ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Number 33, January 2002

Hypertensive disease occurs in approximately 12-22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States (1,2). However, there is confusion about the terminology and classification of these disorders. This bulletin will provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy (ie, preeclampsia and eclampsia), as well as the various associated complications. Chronic hypertension has been discussed elsewhere (3).     

ABO and RhD blood groups and gestational hypertensive disorders: a population-based cohort study

Please cite this paper as: Lee B, Zhang Z, Wikman A, Lindqvist P, Reilly M. ABO and RhD blood groups and gestational hypertensive disorders: a population-based cohort study. BJOG 2012;119:1232-1237. Objective To examine the association between ABO and RhD blood groups and gestational hypertensive disorders in a large population-based cohort. Design Cohort study. Risks of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia, estimated by odds ratios for maternal ABO blood group and RhD status. Setting National health registers of Sweden. Population All singleton deliveries in Sweden born to first-time mothers during the period 1987-2002 [total n?=?641?926; any gestational hypertensive disorders, n?=?39?011 (6.1%); pre-eclampsia cases, n?=?29?337 (4.6%); severe pre-eclampsia cases, n?=?8477 (1.3%)]. Methods Using blood group O as a reference, odds ratios of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia were obtained from logistic regression models adjusted for potential confounding factors. Main outcome measures Gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia. Results Compared with blood group O, all non-O blood groups had modest but statistically significantly higher odds of pre-eclampsia. Blood group AB had the highest risk for pre-eclampsia (OR?=?1.10, 95% CI 1.04-1.16) and severe pre-eclampsia (OR?=?1.18, 95% CI 1.07-1.30). RhD-positive mothers had a small increased risk for pre-eclampsia (OR?=?1.07, 95% CI 1.03-1.10). Conclusions In the largest study on this topic to date, women with AB blood group have the highest risks of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia, whereas women with O blood group have the lowest risks of developing these disorders. Although the magnitude of increased risk is small, this finding may help improve our understanding of the etiology of pre-eclampsia.     

Eating disorders and depression in Hungarian women with menstrual disorders and infertility.

Menstrual disorders are among the most frequent somatic complications and symptoms of eating disorders. This study was designed to assess the prevalence of eating disorders connected to menstrual disorders of a non-organic origin in women at two gynecological out-patient departments. We performed a survey via questionnaires (ANIS: Anorexia Nervosa Inventory Scale; BCDS: Bulimic Cognitive Distortions Scale; BITE: Bulimia Investigation Test, Edinburgh; EDI: Eating Disorders Inventory; BDI: Beck Depression Inventory). Among 75 women tested we found a prevalence figure of 4% for anorexia nervosa (AN) and 12% for bulimia nervosa (BN). The total prevalence of clinical and subclinical eating disorders syndromes was 44%. The prevalence of depression was 64% for all respondents, whilst severe depression accounted for 11%. This study demonstrates the (relatively) higher frequency of bulimia nervosa in Hungary, compared with other countries.     

Eating disorders and depression in hungarian women with menstrual disorders and infertility

Menstrual disorders are among the most frequent somatic computations and symptoms of eating disorders. This study was designed to assess the prevalence of eating disorders connected to menstrual disorders of a non-organic origin in women at two gynecological out-patient departments.

We performed a survey via questionnaires (ANIS: Anorexia Nervosa Inventory Scale; BCDS: Bulimic Cognitive Distortions Scale; BITE: Bulimia Investigation list, Edinburgh; EDI: Eating Disorders Inventory; BDI: Beck Depression Inventory). Among 75 women tested we found a prevalence figure of 4% for anorexia nervosa (AN) and 12% for bulimia nervosa (BN). The total prevalence of clinical and subclinical eating disorders syndromes was 44%. The prevalence of depression was 64% for all respondents, whilst severe depression accounted for 11%. This study demonstrates the (relatively) higher frequency of bulimia nervosa in Hungary, compared with other countries.     

Primary clinical analysis of medical disorders in Chinese women with endometrial carcinoma

The objectives of this study were to survey the prevalence of medical disorders in Chinese women with endometrial carcinoma and evaluate their potential impact on the clinical treatment and prognosis. Three hundred and seven women with endometrial carcinoma, from July 1, 1971 to October 31, 2001, were analyzed retrospectively. One hundred and forty-six of them (47.6%) were found to have associated medical disorders. The most common medical disorders were hypertension (33.9%), diabetes mellitus (9.8%), and coronary heart disease (9.4%). As many as 38.4% of the women had two or more medical disorders. The patients with medical disorders were on average elder than those without any medical disorders (P < 0.01). Radiotherapy and chemotherapy were administered more commonly in the group with medical disorders than in the one without (P < 0.01). The rate of surgical procedures was significantly lower in the group with medical disorders than in the group without (P < 0.01). However, the extent of surgical interventions was similar in both groups (P > 0.05). The occurrence of medical disorders was independent of the tumor stage, grade, and histological types (P > 0.05). In addition, follow-up data showed that the 3-year and 5-year survivals were not influenced by the medical disorders (P > 0.05). The results thus suggest that Chinese women with endometrial carcinoma have frequently concurrent medical disorders. Selection of treatment strategies can be influenced by these associated medical disorders, but the overall survival is little changed.     

Parity, mode of delivery, and pelvic floor disorders

OBJECTIVE: This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders. METHODS: The prevalence of pelvic organ prolapse, stress urinary incontinence, overactive bladder, and anal incontinence was assessed in a random sample of women aged 25-84 years by using the validated Epidemiology of Prolapse and Incontinence Questionnaire. Women were categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated with logistic regression, controlling for age, body mass index, and parity. RESULTS: In the 4,458 respondents the prevalence of each disorder was as follows: 7% prolapse, 15% stress urinary incontinence, 13% overactive bladder, 25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder. CONCLUSION: The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery. LEVEL OF EVIDENCE: II-2.     

von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia

OBJECTIVE: To estimate the prevalence of von Willebrand disease and other bleeding disorders in women with and without diagnosed menorrhagia. METHODS: Women with menorrhagia were identified among members of a health maintenance organization in the southeastern United States through a computer search for appropriate International Classification of Diseases, 9th Revision codes. A random sample of members with no such code was selected as controls. The study included 121 women with menorrhagia and 123 controls. Subjects were interviewed in person, and blood was drawn for coagulation testing. Laboratory results for menorrhagia patients were compared with those in controls using race and blood type specific ranges developed from the control group. A test was considered abnormal if it exceeded two standard deviations below the control mean. RESULTS: Bleeding disorders (von Willebrand disease, factor deficiency, or a platelet abnormality) were diagnosed in 10.7% of menorrhagia patients and 3.2% of controls (P =.02). von Willebrand disease was present in eight menorrhagia patients (6.6%) and in one control (0.8%) (P =.02); separate analyses by race revealed a von Willebrand disease prevalence of 15.9% among white and 1.4% among black menorrhagia patients (P =.01). Women with bleeding disorders did not differ significantly from controls in other symptoms of bleeding. CONCLUSION: The prevalence of inherited bleeding disorders among white women with menorrhagia was substantial, consistent with European data published recently. For unknown reasons, the prevalence of von Willebrand disease was lower among black women. These findings indicate the importance of considering inherited bleeding disorders as a cause of menorrhagia.     

Genetic mutations, acquired coagulation system disorders and obstetric pathology. Personal experience

BACKGROUND: To evaluate the incidence of thrombophilic disorders such as Factor II mutation, Leiden factor V and MTHFR genotype, and anti-phospholipid anti-bodies syndrome in women with or without pregnancy related problems. METHODS: Sixty-three patients (group A) with pregnancy complications were included in the study and tested for Factor V mutation, Factor II mutation, 5-10 MTHFR reductase mutation and anti-phospholipid antibodies syndrome. The incidence of disorders was compared with thirty-six pregnancies without complications (control study, group B). RESULTS: Hemostasis thrombophilic like disorders, were significantly high (p=0.001 vs group B). Nobody in both groups was homozygous for Leiden mutation or prothrombin mutation (Factor II). The prevalence of Factor V mutation in heterozygosis was significantly (p=0.01) higher in group A in comparison with group B. The MTHFR mutation in homozygosis was found in 21.4% of group A while in the control group it was 11%. Factor II mutation in heterozygosis and anti-phospholipid antibodies were found only in group A. CONCLUSIONS: It is important to evaluate the hemocoagulation patterns in women with a history of complicated pregnancies.     

Association between maternal panic disorders and pregnancy complications and delivery outcomes

BACKGROUND: The objective of the study was to evaluate the possible association between panic disorders during pregnancy and pregnancy complications, as well as birth outcomes: gestational age and birth weight, as well as preterm birth/low birthweight in newborns. METHODOLOGY: Comparison of newborn infants (without any defects) born to mothers with or without panic disorder in the population-based large data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities. Main outcome measures were medically recorded pregnancy complications, as well as gestational age and birth weight, proportion of preterm birth and low birthweight. PRINCIPAL FINDINGS: Of 38,151 controls, 187 (0.5%) had mothers with panic disorders during pregnancy. Among pregnancy complications, anemia and polyhydramnion showed a higher prevalence in women with panic disorder. There was a higher proportion of males among newborn infants born to mothers with panic diseases compared to newborn infants of mothers without panic disorders. Pregnant women with panic disorders had a shorter (0.4 week) gestational age (adjusted t = 2.3; p = 0.02) and a larger proportion of preterm births (17.1% versus 9.1%) (adjusted POR with 95% CI = 1.9, 1.3-2.8). However, there was no significant difference in the mean birth weight and rate of low birthweight between the two study groups. CONCLUSION: Panic disorders during pregnancy were associated with anemia, a shorter gestational age and a larger proportion of preterm birth. Further studies are needed to confirm and explain or disprove the male excess among newborn infants born to mothers with panic disorders.     

Anal incontinence in women with and those without pelvic floor disorders

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.     

子宫内膜癌合并症146例临床分析

目的探讨子宫内膜癌合并症的发生情况及其对子宫内膜癌治疗和预后的影响.方法对1971年7月～2001年10月在我院住院治疗,伴各种合并症的146例子宫内膜癌患者(合并症组)的临床资料进行回顾性分析,并与同期无合并症的161例子宫内膜癌患者(对照组)进行比较.结果子宫内膜癌常见的合并症为高血压病(104例,71.2%)、糖尿病(30例,20.5%)、冠心病(29例,19.9%)等;合并症组患者平均年龄57.8岁,对照组患者平均年龄53.5岁,两组比较,差异有极显著性(P<0.001);而合并症发生情况与肿瘤分期、分化程度和病理类型无关(P>0.05).合并症组3例因较重合并症未能手术,对照组无因合并症不能手术者,而合并症组患者接受放射治疗(放疗)、化学药物治疗(化疗)的比例(69.2%),明显高于对照组(54.0%),差异有极显著性(P<0.01).对随访的患者进行单因素分析显示,是否存在合并症与子宫内膜癌的预后情况无明显相关性(P>0.05).多因素分析得出,肿瘤分期和分化程度对预后有明显影响,而年龄及合并症情况对预后无明显影响.结论子宫内膜癌患者常合并高血压病、糖尿病、冠心病等,随年龄增大,合并症发生机率增加,合并症对子宫内膜癌的治疗存在一定影响,但对预后无明显影响.     

Consultation-liaison psychiatry in obstetrics and gynecology

Data documenting the activity of Modena and Reggio Emilia University Hospital Consultation-Liaison Psychiatry Psychosomatic Service (C-LPPS) to the 59 bed gynecological-obstetric unit are compared to the corresponding European Consultation Liaison Workgroup (ECLW) study results and discussed in the light of recent epidemiological studies suggesting a low rate of detection and psychiatric referral in obstetric and gynecological patients. All psychiatric consultations of gynecological-obstetric inpatients during a 3-year (1996-1998) period were included in this study and data were derived from valid and reliable consultation forms tested for reliability. Within the 3-year period 55 patients were referred to C-LPPS by the gynecological-obstetric unit for psychiatric consultation. Referral rate was 0.5% of the admitted patients in the unit. The gynecological-obstetric group represented 2.5% (vs. 4.5% ECLW study) of all psychiatric consultations requested in the study period. The most frequent reasons for referral were: current psychiatric symptoms (47.3% Modena study vs. 39% ECLW), psychiatric history (20% vs. 7.3%), unexplained physical symptoms (12.7% vs. 16.2%) and coping-compliance problems (3.6% vs. 16.6%). The most common ICD-10 psychiatric diagnoses were: neurotic, anxiety and adjustment disorders (41.8% vs. 31.2%), mood disorders (29% vs. 18.4%), personality disorders (7.3% vs. 6.1%), schizophrenic and other psychotic disorders (5.5% vs. 7%).     

Clinical evaluation of a sensitive urine pregnancy test in the gynecological emergencies

A rapid sensitive urine pregnancy test (SPT) using monoclonal antibody against human chorionic gonadotropin and a conventional urine pregnancy test (GPT) were performed in 364 women attending 'Gynecological Emergencies' for lower abdominal pain and/or vaginal bleeding, aiming at early detection of ectopic and intra-uterine pregnancy-related disorders. The overall incidence of a positive test was 24%. In 42 patients, with histopathological evidence of ectopic pregnancy, SPT was positive in 41 (98%), while GPT only in 19 (45%). In 47 patients with evidence of intra-uterine pregnancy-related disorders, SPT was positive in 45 (96%), while GPT in 33 (70%). The sensitive urine pregnancy test can improve significantly the efficiency of the early diagnosis of ectopic and intra-uterine pregnancy-related disorders, and can be used as a screening method for patients having even in the slightest way suspect of having an ectopic pregnancy.     

The genetic and cytogenetic basis of male infertility

Despite the difficulties in determining the relative maternal vs. paternal contributions to infertility it is often suggested that a male factor problem is implicated in 50% of cases. This review is concerned specifically with male fertility disorders that have a clearly defined genetic component. The genetic causes of infertility can be broken down into Y chromosome deletions (specifically deletions in the AZF a, b, and c regions), single gene disorders (particularly those relating to the CFTR gene), multifactorial causes and chromosome abnormalities. Chromosome abnormalities can be numerical (such as trisomy—full blown or mosaic) or structural (such as inversions or translocations). Of especial interest at present is the incidence of levels of numerical chromosome abnormalities in the sperm of infertile men; prospects for screening sperm for such abnormalities are discussed.     

Association of thrombophilia and polycystic ovarian syndrome in women with history of recurrent pregnancy loss

Purpose: To evaluate the prevalence of thrombophilic disorders in polycystic ovarian syndrome (PCOS) women with history of recurrent pregnancy loss (RPL). Materials and methods: This study was carried out in 184 women with history of RPL, of which 92 of them were diagnosed with PCOS and 92 patients were without known PCOS. The prevalence of thrombophilic disorders was compared between the two mentioned groups. Results: According to the findings, 70.7% of PCOS women with history of RPL had thrombophilic disorders. The prevalence of protein C deficiency was significantly higher in PCOS group compared to the non-PCOS group (21.7% vs. 10.9%, p = 0.04). There was a trend toward higher prevalence of protein S deficiency in PCOS group compared to the control group, but the difference did not reach statistical significance (23.9% vs. 13%, p = 0.05). The prevalence of other thrombophilic disorders such as antithrombin III deficiency, homocysteine elevation, antiphospholipid antibody and Factor V Leiden was comparable between groups. Conclusion: The prevalence of thrombophilic disorders was more common in PCOS women than the normal group. The protein C deficiency is associated with PCOS in women with history of RPL. There was a trend toward higher prevalence of protein S deficiency in PCOS women, which needs further study.     

The genetic and cytogenetic basis of male infertility

Despite the difficulties in determining the relative maternal vs. paternal contributions to infertility it is often suggested that a male factor problem is implicated in 50% of cases. This review is concerned specifically with male fertility disorders that have a clearly defined genetic component. The genetic causes of infertility can be broken down into Y chromosome deletions (specifically deletions in the AZF a, b, and c regions), single gene disorders (particularly those relating to the CFTR gene), multifactorial causes and chromosome abnormalities. Chromosome abnormalities can be numerical (such as trisomy--full blown or mosaic) or structural (such as inversions or translocations). Of especial interest at present is the incidence of levels of numerical chromosome abnormalities in the sperm of infertile men; prospects for screening sperm for such abnormalities are discussed.     

The experience in genetic laboratory Varna in amniocentesis and genetic analysis for the period 2006-2010

The aim of this report is to present and discuss the results from diagnostic amniocenteses, performed in Varna. The test started as a part of a prophylaxis program for pregnant women with calculated high risk for chromosomal disorders after a screening test. Amniocentesis was performed in total of 283 pregnant women. Of all patients who underwent the screening test, amniocentesis was performed in 1.55% of women under 36 years of age and 5.0% of women over 36 years. In the selected group with calculated high risk for chromosomal disorder these percentages were 28.5% and 26% respectively. Fetal chromosomal disorder was found in 5% (in 7 out of 141) in women under 36 and 3.82% (in 7 out of 83) in women over 36 years. Genetic tests (DNA and cytogenetic analysis) of amniocytes revealed chromosomal disorders in 16 (5.65%) fetuses (8 with trisomy 21, 3 with trisomy 18, 1 with trisomy 13, 1 case with triploidy, 3 cases with structural chromosomal rearrangement). Three additional amniocenteses were performed, indicated by family history of monogenic disorder (thalassaemia, spinal muscular atrophy). The effect of the introduced method for prenatal diagnosis, its interaction with the screening tests and their future as genetic prophylaxis program are discussed.     

Eating disorders and gynecology: knowledge and attitudes among clinicians

BACKGROUND: Eating disorders are common, responsive to treatment and affect women at a peak age of reproductive function, often presenting via gynecological and obstetric sequelae. The author wished to examine gynecologists' knowledge and attitudes towards them. METHOD: Following a pilot study, a questionnaire concerning eating disorders was designed covering aspects of diagnosis, characteristic gynecological manifestations, treatment, and attitudes. All gynecologists and obstetricians with more than 1 year of experience from four teaching hospitals in Australia and the United Kingdom were sent the anonymous, confidential postal questionnaire. One hundred and fifteen doctors replied, with a response rate of 86%. RESULTS: Only 20% of respondents were confident of diagnosing eating disorders. Various diagnostic misconceptions were revealed; for example, 42% overestimated weight loss in anorexia nervosa by 20% or more, and 28% wrongly believed that a sense of strict dietary control' was a feature of bulimia nervosa. Clinicians had least knowledge of bulimia nervosa, underestimating its treatment response. Surprisingly, the greatest deficits in knowledge were of endocrinology and gynecological sequelae. For example, 79% underestimated amenorrhea in anorexia nervosa by 25%, and 85% wrongly believed that regular menses was characteristic of bulimia nervosa at normal weight. Consultants demonstrated significantly more knowledge than junior grades. Thirty-one percent of respondents held pejorative attitudes to eating disorders, which over-represented men (p=0.045) who were also more likely than women to see bulimia nervosa as untreatable (p=0.01). CONCLUSION: The author suggests that these deficits might be addressed by development of simpler screening questionnaires for non-specialists, and elucidation of the interface between eating disorders and reproductive physiology.