Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in pregnancy: a case series of nine patients and review of literature.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by myocardial necrosis and fibrofatty substitution of the myocardium, predominantly of the right ventricle. The evaluation of risk associated with gestation and delivery in patients with ARVC is difficult due to the small number of already reported cases. We present our experience of patients with ARVC who completed a pregnancy and delivery. METHODS: A case series of nine women in Calgary, Canada, from 2013 to 2018, who were diagnosed with ARVC before or during pregnancy. Patients were identified using our Cardiac-Obstetrics database, and information was collected through electronic charts and patient recollection. RESULTS: All pregnancies reported were singleton with an average maternal age of 31 years. Six patients had a related genetic mutation. Beta blockers were being used by eight, and five had an implantable cardioverter-defibrillator (ICD) prior to the pregnancy. None of the patients developed heart failure during pregnancy, but one had a complicated antepartum and postpartum course. All pregnancies delivered at term with eight receiving neuroaxial analgesia. Five patients delivered vaginally. Those without an ICD had continuous cardiac monitoring intrapartum. The incidence of small for gestational age (33%) was higher than the general population. All of the patients breastfed the newborns. CONCLUSIONS: Pregnancies in these patients with ARVC were generally well tolerated. Given the rarity of the disease and absence of any clinical guidelines, multidisciplinary care is essential in the management of these patients.

Botulinum toxin injection for chronic pelvic pain: A systematic review.

INTRODUCTION: Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain. MATERIAL AND METHODS: Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies. RESULTS: In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However, only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported. CONCLUSIONS: Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Can we predict and prevent emergency department visits for postpartum hypertensive complications in patients with hypertensive disorders in pregnancy?

Background: Hypertensive disorders of pregnancy are major causes of maternal mortality and morbidity, and postpartum hypertensive complications have significant implications on maternal health and public health care system. Antepartum community care programs for hypertension are in place at major centers of Canada, however, such a program for postpartum are usually lacking, and could be a cost-effective solution to reduce postpartum hypertensive complications.Objectives: To assess the proportion of women who present to the emergency department (ED) or outpatient clinics for postpartum hypertensive (PPHTN) complications up to 6 weeks postpartum, among pregnancies complicated by antenatal hypertensive disorders in Calgary, Canada. Secondary objectives were to identify risk factors for PPHTN complications, and to perform a cost-benefit analysis to support postpartum community care program (PCCP) as a way to decrease ED and clinic visits for PPHTN complications, and thus has a favorable economic impact on the public health care system.Study design: Retrospective cohort study using administrative databases, followed by chart review of ED visits to confirm diagnoses and estimate cost of visits and admissions. The participants were women followed by the Calgary Antenatal Community Care Program (ACCP) for hypertensive disorders, from 2014 to 2015, inclusive. The primary outcome was ED or clinic visit associated with an outpatient database record of hypertensive disorder diagnosis, within 42 days postpartum.Results: Among 319 deliveries included in the study, 30 women (9.4, 95%CI: 6.2-12.6%) visited ED or clinics for PPHTN. We identified multiple antihypertensive medication uses and abnormal postpartum gestational hypertension labs as risk factors for ED visit among these women. We estimate a CAD$152 per antenatal hypertensive patient cost benefit for PCCP.Conclusion: The proposed PCCP appears to have an economic benefit to health care system with a decrease in ED and clinic visits. Further studies with greater sample size could strengthen the findings in this study.

Prophylactic use of an infrarenal abdominal aorta balloon catheter in pregnancies complicated by placenta accreta.

This study evaluated the surgical and neonatal outcomes of 71 patients diagnosed with placenta accreta before caesarean section with or without placement of a prophylactic abdominal aorta balloon catheter. This study took place at our hospital from January 2013 to May 2015. Thirty patients had a prophylactic balloon catheter inserted (balloon group), and 41 patients did not receive the intervention (control group). The mean estimated blood loss and decrease in haemoglobin after surgery was significantly lower in the balloon group than in the control group. No significant difference was found in duration of operation, transfusion, or percentage requirement of caesarean hysterectomy. The incidence of catheterisation-related complications was 3.3%. One patient had pain in her right leg, caused by an ultrasound-confirmed haematoma in the front wall of the right common femoral artery. No significant difference was found in the rate of surgery-related complications and neonatal outcomes between the groups. Prophylactic placement of an infrarenal abdominal aorta balloon catheter in patients with placenta accreta can effectively reduce intraoperative haemorrhage, without causing any obvious adverse maternal or neonatal outcomes. Impact statement Prophylactic placement of endovascular balloon catheters for controlling intraoperative haemorrhage in women with placenta accreta has been a topic of debate for nearly 2 decades. The most common type of occlusion is internal iliac artery balloon occlusion, only a few studies have focused on intraoperative aortic balloon occlusion This retrospective case-control study included relatively large number of cases and the result shown this technique can effectively reduce intraoperative haemorrhage in patients with placenta accreta, without causing any obvious adverse maternal or neonatal outcomes. It provides another safe and effective method for intraoperative haemorrhage control and even uterine preservation.

[Expression of NKG2A and NKG2C receptors and their ligand HLA-E in decidua of preeclampsia patients].

OBJECTIVE: To investigatethe expressions of NKG2A, NKG2C receptors and their ligand HLA-E in decidua of preeclampsia patients. METHODS: Decidua tissues were collected from 30 patients with mild preeclampsia, 42 patients with severe preeclampsia and 46 normal pregnancy as contrast. The expressions of NKG2A, NKG2C protein were detected by immunohistochemitry and mRNAs of NKG2A, NKG2C and HLA-E genes were detected by RT-PCR. RESULTS: The expression of HLA-E mRNA was significantly decreased in preeclampsia, especially in severe preeclampsia patients (P < 0.05); The mRNA and protein expression of NKG2A, NKG2C in severe preeclampsia group were significantly higher than that in normal pregnancy group (P < 0.05); In the severe preeclampsia group, the ratio of expression level of NKG2A and NKG2C was significantly lower than that of normal group and the mRNA and protein expression of NKG2C receptor were both significantly higher than that of NKG2A (P < 0.05); The mRNA expression level of HLA-E, NKG2A and NKG2C were closely related with clinical and biochemical indexes,such as blood pressure of late pregnancy and 24-hour proteinuria. CONCLUSION: The decreased expression of HLA-E and the unevenly increase of NKG2A and NKG2C may involve in the pathogenesis of preeclampsia.

[Effect of environmental factors on the formation of several typical tetracycline resistance genes in soil].

The extensive use of veterinary tetracycline in the stock husbandry has led to the increasingly serious environmental pollution, the tetracycline resistance genes induced by which could bring more hazardous environmental risk than veterinary tetracycline. This study investigated the effects of environmental factors on the formation of several typical tetracycline resistance genes (tetA, tetC). The results showed that temperature, light and pH could have impacts on the formation of tetracycline resistance genes in soil, the amounts of the tetracycline resistance bacteria and resistance genes induced in different treatments all reached the maximum in the proper environmental condition (25 degrees C, 500 lx, pH7.5), which were all significantly higher than those in other environmental conditions (P < 0.05). In contrast, the adverse condition such as high temperature, strong light and high pH could effectively inhibit the formation of tetracycline resistance genes, probably due to the reduction of tetracycline residues or the direct influence on the formation of tetracycline resistance genes. And the results also showed that environmental factors could affect the growth of tetracycline resistance bacteria. Further analysis proved that the content of tetracycline resistance gene in soil had a positive correlation with the number of tetracycline resistance bacteria in the studied samples, therefore an inferred result was concluded that the growth of tetracycline resistance bacteria played a key role in the formation of the tetracycline resistance genes.

[A comparison of the effectiveness of five types of hemostatic surgeries for intractable postpartum haemorrhage and the factors of failed hemostasis].

OBJECTIVE: To study the different clinical effects of using 5 kinds of hemostatic surgeries to manage the intractable postpartum hemorrhage and analyse the risk factors of failed hemostasis. METHODS: From Jan. 2007 to Jul. 2011, 96 patients with intractable postpartum hemorrhage were studied retrospectively and grouped by the first step surgical treatment. The hemostatic surgeries included uterine tamponade (tamponade group), pelvic blood vessels ligation (ligation group), pelvical arterial embolization (embolization group), uterine compression sutures (sutures group) and uterine compression sutures combining tamponade (combined group). The intraoperative and postoperation datum were compared among groups, so dose the treatment outcomes. Multivariate analysis were used for failed hemostasis. RESULTS: (1) The blood loss of 96 patients ranged from 1200 to 9100 ml, and 71 patients had a succeed hemoatasis after employing these surgeries and 25 failed. (2) The blood loss before hemostasis surgeries in tamponade group and embolization group was statistically greater than in sutures group (P < 0.05). Blood loss during the hemostasis surgeries in ligation group was statistically greater than in embolization and sutures groups (P < 0.05). The operating time of embolization group was statistically shorter than ligation group, sutures group and the combined group (P < 0.05). (3) Fine of 96 patients had uterine atony and 43 had a successful hemostasis with the success rate about 78%. Forty-six had placenta previa and 39 success with success rate 85%. Thirty-three had placenta accrete and 13 of which succeed in hemostasis with success rate about 39%. In patients with uterine atony and placenta previa, the difference of hemostasis rate in groups had no statistically significant (P > 0.05). In patients with placenta accrete, the hemostasis rate in embolization group was higher than in others groups (P < 0.01). (4) The multivariate analysis found that scar uterus, placenta accrete and coagulation defects were the risk factors of failed hemotasis. The OR value respectively was 2.9 (95%CI: 1.1 - 7.6), 17.9 (95%CI: 5.6 - 56.3) and 16.2 (95%CI: 3.2 - 83.5). Embolization had some extent of protective effection (OR = 0.9, 95%CI: 0.8 - 0.9). CONCLUSIONS: (1) Five kinds of hemostatic surgeries were all effective. Though the success rate among groups did show statistical difference, pelvical arterial embolization has the comparative advantage of shorter operating time, less operating blood loss and higher success rate in placenta accrete. (2) Since scar uterus, placenta accrete and coagulation defects were the risk factors of failed hemostasis, sufficient preparation should be made for patients with these risk factors and the hemostatic surgeries should be choosed individually.

[Risk factors of perinatal blood transfusion].

OBJECTIVE: To investigate the risk factors associated with perinatal packed red blood cell transfusion. METHODS: We performed univariable analysis and unconditional multivarible logistic regression analysis to identify risk factors associated with perinatal packed red blood cell transfusion in 19 456 obstetrical inpatients. RESULTS: The transfusion rate was 1.49% (289/19,456). Prenatal hematocrit (HCT) less than 25% (OR 45.3, 95% CI 27.4-74.9), placenta previa (OR 16.8, 95% CI 11.6-24.3), prenatal HCT 25%-30% (OR 11.4, 95% CI 6.7-19.7), ethnic minority (OR 4.8, 95% CI 1.6-14.0), placenta abruption (OR 4.5, 95% CI 1.7-11.5), multiple gestation (OR 2.8, 95% CI 1.6-4.9) and preeclampsia (OR 2.6, 95% CI 1.5-4.4) were risk factors associated with perinatal packed red blood cell transfusion. CONCLUSION: Although the overall perinatal transfusion rate is low, severe prenatal anemia (HCT 25%) and placenta previa can increase the risk of transfusion markedly. It is crucial for obstetricians to provide appropriate perinatal care for those patients.