Adaptation of in vivo amino acid kinetics facilitates increased amino acid availability for fetal growth in adolescent and adult pregnancies alike.

During pregnancy, adult women with a normal BMI synthesise extra amino acids after an overnight fast by increasing body protein breakdown and decreasing amino acid oxidation. It is not known whether adolescent girls can make these adaptations during pregnancy. The present study aimed to measure and compare the protein, glutamine and alanine kinetics of adult women and adolescent girls at early-, mid- and late-pregnancy. Kinetics were measured in the overnight fasted state using intravenous infusions of 13C-leucine, 15N-glutamine and 15N-alanine in ten adults and twenty adolescents aged 14-17 years in the first and second trimesters (phase 1 study) and infusions of 13C-leucine and 15N2-urea in ten adults and eleven adolescents aged 16-17 years in the first and third trimesters (phase 2 study). In phase 1 study, there were no significant differences between the groups with regard to any of the kinetic parameters measured. In both groups, leucine flux increased (P< 0.05), the percentage of leucine flux oxidised decreased (P< 0.05) and non-oxidative leucine disposal to protein synthesis increased (P< 0.05) from the first to the second trimester. In phase2 study, leucine flux was significantly slower (P< 0.05) in the adult group than in the adolescent group during both trimesters, and whole-body leucine flux and non-oxidative leucine disposal increased significantly in the adolescent group (P< 0.05, respectively) and were higher in the adult group from the first to the third trimester. These results suggest that similar to their adult counterparts after an overnight fast, adolescent girls with a normal BMI provide extra amino acids required for net protein deposition during pregnancy by increasing protein breakdown and decreasing amino acid oxidation.

Arginine flux, but not nitric oxide synthesis, decreases in adolescent girls compared with adult women during pregnancy.

NO has been proposed as a mediator of vascular expansion during pregnancy. Inability to increase NO synthesis and/or production of its precursor, arginine, may contribute to pregnancy-induced hypertension. Adolescents have a higher incidence of gestational hypertension. It is not known whether pregnant adolescents can produce sufficient arginine to meet overall demands. Our objective was to measure and compare the arginine flux and NO synthesis rates of pregnant adolescents and adult women. Arginine, citrulline, and NO kinetics were measured by i.v. infusions of (15)N(2)-argininine and (2)H(2)-citrulline in 8 adolescents and 8 adult women in the fasted state at the end of the first and the beginning of the 3rd trimesters of pregnancy. Arginine flux decreased (P < 0.05) from trimester 1 to 3 in the adolescents but not in the adult women. NO synthesis rate did not change significantly in either group from trimester 1 to 3. In trimester 3, there was a positive association (r = 0.55; P = 0.02) between arginine flux and participants' age, indicating that flux was slower in the younger participants. These findings suggest that after a brief period of food deprivation, the pregnant adolescent cannot maintain arginine production like her adult counterpart in late pregnancy. This inability to maintain arginine production seems to be related to her younger age. It does not, however, affect her ability to synthesize NO in late pregnancy.

Mind the gap: primary care physicians and gynecologists' knowledge about menopause and their attitudes to hormone therapy use in Jamaica.

OBJECTIVES: The study objective was to evaluate physicians' knowledge, attitude, and practices toward menopause and hormone therapy. METHODS: This study was a cross-sectional study using a stratified sample of physicians across the four health regions in Jamaica, between September and October 2017. A total of 145 physicians (75% response rate) completed a questionnaire to assess knowledge and attitudes toward menopause and prescribing hormonal therapy. Univariate and bivariate analyses were used to describe and compare the knowledge, attitudes, and practices in participants. RESULTS: The majority of physicians (66%) self-reported a moderate level of knowledge of menopausal treatment options. Self-reported knowledge was associated with years in practice (P < 0.0001) and level of experience (P < 0.0001). Those who identified as having good and moderate knowledge were likely to discuss treatment options with patients (P < 0.005), while physicians with good knowledge were more likely to prescribe hormone therapy (P < 0.05). Correct responses regarding common menopause symptoms were noted in >60% physicians; however, there was a precipitous fall in correct responses regarding findings related to the Women's Health Initiative (<45%). More consultant grade physicians were confident and less confused about prescribing hormone therapy (P < 0.05) compared to junior grade physicians. When stratified by level of experience, knowledge level was the factor that discouraged physicians from seeing symptomatic menopausal patients (P < 0.05). CONCLUSIONS: This study highlights the gaps in knowledge and practices and a need for carefully designed curricula to provide individualized, risk-mitigated training in menopause healthcare.

Video Summary:http://links.lww.com/MENO/A814 .

Shoulder dystocia in a Jamaican cohort.

OBJECTIVE: To assess the risk factors for shoulder dystocia in Jamaica. METHODS: A retrospective cohort analysis of all cases of shoulder dystocia, and birth weight-matched controls identified from January 1, 2000 to December 31, 2004. Multiple factors were analyzed individually and in combination to identify risk factors. RESULTS: The incidence of shoulder dystocia was 0.83%. Nulliparity, a first stage of labor greater than 7 hours, a second stage lasting more than 1 hour, and use of oxytocin augmentation were found to be statistically significant factors with unadjusted odds ratios (95% confidence interval) of 1.78 (0.86-3.34), 1.89 (0.91-3.94), 2.78 (0.24-31.47), and 1.56 (0.77-3.15), respectively. The incidence of shoulder dystocia decreased as parity increased when adjusted for age. CONCLUSION: Individual risk factors for shoulder dystocia remain obscure. The nulliparous pelvis, when controlled for neonatal weight, was associated with a statistically increased risk of shoulder dystocia; this risk decreased with increasing parity.

Cervical dysplasia and cancer and the use of hormonal contraceptives in Jamaican women.

BACKGROUND: This study was conducted to determine whether use of hormonal contraceptives is associated with cervical dysplasia and cancer in a population where there is widespread use of hormonal contraception and the rates of cervical cancer remain high at 27.5/100,000. METHODS: A case-control study was conducted among women visiting the colposcopy and gynaelogical clinics at a tertiary referral hospital. Two hundred and thirty six cases CIN I (72), II (59), III (54), cancer (51) and 102 controls, consented and were interviewed on use of contraceptives using a structured questionnaire. Logistic regression was used to determine odds ratios (ORs) and 95% confidence intervals (CIs) associated with use of hormonal contraception in cases and controls and in low and high risk cases. Recruitment was carried out from 2001-2002. RESULTS: Contraceptives used were: oral contraceptives - 35%, injections (depot medroxy progesterone acetate (Depo-provera) - 10%, Intrauterine devices - 2%, combinations of these and tubal ligation - 30%. 23% reported use of 'other' methods, barrier contraceptives or no form of contraception. Barrier contraceptive use was not significantly different between cases and controls. Current and/or past exposure to hormonal contraceptives (HC) by use of the pill or injection, alone or in combination with other methods was significantly higher in the cases. In multivariate analysis with age and number of sexual partners as co-variates, use of hormonal contraception was associated both with disease, [OR, 1.92 (CI 1.11, 3.34; p = 0.02] and severity of the disease [OR, 2.22 (CI 1.05, 4.66) p = 0.036]. When parity and alcohol consumption were added to the model, hormonal contraception was no longer significant. The significant association with high risk disease was retained when the model was controlled for age and number of sexual partners. Depo-provera use (with age and number of sexual partners as covariates) was also associated with disease [OR, 2.43 (CI 1.39, 4.57), p = 0.006] and severity of disease [OR 2.51 (1.11, 5.64) p = 0.027]. With parity and alcohol added to this model, depo-provera use retained significance. Exposure to HC > 4 years conferred more risk for disease and severity of disease. CONCLUSION: Hormonal contraception did confer some risk of dysplasia and women using HC should therefore be encouraged to do regular Pap smear screening.

Urinary isoflavone and lignan phytoestrogen levels and risk of uterine fibroid in Jamaican women.

BACKGROUND: Isoflavones and lignans are phytoestrogens, and therefore, are able to bind to and activate estrogen receptors. The resultant estrogenic or antiestrogenic effect is dependent on the concentration of these phytoestrogens relative to endogenous estrogens and the site of their action, among others. Thus, isoflavones and lignans act as selective estrogen receptor modulators; having a beneficial effect in some tissues while simultaneously causing deleterious changes in others. OBJECTIVE: This case-control study investigates the relationship between urinary concentrations of genistein, daidzein, equol, and enterolactone, and the presence of uterine leiomyomas (fibroids) in Jamaican women. DESIGN: Phytoestrogen concentration in spot urine samples from 157 uterine fibroid cases and 171 fibroid-free controls diagnosed by ultrasonography, were assessed by Time-resolved Fluoroimmnoassay. Statistical evaluations were performed using SPSS 12.0. RESULTS: The median concentration of urinary enterolactone was significantly different between uterine fibroid cases and controls (p=0.029). However, this was not observed to affect risk of uterine fibroid, as trends across quartiles of urine enterolactone did not differ significantly between cases and controls. Median urinary genistein (p=0.510), daidzein (p=0.838), equol (p=0.621), total isoflavones (0.510) and total phytoestrogens (p=0.084) were similar for both groups. Binary logistic regression analysis of quartiles of urine genistein, daidzein, equol, enterolactone, total isoflavones, and total phytoestrogens showed no association with uterine fibroid. CONCLUSIONS: Uterine fibroid cases had a higher median urine concentration of enterolactone compared with controls. However, this was not observed to affect ones risk of fibroid. Neither was urine genistein, daidzein, equol total isoflavones, and total phytoestrogens observed to be associated with risk of uterine fibroid.

Bone mineral density in Jamaican men on androgen deprivation therapy for prostate cancer.

BACKGROUND: Androgen deprivation therapy (ADT) has been reported to reduce the bone mineral density (BMD) in men with prostate cancer (CaP). However, Afro-Caribbeans are under-represented in most studies. The aim was to determine the effect of androgen deprivation therapy (ADT) on the bone mineral density (BMD) of men with prostate cancer in Jamaica. METHODS: The study consisted of 346 Jamaican men, over 40 years of age: 133 ADT treated CaP cases (group 1), 43 hormone-naïve CaP controls (group 2) and 170 hormone naïve controls without CaP (group 3). Exclusion criteria included metastatic disease, bisphosphonate therapy or metabolic disease affecting BMD. BMD was measured with a calcaneal ultrasound and expressed in S.D. units relative to young adult men (T score), according to the World Health Organization definition. Patient weight, height and BMI were assessed. RESULTS: Mean ± sd, age of patients in group 1 (75± 7.4 yrs) was significantly greater than groups 2 and 3 (67 ± 8.1 yrs; 65±12.0 yrs). There was no significant difference in weight and BMI between the 3 groups. . The types of ADT (% of cases, median duration in months with IQR) included LHRH (Luteinizing hormone releasing hormone) analogues (28.6%, 17.9, IQR 20.4), oestrogens (9.8%, 60.5, IQR 45.6) anti-androgens (11.3%, 3.3, IQR 15.2) and orchiectomy (15.7%, 43.4, IQR 63.9). Unadjusted t score of group 1, mean ± sd, (-1.6± 1.5) was significantly less than group 2 (-0.9±1.1) and group 3 (-0.7±1.4), p <0.001. Ninety three (69.9%), 20 (45%) and 75 (42%) of patients in groups 1, 2 and 3 respectively were classified as either osteopenic or osteoporotic (p<0.001). Adjusting for age, there was a significant difference in t scores between groups 1 and 2 as well as between groups 1 and 3 (p<0.001). Compared with oestrogen therapy and adjusting for duration of therapy, the odds of low bone mineral density (osteopenia or osteoporosis) with LHRH analogue was 4.5 (95%CI, 14.3 to 3.4); with anti-androgens was 5.9 (95%CI, 32.7 to 5); with orchiectomy was 7.3 (95%CI, 30 to 5.8) and multiple drugs was 9.2 ((95%CI, 31 to 7.1). CONCLUSIONS: ADT is associated with lower BMD in Jamaican men on hormonal therapy for prostate cancer.

Prevention of striae gravidarum with cocoa butter cream.

OBJECTIVE: To determine whether cocoa butter cream is effective in preventing striae gravidarum. METHODS: This randomized, double-blind, placebo-controlled trial enrolled 300 pregnant women: 150 women received cocoa butter cream and 150 women received a placebo cream. The women were followed-up from 16 weeks of pregnancy to delivery to assess the development of striae gravidarum. Maternal height, weight, and abdominal girth were recorded at each visit. After delivery the placenta was weighed, and anthropometry and Apgar scores of the neonate were recorded. RESULTS: The 2 groups had similar clinical parameters at booking. Striae gravidarum developed in 44% of patients using cocoa butter cream compared with 55% of those using placebo; the difference was not significant (chi(2)=2.8, df(1), P=0.09). Striae gravidarum were more common among younger women and those with large neonates. However, no relationship was found between development of striae and body mass index. CONCLUSION: Cocoa butter cream does not prevent striae gravidarum. In Afro-Caribbean women, development of striae is related to young age of the mother and large neonates.

Comparing the glucose kinetics of adolescent girls and adult women during pregnancy.

BACKGROUND: Fetal energy demands are met mostly from oxidation of maternally supplied glucose. In pregnant adults this increased glucose requirement is met by an increase in gluconeogenesis. It is not known, however, whether, like their adult counterparts, pregnant adolescent girls can increase gluconeogenesis-hence, glucose production. OBJECTIVE: Our objective was to measure glucose kinetics in 8 pregnant adolescents and 8 adult women. DESIGN: We measured glucose kinetics after an overnight fast by using a primed-constant 6-h U-(13)C-glucose infusion at the end of trimester 1 and early trimester 3. RESULTS: From trimester 1 to trimester 3, whole-body glucose production increased significantly in both groups (P < 0.01). However, whereas the weight-specific rate in adults increased by 18.2%, it increased by only 14.3% in adolescents. In adults, the increase in whole-body glucose production was largely due to a significant increase (P < 0.01) in the rate of gluconeogenesis, but in adolescents there was no change in whole-body gluconeogenesis, and weight-specific gluconeogenesis actually decreased by 11.7%. In both groups, the rate of whole-body glycogenolysis increased significantly (P < 0.05) in trimester 3, and in adolescents, it increased by 95%. CONCLUSIONS: These findings suggest that, in the fasted state in late pregnancy, pregnant adolescents cannot increase weight-specific glucose production by the same magnitude as their adult counterparts. Furthermore, whereas adult women increase glucose production primarily through gluconeogenesis, adolescents do so through glycogenolysis.

Leiomyosarcoma of the uterus with a florid intravascular component ("intravenous leiomyosarcomatosis").

A leiomyosarcoma of the uterus in a 54-year-old woman exhibited striking involvement of large vessels of the myometrium and broad ligament on both gross and microscopic examination. The pattern of vascular involvement resembled that seen in intravenous leiomyomatosis. Imaging studies showed recurrent tumor within the inferior vena cava 3 months after hysterectomy. To our knowledge, this is the first reported such case in the literature, for which we propose the designation intravenous leiomyosarcomatosis of the uterus.

Misoprostol (prostaglandin E1) for induction of labour

Introduction of labour for obstetric problems is of great value in antenatal care. The usual method is to use oxytocin and artificial rupture of membranes. When the cervix is unripe the use of prostaglandin reduces cervical dystocia and makes induction easier. The usual prostaglandin is dinoprostone which is expensive. However, prostaglandin is not without risks as hyperstimulation can occur resulting in fetal distress or demise, abruptio placentae and ruptured uterus misoprostol is a synthetic prostaglandin in use to induce labour since 1989. Some studies have shown that it is as effective as dinoprostone. Other studies have shown that it is safe but is best used under controlled conditions with strict adherence to a protocol. (AU)

A retrospective review of pregnancy outcome after misoprostol (prostaglandin E1) induction of labour

This retrospective study looked at the outcome of using 50-100 ug misoprostol once daily to indicate labour compared to the outcome of the over all patient population delivered during the same period (1994-1996). During that period 11,255 patients were delivered and 1037 (9.2 percent) were induced with misoprostol. Results showed a significantly lower mean Caesarean section rate: 9.3 percent for the misoprostol group versus 13.3 percent for the overall population (p=0.002, Odds Ratio (OR) 0.67, 95 percent CI 0.53, 0.83). The abruption rates were not significantly different: 0.8 percent for misoprostol versus 0.4 percent (p=0.09,OR 1.86, 95 percent CI 0.81, 4.09). There was more postpartum haemorrage in the misoprostol group: 5.6 percent versus 3.5 percent (p=0.0006, OR 1.63, 95 percent CI 1.22, 2.19); a higher incidence of Apgar scores less than 6 at one minute 10.2 percent versus 7.9 percent (p=0.0093, OR 1.33, CI 1.06, 1.65) but not at five minutes 2.9 percent versus 2.4 percent (p=0.674, OR 1.09,CI 0.73, 1.61) and a higher perinatal mortality rate 55/1000 versus 16.1000 (p=0.00, OR 3.5, 95 percent CI 2.55, 4.80). The rate remained higher but not significantly so when a correction was made to eliminate the high number of intrauterine deaths induced with misoprostol 18/1000 (p=0.69, OR 1.11, 95 percent CI 0.66, 1.84). There were no cases of uterine rupture in either group. In conclusion, there was a significantly lower Caesarean section rate among patients who had once daily misoprostol induction of labour. Close monitoring of the foetus, in patients with misoprostol induction, is needed to detect foetal distress and prophylaxis against postpartum haemorrage is still mandatory. (AU)

Marsupialisation of bartholins cysts and abscesses a comparison of interrupted versus continuous suturing - abstract

Bartholins cysts and abscesses are very common in the reproductive-age group. Unless these conditions are treated properly the recurrence rate is very high. Marsupialisation of lesions offers an ideal method for treating these conditions, as it is simple, cheap and effective. Interrupted sutures are used to maintain patency of the defect made at operation. This is the method described originally by Jacobson in 1960. Continuous suture has never been described but theoretically could simplify the procedure even if it is as effective as the interrupted method. A clinical trial was therefore conducted to compare the continuous and interrupted methods of marsupialisation in terms of the length of time taken, the quantity of suture used and the outcome in terms of complications and efficacy. The sample comprised 30 women with cysts or abscesses who were randomly assigned to receive continous or interrupted sutures. The continuous method was better in using less suture, (47.1 cm, vs 67.8 cm;p<0.001) and taking less operating time (226.7 secs vs 345.7 secs;p > 0.00 (AU)

An update on the management of uterine fibroids

Uterine fibroids are common especially in women of African ancestry. When they are symptomatic they need to be treated. Treatment with medical therapy alone, such as gonadotropin-releasing hormone (GnRH) agonists, has been disappointing. Hysterectomy is recommended in women who have completed their family. Myomectomy is done in women who wish to conserve their uterus, this can be done in some women by laparoscopy or by hysteroscopy. Most women with large fibroids still require laparotomy. Intraoperative haemorrhage is, however, still a major concern. Pretreatment with GnRH agonists and intraoperative perivascular vasopressin injections are new methods, which have been shown to be valuable in reducing the impact of this complication (AU)

Successful pregnancies in patients with the antiphospholipid syndrome treated with low-dose aspirin

Four patients with bad obstetrical and with positive lupus anticoagulant tests were treated with low-dose aspirin, prednisone or heparin. They had pre-term deliveries of live babies who all survived.

The impact of routine misoprostol (prostaglandin E1) induction on antenatal care at the University Hospital of the West Indies, Mona, Jamaica - abstract

Induction of labour for obstetric problems is of great value in antenatal care. The usual method is to use oxytocin and artificial rupture of membranes. This, however, is sometimes not easily done when the patient's cervix is unripe. The use of prostaglandin reduces cervical dystocia and should therefore make induction easier with less need to resort to caesarean section. However, prostaglandin is not without risks as hyperstimulation can occur with foetal distress or demise, abruptio placetae and ruptured uterus. Since 1992, induction of labour with misoprostol, a synthetic prostaglandin E1 analogue, has become very common in the Department of Obstetrics, U.W.I., Mona. A retrospective study was done to look at certain variables two years preceeding routine prostaglandin induction (1990 and 1991) and this was compared to the two years after routine prostaglandin induction became established, 1993 - 1994. Results showed a significantly lower mean caesarean section rate - 16.3 per cent for 1990 - 1991 versus 14.4 per cent for 1993 - 1994 with the advent of increased prostaglandin inductions (p = 0.006). There was also a significant reduction in the number of oxytocin inductions as the number of prostaglandin inductions rose - total number of oxytocin inductions for 1990 - 1991 was 431 of 6192 deliveries (7.1 per cent) and for 1993 - 1994 it was 307 of 5537 deliveries (5.5 per cent; p = 0.001). The forceps rate was higher in the prostaglandin group (1.6 per cent vs 2.4 per cent; p = -0.004). The abruption rates were almost identical (0.45 per cent vs 0.46; p= 0.97). The stillbirth and neonatal death rates were not significantly different. There were no cases of ruptured uterus in either group. Prostaglandin induction may be important in reducing caesarean section rate and appears to be a safe alternative to oxytocin induction in some patients (AU)

Successful pregnancy outcome after hysteroscopic adhesiolysis in Asherman's syndrome

Asherman's syndrome is an uncommon finding at hysterosalpingography for infertility. Modern day management entails hysteroscopic confirmation and adhesiolysis. We present one such case of a young woman who had secondary infertility after dilatation and curettage, and who was diagnosed and treated with a successful outcome.(AU)

Successful pregnancies in patients with the antiphospholipid syndrome treated with low-dose aspirin

Four patients with bad obstetrical histories and with positive lupus anticoagulant tests were treated with low-dose aspirin, prednisone or heparin. They had pre-term deliveries of live babies who all survived (AU)

Extra-amniotic misoprostol as a cervical ripening agent - abstract

There are many indications for induction of labour. When the cervix is ripe, induction of labour with oxytocin is easy. When the cervix is unripe, induction can fail, leading to prolonged labour and an increased Caesarean Section rate. Dinoprostone (Prostin, Upjohn) is the drug of choice used to ripen the cervix prior to induction. This drug is, however, very expensive and is sometimes not readily available. We have used a cheaper prostaglandin, misoprostol (Cytotec, Searle) as an extra-amniotic preparation in two studies, to test its efficacy in cervical ripening and achieving a safe vaginal delivery. In a double-blind controlled trial in 23 women with post-dates pregnancy, misoprostol was better than placebo in ripening the cervix (mean change in Bishop score 5.8 vs 1.9, p = 0.002) and fewer patients had no change in the Bishop score (1/12 vs 6/11, p = 0.03). Almost all of the patients given misoprostol went into spontaneous labour (10/12 vs 1/11, p = 0.002) and the mean time from insertion to delivery was shorter (34.1 hours vs 54.0 hours, p = 0.01). In a prospective randomised trial in 26 pre-eclamptic women, misoprostol was better than dinoprostone in ripening the cervix (mean change in Bishop score 5.1 vs 2.8, p = 0.015.). The mean time from insertion to delivery was also shorter (16.4 hours vs 39.3 hours, p = 0.48). In both studies, there were no significant differences between misoprostol and the other drugs in route of delivery. Maternal complications were slightly more than with placebo but of a minor nature. Maternal and foetal outcomes were not significantly different from dinoprostone (AU)

Ovarian hyperstimulation syndrome associated with clomiphene Citrate

Ovarian hyperstimulation is a recognized complication of ovulation induction with gonadotrophins. The syndrome is becoming more common as the number of women undergoing in-vitro fertilization increases. It is rarely seen in conjunction with clomiphene citrate usage. This case report is of moderate to severe ovarian hyperstimulation in a patient who was treated with clomiphene citrate because of infertility secondary to anovulation. She presented with amenorrhoea for five weeks, lower abdominal pain and a positive urinary human chronic gonadotrophin (hCG) test. Pelvic ultrasonography was suggestive of a possible ectopic pregnancy with a different diagnosis of a ruptured ovarian cyst. Diagnostic laparoscopy was done followed by laparotomy. Oophorectomy was performed because the ovary was thought to be complex with solid areas. However, conservative management with advance of laparotomy is the recommendation in confirmed cases of ovarian hyperstimulation but this requires a high level of suspicion in patients who have ovulation induction. (AU)