Pregnancy outcomes of women with cardiac disease.

OBJECTIVE: To determine and predict the maternal and neonatal outcomes of pregnancies occurring in patients with cardiac disease. METHOD: This retrospective review included 147 pregnancies identified from antenatal, delivery, and nursery records. Information concerning the nature and severity of the pre-existing cardiac disease, comorbidities, risk scores, obstetric or cardiac complications, and pregnancy outcomes were collected. The data were analyzed using SPSS Windows version 22. RESULTS: In all, 111 (73.5%) of the cohort had acquired heart disease and 4 (2.7%) of patients belonged to WHO class IV, in which pregnancy is not recommended. Additionally, 12 (8.1%) were categorized as being at significant risk of having a cardiac complication. The proportion of patients that had maternal and perinatal mortality was 6 (4.0%) and 7 (4.8%), respectively. The WHO and CARPREG scoring systems were reliably able to predict cardiac events (P < 0.01). Mothers who received preconception counseling had significantly fewer occurrences of cardiac and obstetric events than those who did not. CONCLUSION: Cardiac disease in pregnancy in women managed at our center was most often an acquired disease. The baseline risk assessment scores accurately predicted the likelihood of adverse cardiac outcomes.

Maternal morbidity and mortality associated with mode of delivery in sickle cell disease.

This retrospective observational study compared pregnancy outcomes based on mode of delivery in women with homozygous sickle cell disease (HbSS) to women without (HbAA) using delivery records of 48,600 parturients between January 1992 and January 2020. Fisher's exact tests and Mann-Whitney's test were used to analyse variables based on sickle cell status. Vaginal delivery and HbSS were more associated with labour induction/augmentation (AOR = 2.4, (0.7-7.8)), intrapartum complications (AOR = 2.6, (0.5-14)), postpartum haemorrhage (AOR = 2.8 (0.5-15.2)) and postpartum infections (AOR = 9.6 (1.7-54.4)). Caesarean delivery resulted in more postpartum infections in the HbSS group (AOR = 23.6 (0.9-638.4)). Vaginal delivery in HbSS resulted in more intrapartum complications and postpartum haemorrhage but caesarean delivery greatly increased the risk of postpartum infections and hypertensive disorders. Sickle cell disease (SCD) did not confer increased risk of adverse perinatal outcomes regardless of mode of delivery.Impact StatementWhat is already known on this subject? Women with homozygous sickle cell disease (SCD) are at an increased risk of postpartum infections, undergoing caesarean delivery, admission to the neonatal intensive care unit and overall perinatal mortality when compared to women with normal haemoglobin genotype. Comparisons have been made between homozygous SS disease and haemoglobin SC disease revealing higher rates of maternal and foetal morbidity in both groups.What do the results of this study add? Studies comparing maternal and foetal morbidity based on mode of delivery are lacking. To our knowledge, this study is the first examine maternal and perinatal outcomes in women with SCD undergoing vaginal and abdominal delivery compared to women with normal haemoglobin. We found that vaginal delivery in SCD is associated with more postpartum haemorrhage and caesarean delivery was linked to more hypertensive disorders and postpartum infections then compared to women with normal haemoglobin. Converse to other reports, there was no difference in perinatal outcomes based on mode of delivery.What are the implications of these findings for clinical practice and/or further research? Caesarean delivery and SCD greatly increased the risk of postpartum infections and hypertensive disorders but did not confer a higher risk of postpartum haemorrhage. There were more maternal deaths in SCD women who underwent caesarean vs. vaginal delivery and this requires further study to determine the pregestational predictors of adverse outcomes. Women with SCD who achieve a successful primary vaginal delivery may have reduced risk of complications in subsequent pregnancies, possibly comparable to women without the disease.

A single nucleotide polymorphism assay sheds light on the extent and distribution of genetic diversity, population structure and functional basis of key traits in cultivated north American cannabis.

BACKGROUND: The taxonomic classification of Cannabis genus has been delineated through three main types: sativa (tall and less branched plant with long and narrow leaves), indica (short and highly branched plant with broader leaves) and ruderalis (heirloom type with short stature, less branching and small thick leaves). While still under discussion, particularly whether the genus is polytypic or monotypic, this broad classification reflects putative geographical origins of each group and putative chemotype and pharmacologic effect. METHODS: Here we describe a thorough investigation of cannabis accessions using a set of 23 highly informative and polymorphic SNP (Single Nucleotide Polymorphism) markers associated with important traits such as cannabinoid and terpenoid expression as well as fibre and resin production. The assay offers insight into cannabis population structure, phylogenetic relationship, population genetics and correlation to secondary metabolite concentrations. We demonstrate the utility of the assay for rapid, repeatable and cost-efficient genotyping of commercial and industrial cannabis accessions for use in product traceability, breeding programs, regulatory compliance and consumer education. RESULTS: We identified 5 clusters in the sample set, including industrial hemp (K5) and resin hemp, which likely underwent a bottleneck to stabilize cannabidiolic acid (CBDA) accumulation (K2, Type II & III). Tetrahydrocannabinolic acid (THCA) resin (Type I) makes up the other three clusters with terpinolene (K4 - colloquial "sativa" or "Narrow Leaflet Drug" (NLD), myrcene/pinene (K1) and myrcene/limonene/linalool (K3 - colloquial "indica", "Broad Leaflet Drug" (BLD), which also putatively harbour an active version of the cannabichrometic acid Synthase gene (CBCAS). CONCLUSION: The final chemical compositions of cannabis products have key traits related to their genetic identities. Our analyses in the context of the NCBI Cannabis sativa Annotation Release 100 allows for hypothesis testing with regards to secondary metabolite production. Genetic markers related to secondary metabolite production will be important in many sectors of the cannabis marketplace. For example, markers related to THC production will be important for adaptable and compliant large-scale seed production under the new US Domestic Hemp Production Program.

Commonly used botanicals and vitamins and their impact on blood pressure and blood loss in surgical gynaecology patients.

We wanted to determine botanical and vitamin use in surgical gynaecology patients at UHWI and their effects on blood pressure and blood loss. The study was prospective and observational. Before elective surgery, we evaluated 133 patients on the use of botanicals and vitamins. We measured pre- and intraoperative blood pressure and intraoperative blood loss to determine any association with botanical use. Botanicals were used by 68.4% of patients with a 45.1% use within 2 weeks before surgery, p = 0.002). Users were older (p = 0.024) and had more chronic illnesses (p = 0.003). They also had higher mean preoperative diastolic blood pressure (p = 0.016) but no statistically significant difference in intraoperative blood pressures. Blood loss was greater with recent use of certain anticoagulant botanicals. We conclude that the use of certain botanicals may increase blood pressure or increase surgical bleeding and patients and doctors should be aware of their risk.

Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis.

OBJECTIVE: To examine the agreement between telephone and office management of vulvovaginal complaints and to assess the accuracy of diagnosis of vulvovaginitis. METHODS: Prospective structured telephone nurse interviews of all patients with vulvovaginal complaints who called the Kaiser Permanente Telephone Call Center were conducted. Patients were appointed to a physician, nurse midwife, or physician's assistant for office evaluation. Both groups (nurses and practitioners) made independent diagnosis and treatment decisions. kappa coefficients were used to evaluate the interexaminer agreement between telephone nurses and practitioners, and practitioners and traditional diagnostic tests. RESULTS: A total of 485 patients underwent telephone interviews, and 253 (52%) completed the study protocol. kappa values showed poor agreement between nurses and practitioners for bacterial vaginosis (0.12), candidiasis (0.22), and trichomoniasis (-0.05). Practitioners failed to accurately diagnose vaginitis when kappa values were analyzed. There was also poor agreement between telephone nurses and practitioners regarding the necessity of an office visit (0.14). CONCLUSION: This prospective study challenges the notion that the telephone is an effective tool to diagnose and treat vulvovaginal complaints. Moreover, given the poor agreement between practitioners' diagnoses and microbiologic and microscopic data, further study into optimal diagnosis of vulvovaginitis is needed.

Assessment of vulvovaginal complaints: agreement between phone and office management.

Objective: To examine the agreement between nursing phone and provider office management of vulvovaginitis.Methods: Patients who called the Kaiser Permanente Phone Call Center with vulvovaginal complaints were evaluated by a registered nurse, who took a standardized history, and made an assessment and plan; additionally, she made a judgment regarding whether she would have treated the patient over the phone. These patients were seen in the office the same day and examined and treated by a clinician following a protocol that included cultures for typical vaginal and cervical pathogens. Providers also made a judgment about phone treatment. Nurses and providers were blinded to each others' diagnosis and therapy. Kappa coefficients were used to evaluate the interexaminer agreement between nurses on the phone and providers in the office with respect to diagnosis and treatment.Results: Four hundred eighty-five patients underwent phone evaluation. Of these, 253 (52%) completed the study protocol and were considered in the final analysis. Kappa values for the diagnosis of trichomoniasis (0.05), bacterial vaginosis (0.12), candidiasis (0.22), chlamydia, herpes simplex, and urinary tract infections (0.05), and "other" (0.05) demonstrated poor agreement between nurses and providers. There was also poor agreement between phone nurses and providers regarding the necessity of an office visit (0.14).Conclusion: This prospective study challenges the notion that the telephone is an effective tool for diagnosing and treating vulvovaginal complaints. Patients with these complaints should be evaluated in the office. Alternatively, programs should be developed and analyzed to educate nurses involved in telephone triage of vulvovaginitis.

Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging in a 15-year-old girl.

STUDY OBJECTIVE: Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging (MRI) in a 15-year-old girl with primary amenorrhea is reported. DESIGN: The presentation, MRI, and the subsequent evaluation and treatment of an adolescent female patient with Rokitansky syndrome are described. Correlation is made with previous clinical, pathologic, and imaging reports in the literature. SETTING: An adolescent girl with primary amenorrhea was referred to our institution for completion of her diagnostic work-up. Previous limited evaluations suggested the presence of anomalies of the genitourinary tract. Further delineation of the suspected congenital defects was necessary. PARTICIPANT: The 15-year-old female patient was evaluated by the gynecology service. Diagnostic radiology and pediatric urology were consulted. INTERVENTIONS: MRI, physical examination under anesthesia, and cystoscopy were performed. After initial nonoperative treatment, the patient underwent hysterectomy and sigmoid vaginoplasty. MAIN OUTCOME MEASURES: The patient's primary amenorrhea was explained. Mayer-Rokitansky-Kuster-Hauser syndrome was diagnosed. Vaginal agenesis and widely separated rudimentary uterine horns were well shown by the MRI. Associated skeletal anomalies were noted. A treatment plan was initiated based on a good understanding of the anatomic defects. RESULTS: The MRI and physical examination firmly established the diagnosis. The patient was counseled and managed conservatively at first. Hysterectomy and vaginoplasty were subsequently performed. CONCLUSIONS: Mayer-Rokitansky-Kuster-Hauser syndrome is an unusual müllerian-duct anomaly that is a cause of primary amenorrhea. It can be confidently and noninvasively diagnosed with MRI. The MRI demonstration of vaginal, cervical, and uterine morphology contributes significantly to treatment planning and patient management.

Cavernous lymphangioma presenting as a vaginal discharge in a six-year-old female: a case report.

STUDY OBJECTIVE: This case report is written to describe a new and unusual presentation of retroperitoneal cavernous lymphangioma. INTERVENTIONS: A large cystic abdominal mass was discovered during an examination under anesthesia to evaluate a vaginal discharge in a 6-year-old girl. The mass was diagnosed by computed tomography (CT) and removed via laparotomy with argon beam coagulation of smaller cystic lesions. RESULTS: Six months postoperatively, the patient had a negligible amount of vaginal discharge. CONCLUSIONS: Cavernous lymphangioma should be considered as a rare cause of vaginal discharge in young females.

Assessing the acceptability of Norplant contraceptive in four patient populations.

The object of this study was to review the experience of Norplant implants insertion at the University of Colorado Health Sciences Center with specific attention to the potential impact of source of care and/or clinic site of of insertion. Norplant implants were inserted at four different office sites, namely, adolescent-teen, resident, certified nurse midwife, and faculty physician. The charts of all patients who had Norplant implants inserted between April 1991 and September 1992 were reviewed and we attempted to contact each patient by telephone to assess clinical course and acceptability of Norplant contraceptive. We were able to contact 254 of 414 women (61%) who had Norplant implants inserted. The average length of time since Norplant implants insertion was 13.2 months. The only significant demographic difference between groups was that the adolescent-teen patients were younger, of lower parity, less educated, and were more likely to be single than the other three groups. The overall removal proportion was 14.6%, and removal proportions were not significantly different between any of the four groups. The primary reason for removal was unacceptable bleeding (32% of removers). Only 59% of patients returned for follow-up care. Faculty physician patients were significantly more compliant with follow-up compared to adolescent-teen and resident patients (p < 0.01). Patient retention of Norplant contraceptive is unrelated to age or the clinic setting in which the device was inserted. Since similar side effects are experienced by retainers and removers, it is unclear what other factors prompt women to seek removal. Particularly in the teen and resident groups, follow-up is poor.

PIP: To refine understanding of the acceptability of Norplant in the US on the basis of different target populations and sources of care, the experiences of four groups of clients who had the implants inserted at University of Colorado Health Sciences Center between April 1991 and September 1992 and could be reached for a postinsertion telephone interview were compared. The 254 women interviewed (61% of total acceptors over this period) were drawn from four clinics: adolescent, resident, certified nurse midwife, and faculty physician. The average length of time since insertion was 13.2 months. As expected, adolescent patients were significantly more likely to be younger, single, less educated, and of lower parity than women in the three other groups. The overall removal rate was 14.6%, with no significant difference among groups or in terms of factors such as age, race, or socioeconomic status; the mean time to removal was 10.2 months. The most common reason for removal (32%) was unacceptable bleeding; however, abnormal bleeding was not significantly associated with the decision to discontinue the method. Weight gain and headache were the only side effects reported significantly more frequently by removers than retainers. Only 150 (59%) women returned for a scheduled postinsertion follow-up visit; compliance was lowest among teens (41%) and highest among patients of faculty (77%). 10 of the 37 women who opted for removal had this procedure performed at another clinic site; this finding suggests that clinic-based studies may underestimate the actual Norplant discontinuation rate.

Which teen mothers choose Norplant?

PURPOSE: The objective of this study was to determine if there are sociodemographic differences between adolescent mothers who choose to use Norplant after delivery and those who do not. We hypothesized that those adolescent mothers who are at highest risk for repeat adolescent pregnancy are least likely to select Norplant as a postpartum contraceptive. METHODS: We prospectively compared the prevalence of epidemiologic risk factors for repeat adolescent pregnancy in a group of 187 consecutively delivered 13-18-year-olds who were enrolled in a comprehensive, multidisciplinary, adolescent-oriented maternity program. The study subjects were interviewed at delivery; 100 subsequently had a Norplant inserted (Norplant users). Student's t-tests and chi-square analyses were used to compare Norplant users and refusers. RESULTS: We found no statistically significant differences between Norplant users and refusers with regard to: age, race, Medicaid, or marital or school status. Compared to Norplant refusers, Norplant users were less likely to be primiparous (79% compared to 90%; p = .04) and more likely to have poor school grades (20% compared to 7%; p = .001). Norplant users were more likely to state that they had had trouble remembering to use contraceptives in the past (32% compared to 14%; p = .005). CONCLUSIONS: These data do not support the study hypothesis and are encouraging because they suggest that Norplant may reduce repeat pregnancy among adolescent parents.

PIP: The hypothesis that those adolescent mothers at greatest risk of a repeat unintended pregnancy are the least likely to select Norplant as a postpartum contraceptive was investigated in a prospective study of 187 consecutively delivered 13-18 year olds enrolled in the Colorado Adolescent Maternity Program. After delivery and prior to hospital discharge, teen mothers participated in a structured interview that collected data on known sociodemographic, psychosocial, pregnancy outcome, and family planning risk factors associated with repeat adolescent pregnancy. There were no statistically significant differences between the 100 postpartum Norplant acceptors and the 87 refusers in terms of age, race, marital status, Medicaid, school enrollment, career goals, social support, or pregnancy and neonatal outcome; however, Norplant users were less likely than refusers to have only one child (79% versus 90%) and more likely to have poor school grades (20% versus 7%). Adolescents who had Norplant inserted after delivery were less likely to express a desire for more children in the next two years than their counterparts who selected other methods. Finally, Norplant acceptors were significantly more likely than refusers to have tried other contraceptive methods (81% versus 63%) and to have experienced problems with other methods (69% versus 46%). 32% of Norplant acceptors compared to only 14% of refusers identified problems remembering to use other methods consistently. Although the teen mothers in this study with a high loading of risk factors for a repeat pregnancy were just as likely to accept Norplant as those considered at lower risk, their participation in a comprehensive adolescent-oriented maternity program may have limited the range of intragroup variability.