Shadi Rezai

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.

Essure Microinsert Abdominal Migration after Hysteroscopic Tubal Sterilization of an Appropriately Placed Essure Device: Dual Case Reports and Review of the Literature

Background. The Essure device is a method of permanent sterilization widely used in the US that has proven to be safe and effective in most cases. However, there have been reports of device migration that have led to failed tubal occlusion as well as several other serious complications resulting from the presence of the device in the abdominal cavity. Case. This paper represents two cases of failed tubal occlusion by an appropriately placed Essure device without signs or symptoms of further complications related to device migration. Conclusion. Although there have only been 13 reported cases of abdominal device migration since November 2014, this case indicates that the actual number may be higher than reported since it is possible for migration to occur without additional complications. In the majority of reported cases of abdominal migration a major complication requiring surgical correction occurred, such as adhesions, small bowel obstruction, bowel perforation, or persistent pelvic pain. To avoid these complications it is recommended that migrating implants be removed; however, this case also represents an example of when a migrating device may remain in situ in an asymptomatic patient.

Didelphys Uterus: A Case Report and Review of the Literature.

Background. Mullerian duct anomalies (MDAs) are congenital defects of the female genital system that arise from abnormal embryological development of the Mullerian ducts. A didelphys uterus, also known as a “double uterus,” is one of the least common amongst MDAs. This report discusses a case of didelphys uterus that successfully conceived, carried her pregnancy to term, and delivered vaginally without any significant complications. Case. Patient is a 29-year-old G2P0010 from Bangladesh, initially came a year prior in her first pregnancy, with spontaneous abortion (SAB). Pelvic Sonogram at that time showed a diagnosis of bicornuate versus didelphys uterus. There were no renal anomalies on subsequent abdominal CT scan. Patient presented with the second pregnancy and had uncomplicated prenatal care and did not have signs of preterm labor; fetus showed appropriate growth and the pregnancy was carried in the left uterus. Patient presented at 38 4/7 wks with Premature Rupture of Membrane and underwent induction of labor with Cytotec. Antibiotics were started for chorioamnionitis. Patient had a vaginal delivery with left mediolateral episiotomy and complete tear of vaginal septum. Third stage of labor was complicated with retained placenta, which was removed manually in the operating room with total EBL of 600 cc.

Spontaneous Heterotopic Pregnancy: Dual Case Report and Review of Literature.

Introduction. Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required. Case. This paper represents two cases of heterotopic pregnancies as well as a literature review. Conclusion. Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome.

Human amniotic fluid: a source of stem cells for possible therapeutic use

TO THE EDITORS: The review by Dziadosz et al 1 brings a very relevant immunological discussion to the forefront of obstetrics. The authors describe the limitless clinical advantages of amniotic fluid’s versatile stem cell population. With this in mind, we would like to further the discussion by providing an update on amniotic stem cell use in therapy for individuals affected by type 1 diabetes therapy. Numerous in vitro studies are exploring the possibility of differentiating amniotic epithelial cells into insulin-producing cells in vivo. The use of a stem cell source that is virtually unlimited would be groundbreaking for a disease that has long been considered incurable. Ar ecent study by Okere et al 2 has shown that 3-dimensional spheroids formed by human amniotic epithelial cells can be differentiated into insulin-producing cells in vitro. Moreover, this study determined that the immunogenicity of human amniotic epithelial cells was not altered during differentiation. 2 This is especially important when considering the relevance of a cell’ si mmunogenic profile during transplantation. Although this cell-based therapy is in its early stages of development, conducted research on modifiable transcription factors is quite promising. The transcription factor at the forefront of this in vitro pancreatic induction is pancreatic duodenal homeobox-1 (PDX1), which is essential for the differentiation of human amniotic stem cells into endocrine pancreatic cells. 3 Amniotic stem cells are known to express large amounts of PDX1, which makes them an ideal target for cell-based therapy. The importance of targeting PDX1 is its connection to both pancreatic islet cell and ductal cell development as well as its ability to direct cells into differentiation rather than proliferation. 3

Treatment for and Clinical Characteristics of Granulomatous Mastitis.

There are no randomized controlled trials demonstrating efficacy of any treatment modalities (glucocorticoids, antibiotics, or surgical interventions) in treatment of idiopathic granulomatous mastitis. Sheybani et al report their experience with oral corticosteroids and methotrexate. They should be congratulated on comprehensive reporting of their treatment outcomes. Although they achieved very excellent treatment outcomes, there are many important points that should be clarified. The authors report a low recurrence rate of three (13.6%) patients after steroid cessation. In our clinic, we treated nine patients with idiopathic granulomatous mastitis (age range 21–39 years) with initial steroid therapy (1 mg/kg for 3 weeks and tapered in 2 months). All patients had recurrence after steroid tapering within 3 months, except one patient who got pregnant and recovered spontaneously. The tuberculin skin test is not a reliable marker to make a differential diagnosis between idiopathic granulomatous mastitis and tuberculosis mastitis in moderate or high tuberculosis endemic countries. The authors state that almost all patients received previous antibiotic therapy with several antibiotics, but they did not clarify details of treatment at presampling time. Antibiotics and duration of treatment are very important before Gram staining and routine culture evaluation in idiopathic granulomatous mastitis. Although the role of Corynebacterium species in the pathogenesis of idiopathic granulomatous mastitis has not been clearly confirmed, remarkable supporting evidence has been reported by Taylor et al. Also, we treated two patients with idiopathic granulomatous mastitis (confirmed with presence of granuloma) with teicoplanin and doxycycline after revealed Corynebacterium species from their mammarian abscesses after a 2-week antibioticfree period with full recovery. All of our patients had received several antibiotics before presentation to the clinic. Therefore, we conclude that screening for Corynebacterium species is important before making a diagnosis of idiopathic granulomatous mastitis and starting steroid therapy.

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.

Amniotic Band Syndrome, Perinatal Hospice, and Palliative Care versus Active Management

Introduction. Amniotic band syndrome and sequence are a relatively rare condition in which congenital anomalies occur as a result of the adherence and entrapment of fetal parts with coarse fibrous bands of the amniotic membrane. A large percentage of reported cases have an atypical gestational history. The frequency of this obstetric complication is not affected by fetal gender, genetic abnormality, or prenatal infection. Case. A 21-year-old, G1P0 female parturient at 18 weeks and 5 days with a single intrauterine gestation during a routine ultrasound evaluation was noted to have amniotic band sequence. The pregnancy was subsequently complicated by preterm premature rupture of membranes with oligohydramnios, resulting in a surviving neonate scheduled for rehabilitative treatment. Conclusion. Amniotic band syndrome is an uncommon congenital anomaly resulting in multiple disfiguring and disabling manifestations. Several theories are proposed with most involving early rupture of the amnion and entanglement of fetal parts by amniotic bands. This syndrome can be manifested by development of multiple malformations, with the majority of the defects being limb abnormalities of a disorganized nature, as in the case we present. In the absence of a clear etiology of consequential congenital abnormalities, obstetric management guidelines should use shared decision models to focus on the quality of life for the offspring.

Essure Surgical Removal and Subsequent Resolution of Chronic Pelvic Pain: A Case Report and Review of the Literature

Background. Hysteroscopic tubal sterilization (Essure) is a minimally invasive option for permanent contraception with high reported rates of patient satisfaction. A small percentage of these women subsequently choose to have the tubal inserts removed due to regret or perceived side effects such as late-onset pelvic pain secondary to placement of the Essure device. Case. A twenty-nine-year-old woman G4P4014 presented with a two-year complaint of chronic pelvic pain and dyspareunia after the hysteroscopic placement of an Essure device for sterilization. On reviewing the images of the HSG, it was noted that although tubal occlusion was confirmed, the left Essure coil appeared curved on itself in an elliptical fashion and did not seem to follow the expected anatomic trajectory of the fallopian tube. The patient reported resolution of chronic pelvic pain following laparoscopic removal of Essure device. Conclusion. A misplaced Essure device should be considered in the differential diagnosis of chronic pelvic pain in women who had difficult placement of the device. In addition to demonstrating tubal occlusion, careful examination of the configuration of the Essure microinserts on HSG examination provides valuable information in patients with pelvic pain after Essure placement.

Effect of an Exercise Intervention on Gestational Diabetes Mellitus: A Randomized Controlled Trial.

Nobles et al’s recently published study investigates the premise that antepartum exercise benefits women at high risk for gestational diabetes mellitus as well as their unborn babies. Their pursuit at exploring the implications across a diverse population is commendable; however, there were minor weaknesses in execution. The exclusion of participants capable of reading at a sixth-grade level limits the application of the authors’ findings to many women in the targeted at-risk population. Although the majority of pregnant women in our institution are at increased risk for developing gestational diabetes mellitus as a result of their obesity or minority group status, many have limited English language proficiency. Informing participants with appropriate materials in their native language would include a more representative participant population. Also, ethnic categorical data are potentially skewed by classifying participants as either Hispanic or non-Hispanic, which groups higher risk minorities of Asian, Native American, and African American participants with lower risk Caucasian participants. Data validity also comes into question, because interventional group participants may misleadingly claim compliance in mailed questionnaires only for reimbursement of gift cards for their time. A potential solution would be to use remotely monitored digital pedometers in interventional group participants. Also, it would be imperative to expand interventional group data to compare results across all races. Despite the article’s focus on gestational diabetes mellitus, it would also be compelling to explore other potential benefits of prenatal exercise, including improved mood and self-esteem. Although the researchers reported no statistically significant difference between study groups, their undertaking to explore a relevant, yet complex disease association deserves merit.