Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Knowledge, Attitudes and Practices About Contraception in Patients who had Undergone A Caesarian Section in N’Djamena Mother and Child University Hospital

Summary

Background: Postpartum contraception is the set of methods designed to prevent pregnancy after a caesarean section [1]. It can be instituted during the caesarean section or in the post-partum period.

The aim of this study is to evaluate the knowledge and practice of contraception in patients who have undergone a caesarean section at N’Djamena Mother and Child University Hospital.

Patients and method: This were a 3-month cross-sectional and descriptive study from September 1st, 2020 - November 30th, 2020 on knowledge, attitudes and practices about contraception in caesarian section patients.

Results: The 20-24 age group was the most represented with 42%.Patientts resided in N’Djamena in 60%.Married women were the most represented with 93.3% . Patients had average knowledge about contraception in 77.3%. Injectable contraceptives were the commonly known of the modern contraceptive methods with 80.7%. Periodic abstinence was the best-known natural method with 61.3%. Implants were the most chosen contraceptive method with 48%. The proposal to use the contraceptive method was made in 79 , 3% of cases by health workers. The most well-known advantages of contraceptives by clients were birth spacing with 82.7%. Infertility was the contraceptive method disadvantage most reported by clients with 54%.

Conclusion: The prescription of contraceptive methods in patients who have undergone a caesarean section is part of our common practice. Injectable contraception remains the commonly known hormonal contraception. The desire to avoid pregnancy is the benefit most noted by patients.

Keywords: Contraception; Caesarean section; NMCUH

Introduction

Postpartum contraception is the set of methods designed to prevent pregnancy after a caesarean section [1]. It can be instituted during the caesarean section or in the post-partum period. There is a disparity in the rate of use of contraceptive methods around the world. The rate of modern contraceptive use is 55% worldwide, reaching 22% in Africa with a rate less than 10% in its central part [1,2]. These disparities in contraceptive use rates also exist between urban and rural areas. For example, high rates can be observed in urban areas compared to rural areas. In Chad, according to data from the 2015 mixed survey, the prevalence of modern contraception is less than 5% for all women of childbearing age [3]. Foumsou L, et al [4] in a hospital series at N’Djamena Mother and Child University hospital in 2016 reported that the rate of contraceptive use in the post-partum period is 15.9%. However, several factors such as social and cultural factors are involved in the use of contraceptives. Few data exist on contraception after Caesarean section in our context. The aim of this study is to evaluate the knowledge and practice of contraception in patients who have undergone a caesarean section at N’Djamena Mother and Child University Hospital.

Patients and Methods

This was a three (3) month cross-sectional and descriptive study from September 1, 2020 - November 30, 2020 on knowledge, attitudes and practices about contraception in caesarian section patients.

Patients were interviewed. According to the answers given during the interview, the knowledge of the patients is classified as follows:

Average knowledge = knowledge of contraceptive methods or their effects.

Good knowledge = knowledge of contraceptive methods and their effects

The data was entered using Word and Excel 2014 software and analyzed using SPSS 18.0.

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Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Gestational Sac vs Pseudosac

Mini Review

It is important to diagnose intrauterine pregnancy in the presence of empty gestational sac and not to confuse with pseudosac and avoid unnecessary investigations and follow up. Intrauterine gestational sac identification via ultrasonography has 97.6% specificity for the diagnosis of IUP, while the yolk sac visualization has 100% specificity [1].

Mean sac diameter (MSD) of 25mm without an embryo is indicative of pregnancy failure, while MSD between 16 and 25 mm without an embryo is suggestive of possible pregnancy failure.

Since the incidence of ectopic pregnancies is approximately 2%, a nonspecific intrauterine fluid collection with normal imaging of adnexa is more likely to represent an early intrauterine pregnancy.

Intradecidual sign – The intradecidual sign is the earliest US finding associated with an IUP. On TVUS, this sign typically can be seen at approximately 4.5 weeks of gestation, when the hCG is equal or greater than 1500 IU/L, and/or when the mean sac diameter (i.e., the average measurement of the sac obtained in three planes) is 3 mm or greater.

The intradecidual sign is a small round fluid collection surrounded by an echogenic rim. It is eccentrically located within the endometrial cavity and should deviate the endometrial lining. This structure and its echogenic rim represent the chorionic cavity, implanting chorionic villi, and associated decidual tissue.

The double decidual sac sign (DDSS) is defined as two concentric echogenic rings of tissue surrounding an intraendometrial fluid collection that impress upon the endometrial stripe in an early IUP. Conversely, in an EP, the decidual reaction presents as only a single echogenic ring around the endometrial fluid collection [2].

A recent systematic review and meta-analysis reported that the DDSS predicted an IUP with a sensitivity of 81.8% and specificity of 97.3%.

Features of Pseudosac

• Does not have an echogenic rim

• Tends to be located in the middle of the uterine cavity rather than embedded in the decidua

• Can change in shape during the scan

• May appear to be complex since it contains blood

When an obvious extrauterine pregnancy is not present, the ultrasonographic findings of an empty uterus, a pseudosac, an adnexal mass and/or free fluid have poor sensitivity for identifying a tubal pregnancy (Table 1).

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Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Pravastatin Improves Angiogenic Factors and Feto- Placental Doppler in Pregnancy with Early Severe Fetal Growth Restriction: A Case Report

Summary

Early fetal growth restriction (FGR) is a leading cause of perinatal morbidity and mortality. No therapeutic strategies have proved to be effective in improving fetal and neonatal outcomes either in growth restricted fetuses or any placenta-related disorder such as preeclampsia. Delivery of the fetus and placenta is the only definitive cure. However, recent studies suggest that pravastatin appears to be safe in pregnancy, improves placental perfusion and fetal growth and prevents angiogenic imbalance. Angiogenic (PlGF) and antiangiogenic (sFlt-1) factors and feto-maternal Doppler evaluation are strongly associated with fetal growth restriction prognosis and severity. Thus, pravastatin has been proposed as a promising therapeutic drug for fetal growth restriction. We report the findings of a case of early-onset FGR treated with pravastatin 40mg daily until delivery. During this time, feto-maternal Doppler and angiogenic profile evolution were recorded. Fetal and placental perfusion observed on Doppler and angiogenic imbalance improved after pravastatin was started. sFlt-1 down-regulation was more marked than PlGF up-regulation. The patient developed severe preeclampsia (PE) at 27+6 weeks of gestation, necessitating immediate fetal extraction owing to hypertension refractory to adequate treatment. This report supports further investigation on the use of pravastatin to improve angiogenic profile and feto-maternal circulation in FGR fetuses.

Keywords: Fetal growth restriction; Pravastatin; PlGF, sFlt-1; Feto-placental Doppler

Introduction

Fetal growth restriction (FGR) affects 7-10% of all pregnancies and refers to a fetus that has failed to achieve its biological growth potential [1]. Growth-restricted fetuses have a 5- to 10-fold risk of dying in utero and a higher risk of perinatal morbidity and mortality [2]. Abnormal placentation is a key factor in fetal growth restriction pathophysiology [3]. Several histopathologic features such as villous infarction, maternal vascular changes and villous morphologic alterations are observed more frequently in placentas from pregnancies complicated by FGR [4]. Placental function evaluation by umbilical artery (UA) Doppler velocimetry is the clinical standard for identifying early-onset FGR [1-3] and there is evidence that its use in these pregnancies improves a number of obstetric care outcomes and reduces perinatal deaths [4].

Fetal deterioration latency can vary from case to case; however, it usually lasts weeks and often follows a series of changes reflected in a sequential pattern on Doppler that permits tailoring of fetal monitoring and elective delivery [1].

Uteroplacental insufficiency is associated with a predominantly antiangiogenic environment characterized by up-regulation of soluble fms-like tyrosine kinase-1 (sFlt-1) and down-regulation of placental growth factor (PlGF) [5]. Abnormal angiogenic factor levels in the maternal circulation play a key pathogenic role in the development of endothelial dysfunction with ensuing preeclampsia [5]. The value of angiogenic biomarkers in the prediction, prognosis and characterization of early-onset preeclampsia and FGR has been demonstrated in several studies [5,6]. In uncomplicated pregnancies, PlGF rises until the third trimester of pregnancy and falls thereafter whereas sFlt-1 levels rise as the pregnancy progresses. Thus, the sFlt-1 to PlGF ratio rises with gestational age. These changes are more patent in pregnancies that will eventually develop placental disease [5-7].

No treatment currently exists for placental insufficiency and delivery is the only way to stop disease progression. If preeclampsia or FGR occur early in gestation, the need to deliver the fetus preterm for maternal and/or fetal indications can lead to neonatal death and disability arising from prematurity.

Some studies suggest that statins could be a promising therapeutic or preventive strategy for placental insufficiency [8,9]. Significant clinical benefits and improvement in the angiogenic profile have been reported in patients with early-onset preeclampsia [10] and umbilical artery flow in twin pregnancies with discordant fetal growth seems to improve after pravastatin is started [11]; however, no previous studies reported the effect of pravastatin on the uterine artery Doppler and angiogenic factors of FGR single pregnancies in humans.

Case Report

Case description

A 41-year-old woman with early-onset FGR was referred to our center at 25+4 weeks of gestation (WG). Estimated fetal weight (EFW) at admission (25+4 WG) was 429 grams (g) that corresponded to a zero percentile. After the diagnosis of FGR was confirmed, the patient received a course of antenatal corticosteroids for fetal maturation, amniocentesis was performed and prophylactic low-molecular-weight heparin was initiated owing to the presence of 3 other thrombotic risk factors (obesity, smoking and age >40 years). Negative results were obtained in tests for antiphospholipid antibodies. These tests were repeated on two occasions during pregnancy. Results of the amniocentesis and Doppler findings were suggestive of FGR secondary to severe placental insufficiency (increased pulsatility of the uterine arteries with present bilateral early diastolic notches, normal fetal CGH arrays and negative polymerase chain reaction for cytomegalovirus in amniotic fluid analysis).

The patient was offered treatment with pravastatin and, after being informed of its risks and benefits, consented to its use. Pravastatin was started at 26+2 WG.

This patient was the first to be enrolled in a pilot study where patients presenting FGR before 28+0 WG were offered pravastatin 40mg daily until delivery. The aim of that study was to ascertain whether pravastatin treatment exerted beneficial effects on growthrestricted fetuses. FGR was defined as estimated fetal weight below the third centile or below the 10th centile associated with any fetoplacental Doppler impairment.

The effects of pravastatin were evaluated on feto-maternal Doppler ultrasound (umbilical artery, middle cerebral artery, ductus venosus and uterine arteries) together with serum angiogenic factors (sFlt-1 and PlGF), clinical and biochemical findings related to preeclampsia such as mean systolic and diastolic blood pressures, qualitative proteinuria, 24-hour quantitative proteinuria, prodromal symptoms of eclampsia (headache, visual disturbance, tinnitus, epigastric pain and/or upper right abdominal pain) and other relevant laboratory findings.

Findings

The findings are summarized in Figure 1. No significant effects were observed on any biochemical parameters, blood pressure or middle cerebral artery (MCA) Doppler after pravastatin was started. However, an effect on umbilical artery (UA) pulsatility index (PI), uterine artery (UtA) PI and angiogenic factors was observed after 36 hours. Mean UtA PI dropped significantly (from 3.34 to 2.64, although being both above the 99th percentile for gestational age) and this improvement persisted 7 days later. UA PI had been rising progressively prior to pravastatin and remained around normal values thereafter.

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Iris Publishers_World Journal of Gynecology & Womens Health (WJGWH)

Clinical Characteristics of 18-Trisomy Syndrome Failed to Be Diagnosed After Prenatal Screening

Summary

Objective: To discover the characteristics of trisomies 18 who were prenatal diagnosed or failed to be diagnosed, and to reduce the failed to be diagnosed.

Method: In this multicenter study, we collected a total of 52 babies of 18-trisomy syndrome (34 cases were prenatally diagnosed and 18 failed to be diagnosed) and analyzed their characteristics.

Results: In the past 13 years, according to the data from the prenatal diagnosis center in Jiangsu, the estimated detection rate was 65.4% for trisomies 18 in the second trimester. After analyzed the distribution of the groups according to T18-risk, there were two important cut-off values to be noted: 1/455 and 1/5050. It was worthwhile noting that the risk of 65.4% trisomy 18 cases was higher than 1/455, 90.4% higher than 1/5050. However, 96.1% cases in normal control group were lower than 1/5050. No case from normal control group would be higher than the value of risk in 1/450. Meanwhile, the T18-risk of 50% T18 failed to be diagnosed cases were 1/1001~1/5050. If we chose NIPT follow the standard of 1/5050, we could find 90.4 % T18 cases. It could increase 19.2% T18 babies be detected, but 3.2% normal mother would accept the NIPT examination which maybe unnecessary.

Conclusions: The prediction mode of HCG MoM and AFP MoM might be able to help us reduce the failed to be diagnosed. It is also necessary to adjust more reasonable range of NIPT with further clinical researches.

Keywords: 18 trisomy syndrome; Prenatal screening; Biomarkers; Prenatal diagnosis; Non-invasive prenatal testing

What Is Already Known on This Subject?

It is well known that prenatal screening and diagnosis is the effective way to avoid the birth of trisomy 18. However, there are still some cases will be missed.

What Do the Results of This Study Add?

There were two important cut-off value of prenatal screening to be noted: 1/455 and 1/5050. The T18-risk of 50% T18 failed to be diagnosed cases were 1/1001~1/5050. If we chose NIPT follow the standard of 1/5050, we can find 90.4 % T18 cases. It can increase 19.2% T18 babies be detected, while add 3.2% normal mother accepted the NIPT.

What are the Implications of These Study?

The prediction mode of HCG MoM and AFP MoM might be able to help us reduce the failed to be diagnosed. It is also necessary to adjust more reasonable range of NIPT with further clinical researches.

Introduction

Edwards syndrome, also named as 18-trisomy syndrome, is the common chromosomal abnormalities with an incidence of 1 in 3000~8000 in live births [1]. Due to an extra chromosome 18, the main clinical manifestations are multiple malformations and severe mental retardation, which caused only few children could survive the first year and very few cases could live longer [1,2]. According clinical researches, about 50% of babies with trisomy 18 could live longer than one week and about 5-10% of children beyond the first year [3]. So, it seriously affected the health of children. It is well known that the program of prenatal screening and diagnosis is the effective way to avoid the birth of trisomy 18 baby.

In the past three decades, prenatal screening for 18-trisomy syndrome has been widely used in pregnant women worldwide [4,5] which based on screening by maternal age, maternal serum markers screening, or detection of sonographic abnormalities (e.g., increased nuchal translucency thickness, growth retardation, choroid plexus cyst, overlapping of fingers, and congenital heart defects) [3]. The most common prenatal screening method for 18-trisomy syndrome is the serological prenatal screening in the second trimester, which detect the serum levels of free beta subunit of human chorionic gonadotropin (fβhCG) and alpha-fetoprotein (AFP) with maternal age [6,7]. The approximately detection rate was 57% with 0.7% false positive rate (Spencer K 1999). Effective screening can be carrying out in the first trimester screening (between 8 and 13 weeks), combination of serum levels of fβhCG, pregnancy-associated plasma protein A (PAPP-A), maternal age and ultrasound nuchal translucency (NT) measurements. The estimated detection rate was 87.0% for Down syndrome and 91.8% for 18-trisomy syndrome and trisomies 13 with the false-positive rate of 2.2% [9]. So, regardless of the kind of prenatal screening, it still had some cases of 18-trisomy syndrome would miss diagnosis because of the technical limitations of the prenatal screening.

Recently, non-invasive prenatal testing (NIPT), detection of fetal cell-free DNA (cfDNA) in maternal plasma, was proved to be a better prenatal screening program for common fetal aneuploidies. Nowadays, NIPT was widely used to prenatal screen the T21, T18, T13 [10]. Some societies and organizations , such as ACOG [11] and ISPD [12], have issued the committee opinions or guidelines about the clinical application of NIPT, and they both recommend the patients of high-risk group to accept NIPT. In 2015, Chinese scholars firstly suggested the mothers whose T18 screening results were intermediate risk (1/350~1/1000) to accept NIPT to reduce the failed to be diagnosed.

However, it is necessary to adjust more reasonable range of NIPT with further clinical researches.

In the present study, we have collected the cases of trisomies 18 who were prenatal diagnosed or failed to be diagnosed from the prenatal diagnosis center and analyzed their characteristics. With statistical analysis, we hope to be able to improve the programs of prenatal screening and reduce the failed to be diagnosed of 18-trisomy syndrome.

Materials and Methods

Patients and Design

The study design and protocol were reviewed and approved by the ethics committee of Changzhou Maternity and Child Health Care Hospital affiliated to Nanjing Medical University. From October 2002 to June 2015, the pregnant women received the prenatal screening in the hospital. A total of 52 babies of 18-trisomy syndrome were found in the center, included 34 cases were prenatally diagnosed and 18 cases failed to be diagnosed. We selected the objects of their mothers. Meanwhile, 309 mothers were selected as the normal control group. They accepted prenatal screening in our hospital and were confirmed have normal babies after followed-up. Both common characteristics were shown in Table 1.

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