A Systematic Review of Sildenafil Mortality Through the Years.

Sildenafil is a medication used for the treatment of erectile dysfunction. It was approved by the U.S. Food and Drug Administration (FDA) in 1998. Several articles have raised concerns regarding the use of sildenafil and the occurrence of serious adverse events, such as myocardial ischemia, stroke, and even death. Our aim is to systematically review the existing literature on mortality associated with sildenafil use. The method used for this systematic review was completed by searching three databases: PubMed, Scopus, and Web of Science. Articles were screened and assessed for eligibility. This review uses the articles found to address the concerns associated with sildenafil and mortality. A total of 19 reports were used in our systematic review, in which there were 10 case reports, two case series, three systematic reviews, one narrative review, one retrospective study, one article in the British Medical Journal, and one commentary article. One FDA article in particular included case reports and reports to the FDA on the use of sildenafil eight months after its introduction to the market in 1998, with 522 deaths reported. Another retrospective study examined the use of sildenafil on infants below the age of 1 who did not have congenital heart disease but did suffer from severe pulmonary hypertension. The study found a mortality rate of 29%, which increased with sildenafil dosage. A case series examined six deaths related to non-prescription use of sildenafil. All these cases were subjected to autopsies and related to sexual activity. The study suggests that phosphodiesterase 5 inhibitors induced the deaths, and the concentration of sildenafil in the femoral blood was found to be between 0.032and0.087 µg. To conclude, the literature available on this topic is deemed insufficient to provide enough data to establish a direct link of causality between sildenafil and mortality. Although some studies paint sildenafil as the culprit behind these deaths, further studies and research are needed to explain the unexpected deaths following sildenafil use.

Post-Acute Effect of SARS-CoV-2 Infection on the Cardiac Autonomic Function.

Background: Recent studies reported a long-lasting effect of COVID-19 infection that extends beyond the active disease and disrupts various body systems besides the respiratory system. The current study aims to investigate the post-acute effect of SARS-CoV-2 infection on cardiovascular autonomic activity, reactivity and sensitivity in patients who had the infection at least 3 months before. Methods: This was a comparative cross-sectional observational study. Fifty-nine subjects were allocated into two groups, controls (n=31), who had no history of positive COVID-19 infection, and the post-COVID patients (n=28) who were recruited 3 to 8 months after testing positive for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR). Baseline cardiovascular autonomic activity was evaluated through recording of baseline heart rate variability (HRV), autonomic reactivity was determined through standard cardiovascular autonomic reflex tests (CART), and cardiac autonomic sensitivity was assessed through cardiac baroreceptor sensitivity (cBRS). Results: Higher incidence of orthostatic hypotension was observed in post-COVID patients compared to controls (39.3% and 3.2%, respectively, p <0.001). Additionally, significantly reduced handgrip test, and heart rate response to head-up tilt was illustrated in the post-COVID group (p <0.001). About 85.7% of post-COVID participants had at least one abnormal cardiovascular reflex test (CART) compared to the control group (p <0.001). Although HRV parameters (TP, LF, HF, SDRR, RMSSD, pRR50), and the cBRS were numerically lower in the post-COVID-19 group, this did not reach the level of significance. Conclusion: The results of the present study are suggestive of altered cardiovascular reactivity in post-acute COVID patients and demand further investigation and longer term follow up.

Maternal low-intensity psychosocial telemental interventions in response to COVID-19 in Qatar: study protocol for a randomized controlled trial.

INTRODUCTION: As COVID-19 is spreading, new psychological health problems are suspected to be emerging among pregnant women. Higher maternal mental health distress, including perinatal anxiety, depression, and COVID-19-specific phobia, is supposed to be increasing during the pandemic, which impacts pregnant women's health and their infants and calls for intervention. Due to the social distancing protocols posed by the pandemic, telemental health interventions have fast become the most common form of psychosocial support for maternal mental health. However, there is no evidence of the effectiveness of maternal low-intensity psychosocial telemental interventions in improving mental health outcomes. The trial's objective is to evaluate the clinical efficacy of telemental low-intensity psychosocial interventions in pregnant and postpartum women attending the Women Wellness and Research Centre in Qatar in the era of the COVID-19 pandemic. METHODS AND ANALYSIS: The clinical trial is randomized in which pregnant women will be assigned equally through block randomization between two arms: (1) a control group and (2) an intervention group. The primary endpoint is the perinatal psychological distress, including perinatal depression, anxiety, and COVID-19 phobia in their third trimester; the secondary, tertiary, fourth, and fifth endpoints will be in the postnatal period (3-5 weeks, 2-4 months, 5-7 months, and 8-10 months). This trial involves pregnant women in their second trimester with no mental health illness history who communicate in English and Arabic and consent to participate. A sample size of 58 (29 participants per arm) is targeted. DISCUSSION: This study will provide recommendations about the efficacy of low-intensity psychosocial maternal telemental interventions to be implemented as a preventive service. TRIAL REGISTRATION: 2a-ClinicalTrials.gov NCT04594525 . Registered on October 20, 2020.

'The newest vital sign among pregnant women attending women wellness and research Centre in Qatar: a cross-sectional study'.

BACKGROUND: Health literacy is a vital strategy to consider when designing health-promoting programs, and health literacy is a priority in Qatar's national health agenda. In the context of pregnancy, inadequate health literacy has been linked to several adverse outcomes among pregnant women such as unplanned conception, smoking, and lack of multi-vitamin intake. Given the paucity of data, this study aimed to assess the level of health literacy and its determinants among pregnant women in the State of Qatar. METHODS: An analytical cross-sectional design was utilized. First, we piloted the measurement tools on 10% of the calculated sample size. Accordingly, the items of the measurement tools were revised. Next, we utilized a structured questionnaire to interview the participants about their socio-demographic characteristics, pregnancy-related factors, and the Newest Vital Sign Tool. A chi-square test was employed to investigate the association level among variables, with significance set to P < 0.05. A logistic regression model was used to identify the factors associated with a low literacy level. RESULTS: We found that almost four in 10 pregnant women (n = 138,45.4%) had inadequate health literacy. Furthermore, the insufficient level of health literacy was significantly associated with low educational background, decreased household income, and primigravida. However, uncontrolled glycaemia was the only significant predictor of inadequate health literacy through logistic regression. The scale was found to be reliable, with a calculated Cronbach's alpha of 0.8. CONCLUSIONS: Low health literacy is common among pregnant women in the State of Qatar. Thus, public health officials should focus on delivering tailored health literacy interventions to pregnant women in the country.

Management of monochorionic twins discordant for structural fetal anomalies.

OBJECTIVE: To review the perinatal management and outcomes of monochorionic twin pregnancies (MC) discordant for congenital anomalies (DCA). METHODS: Retrospective, study of all MC DCA cases referred to our tertiary referral center from 1997 to 2018. We excluded cases complicated with twin-to-twin transfusion syndrome, twin anemia-polycythemia sequence, twin reversed arterial perfusion sequence or selective intra-uterine growth restriction. Patients were counseled about the possibility of expectant (EM) or interventional management (selective feticide [SF] or termination of the entire pregnancy [TOP]). RESULTS: One hundred eight of 4157 (2.6%) MC pregnancies were discordant for anomaly. Fifty two of 108 n(48.1%) underwent SF at a mean gestational age of 31.4 ± 5.9 weeks while 52/108(48.1%) opted for EM. Livebirth rate of the healthy co-twin was similar between the two groups (SF: 88.5% vs EM: 82.7%, P = .87). In the SF group, six healthy co-twins (6/52, 11.5%) died 5.3 ± 3.1 days after SF of the abnormal co-twin. In the EM group, in-utero demise of the abnormal twin occurred in 9 of 52 (17.3%) of the cases and was followed by the spontaneous demise of the healthy co-twin in 4 of 9 (44.4%) of these cases. CONCLUSION: Selective feticide does not seem to significantly alter survival of the healthy co-twin compared to EM.

Third trimester ultrasound accuracy and delivery outcome in obese and morbid obese pregnant women.

OBJECTIVE: Several studies have highlighted the negative impact of maternal obesity on ultrasound accuracy for fetal weight estimation (EFW). However, the evidence is conflicting. We aimed in our study to find if the ultrasound accuracy for EFW would differ or decrease in obese and morbid obesity classes. We also studied the mode of delivery within the same cohort. METHODS: It is a retrospective study of obese patients with recorded BMI ≥30 kg/m2, class I and II (BMI: 30-39.9 kg/m2) compared with extreme obese class III (BMI ≥40 kg/m2), who gave birth after 28-week gestation of viable singleton, who had an ultrasound within 7 d of delivery with reported normal amniotic fluid and no major fetal anomaly; the EFW was consistently measured through Hadlock regression formula in the period of 2014-2015 inclusive. Differences between the EFW and actual birth weight (ABW) were assessed by percentage error, accuracy in predictions within ±10% of error and the Pearson correlation coefficient were used to correlate EFW with the ABW. The study's secondary outcome was to study the mode of delivery and the rate of cesarean section in obese and morbid obese patients. RESULTS: Total 106 cases fulfilled our criteria. Class I and II as the first group (n = 53). Class III as the second group (n = 53). Maternal and birth characteristics were similar. The Pearson correlation coefficient equal 1 in both groups. The overall mean absolute difference (MAD) in grams of the whole obese cohort was 242 ± 213. The MAD was 242 ± 202 and 242 ± 226 g for the first and second group, respectively (p = 1.0). The overall mean absolute percentage error (MAPE) in this obese cohort was 8%. The MAPE for the first and second group, respectively were 8 and 7% (p = 0.4). The overall rate of cesarean delivery was 60% (64/106) with no differences between the obese and morbid obese BMI classes. Sixty-six percentage (42/64) of these cesarean cases was for repeat cesarean section. CONCLUSION: Despite what has been previously reported about the negative impact of maternal obesity on EFW accuracy, we could not demonstrate this relationship in our obese cohort (MAPE <10%). In addition, we could not illustrate a significant difference in ultrasound accuracy across various obesity classes. However, we found a significantly increased rate of delivery by repeated cesarean section in this obese cohort.

Pregnancy with Takayasu's Arteritis: A Case Report and Literature Review.

Takayasu's arteritis (TA) is a rare and chronic inflammatory disease of the large vessels. It affects women of reproductive age and leads to an increased risk of cardiovascular complications, such as hypertension and congestive heart failure. We are presenting a case of a pregnant woman with TA, who was seen and managed at a tertiary care institute and ultimately enjoyed a favorable outcome. Thus, multidisciplinary care for patients with TA has proven to be crucial in optimized and favorable maternal and fetal/neonatal outcomes.

Anencephaly and obstetric outcome beyond the age of viability.

Objective To review the obstetric impact and natural history of anencephalic pregnancies beyond the age of viability. Study design A retrospective chart review of all cases with a prenatal diagnosis of anencephaly who delivered after 24 weeks' gestation during the period 1990 until 2016. Obstetric outcomes including mode of delivery, live births, shoulder dystocia, antepartum haemorrhage (APH), postpartum haemorrhage (PPH) and uterine rupture were studied. Results A total of 42 cases were studied. The average gestational age at diagnosis was 22 weeks (range 10-41). The average gestational age at birth was 36 weeks (range 25-44 weeks). Induction of labour was performed in 55% (23/42) of the cases. Livebirths were documented in 40% (17/42) of the cases. The average birth weight was 1597±746 g. The rate of vaginal birth was 69% (29/42), the overall rate of caesarean section was 31% (13/42), with a primary caesarean section in 31% (4/13) and a repeat caesarean section in 69% (9/13) of the patients. There were two cases of shoulder dystocia. No other complications were encountered. Conclusion Overall, anencephaly is not associated with an increased risk of obstetric complications; however, there is a tendency towards delivery via repeated caesarean section in women with a previous uterine scar and anencephaly. The prenatal counselling of potential obstetric outcomes could be of robust value for parents who opt to continue with anencephalic pregnancies.

Expectant management of caesarean scar ectopic pregnancy: a systematic review.

AIM: The purpose of this review is to systematically review all the reported cases and case series of caesarean scar pregnancy (CSP) managed expectantly without any intervention in order to understand the outcomes of pregnancy which will guide clinicians and patients in making treatment choices. METHODS: An electronic search on PubMed, EMBASE and Cochrane databases and a manual search from references of the articles were performed. Studies were selected based on inclusion and exclusion criteria. Data were extracted for various outcomes of pregnancy and the quality of the reports was assessed using a modified Delphi technique. RESULTS: A total of 56 cases of CSP from 11 reports were included in the review, including 44 cases with foetal cardiac activity. Live births were achieved in 73% of cases with a quarter of them born before 34 weeks. Hysterectomy rates were 70%. In 12/44 (27%) of cases pregnancies were lost due to complications before 24 weeks. Most (67%) of the CSPs with no foetal cardiac activities resolved on expectant management and the remaining required intervention for bleeding. CONCLUSIONS: Caution should be exercised when choosing expectant management in cases of viable CSPs, and if chosen, the patient should be counselled adequately for possible outcomes including loss of pregnancy and hysterectomy. Expectant management is acceptable in CSPs with no foetal cardiac activity. There is a need for prospective research on this topic with adequate reporting on possible prognostic markers, as well as a need to improve on the techniques to prevent loss of fertility during delivery.

A review of Meckel-Gruber syndrome--incidence and outcome in the state of Qatar.

Meckel-Gruber (MKS) syndrome is a lethal autosomal abnormality diagnosed most commonly from classical findings on ultrasound scan after the late first trimester. There are few reports of cases followed up antenatally until delivery. We report here one of the largest series of 19 cases diagnosed antenatally from as early as 11 weeks gestation with 5 born alive. Of the 12 cases followed up antenatally, 7 were stillbirths while 5 were live births. The absence of obvious polycystic kidneys and severe oligohydramnios were prognostic features consistent with a live birth; however, mortality was 100% within a few weeks of delivery. The incidence of 2/1000 live births in the local population is similar to that reported from similar groups where consanguinity is more than 40%. The recurrence rate was high with 50% of the parous patients having had an affected baby. We conclude that diagnosis in early pregnancy does not require the classical triad of encephalocele, polydactyly and polycystic kidneys as some of these features do not manifest on imaging until much later.

The value of ultrasound and magnetic resonance imaging in diagnostics and prediction of morbidity in cases of placenta previa with abnormal placentation.

BACKGROUND: The purpose of the study was to evaluate the role of ultrasound (US) and magnetic resonance imaging (MRI) in the diagnostics and management of abnormal placentation in women with placenta previa and to compare the morbidity associated with that to placenta previa alone. MATERIAL/METHODS: The study includes 100 pregnant women with placenta previa with and without abnormal placentation. The results of MRI and US in abnormal placentation were compared with post-operative data. The patients' files were reviewed for assessment of operative and post-operative morbidity. The results of our statistical analysis were compared with data from the literature. RESULTS: US and MRI showed no significant difference in sensitivity and specificity in diagnosing abnormal placentation (97-100% and 94-100%, respectively). MRI was more sensitive than US for the detection of myometrial invasion and the type of abnormal placentation (73.5% and 47%, respectively). The difference between pre- and post-operative hemoglobin values and estimated blood loss were the most significant risk factors for abnormal placentation, added to risk factors known for placenta previa. Post-partum surgical complications and prolonged hospital stay were more common in the cases of placenta previa with abnormal placentation, however statistically insignificant. CONCLUSIONS: US and MRI are accurate imaging modalities for diagnosing abnormal placentation. MRI was more sensitive for the detection of the degree of placental invasion. The patient's morbidity increased in cases with abnormal placentation. There was no significant difference in post operative-complications and hospitalization time due to pre-operative planning when the diagnosis was established with US and MRI.

Comparison of maternal and fetal outcomes, in epileptic and non-epileptic women.

OBJECTIVE: To assess maternal and fetal outcomes, in epileptic and non-epileptic pregnant women. METHODS: A retrospective case-control study was conducted from January 2005 - December 2006 at Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia. A total of 16508 live birth charts were reviewed. Maternal, obstetrical, and fetal outcomes were compared between women with epilepsy Group 1 (n = 53) and women who did not have epilepsy (controls) Group 2 (n = 60). RESULTS: There were no significant differences between either group in total length of labor, labor induction and oxytocin augmentation, need for labor analgesia, total blood loss and the need for blood transfusion, mode of delivery, and the length of hospital stay. There were no significant differences in all maternal complications between either group (p=0.8, 95% CI: 0.3-2.1). There was an increase in the mean dose of the antiepileptic medications needed during pregnancy. However, 4 women (7.5%) in the epileptic group had major seizures during pregnancy. All of these women needed addition of a second antiepileptic medication. Major congenital malformations occurred in 2 newborns (3.8%) of epileptic women, and none occurred in the control group. Both newborns were from women who received polytherapy. CONCLUSION: Women with epilepsy are not at increased risk for obstetric and neonatal complications, provided there is a combined team management approach by a neurologist and an obstetrician.