1.33-10.02) versus women weighing=2,500 g at birth and who were not obese prior to pregnancy (<30 kg/m2). CONCLUSIONS: Results confirm earlier findings linking maternal low birth weight with future risk of preterm delivery.     

Risk of partial and complete hydatidiform molar pregnancy in relation to maternal age

All cases of first histologically confirmed complete and partial moles registered between 1985 and 1999 were identified from the database of a Trophoblastic Disease Registration Centre. The maternal age distribution at diagnosis was calculated for the 7916 molar pregnancies and compared with the maternal age distribution of an unselected population of women from a routine obstetric database. Likelihood ratios were calculated for complete and partial molar pregnancies by maternal age. A positive relationship was found between the risk of molar pregnancy and both upper and lower extremes of maternal age (≥45 years and ≤15 years, respectively). This association, although present for both complete and partial moles, is much greater for complete mole at all maternal ages, and the degree of risk is much greater with older (≥45 years) rather than younger (≤15 years) maternal age. This study provides, for the first time, data regarding specific risk of partial versus complete hydatidiform mole with maternal age.     

Complement activation in relation to development of preeclampsia

Six hundred eighty-five primigravidas followed as a series had complement activation evaluated by the formation of anaphylatoxins (C3a and C5a) and terminal C5b-9 complement complexes in venous blood. Samples for complement determinations were obtained four times during pregnancy, in pregnancy weeks 12-16, 20-24, 28-32, and 34-36. Seven of the women developed preeclampsia and one of them the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). Eleven others with uncomplicated pregnancies were selected as a control group. Plasma samples were taken from these 18 women at delivery and 1 and 7 days after delivery. At delivery, plasma C5a levels were significantly greater in the preeclamptics than in controls, and four of the seven preeclamptics had elevated plasma C3a values compared with controls. One week after delivery, these plasma anaphylatoxins had returned to normal. Elevations of the anaphylatoxins could not be detected before the women developed clinical signs of preeclampsia. No alterations in terminal C5b-9 complement complexes could be observed in the women with preeclampsia. However, the women who developed HELLP syndrome had elevated plasma concentrations of C3a, C5a, and terminal C5b-9 complement complex at delivery. These values returned to the normal range 1 week after delivery. We conclude that complement activation in the systemic circulation does not occur early in pregnancy and that plasma concentrations of C3a, C5a, or terminal C5b-9 complement complex cannot be used as predictors of preeclampsia.     

Elevated ratio of maternal plasma ApoCIII to ApoCII in preeclampsia

Preeclampsia is a hypertensive disorder unique to pregnancy. Although the pathogenesis of the disease begins with aberrant spiral artery invasion in the first trimester, clinical symptoms usually do not present until late in pregnancy. Apolipoprotein CII (ApoCII) and its negative regulator, apolipoprotein CIII (ApoCIII), have recently been described as atherogenesis biomarkers in models of cardiovascular disease. Given the similarities in pathology, etiology, and clinical presentation between cardiovascular disease and preeclampsia, we hypothesized that the ratio of ApoCIII to ApoCII in maternal first trimester plasma would predict preeclampsia later in pregnancy. To test this hypothesis, plasma was prospectively collected from 311 nulliparas at 8 to 12 weeks gestation. After delivery, patients were divided into cohorts based on preeclampsia diagnosis. Conditioning monocytes with preeclamptic plasma potentiated monocyte adhesion to endothelial cells in an in vitro model. The ratio of ApoCIII to ApoCII was significantly elevated in patients with severe preeclampsia relative to normotensive and gestational hypertensive individuals (P < .05) as determined by mass spectrometry and competitive enzyme-linked immunosorbent assay (ELISA) assays. These results support a predictive change in the ratio of ApoCIII to ApoCII in pregnancies complicated by severe preeclampsia.     

Histomorphometry of the human placenta in maternal preeclampsia

The placentas of five mothers with severe preeclampsia who gave birth to moderately growth-retarded term infants were compared to a group of placentas collected from mothers who had uncomplicated pregnancies and normal term infants who were appropriate for gestational age. This study demonstrated that, on a quantitative histologic basis, the placentas of the preeclamptic mothers were morphologically very similar to the control placentas in terms of weight, parenchymal and cellular content, and surface areas of exchange between mother and fetus. The findings of this study support the hypothesis that, in preeclampsia not associated with severe intrauterine growth retardation, the perinatal morbidity associated with this condition is probably related more to some alterations in uteroplacental and, possibly, umbilical blood flows than to significant changes in placental structure and function. This may be due to compensatory repair mechanisms and extensive functional reserve capacities in these placentas.     

Prediction of maternal and fetal complications in preeclampsia

INTRODUCTION: Preeclampsia is associated with an increased risk for maternal and fetal morbidity. The aim of this study was to identify factors predicting for maternal or fetal complications. MATERIAL AND METHODS: One hundred and eleven patients with preeclampsia were included. Endpoint variables were maternal and fetal complications. Any of the diagnosis eclampsia, hemolysis elevated liver low platelet (HELLP) syndrome, oliguria or placental abruption was considered a maternal complication. Fetal complications were: small for gestational age (SGA) infant, umbilical artery pH<7.10 and admittance of the infant to a neonatal intensive care unit (NICU). Independent variables were maternal age, parity, gestational age, renal function, platelet count, liver enzymes and blood pressure. Logistic regression analysis was used for statistical evaluation. RESULTS: The following independent significant predictors were identified: Maternal complication (n=10) was predicted only by diastolic blood pressure; odds ratio (OR) 1.13 (95% confidence interval 1.01-1.25). SGA (n=21) was associated with maternal prepregnancy weight, OR 0.94 (0.89-0.99) and gestational age at debut of preeclampsia, OR 0.97 (0.94-0.99). NICU admittance (n=31) was only predicted by gestational age at delivery, OR 0.80 (0.67-0.96). No association was found between any of the independent variables and a low umbilical artery pH (n= 10). CONCLUSIONS: In the surveillance of patients with established preeclampsia, the value of serial blood and urine sampling, which is common practice in many obstetrical units, might be questioned.     

Physical well-being in women with a history of severe preeclampsia.

OBJECTIVE: To evaluate the physical and mental health of women with a history of severe preeclampsia. METHODS: In a historical cohort study 131 former patients with a history of severe preeclampsia and 127 control patients received questionnaires about experienced physical and mental complaints after delivery. At a follow-up visit blood pressure, body mass index, and proteinuria were measured and venous blood was drawn. RESULTS: Former patients experienced significantly (p < 0.001) more frequent problems of headache (31% vs. 2%), right upper quadrant pain (16% vs. 1%), visual disturbances (21% vs. 1%), tiredness (66% vs. 27%), subjective loss of concentration (37% vs. 16%), and mental health (37% vs. 6%) compared with controls. When present, these health problems, except for tiredness, lasted significantly more often beyond six months postpartum compared to controls. Admittance to the intensive care unit was associated with headache, and subjective loss of memory and concentration over a longer period of time. The risk of recurrence of severe preeclampsia was a subject of concern in 20% of former patients. At follow-up, systolic and diastolic blood pressures were significantly higher (p < 0.001) among former patients. CONCLUSION: Patients with a history of severe preeclampsia more frequently reported physical and mental complaints, also during a longer period of time.     

Risk of coronary artery disease in women with history of pregnancies complicated by preeclampsia and LBW

Women with a history of pregnancy complicated by preeclampsia or intrauterine growth restriction and low infant birth weight looks at a higher risk for subsequent ischemic heart disease. Objective: To determine the relationship between pregnancy complications and maternal coronary artery disease (CAD) in the future. Materials and method: We performed a case-control study on 690 patients (345 patients in each group) referred to Tehran Heart Center. Women with CAD were in the case group and women without CAD were in the control group. The history of pregnancy complications (including preeclampsia, low birth weight [LBW] delivery, preterm labor and gestational hypertension) was evaluated in the two groups. Results: 12.5% of the patients in the case group had a history of preeclampsia, compared with the control group (1.7%). (p?<?0. 0001). Seven percent of the patients in the case group and 0.9% of the patients in the control group had history of LBW delivery. The difference was significant (p?<?0.0001). A history of preterm labor was recorded in 11% of cases and 3.2% of controls. Performing multivariate analysis showed that there is a strong association between preeclampsia and CAD (OR: 16.92; 95% CI; p?<?0.0001), LBW delivery and CAD (OR: 6.52; 95% CI; p: 0.0038), and also between high parity and CAD. (OR: 1.135; 95% CI; p: 0.0479). Conclusion: Our results suggest preeclampsia, LBW delivery and high parity of the mother as independent risk factors for CAD in the future.     

Risk of cancer development in relation to oral contraception.

Combined oral contraceptives (COCs) are among the most widely used effective and reversible means of family planning. Their beneficial effects are well documented, but many questions are still raised concerning a possible association between the use of COCs and the development of cancer. The authors provide a broad and up-to-date review of the literature regarding the relation between COC use and carcinogenesis in different organs. Studies have not unequivocally confirmed that such a relation exists with regard to breast cancer. Much research focused on the influence COC use could have on the incidence of cervical cancer; most of it was analyzed by J. Smith and co-workers. These authors confirmed the existence of a weak relation between COC use and the development of cervical carcinoma, especially in women using COCs for longer periods. Ovarian carcinoma has the worst prognosis of all cancers of reproductive organs in women. The risk of developing ovarian cancer in women using COCs is at least 40% smaller than in other women; the degree of protection given by COCs is directly proportional to the duration of use of this form of contraception. Reliable scientific data prove convincingly that the risk of endometrial cancer is smaller in women who used COCs than in women who never took them.