Adverse outcome of acute splenic sequestration crisis in pregnancy.

BACKGROUND: Acute splenic sequestration crisis, characterized by abrupt fall in hemoglobin, splenomegaly, hypovolemia, and often thrombocytopenia, occurs infrequently in adults with sickle cell disease and extremely rarely during pregnancy. CASE: A 25-year-old woman with HbSC presented at 33 weeks' gestation with vaso-occlusive pain. Sudden worsening of abdominal pain and non-reassuring fetal surveillance on day 3 of admission led to emergent delivery. Acute splenic sequestration crisis was the diagnosis of exclusion based on clinical presentation and intra-operative hemoglobin of 37 g/L. Five- and 10-minute Apgar scores were 4. Neonatal brain magnetic resonance imaging revealed significant diffuse white matter abnormalities. CONCLUSION: Acute splenic sequestration crisis in pregnancy must be considered in the differential diagnosis for this patient population as it can evolve rapidly and lead to maternal and fetal compromise.

Is overactive bladder independently associated with anxiety?

INTRODUCTION AND HYPOTHESIS: Although some psychiatric anxiety questionnaires include overactive bladder (OAB) questions, there are few controlled data to confirm such an association. We tested the association between OAB and anxiety using a control group of women with non-OAB lower urinary tract symptoms (LUTS). METHODS: Patients referred to a urogynecology clinic for LUTS completed two questionnaires: the International Consultation on Incontinence Modular Questionnaire for Overactive Bladder (ICIQ-OAB), and the Generalized Anxiety Disorder 7-Item Scale (GAD-7). Based on ICIQ-OAB scores, patients were dichotomized as having OAB versus LUTS-other, and GAD-7 scores categorized patients as having anxiety. A 2-tailed Fisher's exact test was used to test the association between OAB and anxiety. Demographic variables were collected and significant confounders were included in a logistic regression analysis. Sample size calculation indicated a need for 100 subjects, but we recruited 105 subjects to account for incomplete questionnaires. RESULTS: One hundred and five subjects were enrolled (one excluded owing to incomplete questionnaires). Sixty-five patients had OAB and 39 had LUTS-other. Of the OAB patients, 17 out of 65 (26.2%) had anxiety, compared with 3 out of 39 (7.7%) of the LUTS-other group (p = 0.038 by Fisher's exact test, with a slight drop to p = 0.056 in the regression analysis). CONCLUSIONS: There appears to be an association between OAB and anxiety and it may be of clinical importance to assess for anxiety in patients that present with OAB symptoms. The drop in statistical significance from p = 0.038 to a borderline significance of p = 0.056 in the regression analysis may be a reflection of the sample size.

Prediction models for determining the success of labor induction: A systematic review.

INTRODUCTION: The purpose of this study was to systematically identify and compare clinical models using universally accessible clinical and demographic factors that were derived and/or validated to predict the success of labor induction with a view to making recommendations for practice. MATERIAL AND METHODS: MEDLINE, Embase, www.clinicaltrials.gov, and PubMed (for non-MEDLINE and studies in-progress) were searched from inception to November 2017. Only studies that derived and/or validated clinical prediction models using variables obtained through antenatal history and digital cervical examination were included. Two reviewers independently screened titles and abstracts and extracted data from eligible studies into a standardized form. Extracted data included: participant characteristics, sample size, variables considered and included, endpoint definitions, study design and model performance. The Prediction Study Risk of Bias Assessment Tool (PROBAST) was used to appraise included studies. In view of clinical and methodologic heterogeneity between studies, only descriptive analysis was possible. The protocol was registered with the PROSPERO International prospective register of systematic reviews [CRD42017081548]. RESULTS: The search identified 16 studies describing 14 prediction models derived between 1966 and 2018. Models varied and demonstrated major limitations with regard to methodology, scope and performance. Of the derived models, six were internally validated and three were externally validated. Performance was most commonly measured using the area under the receiver operator characteristic curve, which ranged from 0.68 to 0.79, 0.67 to 0.77 and 0.61 to 0.73 for derived, internally validated and externally validated models, respectively. The risk-of-bias of included studies ranged from some studies fulfilling only 36% and some others fulfilling 86% of eligible PROBAST items. CONCLUSIONS: No published model can be recommended for use at the bedside to determine the success of vaginal birth after labor induction. Based on the limitations of included models, a list of recommendations for improving model performance and utilization is provided, as well as measures for encouraging appropriate use of prediction models. The attitudes of women and care providers, and the clinical and resource implications must be explored prior to recommending the use of prediction models for determining the success of labor induction.

Obstetrical Outcomes of Head and Neck (Nonthyroid) Cancers: A 27-Year Retrospective Series and Literature Review.

Objective To describe the clinical presentation and obstetrical outcomes of nonthyroid head and neck cancers (HNCs), and to review literature on this rare condition in pregnancy. Study Design Pregnant women with nonthyroid HNC were identified retrospectively from 1990 to 2017. Maternal, neonatal, pregnancy, and demographic data were collected. A review of the literature from January 1980 to May 2018 was performed. Results Over the 27-year time period, 16 women with history of nonthyroid HNC were identified (9 diagnosed during and 7 diagnosed before current pregnancy). The cases were analyzed in detail and the most updated review of management of each type of HNC was provided. Conclusions HNCs are rare with diagnosis and management challenges during pregnancy. In this series, the cases diagnosed and managed previously to pregnancy presented better perinatal outcomes than the cases presented during pregnancy. The maternal outcomes appeared similar for HNC diagnosed before or after pregnancy.

Breast Cancer in Pregnancy: A Retrospective Cohort Study.

Gestational breast cancer (GBC) is the second most commonly occurring malignancy affecting pregnant women. Management is complex due to potential foetal risks in the setting of maternal treatment. We report on the maternal, foetal, short-term neonatal and placental histopathologic findings of a retrospective cohort of pregnant women with either pre-gestational (group 1) or GBC (group 2) from a tertiary-level maternity care centre. Of the 69 women identified over 12 years, there were 47 in group 1 and 22 in group 2. Demographics, stage of breast cancer at diagnosis were similar in the 2 groups. Women with GBC (group 2) were more likely to receive surgery and chemotherapy or surgery alone as compared to those in group 1. No women with GBC received radiation during pregnancy, but 2 received this treatment postpartum. With regard to pregnancy outcomes, induction of labour was more common in women with GBC, as was preterm birth. Most preterm birth in women with GBC was late preterm, iatrogenic in nature to facilitate postpartum treatment. We conclude comparable pregnancy outcomes for women with GBC as compared to those with pregestational breast cancer.

Maternal and Fetal Outcomes in Pregnancies affected by Bone and Soft Tissue Tumors.

Objective This study was aimed to describe perinatal outcome of a cohort of pregnant patients with bone and soft tissue tumors and to compare the current series with our group's previously reported experience. Methods Pregnant women diagnosed before and during pregnancy were identified, retrospectively, for the years 2004 to 2014. Relevant maternal and neonatal data were collected. Results Forty-eight patients were identified. Ten cases were diagnosed during pregnancy. Pelvis, abdomen, and extremities were the most common tumor locations. Osteosarcoma, liposarcoma, and Ewing's sarcoma were the most common histological types and comprise more than 50% of the cases. Metastases occurred in nine cases. Most of the cases (60%) were treated surgically during pregnancy and delivery occurred at term. Chemotherapy was delayed until after delivery. There were no perinatal or infant deaths. Patients presented with advanced maternal disease in 18% in previous report (1983-2003) versus 40% in present report (2004-2014). Metastases were present in 40% and maternal death rate was approximately 20% in both cohorts. Conclusion Pregnant women with bone and soft tissue tumors are candidates for standard surgical management during pregnancy. Other treatments, such as chemotherapy and radiotherapy must be evaluated for each woman on a case-by-case basis. Iatrogenic prematurity was common in our findings.

Should an Early Anatomy Ultrasound Scan Be Offered Routinely to Obese Pregnant Women?

OBJECTIVE: The primary objective of this study was to determine whether an early anatomic scan (EAS), either on its own or in combination with the routine transabdominal scan (R-TAS), would improve overall completion rates of the fetal anatomic survey in the obese pregnant woman. The study's secondary objectives were to compare patients' and sonographers' satisfaction with EAS versus R-TAS. METHODS: A prospective observational study was carried out over a 2.5-year period including consecutive pregnant women with a pre-pregnancy BMI ≥30 kg/m2 who consented at a dating ultrasound appointment to undergo EAS at 15 ± 1 GA in addition to the second trimester R-TAS. Anatomic structures were categorized as normal, not well seen, or abnormal by using the institutional 26-item anatomic standardized reporting template. Examination completion and study duration were recorded. Neonatal follow-up was performed to evaluate for any missed diagnoses. Patients' and sonographers' satisfaction questionnaires were completed. RESULTS: A total of 120 pregnant women completed the study. Visualization of all anatomic components was complete in 14% at EAS and in 61% at R-TAS (combined completion rate, 90%). Mean scan time was 30.4 minutes at EAS and 51 minutes at R-TAS. No missed diagnoses of structural anomalies were identified at neonatal follow-up. EAS and R-TAS differed in terms of sonographers' reports of difficult or suboptimal scans (9% vs. 58%), well-seen anatomy (85% vs. 78%), and good visibility (44% vs. 12%). Most sonographers expressed a preference for performing EAS in future pregnancies, rather than the R-TAS (96% vs. 6%). Although patients reported greater satisfaction with EAS (93% vs. 74%), for reasons that could not be determined, they expressed a preference for R-TAS in a subsequent pregnancy (23% vs. 63%). CONCLUSION: Performing EAS along with R-TAS improves completion rates for anatomic evaluation in the obese gravida and is associated with greater patient and sonographer satisfaction.

Venous thromboembolism in obese pregnant women: approach to diagnosis and management.

Venous thromboembolism (VTE) remains among the leading causes of maternal mortality in the developed world, presenting variably as deep vein thrombosis (DVT), pulmonary embolism (PE) or cerebral vein thrombosis (CVT), among others. Obesity in particular has been recognized as the principal contributing factor to the risk of VTE in pregnancy and with the global increase in the rates of obesity affecting reproductive age women, heightened awareness of the risk and consequences of VTE in this population are vital. Thus, prophylaxis, diagnosis and treatment of VTE in the obese gravida are discussed.

Splenic Artery Aneurysm in Pregnancy.

BACKGROUND: Splenic artery aneurysm (SAA), a rare condition chiefly affecting women, poses significant challenges for management when it occurs during pregnancy. Reports of successful management of SAA before rupture in pregnancy are limited, with several post-rupture cases reported. CASE: We describe the case of a woman with an SAA of 13 × 9 mm near the hilum of the spleen who subsequently became pregnant. Embolization of the splenic artery in the third trimester resulted in occlusion of the aneurysm but was followed three weeks later by a splenic abscess. The patient went on to deliver a healthy baby. CONCLUSION: This case illustrates the importance of maintaining awareness of SAA in pregnancy because the condition carries a high risk of rupture and hemorrhage with high rates of fetal and maternal mortality.

Contexte : L'anévrisme de l'artère splénique (AAS) est une maladie rare qui affecte principalement les femmes et dont la prise en charge pose des défis considérables lorsqu'elle se manifeste pendant la grossesse. Les signalements de prise en charge réussies de l'AAS avant la rupture pendant la grossesse sont limités, plusieurs cas post-ruptures ayant été signalés. Cas : Nous décrivons le cas d'une femme présentant un AAS de 13 mm sur 9 mm près du hile de la rate qui est subséquemment devenue enceinte. Bien que l'embolisation de l'artère splénique au cours du troisième trimestre ait mené à l'occlusion de l'anévrisme, elle a été suivie par la manifestation d'un abcès splénique trois semaines plus tard. La patiente en est venue à accoucher d'un enfant en santé. Conclusion : Ce cas illustre l'importance de garder la présence d'un AAS à l'esprit pendant la grossesse, car cette pathologie donne lieu à un risque élevé de rupture et d'hémorragie qui se traduit en des taux élevés de mortalité fœtale et maternelle.

The Accuracy of Estimating Fetal Weight and Inter-Twin Weight Discordance by Ultrasound in Twin Pregnancies in Women With Increased Body Mass Index.

OBJECTIVES: The purpose of this study was to determine whether increased maternal pre-pregnancy BMI decreases the ultrasound accuracy of fetal weight estimation and inter-twin weight discordance in twin pregnancies compared with women with normal BMI. METHODS: We conducted a retrospective cohort study of women with a known pre-pregnancy or early pregnancy BMI who delivered a viable twin pregnancy after 28 weeks' gestation between 2008 and 2011, and who had an ultrasound examination for fetal weight estimation within two weeks of delivery. The sonographically estimated fetal weight (EFW) was compared with the actual weight for each twin, and inter-twin weight discordance (defined as a weight difference between twins of more than 25%) was stratified for the patient's BMI. We sought to determine if EFW and inter-twin weight discordance were affected if delivery occurred at eight to 14 days after ultrasound compared to within seven days of ultrasound. RESULTS: A total of 300 twin pregnancies with known pre-pregnancy maternal BMI were identified. Of these, 179 were underweight or of normal weight (BMI<25 kg/m2), 67 were overweight (BMI 25 to 29.9 kg/m2), and 54 were obese (BMI≥30 kg/m2). Ultrasound accuracy among all BMI groups were compared when done between 8 and 14 days and within seven days from delivery. There was a significant increasing trend in mean absolute percent errors for both twins in the obese compared to normal weight (P<0.05) if delivery happened between eight and 14 days from ultrasound. This difference was diminished if the ultrasound was performed within seven days of delivery. The ultrasound detection of inter-twin weight discordance was similar among the three BMI groups. CONCLUSION: Estimation of fetal weight using ultrasound in obese women with twin pregnancies appears to be more reliable when performed close to delivery. Résumé.

Objectifs : Cette étude avait pour objectif de déterminer si la présence d'un IMC maternel prégrossesse accru entraînait une baisse de la précision de l'échographie pour ce qui est de l'estimation du poids fœtal et de la discordance intergémellaire en matière de poids dans le cadre de grossesses gémellaires, par comparaison avec des femmes présentant un IMC normal. Méthodes : Nous avons mené une étude de cohorte rétrospective portant sur des femmes qui présentaient un IMC prégrossesse (ou aux débuts de la grossesse) connu, qui ont accouché après 28 semaines de gestation à la suite d'une grossesse gémellaire viable entre 2008 et 2011, et qui ont subi un examen échographique visant l'estimation du poids fœtal dans les deux semaines ayant précédé l'accouchement. Le poids fœtal estimé (PFE) par échographie a été comparé au poids réel de chacun des jumeaux, puis la discordance intergémellaire en matière de poids (définie comme une différence de poids entre les jumeaux de plus de 25 %) a été stratifiée en fonction de l'IMC de la patiente. Nous avons cherché à déterminer si le PFE et la discordance intergémellaire en matière de poids avaient été affectés lorsque l'accouchement était survenu de 8 à 14 jours à la suite de l'échographie, par comparaison avec un accouchement étant survenu dans les sept jours de la tenue de l'échographie. Résultats : Nous avons pu identifier, au total, 300 grossesses gémellaires pour lesquelles l'IMC maternel prégrossesse était connu : 179 femmes présentaient une insuffisance pondérale ou un poids normal (IMC < 25 kg/m2), 67 présentaient une surcharge pondérale (IMC = de 25 à 29,9 kg/m2) et 54 étaient obèses (IMC ≥ 30 kg/m2). Dans tous les groupes d'IMC, la précision de l'échographie menée entre 8 et 14 jours avant l'accouchement a été comparée à celle de l'échographie menée dans les sept jours de l'accouchement. Une tendance à la hausse considérable en matière d'erreur absolue moyenne en pourcentage pour les deux jumeaux a été constatée chez les femmes obèses, par comparaison avec les femmes de poids normal (P < 0,05), lorsque l'accouchement avait eu lieu de 8 à 14 jours à la suite de l'échographie. Cette différence était moindre lorsque l'échographie avait été menée dans les sept jours de l'accouchement. La détection par échographie d'une discordance intergémellaire en matière de poids était semblable dans les trois groupes d'IMC. Conclusion : Chez les femmes obèses qui connaissent une grossesse gémellaire, l'estimation du poids fœtal par échographie semble être plus fiable lorsqu'elle est menée peu avant l'accouchement.

Analysis of mRNA expression for genes associated with regulatory T lymphocytes (CD25, FoxP3, CTLA4, and IDO) after experimental infection with bovine viral diarrhea virus of low or high virulence in beef calves.

Immunosuppression caused by bovine viral diarrhea virus (BVDV) has been associated with lymphocyte depletion, leukopenia and impairment of leukocyte function; however, no work has been done on the relationship between BVDV and regulatory T lymphocytes (Tregs). The objective of this study was to compare the mRNA expression of genes associated with Tregs (CD25, FoxP3, CTLA4, and IDO), after experimental infection of beef calves with low (LV) or high (HV) virulence BVDV. Thirty BVDV-naïve calves were randomly assigned to three groups. Calves were intra-nasally inoculated with LV (n=10, strain SD-1) or HV (n=10, strain 1373) BVDV or BVDV-free cell culture medium (control, n=10). Quantitative RT-PCR was used to determine the expression of target genes in tracheo-bronchial lymph nodes and spleen on day 5 post-infection. The mRNA expression of CD25 was up-regulated in tracheo-bronchial lymph nodes of LV (P<0.05), but not in HV compared to the control group. The expression of FoxP3 and CTLA4 was not increased in tracheo-bronchial lymph nodes of either of the BVDV-inoculated groups. A dramatic up-regulation of IDO mRNA was observed in tracheo-bronchial lymph nodes of LV (P<0.05), but not HV compared to the control calves. In conclusion, experimental infection with BVDV did not provide evidence of Treg activation based on expression of FoxP3 and CTL4. Differential expression of CD25 and IDO mRNA on day 5 post-infection with HV or LV BVDV might reflect temporal differences in transcription occurring during the immune response elicited by these viral strains, or differences in viral infectivity of the host cells.

Expression of toll-like receptors and co-stimulatory molecules in lymphoid tissue during experimental infection of beef calves with bovine viral diarrhea virus of low and high virulence.

The objective of this study was to compare the mRNA expression of Toll-like receptors (TLR3 and TLR7), and costimulatory molecules involved in activation of lymphocytes and antigen presenting cells (CD80, CD86, CD28, and CD40L) after experimental infection of beef calves with low or high virulence noncytopathic (ncp) bovine viral diarrhea virus (BVDV) strains. Thirty BVDV-naïve, beef calves were intranasally inoculated with low (LV; n=10, SD-1) or high (HV; n=10, 1373) virulence ncp BVDV or with BVDV-free cell culture medium (Control, n=10). Calves were euthanized on day 5 post-inoculation and tracheo-bronchial lymph node (TBLN) and spleen samples were collected for mRNA expression through quantitative-RT-PCR. Levels of mRNA for TLR3 and TLR7 were increased in spleen of HV group (P<0.05), but not in LV group, compared to the control group. Expression of CD86 mRNA was up-regulated in TBLN of both LV and HV groups (P<0.05). A significant up-regulation of CD80 mRNA was observed in TBLN for LV calves (P<0.05), but not for HV calves. In conclusion, experimental inoculation with high virulence BVDV-2 1373 stimulated the expression of TLR3, TLR7 and CD86 in spleen and TBLN on day 5 post infection. In contrast, experimental challenge with the low virulence BVDV-1 SD-1 uniquely resulted in up-regulation of both CD80 and CD86 in TBLN samples on day 5 post infection. The observed differential expression during acute infection with high or low virulence BVDV might reflect differences in immune activation by these strains, which could be associated with differences in genotype and/or virulence.

Pregnancy and maternal outcomes in women with prior or current gastrointestinal malignancies.

OBJECTIVES: To review the fetal and maternal outcomes of women with a diagnosis of gastrointestinal (GI) cancer before or during pregnancy. METHODS: We conducted a retrospective cohort study of pregnant women referred to a single tertiary care centre with a current or previous diagnosis of GI malignancy. Maternal, obstetric, and infant data were recorded. RESULTS: We identified 18 pregnancies in 13 women. Nine women were found to have a GI malignancy during pregnancy (group 1). There was an indirect maternal death in this group in a woman with advanced gastric adenocarcinoma. Nine unique pregnancies occurred in eight women with diagnosis and management of GI malignancies before their pregnancies (group 2). CONCLUSION: GI malignancies are difficult to diagnose and manage during pregnancy and are usually advanced at the time of diagnosis. Surgery can be performed during pregnancy if necessary, with chemotherapy and radiotherapy usually deferred to the postpartum period. Women who have had a prior GI malignancy have special circumstances related to the type of surgery performed and previous exposure to chemotherapy. These patients may benefit from a multidisciplinary team effort to optimize their care.

Objectifs : Analyser les issues fœtales et maternelles des femmes ayant reçu un diagnostic de cancer gastro-intestinal (GI) avant ou pendant la grossesse. Méthodes : Nous avons mené une étude de cohorte rétrospective portant sur des femmes enceintes orientées vers un seul centre de soins tertiaire en raison d'un diagnostic actuel ou précédent de tumeur maligne GI. Les données maternelles, obstétricales et infantiles ont été consignées. Résultats : Nous avons identifié 18 grossesses chez 13 femmes. Une tumeur maligne GI a été constatée chez neuf de ces femmes pendant la grossesse (groupe 1). Un décès maternel indirect a été signalé dans ce groupe chez une femme présentant un adénocarcinome gastrique avancé. Neuf grossesses uniques ont été constatées chez huit femmes ayant obtenu un diagnostic de tumeur maligne GI et ayant fait l'objet d'une prise en charge avant la grossesse (groupe 2). Conclusion : Les tumeurs malignes GI sont difficiles à diagnostiquer et à prendre en charge pendant la grossesse, et se trouvent habituellement à un stade avancé au moment du diagnostic. Une chirurgie peut être menée pendant la grossesse, au besoin, les traitements de chimiothérapie et de radiothérapie étant habituellement reportés à la période postpartum. Les femmes ayant déjà présenté une tumeur maligne GI comptent des circonstances particulières liées au type de la chirurgie dont elles ont fait l'objet et à leur exposition précédente à la chimiothérapie. Ces patientes pourraient tirer avantage d'une approche d'équipe multidisciplinaire pour optimiser les soins qu'elles reçoivent.