Endothelial dysfunction after pregnancy-induced hypertension

Objective

To carry out long-term analysis of the presence of endothelial dysfunction after the development of pregnancy-induced hypertension (PIH).

Methods

In a retrospective cohort study, data were analyzed from 60 women who delivered at a tertiary maternity hospital in Fortaleza, Ceara, Brazil, between 1992 and 2002. Thirty women had a history of PIH and 30 had no history of complications. Anthropometric and laboratory data were collected, and endothelial function was evaluated by flow-mediated dilatation of the brachial artery. Continuous variables were analyzed via Student t test, and Mann–Whitney test was used to compare means. Clinical and metabolic measures were categorized according to cardiovascular risk by cutoff points determined by national consensus; χ² and Fisher exact tests were used to compare the groups. Relative risk was calculated for variables that were statistically significant (P < 0.05).

Results

Women with a history of PIH had higher body mass index (P = 0.03), systolic blood pressure (P = 0.03), low-density lipoprotein cholesterol (P = 0.02), and fasting glucose (P = 0.02) compared with women with no pregnancy complications. The frequency of endothelial dysfunction was 60% among all women, with a significant difference between the 2 groups (P = 0.01).

Conclusion

Women with a history of PIH were found to have a higher frequency of long-term endothelial dysfunction.     

National variations in operative vaginal deliveries in Ireland

Objective

To compare the percentage of operative vaginal delivery (OVD) among all publicly funded maternity hospitals in Ireland and to develop quality control performance tables to facilitate national benchmarking.

Methods

The analysis included deliveries of neonates weighing 500 g or more in publicly funded hospitals in Ireland in 2010. Information was obtained from the Irish National Perinatal Reporting System. Maternities delivering in 1 private hospital or at home, and those with unknown parity were excluded. Mean ± SD OVD rates were calculated per hospital. Quality control tables were devised.

Results

In 2010, there were 75 600 deliveries, of which 73 029 met the inclusion criteria. The number of deliveries per hospital ranged from 1284 to 9759. The OVD rate per hospital was 15.3 ± 2.6% (range, 11.7–20.4%). The OVD rate was 29.1% among primigravidas (n = 30 468) compared with 6.7% among multigravidas (n = 42 561) (P < 0.001). Using quality control tables, 52.6% (n = 10) and 31.6% (n = 6) of hospitals were more than 1 SD outside the national mean for forceps and ventouse delivery, respectively.

Conclusion

Wide variations were found in both the range of OVD and instrument choice among maternity hospitals in Ireland, raising questions about practice and training in contemporary obstetrics.     

Quality of life of infertile Tunisian couples and differences according to gender

Objective

To compare quality-of-life gender differences within infertile couples from Tunisia and between infertile couples and controls.

Methods

The present case–control study included 100 couples with primary infertility who, during 2009, underwent assisted reproductive technology at Farhat Hached Hospital in Sousse, Tunisia, and 100 control couples. The 36-item Short-Form Health Survey (SF-36) was administered to assess quality of life.

Results

Compared with male controls, men in the infertility group had lower scores in the mental dimension (P = 0.020), social functioning (P = 0.007), and role–emotional (P < 0.001) categories of the SF-36. Women in the infertility group had lower mental and physical dimension scores (P < 0.001) and lower vitality (P = 0.022), social functioning (P < 0.001), role–emotional (P < 0.001), and mental health (P < 0.001) scores than female controls. Within infertile couples, female partners had lower total (P = 0.01) and mental dimension (P < 0.001) scores than their spouses. Delay of the first consultation was correlated with bodily pain, vitality, and mental health among women in the infertility group.

Conclusion

Women in infertile couples had a lower quality of life than their spouses, and infertile couples had a lower quality of life than controls. These findings confirm the need for psychological support for infertile couples.     

Concentraciones de quimiocina RANTES en preeclámpticas y embarazadas normotensas sanas

Objective

To compare concentrations of chemokine RANTES in pre-eclampsia patients and healthy normotensive pregnant women.

Method

A total of 100 patients were selected. We included 50 pre-eclamptic patients as cases (group A) and a control group of 50 healthy normotensive women with the same age and body mass index as the study group (group B). Blood samples were collected in all patients before labor and immediately after diagnosis in group B to determine RANTES concentrations.

Results

There were no significant differences in maternal age, gestational age, or body mass index when the samples were taken (P = ns). RANTES concentrations showed statistically significant differences between cases (group A; 2484.6 ± 113.7 pg/mL) and controls (group B; 2002.8 ± 62.6 pg/mL; P < .05). There was a moderate, positive and significant correlation with systolic blood pressure values (r = .283; P < .05) and with diastolic blood pressure values (r = .322; P < .05).

Conclusions

Chemokine RANTES concentrations were significantly higher in pre-eclampsic patients than in healthy normotensive pregnant women.     

Clinical evaluation of peripartum outcomes of mediolateral versus lateral episiotomy

Objective

To evaluate the incidence and extent of vaginal and perineal trauma among primiparous women after mediolateral and lateral episiotomy.

Methods

In a prospective randomized study at University Hospital Pilsen, Czech Republic, 790 consecutive primiparous women were enrolled between April 2010 and April 2012. Mediolateral episiotomy (MLE) followed an angle of at least 60° from the midline. Lateral episiotomy (LE) started 1–2 cm laterally from the midline and was directed toward the ischial tuberosity. A rectal examination was performed before episiotomy repair.

Results

MLE was performed for 390 women, and LE for 400. The groups did not differ in maternal or neonatal characteristics. No difference was found in incidence or extent of vaginal and perineal trauma; or in additional perineal (1.8% vs 1.5%, P = 0.6) or vaginal (8.5% vs 10.6%, P = 0.2) trauma continuing along the episiotomy incision. The incidence of anal sphincter injury did not differ between MLE and LE (1.5% vs 1.3%, P = 0.7). MLE was associated with shorter repair times (P < 0.05), less suturing material (P < 0.05), and shorter distances from the anus (P < 0.001).

Conclusion

Risk of additional vaginal and perineal trauma, and anal sphincter injury after adequately performed mediolateral episiotomy is relatively low and corresponds to that of lateral episiotomy.     

Mifepristona 5 mg frente a 10 mg diarios en el tratamiento del leiomioma. Ensayo clínico aleatorizado

Objective

To estimate the efficacy and safety of 5 mg or 10 mg mifepristone daily in the treatment of leiomyoma.

Material and methods

Ninety women with symptomatic uterine myomas were randomised to receive 5 mg or 10 mg of mifepristone (45 per group). Leiomyomata and uterine volumes were evaluated by ultrasonography. Efficacy was estimated by the reduction of the leiomyomata and uterine volumes and the prevalence of symptoms.

Results

After treatment, in the 5 mg group there was a 60.8%, (P < .001), reduction in the fibroid volume and it was 59.4%, (P < .001), in the 10 mg group. The prevalence of symptoms decreased significantly. After treatment, 93.8% subjects from the 10 mg mifepristone group and 86.4% subjects from the 5 mg group were amenorrheic, respectively.

Conclusions

Both treatments were effective for treating uterine fibroids.     

Preoperative planning of surgery for deeply infiltrating endometriosis using the ENZIAN classification

Objective

To use the ENZIAN classification for preoperative estimation of laparoscopic operating time in patients with deeply infiltrating endometriosis (DIE).

Study design

Retrospective study of women with DIE (n = 151) who underwent laparoscopic surgery.

Results

151 of 470 patients had DIE (n = 205 lesions) exclusively in compartments A (rectovaginal septum, vagina), B (sacrouterine ligament to the pelvic wall) and C (rectum, sigmoid colon). These laparoscopically treated lesions were used to calculate a model for estimating operating time for DIE, assuming complication-free procedures (overall significance for model's predictive power: P < 0.001). The error of estimation for the operating time prediction is 0 ± 35.35 min (mean ± SD; range −83 to +117 min). The actual operating time for all operations was 109.32 ± 74.38 min (mean ± standard deviation).

Conclusions

Using a model for predicting operating time based on the ENZIAN classification enables resources to be planned more precisely in surgery management. Patients with DIE can also be given more precise information regarding the expected operating time.     

Intraoperative hypothermia during primary surgical cytoreduction for advanced ovarian cancer: Risk factors and associations with postoperative morbidity

Objective

The objective of this study was to evaluate the risk factors and potential morbidity associated with intraoperative hypothermia (IH) during cytoreductive surgery (CRS) for advanced ovarian cancer.

Methods

Demographic and perioperative data were collected for all patients with stage IIIC–IV ovarian, fallopian tube, and primary peritoneal carcinoma who underwent primary CRS at our institution from 2001 to 2010. Only patients with carcinomatosis and/or bulky upper abdominal disease and residual disease of < 1 cm were included. Intraoperative hypothermia was defined as temperature of < 36.0 degrees Celsius (°C). Associations with 21 perioperative factors, 12 systems-based complications, and specific complications including but not limited to venous thromboembolism and surgical site infection were evaluated.

Results

Two hundred ninety-seven patients met the inclusion criteria. An intraoperative temperature < 36 °C was noted in 72.1% of patients, and a temperature < 36 °C at the time of abdominal closure was noted in 45.5%. Intraoperative vasopressors (P = 0.02), epidural anesthesia (P = 0.01), transfusion of fresh frozen plasma (P < 0.05), and blood loss (P = 0.01) were associated with IH. There was no association between IH and postoperative complications in general (P = 0.48) or specifically grade 3–5 complications (P = 0.34). Univariate analysis did show an association between hematologic complications and IH; however, this did not persist on multivariate analysis (P = 0.14).

Conclusions

In patients who underwent optimal primary CRS for advanced ovarian cancer, IH alone was not associated with the development of postoperative complications. Postoperative morbidity in these patients is multifactorial and further investigation into modifiable risk factors is warranted.     

Maternal polycystic ovary syndrome may be associated with adverse pregnancy outcomes

Objective

To determine whether maternal polycystic ovary syndrome (PCOS) is associated with adverse pregnancy outcomes in a population of Italian parturients.

Study design

Retrospective study carried out in an academic hospital in Bologna, Italy, including 516 consecutive Italian women who delivered between January and April 2006. PCOS women, women with hyperandrogenic features not configuring PCOS (Intermediate group) and non-hyperandrogenic controls were identified by a telephone survey of 229 women. Statistical analysis was performed using ANOVA or chi-square.

Results

PCOS women, accounted for 6.6% of our cohort. Gestational diabetes mellitus (GDM) was significantly more frequent in the PCOS group than in the other groups (20% vs. 3.6% and 4%; P < 0.01). The association of GDM and pregnancy-induced hypertension occurred in one subject in the PCOS group but in none of the other groups (P < 0.001). Preterm birth was more frequent in the PCOS group than in control group (20% vs. 6.9%; P < 0.05), whereas mean length of gestation was not different. The higher occurrence of adverse outcomes may be, at least partly, related to a higher weight gain during pregnancy in PCOS group with respect to the other groups (P < 0.05).

Conclusions

Women affected by PCOS carry an increased risk of adverse pregnancy outcomes.     

Randomized study of bipolar vessel sealing system versus conventional suture ligature for vaginal hysterectomy

Objective

This study was undertaken to compare the use of bipolar vessel sealing system (BVSS) with conventional suture ligature in vaginal hysterectomy (VH) on a non-prolapsed uterus.

Study design

Women referred for VH for uterine myoma were randomized to BVSS (n = 45) or conventional suture ligature VH (n = 45). Exclusion criteria were uterine prolapse and indication associated surgical procedures. Main outcome measures were operative time, blood loss, hospital stay, pain status, peri and post-operative complications. Data of patients were collected prospectively. Statistical analysis was performed using chi-square and Student's t-test as appropriate.

Results

There were no differences in patients’ mean age, parity and uterine size between groups. Patients in the BVSS group had a significantly reduced operating time (29.2 ± 2.1 min vs. 75.2 ± 5 min; p < 0.001), operative blood loss (84 ± 5.9 mL vs. 136.4 ± 89.1 mL; p = 0.001), requirement of surgical sutures (1.2 ± 0.6 units vs. 7.4 ± 0.3 units; p < 0.001), pain status (1.6 ± 0.4 vs. 3.6 ± 0.4; p < 0.001) and hospital stay (25.6 ± 0.9 h vs. 33.2 ± 1.7 h; p < 0.001) compared to the control group. The overall complication rate in the study was 7.8% (7/90), and did not differ between patients of the BVSS and control group.

Conclusion

Bipolar vessel sealing for vaginal hysterectomy appears to be an effective and safe haemostatic control method, with reduced operating time, peri-operative blood losses, post-operative pain and hospital stay.     

Determination of hyperelastic properties for umbilical artery in preeclampsia from uniaxial extension tests

Objective

Preeclampsia often results in altered hemodynamics and structurally remodeled umbilical arteries in the fetus – alterations that may be associated with arterial stiffening. We therefore hypothesized that the mechanical function of preeclamptic (PE) umbilical arteries had increased stiffness compared to control.

Study design

Umbilical arteries were collected from control (n = 9) and PE (n = 6) pregnancies without any other complications. Samples were tested uniaxially in axial and circumferential directions for the passive mechanics. The umbilical artery was modeled as a fiber reinforced hyperelastic material in both control and PE conditions.

Results

The PE arteries were stiffer than control arteries at stresses of 20–160 mmHg in the axial direction and 65–200 mmHg in the circumferential direction (P < 0.05). The PE umbilical arteries exhibited a 58% and 48% increase in circumferential moduli at the systolic and diastolic blood pressure respectively compared to the controls (P < 0.05). A hyperelastic model showed a substantial increase in both isotropic and anisotropic contribution in the mechanical behavior. Collectively, the changes observed correlated to a higher collagen fiber density in the PE group with increased hyperelastic material parameters (P < 0.05).

Conclusion

PE umbilical arteries demonstrated stiffer biomechanics compared to the controls due to the change in collagen fiber content. These altered biomechanical and structural changes provide a potential snapshot into systemic vasculature remodeling occurring in the newborn.     

Prevalence of Candida species and potential risk factors for vulvovaginal candidiasis in Aligarh,India

Objectives

The objectives were to determine the frequency of Candida species in women of different age groups as well as to suggest the criteria for the diagnosis of vulvovaginal candidiasis (VVC).

Study design

A prospective study of vulvovaginal candidiasis was carried out using laboratory diagnosis, with the estimation of vaginal pH and the direct microscopic and biochemical examination of vaginal discharge/secretions. Vaginal cultures for Candida species were collected from 1050 women with vulvovaginal symptoms.

Results

Out of 1050 women, 215 (20.47%) were positive for Candida species. Of 215 women, 172 (80%) had pH within the normal range and 167 (77.67%) were showing yeast cells and mycelia on direct microscopic examination. Candida albicans accounted for 46.9% of cases, Candida glabrata 36.7%, Candida parapsilosis 10.2%, Candida tropicalis 2.8%, Candida krusei 1.4%, and Candida kiefer 1.9%. The frequency of culture positivity was related to pregnancy (P < 0.001), an increase in parity (P < 0.001), and use of oral contraceptives (P < 0.001) and antibiotics (P < 0.001). The most common signs and symptoms in 215 women with positive cultures were pruritus with or without vaginal discharge and vaginal erythema.

Conclusion

Our study suggests that vulvovaginal candidiasis can only be diagnosed by using clinical criteria in correlation with vulvovaginal symptoms and Candida cultures.     

Effect of latency period after premature rupture of membranes on 2 years infant mortality (DOMINOS study)

Objective

To assess the impact of a short latency period after preterm premature rupture of the membranes (PPROM) on infant mortality.

Study design

A prospective cohort study of women with PPROM between 24^0/7 and 33^6/7 weeks’ in singleton gestation was performed in all maternity wards of the Rhône-Alpes Region. Neonatal and infant outcomes were compared according to the latency period (<48 h and ≥48 h). The primary outcome was the mortality rate and the secondary outcome was a composite variable of significant neurological disorders at 2 years of age. Outcomes was stratified according to gestational age at rupture. Univariate and multiple logistic regression analyses were used with SAS statistical software.

Results

Out of 471 women recruited in the study at a mean gestational age of 30.5 ± 0.2 weeks, 170 (37%) presented with a <48-h latency period, and 301 (63%), a ≥48-h latency period. While prior to 30 weeks’ gestation, the mortality rate was higher in neonates with a short latency period (16.3% versus 7.3%, p < 0.01) with pulmonary disease being the major cause of death, a short latency period was associated with a lower mortality rate after 30 weeks’ gestation (0% versus 3.7%, p = 0.02). After adjusting for confounding factors, a <48-h latency period remained an independent factor associated with infant mortality prior to 30 week's gestation (odds ratio 3.8, 95% confidence interval 1.3–11.7). Significant neurological disorders were not modified by the length of the latency period.

Conclusion

For PPROM that occur before 30 weeks’ gestation, a short latency period was associated with a higher infant mortality rate. Inversely, it was associated with a lower mortality rate after 30 weeks’. There is an urgent need for a thorough evaluation of expectant management of PPROM after 30 weeks’ gestation.     

Appropriate second-line therapies for management of severe postpartum hemorrhage

Objective

To explore appropriate second-line therapies for management of severe postpartum hemorrhage at cesarean delivery.

Methods

A retrospective study was done of 87 women who underwent cesarean delivery and received uterotonics after placental separation at the Beijing Haidian Maternal and Child Health Hospital, China, between 2009 and 2013. Group 1 (n = 52) included patients with 500–700 mL of blood loss before application of intrauterine gauze tamponade or B-Lynch suture as second-line therapy, while group 2 (n = 35) included patients with blood loss of more than 700 mL before application of either gauze tamponade or B-Lynch suture.

Results

Management was successful in all patients in group 1. In group 2, additional management was needed in three of four patients who underwent a B-lynch suture. Factors significantly associated with total blood loss were blood loss before application of second-line therapy (P < 0.001), fibrinogen levels (P < 0.001), and time from placental separation to second-line therapy (P = 0.015).

Conclusion

When blood loss is 500–700 mL, compression sutures or intrauterine gauze tamponade can be used as second-line treatment of postpartum hemorrhage. When blood loss is more than 700 mL, intrauterine gauze tamponade should be used.     

The customized fetal growth potential: a standard for Ireland

Objective

To identify maternal and pregnancy-related physiological and pathological variables associated with fetal growth and birthweight in Ireland and to develop customized birthweight centile charts for the Irish population that will aid in appropriate identification and selection of growth-restricted fetuses requiring increased antenatal surveillance.

Study design

Prospectively collected outcome data of 11,973 consecutive ultrasound-dated singleton pregnancies between 2008 and 2009 from six maternity units in Ireland (Dublin, Galway, Limerick and Belfast) were included for analysis. Maternal weight and height at booking, parity and ethnicity were recorded and combined with birthweight, fetal gender and pregnancy outcomes. Coefficients were derived by backward multiple regression using a stepwise backward elimination approach.

Results

A total of 11,973 ultrasound-dated singleton pregnancies were included in the analysis. Over 90% of women (n = 10,850) were of Irish or European descent, 3.4% (n = 407) were African or African Caribbean, 1.7% (n = 208) were Indian; 42.2% (n = 5057) were nulliparous, 32.8% (n = 3923) had one previous delivery after 24 weeks’ gestation, 15.6% (n = 1872) had two previous deliveries and 9.4% (n = 1121) had three or more previous deliveries. Mean term birthweight for a standard Irish mother was 3491grams. Babies of all other ethnic origins were smaller than their Irish counterparts. African Caribbean, Bangladeshi, Indian and Pakistani babies were on average 237 g, 196 g, 181 g and 181 g lighter, respectively, when compared to the average Irish offspring. Pathological factors significantly affecting term birthweight were pre-gestational diabetes (+137 g; p < 0.001), smoking (−225 g; p < 0.001), pregnancy-induced hypertension (−37.6 g; p = 0.009) and maternal obesity (−41.6 g; p = 0.012).

Conclusion

Birthweight in this Irish maternity population is subject to similar influences to those observed in studies from the UK, Sweden, USA and Australasia. The derived coefficients can be used for customized assessment of fetal growth potential in Ireland. The implementation of these customized centile charts and their free online availability will aid clinicians in Ireland in the interpretation of fetal weight estimation.     

A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery

Objective

To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair.

Methods

The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012–2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n = 500) and in situ repair in group 2 (n = 500). The primary outcome measure was the surgery duration.

Results

Surgery duration was significantly longer in group 1 than group 2 (49.9 ± 2.3 minutes vs 39.9 ± 1.8 minutes; P < 0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P = 0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P < 0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0 ± 2.7 hours vs 14.0 ± 1.9 hours; P < 0.001).

Conclusion

In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement.ClinicalTrials.gov:NCT01723605     

Evaluation of confounding factors interfering with sexual function in women with minimal pelvic organ prolapse

Objective

To evaluate the effects of confounding factors on sexual function in women with minimal pelvic organ prolapse (POP).

Methods

A cross-sectional study was conducted at a cervical cancer screening center in Turkey between December 1, 2012, and March 31, 2013. Symptom-free women with stage I or II POP were enrolled to evaluate the association between sexual function and sociodemographic variables, POP, POP-related quality of life, stress incontinence, and overactive bladder.

Results

Of 243 volunteers (mean age 46.0 ± 9.1 years), 188 (77.4%) had a low Female Sexual Function Index score. Women with better sexual function tended to be younger, have a higher salary, not be in the menopause, and have no chronic illness (P < 0.05 for all). There was no difference between the groups in terms of POP Quantification measurements (P > 0.05), apart from transvaginal length (P = 0.011). Overactive bladder was more common (P = 0.005) and more severe (P = 0.002) in women with sexual dysfunction, and their POP-related quality of life was worse (P < 0.05). In a linear regression analysis, high salary had a positive effect and overactive bladder had a negative effect on sexual function.

Conclusion

Sexual dysfunction is highly prevalent in women with minimal POP. Overactive bladder and low income are the major factors adversely affecting sexual function.     

Demand and supply factors affecting the rising overmedicalization of birth in India

Objective

To understand the interaction between health systems and individual factors in determining the probability of a cesarean delivery in India.

Methods

In a retrospective study, data from the 2007–2008 District Level Household and Facility Survey was used to determine the risk of cesarean delivery in six states (Punjab, Delhi, Maharashtra, Andhra Pradesh, Kerala, and Tamil Nadu). Multilevel modeling was used to account for district and community effects.

Results

After controlling for key risk factors, the analysis showed that cesareans were more likely at private than public institutions (P < 0.001). In terms of demand, higher education levels rather than wealth seemed to increase the likelihood of a cesarean delivery. District-level effects were significant in almost all states (P < 0.001), demonstrating the need to control for health system factors.

Conclusion

Supply factors might contribute more to the rise in cesarean delivery than does demand. Further research is needed to understand whether the quest for increased institutional deliveries in a country with high maternal mortality might be compromised by pressures for overmedicalization.     

A comprehensive assessment of outcomes in pregnancies conceived by in vitro fertilization/intracytoplasmic sperm injection

Objective

To assess the association between in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) and adverse birth outcomes.

Study design

Retrospective cohort study involved IVF/ICSI patients who were treated in the Ottawa Fertility Centre from 1996 to 2005 with a viable pregnancy (>20 weeks of gestation) and mothers who conceived naturally.

Results

Eleven of the 1044 infants conceived with IVF/ICSI (1.1%) and 7 of the 1910 naturally conceived infants (0.4%) had congenital heart defects (P < 0.01). Five of the 138 infants (3.6%) born to mothers with a body mass index > 30 and conceived by IVF/ICSI had congenital heart defects, compared with none in the 240 infants born to mothers with a body mass index > 30 and conceived naturally (P < 0.01).

Conclusion

Infants conceived with use of IVF/ICSI have three times as high a risk of a congenital heart defect as naturally conceived infants.