Assaad Kesrouani

Early identification of women at risk of postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) in a sample of Lebanese women

BackgroundDuring the postpartum period, women are vulnerable to depression affecting about 10 to 20% of mothers during the first year after delivery. However, only 50% of women with prominent symptoms are diagnosed with postpartum depression (PPD). The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening instrument for PPD . The main objectives of this study are to assess whether an EPDS score of 9 or more on day 2 (D2) postpartum is predictive of a depressive episode between days 30 and 40 postpartum (D30-40), to determine the risk factors as well as the prevalence of PPD in a sample of Lebanese women and to determine a threshold score of EPDS predictive of PPD.MethodsA sample of 228 women were administered the EPDS on D2. An assessment for PPD was done on D30-40 during a telephone interview.ResultsOn D2, the average score on EPDS was 7.1 (SD = 5.2) and 33.3% of women had an EPDS score ≥ 9. On D30-40 postpartum, the average score was 6.5 (SD = 4.7) and 19 women (12.8%) presented with PPD. A positive correlation was shown between scores on EPDS on D2 and D30-40 (r = 0.5091, p < 0.0001). A stepwise regression shows that an EPDS score ≥9 on D2 (p < 0.001) and a personal history of depression (p = 0.008) are significantly associated with the diagnosis of PPD on D30-40.ConclusionThe EPDS may be considered as a reliable screening tool on as early as D2 after delivery. Women with EPDS score ≥ 9 and/or a positive personal history of major depressive disorder should benefit from a closer follow-up during the rest of the post-partum period.

Use of Oral Misoprostol for Cervical Priming before Hysteroscopy: A Randomized Comparison of Two Dosages

Objective: The study aims to compare the safety and effectiveness of 200 and 400 µg of oral misoprostol for cervical priming before hysteroscopy. Methods: A double-blinded randomized study included 70 patients scheduled for hysteroscopy in a Lebanese University Hospital. Two dosages of oral misoprostol (200 or 400 µg) were randomly distributed to these patients 1 h before surgery under general anesthesia. Subjective assessment of the ease of dilatation, size of the first used Hegar, cervical injuries, bleeding or uterine perforation, duration of the procedure and misoprostol adverse effect were all noted and compared. Results: The difficulty of dilation until a Hegar 10 was similar for both treatment groups. Operative time was not reduced with a higher misoprostol dosage. We found 2 uterine perforations within the 200 µg group (6.7%), and none within the 400 µg group. Cervical lacerations and bleeding were similar (20%) for both treatment groups. A 2-fold increase in side effects (nausea, vomiting and cramps) is reported among the 400 µg group. Conclusions: Increasing the dose of misoprostol from 200 to 400 mg doubled the rate of side effects while no clinical benefit was noted. Larger trials are needed to assess rates of uterine perforation with the 200 µg dosage.

Associations between quality of life, physical activity, worry, depression and insomnia: A cross-sectional designed study in healthy pregnant women

Health-related quality of life (QOL) is reported to be reduced during pregnancy. Associations between QOL, physical activity (PA), insomnia, depression and worry are insufficiently investigated among pregnant women. The aim of this study was to evaluate QOL and PA patterns among healthy pregnant women, and to examine how QOL might correlate to PA, sleep, worry and depression. This is an observational cross-sectional study, conducted among a convenient sample of 141 healthy pregnant women using five questionnaires: WHOQOL-brief (WHO quality of life questionnaire, brief version, ISI (Insomnia Severity Index), PSWQ (Penn State Worry Questionnaire), ZSRDS (Zung Self-Rating Depression Scale), and Pregnancy Physical Activity Questionnaire (PPAQ). Pre-gestational BMI was inversely correlated to overall health while education was positively correlated to psychological health, social relationships and environment domains. Smoking before and during pregnancy significantly impacted the general health and psychological health. Total and light PA were positively correlated to psychological health and social relationships. Sports/exercise showed positive correlations with several QOL domains. Insomnia and depression were significantly associated with a decrease in all domains of QOL, while worries were associated with a decrease in physical, psychological and environmental domains. There were significant negative correlations between ZSRDS scores and total activity. PA, worries, depression and insomnia affected QOL during pregnancy. Furthermore, pregnant women presenting depression had a reduced total PA. Sleep and mental health as well as encouraging PA during pregnancy are necessary to improve the quality of life of pregnant women.

Prediction of preterm delivery by second trimester inflammatory biomarkers in the amniotic fluid

OBJECTIVE To search for a correlation between mid-pregnancy altered levels of inflammatory markers and preterm delivery. METHODS A prospective cohort series included 39 patients undergoing amniocentesis one additional milliliter of amniotic fluid (AF) was stored for later dosage of interleukin-6 (Il-6), matrix metalloproteinase-9 (MMP-9), glucose and C-reactive protein (CRP). Maternal serum CRP and glucose levels were also obtained. Exclusion criteria were multiple pregnancies, chorioamnionitis, group B streptococcus colonization, bacterial vaginosis and cases with proven aneuploidy. We searched for correlation between AF and plasmatic markers and also for a difference between patients with term and preterm delivery. RESULTS 33 participants were eligible and one third had preterm delivery. Levels of the plasmatic biomarkers did not correlate with the AF biomarkers except for plasmatic glucose and AF IL-6 levels (r=0.350; p=0.016). The levels of all AF biomarkers did not differ significantly between the pre-term and the term groups (p>0.05). The optimal screening cutoffs for identifying pregnancies at risk were different than the ones initially indicated. CONCLUSION Mid-pregnancy amniotic fluid biomarker levels do not correlate with preterm delivery. Plasma CRP is not correlated with these markers. Cutoff levels suggested are sparse and heterogeneous. Larger studies are needed before advising routine measurement of these markers.

Treatment of Tracheal Mucoepidermoid Carcinoma by Argon Plasma Coagulation During Pregnancy

Mucoepidermoid carcinoma of the tracheobronchial tree is a rare airway tumor (<1% of all lung tumors). In adults, the majority of primary tracheal tumors are malignant. Management during pregnancy is complex and requires weighing maternal and fetal prognosis. Reported cases describe surgical resection following cesarean section. We report the first case to be treated by Argon-Plasma Coagulation (APC) in pregnancy. A 35-year-old Caucasian woman G1P0, at 27 weeks of gestation was admitted to the emergency department because of hemoptysis and severe dyspnea. Bronchoscopy and biopsies diagnosed primary tracheal mucoepidermoid carcinoma. Following an episode of tracheal bleeding, she was intubated. After thorough explanations to the family and obtaining informed consent, therapeutic bronchoscopy, under general anesthesia using a rigid bronchoscope, was performed. The tumor was cored out with the tip of the bronchoscope and removed with an alligator forceps. The tumor bed was coagulated with APC. The obstetrical team was ready to intervene in case of maternal emergency. Immediate follow-up was good, and she left the hospital 4 days later. She delivered at 39 weeks of gestation by cesarean section because of dystocia. Five years later, the patient is doing well without any signs or symptoms of recurrence. Pediatric follow-up is normal. Argon Plasma Coagulation for treatment of mucoepidermoid tracheal carcinoma is feasible during pregnancy. Reporting this case could lead to less aggressive management of mucoepidermoid carcinoma in pregnant patients.

Rapid Evolution of Placental Chorioangioma: Natural Progression and Outcome

Placental chorioangioma is a benign vascular tumor most frequently diagnosed in the second trimester of pregnancy by sonographic and Doppler evaluation. The course of the tumor may be totally indolent, with minimal to no maternal and fetal consequences, or it may also lead to premature labor, intrauterine growth restriction, hydrops fetalis, and high-output fetal heart failure, which may be due to arteriovenous anastomoses between the tumor and the placenta. We present the case of a rapidly growing chorioangioma, which culminated in premature labor, neonatal anemia, and heart failure, eventually leading to neonatal death. The uniqueness of our case resides in its sudden and brisk temporal evolution, which led to critical consequences. The patient was a 32-year-old woman, gravida 3, para 2, with a history of 2 cesarean deliveries, 1 of which resulted in a live birth and the other in neonatal death due to sepsis. First-trimester screening for major abnormalities and aneuploidy yielded negative findings. On a second trimester scan at 18 weeks, a chorioangioma was discovered, and close surveillance was initiated. At 22 weeks, the tumor measured 58 × 43 mm (Figure 1A). No single vascular pedicle was identified, and the fetus was growing appropriately without any signs of impairment. At 27 weeks 3 days, the tumor nearly doubled in size and measured 96.7 mm; this rapid increase motivated close surveillance, despite the normal fetal growth, the normal amniotic fluid index, and the normal umbilical and middle cerebral artery Doppler findings (1.29 multiples of the median). Prenatal treatment was discussed at that time. Eight days later, the sonographic evaluation showed further tumor growth, which now measured 15 cm. In addition, the fetus now manifested signs of hydrops, with scalp edema, ascites, and polyhydramnios present as well. She was thus admitted at 28 weeks 4 days for close surveillance, and cortisone was administered in anticipation of imminent delivery. Blood work values were within the normal range except for maternal anemia. She received 12 mg of betamethasone twice over 24 hours. Nonstress fetal heart testing maintained reactivity and was performed repeatedly. She underwent a cesarean delivery 24 hours after admission because of the fetal hydrops. We noticed an excess of fluid, and the placenta and cord were hydropic. Surgery was complicated by transient uterine atony, which responded to medical treatment. The female neonate had considerable edema, weighed 2100 g, and had an Apgar score of 7 at 1 minute but rapidly became cyanotic. No heart murmur was heard. She had substantial ascites, and the presence of ecchymosis was noted on several areas of her body. She later had spontaneous bleeding from her mouth. The neonate’s hemodynamic status was critical, with substantial desaturation, which necessitated mechanical ventilation. Fetal bradycardia ensued as well and partially responded to dobutamine, a continuous adrenaline infusion, as well as cardiac massage. Neonatal echocardiography revealed a structurally normal heart that was, however, in severe heart failure. The neonate then went into a cardiac arrest, and resuscitation for 20 minutes was unsuccessful, leading to neonatal death. Postmortem blood work revealed severe anemia (hemoglobin level, 5.6 g/dL) and disseminated intravascular coagulation. The mother had an uncomplicated postoperative medical course and was discharged home on postoperative day 2 in good physical condition and without complications. Our medical team provided her with ongoing psychological support and follow-up. The pathology report showed a hypertrophic 1130-g placenta with a 15-cm chorioangioma. Vascularization of the chorioangioma was seen (Figure 1B). Placental chorioangioma is the most common placental tumor, with an estimated prevalence of 1% in systematic placental histologic studies.1 The first case of a prenatal sonographically diagnosed chorioangioma was reported by Asokan et al2 in 1978. Small chorioangiomas tend to remain asymptomatic during pregnancy. Large or giant chorioangiomas (>4–5 cm in diameter) are more often diagnosed prenatally by sonography during the second trimester. Chorioangioma presents as a well-circumscribed hypoechoic placental tumor located in most cases at the chorionic plate, adjacent to the cord insertion. The vascular nature of the tumor can be confirmed by a Doppler study.3 Signs of shunting with the umbilical vein may also be shown. In our case, after the rapid growth of the tumor, several abnormal flow velocity signals were shown, thus possibly indicating the formation of a vascular communication between the fetal circulation and the tumor. Complications are due to anastomosis of the arteriovenous system within the placenta, by means of a “stealing” phenomenon, which short circuits blood from a highto a low-resistance vascular bed, leading to heart failure; this condition can be suspected by the presence of hydrops, serous effusions, subcutaneous edema, cardiomegaly and increased tricuspid regurgitation, an enlarged a wave in the inferior vena cava, and pulsations in the umbilical vein, with reduced or no diastolic flow.4

Re: Misoprostol for cervical priming prior to hysteroscopy in postmenopausal and premenopausal nulliparous women: a multicentre randomised placebo controlled trial

labour resulted in a lower rate of chorioamnionitis (4%versus8.6%,P<0.001), the rate of neonatal infection was not significantly lower (2–3%). Although women in this study who had labour induced viewed labour more positively than those managed expectantly, the fact that 8% of term labours start with PROM raises concerns about the overmedicalisation of labour, which continue to this day. In a follow-up analysis of the TERMPROM study, Seaward et al. reported that being an identified carrier of GBS significantly increased the risk of chorioamnionitis (odds ratio 1.7, 95% CI 1.23–2.38), but in a screened population they will be receiving penicillin anyway. The meta-analysis by Saccone and Berghella published in 2015 which included 2639 women showed that although antibiotic prophylaxis with an interval of more than 12 hours between admission and delivery reduced chorioamnionitisby51%andendometritis by 88%, there were no significant improvements in any other fetal or maternal outcomes. In the latest RCOG guidelines we state in relation to PROM at term: ‘Women who are known GBS carriers should be offered immediate IAP (intrapartum antibiotic prophylaxis) and induction of labour as soon as reasonably possible’ (grade of recommendation C). The problem is that although there is good evidence that this will benefit known GBS carriers, it is not clear from the currently available data that extending that recommendation to the entire population (as must be the case where there is no routine screening) will produce an overall benefit significant enough to justify routine antibiotic administration. Because early-onset GBS disease affects fewer than one infant per 1000 births, it is difficult to estimate case rates reliably in single centres. It would not be surprising if a cluster of cases were followed over a period during which fewer cases were observed and we would be cautious about considering the reported experience to represent reliable evidence of a change in case rates in association with a change in practice.

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population

Abstract Objective: Evaluate the outcome of prenatally diagnosed nuchal cord. Methods: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction. Results: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops. Conclusion: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.

Data on clinical significance of second trimester inflammatory biomarkers in the amniotic fluid in predicting preterm delivery.

In this article second trimester amniotic fluid biomarkers are measured for correlation with preterm delivery. One additional milliliter of amniotic fluid is collected during amniocentesis for dosages of IL-6, MMP-9, CRP and glucose levels, along with maternal serum CRP and glucose. MMP-9 and Il-6 levels were measured with the corresponding Human QuantikineR ELISA Kit (R&D systems) according to the instructions provided by the manufacturer. Cut-off values for AF MMP-9 and IL-6 were fixed by the kit sensitivity thresholds. Data includes ROC curves for glucose (Fig. 1), IL-6 (Fig. 2) and MMP-9 (Fig. 3), aiming to search for sensitivity and specificity in the prediction of premature delivery. Statistical analyses are performed with SPSS v20.0 software. Statistical significance is determined using the Mann–Whitney and one way ANOVA test. The association with preterm delivery is performed using a two proportions test. Correlations are measured using the Pearson׳’s coefficient. A p value<0.05 is considered statistically significant. The data is presented in the figures provided. Data relied on a previous publication “Prediction of preterm delivery by second trimester inflammatory biomarkers in the amniotic fluid” (A. Kesrouani, E. Chalhoub, E. El Rassy, M. Germanos, A. Khazzaka, J. Rizkallah, E. Attieh, N. Aouad, 2016) [1].

Impact of female gender and perspectives of pregnancy on admission in residency programs

BackgroundMotherhood is a demanding part of any women’s life. Female interns could encounter difficulties during selection for residency program according to their plans of conceiving. Our aim is to explore the influence of female gender on the selection process of residency programs.MethodA cross sectional study was conducted in 2016 at a University Hospital in Beirut, Lebanon. Female residents and chief of departments were interviewed about the impact of the timing of motherhood during residency on the interview for admission. The questionnaire reviewed concerns among female Lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities.ResultsEighty nine female residents and 22 head of department agreed to participate in this study. During the interviews for residency acceptance, 29 residents (34.5%) were directly asked about their family and motherhood plans; 9% of them did not reveal their intention. 35% of the residents thought that this subject could affect the program directors’ decision. 47% of residents felt that having pregnant colleagues would add to their workload, and almost half of them (46%) believed that pregnant colleagues showed less productivity. 45% of program directors stated that it was an important factor taken into consideration during the interview, and 68% believed that residents tended to choose their specialty according to their life priorities.ConclusionPregnancy during residency training represents major challenges for female residents and their program directors. Rules and laws designed to set a balance between career and personal life are required to improve women’s ability to participate equally in the workforce.