Motor neuron disease presenting with acute hypercapnic respiratory failure

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The Joys of Older Motherhood: A questionnaire-based survey of mothers who delivered over the age of 50 years

OBJECTIVE

It is recognised that advanced maternal age is associated with adverse pregnancy outcomes. It is less known what the psychological impact of having a pregnancy in later maternal age is. This study aimed to establish whether women having children over 50 experience challenges with regards to their mental well-being during the pregnancy and thereafter.

STUDY DESIGN

17 women delivered aged ≥ 50 at our maternity unit in a central London hospital between 2014 and 2020. Of these, one had died of metastatic ampullary carcinoma two years following delivery, one declined taking part, and two we were unable to get hold of, leaving 13 women in the study. Two validated questionnaires were used to survey the women: (i) Warwick-Edinburgh Mental Well-being Scale (WEMWBS), (ii) Parenting Daily Hassles Scale (PDHS). We analysed the questionnaire data using their individual scoring systems.

RESULTS

The WEMWBS showed a median score of 60 out of a possible 70 (range: 45-70), indicating a high level of mental well-being among these women. The PDHS results indicated that reported hassles were overall low in both frequency and intensity for the mothers.

CONCLUSION

Women giving birth over 50 have often experienced long, emotional and financially-burdensome journeys in order to fall pregnant, usually involving assisted reproductive techniques (ART), with multiple antenatal and delivery complications thereafter. As a result, they are extremely happy and grateful to have the child, and are often in better socioeconomic positions that can help with the stress that comes with child-caring.

Retrospective observational RT-PCR analyses on 688 babies born to 843 SARS-CoV-2 positive mothers, placental analyses and diagnostic analyses limitations suggest vertical transmission is possible

Research question

Is there vertical transmission (from mother to baby antenatally or intrapartum) after SARS-CoV-2 (COVID-19) infected pregnancy?

Study design

A systematic search related to SARS-CoV-2 (COVID-19), pregnancy, neonatal complications, viral and vertical transmission. The duration was from December 2019 to May 2020.

Results

A total of 84 studies with 862 COVID positive women were included. Two studies had ongoing pregnancies while 82 studies included 705 babies, 1 miscarriage and 1 medical termination of pregnancy (MTOP). Most publications (50/84, 59.5%), reported small numbers (<5) of positive babies. From 75 studies, 18 babies were COVID-19 positive. The first reverse transcription polymerase chain reaction (RT-PCR) diagnostic test was done in 449 babies and 2 losses, 2nd RT-PCR was done in 82 babies, IgM tests were done in 28 babies, and IgG tests were done in 28 babies. On the first RT-PCR, 47 studies reported time of testing while 28 studies did not. Positive results in the first RT-PCR were seen in 14 babies. Earliest tested at birth and the average time of the result was 22 hours. Three babies with negative first RT-PCR became positive on the second RT-PCR at day 6, day 7 and at 24 hours which continued to be positive at 1 week.

Four studies with a total of 4 placental swabs were positive demonstrating SARS-CoV-2 localised in the placenta. In 2 studies, 10 tests for amniotic fluid were positive for SARS-CoV-2. These 2 babies were found to be positive on RT-PCR on serial testing.

Conclusion

Diagnostic testing combined with incubation period and placental pathology indicate a strong likelihood that intrapartum vertical transmission of SARS-CoV-2 (COVID-19) from mother to baby is possible.

Pregnancy with known syndrome of inappropriate antidiuretic hormone

Syndrome of inappropriate antidiuretic hormone (SIADH) is rarely encountered in pregnancy. We report a case of severe hyponatraemia with idiopathic SIADH. A total of 18 cases of hyponatraemia in pregnancy have been reported; seven fit the criteria of SIADH. Unlike our case, none were diagnosed before pregnancy. Of the cases, 13 were associated with pre-eclampsia. Our patient developed intrauterine growth restriction (IUGR) but did not develop pre-eclampsia.

Kaposi's sarcoma in pregnancy after initiation of highly active antiretroviral therapy: a manifestation of immune reconstitution syndrome

A case of Kaposi's sarcoma (KS) presenting as an immune reconstitution inflammatory syndrome in pregnancy with conservative management is reported. Successful outcomes for mother and baby were achieved. HIV was diagnosed at antenatal booking and highly active antiretroviral therapy commenced at 20 weeks. Multiple lymphadenopathies developed two months later. Excision biopsy of a node confirmed KS. In the absence of advanced disease, she was managed conservatively until delivery. The placenta showed no evidence of KS or human herpes virus 8 (HHV-8). The baby had negative HIV and HHV-8 polymerase chain reaction tests at zero, six and 12 weeks of life. Six months postpartum, the KS had regressed and HHV-8 viral load was undetectable.

Prevalence of vitamin D deficiency in a North London antenatal population

OBJECTIVE

We evaluated the prevalence of vitamin D deficiency in the antenatal patients attending North Middlesex University Hospital between March 2008 and March 2009.

STUDY DESIGN

A prospective study of maternal levels of vitamin D at booking.

RESULTS

The prevalence of both deficient and insufficient levels of 25[OH]D was 87.6% across all included patients.

CONCLUSION

There is a high prevalence of asymptomatic vitamin D deficiency in the antenatal booking population.

Obstructive nephropathy and chronic kidney disease secondary to uterine leiomyomas

We present three cases of chronic kidney disease secondary to large fibroid uterus. The difficulties experienced in their clinical management and a review of literature is outlined.

Anaesthetic burns

Patients frequently complain of numbness after surgery via the Pfannensteil incision. The two cases in this report demonstrate clear evidence of impaired sensory perception following such an incision. While this is often regarded as a trivial complication, a brief warning to patients should help avoid such superficial burns.

Myasthenia gravis and pregnancy

Myasthenia gravis (MG) is a chronic autoimmune disorder of neuromuscular transmission characterized by varying degrees of weakness and easy fatigability of the skeletal muscles. Precipitants of myasthenic symptoms or crises include physical and emotional stress, systemic illness, infections, hypo or hyperthyroidism, pregnancy, any type of surgery with general anaesthesia as well as corticosteroids. The authors report two cases of MG in pregnancy and discuss briefly the various aspects of the disease course and management in pregnancy. As MG occurs predominantly in women of reproductive years, it is important that obstetricians are aware of this condition and its management in pregnancy.

Do polycystic ovaries on ultrasound scan indicate decreased insulin sensitivity in sisters of women with polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is associated with hyperandrogenemia, insulin resistance, altered lipid profile, and therefore with subsequently increased risk for metabolic complications such as type 2 diabetes and cardiovascular diseases. It has been reported that sisters of probands with PCOS, who themselves had PCOS or hyperandrogenemia with normal menses, were more insulin resistant than unaffected sisters. We have previously reported that 60% of first-degree relatives (premenopausal mothers and sisters) of PCOS probands had polycystic ovaries (PCO) on ultrascan. Sisters with PCO were more likely to have oligomenorrhea and increased androgen levels than sisters without PCO. The aims of this study were to assess insulin sensitivity status [homeostasis model of assessment, quantitative insulin sensitivity check index, glucose to insulin ratio (G/I)] and lipid profiles in probands with PCOS and their sisters with PCO and without PCO on ultrascan. Mixed model hierarchical regression analysis, to accommodate the nonindependent nature of the subjects (family relationships), with the three groups together did not show significant differences in insulin sensitivity, calculated as quantitative insulin sensitivity check index, homeostasis model of assessment, and G/I for PCOS probands, through sisters with PCO on ultrascan, to sisters without PCO on ultrascan. There was a significant association of measures of insulin sensitivity with body mass index. Lipid parameters did not differ between the groups. These data suggest that presence of PCO on ultrasound scan per se does not predispose to reduced insulin sensitivity in sisters of women with PCOS. Because about 20% of premenopausal women in the general population have PCO on ultrascan, and obesity/overweight is becoming more prevalent, it is important that future studies take full account of the contribution made by obesity to risk factors for metabolic/vascular complications.

Polycystic ovaries are inherited as an autosomal dominant trait: analysis of 29 polycystic ovary syndrome and 10 control families

The aim of this study was to obtain evidence for the genetic basis of polycystic ovaries (PCO) and premature male pattern baldness (PMPB) by screening first-degree relatives of women affected by polycystic ovary syndrome (PCOS). Because of the high prevalence of PCO in the general population, we also studied first-degree relatives of ten asymptomatic control volunteers of reproductive age. The probands were recruited prospectively from infertility and endocrine clinics, where they presented with various clinical symptoms of PCOS. Each had PCO, on transvaginal ultrasound scan. The families of 29 probands and 10 volunteers agreed to take part in the study. Clinical, ultrasound, and biochemical parameters were used to define PCO/PCOS. All female relatives had an ovarian ultrasound scan and hormone profile performed. History was used to assign status in postmenopausal women. All male relatives were assessed for early onset (<30 yr old) male pattern baldness, by photographs. All relatives were assigned affected (PCO/PMPB) or nonaffected status, and segregation analysis was performed. Of the relatives of 29 PCOS probands, 15 of 29 mothers (52%), 6 of 28 fathers (21%), 35 of 53 sisters (66%), and 4 of 18 brothers (22%) were assigned affected status. First-degree female relatives of affected individuals had a 61% chance of being affected. Of the first-degree male relatives, 22% were affected. Of a total of 71 siblings of PCOS probands, 39 were affected, giving a segregation ratio of 39/32 (55%), which is consistent with autosomal dominant inheritance for PCO/PMPB. In the control families, 1 of 10 probands (10%), 1 of 10 mothers (10%), no fathers, 2 of 13 sisters (15%), and 1 of 11 brothers (9%) were affected. Of a total of 24 siblings, 3 were affected (13%), giving a segregation ratio (observed/expected) of 3/12, which was significantly different from autosomal dominant inheritance. The inheritance of PCO and PMPB is consistent with an autosomal dominant inheritance pattern in PCOS families, perhaps caused by the same gene. There was no such genetic influence in families of women without PCOS. Sisters of PCOS probands with polycystic ovarian morphology were more likely to have menstrual irregularity and had larger ovaries and higher serum androstenedione and dehydroepiandrosterone-sulfate levels than sisters without PCO. This suggests a spectrum of clinical phenotype in PCOS families. Men with PMPB had higher serum testosterone than those without. Collectively, these data are consistent with a role for genetic differences in androgen synthesis, metabolism, or action in the pathogenesis of PCOS.

Outcome of twin pregnancies complicated by a single intrauterine death: a comparison with viable twin pregnancies

OBJECTIVE

To examine the perinatal and maternal outcomes in twin pregnancies when a single intrauterine death occurs.

METHODS

This was a retrospective, observational study. Comparison was made to viable twin pregnancies.

RESULTS

Of a total 34,804 live deliveries, 342 were documented as twin births at a gestation of greater than 20 weeks (incidence 0.98%). Of the twin pregnancies over this period, 20 (5.85%) were complicated by a single intrauterine death. There was an increase in the incidence of congenital structural abnormalities among those twins dying in utero as compared to uneventful twin pregnancies (25 versus 0.3%; P < .001). A significant proportion of these twin pregnancies had monochorionic placentas (35 versus 9%; P < .001) and were admitted to special care units (70 versus 5.6%; P < .001) as compared to the normal twin sample. Maternal morbidity has previously been described as being increased. Although there was an increased risk of nonproteinuric and mild pregnancy-induced hypertension, no adverse maternal effects of conservative management were noted in this study.

CONCLUSION

The risk of a single fetal death in twin pregnancies is increased with a monochorionic placenta or a structural abnormality. Conservative management and regular surveillance seem advisable.

Impact of freeze drying on drug resistance pattern of few Escherichia coli strains

Drug resistant strains of E. coli were freeze dried for long term preservation. Certain drug resistance markers were maintained after freeze drying while others were not. Streptomycin and sulphonamide resistance markers resisted freeze drying. Ampicillin, cephelaxin and neomycin resistances developed very frequently and except gentamicin all the markers were lost in varying percentage after freeze drying.

Retinal hemorrhages in newborn

Two hundred and fifty eight newborn babies were studied for the presence of retinal hemorrhages between 1-3 days of birth. The overall incidence of retinal hemorrhages was found to be 18.9%. It was observed that the incidence of retinal hemorrhages was higher in unassisted vaginal deliveries than in assisted births. Also, a two fold higher incidence was noted in term infants as compared to preterm babies. No association was seen with birth asphyxia.

Aphakic macular edema: some observations on prevention and pathogenesis

A prospective controlled trial of topical 0.1% dexamethasone drops was undertaken with the purpose of determining its efficacy in the prevention of aphakic macular edema. Of the 56 eyes studied specifically at the second and sixth postoperative weeks, none of the 28 in the steroid group showed macular edema, whereas the incidence in the nonsteroid group was 17.1% (P less than .01). The study highlights the role of steroids in reducing the incidence of postoperative macular as well as corneal edema. On the basis of earlier evidence and our observations on the conjunctival hyperfluorescence, the hypothesis for the genesis of macular edema has been modified.