Current Women's Health Reviews

ISSN: 1573-4048

Current Women’s Health Reviews
Volume 3, Number 3, August 2007

Contents


Editorial: Think and Act Globally Pp. i
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Growth Restriction: Etiology, Maternal and Neonatal Outcome. A Review Pp. 145-160
Kjell Haram, Einar Svendsen and Ole Myking
[Abstract] [Purchase Issue/Articles]


Current Concepts and Controversies in the Use of Antenatal Corticosteroid Therapy for Prevention of Neonatal Morbidities Pp. 161-165
Praveen Kumar
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Preeclampsia as a Multifactorial Pregnancy Disorder: Clinical Symptoms, Diagnostic Tools and Research Strategies Pp. 166-176
Ralf Hass, Ismini Staboulidou, Max Wüstemann, Sudip Kundu, Katrin Oehler and Alexander Scharf
[Abstract] [Purchase Issue/Articles]


Fetal Risks of Maternal Diabetes Pp. 177-181
Mikko Loukovaara, Sture Andersson, Vedran Stefanovic and Kari Teramo
[Abstract] [Purchase Issue/Articles]


Season of Birth Effects on Reproduction in Women Pp. 182-189
Susanne Huber and Martin Fieder
[Abstract] [Purchase Issue/Articles]


Primary Prevention of Congenital Abnormalities Due to High Fever Related Maternal Diseases by Antifever Therapy and Folic Acid Supplementation Pp. 190-201
Andrew E. Czeizel, Nándor Ács, Ferenc Bánhidy, Erzsébet H. Puhó and Gábor Vogt
[Abstract] [Purchase Issue/Articles]


Metabolic Syndrome the Gynecologist’s Approach Pp. 202-208
Mira Aubuchon and Margery Gass
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Oocyte Cryopreservation for Elective Preservation of Reproductive Potential Pp. 209-215
Kurt Martinuzzi and Alan B. Copperman
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Abstracts

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Editorial: Think and Act Globally

Our profession is devoted to obtain the wellbeing of those assisted by us but we should be more concerned about the relief of those with major needs. Global health is a major concern of many health sectors on the view that the more deprived populations in the world have an unacceptable low standard of health. In order to obtain an equitable distribution of health care, finding out better solutions and translation of the current knowledge to deprived populations is imperative. In this Journal, we are willing to publish review of interventions that can be broadly applied to low and middle income countries. Also, we are very pleased if any review will be received for publication stating that what is the condition of health care in the developing world. If the review addresses an intervention we would be pleased with the authors providing information about the implementation and results obtained with this intervention in deprived populations.

In this issue, Haram and coworkers updated a severe problem in developing countries such as fetuses who suffered an intrauterine growth restriction. Around 27.6 million of fetal growth retarded infants are born every year around the world and from these about 26.6 millions (96.4%) are born in developing countries. This article reveals the consequences that fetal growth impairment would have in the survival and the quality of life of these newborns. Furthermore, these newborns, on growing up into adults females, will have a greater chance to deliver an IUGR newborn, implying a vicious circle or intrauterine growth restriction.

Several studies have shown that there are two types of IUGR depending on the intrauterine period where growth is impaired. Those having a chronic growth insult are the ones showing significantly poor performance. Populations in developing countries have a higher incidence of chronically malnourished neonates within their IUGR population.

We hope that this Journal could serve as an instrument to provide information not only to health providers but also to health stakeholders, thereby contributing to highlight the major global health needs and to offer review of interventions that can be broadly applied to relief health inequities.


José M. Belizán
(Editor-in-Chief)
Department of Mother &
Child Health Research
Institute for Clinical Effectiveness
and Health Policy (IECS)
Viamonte 2146 (3er Piso)
(C1056ABH) Buenos Aires
Argentina
E-mail: belizanj@allstat.org


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Growth Restriction: Etiology, Maternal and Neonatal Outcome. A Review
Kjell Haram, Einar Svendsen and Ole Myking

Intrauterine growth restriction (IUGR) is an important clinical problem associated with increased perinatal mortality and morbidity. The most preferred small for gestational age (SGA) definition is birth weight below the 10th percentile, adjusted for gestational age. The incidence of IUGR is about 4 to 7 %. A variety of hormones are involved. IUGR may be due to chromosomal defects, smoking, early-onset preeclampsia (< 34 weeks), connective tissue and inflammatory rheumatic diseases, maternal infections, several drugs, twin-to twin transfusion, anorexia nervosa, low maternal pre-pregnancy or small weight gain during pregnancy. High hemoglobin (Hb) levels during the first 10-20 weeks of pregnancy may also cause IUGR. Complications due to IUGR include fetal or neonatal death, dysmaturity, and physical as well as temporary or permanent mental defects. Low birth weight children may have behavioral problems, psychiatric disorders and lower intelligence test scores later in life. There is a relationship between IUGR, timing and progression of puberty, and polycystic ovary syndrome. Fetal changes of lipid metabolism and homeostasis in IUGR may place the grown adult at risk for hypertension, diabetes mellitus and coronary artery disease. Mothers of low weight offspring have an increased risk for cardiovascular and kidney disease later in life.


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Current Concepts and Controversies in the Use of Antenatal Corticosteroid Therapy for Prevention of Neonatal Morbidities
Praveen Kumar

Since Liggins first reported the beneficial pulmonary effects in fetus after maternally administered corticosteroids in 1972, many subsequent studies have demonstrated that antenatal corticosteroids (ACS) administered to mothers can reduce the morbidity and mortality in their preterm neonates. However, serious concerns have been raised that this therapy is being overused and the use of repeated courses of antenatal corticosteroids may be associated with adverse effects on somatic and brain growth in a growing fetus. These concerns have led to the revised guidelines for antenatal corticosteroids use from National Institute of Health. This article will review the normal anatomy, physiology and regulation of function of adrenal gland in the fetus; rationale and evidence for use of antenatal corticosteroids for enhancement of fetal lung maturation; unresolved issues regarding antenatal corticosteroids therapy; and current guidelines for its use.


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Preeclampsia as a Multifactorial Pregnancy Disorder: Clinical Symptoms, Diagnostic Tools and Research Strategies
Ralf Hass, Ismini Staboulidou, Max Wüstemann, Sudip Kundu, Katrin Oehler and Alexander Scharf

Preeclampsia represents a severe pregnancy disorder associated with premature delivery and fetal growth retardation in about 15 per cent of premature births. The clinical symptoms are high blood pressure, proteinuria and edema. This disease may progress into serious complications such as eclampsia, whereby the main problem is represented by convulsions. Other complications may include kidney failure and development of a HELLP syndrome, which includes hypertension, a disruption of the liver, and a significant decrease of red blood cells and platelets. Consequently, the continuously increasing complications during this pregnancy-associated disorder can be life threatening for the mother and the fetus. Whereby the fetal death rate has decreased in recent times, perinatal morbidity continues to be a major problem due to clinically indicated interventional prematurity. Although the sources and specific prognostic markers for this severe pregnancy disorder remain unclear, women with a persistently high resistance in uterine arteries have an increased risk of the subsequent development of a preeclampsia. Doppler ultrasound investigation of the uterine artery in the second trimester of gestation provides a non-invasive method for the study of the uteroplacental blood flow and for the prediction of abnormal outcomes in risk pregnancies with high negative predictive values. Particularly in high-risk women, uterine artery Doppler waveform analysis performs best in the prediction of preeclampsia. In this context, uteroplacental insufficiency, placental abruption and interventional prematurity exhibit major causes of perinatal morbidity and mortality. Moreover, the gestational age at delivery represents a key factor for the neonate, whereby neonatal sepsis remains a cause for concern. In the search for prognostic markers, several research activities at the molecular levels suggested the development of preeclampsia as a multifactorial interplay between oxidative stress products and distinct immunological imbalances. Considering the fetus as an allogene transplant, a continuously increasing accumulation of reactive oxygen species (ROS) together with an enhanced immunological barrier may contribute to endothelial dysfunctions and high blood pressure due to a reduced placental supply followed by placental and fetal growth retardation. Certain growth factors and their cellular receptors have been suggested to contribute to a proper endothelial function, however, imbalances leading to the development of preeclamptic symptoms remain unclear. Likewise, appropriate therapeutic approaches for preeclampsia are still unavailable to date.


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Fetal Risks of Maternal Diabetes
Mikko Loukovaara, Sture Andersson, Vedran Stefanovic and Kari Teramo

Diabetes mellitus is a growing problem globally. Similarly, the number of diabetic pregnancies can be expected to grow. Maternal diabetes increases the risk for congenital malformations, respiratory distress syndrome, and metabolic derangements in the newborn. Maternal diabetes also appears to predispose the offspring to the development of type 2 diabetes. Macrosomia, i.e. excessive growth of the fetus, is probably the most essential problem in diabetic pregnancies in the perinatal period. Macrosomia increases the risk for chronic fetal hypoxia, which may explain the increased occurrence of stillbirth in diabetic pregnancies during the third trimester. In addition, macrosomia increases the risk for shoulder dystocia, which can result in brachial plexus injury and permanent impairment of the function of the arm. The biochemical mechanisms by which maternal diabetes stimulates fetal growth are complex. According to a classical hypothesis, maternal hyperglycemia causes hyperglycemia in the fetus. This increases the secretion of insulin, which acts as the primary anabolic hormone of fetal growth. Moreover, the insulin-like growth factor system, fibroblast growth factor-2 and leptin may play a role in the regulation of intrauterine growth. The risks associated with maternal diabetes emphasize close pregnancy surveillance especially during the third trimester.


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Season of Birth Effects on Reproduction in Women
Susanne Huber and Martin Fieder

Environmental conditions experienced during foetal and neonatal life influence early development with potential long-term consequences for later life events. In many parts of the world, the external environment varies with the season. This includes factors such as photoperiod, climatic factors, nutrition or prevalence of infectious agents. Birth season is one surrogate for the environmental conditions experienced at conception, during pregnancy, around birth and during early postnatal life. The seasonal variation of environmental factors may thus influence early pre- and postnatal developmental processes differently in individuals born at different times of the year, causing respective downstream effects on later life events. Accordingly there is accumulating evidence that effects of birth season may impact a variety of physical, physiological and psychological parameters in humans. This review covers a survey of birth season effects on reproductive characteristics in women together with a discussion of possible causes, focussing on environmental factors that might play a central role during development, crucial periods of early development that might be influenced by these environmental factors, and potential underlying physiological mechanisms.


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Primary Prevention of Congenital Abnormalities Due to High Fever Related Maternal Diseases by Antifever Therapy and Folic Acid Supplementation
Andrew E. Czeizel, Nándor Ács, Ferenc Bánhidy, Erzsébet H. Puhó and Gábor Vogt

Background: Our previous case-control studies showed an association between high fever related maternal diseases and some congenital abnormalities (CAs). The aim of this review is to summarize the result of these studies completed with available animal and clinical data from the international literature.

Materials and Methods: The Hungarian studies were based on the population-based Hungarian Congenital Abnormality Registry and the Hungarian Case-Control Surveillance of Congenital Abnormalities. The latter included 22,843 cases with 25 different CA and 38,151 matched controls without CA

Results: High fever related maternal diseases such as influenza, common cold with secondary complications, recurrent orofacial herpes and some other acute infectious diseases showed associations with the higher risk for isolated neural-tube defects, cleft lip ± palate, posterior cleft palate, cardiovascular CAs and multiple CAs. These findings were confirmed in the studies of etiological factors in the origin of isolated neural-tube defects, orofacial clefts and multiple CAs, in addition to congenital cataract. The most important results of animal investigations and other human studies related to the teratogenic effect of high fever are also summarized in order to achieve some general conclusions.

Conclusions: Maternal high fever related diseases may associate with some CA and these CAs cover an unusual wide spectrum, which may be connected with the less specific antimitotic effect and heat stress response of hyperthermia. A higher risk for CAs can be expected due to high fever being over 38.5 ºC continuing for one or more days. The timing of hyperthermia determines the risk of specific CAs. The high fever induced CAs represent a high proportion (5-7%) of CAs. The basic indication of our studies is that antifever drugs and periconceptional folic acid/multivitamin supplementation can significantly reduce the teratogenic effect of high fever related maternal diseases. Thus, CAs induced by maternal high fever related diseases are preventable.


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Metabolic Syndrome the Gynecologist’s Approach
Mira Aubuchon and Margery Gass

Metabolic syndrome represents a constellation of symptoms that includes abdominal obesity, lipid abnormalities, and elevated serum glucose. Given that metabolic syndrome affects a high percentage of women and is a risk factor for future cardiovascular disease, gynecologists are in a unique position to recognize and provide initial management for affected patients. The following review will outline screening and basic management strategies for women with metabolic syndrome.


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Oocyte Cryopreservation for Elective Preservation of Reproductive Potential
Kurt Martinuzzi and Alan B. Copperman

Two decades ago the first pregnancy achieved with a frozen thawed human oocyte was reported. This technique transformed the potential for fertilization of an oocyte from a 24-hour window to an unlimited number of years. This paper will review progress in this field including advances in freeze/thaw protocols, the addition of intracytoplasmic sperm injection, and improvements which have led to increased oocyte survival, fertilization, and live birth rates.

We will review clinical scenarios in which this intervention is beneficial including:

1. women requiring treatments for benign or cancerous processes which diminish or destroy ovarian reserve

2. women who choose to delay childbearing for personal reasons

3. couples undergoing IVF cycles who prefer to freeze excess oocytes rather than embryos

4. flexibility in IVF cycles when sperm is not available

5. potential to create banks to allow couples seeking donor oocytes a wide selection of immediately available quarantined oocytes

We will compare success with cryopreservation of individual oocytes vs. cryopreservation of ovarian tissue and the ethical and societal concerns with both techniques.

Information will also be provided on perinatal outcome and follow up of children conceived from frozen oocytes.