Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Incidence of Post-Partum Depression among Female Patients Presenting in the Outpatient Clinic of Obstetrics & Gynecology Department in ACTH At Khartoum State, September - November 2017

Abstract

Purpose: To determine the incidence of post-partum depression among female patients as this form of mental illness is much more serious than the “baby blues” (relatively mild depressive and anxiety symptoms that typically clear within two weeks after delivery) that many women experience after giving birth. Women with PPD may experience full-blown major depression during pregnancy or after delivery. The feelings of extreme sadness, anxiety, and exhaustion that accompany PPD may make it difficult for these new mothers to complete daily care activities for themselves and/or for their newborns. Early diagnosis and management are essential for the prevention of serious complications.

Materials and methods: This is a descriptive analytical hospital-based prospective study. Study included a total coverage of all women attending the outpatient clinic of Obstetrics and gynecology 4-6 weeks post-partum, which was a total of 40 women. Each woman answered the questionnaire in an interview method and the score of the Edinburgh Post Natal Depression Scale (EPDS) was recorded along with the factors included in the “added” questionnaire; marital status, partner support, employment and socioeconomic status. As for the EPDS scoring, any score of 10 or higher is considered suggestive of PPD.

Results: The incidence of PPD among the taken sample was found to be was found to be 7.5% - only three women presented with a score of equal/more than 10. With regards to marital status; single, widowed and divorced women all had EPDS scores less than 10; so, no depression. Of married women, 8.8% had EPDS scores of equal to or greater than 10 suggesting PPD. However, the p value for the association between marital status and PPD was (0.903) which is considered insignificant. Significant EPDS scores for depression were also shown to present with women complaining of “rarely supportive” partners, as all three women presenting with PPD were in that category. The p value for this association was found to be (0.301), also insignificant. When it comes to socioeconomic status, all three women with PPD were of low socioeconomic status, that is 8.6% of all those with low socioeconomic status presented with EPDS scores of 10 or higher. The p value for this association was found to be (0.496), insignificant. 12.5% of women who are unemployed presented with PPD while all those employed had no significant EPDS scores. The p value for this association was (0.141) which is, once again, insignificant.

Conclusion: According to the results obtained, the incidence of PPD is 7.5% and it appears that there is no significant association between PPD and any of the factors mentioned; marital status, employment, partner support and socioeconomic status. All P values were greater than 0.05.

Keywords: Post-partum depression; Edinburgh postnatal depression scale

Abbreviations: ACTH: Academy Charity Teaching Hospital; EPDS: Edinburgh Postnatal Depression Scale; PPD: Post-Partum Depression

Introduction

Post-Partum Depression (PPD), also known as Post Natal Depression is a form of depression and/or anxiety that presents after childbirth. It usually presents about 4-6 weeks after delivery and may last up to a few years if left untreated. Patients with this mood disorder can present with low mood, irritability, feelings of anxiousness, low levels of energy, changes in sleeping and eating patterns, feelings of guilt and crying episodes. Patients may even present with suicidal thoughts. As with Major Depressive Disorder (MDD), these symptoms must be present for two consecutive weeks to confirm the diagnosis of PPD. This condition can affect both sexes, the father of the newborn may experience these symptoms too, but in this research, I will be focusing on the new mothers rather than their partners. In the past, many risk factors for PPD have been studied. The emphasis has historically been on psychosocial aspects, such as a personal history of psychiatric illness (previous PPD being a highly significant risk factor) [1] low socioeconomic status, low level of education, alcohol and drug abuse, and low levels of social or partner support [2,3].

After pregnancy, hormonal changes in a woman’s body may trigger symptoms of depression. During pregnancy, the amount of two female hormones, estrogen and progesterone, in a woman’s body increases greatly. In the first 24 hours after childbirth, the amount of these hormones rapidly drops back down to their normal non-pregnant levels. Researchers think the fast change in hormone levels may lead to depression, just as smaller changes in hormones can affect a woman’s moods before she gets her menstrual period.

Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those women with more resources, such as financial. Rates of PPD have been shown to decrease as income increases [4]. Women with fewer resources may be more likely to have an unintended or unwanted pregnancy; increasing risk of PPD. Women with fewer resources may also include single mothers of low income. Single mothers of low income may have more limited access to resources while transitioning into motherhood.

Occasionally, levels of thyroid hormones may also drop after giving birth. Low thyroid levels can cause symptoms of depression including depressed mood, decreased interest in things, irritability, fatigue, difficulty concentrating, sleep problems, and weight gain. A simple blood test can tell if this condition is causing a woman’s depression. If so, thyroid medicine can be prescribed.

Once diagnosed, PPD is treated just like any other MDD through “Biopsychosocial” care which consists of anti-depressants/ hormone replacement if needed, appropriate psychotherapy and social support. However, making the diagnosis is not easy as most mothers do not seek help or pay attention to their symptoms; it’s usually ignored and assumed to just be a phase that will go away on its own. That is why the EPDS is a very important screening tool that helps many women face their problems and seek the appropriate care that they need for themselves and subsequently for their children.

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression [5,6]. These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy [5] Support is an important aspect of prevention, as depressed mothers commonly state that their feelings of depression were brought on by “lack of support” and “feeling isolated” [7].

In couples, according to a systematic review and meta-analysis of 2015, emotional closeness and global support by the partner protect against both perinatal depression and anxiety. Further factors such as communication between the couple and relationship satisfaction have a protective effect against anxiety alone [8].

A major part of prevention is being informed about the risk factors. The medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Also, proper exercise and nutrition appear to play a role in preventing postpartum depression and depressed mood in general.

Materials and Methods

Descriptive Analytical hospital-based prospective study was conducted in Academy Charity Teaching Hospital (ACTH). The sample obtained was representative of the total coverage during September- November 2017, which equated to 40 cases. Data was collected through an interview-based questionnaire (an Arabic translated version of Edinburgh Post Natal Depression Scale).

Data analysis

Data was processed and analyzed using the Statistical Package of Social Sciences (SPSS version 20). Chi square test and independent T test were used to study the significance and associations of variables in the study. Data will be presented in forms of tables and charts for this study.

Ethical approval

Ethical clearance was obtained from the research technical and ethical committee at the faculty of Medicine in UMST and ACTH administration.

Verbal consent was taken from all patients participating in the study. The process was clearly explained to each patient. They were assured about their safety and confidentiality and that there was no harm in responding.

Results

EPDS considered those who score equal to or more than 10 are positive for symptoms of PPD, and regarding this study 40 of women who interviewed only 3 had scored 10 or higher, making the incidence of PPD among the study group equaling approximately 7.5% (Figure 1).

For More Open Access Journals in Iris Publishers Please click on:
https://irispublishers.com/
 
For More Articles in World Journal of Gynecology & Womens Health
https://irispublishers.com/wjgwh/

For More Information:https://irispublishers.com/wjgwh/fulltext/incidence-of-post-partum-depression-among-female-patients-presenting-in-the-outpatient-clinic.ID.000584.php 

Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Minimal Laparotomy Management of a Giant Asymptomatic Ovarian Teratoma in a Woman of Reproductive Age: A Case Report

Abstract

Background: The majority of giant teratomas are symptomatic. The preoperative evaluation for possible malignancy is challengeable, as is the surgical approach. A consensus has not yet been drawn regarding the optimal treatment approach in cases of exceptionally large teratomas.

Case presentation: We report a rare case of minimal laparotomy management of a giant ovarian cystic teratoma in a 32-year-old asymptomatic multiparous woman. The patient was diagnosed while performing a fitness-to-work checkup where the physician noted a suspicious abdominal swelling. Subsequently, she was referred to us for further evaluation. Her CA125 level was raised, and an abdominal contrast computed tomography revealed a huge teratoma. After appropriate counselling, laparotomy and adenectomy were performed. Histopathological examination diagnosed a mature cystic teratoma with no malignant transformation. The patient had an uneventful recovery and was discharged on the third post-operative day.

Conclusions: We conclude that dermoid cysts can reach enormous sizes in the absence of serious symptoms or evidence of malignancy, although the size is a well-known risk factor for malignant transformation.

Keywords: Giant teratoma; Pelvic mass; Laparotomy; Computed tomography

Abbreviations: AFP: α-Fetoprotein; CEA: Carcino Embryonic Antigen; CT: Computed Tomography; SCC Ag: Squamous Cell Carcinoma Antigen

Background

Ovarian tumors can originate from any of its different layers. The three major histological types are: epithelial tumors, sex cord stromal cell tumors, and germ cell tumors, which constitute approximately 25% of all ovarian tumors (Figure 1) [1].

Teratomas are slow-growing tumors, composed histologically of diverse tissues, such as bone, skin, sebaceous glands, etc., owing to its cell of origin. Pathologically, teratomas are classified into benign mature, malignant immature, and mono-dermal types that are composed of one type of tissue [2]. In 10-17% of cases, both ovaries are involved [3].

Ovarian teratomas rarely exceeds the diameter of 15cm. Teratomas that exceed this size have an increased likelihood of malignant transformation. Other risk factors include elevated tumor markers and advanced age [4]. Giant teratomas usually present with complications, including torsion, pressure symptoms, and rupture. Here, we report a rare case of an asymptomatic giant teratoma in a 32-year-old multiparous woman. The CARE guidelines were followed for this case report [5].

A 32-year-old multiparous woman was referred for further evaluation of a suspicious abdominal mass. During a discussion of the patient’s medical history, the patient admitted to the existence of this mass for more than one year in association with vague, intermittent abdominal pain. She reported no changes in her menstrual cycle or bowel habits. There was no other significant medical or family history. On inspection of the abdomen, a clear bulge was evident approximately 20×30cm in size in the periumbilical region. It was soft, and no area of tenderness could be detected (Figure 2).

Due to its huge size, an extensive workup was performed to assess the possible risks of malignancy. The levels of serum tumor markers α-fetoprotein (AFP), carcinoembryonic antigen (CEA), and β-human chorionic gonadotropin, were normal. However, the patient’s CA125 level was abnormally high at 50 U/ml (normal range, <35 U/ml). Abdominal contrast computed tomography (CT) revealed a 25×20×14cm pelviabdominal cystic multilocular mass with fluid/fat density and internal nodules of fat and calcific teeth (Rokitansky nodules) suggestive of a dermoid cyst, originating from the left ovary. Displacement of the surrounding bowel loops and diffuse anterior abdominal wall contour bulge were also noted (Figure 3). There was no evidence of enlarged lymph nodes, ascites, or tumor deposits in the abdomen or pelvis.

Other blood test findings were within the normal ranges, and liquid base cytology was negative for malignant cells. The radiological and laboratory findings were discussed in detail with the patient, and the possible risks of malignancy were highlighted. Written informed consent for surgery was obtained.

A mini-midline laparotomy was performed. A huge mass was seen originating from the left ovary, extending to the liver, with an approximate size of 20×40×20cm. The fallopian tube was stretched out by the mass. The cyst was aspirated completely without spillage in the peritoneal cavity. A total 5 L of thick, yellowish fluid was aspirated. No ascites or organ infiltrate was noted. Complete adenectomy was performed due to the absence of a cleavage line between the cyst and the ovary; the ovarian tissue was completely destroyed by the mass (Figure 4a). However, the contralateral tube and uterus were normal. The patient had an uneventful recovery and was discharged on the third post-operative day.

For More Open Access Journals in Iris Publishers Please click on:
https://irispublishers.com/
 
For More Articles in World Journal of Gynecology & Womens Health
https://irispublishers.com/wjgwh/

For More Information:https://irispublishers.com/wjgwh/fulltext/minimal-aparotomy-management-of-a-giant-asymptomatic-ovarian-teratoma-in-a-woman.ID.000583.php 

Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Vitamin D Levels are found to be higher in Gestational Diabetics in Vitamin D Depleted Population

Abstract

Objective:b> Vitamin D levels are studied in Gestational Diabetes in many researches. Our aim is to investigate the relationship of vitamin D deficiency with gestational diabetes mellitus (GDM) in pregnancy.

Methods:b> In this study, 210 Pregnant women were included, of them 108 had GDM, 102 were controls. 25-hydroxyvitamin D (25(OH)D) levels of GDM group were compared with healthy pregnant controls. The maternal and fetal outcomes were recorded.

Results: GDM group had significantly higher mean 25(OH)D (11.8±8.0 ng/ml) compared to controls (7.7±6.1 ng/ml, p<0.01). There was no correlation of vitamin D levels with; maternal age, Apgar levels, birth week and fetal weight. Furthermore, there was no correlation of 25(OH)D levels with mode of delivery, intensive care need of new-born and macrosomia.

Conclusions: Although there are numerous reports about positive correlation between vitamin D deficiency and GDM in pregnancy, we found the opposite. In severe vitamin D deficiency, the mechanisms may differ and should be identified further.

Keywords: Gestational Diabetes; 25OHD; Fetal; Maternal outcomes

Introduction

Deficiency of 25-hydroxyvitamin D [25(OH)D] levels are found to be correlated with many adverse pregnancy outcomes like preeclampsia, stillbirth, intrauterine growth retardation, gestational diabetes (GDM), preterm birth [1,2]. The major source of vitamin D in humans is ultraviolet B induced dermal synthesis of cholecalciferol, whereas food sources are believed to play a lesser role [3]. Factors like skin pigmentation, age, attire, environment and sun exposure affect this cycle. GDM is characterized by increased resistance to and impaired secretion of insulin, may affect up to 18% of pregnant women and results in higher risk of adverse pregnancy outcomes [4].

There isn’t still full agreement on the association between GDM and vitamin D deficiency up till now [1,2,5]. Some studies report positive, some report negative or none association. Our aim is to investigate the correlation vitamin D deficiency with GDM in our vitamin D depleted population.

Methods

In this prospective cohort study, fasting serum levels of 25(OH) D were measured in pregnant women grouped according to Oral Glucose Tolerance Test (OGTT) at 24 weeks. 108 GDM patients and 102 normal healthy pregnant women were compared according to their fasting serum levels of 25(OH)D in second trimester after GDM screening (24-28 weeks of gestation). Vitamin D was measured by chemiluminescence assay and deficiency was defined as < 20 ng/ mL. Participants were followed until puerperium. GDM screening is performed to the pregnant attending to our hospital.

For GDM, screening is done by one step 75 g OGTT. Diagnosis of GDM is confirmed if one of the glucose levels exceeds the IADPSG criteria (International Association of Diabetes Pregnancy Study Group): fasting ≥ 92 mg/dl, 1-hour ≥ 180 mg/dl, 2-hour ≥ 153mg/dl [4]. After reviewing the results of the HAPO Study, many international diabetes study groups, including the IADPSG and American Diabetes Association, have adopted the 75-g OGTT at 24–28 weeks as a screening and diagnostic test.

Body Mass Indexes (BMI) were calculated by weight/height2 and compared. After delivery, Maternal and infant medical outcomes were recorded. Gestational diabetes group (study group) compared with healthy pregnant regarding 25(OH)D levels at the same season (spring). Maternal and fetal outcomes were recorded in our hospital. The study was approved by Hospital’s Ethics Committee.

Statistical analyses were performed using SPSS, version 16.0 (SPSS Inc, Chicago, Ill, USA). Student t test is used for parametric variables; χ2 square test is used for nonparametric variables. Pearson correlation analysis is used for normally distributed data. Relation of continuous variables with dichotom outcomes were analysed by Logistic regression analysis. A p value <0.05 was considered statistically significant.

For More Open Access Journals in Iris Publishers Please click on:
https://irispublishers.com/
 
For More Articles in World Journal of Gynecology & Womens Health
https://irispublishers.com/wjgwh/

For More Information: https://irispublishers.com/wjgwh/fulltext/vitamin-d-levels-are-found-to-be-higher-in-gestational-diabetics-in-vitamin-d-depleted-population.ID.000582.php 

Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

The Effect of High-Intensity Focused Ultrasound Rays in the Treatment of Uterine Fibroids on Tissue Parameters of Endometrial Receptivity

Abstract

Objective: To analyse the effect of the ultrasonic energy during MRI-guided high-intensity focused ultrasound ablation (HIFU) of uterine fibroids on molecular markers of endometrial receptivity in women of reproductive age.

Study design: A prospective comparative cohort study of 60 women of reproductive age was conducted. The main group consisted of 32 patients suffering from the symptomatic course of uterine fibroids who received treatment with HIFU ablation of uterine fibroids: 17 women with node localization at the front wall of the uterus and the reflected action of ultrasonic waves on the endometrium and 15 women with the back wall node localization and penetrating effect of the waves. The control group consisted of 28 healthy fertile women examined voluntarily. The endometrium obtained with pipelle-biopsia on days 20-22 of the cycle was examined by immunohistochemistry before and three months after the treatment. The results were processed by the method of variation statistics using the SPSS 22.0.

Results: A significant decrease in the stromal expression of CD95bright in the endometrium to the level comparable with control values was observed after HIFU ablation of uterine fibroids (from 70.22±9.77 c/s to 48.81±5.47 c/s; p<0.001; the control level – 47.80±2.13 c/s). The ratio and expression of steroid receptors, proliferation markers, p53-dependent apoptosis and itsblockers, regulators and markers of angiogenesis, LIF and LIF-R signalling molecules in thestroma and endometrial glands did not change significantly after treatment (p>0.05 in treatment dynamics). It was demonstrated that focused ultrasound causes an increase in the level of expression of estradiol alpha receptors in the endometrial glands (118.07±14.01 points vs.153.33±11.43 points; p=0.02) and a decrease in stromal p53 expression (30.80±21.61% vs.14.66±3.74%; p=0.007). No influence of the localization of fibroid node on the stromal expression of CD56bright+ was demonstrated. A significant increase in the stromal expression of CD34+ to the level statistically comparable with control values (from 26.00±1.63 c/s to 32.47±2.03 c/s; p=0.011; the control level - 37.99±1.23 c/s) was associated with ultrasound action.

Conclusion: This study did not reveal any significant negative effects of HIFU ablation of uterine fibroids on endometrial receptivity in women of reproductive age.

Keywords: Uterine fibroids; Magnetic resonance imaging guided high-intensity focused ultrasound ablation; Endometrial receptivity

Abbreviations: MRg: Magnetic Resonance Imaging Guided; HIFU: High-Intensity Focused Ultrasound

Introduction

Uterine fibroids are a clinically relevant problem due to their high incidence: about 25% of women older than 35 years have myomas and one-third of those patients have symptoms associated with fibroids [1-2]. A combination of uterine fibroids and infertility occurs in 1.2 - 2.4% of women, while the mechanisms of the influence of uterine fibroids on fertility today remain a subject of discussion [1-6].

The problem of choosing the therapeutic tactics of uterine fibroids in patients of reproductive age planning pregnancy is associated not only with a change in the functional state of the myometrium after treatment, but also with a corresponding change in the function of the endometrium, which plays a key role in the initiation of implantation and invasion of trophoblast [6,7].

In the presence of indications, myomectomy with careful layer- by-layer closure of the node bed is the first-line treatment method for patients with uterine fibroids planning a pregnancy [1,2,8- 10]. In this case, the risk of uterine rupture after laparoscopic myomectomy does not exceed 0.5 - 1% [11,12]. At the same time, when planning pregnancy for women of late reproductive age that have a certain decrease in ovarian reserve, the question of recovery time after myomectomy sometimes acquires fundamental importance. In addition, a uterine scar after myomectomy can consider an indication for abdominal delivery during subsequent pregnancy, which may increase perinatal risks in some way. In addition, there are certain risks of pregnancy with a scar on the uterus [2,12].

These circumstances dictate the feasibility of a thorough study of alternative methods of preparing patients with uterine fibroids for pregnancy. As an alternative, there are conservative regression methods for the treatment of uterine fibroids, including magnetic resonance imaging guided high- intensity focused ultrasound (HIFU), which allows accelerating pregravid preparation and to avoid surgical intervention with scar formation on the uterus [13,14].

The mechanisms of the influence of focused ultrasound rays passing through the endometrium during the procedure of HIFU ablation on the indicators of its receptivity are not fully understood, the results of individual studies are very contradictory. In this regard, it seems very relevant to study the functional activity of the endometrium after treatment using HIFU ablation of uterine fibroids.

The aim of this study is to analyse the effect of MRg HIFU ablation of uterine fibroids on molecular markers of endometrial receptivity in women of reproductive age.

Material and Methods

A prospective comparative cohort study of 60 women of reproductive age was conducted. The main group consisted of 32 patients suffering from the symptomatic course of uterine fibroids who received treatment with HIFU ablation of uterine fibroids. The control group consisted of 28 healthy fertile women who were examined on a voluntary basis, and who did not have a history of miscarriage and had a history of normal vaginal delivery after the physiological pregnancy. Depending on the predominant localization of the uterine fibroids, the patients were divided into two subgroups: A - 17 women with localization of the dominant node at the front wall of the uterus (in this case the endometrium was impacted by reflected ultrasonic waves); B - 15 women with localization of the fibroids at the posterior wall of the uterus and direct impact of ultrasound energy upon the endometrium.

The procedure of HIFU ablation was performed on the ExAblate- 2000 (InSightec, Israel), combined into a single system with a 1.5 Tesla magnetic resonance imager (General Electric, USA). MR images were used for treatment localization, feedback control (beam guidance), real- time temperature mapping with the proton resonance frequency shift (PRFS) thermometry method, and post treatment verification of the ablated tissue.

The endometrial study was performed using the pipelle-biopsia method for LG7+ day, determined by the urinary test for ovulation, as the period of the alleged “implantation window” in both case groups.

For the Immunohistochemical study, a two-stage streptavidin- biotin-peroxidase method was used with antigen unmasking using standard sets of monoclonal and polyclonal antibodies from Bond RTU Primary, USA and DAKO, Denmark. Using the DakoCytomation imaging system, a Reaction was performed. The Super Sensitive Polymer-HPR Detection System (BioGenex, USA) bezbiotin- free detection system was used to visualize primary antibodies.

For Immunohistochemical studies used serial paraffin sections. For Immunohistochemical reactions, paraffin sections were processed according to the traditional method using murine monoclonal antibodies to estrogen receptors-α, progesterone receptors.

To analyse the results the H-score method of histological counting was used. To assess the expression of Ki-67, bcl-2, p53 antigens in the glands and stroma, proliferation and apoptosis indices were calculated - the ratio of the number of stained cell nuclei to the total number of nuclei in percent when counting at least 400 nuclei. Expression of CD56bright+ was evaluated by counting positive cells in the field of view at an increase of 400 when counting at least 10 fields of view. The expression of CD34+, VEGF-A and VEGFR-1 was determined in the epithelium, stroma of the endometrium and vascular endothelium. Activity was manifested in the form of staining of the membrane and cytoplasm of epithelial and endothelial cells. The expression of LIF, LIFR was determined on the cell membranes of the surface epithelium of the endometrial glands by counting the number of stained cells in the field of view at an increase of 400, while not less than 10 fields of view were studied.

For More Open Access Journals in Iris Publishers Please click on:
https://irispublishers.com/
 
For More Articles in World Journal of Gynecology & Womens Health
https://irispublishers.com/wjgwh/

For More Information: https://irispublishers.com/wjgwh/fulltext/the-effect-of-high-intensity-focused-ultrasound-rays-in-the-treatment-of-uterine--fibroids-on-tissue.ID.000581.php