Cynthia Brincat

Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study

OBJECTIVE This study aimed to prospectively examine the impact of chronic vs pregnancy-onset habitual snoring on gestational hypertension, preeclampsia, and gestational diabetes. STUDY DESIGN Third-trimester pregnant women were recruited from a large, tertiary medical center from March 2007 through December 2010 and screened for the presence and duration of habitual snoring, as a known marker for sleep-disordered breathing. Clinical diagnoses of gestational hypertension, preeclampsia, and gestational diabetes were obtained. RESULTS Of 1719 pregnant women, 34% reported snoring, with 25% reporting pregnancy-onset snoring. After adjusting for confounders, pregnancy-onset, but not chronic, snoring was independently associated with gestational hypertension (odds ratio, 2.36; 95% confidence interval, 1.48-3.77; P < .001) and preeclampsia (odds ratio, 1.59; 95% confidence interval, 1.06-2.37; P = .024) but not gestational diabetes. CONCLUSION New-onset snoring during pregnancy is a strong risk factor for gestational hypertension and preeclampsia. In view of the significant morbidity and health care costs associated with hypertensive diseases of pregnancy, simple screening of pregnant women may have clinical utility.

The Clinical Urine Culture: Enhanced Techniques Improve Detection of Clinically Relevant Microorganisms

ABSTRACT Enhanced quantitative urine culture (EQUC) detects live microorganisms in the vast majority of urine specimens reported as “no growth” by the standard urine culture protocol. Here, we evaluated an expanded set of EQUC conditions (expanded-spectrum EQUC) to identify an optimal version that provides a more complete description of uropathogens in women experiencing urinary tract infection (UTI)-like symptoms. One hundred fifty adult urogynecology patient-participants were characterized using a self-completed validated UTI symptom assessment (UTISA) questionnaire and asked “Do you feel you have a UTI?” Women responding negatively were recruited into the no-UTI cohort, while women responding affirmatively were recruited into the UTI cohort; the latter cohort was reassessed with the UTISA questionnaire 3 to 7 days later. Baseline catheterized urine samples were plated using both standard urine culture and expanded-spectrum EQUC protocols: standard urine culture inoculated at 1 μl onto 2 agars incubated aerobically; expanded-spectrum EQUC inoculated at three different volumes of urine onto 7 combinations of agars and environments. Compared to expanded-spectrum EQUC, standard urine culture missed 67% of uropathogens overall and 50% in participants with severe urinary symptoms. Thirty-six percent of participants with missed uropathogens reported no symptom resolution after treatment by standard urine culture results. Optimal detection of uropathogens could be achieved using the following: 100 μl of urine plated onto blood (blood agar plate [BAP]), colistin-nalidixic acid (CNA), and MacConkey agars in 5% CO2 for 48 h. This streamlined EQUC protocol achieved 84% uropathogen detection relative to 33% detection by standard urine culture. The streamlined EQUC protocol improves detection of uropathogens that are likely relevant for symptomatic women, giving clinicians the opportunity to receive additional information not currently reported using standard urine culture techniques.

Snoring during pregnancy and delivery outcomes: a cohort study.

STUDY OBJECTIVE This cohort study examined the impact of maternal snoring on key delivery outcomes such as mode of delivery, infant birth centile, and small-for-gestational age. DESIGN Cohort study. SETTING A large tertiary medical center. PATIENTS OR PARTICIPANTS Pregnant women in their third trimester were recruited between March 2007 and December 2010. MEASUREMENTS AND RESULTS Women were screened for habitual snoring, as a known marker for sleep disordered breathing. Outcome data were obtained from medical records following delivery and birth centiles were calculated. Of 1,673 women, a total of 35% reported habitual snoring (26% with pregnancy-onset snoring and 9% with chronic snoring). After adjusting for confounders, chronic snoring was associated with small-forgestational age (OR 1.65, 95%CI 1.02-2.66, P = 0.041) and elective cesarean delivery (OR 2.25, 95%CI 1.22-4.18, P = 0.008). Pregnancy-onset snoring was associated with emergency cesarean delivery (OR 1.68, 95%CI 1.22-2.30, P = 0.001). CONCLUSION Maternal snoring during pregnancy is a risk factor for adverse delivery outcomes including cesarean delivery and small-for-gestational age. Screening pregnant women for symptoms of SDB may provide an early opportunity to identify women at risk of poor delivery outcomes. CLINICAL TRIALS REGISTRATION IDENTIFIER: NCT01030003.

Fecal Incontinence in Older Women: Are Levator Ani Defects a Factor?

OBJECTIVE We sought to compare pelvic floor structure and function between older women with and without fecal incontinence (FI) and young continent (YC) women. STUDY DESIGN YC (n=9) and older continent (OC) (n=9) women were compared to older women with FI (older incontinent [OI]) (n=8). Patients underwent a pelvic organ prolapse quantification, measurement of levator ani (LA) force at rest and with maximum contraction, and magnetic resonance imaging. Displacement of structures and LA defects were determined on dynamic magnetic resonance imaging. RESULTS LA defects were more common in the OI vs the YC (75% vs 11%, P=.01) and OC (22%, P=.14) groups; women with FI were more likely to have LA defects than women without (odds ratio, 14.0, 95% confidence interval, 1.8-106.5). OI women generated 27.0% and 30.1% less force during maximum contraction vs the OC (P=.13) and YC (P=.04) groups. During Kegel, OI absolute structural displacements were smaller than in the OC group (P=.01). CONCLUSION OI women commonly have LA defects, and cannot augment pelvic floor strength.

Fecal incontinence in pregnancy and post partum

To assess the prevalence of fecal incontinence (FI) during pregnancy and post partum, and to determine any associations with demographic and birth variables.

Intravascular histiocytosis presenting with extensive vulvar necrosis

Intravascular histiocytosis (IVH) is a rare reactive cutaneous lesion of unknown pathogenesis. Most cases are reported in association with rheumatoid arthritis, and cutaneous eruptions typically occur near swollen joints. The skin changes have included erythematous and violaceous macules, papules, plaques and indurated patches with a livedo‐like pattern of erythema. We report the first case of IVH presenting with florid vulvar necrosis in an 87‐year‐old patient without a history of rheumatoid arthritis. Physical examination revealed an edematous, exudative and diffusely necrotic vulva with erythema surrounding the areas of necrosis, extending out to the thighs. The debrided skin revealed an extensively necrotic epidermis and multiple clusters of markedly dilated blood vessels within the dermis. These vessels contained fibrin thrombi admixed with numerous CD68+ and CD163+ histiocytes. Her skin changes improved significantly after surgical debridement and treatment with antibiotics. Interestingly, our patient was also found to have a lupus anticoagulant with elevated anticardiolipin antibodies. This is the first report of IVH possibly related to a thrombogenic diathesis associated with a hypercoagulable state. A diagnosis of IVH is important and may necessitate further clinical evaluation to exclude the possibility of co‐existent systemic disease.

Levator defects affect perineal position independently of prolapse status

OBJECTIVE The purpose of this study was to determine the effect of levator defects on perineal position and movement irrespective of prolapse status. STUDY DESIGN Forty women from an ongoing study were divided into 2 groups of 20 women with and without severe levator defects. Prolapse status was matched between groups, with 50% of the women having stage III or greater anterior wall prolapse. Perineal structure locations were measured against standard axes on magnetic resonance scans at rest, maximum contraction (Kegel), and maximum Valsalva maneuver. Differences in location were calculated and compared. RESULTS In women with levator defects, independently of prolapse status: (1) At rest, the perineal body was 1.3 cm, and the anal sphincter was 1.0 cm more caudal (P ≤ .01); at maximum contraction, the perineal body and the anal sphincter were both 1.2 cm more caudal (P ≤ .01); with maximum Valsalva maneuver, the perineal body was 1.3 cm more caudal, and the anal sphincter was 1.2 cm more caudal (P ≤ .01). (2) At rest, the levator hiatus was 0.8 cm larger, and the urogenital hiatus was 1.0 cm larger (P ≤ .01). (3) At rest, the bladder was 0.07 cm more posterior (P ≤ .02); with maximum contraction, it was 1.9 cm lower (P ≤ .02). (4) With maximum Valsalva maneuver, the bladder was 1.5 cm lower and displaced further caudally (P ≤ .03). CONCLUSION When we controlled for prolapse, the women with levator defects had a more caudal location of their perineal structures and larger hiatuses at rest, maximum contraction, and maximum Valsalva maneuver.

Racial differences in bother for women with urinary incontinence in the Establishing the Prevalence of Incontinence (EPI) study

OBJECTIVE The purpose of this study was to compare differences in degree of bother in black and white women with urinary incontinence (UI). STUDY DESIGN A population-based study was conducted in black and white women in Michigan. Participants completed an interview and the Incontinence Impact Questionnaire short form (IIQ-7). Statistical analysis included 2-way analysis of variance for post hoc comparisons of IIQ-7 scores between races at different frequencies, amounts, and types of UI. RESULTS Black women with moderate UI had significantly higher IIQ-7 scores than white women (31.4 +/- 3.5 vs 23.7 +/- 1.9; P = .03). Overall, black women with urge incontinence had higher scores than white women (30.5 +/- 4.0 vs 21.0 +/- 3.0; P = .05). After adjustment for severity, black women with urge and mixed incontinence tended to be more bothered (P = .06). CONCLUSION With moderate UI (not mild or severe), black women are more bothered than white women. At this discriminatory level of UI severity, racial differences are important, because they may dictate care-seeking behavior.

IL22 Regulates Human Urothelial Cell Sensory and Innate Functions through Modulation of the Acetylcholine Response, Immunoregulatory Cytokines and Antimicrobial Peptides: Assessment of an In Vitro Model

Human urinary disorders are generally studied in rodent models due to limitations of functional in vitro culture models of primary human urothelial cells (HUCs). Current HUC culture models are often derived from immortalized cancer cell lines, which likely have functional characteristics differ from healthy human urothelium. Here, we described a simple explant culture technique to generate HUCs and assessed their in vitro functions. Using transmission electron microscopy, we assessed morphology and heterogeneity of the generated HUCs and characterized their intercellular membrane structural proteins relative to ex vivo urothelium tissue. We demonstrated that our cultured HUCs are free of fibroblasts. They are also heterogeneous, containing cells characteristic of both immature basal cells and mature superficial urothelial cells. The cultured HUCs expressed muscarinic receptors (MR1 and MR2), carnitine acetyltransferase (CarAT), immunoregulatory cytokines IL7, IL15, and IL23, as well as the chemokine CCL20. HUCs also expressed epithelial cell-specific molecules essential for forming intercellular structures that maintain the functional capacity to form the physiological barrier of the human bladder urothelium. A subset of HUCs, identified by the high expression of CD44, expressed the Toll-like receptor 4 (TLR4) along with its co-receptor CD14. We demonstrated that HUCs express, at the mRNA level, both forms of the IL22 receptor, the membrane-associated (IL22RA1) and the secreted soluble (IL22RA2) forms; in turn, IL22 inhibited expression of MR1 and induced expression of CarAT and two antimicrobial peptides (S100A9 and lipocalin-2). While the cellular sources of IL22 have yet to be identified, the HUC cytokine and chemokine profiles support the concept that IL22-producing cells are present in the human bladder mucosa tissue and that IL22 plays a regulatory role in HUC functions. Thus, the described explant technique is clearly capable of generating functional HUCs suitable for the study of human urinary tract disorders, including interactions between urothelium and IL22-producing cells.

Anterior vaginal wall prolapse: assessment and treatment.

Assessment and management of anterior vaginal wall defects presents a unique surgical challenge. It is often the most common site of initial prolapse in women and the most common site of recurrence. This chapter discusses the anatomy, evaluation, and surgical approach to the treatment of anterior vaginal wall defects. We also review outcomes of various surgical approaches and discuss why the anterior vaginal wall presents such a challenge.