Isabella Neri

Characteristics of headache at menopause: A clinico-epidemiologic study

The prevalence and characteristics of primary headaches in a large sample of postmenopausal women were investigated. Seventy-six out of 556 women (13.7%) were affected by headache of either the migraine or tension type. In 82% of cases onset had preceded the menopause. The postmenopausal course of headaches with a premenopausal onset differed according to type of headache and type of menopause. Indeed, while migraine improved in almost two-thirds of cases, tension-type headache worsened or did not change in 70% of cases. However, in women who had undergone surgical ovariectomy, the natural course of migraine was worse than in those who had a physiological menopause (P = 0.003). Among the symptoms covered by the Kuppermann Index, only anxiety and insomnia were correlated with headache. The favourable course of migraine in the postmenopausal period can be attributed primarily to the absence of variations in sex hormone levels although psychological factors also seem to play a fundamental role.

Hyperemesis gravidarum complicated by Wernicke encephalopathy: Background, case report, and review of the literature

Wernicke encephalopathy (WE) is a rare but known complication of severe hyperemesis gravidarum caused by thiamine deficiency. This article presents an unusual case that occurred at our institution and reviews the 48 previously published cases of WE in pregnancy. Considering all the 49 cases, the mean (±standard deviation) patients’ age was 26.7 ± 4.9 years, the mean gestational age when WE manifested was 14.3 ± 3.4 weeks, and the mean duration of vomiting and feeding difficulties was 7.7 ± 2.8 weeks. Wernicke’s classic triad (confusion, ocular abnormalities, and ataxia) manifested in only 46.9% (23 of 49) of the patients. Confusion affected 63.3% (31 of 49) of the patients, ocular signs 95.9% (47 of 49) and symptoms 57.1% (28 of 49), and ataxia 81.6% (40 of 49). Deterioration of consciousness affected 53.1% (26 of 49) of the subjects and memory impairment 61.2% (30 of 49). Complete remission of the disease occurred in only 14 of 49 cases. Symptom resolution required months and permanent impairments were common. The overall pregnancy loss rate, directly (spontaneous fetal loss) and indirectly (planned abortion) attributable to WE, was 47.9% (23 of 49). The diagnosis of WE is clinical and can be rapidly confirmed by magnetic resonance imaging. We emphasize the importance of thiamine supplementation to women with prolonged vomiting in pregnancy, especially before intravenous or parenteral nutrition. We also underline the necessity to promptly replace vitamin B1 when neurologic symptoms and/or signs develop in a patient with hyperemesis gravidarum. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to list the signs and symptoms of Wernicke encephalpathy associated with hyperemesis gravidarum, outline the methods to make a clinical diagnosis, and recall the importance of thiamine supplementation in patients with prolonged hyperemesis gravidarum.

L-arginine infusion reduces blood pressure in preeclamptic women through nitric oxide release.

OBJECTIVE This study investigates the biochemical and cardiovascular effects of L-arginine administration in normotensive pregnant women and women with preeclampsia. METHODS The study groups consisted of 12 women with uncomplicated pregnancies and 17 preeclamptic patients, four of whom were on antihypertensive treatment. In both groups, saline infusion was started, followed by 30 g L-arginine administration, and finally more saline. Blood pressure was recorded every 5 minutes and blood samples were collected for measurement of serum citrulline, arginine, and nitrite levels. Amino acid assays were done by using high-performance liquid chromatography with fluorometric detection. RESULTS L-Arginine infusion was associated with a significant reduction of blood pressure in both groups, the decrease being greater in the women with preeclampsia. Baseline serum citrulline and arginine levels were not significantly different between the two groups. L-Citrulline levels were significantly increased during infusion of L-arginine, and the increase was significantly lower in the women with preeclampsia. Serum nitrite levels were increased only in controls and not in preeclampsia patients. The total citrulline production stimulated by L-arginine was related inversely to baseline blood pressure values and was unrelated to clinical parameters such as gestational age at delivery, birth weight, and Apgar score. CONCLUSIONS L-Arginine load in pregnant women is associated with increased nitric oxide (NO) production and hypotension. Despite a reduced ability to produce NO, patients with preeclampsia may benefit from L-arginine supplementation. Overall, these findings partially support the hypothesis that preeclampsia is characterized by a dysfunction of the L-arginine-NO pathway.

Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study

Objective: In many Western countries breech presentation is an indication for elective Cesarean section. In order to correct fetal presentation, the stimulation of the acupoint BL67 by moxibustion, acupuncture or both has been proposed. Since no studies had previously been carried out on Western populations, pregnant Italian women at 33–35 weeks gestational age carrying a fetus in breech presentation were enrolled in a randomized, controlled trial involving an active BL67 point stimulation and an observation group. Methods: A total of 240 women at 33–35 weeks of gestation carrying a fetus in breech presentation were randomized to receive active treatment (acupuncture plus moxibustion) or to be assigned to the observation group. Bilateral acupuncture plus moxibustion was applied at the BL67 acupoint (Zhiyin). The primary outcome of the study was fetal presentation at delivery. Results: Fourteen cases dropped out. The final analysis was thus made on 226 cases, 114 randomized to observation and 112 to acupuncture plus moxibustion. At delivery, the proportion of cephalic version was lower in the observation group (36.7%) than in the active-treatment group (53.6%) (p = 0.01). Hence, the proportion of Cesarean sections indicated for breech presentation was significantly lower in the treatment group than in the observation group (52.3% vs. 66.7%, p = 0.03). Conclusions: Acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech presentation. Such a method appears to be a valid option for women willing to experience a natural birth.

Effects of L-arginine on utero-placental circulation in growth-retarded fetuses

Background To evaluate the effects of L‐arginine (ARG) infusion, the nitric oxide as substrate. on the utero‐placental circulation at third trimester.

The association of menstrual migraine with the premenstrual syndrome

To investigate the comorbidity of premenstrual syndrome (PMS) and menstrual migraine, the Menstrual Distress Questionnaire (MDQ) was prospectively administered for two consecutive menstrual cycles to 22 patients with menstrual migraine, 12 cases with migraine without aura and 15 patients with PMS. MDQ scores varied throughout the menstrual cycle in each patient group, the wider changes being shown by patients with PMS. Fourteen menstrual migraine patients and 4 migraine without aura patients achieved diagnostic criteria for PMS over two menstrual cycles. In these patients MDQ scores did not differ from PMS sufferers at any stage of the menstrual cycle. The premenstrual increase of each cluster of PMS symptoms was identical in menstrual migraine and PMS subjects with the exception of negative affect. We suggest that PMS symptoms should be taken into account in the IHS diagnostic criteria for menstrual migraine.

L-ARGININE INFUSION DECREASES PLATELET AGGREGATION THROUGH AN INTRAPLATELET NITRIC OXIDE RELEASE

Nitric Oxide (NO) inhibits platelet aggregation via activation of an intraplatelet soluble guanylate cyclase which induces an increase in cyclic GMP (1). It has been also demonstrated that platelets contain a constitutive, calcium-dependent, NO synthase which is activated by collagen-induced platelet aggregation. This leads to a NO synthesis from L-Arginine (L-Arg), which in turn increases cyclic GMP and down-regulates platelet aggregation (2). In vitro administration of supraphysiological concentrations of L-Arg enhances platelet cyclic GMP levels by increasing NO production and reduces platelet aggregation. This effect is reversed by pre-incubation with NO-synthase inhibitors (3). These results indicate that the L-Arg: NO pathway plays an important role in the modulation of human platelet aggregation (4). In vivo L-Arg, when administered i.v., induces hypotension (5) and vasodilatation (6,7) in humans, and when orally supplemented reduces platelet aggregability both in hypercholesterolemic rabbits and healthy men (8,9).

Myo-inositol Supplementation for Prevention of Gestational Diabetes in Obese Pregnant Women: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether myo-inositol supplementation, an insulin sensitizer, reduces the rate of gestational diabetes mellitus (GDM) and lowers insulin resistance in obese pregnant women. METHODS: In an open-label, randomized trial, myo-inositol (2 g plus 200 micrograms folic acid twice a day) or placebo (200 micrograms folic acid twice a day) was administered from the first trimester to delivery in pregnant obese women (prepregnancy body mass index 30 or greater. We calculated that 101 women in each arm would be required to demonstrate a 65% GDM reduction in the myo-inositol group with a statistical power of 80% (&agr;=0.05). The primary outcomes were the incidence of GDM and the change in insulin resistance from enrollment until the diagnostic oral glucose tolerance test. RESULTS: From January 2011 to April 2014, 220 pregnant women at 12–13 weeks of gestation were randomized at two Italian university hospitals, 110 to myo-inositol and 110 to placebo. Most characteristics were similar between groups. The GDM rate was significantly reduced in the myo-inositol group compared with the control group, 14.0% compared with 33.6%, respectively (P=.001; odds ratio 0.34, 95% confidence interval 0.17–0.68). Furthermore, women treated with myo-inositol showed a significantly greater reduction in the homeostasis model assessment of insulin resistance compared with the control group, −1.0±3.1 compared with 0.1±1.8 (P=.048). CONCLUSION: Myo-inositol supplementation, started in the first trimester, in obese pregnant women seems to reduce the incidence in GDM through a reduction of insulin resistance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01047982.

Gestational weight gain in overweight and obese women enrolled in a healthy lifestyle and eating habits program

Abstract Objectives: To determine whether changes in lifestyle in women with BMI > 25 could decrease gestational weight gain and unfavorable pregnancy outcomes. Methods: Women with BMI > 25 were randomized at 1st trimester to no intervention or a Therapeutic Lifestyle Changes (TLC) Program including diet (overweight: 1700 kcal/day, obese: 1800 kcal/day) and mild physical activity (30 min/day, 3 times/week). At baseline and at the 36th week women filled-in a Food Frequency Questionnaire. Outcomes: gestational weight gain, gestational diabetes mellitus, gestational hypertension, preterm delivery. Data stratified by BMI categories. Results: Socio-demographic features were similar between groups (TLC: 33 cases, Controls: 28 cases). At term, gestational weight gain in obese women randomized to TLC group was lower (6.7 ± 4.3 kg) versus controls (10.1 ± 5.6 kg, p = 0.047). Gestational diabetes mellitus, gestational hypertension and preterm delivery were also significantly lower. TLC was an independent factor in preventing gestational weight gain, gestational diabetes mellitus, gestational hypertension. Significant changes in eating habits occurred in the TLC group, which increased the number of snacks, the intake of fruits–vegetables and decreased the consumption of sugar. Conclusions: A caloric restriction associated to changes in eating behavior and constant physical activity, is able to reduce gestational weight gain and related pregnancy complications in obese women.

L-Arginine Supplementation in Patients with Gestational Hypertension: A Pilot Study

Objective: To evaluate the effects of L-arginine (L-Arg) supplementation on clinical outcomes and blood pressure (BP) changes in patients with gestational hypertension. Methods: Patients with gestational hypertension and proteinuria (n = 28, >300mg/24 h) and those without proteinuria (n = 46) were randomized in a double-blind design to receive either L-Arg (20g/500 mL intravenously daily, for 5 days followed by 4g/day orally for 2 weeks) or placebo (PL). The primary outcome variable was time from randomization to delivery (Latency). Automated BP readings were obtained every 2 hours, between 8.00 am and 8.00 pm daily, untill the sixth day after treatment. Results: At inclusion, gestational age and proportions of patients with proteinuria did not differ significantly between the PL and L-Arg group. Latency was significantly longer in the L-Arg group compared with the PL group (19.5 ± 16.9 vs. 31.7 ± 25.2 days; p = 0.008). Compared with baseline, both systolic and diastolic BP 6 days after treatment were significantly reduced in the L-Arg group but not in the PL group. The subgroup of patients without proteinuria randomized to the group receiving L-Arg showed a trend to prolong pregnancy, to attenuate the evolution to PE, and to reduce the rate of low birth weight. Conclusions: The treatment with L-Arg seems promising in prolonging pregnancy and reducing blood pressure, particularly in patients with gestational hypertension and without proteinuria. This benefit should be confirmed in larger studies with the power to evaluate the effectiveness of L-Arg in preventing the development to preeclampsia.