Luis R. Hoyos

Fragile X premutation in women: recognizing the health challenges beyond primary ovarian insufficiency

Fragile X premutation carriers have 55–200 CGG repeats in the 5’ untranslated region of the FMR1 gene. Women with this premutation face many physical and emotional challenges in their life. Approximately 20% of these women will develop fragile X-associated primary ovarian insufficiency (FXPOI). In addition, they suffer from increased rates of menstrual dysfunction, diminished ovarian reserve, reduction in age of menopause, infertility, dizygotic twinning, and risk of having an offspring with a premutation or full mutation. Consequent chronic hypoestrogenism may result in impaired bone health and increased cardiovascular risk. Neuropsychiatric issues include risk of developing fragile X-associated tremor/ataxia syndrome, neuropathy, musculoskeletal problems, increased prevalence of anxiety, depression, and sleep disturbances independent of the stress of raising an offspring with fragile X syndrome and higher risk of postpartum depression. Some studies have reported a higher prevalence of thyroid abnormalities and hypertension in these women. Reproductive health providers play an important role in the health supervision of women with fragile X premutation. Awareness of these risks and correlation of the various manifestations could help in early diagnosis and coordination of care and services for these women and their families. This paper reviews current evidence regarding the possible conditions that may present in women with premutation-sized repeats beyond FXPOI.

Labor and neonatal outcomes after term induction of labor in gestational diabetes.

Objective:To identify the optimal gestational age (GA) for induction of labor (IOL) at term among patients with gestational diabetes (GDMA) according to perinatal outcomes.Study Design:The US Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were singleton delivery, IOL at 37 to 42 weeks and GDMA. Exclusion criteria included congenital anomalies, pre-gestational diabetes, hypertensive disorders, previous cesarean, breech presentation and rupture of membranes. Controls were non-GDMA cases delivered in geographic and temporal proximity. Delivery mode, macrosomia and perinatal complications were analyzed. Logistic regression adjusted for confounders was used to calculate odds ratios by GA using 39 weeks non-GDMA as reference.Results:In all, 96 964 cases and 176 079 controls were included. Increased risk for all adverse outcomes among GDMA cases was found. The nadir for intrapartum and neonatal complications was 38 and 40 weeks, respectively, whereas for cesarean and macrosomia was 39 weeks.Conclusion:The optimal timing for IOL at term in GDMA appears to be 39 to 40 weeks.

Intrapartum mean platelet volume is not a useful predictor of new‐onset delayed postpartum pre‐eclampsia

To determine whether intrapartum mean platelet volume (MPV) can predict new‐onset delayed postpartum pre‐eclampsia.

Endometriosis and Imaging

Endometriosis is a condition with variable location, size, and lesion composition which poses a diagnostic imaging challenge for the practicing gynecologist. Transvaginal ultrasound and magnetic resonance imaging are the most frequent imaging techniques used for its evaluation, but transvaginal ultrasound should be the first-line approach, as it is often sufficient, followed by modified ultrasound techniques. Magnetic resonance imaging should be considered when a diagnosis has not been achieved by sonographic means or when the renal system needs to be concurrently evaluated. Computed tomography has no role in the routine evaluation of endometriosis except in very few particular scenarios.

Imaging in Endometriosis and Adenomyosis.

Endometriosis and adenomyosis may be accurately diagnosed using ultrasound (US). Several findings are characteristic and various US modalities have been described. Recent development of 3-dimensional transvaginal US has resulted in a major advance in the evaluation of adenomyosis. Endometriotic manifestations can also be accurately evaluated with US, which is and should remain the first-line approach for the evaluation of these conditions. Obvious advantages over magnetic resonance imaging include its wide-availability, tolerability, less time-consumption, more accessible price and familiarity of gynecologists with its use. This technology’s full potential can be achieved using 3-dimensional imaging and/or modified techniques according to the particular clinical scenario.

Differences in clinical presentation and pregnancy outcomes in antepartum preeclampsia and new-onset postpartum preeclampsia: Are these the same disorder?

Objective New-onset postpartum preeclampsia is a poorly defined condition that accounts for a significant percentage of eclampsia cases. It is unclear whether new-onset postpartum preeclampsia is a different disorder from or belongs to the same spectrum of classic antepartum preeclampsia. The objective of this study was to compare the clinical presentation and pregnancy outcomes of antepartum preeclampsia and new-onset postpartum preeclampsia. Methods A retrospective study including 92 patients with antepartum preeclampsia and 92 patients with new-onset postpartum preeclampsia was performed. Clinical presentation and pregnancy outcomes were compared. Chi-square test was used to analyze categorical variables, and independent t-test and Mann-Whitney U-test for numerical variables. P-values of <0.05 were used to indicate statistical signifi cance. Results Patients with antepartum preeclampsia and new-onset postpartum preeclampsia differ significantly in profile, symptoms at presentation, laboratory markers and pregnancy outcomes. Conclusion New-onset postpartum preeclampsia has a distinct patient profile and clinical presentation than antepartum preeclampsia, suggesting they may represent different disorders. Characterization of a patient profile with increased risk of developing this condition will help clinicians to identify patients at risk and provide early and targeted interventions to decrease the morbidity associated with this condition.

Optimal Timing for Term Delivery of Twin Pregnancies: A Population-Based Study

OBJECTIVE The objective of this study was to examine the risk of adverse neonatal outcomes after twin delivery according to gestational age. MATERIALS AND METHODS The U.S. Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were twin deliveries and gestational age of 37 to 42 weeks. Exclusion criteria were congenital anomalies and missing/incomplete data. Cases were subdivided by gestational age into early term, term, and late term. Singleton pregnancies matched by delivery time and location were selected as controls. Outcome variables included were low Apgar score, assisted ventilation, neonatal intensive care unit admission, surfactant/antibiotic use, seizures, and birth injury. Logistic regression analysis was used to calculate adjusted odds ratios according to gestational age and plurality, using singleton term as reference. RESULTS A total of 220,169 twin and 270,540 singleton deliveries were identified. The risk of adverse neonatal outcomes for twins was higher than for singletons. For twins, the distribution of the risks of the composite of adverse neonatal outcomes was linear, being the lowest at early term and the highest at late term, whereas the distribution for singletons was u-shaped being lowest at term compared with early and late term. CONCLUSIONS Twins are at higher risk of suboptimal neonatal outcomes than singletons, but do better when delivered at early term rather than term or late term.

Pregnancy following hysteroscopic sterilization at an Urban Abortion Clinic- A case series: Are We looking in the wrong places?

OBJECTIVE Hysteroscopic sterilization (HS) has become one of the most common permanent contraception methods in the U.S. However, recent evidence suggests that the failure rate may be higher than previously reported. We describe women with a history of HS presenting for abortion at a 3-site urban abortion clinic. STUDY DESIGN Retrospective case series of patients with previous HS who presented to a 3-site urban abortion clinic for pregnancy termination from October 2012 to February 2015. RESULTS In 28months, 9 patients with prior HS had failure of the method and then an abortion. CONCLUSIONS This study identifies a number of failures from a setting previously unaccounted. It suggests that perhaps the failure rate is higher than previously reported. The cases here presented, from a 3-site urban abortion clinic over 28months, almost match and sometimes surpass the number of failures reported in multicenter case series in the literature. Surveys of other abortion clinics in the U.S. and elsewhere might also discover other patients whose HS had failed. IMPLICATIONS We identified a number of hysteroscopic sterilization failures at termination of pregnancy at a 3-site urban abortion clinic. We hypothesize that the HS failure rate underestimates the true method failure because previous analysis have excluded cases such as these.

Outcomes in subsequent pregnancies after wedge resection for interstitial ectopic pregnancy: a retrospective cohort study

Abstract Objective: The objective of this study is to evaluate pregnancy outcomes in patients with a history of wedge resection for interstitial ectopic pregnancy (WRIEP). Methods: Retrospective cohort study of pregnancies with a history of WRIEP from 2000 to 2013 at two inner city hospitals in Detroit, MI. Pregnant-matched controls (1:3) were selected and included patients with history of surgically treated tubal ectopic pregnancy and delivered patients without history of ectopic pregnancy. Pregnancy outcomes, including a composite, were compared among the groups. Results: Eighty-three cases of interstitial pregnancy were identified. Sixty-three (75.9%) underwent WRIEP from which 19 (30.2%) had a subsequent pregnancy and 11 (57.9%) carried it ≥20 weeks. No difference in subsequent pregnancy outcomes including the composite was found among patients with prior WRIEP and patients with history of surgically treated tubal ectopic pregnancy except for a longer interpregnancy interval. Compared with delivered patients without a history of ectopic pregnancy, no difference in late obstetric outcomes was found including the composite, gestational age at delivery in weeks (38.2 versus 38.1, p = .955), preterm delivery rate (30% versus 21%, p = .674), and proportion of term vaginal (40% versus 52%, p = .721) or cesarean deliveries (60% versus 30%, p = .137). The most common indication for cesarean among patients with a history of WRIEP was a history of such (5/6, 83.3%) and there were no cases of abnormal placentation. Conclusion: Findings suggest that a history of WRIEP is not associated with increased risk of adverse pregnancy outcomes.

Does Morbid Obesity Influence the Outcome of Ectopic Pregnancy When Treated With Single-Dose Regimen Methotrexate? [11G]

INTRODUCTION: Our goal was to determine whether morbid obesity influenced the outcome of tubal ectopic pregnancy when treated with single-dose regimen methotrexate capped at 100 mg. METHODS: 150 of 573 patients who underwent methotrexate (MTX) treatment for ectopic pregnancy between January 2000 to December 2013 were analyzed. Patients in whom their BMI was not recorded, those with a non-tubal ectopic pregnancy, heterotopic pregnancy, twin ectopic pregnancy and pregnancy of unknown location, lack of Bhcg follow up, initial Bhcg <1,000 and patients that received multiple-dose regimen were excluded. A single-dose MTX regimen was administered as per hospital protocol at a dose of 50 mg/m2 with the maximum dose capped at 100 mg. Patients not morbidly obese (BMI<40, n=134) were compared to those that were (BMI≥40, n=16). Demographic variables, Bhcg levels before MTX treatment, presence of embryonic heart tones, decrease of Bhcg ≥80% following treatment, need for ≥2 doses of MTX and need for surgery despite treatment were compared. RESULTS: Following treatment with MTX, patients with at least an 80% decrease in their Bhcg levels or need for surgery were similar, however, morbidly obese patients were significantly more likely to require an additional dose of MTX. CONCLUSION: When a single-dose MTX regimen capped at 100 mg is used for medical treatment of tubal ectopic pregnancy, morbidly obese patients are more likely to require an additional dose compared to their non-morbidly obese counterparts to achieve complete resolution. A larger and well powered study will be required to confirm our results.