Radiation damage to the uterus — Review of the effects of treatment of childhood cancer

At the present time approximately 1 in 1000 young people aged between 16 and 35 years will have been cured of cancer in childhood and some of the treatment regimens used will have predictable effects on their future fertility prospects. In young women who have been exposed to radiotherapy below the diaphragm, the reproductive problems include the risk of ovarian failure and significantly impaired development of the uterus. The magnitude of the risk is related to the radiation field, total dose and fractionation schedule. Premature labour and low birth weight infants have been reported after flank abdominal radiotherapy. Female long-term survivors treated with total body irradiation and marrow transplantation are also at risk of ovarian follicular depletion and impaired uterine growth and blood flow, and of early pregnancy loss and premature labour if pregnancy is achieved. Despite standard oestrogen replacement, the uterus of these young girls is often reduced to 40% of normal adult size. Uterine volume correlates with the age at which radiation was received. Regrettably, it is likely that radiation damage to the uterine musculature and vasculature adversely affects prospects for pregnancy in these women. It has been demonstrated that, in women treated with total body irradiation, sex steroid replacement in physiological doses significantly increases uterine volume and endometrial thickness, as well as re-establishing uterine blood flow. However, it is not known whether standard regimens of oestrogen replacement therapy are sufficient to facilitate uterine growth in adolescent women treated with total body irradiation in childhood. Even if the uterus is able to respond to exogenous sex steroid stimulation, and appropriate assisted reproductive technologies are available, a successful pregnancy outcome is by no means ensured. The uterine factor remains a concern and women who are survivors of childhood cancer and their carers must recognize that these pregnancies will be at high risk.     

Physicians’ information to patients and prescription of the emergency contraceptive pill according to their personal experience of using the method and perception of its mechanism of action

Objectives: The aim of the study was to evaluate the association between physicians’ understanding of the mechanism of action of the emergency contraceptive pill (ECP), their personal use of it, and their practice in informing their patients about the method and in prescribing it.

Methods: The study was carried out in a sample of 3337 obstetrician-gynaecologists who responded to a mailed questionnaire. Bivariate analysis was used to test the association between physicians’ personal use of the ECP, their understanding of its mechanism of action, and their practice in informing their patients about the method and in prescribing it. Multiple Poisson regression analysis was carried out to identify variables independently associated with the two dependent variables.

Results: Multiple regression analysis showed that the percentage of physicians who had informed their patients about the ECP was significantly lower among those who had needed it themselves but had not used it and among those living in the northeast of Brazil. A significantly higher percentage of female than male physicians had provided information on the ECP. The percentage of physicians who had prescribed the ECP was significantly lower among those who had needed it themselves but had not used it and among those who believed that it caused a mini-abortion. The proportion of physicians who had ever-prescribed the ECP was greater among those who worked exclusively in private practice and among those who worked in a state capital.

Conclusions: The misconception that emergency contraception could cause a mini-abortion was associated with its denial to potential users, while physicians’ personal experience of needing to use it favoured the likelihood of their informing potential users about it and prescribing it.     

Endometriosis of the Appendix: When to Predict and How to Manage—A Multivariate Analysis of 1935 Endometriosis Cases

Study ObjectiveTo evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery.DesignA retrospective cohort study.SettingA tertiary level referral center, university hospital.PatientsOne thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis.InterventionsElectronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants.Measurements and Main ResultsAE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32–4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08–15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63–29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05–3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82–11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10–4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07–75.75).ConclusionAmong patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.     

Could the theory of chaos contribute to the interpretation of pathogenesis of polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is a syndrome involving defects in primary cellular control mechanisms that result in the expression of chronic anovulation and hyperandrogenism. In this syndrome the relation between the various parameters is of particular interest. These relations constitute the cornerstone of the pathogenesis of PCOS. The fact that the pathogenesis of the PCOS has not yet been clarified, despite the plethora of relative information, may be the result of a general way of thinking in the interpretation of several scientific data, and especially those that refer to biochemical phenomena. The use of the various models of the theory of chaos, that permits a concrete approach for the interpretation of data, may constitute an optional procedure for the future understanding of the association of different parameters and their disturbances in the pathogenesis of PCOS.     

The art of midwifery: Lost to technology?

This paper looks at how the art of midwifery is affected by the increasing availability and use of sophisticated technology. The use of the cardiotocograph is an example of how overuse of such technology can have detrimental affects, not only for the midwife but also for the woman in labour.While this technology has made a great impact in obstetric nursing, the effects on the low-risk pregnancy need to be evaluated. Midwives need to be research-based in their clinical practice and question the overuse of technology, such as the cardiotocograph, in cases where it is not warranted.     

Induction of labour: which method to use?

Induction of labour is a common obstetric instrument to employ when the potential risk to continue a pregnancy is higher than to terminate it. The methods of induction can be pharmacological or mechanical; the choice of the method mainly depends by the cervical ripening, as it is significantly able to influence, according to the type of induction, its final issue. The mechanical methods are: stripping and sweeping of the membranes, hand dilatation of cervix, intrauterine pressure catheters, Laminaria Japonicum, transcervical Foley catheter and amniotomy. To pharmacological methods include some agents such as the prostaglandins (PG), the most common approach to induce a labour, and used above all by vaginal way in patients with unripe cervix. They simulate the natural PG effects at the beginning of delivery and show a great efficiency. There are a lot of PG on the market, but except some of them, as Dinoprostone for PGE2 and Misoprostol for PGE1, no one of them shows the same safety in management of labour. Oxytocin, another inductive method, administered by diluted intravenous infusion, is utilized alone or mainly with other methods when the labour is started or with rupture of the membranes, because it begins or maintains the myometrial contraction.     

Why more attentions to fetus in cases of intrahepatic cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy(ICP) is a peculiar disease in middle-late pregnancy with the pathological characteristics of hepatic capillary bile duct silts and is accompanied by clinical presentations of pruritus and bile acid(BA) elevation in serum. Maternal outcomes for patients diagnosed with ICP are usually good. However, fetal outcomes can be devastating with high frequencies of perinatal complications. Patients with ICP generally have an early delivery due to fetal complications. The current hypothesis is that ICP has higher frequencies of fetal complications due to high concentrations of BA which has toxic cellular effects to many organs. In lungs, it destroys the AT-II cells, decreasing phospholipids synthesis leading to the alveolar capillary permeability to increase and pulmonary surfactant to decrease. In heart, cholate can cross into the fetal compartment and causing fetal arrhythmias and decreased contractility. In the nervous system, high BAs can cause nerve cell denaturation and necrosis, mitochondria edema and membrane dissolve. In the placenta, high BA concentration can cause edema of the villous, decrease number of villous, intervillous thickening and balloon formation.In addition, high total BA can result in chorionic vein constriction and impaired fetal adrenal function.     

Why is continuum of care from home to health facilities essential to improve perinatal survival?

The period around the time of delivery is extremely hazardous for infants in developing countries. After the first week the risk drops sharply, and survival improves markedly. To reduce perinatal mortality, a continuum of care between the home and the various facilities is essential during pregnancy, childbirth and the newborn period. This paper reviews strategies to promote the establishment of this continuum: providing health care within or close to home by frontline workers and increasing the use of services in health facilities through community mobilization and financing strategies. As perinatal care and care for seriously sick children face common challenges and lessons could be learned from successful strategies for management of other illnesses, this paper also reviews intervention models involving community health workers (CHWs) to improve case management of sick children at the household and community levels. Available evidence suggests that the community strategy with the greatest impact on neonatal mortality is home visits by CHWs combined with community mobilization. The same strategy appears to be effective in increasing health facility utilization. An equally effective strategy for increasing health facility utilization seems to be financing health care to remove financial access barriers, particularly using conditional cash transfers or vouchers. Although the availability of information on the effect of community interventions to improve newborn health has increased in the recent past, significant gaps remain. Information on the effectiveness of strategies in different settings, particularly in sub-Saharan Africa, cost-effectiveness and sustainability are particularly needed and should be gathered in future studies.     

Continuity of carer: what matters to women? A review of the evidence

OBJECTIVES: To consider how 'continuity of carer' has been defined in the literature and to review the literature on what aspects of continuity matter to women. DESIGN: Structured literature review. SETTING: The first objective was addressed within the context of a review of the organisation of midwifery services in the UK; for the second objective a wider literature was drawn on. MEASUREMENTS AND FINDINGS: Data were systematically extracted from the identified 'core' studies on the methods used for assessing continuity of carer and on women's satisfaction with periods of care. Continuity of carer was found to be defined in these studies as fewer caregivers, either overall or during pregnancy, or as a known caregiver in labour. Little attention was paid to other possible interpretations of continuity of carer. The literature on what is important to women was found to have used four distinct methods and findings were consistent within methods. Studies comparing women who had and had not had a known carer in labour found no significant differences in satisfaction; those using rankings or ratings found that a known intrapartum carer was a relatively low priority and most of those using open-ended questions found that few women mentioned continuity. In contrast, all studies which asked postnatal women whether a known intrapartum carer was important reported that those who had experienced it said 'yes', while those who had not, generally thought it unimportant. KEY CONCLUSIONS: There has been an emphasis in existing literature on continuity of carer but little attempt to assess continuity or quality of care. Limited definitions of continuity of carer have been used. There is no evidence that women who were cared for in labour by a midwife that they had already met were more satisfied than those who were not. Other aspects of woman-centred care were likely to be more important. Women wanted consistent care from caregivers that they trust, but most did not value continuity of carer for its own sake. IMPLICATIONS FOR PRACTICE: Limited definitions of continuity of carer seem to be becoming ends in themselves. This has particularly been the case with defining continuity as 'having a known carer in labour'. The available evidence does not justify prioritising this definition of continuity--rather the reverse. This is important for both women and midwives since it opens up other possibilities for organising services that put less strain on midwives' lives and may be equally satisfying for both women and midwives.     

Awareness of the effects of postponing motherhood among hospital gynecologists: is their knowledge sufficient to offer appropriate help to patients?

Purpose

The aim of this study is to ascertain the awareness of hospital gynecologists about the effects of woman’s age on spontaneous fecundity and on the efficacy of assisted reproduction techniques (ARTs).

Methods

One hundred fifty-six gynecologists working in public or private Italian hospitals, without specific experience in reproductive medicine and ART, were administered a multiple-choice answer questionnaire addressing (a) the effect of age on woman’s spontaneous fecundity, (b) the tools to estimate the ovarian follicular reserve, and (c) the outcome of ART in women above 40 years.

Results

Approximately half of the interviewed gynecologists indicated the woman’s age limit for successful reproduction between 44 and 50 years; fertility lifespan was believed to be prolonged by oral contraception, pro-fertility medical treatments, or ART. The correct meaning of serum FSH measurement was known by approximately one third of the interviewed doctors. The effectiveness of ART for women of advanced age was overestimated by half of the gynecologists, especially in case of patients having regular cycles and/or small follicles at ultrasound.

Conclusions

Overall, the survey clearly showed that the knowledge of hospital gynecologists about the effects of age on woman’s fertility and ART effectiveness is largely insufficient to offer scientifically correct, helpful information to patients. Properly targeted corrections to academic and periodical educational programs for Ob/Gyn specialists are warranted.

     

Effective counselling of pre-natal diagnosis of serious heart disease--an aid to maternal bonding?

The pre-natal diagnosis of a serious anomaly in the fetus precipitates a crisis for the parents. Effective counselling may help during this difficult phase. We postulated that if parents opted to continue with the pregnancy, then they are better prepared to care for the newborn infant having already experienced the grieving process. OBJECTIVES: This paper reviews our early experience, focusing on the parental perception of the counselling. METHODS AND SUBJECTS: Questionnaires were developed and forwarded to patients previously seen in a private obstetric ultrasound practice, diagnosed with or specifically referred because of the diagnosis of a complex cardiac abnormality in the fetus. The diagnosis was subsequently confirmed by a further scan in the presence of a paediatric cardiologist, who initiated explanation of the anomaly with the obstetrician ultrasonologist asking and seeking explanations in lay terms on behalf of the parents, concerning the nature of the anomaly, its possible consequences, the need for intervention, the short- and long-term risks, concentrating on quality of life issues. RESULTS: Over a 3-year period a cohort of 40 such patients were reviewed of whom a third opted for termination. The anomalies were complex and many life-threatening, most requiring surgical intervention in the newborn period or subsequently. Of the 27 that proceeded to term, responses were obtained from 21. Most described the shock at learning the diagnosis and of being very distressed at the time. Most commented that the information provided was 'just right'. The majority felt that the previous contact with the obstetrician and cardiologist was very helpful in their subsequent care of their newborn infant. Three parents noted that they continued to experience anxiety about their baby, while 3 others indicated that the previous counselling had 'no effect' on the handling of their baby. Anecdotal observations made of the parents especially of the mother's handling of the newborn infant seemed to support the parents' perception that they were helped by their prior knowledge of the diagnosis. CONCLUSION: With increasing pre-natal diagnosis of major anomalies, it is important that parents so affected have the opportunity to understand the nature of the abnormality, its significance and effects on the infant's and child's functioning and survival, and the need for intervention. Such information together with working through the grieving process during the latter part of the pregnancy may help with the handling of the infant once born and further improve their bonding with their baby, despite the need for, at times, life-threatening intervention. Further objective studies are required to confirm these preliminary observations.     

Uterine Fibroids in the Setting of Infertility: When to Treat,How to Treat?

Purpose of Review

We aim to provide insight on the treatment of fibroids in the infertile patient. Specifically, we discuss which fibroids, based on size and location within the uterine wall, have the most impact on fertility outcomes. In addition, we demonstrate which methods are best for treatment of fibroids in the infertile patient, focusing on minimally invasive techniques.

Recent Findings

Current research demonstrates that, in addition to submucosal fibroids, also intramural fibroids can have a negative impact on fertility via molecular and mechanical disruption of the endometrium and of normal uterine peristalsis. Certain intramural fibroids should be considered for removal or treatment in the infertile patient, depending on size and patient history. We also provide a large body of evidence demonstrating the safety and clinical advantages of minimally invasive techniques, such as hysteroscopy, laparoscopy, and robot-assisted laparoscopy in the treatment of uterine fibroids.

Summary

All submucosal and many intramural fibroids interfere with uterine function. In the evaluation of the infertile patient, accurate fibroid mapping within the uterus is essential to identify those submucosal and intramural fibroids that are likely to have the most impact of fertility outcomes. The mainstay of treatment is surgery for those fibroids with the most detrimental impact. Nonsurgical alternatives such as magnetic resonance-guided focused ultrasound (MRgFUS) and radiofrequency volumetric thermal ablation (RFVTA) need further validation before their widespread adoption in infertile patients.