Colposcopy in Evaluating Bleeding During the Second and Third Trimesters: Short-Term and Postpartum Implications.

BACKGROUND: The etiology of vaginal bleeding during pregnancy may be obstetric or non-obstetric. Though colposcopy is generally not part of the routine evaluation of 2nd- or 3rd-trimester vaginal bleeding without obvious obstetrical cause, our department does perform colposcopy and cervical cytology testing in these patients. This study assessed the need and possible contribution of colposcopy in diagnosing the etiology of 2nd- and 3rd-trimester bleeding. METHODS: Retrospective analysis of colposcopy findings from 2012-2015 in patients with 2nd- or 3rd-trimester bleeding where an obstetrical cause was not found. Data collected included demographics, obstetric data, bleeding characteristics, colposcopy results, cervical cytology testing, a sonogram directed at the placenta, and birth details. RESULTS: Of the 168 patients who underwent colposcopy, 29 (17.3%) complained of postcoital bleeding (PCB). The following were the colposcopy results: 5 (3%) had abnormal colposcopy findings, 14 (8.3%) ectropion, 4 (2.4%) polyps, and 1 (0.6%) vaginal varices. Postpartum follow-up of women with PCB or pathologic cervical cytology testing diagnosed 1(0.6%) patient with high-grade cervical intraepithelial neoplasia 2-3, human papillomavirus 18 and 45 positive. CONCLUSIONS: Colposcopy diagnosed the origin of bleeding in 24 cases (13.7%). These findings support the use of colposcopy in evaluating vaginal bleeding of undetermined obstetric origin during pregnancy.

Does low peritoneal glucose load protect from the development of left ventricular hypertrophy in peritoneal dialysis patients?

BACKGROUND: Left ventricular hypertrophy (LVH) is a major predictor of the development of cardiovascular events that is considered the main cause of morbidity and mortality in peritoneal dialysis (PD) patients. This study aimed to evaluate retrospectively the impact of low peritoneal glucose load on left ventricular mass (LVM) in PD patients. METHODS: 36 patients who were on continuous ambulatory PD for at least a period of 2 years enrolled in the study. Of them, 23 patients received only glucose-based solutions (GBS) [high peritoneal glucose load group (HPGL group)] from the start of PD, and 13 patients received AAS in combination with GBS when their serum albumin decreased to levels <3.5 g/dl [low peritoneal glucose load group (LPGL group)]. AAS was substituted with 1.36 % GBS when serum albumin rose to ≥3.5 g/dl and restarted when serum albumin fell to <3.5 g/dl. Medical history, physical findings, echocardiographic, laboratory and hydration status data from the first month of PD and after 24 months, were obtained from each patient's medical records. RESULTS: Mean LVM index (LVMI) increased in both groups (p ≤ 0.010). The increment in mean LVMI was higher in HPGL group compared to LPGL group (p = 0.006). At 24 months: peritoneal glucose load index (PGLI), fluid overload, mean arterial pressure (MAP), HbA1c and hsCRP were higher in HPGL group (p ≤ 0.010), while 24 h ultrafiltration, weekly Kt/V, serum albumin levels and RRF were higher in LPGL group (p ≤ 0.025). The increment (Δ between the values of each parameter from the start of PD and after 24 months) in PGLI, fluid overload, MAP, HbA1c and hsCRP values were higher in HPGL group (p < 0.001). CONCLUSIONS: Low peritoneal glucose load may be associated with a protective effect from the development of LVH in PD patients.

The impact of sub-clinical over-hydration on left ventricular mass in peritoneal dialysis patients.

OBJECTIVE: Left ventricular hypertrophy (LVH) represents a major predictor of the development of cardiovascular (CV) complications. Over-hydration (OH) is an important uremic risk factor associated with LVH and increased CV morbidity and mortality in peritoneal dialysis (PD) patients. In the present study we evaluated the prevalence of sub-clinical OH (SCOH) among PD patients and its effects on left ventricular mass (LVM). METHODS: In this cross sectional study hydration status, blood pressure, glucose load, systemic inflammation and LVM were evaluated in 43 clinically stable patients on maintenance PD for 24-76 months. The hydration status was assessed by whole-body bio-impedance spectroscopy (BIS). Peripheral edema and any evidence of pulmonary congestion were considered clinical signs of OH. RESULTS: OH ≥ 1.5 L was detected in 26 (60.5%) of the study participants; the OH in 19 (73.1%) of them was sub-clinical. Only 23.5% (4/17) of patients with OH < 1.5 L had LVH compared to 68.4% (13/19) of those with SCOH ≥ 1.5 L (P = 0.007). Compared to patients with OH < 1.5 L, patients with SCOH ≥ 1.5 L had higher levels of blood pressure, peritoneal glucose load, plasma brain natriuretic peptide, high sensitive C-reactive protein, interleukin-6 and LVMI; and lower levels of serum albumin (P < 0.001). No significant differences were found between patients with clinical OH or SCOH with OH ≥ 1.5 L. CONCLUSIONS: SCOH is highly prevalent among PD patients and may contribute to the development of LVH. Considering the poor prognosis associated with over-hydrated PD patients, periodic assessment of hydration status using accurate BIS is suggested.

The impact of glucose load on left ventricular mass in peritoneal dialysis patients.

BACKGROUND: Cardiovascular (CV) complications are the main cause of morbidity and mortality in peritoneal dialysis (PD) patients. Left ventricular hypertrophy (LVH) is a well-known major CV risk factor. AIM: To evaluate the impact of peritoneal glucose load on left ventricular mass (LVM) in PD patients. METHODS: In this cross sectional study the glucose load and LVM were evaluated in 43 stable patients on maintenance PD for 24 - 78 months. Glucose load was calculated using a unique peritoneal glucose load index (PGLI) referred to g/kg/day glucose given in the daily PD prescription. LVM index (LVMI) was calculated using the Devereux et al. formula. RESULTS: The PGLI was positively correlated with HbA1c and LVMI (p < 0.001). Patients with PGLI > 3 g/kg/day had higher HbA1c and LVMI compared to those with PGLI ≤ 3 g/kg/day (p < 0.001). CONCLUSIONS: Higher PGLI values were associated with worse glycemic control and increased LVMI. Efforts should be made to minimize the PGL. All other risk factors that may contribute to the development of LVH in PD patients should be identified and treated. Additional multicenter, randomized control trials are needed to determine the target objectives of PGLI.

Takotsubo cardiomyopathy associated with peritonitis in peritoneal dialysis patient.

Takotsubo cardiomyopathy (TTC) is characterized by clinical and electrocardiographic features that mimic acute myocardial infarction, normal or mildly elevated cardiac enzymes, distinctive left ventricular wall motion abnormalities, and absence of significant obstructive coronary artery disease. Often there is a history of emotional stress and usually encountered in postmenopausal women. Excessive catecholamine stimulation plays an important role in the pathogenesis of TTC. Usually, this condition is reversible within several weeks to months. Only two cases of TTC were described in patients on hemodialysis. To our knowledge, we report the first case of TTC in peritoneal dialysis and the first case associated with peritonitis.