Cassandra E. Henderson

Prevalence and predictors of positive screening for postpartum depression in minority parturients in the South Bronx.

It is reported that the rates of perinatal depressive disorders are high in ethnic minority groups from non-English speaking countries. However, very few studies have compared the prevalence of positive screening for postpartum depression (PPD) in minority communities living in an inner city. The goal of this study is to determine the prevalence and the predictors of positive screening for postpartum depression in minority parturients in the South Bronx. The study is a chart review of 314 minority parturients, Black or Hispanic, screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) tool. The overall prevalence of a positive EPDS screen among Black and Hispanic women was similar, 24.04 and 18.75%, respectively. The Black immigrant cohort had comparable positive screens with 23.81 as African Americans. Hispanic women born in the USA had the least prevalence of positive screens, 7.14%, and those who moved from the Dominican Republic and Puerto Rico had a prevalence of 17.24% of positive screens. The women who immigrated from Mexico, Central America, or South America had the highest prevalence of positive screens for PPD, 32.26%. As to the socioeconomic status (SES), there was a significant increase of 27.04 vs. 13.95% (P < 0.019) in positive screens for PPD for the unemployed mothers. Overall, Black and Hispanic parturients had similar rates of positive screens for PPD. Among the Hispanic women, immigrants had higher rates of positive screens, with those from Mexico, Central, and South America as the highest. The hospital experience did not affect the rates of positive screens. Neither did the SES with one exception; those unemployed had the higher rates of positive screens.

Amniorrhexis lowers the incidence of positive cultures group B streptococci

OBJECTIVE Our purpose was to determine the effect of amniorrhexis on cultures for group B streptococci. STUDY DESIGN Intrapartum vaginal cultures for group B streptococci were obtained before and after rupture of membranes in 166 women; in addition, rectal cultures were obtained from the last 35 patients. RESULTS Before rupture of membranes 49 of 166 (30%) of the vaginal cultures were positive for group B streptococci; only 28 of 166 (17%) remained positive after rupture of membranes (p = 0.0009). Similarly, before rupture of membranes 10 of 35 (30%) rectal cultures were positive, whereas only three of 35 (0.9%) remained positive for group B streptococci after rupture of membranes (p = 0.03). CONCLUSION The prevalence of positive genital cultures for group B streptococci is significantly lower immediately after rupture of membranes.

Diabetes prevention: Reproductive age women affected by insulin resistance:

In the United States, 29.1 million people are affected by diabetes, of which 95% have type 2 diabetes. There has been a fivefold increase in type 2 diabetes in the latter half of the 20th century, an increase strongly linked to the obesity epidemic in the United States. In addition, insulin resistance affects 86 million Americans, or more than one-third of the adult population, as manifested by impaired fasting glucose tolerance with random glucose values ranging from ⩾100 to <126 mg/dL. In all, 90% of those affected by impaired fasting glucose tolerance or pre-diabetes are unaware of their metabolic derangement. Although impaired fasting glucose tolerance increases one’s risk of developing type 2 diabetes, once identified, application of lifestyle changes by affected individuals may avoid or delay the onset of type 2 diabetes. For reproductive age women who are found to have impaired fasting glucose tolerance, lifestyle changes may be an effective tool to diminish the reproductive health consequences of insulin resistance related diseases.

Comment on Hughes et al. An Early Pregnancy HbA1c ≥5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes. Diabetes Care 2014;37:2953–2959

We welcome the article by Hughes et al. (1) on glycosylated hemoglobin A1c (HbA1c) as a readily available screening tool that the authors propose be used to identify undiagnosed diabetes during the early prenatal period. However, we submit that the low subject participation rate of 23% severely limits the validity of their findings. Data obtained from only 23% of the study participants do not allow one to have confidence that the selected 5.9% (41 mmol/mol) HbA1c cutoff correlates …

Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels

TO THE EDITORS: We read with interest the retrospective review of intrahepatic cholestasis of pregnancy (ICP) by Brouwers et al. During the study period, to avoid unexplained term stillbirth, the standard of care for ICP-affected pregnancies included active management to deliver infants as early as 37 weeks of gestational age (GA). However, despite routine implementation of active management, 2 fetal deaths occurred in the group affected by severe ICP. Regrettably, the reader is not provided with any information to consider confounders that may have contributed to the perinatal mortality such as fetal gestational age, maternal cardiovascular disease, or prior cases of intrauterine death or growth restriction. We are chagrined that in the absence of supportive evidence, because active management did not prevent the 2 fetal deaths, the authors suggest future investigation is warranted to evaluate earlier delivery of ICP-affected pregnancies between 35 and 37 weeks’ GA. Given that active management to deliver late preterm infants at 37 weeks’ GA is associated with documented maternal and perinatal harm without substantiated evidence of perinatal benefit, we oppose the consideration of earlier delivery of ICP-affected pregnancies. Brouwers et al reported that 30% of gravidas in the severe ICP group had either spontaneous or iatrogenic preterm births. The author cites evidence that elevated bile acids increase the sensitivity and expression of oxytocin receptors in human myometrium. However, in this retrospective report, the severity of ICP was not directly related to the incidence of spontaneous preterm labor. Indeed, the mildly affected group had the highest rate of spontaneous preterm labor. The mild, moderate, and severe ICP study groups had spontaneous preterm labor rates of 28 of 108 (25.9%), 10 of 86 (11.68%) and 4 of 21 (19.0%), respectively. Whereas this lack of direct correlation between preterm labor and ICP severity likely is due to inadequate power for this subgroup analysis, these findings do not suggest bile acids have a direct effect on oxytocin receptors in the myometrium. -

Laparoendoscopic Single-Site Surgery for Management of Heterotopic Pregnancy: A Case Report and Review of Literature

Background Heterotopic pregnancy occurs when two pregnancies occur simultaneously in the uterus and an ectopic location. Treatment includes removal of the ectopic pregnancy with preservation of the intrauterine pregnancy. Treatment is done laparoscopically with either a Laparoendoscopic Single-Site Surgery (LESS) or a multiport laparoscopic surgery. Case We present a case of a first trimester heterotopic pregnancy in a 42-year-old gravida 5, para 0-1-3-1 female with previous history of left salpingectomy, who underwent laparoscopic right salpingectomy and lysis of adhesions (LOA) via Single-Incision Laparoscopic Surgery (SILS). Conclusion Although LESS for benign OB/GYN cases is feasible, safe, and equally effective compared to the conventional laparoscopic techniques, studies have suggested no clinically relevant advantages in the frequency of perioperative complications between LESS and conventional methods. No data on the cost effectiveness of LESS versus conventional methods are available. LESS utilizes only one surgical incision which may lead to decreased pain and better cosmetic outcome when compared to multiport procedure. One significant undesirable aspect of LESS is the crowding of the surgical area as only one incision is made. Therefore, all instruments go through one port, which can lead to obstruction of the surgeons vision and in some cases higher rate of procedure failure resulting in conversion to multiport procedure.

Psychotherapy With Somatosensory Stimulation for Endometriosis-Associated Pain: A Randomized Controlled Trial

We applaud the work done by Meissner et al,1 in which their results demonstrate the potential for the use of psychotherapy with somatosensory stimulation in treating endometriosis. Although their results are encouraging, the authors did not discuss or control for comorbid conditions that can lead to confounding variables. Meissner et al did not screen patients with comorbid conditions that can affect their pain tolerance such as fibromyalgia. Fibromyalgia in the presence of endometriosis has been described by Sinaii et al.2 In conditions such as this, the patient’s perception of pain might be drastically different because fibromyalgia is a chronic condition of pain. This altered perception of pain could affect data regarding the subjective feeling of the patient’s perceived pain; this can therefore alter the patient’s perceived outcome of how somatosensory stimulation improved their pain. We ask Meissner et al their rationale for using an unblinded randomized control trial in lieu of a crossover randomized prospective trial. We believe that this study should have been a crossover randomized prospective trial, because all participants would have been exposed to the treatment for a certain duration and, more importantly, it would control for confounding variables or even draw other associations, such as comorbid conditions that affect the patient’s perception of pain.

An Important Cause of Child and Youth Homelessness

PEDIATRIC QUALITY MEASURES An Important Cause of Child and Youth Homelessness To the Editor There is a preconception that children who participate in activities outside the standard regulations of a stable household are predominantly juvenile delinquents.1 Embleton et al2 present a large, generalized study with statistical depth that illuminates the environmental factors giving rise to millions of displaced children. The study emphasizes that children do not just become involved in “street life” because of an innate delinquency.3 Rather, children are a product of their experiences, particularly those experiences that expose them to psychosocial disruption and inhibited child development. Within the study, extensive analysis reveals that poverty, family conflict, and abuse are major identifying factors that predispose children to displacement and inadequate living conditions.2 Although these are significant risk factors, the study overlooks the effect of childhood mental illness on decision making because participants were not screened for mental illness prior to inclusion in this study. This screening is important because in a meta-analysis performed by Bassuk et al,4 10% to 26% of homeless preschoolers and 24% to 40% of homeless school-aged children have mental health problems requiring clinical evaluation. By not screening for mental illness prior to the study, the authors overlook mental illness as a substantial contributor to poor insight. This is particularly relevant when considering how mental illness may affect the participants’ responses to the study questions. Therefore, to obtain more accurate results, study participants must be screened for mental illness, and those with mental illness should be taken into special consideration on account of impaired decision making. It is increasingly important to understand that children are being socially excluded, criminalized, and oppressed owing to preconceived notions that they are delinquents by nature,2 and those who are mentally ill are no exception. Although significant data have not been gathered to determine whether early prevention will decrease the number of children participating in “street life,” it would be negligent of us as clinicians to not consider the effect that psychological development and resulting mental illness have on decision making in impressionable youth. With more accurate studies, we may better ensure childhood success and break the cycle of child homelessness.

Health care justice and its implications for current policy of a mandatory waiting period for elective tubal ligation

TO THE EDITORS: We welcome the report appearing in the June edition of the American Journal of Obstetrics and Gynecology that adds voices to ours and that of other commentators calling for revision of the 30-day mandatory sterilization

Untreated Active Tuberculosis in Pregnancy with Intraocular Dissemination: A Case Report and Review of the Literature

Background. Tuberculosis (TB) is a disease that affects hundreds of millions of people across the world. However, the incidence in developed countries has decreased over the past decades causing physicians to become unfamiliar with its unspecific symptoms. Pregnant individuals are especially difficult because many symptoms of active TB can mimic normal physiological changes of pregnancy. We present a case report of a 26-year-old multiparous woman, G4P3003, at 38-week gestation with a history of positive PPD who emigrated from Ghana 6 years ago. She came to the hospital with an initial complaint of suprapubic pain, pressure, and possible leakage of amniotic fluid for the past week. Patient also complained of a productive cough for the past 3 to 4 months with a decrease in vision occurring with the start of pregnancy. Visual acuity was worse than 20/200 in both eyes. Definitive diagnosis of active TB was delayed due to patient refusal of chest X-ray. Fortunately, delay in diagnosis was minimized since patient delivered within 24 hours of admission. Active TB was confirmed with intraocular dissemination. Patient had optic atrophy OS (left eye) and papillitis, choroiditis, and uveitis OD (right eye) due to TB infiltration. Fetus was asymptomatic and anti-TB therapy was started for both patients.