Maternal blood viscosity and perinatal outcome in steady-state homozygous sickle cell disease.

Homozygous sickle cell disease (HbSS) is a complicating factor in pregnancy resulting in perinatal morbidity and mortality. One of the hallmarks of sickle cell disease is increased whole blood viscosity. The present study was designed to investigate the effect of the maternal blood viscosity on perinatal outcome in steady-state homozygous sickle disease in 19 women admitted to the labor ward of the University Hospital of the West Indies, Mona. Whole blood viscosity was measured with the Wells-Brookfield viscometer at 370C at low (23 sec-1) and high (230 sec-1) shear rates. Measurements were done at native hematocrit. Perinatal outcome was classified as adverse if there was one or more of the following: admission to nursery, birth weight less than 2.5 kg, 5 minute Apgar score less than 7, caesarean section for fetal distress, perinatal death or death before discharge from nursery. The whole blood viscosity value (mean ± SD) at low shear rate was 2.04 ± 0.55 mPa.s and 2.96 ± 0.80 mPa.s at high shear rate. The hematocrit was 25.13 ± 4.18%. The perinatal outcome was good in 10 (53%) subjects and adverse in 9 (47%) subjects. There was no statistically significant difference in the incidence of adverse perinatal outcome between women with low and high blood viscosities in either the low or high shear rates. Similarly, low or high hematocrit did not significantly affect the incidence of adverse perinatal outcome. This could be attributed to their similarity in the whole blood viscosity and hematocrit values.

Are published standards for haematological indices in pregnancy applicable across populations: an evaluation in healthy pregnant Jamaican women.

BACKGROUND: The haematological profile of the pregnant woman has an impact on the outcome of the pregnancy. Published guidelines indicate acceptable levels for haematological indices in pregnancy but they are population specific. Indicators of haemoglobin concentration are the most commonly utilized of the indices. These published international norms are used across populations, however, there is no evidence confirming their applicability to a population such as the Jamaican pregnant woman. This study was therefore undertaken with the intent of documenting the haematological profile of pregnant primigravid Jamaican women and comparing these to the established norms to determine whether the norms apply or whether there was a need to establish local norms. METHODS: This was a longitudinal study done on a cohort of 157 healthy primigravid women ages 15 to 25 and without anaemia, and who were recruited from the antenatal clinic of the University Hospital of the West Indies, Kingston, Jamaica. The haemoglobin concentration, packed cell volume, mean cell volume, mean cell haemoglobin, mean cell haemoglobin concentration, white blood cell count, red blood cell count and platelet count were measured on samples of blood obtained from each consenting participant during each of the three trimesters. The results were analysed using SPSS for windows (Version 11) and the data expressed as means +/- S.D. Means were compared using the student's paired t-test. Comparison was then made with the international norms as recommended by the United States Center for Disease Control (1989). Ethical approval for this study was obtained from the University Hospital of the West Indies/University of the West Indies Ethics Committee. RESULTS: The results showed changes by trimester in all measured variables. For most of the indices the changes achieved levels of significance across trimesters. These changes were however in keeping with the expected physiological response in pregnancy and the values were similar to the published international norms. CONCLUSION: The findings suggest that the international norms for haematological indices in pregnancy are applicable across populations and to the pregnant Jamaican primigravid woman. This finding may be reassuring to others with a similar population and stage of development as Jamaica.

Depressive symptoms in children of women with newly diagnosed type 2 diabetes.

OBJECTIVE: Type 2 diabetes is a chronic disease with increasing prevalence. Individuals with diabetes are at risk for long-term complications such as nephropathy, retinopathy, and cardiovascular complications. Additionally, several studies have indicated that diabetes doubles the risk for depression. Individuals with depression are also said to be at greater risk for developing diabetes. Studies have shown depressive symptoms to be higher in children with diabetes than in those without the disease. This study measured depressive symptoms in children without diabetes of women with recently diagnosed type 2 diabetes. METHOD: Fifty children whose mothers were newly diagnosed with type 2 diabetes were assessed with the Children's Depression Rating Scale, Revised (CDRS-R) to measure the psychological impact of the mothers' newly diagnosed diabetes on their children. This cross-sectional study was conducted in public and private clinics from April 2001 to June 2003. RESULTS: Sixty percent of children (N = 30) whose mothers were recently diagnosed with type 2 diabetes had CDRS-R scores consistent with likely or very likely having major depressive disorders. Mean ± SD CDRS-R scores were highest in children of women with diabetes affecting greater than or equal to 3 generations of their families (68.2 ± 8.9, p = .02). CONCLUSION: The findings suggest that depressive symptoms are common in children of women with newly diagnosed type 2 diabetes. Severity of depressive symptoms positively correlated with the number of generations of diabetes in the family.

The effectiveness of the Gram stain of high vaginal swabs in the diagnosis of bacterial vaginosis at the University Hospital of the West Indies [abstract]

OBJECTIVE: To correlate the gram-stain of high vaginal swabs (HVS) with the diagnosis of bacterial vaginosis (BV) and to compare this with bacterial culture reports to determine whether any useful additional information is gained by culture. METHODS: HVS submitted to the microbiology laboratory (UWI) from patients diagnosed clinically with vaginal infection were used in this study. Specimens were submitted from the Family Planning, Gynaecology and Antenatal clinics at the University Hospital of the West Indies. Swabs were placed in Stuart's Transport Medium and taken to the microbiology laboratory within 24 hours. The specimens were subjected to standard bacteriological procedures of culture on blood and MacConkey agar and microscopic procedures of wet prepartion and gram stain. The gramstain was recorded on a specially designed data sheet for each patient with a standardized scoring method for the evaluation of gram-stained smears based on the recognition of both presence and amount of significant morphotypes. This result was then compared with the bacterial culture, available a few days later, to see the degree of correlation and to determine whether any relevant additional information was gained. Almost 60 percent of the specimens collected yielded no pathogens on culture. However, one-third of this 60 percent was diagnosed as BV by standardized scoring method. One-third of all specimens submitted yielded yeast (Candida albicans and yeast not-Candida albicans) on culture and by gram stain. Streptococcus group B was isolated in < 4 percent of all specimens and a miscellaneous group of organisms including Klebsiella sp, Pseudomonas sp and anaerobic Streptoccus made up the rest of bacterial isolates. CONCLUSIONS: The standardized scoring method of evaluating the HVS gram stains yielded a more accurate and rapid diagnosis of BV than the traditional culture method. This is worthy of further study, as implementation of this method would result in considerable cost and time saving. (AU)

Is there hyperviscosity in Pre-eclampsia?

There are conflicting reports on blood viscosity and its determinants in pre-eclampsia. We investigated the presence of hyperviscosity and its determinants in 24 nulliparous, pre-eclamptic Jamaican women. An equal number of non-pre-eclamptic, gestation-matched women served as controls. There was no statistically significant difference in whole blood, plasma and serum viscosities, as well as their determinants, namely, haematocrit, fibrinogen, IgM and IgG concentrations between the pre-eclamptic and control groups. This suggests that hyperviscosity is not a feature of pre-eclampsia in this Jamaican population.(Au)

Is there hyperviscosity in Pre-eclampsia?

There are conflicting reports on blood viscosity and its determinants in pre-eclampsia. We investigated the presence of hyperviscosity and its determinants in 24 nulliparous, pre-eclamptic Jamaican women. An equal number of non-pre-eclamptic, gestation-matched women served as controls. There was no statistically significant difference in whole blood, plasma and serum viscosities, as well as their determinants, namely, haematocrit, fibrinogen, IgM and IgG concentrations between the pre-eclamptic and control groups. This suggests that hyperviscosity is not a feature of pre-eclampsia in this Jamaican population.

The hypertensive diabetic pregnancy

Hypertension (Htn), is a condition describing the presence of a consistently elevated blood pressure in an individual, and diabetes mellitus (DM), is a heterogeneous condition due to defective production or action of insulin and characterised by a state of hyperglycemia. The two types of diabetes are chronic medical conditions with varying prevalence depending on the population studied. Pregestational diabetes mellitus (PGDM) and chronic (essential) hypertension (CH) are associated with tissue damage resulting in complications, the most severe of which results in vascular disease. In the pregnant woman these entities occur either separately or together and are associated with a significant increase in both maternal and perinatal morbidity and mortality. The other entities of concern are gestational diabetes mellitus (GDM) and pregnancy induced hypertension (PIH) with or without proteinuria.(Au)

The hypertensive diabetic pregnancy

Hypertension (Htn), is a condition describing the presence of a consistently elevated blood pressure in an individual, and diabetes mellitus (DM), is a heterogeneous condition due to defective production or action of insulin and characterised by a state of hyperglycemia. The two types of diabetes are chronic medical conditions with varying prevalence depending on the population studied. Pregestational diabetes mellitus (PGDM) and chronic (essential) hypertension (CH) are associated with tissue damage resulting in complications, the most severe of which results in vascular disease. In the pregnant woman these entities occur either separately or together and are associated with a significant increase in both maternal and perinatal morbidity and mortality. The other entities of concern are gestational diabetes mellitus (GDM) and pregnancy induced hypertension (PIH) with or without proteinuria.

Granulosa-theca cell tumour of the ovaries. A late metastasizing tumour

Granulosa-theca cell tumours are ovarian neoplasms of low malignancy with hormone secreting potential, accounting for 2-3 percent of all ovarian cancers. They have an uncertain clinical course and a potential for late recurrence aftet surgical removal. Clincal features of a patient presenting with pulmonary metastases 21 years after removal of the primary tumour are described, along with a review of the management options.(AU)

Knowledge, attitudes and practices of women regarding pap smears - abstract

The aims of the study were to assess women's knowledge, attitudes and practices regarding cervical cancer and screening, to see how knowledge influences attitudes and how both influence practice, and to examine certain social and demographic correlates. Between January 29, 1996 and February 29, 1996, 209 female patients, aged 19 years and over, were interviewed in the Casualty Department of the University Hospital of the West Indies. A questionnaire measuring knowledge, attitudes and practices regarding Pap smears and cervical cancer and selected characteristics of the patients and their partners were administered by a single interviewer. Quota sampling methodology was employed. Most of the respondents (98 percent) had heard about Pap smears, but the majority did not know that its main purpose is to help in the prevention of cervical cancer, as opposed to its detection. Only a majority of patients knew what the cervix is and that it is the part of the body that Pap smears are concerned with. The majority of respondents had positive attitudes with respect to cervical screening. However, having positive attitudes and possessing knowledge about Pap smears did not significantly influence compliance with screening, and apathy accounted for a significant portion of non-compliance. If a nationwide screening programme is to be successful, patient motivation and behaviour modification will need to be addressed. (AU)

Insulin response and gestational diabetes related to maternal age? - abstract

Most cases of gestational diabetes are found in women older than 30 years. Insulin response generally decreases with increased age. To correlate the relationship between maternal age; insulin response and subsequent development of gestational diabetes, 120 pregnant women were classified into three age groups; ages 18-24 years, 25-29 years and o30 years. All women were classified as normal weight when adjusted for expected pregnancy weight gain. The three groups were administered a 50g glucose screen at 27 weeks of gestation. Blood samples were taken 1 hour after ingesttion. Analyses were done for glucose, c-peptide and insulin. Patients in the age group in 18 - 24 years had mean ñSD glucose concentration of 5.6ñ 1.0 mmol/l and showed the greatest insulin response with a mean ñSD of 160ñ 24æU/ml. Patients in the age group 25 - 29 years had a mean glucose value of 6.4ñ 1.0 mmol/l and the mean insulin value of 148ñ 31æU/ml was less than that of the younger group. The oldest women had the lowest mean insulin value of 100ñ 49æU/ml and showed some general glucose intolerance with mean glucose value of 8.1ñ 1.0mmol/l. A significant difference (p=0.001) was formed in insulin values when the women in the age groups 18-24 years and 25-19 years were compared. However the difference was greater (p=0.000002) when the women in the age groups 18 - 24 years and o30 years were compared. A 4.25 percent prevalence rate of gestational diabetes was found among the oldest women. Our findings that glucose tolerance and insulin response are lowest in older pregnant women support the concept that gestational diabetes in more prevalent in older gravidas. (AU)

Low dose aspirin in pregnancy are there any benefits

Although the question of major prophylactic benefits of low-dose aspirin in preventing pre-eclampsia or intrauterine growth retardation in pregnancies of mothers who had had such a history has been convincingly negated by the CLASP study, there has remained a question whether pregnancies of primiparae (the group most at risk of such outcomes) might benefit. This study was designed as a randomized controlled trial to address this possibility and other hypotheses arising from the CLASP study. The hypotheses addressed concerns whether low-dose aspirin prevented in or delayed the onset of the hypertensive disorders of pregnancy, including pre-eclampsia, and eclampsia, and whether preterm delivery or low birthweight rates were reduced. In addition, the study was designed to assess whether enrolment, early rather than late, had the most beneficial effect. In parallel, possible adverse effects on mother and infant were monitored. A total of 6275 primiparae were enrolled from 12 weeks gestation in community clinics in Kingston and St. Andrew in Jamaica; 97 percent of them were followed throughout pregnancy. There were no differences in the development of markers of hypertensive disorders, the prevalence of pre-eclampsia or eclampsia except for oedema, which was more prevalent in those on placebo. Mothers on the drug showed no differences in mean diastolic bloodpressure at any stage of pregnancy - they were not less likely to deliver preterm or have a larger foetus. They were, however, significantly more likely to suffer from bleeding disorders antenatally, intrapartum and postpartum. It is concluded that low-dose aspirin has no place in the management of normal pregnancy (AU)

An open trial comparing usual care (hydralazine) with injectable Isradipine in severe pre-eclampsia

Pre-eclampsia is characterised by generalized vasospasm. When this affects the placental bed it causes foetal compromise. These placental bed vessels are under the control of locally acting agents such as electrolytes and are not influenced by neural acting vasodilators such as hydralazine. Calcium channel blockers such as isradipine should work on these vessels and therefore improve the outcome of these pregnancies compared with hydralazine. We did a randomized comparative trial with these two agents used parenterally, in 27 patients with severe pre-eclampsia. The main outcome variables examined were age, parity, bloodpressure before and after treatment, length of prolongation of the pregnancy after start of treatment, complications and foetal outcome. There were no significant differences between the two groups in pre-treatment or post-treatment variables. In conclusion we believe that isradipine offers no advantage over hydralazine in severe pre-eclampsia (AU)

Association of pregnancy-induced hypertension with sexual activity in primigravidae: a preliminary report

Prolonged exposure to semen prior to conception has been associated with a decreased risk of developing pregnancy-induced hypertension. In this study, 257 primigravidae were interviewed about total duration of sexual activity and sexual cohabitation with the father of the index pregnancy and number of sexual partners prior to conception. Each patient was placed in one of three groups: normotensive, transient hypertension and pre-eclampsia. Median duration of cohabitation was significantly less in patients with transient hypertension (9 months) than in normotensive patients (19 months) and those with pre-eclampsia (33 months), whereas total duration of sexual activity was similar in all three groups. Also, significantly more patients with transient hypertension had only one partner (51.5 percent), when compared with those in the normotensive (29.7 percent) and pre-eclamptic (26.7 percent) groups. Further analysis revealed that having one partner prior to conception significantly increases the risk of developing transient hypertension (relative risk 2.19), but not of developing pre-eclampsia. The results suggest that minimal exposure to semen, and having only one partner prior to conception in primigravidae may be risk factors for the development of transient hypertension but not for pre-eclampsia. In addition, the differences in the results for transient hypertension versus pre-eclampsia suggest different pathophysiological mechanisms for the two disorders. (AU)

The glucose tolerance test in pregnancy: at which gestational age should it be performed

Gestational diabetes is defined as intolerance detected during pregnancy. To investigate the effect of time on the screening test for gestational diabetes, patients were administered a 50g oral glucose screening test at 7-13; 24-36 weeks of gestation. There was an increase in the plasma glucose value up to 32 weeks of gestation and a gradual decrease to term. Of the 850 patients screened between 7 and 13 weeks of gestation, 22.2 percent were positive, and of these 2.9 percent were confirmed to be diabetic by the two-hour 75 g oral glucose tolerance test. Patients with negative screen or confirmatory tests between 7 and 13 weeks were rescreened at 24 weeks; 8.3 percent were positive, and of them 3.5 percent were confirmed as gestational diabetics. Patients who tested negative at 24 weeks were retestet between 28 and 36 weeks; 7.5 percent were positive, and of these 0.5 percent were confirmed as having gestational diabetes was found to be 4.25 percent. Currently, glucose screening for gestational diabetes is recommended between 24 and 28 weeks of gestation. From the data collected most cases were detected (3.5 percent) at 24 weeks. This study supports screening of all patients without any previous history of diabetes mellitus at or around 24 weeks of gestation (AU)

Diabetic retinopathy in pregnancy - abstract

Diabetic retinopathy is the leading cause of blindness between the ages of 24 and 64 years. The first half of this period corresponds to the childbearing age in women. The effects of pregnancy on diabetic retinopathy (DR) are unclear. However, the concensus is that pregnancy is an independent risk factor accelerating DR. Co-existing hypertension also potentiates this condition. The duration of diabetes mellitus and the status of the retina prior to pregnancy influence the rate of acceleration of retinopathy. Rapid normalization of blood glucose recommended for optimal obstetric outcome leads to worsening of DR. A baseline opthamological evaluation is recommended at the beginning of each pregnancy and follow-up in each trimester as well as three months post-partum. If there is no, or minimal, non-proliferative diabetic retinopathy (NPDR) at the initial examination, deterioration is unlikely. However, 50 per cent of women with severe NPDR or proliferative diabetic retinopathy (PDR) will worsen during pregnancy. PDR that has been adequately treated by laser photocoagulation prior to pregnancy does not deteriorate and as such it is no longer a contraindication to childbearing. Female diabetic patients ideally should have a planned pregnancy. A team approach has shown significant improvements in maternal and foetal outcome. By the inclusion of the opthalmologist in the team, the effects of pregnancy on DR. can be monitored (AU)

Intramyometrial vasopressin as a haemostatic agent during myomectomy

OBJECTIVE: To assess the efficacy of intramyometrical vasopressin for minimising bleeding and its sequelae at myomectomy. DESIGN: A randomised placebo controlled trial. SETTING: University Hospital of the West Indies, Kingston, Jamaica. SUBJECTS: Twenty women with symptomatic uterine fibroids scheduled for myomectomy who satisfied entry criteria: 10 randomised to the vasopressin group and 10 to the control group. INTERVENTION: Myomectomy was performed after the intramyometrial injection of either 20 units vasopressin diluted to 20 ml in normal saline or placebo (20 ml normal saline). MAIN OUTCOME MEASURES: The efficacy of vasopressin was measured by comparing pre- and post-operative haemoglobin levels and haematocrit, changes in intra-operative pulse and blood pressure, measured blood loss, need for blood transfusion post-operative febril morbidity in the treatment and control groups. RESULTS: The use of vasopressin resulted in median blood loss of 225 ml (range150-400ml) compared with 675 ml (range 500-800ml) in the placebo group (p<0.001). The vasopressin group had a correspondingly lower fall in haemoglobin level (median 1.7g/dl vs 5.3g/dl, P<0.001) and haematocrit (median 5 percent vs 13 percent, P<0.001) compared with the controls. Fifty percent of the placebo group had blood transfusions compared with none in the vasopressin group (P=0.03). There were no significant differences between the groups in intra-operative pulse and blood pressure or post-operative white blood cell counts or temperature. CONCLUSION: The results indicate that vasopressin is effective in preventing blood loss and reducing the need for blood transfusion during myomectomy (AU)

Amniotic fluid index (AFI) in postdates pregnancy - abstract

This a prospective evaluation of the relationship between the amniotic fluid index (AFI) and perinatal outcome in 55 patients managed at the Obstetrical Unit at the University Hospital of the West Indies. The subjects had an otherwise uncomplicated pregnancy and early confirmation of gestational age by ultrasound. Forty-two patients had delivered by 41 weeks and the remaining thirteen by 42 weeks. The gravid abdomen was divided into four quadrants, using realtime ultrasound with a 3.5 Mhz transducer, the largest pocket of amniotic fluid in each quadrant was measured and their sum totalled to arrive at the AFI. The pregnancies were managed without knowledge of this evaluation. Perinatal outcome was assessed by the presence of meconium-stained liquor and its aspiration, intrapartum foetal delivery, low APGAR scores at delivery, the need for admission to the nursery and perinatal death. AFI in this study ranged from 2.8 cm to 22.6 cm. The mean for 41 weeks was 13.52 ñ 4.6 cm and for 42 weeks was 9.93 ñ 4.37 cm. Oligohydramnios was noted in four patients, AFI < 5.3 cm. Two of these cases developed intrapartum foetal distress and had Caesarian Section. All four babies were admitted with meconium aspiration, and one died from this complication (AU)