Should We Be Concerned About Asymptomatic Adnexal Masses in Female Kidney and Liver Graft Recipients?

BACKGROUND

Pathological changes of uterine adnexa are frequently encountered in patients after solid-organ transplantation. The aim of the study was to evaluate the incidence of malignancies among recipients operated with the diagnosis of adnexal tumor with or without clinical symptoms.

METHODS

We retrospectively analyzed data from 146 solid-organ recipients who underwent surgery in the First Department of Obstetrics and Gynecology, Medical University of Warsaw, in the years 2000 to 2014. Among them, we identified 80 patients of mean age 40.9 ± 11.1 years with suspected adnexal tumor. Data on symptoms reported by patients were compared with the results of histopathological examination after surgical treatment.

RESULTS

Kidney recipients were 76.2% of the group studied (including 5 women after kidney and pancreas transplantation); the remaining 23.75% of patients were liver recipients (including 1 kidney and liver). The majority of patients (71.25%) reported no clinical symptoms. The remaining 28.75% of patients had clinical complaints, with the most common symptom being abdominal pain (in 60% of patients). Analysis of the results of histopathological examination revealed that in both groups, the most often encountered pathological findings were serous cystadenoma (33.3% and 47% of patients, respectively), endometrial cysts (24.6% and 21.7%, respectively), and functional cysts (22.8% and 17.3%, respectively). None of the asymptomatic patients were diagnosed as malignant, whereas 2 cases (both ovarian and fallopian tube cancer) were diagnosed among women who reported clinical symptoms.

CONCLUSIONS

Observations of patients after organ transplantation indicate a recurring nature of adnexal changes, resulting in qualification for surgical treatment. The survey results suggest that solid-organ recipients with pathology in the uterine adnexa, with non-suspicious ultrasound image and not reporting clinical symptoms, could safely be subjected to clinical observation providing strict supervision.

Contraception in women after organ transplantation

INTRODUCTION

Organ transplantation has improved the quality and length of life for many people suffering from end-stage diseases, among them women of reproductive age. Therefore, it has made pregnancy possible for those previously unable to conceive. Nevertheless, conception itself should be desired and properly timed in these specific patients to ensure the best possible perinatal outcome.

OBJECTIVE

The objective of the study was to assess whether female graft recipients apply proper family planning methods and use effective contraception.

METHODS

In a single-center, observational study, information was collected using a self-administered questionnaire distributed among 100 female graft recipients (post-transplant group [TG]) and 67 healthy female volunteers (control group [CG]). The survey covered data regarding present menstrual patterns, sexual activity, gynecological counseling, and contraceptive methods used.

RESULTS

Female graft recipients were more sexually active after than before transplantation (87% vs 64%, P = .0001) and equally active as controls. Sexually active post-transplantation patients used contraception less frequently than sexually active controls (51.72% vs 82.76%, P < .0001). Condoms were the most frequently used method in TG, and oral contraception in CG. Oral contraception was used more rarely by counseled graft recipients than by counseled controls (3.9% vs 60.7%, P < .0001). After counseling, intrauterine device usage increased and oral contraception usage decreased in TG. Among women with chronic diseases, intrauterine device was used more often in TG (4% vs 0%), whereas oral contraception was used more often in CG (8.3% vs 50%, P < .0001).

CONCLUSIONS

Despite the fact that post-transplantation women of reproductive age have many indications for highly effective contraception, only few of them actually use it. Contraceptive counseling has to be included as part of routine post-transplantation care by all health professionals involved in the management of female graft recipients of reproductive age.

Intrapartum GBS screening and antibiotic prophylaxis: a European consensus conference

Group B streptococcus (GBS) remains worldwide a leading cause of severe neonatal disease. Since the end of the 1990s, various strategies for prevention of the early onset neonatal disease have been implemented and have evolved. When a universal antenatal GBS screening-based strategy is used to identify women who are given an intrapartum antimicrobial prophylaxis, a substantial reduction of incidence up to 80% has been reported in the USA as in other countries including European countries. However recommendations are still a matter of debate due to challenges and controversies on how best to identify candidates for prophylaxis and to drawbacks of intrapartum administration of antibiotics. In Europe, some countries recommend either antenatal GBS screening or risk-based strategies, or any combination, and others do not have national or any other kind of guidelines for prevention of GBS perinatal disease. Furthermore, accurate population-based data of incidence of GBS neonatal disease are not available in some countries and hamper good effectiveness evaluation of prevention strategies. To facilitate a consensus towards European guidelines for the management of pregnant women in labor and during pregnancy for the prevention of GBS perinatal disease, a conference was organized in 2013 with a group of experts in neonatology, gynecology-obstetrics and clinical microbiology coming from European representative countries. The group reviewed available data, identified areas where results were suboptimal, where revised procedures and new technologies could improve current practices for prevention of perinatal GBS disease. The key decision issued after the conference is to recommend intrapartum antimicrobial prophylaxis based on a universal intrapartum GBS screening strategy using a rapid real time testing.

Intrauterine hypotrophy and premature births in neonates delivered by female renal and liver transplant recipients

BACKGROUND

Neonates born to mothers, who underwent organ transplantation require close medical monitoring. It is unknown how chronically diseased mother's organs or immunosuppressive drugs affect fetal growth and development; some immunosuppressants are teratogenic and contraindicated during pregnancy. The aim of this study was to determine the prevalence of prematurity and intrauterine growth restriction in neonates born to women who have undergone renal or liver transplantation.

METHODS

Our retrospective analysis identified 53 (25 renal and 28 liver) cases of neonates delivered by female graft recipients between January 2005 and December 2009. Hypotrophy was defined as a birth weight<10th percentile for gestational age. We excluded newborns diagnosed with severe hypotrophy (<5th percentile).

RESULTS

Neonates born prematurely were predominate in the renal (16/25, 64%), but less than half of the liver cohort (13/28, 46%). Hypotrophy less than the 10th percentile was noted significantly more often among renal than liver recipients; 36% versus 14% (P<.05). Severe hypotrophy was also observed significantly more often among renal than liver transplant neonates: 28% versus 3.6% (P<.001).

CONCLUSIONS

Compared with liver insufficiency, chronic kidney diseases have stronger effects on the fetus, leading to adverse neonatal complications. A greater prevalence of preterm births, as well as hypotrophic newborns, especially less than the 5th percentile, was observed among neonates delivered by mothers after kidney transplantation.

Pregnancy outcomes among female recipients after liver transplantation: further experience

INTRODUCTION

Liver transplantations give female recipients an ability to carry pregnancies successfully. However, solid organ transplantations exacerbate the pregnancy including maternal and neonatal outcomes. The aim of our study was to evaluate and identify the obstetric outcomes in women with a prior liver transplantation.

METHODS

We analyzed all pregnant woman who had undergone a prior liver transplantation and afterward delivered from 2001 to 2011. Complete data were assessed in 39 deliveries and 40 live births. Three women were pregnant twice after liver transplantation.

RESULTS

The mean gestational age at birth measured 37.2±2.2 weeks. The most common obstetric complications were premature labor (12/39,30.8%), hypertension (10/39, 25.6%), and symptomatic urinary tract infections (7/39, 18%). Other complications were pregestational diabetes (n=1), cholestasis (n=3), and of severe anemia treated with blood transfusions (n=2). The mean time from organ transplantation to delivery was 67.6±47.2 months. Acute graft rejections occurred among pregnant women 7.7% (3/39) of studied. Only 8 (20.5%) deliveries were finished vaginally. Infants small for gestational age were diagnosed in 20% (8/40). One case displayed a congenital urinary tract malformation. None of the neonates died neonatally.

CONCLUSIONS

Pregnancies are possible after liver transplantation and likely end with successful maternal and newborn outcomes. Some cases experience an increased risk of obstetric complications. Therefore, posttransplant pregnancies must be regularly monitored with a multidisciplinary approach.

Menstrual function in female liver transplant recipients of reproductive age

BACKGROUND AND AIM

End-stage liver failure is associated with severe abnormalities in menstrual and reproductive function. These abnormalities may be reversed by successful orthotopic liver transplantation (OLT). The aim of the study was to investigate menstrual patterns and sex hormone profiles among female liver transplant recipients of reproductive age.

METHODS

The study group consisted of 24 women of reproductive age with end-stage liver failure who underwent successful OLT. Menstrual patterns and sex hormone profiles were analyzed before as well as 3 and 12 months after OLT. Twenty-seven healthy women of reproductive age served as controls. Biochemical parameters of liver function were assessed before and after OLT.

RESULTS

Amenorrhea was the most commonly observed abnormality of menstrual cycle in women with end-stage liver failure (71% of patients). The recurrence of regular menstrual cycles was observed in 35% of patients 3 months after OLT. The percentage increased to 70% at 1 year after grafting and was clearly associated with stabilization of liver function. Similar levels of follicle stimulation hormone (FSH), luteinizing hormone (LH), prolactine (PRL), and testosterone (T) as well as lower levels of estradiol (E(2)), dehydroepiandrostendione sulphate (DHEA-S), and progesterone, (P) were observed in patients with liver failure compared with healthy women. We observed normalization of E(2) and DHEA-S levels after OLT.

CONCLUSIONS

Amenorrhea, the most common menstrual disturbance in women with end-stage liver failure, may be reversed by OLT. One year after OLT menstrual bleedings were noted in 74% of patients of reproductive age. The recurrence of reproductive function indicated the need for effective and safe family planning methods in that group of patients.

Anti-Co(a) implicated in severe haemolytic disease of the foetus and newborn

The Colton (Co(a)) antigen is of high frequency; its incidence in Caucasians is about 99.8%. Reports on haemolytic transfusion reactions and haemolytic disease of the foetus/newborn (HDFN) due to anti-Co(a) are rare. We report a severe HDFN due to anti-Co(a). The first child of the mother was healthy. The second died a few hours after delivery because of hydrops fetalis, likely due to HDFN; anti-Co(a) in the maternal serum, the father typed as Co(a+). The third pregnancy was followed up by the measurements of anti-Co(a) titre (additional antibodies were excluded), its functional activity by the chemiluminescence test (CLT) and the Doppler flow in the middle cerebral artery of the foetus. Increased values of antibody titre up to 128, the CLT to 30% and multiplex of median of the peak systolic velocity to 1.71 indicated haemolytic disease and the necessity for an intrauterine transfusion. The foetus received the maternal red blood cells (RBCs). Delivery had to be by Caesarean section for obstetrical reasons at 34-week gestation. The newborn (anti-Co(a) on red cells and in plasma, the rise of the bilirubin concentration up to 333 micromol L(-1)) had four exchange transfusions: the first of maternal RBCs, the remaining of donor's Co(a+) cells and one top-up transfusion. The baby was discharged in good health. Anti-Co(a) was responsible for severe HDFN. Proper monitoring during pregnancy and antenatal and post-natal therapy were successful. This is the second severe published HDFN due to anti-Co(a).

Mode of delivery in women after liver transplantation

AIM

A high rate of cesarean sections has been reported among high-risk pregnancies in liver transplant recipients. The aim of this study was to analyze the course of deliveries and the indications for cesarean sections in women after liver transplantation.

MATERIALS AND METHODS

From 2001 to 2006, we noted 21 deliveries in 17 liver recipients. The mean age of women was 27.9 +/- 6.6 years and the mean time from transplantation to pregnancy was 4.3 +/- 3.6 years. Most patients were primigravidas on tacrolimus-based immunosuppressive regimens. We retrospectively analyzed obstetric data regarding the delivery and the early puerperium.

RESULTS

We noted 6 vaginal deliveries (29%) and 15 cesarean sections (71%). Mean gestational age in the group of vaginal deliveries was 37.6 +/- 2.2 weeks. No labor complications were noted. All neonates were delivered in a good state (Apgar score from 8 to 10 points) with mean birth weight of 2725 g. All cesarean sections were performed for obstetric indications: fetal distress, breech presentation, intrauterine growth retardation, or complications related to premature labor. Mean gestational age was 37.0 +/- 1.9 weeks. The Apgar scores ranged from 4 to 10 points; mean birth weight was 2787 g. The mean period of hospitalization after surgical labor was 4 days longer compared with the vaginal delivery group.

CONCLUSION

The high rate of cesarean sections (71%) in liver recipients is associated with a great incidence of obstetric complications of pregnancy. Safe and uneventful vaginal delivery is possible with growing experience in the management of pregnant transplanted women.

Low-dose hormonal contraception after liver transplantation

OBJECTIVES

End-stage liver failure is associated with extremely reduced fertility. After liver transplantation, restoration of menstrual function is observed; thus effective contraceptive methods should be employed in patients who do not plan to conceive. The aim of this study was to assess tolerability and safety of hormonal contraceptives in female liver transplant recipients.

MATERIALS AND METHODS

We retrospectively analyzed data on 15 female liver graft recipients, aged 24 to 35 years, who used hormonal contraceptives after liver transplantation for a time not shorter than 12 months. The period from grafting to administration of hormonal contraceptives varied from 6 months to 7 years. Biochemical parameters of liver function, fasting glucose levels, body mass index (BMI) as well as blood pressure were monitored at 0, 3, 6, and 12 months of therapy. Side effects of the treatment were noted on regular follow-up examinations.

RESULTS

No case of pregnancy or graft rejection was observed on therapy. Changes of biochemical parameters were not significant (aspartate transferase 22.92 +/- 6.67 vs 25.54 +/- 7.90, alanine transferase 22.08 +/- 5.66 vs 24.27 +/- 7.57, total bilirubin 0.96 +/- 0.17 vs 1.02 +/- 0.15). Blood pressure and BMI remained stable in the group. None of the patients discontinued therapy for medical indications.

CONCLUSION

Hormonal contraception was administered as soon as liver transplant function was stable. It was effective, well tolerated, and did not seem to impair graft function. However, a long-term prospective study is necessary to assess the safety of hormonal contraception in transplant recipients.

Menstrual Cycle and Sex Hormone Profile in Perimenopausal Women After Liver Transplantation

Excellent long-term outcomes of transplant patients let many female liver-recipients experience perimenopausal problems. This study assessed menstrual patterns and sex hormone profiles in women of perimenopausal age who experienced end-stage liver failure treated by transplantation (OLT).

MATERIALS AND METHODS

Menstrual patterns, sex hormone profiles, and biochemical parameters of liver function were analyzed before and after OLT in 13 liver-transplanted patients of perimenopausal age. Nineteen healthy perimenopausal women served as controls.

RESULTS

The most common abnormality of the menstrual cycle observed in the study group was secondary amenorrhea, which affected six liver-transplanted women. Three months after OLT amenorrhea was still observed in six patients, regular menstrual cycles in six and irregular bleeding in one graft recipient. One year after transplantation regular menstruations were noted in four, irregular bleeding in four, and secondary amenorrhea in five liver-transplanted women. Similar levels of follicle stimulating hormone, luteinizing hormone, prolactin, progesterone and testosterone as well as lower levels of estradiol and DHEA-sulfate were observed in patients with liver failure, both before and after grafting, compared with healthy women. After OLT E2 levels increased from 32.05 +/- 18.04 to 49.12 +/- 22.21.

CONCLUSIONS

One year after OLT disturbances in menstrual patterns affect most (69%) perimenopausal female liver recipients. Both before and after OLT significantly lower levels of estradiol and DHEA-S were observed in transplanted patients compared with healthy controls. Hormonal therapy of amenorrhea or irregular menstruations may be required in that group of patients.