BACKGROUND The management of asymptomatic cryptococcal antigenemia in pregnant women with advanced human immunodeficiency virus (HIV) disease presents a therapeutic dilemma. Clinicians must balance the risks of vertical transmission, immune reconstitution inflammatory syndrome (IRIS), and antifungal teratogenicity. CASE SUMMARY We report a case of a 28-year-old HIV-positive woman in Kenya who presented at 34 weeks of gestation with symptoms suggestive of meningitis. She had self-discontinued her antiretroviral therapy (ART) 18 months prior. Laboratory investigations confirmed a positive serum cryptococcal antigen (CrAg) with a high HIV viral load (41200 copies/mL). Lumbar puncture ruled out meningeal involvement. A multidisciplinary team initiated preemptive therapy with high-dose fluconazole (800 mg daily). Faced with her advanced gestation and the imperative to prevent perinatal transmission, a calculated risk was taken to initiate ART (tenofovir/lamivudine/dolutegravir) after only 7 days, a significant deviation from standard guidelines. At 36 weeks, she had a spontaneous vaginal delivery complicated by uterine inversion and postpartum hemorrhage, which was managed successfully. She did not develop cryptococcal IRIS. At 3-month follow-up, her viral load was suppressed (51 copies/mL), and her infant was HIV-negative with normal development at 6 months. CONCLUSION This case highlights the importance of routine CrAg screening in pregnant women with advanced HIV. Preemptive fluconazole in the third trimester is feasible. The timing of ART initiation may need individualization to prevent vertical transmission in late gestation, particularly in the context of isolated antigenemia, where the IRIS risk profile may differ from cryptococcal meningitis. These decisions require multidisciplinary input and close monitoring.
Heart failure (HF) during pregnancy presents unique challenges due to the complex interplay between physiological changes and underlying cardiac conditions. Pregnancy-induced increases in blood volume, cardiac output, and heart rate can exacerbate pre-existing heart diseases or trigger new-onset HF, such as peripartum cardiomyopathy and preeclampsia-related HF. With pregnancy-related physiological changes altering pharmacokinetics, dosage adjustment becomes crucial, making its application limited to carefully selected cases where benefits outweigh the risks. Medication management for these patients requires a meticulous approach. Beta-blockers like metoprolol and bisoprolol are preferred despite limited evidence, and carvedilol may be cautiously used per clinical experience; atenolol is contraindicated for low-birth-weight risk. Diuretics (furosemide, bumetanide) are safe for congestion relief but warrant judicious dosing. Digoxin is generally safe but requires dose adjustment and regular monitoring due to pregnancy-induced pharmacokinetic alterations. Among positive inotropes, dobutamine exhibits favorable safety in pregnancy, whereas milrinone should be used cautiously for hypotension risk. Renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors are all contraindicated owing to risks of fetal malformations, male fetal feminization, and insufficient safety evidence, respectively.
A progressive decline in fertility is a well-documented aspect of female aging and is associated with a range of cellular and molecular alterations, including genomic instability and modifications in epigenetic regulation. Epigenetic clocks, which estimate biological age based on DNA methylation patterns, have been extensively utilized to evaluate general health status and the risk of various diseases. Despite their broad application, the utility of epigenetic clocks in assessing female reproductive health remains only partially characterized. This minireview consolidates recent advancements in the application of epigenetic clocks to evaluate the functional status of the female reproductive system. The objective is to investigate their potential for quantifying and predicting the biological age of reproductive tissues, thereby establishing a theoretical basis for clinical applications in reproductive medicine. To date, no comprehensive minireview has systematically examined multi-tissue epigenetic clock models in the context of female reproductive aging, positioning this minireview as a novel contribution to the field.
BACKGROUND Fear of childbirth (FoC) is a widespread issue that impacts the health and well-being of mothers and newborns. However, there is inconsistency regarding the prevalence of FoC in the and there is limited research on the prevalence of FoC among Australian pregnant women. AIM To investigate the prevalence of FoC, its risk factors and birth outcomes in Australian multiparous women. METHODS In this prospective cohort quantitative study, 212 multiparous women were recruited from antenatal clinics at Westmead Hospital in western Sydney from 2019 to 2022. Pregnant women who attended antenatal visits and met the inclusion criteria signed the consent forms and completed several online questionnaires at baseline. After they gave birth, their birth outcomes were collected from the hospital’s medical record database. The data were analyzed using SPSS software and descriptive statistics, χ 2 test, independent samples t -test, and multivariable logistic regression analysis. RESULTS Out of 212 participants, 24% experienced a high level of FoC and 7% experienced severe FoC. The χ 2 test results revealed that a family income of ≤ $100000, no alcohol intake during pregnancy, pre-existing health problems, previous caesarean section (emergency or planned), and previous neutral/traumatic childbirth experiences were significantly associated with higher levels of FoC (P < 0.05). Other risk factors included being moderately to very worried and fearful about the upcoming birth, having severe to extremely severe anxiety throughout pregnancy, and expressing low relationship satisfaction. According to multivariable logistic regression, the odds of a high level of FoC were higher in women with anxiety, a history of traumatic childbirth experience, a history of sexual assault during childhood, pre-existing health problems, and lower relationship satisfaction (P < 0.05). CONCLUSION High-severe levels of FoC are experienced by pregnant multiparous women and are affected by several demographic factors. However, due to the small sample size in the present study, further studies with larger sample sizes are required to draw a firm conclusion on the prevalence of severe FoC among multiparous women and its associated risk factors and birth outcomes.
BACKGROUND The prevalence of gestational diabetes mellitus (GDM) has been increasing worldwide and is associated with multiple adverse pregnancy outcomes. Despite standard screening, some cases remain undiagnosed. Fibroblast growth factor 21 (FGF21) plays a role in modulating glucose metabolism. There is an ongoing controversy regarding the relevance of FGF21 to GDM. AIM To evaluate the association between early second trimester serum FGF21 levels and gestational diabetes, and its predictive potential for outcomes. METHODS This cross-sectional observational study was conducted at a tertiary medical center, Chiang Mai University, Thailand. It included 28 pregnant women diagnosed with GDM and 81 pregnant women with normal glucose status. Blood samples were collected according to the study schedule, and pregnancy outcomes were recorded meticulously. Descriptive analysis was employed to evaluate the data. RESULTS Most participants in our study had no risk factors for GDM (body mass index < 24 kg/m2, no first-degree relatives with diabetes, no history of GDM), normal baseline glucose status (fasting glucose < 110 mg/dL), and no insulin resistance (homeostatic model assessment of insulin resistance < 2). There was a trend of increased FGF21 levels in the insulin-treated GDM group compared with dietary-treated GDM and non-GDM (73.58 pg/mL vs 62.94 pg/mL vs 63.59 pg/mL, respectively, P = 0.73). However, no significant association was found between FGF21 concentrations and pregnancy outcomes based on quintiles of FGF21 levels. CONCLUSION FGF21 was not associated with GDM or pregnancy outcomes; however, due to the small sample size, larger clinical trials with a diverse population are suggested to confirm these results.
BACKGROUND Eclampsia is a generalized tonic-clonic seizure induced by pregnancy. It contributes to a high rate of maternal and neonatal morbidity and mortality worldwide. Eclampsia is characterised by classic signs such as elevated blood pressure, proteinuria, and seizures. However, it may occur in the absence of hypertension and/or proteinuria. The uncommon appearance of eclampsia makes it difficult to immediately assess and treat it. In addition, the occurrence of this case in a remote area makes it more challenging to handle. The objective of this case report is to increase awareness of uncommon manifestations of eclampsia, particularly in limited-resource settings. CASE SUMMARY A young primigravida experienced a generalised seizure without hypertension and/or proteinuria. Sudden hearing loss, blurred vision, and vomiting were complained about before the seizure attack. The patient was diagnosed with eclampsia. A loading dose of magnesium sulphate was administered immediately. The patient was referred from community healthcare to a hospital and discharged without any complications. CONCLUSION Atypical eclampsia may be a diagnostic challenge. However, other symptoms may be beneficial, such as awareness of eclampsia signs.
This paper reviews management of obstetric anaemia and the role of intravenous iron for the treatment of obstetric anaemia. Red blood cell transfusions are routinely used for haemoglobin restoration in anaemic women. The decision for red blood cell transfusion is made on a combination of haemoglobin level and clinical status, and it is suggested that transfusions are not necessary in those who are well compensated or when alternative therapy is available. To reduce the risk, intravenous iron infusion is proposed as a bloodless therapeutic approach. There are a variety of iron preparations. Intravenous iron infusion can reduce the requirement for blood transfusion in hemodynamically stable women with perinatal anaemia, especially in resource-scarce settings. It a cost-effective bloodless approach for the treatment of anaemia than can enhance patient outcomes. According to the literature, when haemoglobin is greater than 90 g/L, blood transfusion is not often required. In perinatal women with anaemia, the decision whether to administer blood or iron is based on patient preferences, haemoglobin levels, clinical symptoms, past and present medical conditions and the clinician’s judgement. Nevertheless, due to the lack of rigid criteria for blood transfusions in the majority of clinical settings, it is considered the default treatment for anaemia in perinatal women.
BACKGROUND Preeclampsia（PE） is a pregnancy syndrome of undetermined etiology; inflammation was one of the proposed theories for its development.AIM To examine the platelet to lymphocyte ratio（PLR）, an inflammatory biomarker, as a marker to predict poor maternal-neonatal outcomes in early-onset PE（EoPE）.METHODS A cross-sectional study enrolled 60 pregnant women with EoPE（at 32-30 wk of gestation） at a university hospital. Demographic criteria and hematological indices were collected, including platelet counts and indices（mean platelet volume and platelet distribution width）, PLR, and the Doppler study, which calculated estimated fetal weight（EFW）, amniotic fluid index（AFI）, resistance index（RI）, and pulsatility index（PI）. Participants were followed until delivery,where maternal outcomes were recorded, including; delivery mode and reason for cesarean section, and neonatal outcomes, including fetal growth restriction（FGR）, meconium-stained liquid, the 5-min Apgar score, and admission to the intensive care unit.RESULTS There was a trend of insignificant increases in cesarean sections. Sixty-one-point two percent（37/60） fetuses were admitted to the neonatal care unit; 70.0% of admitted fetuses were meconium-stained liquor, and 56.7% of them had FGR.PLR was positively correlated with AFI and EFW as r = 0.98, 0.97, P ＜ 0.001; PLR showed negative correlations with PI and RI as r =-0.99,-0.98, P ＜ 0.001. The Apgar score and the number of days admitted to the intensive care unit had a positive and negative correlation（0.69,-0.98）, P ＜ 0.0001, respectively. Receiver operating characteristic calculated a PLR cutoff value（7.49） that distinguished FGR at 100%sensitivity and 80% specificity.CONCLUSION Strong, meaningful relationships between PLR and FGR parameters and a poor neonatal outcome with a significant P value make it a recommendable biomarker for screening EoPE-related complications. Further studies are suggested to see the impact on maternal-neonatal health.
BACKGROUND Vaginal stones are rare with current literature limited to case reports. Vaginal stones are classified as primary or secondary stones. Primary stones form in the vagina when there is urinary stasis. Secondary stones form in the presence of a vaginal foreign body that acts as a nidus for the deposition of urinary salts.Foreign bodies, such as surgical mesh, make vaginal stone formation more likely,particularly in patients with urinary incontinence and conditions that predispose them to urinary calculi formation.CASE SUMMARY A 71-year-old female with a history of sacrocolpopexy, hyperaldosteronism, and urgency urinary incontinence presented with vaginal stone accumulation overlying two areas of vaginal sacrocolpopexy mesh exposure. The vaginal stones were initially removed to permit examination, but the stones reaccumulated at the site of the exposed mesh, later requiring definitive surgical management.CONCLUSION Patients with vaginal mesh exposure and conditions that predispose them to kidney stones are not ideal candidates for expectant management of mesh exposure, particularly if they have coexisting urinary incontinence. These individuals should be counseled about possible vaginal stone accumulation, and surgical management should be considered.
BACKGROUND Spilled gallstones from previous cholecystectomy is not an uncommon situation. It may further mimic neoplastic disease and can be misled by fluorine 18 fluorodeoxyglucose position emission tomography with computed tomography（[18F]FDG PET/CT）.CASE SUMMARY A 63 year-old patient was diagnosed with a cancer of the cervix. Pretreatment [18F]FDG PET/CT showed a peritoneal lesion suspicious for metastasis. Surgical exploration and histologic examination revealed the lesion to be a spilled gallstone from a previous cholecystectomy.CONCLUSION [18F]FDG PET/CT carries pitfalls since benign conditions such as intraperitoneal gallstones may be confused as malignant lesions. This case highlights the importance to be aware of the possible implications of dropped gallstones for the future, minimize its occurrence, and make all efforts to properly evaluate cancer staging, particularly for the cervix cancer.
Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version（ECV） refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.
BACKGROUND One of the main difficulties faced in the prevention of the vertical transmission of syphilis is the inadequate treatment of pregnant women and their partners. The disease causes serious repercussions in infected newborns.AIM To evaluate the prevalence and factors associated with the therapeutic adhesion among partners of pregnant women with syphilis in a county in Northeastern Brazil.METHODS This is a descriptive, analytic, quantitative, cross-sectional study that was carried out through interviews with 46 pregnant women diagnosed with syphilis between 2017 and 2018 as well as with their partners. The interviews aimed at collecting data regarding sociodemographic characteristics, obstetric variables and information about syphilis, and partners’ related variables.RESULTS Our results showed that 73.91% of the partners did not undergo appropriate treatments, and obtaining negative results in syphilis tests was the main reason for the absence of therapies. The following factors were significantly associated with the lack of treatment among partners: Being a partner that is not the current mate of the pregnant woman, having a level of schooling inferior to 8 years [odds ratio（OR） = 10.28], and the pregnant woman undergoing up to two syphilis tests during the prenatal care（OR = 8.6）. The study found a higher odds of absent treatment among partners if the pregnant woman is not white（OR = 13.88） or if the partner has less than 8 years of schooling（OR = 21.00） or has a monthly income of less than half the minimum wage（OR = 13.93）.CONCLUSION The findings of this study show a high prevalence of partners that are not adequately treated for syphilis, a phenomenon that is strongly associated with socioeconomic factors.
BACKGROUND Epithelioid hemangioendothelioma（EHE） is an extremely rare tumor with a prevalence of one in a million and a very heterogenous spectrum of disease that varies from an indolent to a metastasizing aggressive disease, with the liver, lung and bone being the primarily involved organs. Peritoneal forms of EHE are even rare, and only 12 cases have been reported to date in the literature.CASE SUMMARY A 66-year-old female came to our attention complaining low abdominal and perineal pain. Magnetic resonance imaging examination showed a 52 mm × 58 mm × 32 mm cystic mass with some smooth septa, simulating an ovarian cyst. Explorative laparoscopy demonstrated the presence of a peritoneal mass of augmented consistency connected with a sigmoid epiploic appendix in the right side of the Pouch of Douglas, that was surgically removed. Histological examination revealed a primitive peritoneafl hemangioendothelioma. The patient easily recovered from surgery with no residual pain or discomfort. She is regularly attending a 3-years follow-up that is negative for local recurrence of disease or distant metastases.CONCLUSION Peritoneal form of EHE often simulates masses of other nature, as in our case. Given its unspecific clinical and radiological presentation, patients are often forced to a large series of tests and examinations before reaching a definitive diagnosis, that can only histologically made. The possibility of EHE should always be considered in case of unexplained chronic abdominal pain associated to a non-specific mass.
Self-monitoring of blood glucose（SMBG） is critical for gestational diabetes mellitus（GDM） care. However, there are several hurdles to its practice during the coronavirus disease 2019（COVID-19） pandemic in GDM patients in low-and middle-income countries when GDM care recommendations emphasize telemedicine-based care. Based on available knowledge, this letter proposes the following barriers to SMBG in these GDM patients during the ongoing COVID-19 pandemic: Poor internet connectivity, affordability of SMBG and digital applications to connect with healthcare providers, government-imposed social mobility restriction, psychological stress, and mental health conditions. Nevertheless, definitive evidence will only be acquired from rigorous research.
BACKGROUND Hormones could play a role in the evolution of follicular thyroid cancer（FTC） for which we discuss an unusual presentation of FTC occurring during pregnancy.CASE SUMMARY A pregnant woman was admitted with FTC metastasis resulting in a gluteal mass. Preoperative abdominal computed tomography revealed liver metastasis for which the patient underwent total thyroidectomy and liver resection, oral radioiodine therapy and radiotherapy, followed by embolization of the pelvic mass. The patient died of cerebral hemorrhage 16 mo after the initial diagnosis.CONCLUSION Human chorionic gonadotropin and estrogen stimulation might have a role in cancer growth, especially during pregnancy. FTC management aims to stop disease progression and overcome hormonal imbalances after thyroidectomy thus reducing fetal complications. It is still under debate whether it is possible to combine optimal timing for treatment to ensure the best possible outcome with reduction of fetal complications and risk of cancer growth.
BACKGROUND Microglandular hyperplasia（MGH） is a proliferation of endocervical glands, related to estrogen stimulation, mainly occurring in the reproductive age group. The differential diagnosis includes endometrial adenocarcinoma with MGH-like pattern（MGA）, a distinction that may be particularly problematic in curettage specimen.CASE SUMMARY A 57-year-old, postmenopausal woman was admitted in our hospital for surgical treatment. She had been diagnosed with a uterine leiomyoma, after complaints of irregular vaginal bleeding. She underwent dilatation and curettage（D＆C） and subsequent total abdominal hysterectomy with bilateral salpingo-oophorectomy. D＆C were compatible with MGA. Histologically, a proliferation of small glands, without intervening stroma, with mucin production, accumulation of neutrophils in the gland lumen and stroma, mild nuclear atypia and rare mitoses, were seen. In the hysterectomy specimen, the endometrium was thickened, but without apparent tumor formation. On microscopic examination, a residual similar adenocarcinoma was seen in the isthmus and more conventional-of endometrioid and mucinous type, in the rest of the endometrium.CONCLUSION MGH-like proliferation with mild cytologic atypia, detected in the endometrial curettage specimen of a postmenopausal woman, should alert pathologists for MGA of the endometrium. VIM, p16, PAX-2, CD10 and CD34 may help in the differential diagnosis.
Transition into fatherhood is often marked by a period of adjustment, uncertainty and psychological distress and challenges for many men, along with social isolation and relationship problems. Risk factors for paternal mental health issues are maternal depression, marital distress, parenting stress, gender role stress, mismatched expectations for pregnancy and after childbirth, poor physical health, inadequate self-care behaviours, avoiding seeking help for mental health issues, and having a child with sleeping, feeding and temperament problems. Paternal depression, anxiety and post-traumatic stress disorder can have negative impacts on the social and emotional wellbeing of fathers, their partners and their children. Nevertheless, these issues are not widely acknowledged, recognised or treated. Men’s mental health illness is a silent crisis. They often fail to seek help due to their feeling of shame, stigma for a lack of emotional control, distress or anxiety related to utilising mental health support services, and underrating the severity of their symptoms. These necessitate the need for timely attention, psychological support and proper education to minimise their risk of mental health issues. Although research has indicated fathers’ inclination toward being included in practices such as the mental health assessment, perinatal education and postnatal educational approaches need to be inclusive of fathers and encourage them to seek support for their paternal mental health issues and parenting difficulties.
