Current Women's Health Reviews - Volume 12, Issue 1, 2016

Heart failure is a leading cause of long-term maternal morbidity and mortality in developed countries. The most common cause of maternal heart failure is cardiomyopathy. Peripartum Cardiomyopathy (PPCM) is a distinct idiopathic disease that is not triggered by the hemodynamic changes and myocardial overload associated with pregnancy. Diagnostic criteria include the development of heart failure in the time frame between the last months of pregnancy and the months following delivery, the absence of prior heart disease or other identifiable causes of heart failure and an echocardiography demonstrating LV ejection fraction<45% and/or fractional shortening. Diagnosis requires a high level of suspicion; signs of heart failure may be masked by the pregnancy itself and/or by associated diseases such as hypertension and preeclampsia. The hallmark of the disease is the typical reduction in LV function. The incidence of PPCM ranges between 1:100 to 1:3000 live births, and is particularly high among women of African descent. It remains unclear whether race is a modifier of the disease or a risk factor unto itself. Plausable causes for the disease include: exacerbation of pregnancyinduced myocardial injury caused by certain virus strains, genetic and/or environmental factors, circulating autoantibodies, and a flaw in the normal cardioprotective mechanisms of pregnancy allowing development of a vasculopathy triggered by abnormal peripartum hormonal changes. Treatment is comprised of standard heart failure therapy (restriction of salt and water intake, diuretics, angiotensinconverting enzyme (ACE) inhibitors, mineralocorticoid receptor antagonists, beta blockers and digoxin) and preventive anticoagulation if the ejection fraction ≤35%. Delivery should be planned and carried out by a multidiscipliniary team. Maternal health should always take precedence over fetal health. Failed therapy should prompt further workup (magnetic resonance imaging (MRI) of the heart and/or cardiac catheterization and endomyocardial biopsy) and consideration of less conventional treatment modalities (e.g. immune modulation, bromocriptine), resynchronization, mechanical support and even heart transplant. The prognosis of PPCM is associated with the severity of heart failure at presentation and the response to therapy and is generally better than that of other cardiomyopathies. Approximate mortality rates are <2% in-hospital, 10-15% at 6 months after diagnosis and 25-30% at 2-4 years. Recovery of LV function occurs in one-third to one-half of the women and may carry on for almost 2 years after diagnosis. Subsequent pregnancies have been associated with a high likelihood of relapse due to residual impairment of the LV contractile reserve. There is insufficient data on neonatal outcome.

Obstetrical hemorrhage is the leading cause of maternal mortality worldwide. Management of obstetrical hemorrhage involves medical knowledge and surgical skill. Uterotonics for the prevention and treatment of uterine atony remain the cornerstone of medical management. The rising rate of placenta accreta emphasizes the importance of definitive surgical management. Proficiency of uterinesparing techniques for the management of uterine atony or placenta accreta allow alternative options for those who wish to preserve fertility. New concepts in the management of severe obstetrical hemorrhage have changed how we care for this unique emergent condition. The use of massive transfusion protocols in conjunction with products such as tranexamic acid, fibrinogen concentrates and prothrombin complex concentrates are emerging techniques to reduce morbidity and mortality.

Sepsis represents a leading cause of maternal morbidity and mortality in the United States and worldwide. Clinical management of sepsis in pregnancy must take into consideration the unique pathophysiology of pregnancy. Etiologies of sepsis in pregnant and post-partum women differ from a patient who is non-pregnant. Moreover, the clinical diagnosis of sepsis in pregnancy can be quite challenging due to the anticipated physiologic changes that occur in pregnancy, contributing to variability in recognition. Pre-existing maternal medical conditions and other demographic factors may also predispose certain women to developing sepsis. Prompt recognition and subsequent treatment of sepsis in pregnancy can improve both maternal and neonatal outcomes. In the present review, we will summarize the perinatal implications of sepsis in the obstetric population during the antepartum and postpartum periods. Further understanding of systemic inflammation leading to multi-system organ failure, non-obstetric and obstetric etiologies of sepsis, and subsequent perinatal complications will help to expeditiously identify and treat women with this life-threatening condition to ultimately improve outcomes.

Acute-onset, severe systolic or diastolic hypertension can occur during pregnancy or in the postpartum period. The American College of Obstetricians and Gynecologists Taskforce on Hypertension during pregnancy recently modified the diagnosis and management of hypertension, describing a hypertensive emergency in pregnancy as persistent (≥ 15 min), acute-onset, severe hypertension, defined as a systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 110 mmHg. Pregnancy can be complicated by a hypertensive emergency with a lower blood pressure threshold for end-organ damage than non-pregnant patients. Labetalol, hydralazine and nifedipine are all considered first-line anti-hypertensive agents for the treatment of severe hypertension. The objective of this article is to review the current understanding, diagnosis and management of a hypertensive emergency during pregnancy or postpartum.

Postpartum depression (PPD) represents the most frequent cause of postpartum morbidity for mothers. PPD also impairs maternal-infant interactions, often contributing to poor developmental outcomes for children. Recent evidence suggests that telephone-based peer support can help prevent mothers’ symptoms of PPD. In this descriptive qualitative study, integrated knowledge transfer (IKT) and implementation science approaches were used to: (1) adapt a research model of telephone-based peer support designed to prevent PPD symptoms into an intervention program to treat PPD symptoms and (2) integrate telephone-based peer support to treat PPD into the real-world health service delivery setting. IKT involved extensive partnership with a provincial government of a Canadian province. Research questions included: What are the required characteristics of telephone-based peer support to: a) reflect contemporary research, b) seamlessly integrate with established provincial telephone support line technology, and c) operate in an innovative, effective, accessible, and sustainable manner? Qualitative individual (n=19) and group (n=2) interviews with expert stakeholders from service delivery, government, and consumer and advocacy associations were undertaken. Thematic analysis was employed to identify broad perspectives of the program’s training manual, training sessions as well as planned program content and delivery. Findings revealed a focus on improving clarity and inclusivity of the manualized content, lengthening and enriching training opportunities for peer mentors, and addressing program structure, sustainability, outreach and peer mentor selection and needs, including ongoing supervision and support. Findings were incorporated into program design. Thus, innovative implementation science and IKT approaches served to adapt and integrate telephone-based peer support into existing telephone support line technology, promoting accessibility to evidence-based programs for more mothers suffering from PPD.

This study aimed to examine the effects of smoking cigarettes on the sperm feature of healthy, normospermia and subnormospermia men. 420 samples of semen were derived from healthy patients and categorized into two groups; normospermia (G. I, n=100; A: smokers=50, B: non-smokers=50) and subnormospermia (G.II; n=320; A: smokers=160, B: non-smokers=160). Semen analysis was performed for all samples. Sperm vitality was assessed with Eosin test and Hypo-osmotic swelling test (HOS-Test) and was utilized to test the membrane integrity of the sperm. It was determined that heavy smoking (greater than 20 cigarettes per day) was significantly correlated with a decrease in sperm concentration (mill/ml), percentage of vitality (%), motility (%) and membrane integrity in all examined semen samples as well as sample from normo- and subnormosperrmia. These results propose that heavy smoking causes to a significant deterioration in semen quality (sperm concentration, vitality, motility and membrane integrity not only by subnormospermia but also by normospermia men), thus smoking may negatively affect the fertilization efficiency. Sperm cell membrane integrity test (HOS-test) could be used as standard screening test and a biomarker for the sperm quality in patients.

Background: A potential complication of gynecologic surgery is ureteral injury, which if unidentified can result in significant morbidity for the patient. Intraoperative cystoscopy is currently used to screen for ureteral injury during pelvic surgery. Color Doppler sonography has previously been reported as a possible screening modality for ureteral injuries in postoperative patients. Technique: Color Doppler sonography is a minimally invasive procedure that can document ureteral jets. Ureteral jets are episodic flame shaped areas within the color Doppler range that correspond to turbulent flow as urine passes from the ureteral orifices into the bladder. An absent ureteral jet indicates absent flow of urine through the ureteral orifice suggesting ureteral injury proximal to the ureteral orifice. This technique does not require use of dyes or contrast agents for direct visualization. Experience: We present a series of twenty women where intraoperative transabdominal color Doppler sonography documented bilateral ureteral jets with cystoscopy confirming ureteral patency in all patients. Conclusion: Transabdominal color Doppler sonography is technically feasible to evaluate for ureteral jets intraoperatively. Larger studies are needed to determine whether color Doppler sonography can be used for intraoperative screening for ureteral injury.

Background and Aim: Cervical pregnancy is a rare form of ectopic pregnancy. Treatment approach depends on hemodynamic status; so, it could be medical therapy or more aggressive treatment like emergent hysterectomy. Case report: We present an interesting case of cervical ectopic pregnancy with high level of βhCG which was successfully treated with multidose methotrexate. Conclusion: In cases of early diagnosis of cervical pregnancy in patients with stable hemodynamic status, medical therapy could successfully treat cervical ectopic pregnancy even with high level of βhCG.