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Raj VI, Hassan A, Hanafiah N, Azhary JMK, Lim BK, Saaid R, Gan F, Tan PC. Polyethylene glycol compared to lactulose for constipation in pregnancy: A randomized controlled trial. Int J Gynaecol Obstet 2024; 166:828-836. [PMID: 38391250 DOI: 10.1002/ijgo.15431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 12/21/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To compare polyethylene glycol 4000 versus lactulose in chronic constipation during pregnancy. METHODS Women at 28-32 weeks' gestation attending antenatal clinic for routine care were screened using the Rome IV chronic constipation criterion. Eligible women were approached and consented. Participants were randomized to oral polyethylene glycol (10 g/day) or lactulose (10 g/day) for 4 weeks. A bowel movement diary was kept and outcomes using the Patient Assessment of Constipation Symptoms questionnaire (PAC-SYM), Patient Assessment of Constipation Quality of Life questionnaire (PAC-QoL) and Bristol Stool Form Scale (BSFS), which were evaluated at the start and end of the four-week period. Relative risks (RR) were determined for the coprimary outcomes of complete spontaneous bowel movement (CSBM) and PAC-SYM mean score improvement (decrease in score of >1 from the baseline). RESULTS A total of 4323 women underwent screening, of which 780 fulfilled the Rome IV criterion, and 360 consented to participate (180 randomized to PEG and lactulose, respectively). Data from 247 women who completed the study were analyzed. CSBM was achieved in 107/124 (86.3%) versus 102/123 (82.9%) (RR 1.04, 95% CI: 0.93-1.16, P = 0.464) for PEG and lactulose trial arms, respectively. PAC-SYM mean score improvement was 62/118 (52.5%) in the PEG arm versus 44/118 (37.3%) in the lactulose arm (RR 1.40, 95% CI: 1.05-1.88). Of secondary outcomes, a significant difference was found in favor of PEG, with respect to PAC-SYM abdominal symptoms subscale, normal stool versus loose stool consistency and side effects of vomiting and diarrhea. After controlling for parity, baseline PAC-SYM, PAC-QoL scores, characteristics different at baseline, only diarrhea and loose stools remained significant. CONCLUSION Both PEG 4000 and lactulose are effective laxatives in pregnancy with similar performance after adjusted analysis. Diarrhea and loose stools are less frequently reported with PEG.
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Affiliation(s)
- Victoria Ivy Raj
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Azyyati Hassan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Nurulashikin Hanafiah
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Jerilee Mariam Khong Azhary
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Boon Kiong Lim
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Rahmah Saaid
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Farah Gan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
| | - Peng Chiong Tan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University Malaya, Jalan Profesor Diraja Ungku Aziz, Kuala Lumpur, Malaysia
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Hierink GM, Brinkman LAM, Malmberg GGA, van Eijndhoven HWF, Trzpis M, Broens PMA. Association of Constipation with Modes of Delivery: A Retrospective Questionnaire-based Study. Int Urogynecol J 2024; 35:1477-1485. [PMID: 38847821 PMCID: PMC11315744 DOI: 10.1007/s00192-024-05824-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/29/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic floor damage can contribute to pelvic floor dysfunction, including constipation. Most studies focus on constipation during pregnancy, whereas information regarding the mode of delivery in relation to constipation is limited. We hypothesise that women with a history of vaginal delivery report constipation more often than women with a history of caesarean section. METHODS This was a retrospective cross-sectional multicentre study conducted in the Netherlands. All included patients (n = 2,643) completed the Groningen Defecation and Fecal Continence questionnaire to assess bowel problems of the last 6 months. Parametric tests, Chi-squared, univariable and multivariable regression analyses were performed. RESULTS Among 2,643 parous women, 2,248 delivered vaginally (85.1%) and 395 (14.9%) by caesarean section. Altogether, 649 women (24.6%) suffered from constipation. Women in the vaginal delivery group were constipated more often than women in the caesarean section group (25.5% versus 19.0%, p = 0.005). For women who had delivered vaginally, multivariable regression analysis showed an odds ratio for constipation of 1.47 (95% confidence interval, 1.109-1.938, p = 0.007). The odds ratio for constipation in women with a spontaneous perineal tear was 1.4 times higher than in women with an intact perineum (p = 0.030). Furthermore, the vaginal delivery group reported difficulties regarding bowel emptying (p = 0.048), straining (p = 0.027), incomplete defecation (p = 0.043), not able to defecate daily (p = 0.018), manually assisted defecation (p = 0.015) and had higher Renzi scores (p = 0.043) more often. CONCLUSIONS Women in the vaginal delivery group have higher prevalences and odds ratios for constipation. Furthermore, a perineal tear during vaginal delivery increases the odds ratio for constipation.
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Affiliation(s)
- G Marije Hierink
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lauret A M Brinkman
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - G G Alec Malmberg
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M A Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Christopher SM, Donnelly G, Brockwell E, Bo K, Davenport MH, De Vivo M, Dufour S, Forner L, Mills H, Moore IS, Olson A, Deering RE. Clinical and exercise professional opinion of return-to-running readiness after childbirth: an international Delphi study and consensus statement. Br J Sports Med 2024; 58:299-312. [PMID: 38148108 DOI: 10.1136/bjsports-2023-107489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/28/2023]
Abstract
Female athletes have identified a lack of guidance as a barrier to successfully returning to running postpartum, and existing guidelines are vague. Our aim was to define the current practice of determining postpartum run-readiness through a consensus survey of international clinicians and exercise professionals in postpartum exercise to assist clinicians and inform sport policy changes.A three-round Delphi approach was used to gain international consensus from clinicians and exercise professionals on run-readiness postpartum. Professionals who work with postpartum runners participated in an online survey to answer open-ended questions about the following postpartum return-to-running topics: definitions (runner and postpartum), key biopsychosocial milestones that runners need to meet, recommended screening, timeline to initiate running, support items, education topics and factors that contribute to advising against running. Consensus was defined as ≥75% participant agreement.One hundred and eighteen professionals participated in round I, 107 participated in round II (response rate 90.6%) and 95 participated in round III (response rate 80.5%). Responses indicated that, following a minimum 3-week period of rest and recovery, an individualised timeline and gradual return to running progression can be considered. Screening for medical and psychological concerns, current physical capacity, and prior training history is recommended prior to a return to running.This study proposes recommendations for the initial guidance on return-to-running postpartum, framed in the context of current research and consensus from professionals. Future research is needed to strengthen and validate specific recommendations and develop guidelines for best practice when returning-to-running after childbirth.
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Affiliation(s)
- Shefali Mathur Christopher
- Department of Rehabilitation Sciences, Doctor of Physical Therapy, Tufts University, Seattle, Washington, USA
- Elon University, Elon, North Carolina, USA
| | - Gráinne Donnelly
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | | | - Kari Bo
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lorenskog, Norway
| | - Margie H Davenport
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Kinesiology, Sport and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Marlize De Vivo
- Perinatal Physical Activity Research Group, School of Psychology and Life Sciences, Section of Sport, Exercise and Rehabilitation Science, Canterbury Christ Church University, Canterbury, UK
- Active Pregnancy Foundation, None, UK
| | - Sinead Dufour
- The World of my Baby (WOMB), Faculty of Health Science, McMaster University, Hamilton, Ontario, Canada
| | - Lori Forner
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Hayley Mills
- Perinatal Physical Activity Research Group, School of Psychology and Life Sciences, Section of Sport, Exercise and Rehabilitation Science, Canterbury Christ Church University, Canterbury, UK
| | - Isabel S Moore
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | | | - Rita E Deering
- Department of Physical Therapy, Carroll University, Waukesha, Wisconsin, USA
- Department of Orthopedics & Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Muhammad A, Hixon JC, Pharmacy Yusuf A, Rivas Zarete JI, Johnson I, Miller J, Adu-Addai B, Yates C, Mahavadi S. Sex-specific epigenetics drive low GPER expression in gastrointestinal smooth muscles in type 2 diabetic mice. Sci Rep 2024; 14:5633. [PMID: 38453938 PMCID: PMC10920797 DOI: 10.1038/s41598-024-54213-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
Type 2 diabetes mellitus (T2D) causes gastroparesis, delayed intestinal transit, and constipation, for unknown reasons. Complications are predominant in women than men (particularly pregnant and postmenopausal women), suggesting a female hormone-mediated mechanism. Low G-protein coupled estrogen receptor (GPER) expression from epigenetic modifications may explain it. We explored sexually differentiated GPER expression and gastrointestinal symptoms related to GPER alterations in wild-type (WT) and T2D mice (db/db). We also created smooth muscle-specific GPER knockout (GPER KO) mice to phenotypically explore the effect of GPER deficiency on gastrointestinal motility. GPER mRNA and protein expression, DNA methylation and histone modifications were measured from stomach and colon samples of db/db and WT mice. Changes in gut motility were also evaluated as daily fecal pellet production patterns. We found that WT female tissues have the highest GPER mRNA and protein expressions. The expression is lowest in all db/db. GPER downregulation is associated with promoter hypermethylation and reduced enrichment of H3K4me3 and H3K27ac marks around the GPER promoter. We also observed sex-specific disparities in fecal pellet production patterns of the GPER KO mice compared to WT. We thus, conclude that T2D impairs gut GPER expression, and epigenetic sex-specific mechanisms matter in the downregulation.
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Affiliation(s)
- Aliyu Muhammad
- Department of Biology, Center for Cancer Research, Tuskegee University, Tuskegee, AL, 36088, USA
- Department of Biochemistry, Faculty of Life Sciences, Ahmadu Bello University, P.M.B. 1044, Zaria, Kaduna State, Nigeria
| | - Juanita C Hixon
- Department of Biology, Center for Cancer Research, Tuskegee University, Tuskegee, AL, 36088, USA
| | | | - Jatna I Rivas Zarete
- Department of Biomedical Sciences, College of Veterinary Medicine, Tuskegee University, Tuskegee, AL, 36088, USA
| | - India Johnson
- Department of Biology, Center for Cancer Research, Tuskegee University, Tuskegee, AL, 36088, USA
| | - Jamial Miller
- Department of Biology, Center for Cancer Research, Tuskegee University, Tuskegee, AL, 36088, USA
| | - Benjamin Adu-Addai
- Department of Biomedical Sciences, College of Veterinary Medicine, Tuskegee University, Tuskegee, AL, 36088, USA
| | - Clayton Yates
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sunila Mahavadi
- Department of Biology, Center for Cancer Research, Tuskegee University, Tuskegee, AL, 36088, USA.
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Sarofim M, Slaar A, Dermout S, den Boer F, Engel A. Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries. Colorectal Dis 2024; 26:508-514. [PMID: 38229253 DOI: 10.1111/codi.16862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
AIM Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV). METHOD A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria. RESULTS There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores. CONCLUSION OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.
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Affiliation(s)
- Mina Sarofim
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Annelie Slaar
- Department of Radiology Dirksland Ziekenhuis, Hoorn, The Netherlands
| | - Sylvia Dermout
- Department of Gynaecology and Obstetrics, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Frank den Boer
- Department of Surgery, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Alexander Engel
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Deering RE, Donnelly GM, Brockwell E, Bo K, Davenport MH, De Vivo M, Dufour S, Forner L, Mills H, Moore IS, Olson A, Christopher SM. Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement. Br J Sports Med 2024; 58:183-195. [PMID: 38191239 DOI: 10.1136/bjsports-2023-107490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/10/2024]
Abstract
Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications.A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement).118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care.Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.
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Affiliation(s)
- Rita E Deering
- Department of Physical Therapy, Carroll University, Waukesha, Wisconsin, USA
- Department of Orthopedics and Rehabilitation, School of Medicine & Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Gráinne M Donnelly
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | | | - Kari Bo
- Department of Sport Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lorenskog, Norway
| | - Margie H Davenport
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Kinesiology, Sport and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Marlize De Vivo
- The Active Pregnancy Foundation, England, UK
- Sheffield Hallam University, Sheffield, UK
- Perinatal Physical Activity Research Group, School of Psychology and Life Sciences, Section of Sport, Exercise and Rehabilitation Science, Canterbury Christ Church University, Canterbury, Kent, UK
| | - Sinead Dufour
- McMaster University Faculty of Health Sciences, Hamilton, southeastern Ontario, Canada
| | - Lori Forner
- University of Queensland, Brisbane, Queensland, Australia
| | - Hayley Mills
- Perinatal Physical Activity Research Group, School of Psychology and Life Sciences, Section of Sport, Exercise and Rehabilitation Science, Canterbury Christ Church University, Canterbury, Kent, UK
| | - Isabel S Moore
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | | | - Shefali Mathur Christopher
- Doctor of Physical Therapy Program, Tufts University, Seattle, Washington, USA
- Elon University, Elon, North Carolina, USA
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Giroux M, Naqvi N, Alarab M. Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS). Int Urogynecol J 2023; 34:2241-2247. [PMID: 37071137 DOI: 10.1007/s00192-023-05491-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/25/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASIS) predispose to development of anorectal symptoms that affect women's quality of life. METHODS A retrospective cohort study was conducted for all women with singleton vaginal deliveries who had a primary OASIS repair and attended the Postpartum Perineal Clinic between July 1st 2017 and December 31st 2020. This study was approved by the Research Ethics Board. The purpose of this study was (1) to determine correlation between endoanal ultrasound (EAUS) findings and anorectal symptoms quantified by the St. Mark's Incontinence Score (SMIS), (2) to determine the incidence of residual anal sphincter defects, and (3) to determine the rate of clinical overdiagnosis of OASIS. Pearson correlation coefficient was used to assess correlation between anorectal symptoms and EAUS findings. RESULTS A total of 247 participants with clinical diagnosis of OASIS met the inclusion criteria. A 3rd-degree tear was identified in 126 (51.0%) and 4th-degree tear was identified in 30 (12.1%) participants. In participants with sonographic evidence of OASIS, there was a statistically significant weak positive correlation between the size of residual defect and SMIS for both external anal sphincter (EAS) (r = .3723, p < .0001) and internal anal sphincter (IAS) (r = .3122, p = .0180). Residual defect in the anorectal sphincter of greater than 1 hour (> 30°) in width was present in 64.3% participants with 3rd-degree tear and 86.7% participants with 4th-degree tear. The rate of overdiagnosis was 36.8%. CONCLUSION The size of residual defect of EAS and IAS has a weak positive correlation with anorectal symptoms, emphasizing the importance of EAUS for counselling regarding mode of subsequent delivery.
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Affiliation(s)
- Maria Giroux
- Division of Urogynecology and Reconstructive Pelvic Surgery, Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Suite 8-816, 700 University Ave, Toronto, ON, M5G 1Z5, Canada
| | - Nawazish Naqvi
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - May Alarab
- Division of Urogynecology and Reconstructive Pelvic Surgery, Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Suite 8-816, 700 University Ave, Toronto, ON, M5G 1Z5, Canada.
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Reppucci ML, Alaniz VI, Wehrli LA, Torre LDL, Wood D, Wilcox DT, Appiah LC, Peña A, Bischoff A. Reproductive and Family Building Considerations for Female Patients with Anorectal And Urogenital Malformations. J Pediatr Surg 2023; 58:1450-1457. [PMID: 36229236 DOI: 10.1016/j.jpedsurg.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/04/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about fertility and pregnancy outcomes in patients with anorectal malformations (ARM), particularly those with long common channel cloaca and cloacal exstrophy who may have impaired fertility. The purpose of this study is to describe pregnancy and offspring data from a cohort of patients with ARM. METHODS A retrospective review of female patients with ARM from our database, which includes patients operated on since 1980, was performed as well as a review of the literature. Demographic, operative, and self-reported fertility, obstetric, and offspring data were collected. RESULTS There were 37 females identified in our database who reported any pregnancy or having children. There were 59 pregnancies, 48 (81.3%) of which resulted in live birth. The most common mode of delivery was cesarean delivery. There were five patients with long channel cloaca (>3 cm) and one with cloacal exstrophy that reported 11 total pregnancies, eight of which resulted in live birth. Four cloaca patients in which the native vagina was pulled through were able to conceive spontaneously. Three patients with cloacal anomalies required in vitro fertilization to conceive; one was unsuccessful. No patients who underwent bowel partial vaginal replacement became pregnant. Women with ARM face many unique challenges in assisted reproduction, pregnancy, and delivery owing to their anatomy and associated anomalies. CONCLUSIONS Women with recto-perineal, recto-vestibular, and cloacas in which the native vagina was pulled through are capable of spontaneous pregnancy. Assisted reproduction, however, may be needed those with more complex anomalies and surgical repairs. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marina L Reppucci
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Veronica I Alaniz
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Section of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Lea A Wehrli
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Luis de La Torre
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Dan Wood
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Duncan T Wilcox
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Leslie C Appiah
- Section of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Alberto Peña
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA.
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Luo H, He X, Wang M, Zheng X, Peng R, Wang C, Li Q, Yang B. Comparision of Ligasure hemorrhoidectomy and conservative treatment for thrombosed external hemorrhoids (TEH) in pregnancy. BMC Surg 2023; 23:15. [PMID: 36658522 PMCID: PMC9850810 DOI: 10.1186/s12893-023-01910-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Ligasure hemorrhoidectomy for thrombosed external hemorrhoids in pregnancy has been rarely studied. OBJECTIVE The purpose of this article is to study the efficacy and safety of Ligasure hemorrhoidectomy comparing with conservative treatment for thrombosed external hemorrhoids in pregnancy. DESIGN This was a retrospective cohort study. SETTING The patients were treated at a tertiary referral center in China. PATIENTS 94 pregnant patients hospitalized for thrombosed external hemorrhoids from September 2020 to December 2021. INTERVENTIONS Ligasure hemorrhoidectomy treatment or conservative treatment according to the patient's wishes. MAIN OUTCOME MEASURES Symptom relief, recurrence and satisfaction of thrombosed external hemorrhoids in pregnancy with different interventions. RESULTS There were no differences between groups in maternal age, gestational age, body mass index, parity, constipation and a prior history of thrombosed external hemorrhoids. The pain scores were less in surgical group than in conservative group in post-treatment days 1 and 7. Time to return to normal activities was shorter in surgical group than in conservative group (6.51 vs. 13.52 days, P < 0.001). Post-treatment complications were mild in surgical group and there were no significant differences concerning the rate of abortion, preterm birth, cesarean delivery and weight of fetus. Recurrence rate was significantly lower in surgical group (8.57% vs. 30.43%, P = 0.017). The patient satisfaction scores were significantly higher in surgical group than in conservative group (Z = - 2.979, P = 0.003). LIMITATIONS This was a retrospective study with a limited number of patients, the data was obtained from only one center. CONCLUSIONS Comparing with conservative treatment, Ligasure hemorrhoidectomy for TEH in pregnancy results in more rapid pain relief, shorter time to return to normal activities, lower incidence of recurrence, and better patient satisfaction. This type of surgery has low and mild postoperative complications, is not attended by any risk to the mother or her fetus.
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Affiliation(s)
- Huihua Luo
- grid.410745.30000 0004 1765 1045Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China ,grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Xiaojun He
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Min Wang
- grid.410745.30000 0004 1765 1045Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaosong Zheng
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Rong Peng
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Chenwei Wang
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Qiu Li
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Bolin Yang
- grid.410745.30000 0004 1765 1045Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
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Suzuki S, Obara T, Ishikawa T, Noda A, Matsuzaki F, Arita R, Ohsawa M, Mano N, Kikuchi A, Takayama S, Ishii T. No association between major congenital malformations and exposure to Kampo medicines containing rhubarb rhizome: A Japanese database study. Front Pharmacol 2023; 14:1107494. [PMID: 37033629 PMCID: PMC10073577 DOI: 10.3389/fphar.2023.1107494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023] Open
Abstract
Traditional Japanese (Kampo) medicines containing rhubarb rhizome are prescribed for constipation during pregnancy; however, detailed safety information of their use for pregnant women is lacking. The aim of current study was to clarify the association between prescription Kampo-containing rhubarb rhizome (KRR) in the first trimester of pregnancy and congenital malformations in newborns. Using a large Japanese health insurance claims database, we included pregnant women who enrolled the same health insurance society from 3 months before pregnancy to the delivery date, who gave birth between 2010 and 2019, and those with data related to their infants. Pregnant women who were prescribed magnesium oxide (MgO), commonly used for constipation, during the first trimester of pregnancy and their infants were extracted as controls. Associations between KRR prescribed in the first pregnancy trimester and major congenital malformations (MCM) in the infants were examined using multivariate logistic regression analysis. Of 75,398 infants, 4,607 (6.1%) were diagnosed with MCMs within the first year after birth. Furthermore, 9,852 infants were born to women prescribed MgO, among whom 680 (6.9%) had MCMs; 450 infants were born to women prescribed KRR, among whom 28 (6.2%) had MCMs. Multivariate logistic regression analysis identified no difference in MCM risk between the two types of prescriptions [crude odds ratio (OR) 0.895, 95% confidence interval (CI) 0.606-1.322, adjusted OR 0.889, 95% CI 0.599-1.320]. In conclusion, the risk of MCMs did not differ between those prescribed KRR or MgO in the first trimester of pregnancy.
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Affiliation(s)
- Satoko Suzuki
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Taku Obara
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Division of Molecular Epidemiology, Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Tomofumi Ishikawa
- Laboratory of Clinical Pharmacy, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Aoi Noda
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Division of Molecular Epidemiology, Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Fumiko Matsuzaki
- Division of Molecular Epidemiology, Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Ryutaro Arita
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Minoru Ohsawa
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Obstetrics and Gynecology, Tohoku University Hospital, Sendai, Japan
| | - Nariyasu Mano
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
- Laboratory of Clinical Pharmacy, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Akiko Kikuchi
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Shin Takayama
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
- *Correspondence: Shin Takayama,
| | - Tadashi Ishii
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
- Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
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Saga S, Vinsnes AG, Norton C, Haugan G. Symptoms of anal incontinence and quality of life: a psychometric study of the Norwegian version of the ICIQ-B amongst hospital outpatients. Arch Public Health 2022; 80:251. [PMID: 36494843 PMCID: PMC9733285 DOI: 10.1186/s13690-022-01004-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B), a self-report, condition-specific questionnaire designed to assess symptoms of anal incontinence (AI), measures AI's impact on quality of life (QoL) along with perceived bowel patterns and bowel control amongst individuals with AI. In our study, we aimed to translate the ICIQ-B to Norwegian and investigate the Norwegian version's psychometric properties. METHODS To establish a relevant, comprehensive, and understandable Norwegian ICIQ-B, cognitive interviews were conducted with 10 patients with AI, and six clinical experts reviewed the translated scale. The Norwegian ICIQ-B's structural validity, scale reliability, and content validity were tested amongst patients with AI attending hospital outpatient clinics in three regions of Norway (N = 208). RESULTS Assessing the Norwegian ICIQ-B's content validity revealed that the questionnaire was relevant, comprehensive, and understandable. Missing data were infrequent (3.3%), and no floor or ceiling effects emerged. Three-factor and two-factor solution models, both with advantages and disadvantages, were found. The three-factor model offered the most parsimonious solution by covering most of the original scale, albeit with an unacceptably low reliability (α = .37) for the construct of bowel pattern. The two-factor model showed good reliability in terms of internal consistency for the constructs of bowel control (α = .80) and impact on QoL (α = .85) but was less parsimonious due to dismissing seven of the original 17 items and excluding the bowel pattern construct. Test-retest reliability demonstrates good stability for the Norwegian version, with an intra-class correlation coefficient of .90-.95 and weighted kappa of .39-.87 for single items. CONCLUSIONS Although the Norwegian version of ICIQ-B demonstrates good stability and content validity, the original constructs of bowel pattern and bowel control had to be adapted, whereas the construct of impact on QoL remained unchanged. Further psychometric testing of the Norwegian ICIQ-B's factor structure is therefore recommended.
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Affiliation(s)
- Susan Saga
- grid.5947.f0000 0001 1516 2393Department of Public Health and Nursing, Faculty of Medicine and Health Sciences NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Guttormsen Vinsnes
- grid.5947.f0000 0001 1516 2393Department of Public Health and Nursing, Faculty of Medicine and Health Sciences NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Christine Norton
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Gørill Haugan
- grid.5947.f0000 0001 1516 2393Department of Public Health and Nursing, Faculty of Medicine and Health Sciences NTNU, Norwegian University of Science and Technology, Trondheim, Norway ,Faculty of Nursing and Health Science, North University, Levanger, Norway
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Sentance J, Stocking K, Edmondson RJ, Kearney R. Comparison of two questionnaires to diagnose obstructive defecation syndrome during pregnancy and post-natally. Int Urogynecol J 2022; 33:3129-3136. [PMID: 35267060 PMCID: PMC9569300 DOI: 10.1007/s00192-022-05114-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/30/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstructive defecation syndrome (ODS) is a common urogynaecology presentation. This study compares two questionnaires, the electronic Personal Assessment Questionnaire (e-PAQ), used in urogynaecology clinics, with the ODS-Score (ODS-S), a simple validated scoring system used in colorectal clinics for diagnosing ODS, to identify patients with an ODS-S cut-off ≥9. METHODS A total of 221 paired ODS-S and e-PAQ questionnaires were completed; 80 during the second trimester of pregnancy, 73 during the third and 68 post-natally, including women sustaining obstetric anal sphincter injury (OASI). e-PAQ score and ODS-S were compared and Pearson's correlation coefficient calculated. Areas under the curve assessed the diagnostic ability of e-PAQ scores to identify patients with ODS-S of ≥9. RESULTS The e-PAQ and ODS-S scores showed a positive correlation in the second and third trimesters of pregnancy, post-natally and following OASI. Pearson's correlation coefficient was calculated (0.77; p < 0.001, 0.79; p < 0.001, 0.66; p = 0.001 and 0.79; p < 0.001 respectively). An e-PAQ evacuatory domain score of ≥33 identified women with an ODS score of ≥9 with a sensitivity and specificity of 71% and 94% in the second trimester, 86% and 95% third trimester and 78% and 97% in the OASI group respectively. Area under the curve was >0.90 for all groups. CONCLUSIONS Comparison of e-PAQ evacuatory domain scores and ODS-S show a strong correlation, with an e-PAQ score of ≥33 promising for identifying women with an ODS score of ≥9, indicating ODS. This study will enable us to identify women during pregnancy and post-natally with ODS for whom early recognition and intervention may be beneficial.
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Affiliation(s)
- Joanne Sentance
- Warrell Unit, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Katie Stocking
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Richard J Edmondson
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Saint Mary's Hospital, Manchester, UK
- Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Rohna Kearney
- Warrell Unit, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.
- Division of Developmental Biology and Medicine, School of Medical Sciences, The University of Manchester, Manchester, UK.
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Constipation, Hemorrhoids, and Anorectal Disorders in Pregnancy. Am J Gastroenterol 2022; 117:16-25. [PMID: 36194029 DOI: 10.14309/ajg.0000000000001962] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/23/2022] [Indexed: 11/05/2022]
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Huang A, Stone GL, Gordon B, Kim GJ. Pregnancy-Onset Ulcerative Colitis in a Pediatric Patient Presenting With Altered Mental Status and Severe Anemia. Cureus 2022; 14:e26434. [PMID: 35915702 PMCID: PMC9337714 DOI: 10.7759/cureus.26434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/21/2022] Open
Abstract
Ulcerative colitis (UC) classically presents with abdominal pain, hematochezia, or diarrhea. However, it can present atypically in pediatric and pregnant patients, posing a diagnostic challenge. A healthy, 16-year-old primigravida presented at 18 weeks and six days of gestation with sudden-onset altered mental status and severe anemia. Hematochezia began about 12 hours after admission. She underwent extensive workup, leading to an endoscopic and histopathologic diagnosis of UC, and achieved prenatal remission with high-dose steroids and infliximab. Her pregnancy, however, was complicated by severe preeclampsia, and her child’s post-delivery course was medically complex from an unrelated etiology. Pregnancy-onset inflammatory bowel disease (IBD) in the pediatric population is an uncommon but important consideration. Early diagnosis, treatment, and counseling are vital to achieve results comparable to those of patients without IBD.
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Corbière L, Legendre G, Gaborieau L, Bedouet A, Corroënne R, Venara A. [Acceptability and results of postpartum proctological consultation for women who have had an obstetric injury of the anal sphincter]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:291-297. [PMID: 34706295 DOI: 10.1016/j.gofs.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Early management of perineal disorders after obstetric anal sphincter injury (OASI) may improve the functional prognosis. The objective was to assess the acceptability of the consultation and to report on its results. METHODS This unicentric retrospective study included 64 women who had LOSA 3 or 4 and who were offered a 3-month routine postpartum proctological consultation. The proposed diagnoses and recoveries were identified. RESULTS Of the 5,070 women who gave birth vaginally, 64 women had LOSA (1.2%). 54 came to the clinic (84.3%). At the interview, 21 women had no complaints. A diagnosis of evacuation disorders or hemorrhoidal disease in particular was made in 10 women. A specific management was proposed to 16 women and a control consultation was proposed to 3 women. Of the 33 women with at least one symptom, 31 women were diagnosed and 27 women were offered specific management. A monitoring consultation was offered to 18 women. The main diagnoses were gas incontinence, dyschesia with or without abdominopererial asynchronism and decreased sphincter tone. The main measures undertaken were the extension of laxatives, the proposal of perineal massage and abdominal-perineal rehabilitation by biofeedback. CONCLUSION Systematic proctological consultation was acceptable and allows for a specific management in the majority of cases. The assessment of its long-term impact remains to be defined.
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Affiliation(s)
- L Corbière
- Service de chirurgie viscérale, CHU of Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - G Legendre
- Département de médecine, faculté de santé, Angers, France; Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France
| | - L Gaborieau
- Département de médecine, faculté de santé, Angers, France
| | - A Bedouet
- Département de médecine, faculté de santé, Angers, France
| | - R Corroënne
- Département de médecine, faculté de santé, Angers, France; Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France
| | - A Venara
- Département de médecine, faculté de santé, Angers, France; Service de chirugrie viscérale et endocrinienne, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France; HIFIH, UPRES EA 3858, université d'Angers, Angers, France.
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Ferrari A, Bonciani M, Russo E, Mannella P, Simoncini T, Vainieri M. Patient-Reported Outcome measures for pregnancy-related urinary and fecal incontinence: a prospective cohort study in a large Italian population. Int J Gynaecol Obstet 2022; 159:435-443. [PMID: 35122688 DOI: 10.1002/ijgo.14132] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/26/2021] [Accepted: 02/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To investigate prevalence and risk factors of pregnancy-related urinary/fecal incontinence (UI/FI) in a large Italian population. METHODS This is a prospective cohort study analyzing patient-reported outcome (PRO) measures obtained from the systematic longitudinal survey on the maternity pathway of Tuscany from March 2019 to April 2021. Four questionnaires were completed by 6,023 women from the beginning of pregnancy until six months postpartum, each including two PRO measures - Wexner scale for FI and ICIQ-SF for UI -, and questions investigating sociodemographic/clinical factors. After assessing UI/FI prevalence at each time-point, we run panel regressions to explore the related risk factors. RESULTS Women reporting UI and FI were, respectively, 24.3% and 6.2% in the third trimester, and 12.6% and 4.2% six months postpartum. UI occurrence and severity were higher in highly-educated, aged > 30, and overweight/obese women. Spontaneous tears or episiotomy were risk factors for postpartum UI, while receiving cesarean-section and performing pelvic-floor-muscle-training during pregnancy were protective, mainly in specific groups. Finally, higher FI prevalence and severity emerged in overweight, aged > 40, highly-educated, non-Italian women and in those undergoing tears. CONCLUSION We employed PRO measures to investigate the epidemiology of pregnancy-related UI/FI and detect the main risk groups. Pelvic-floor-muscle-training may be recommended in women with peculiar sociodemographic/clinical features.
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Affiliation(s)
- Amerigo Ferrari
- Anna School of Advanced Studies, Institute of Management, MeS (Management and Health) Laboratory, 56127, Pisa, Italy
| | - Manila Bonciani
- Anna School of Advanced Studies, Institute of Management, MeS (Management and Health) Laboratory, 56127, Pisa, Italy
| | - Eleonora Russo
- University of Pisa, Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, 56126, Pisa, Italy
| | - Paolo Mannella
- University of Pisa, Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, 56126, Pisa, Italy
| | - Tommaso Simoncini
- University of Pisa, Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, 56126, Pisa, Italy
| | - Milena Vainieri
- Anna School of Advanced Studies, Institute of Management, MeS (Management and Health) Laboratory, 56127, Pisa, Italy
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Palmieri S, De Bastiani SS, Degliuomini R, Ruffolo AF, Casiraghi A, Vergani P, Gallo P, Magoga G, Cicuti M, Parma M, Frigerio M. Prevalence and severity of pelvic floor disorders in pregnant and postpartum women. Int J Gynaecol Obstet 2021; 158:346-351. [PMID: 34778951 DOI: 10.1002/ijgo.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/31/2021] [Accepted: 11/10/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This multicenter study aimed to evaluate risk factors, prevalence and severity of pelvic floor disorders (PFDs) as well as their consequences on women's emotional well-being, using a questionnaire validated specifically for pregnancy and postpartum. METHODS Prospective study conducted in eight teaching hospitals in Italy and Italian-speaking Switzerland. Pregnant and postpartum women completed the Italian Pelvic Floor Questionnaire for Pregnancy and Postpartum anonymously. Prevalence of, severity of, and risk factors for PFDs were evaluated for all the four domains considered: bladder, bowel, prolapse, and sexual function. RESULTS A total of 2007 women were included: 983 of the patients were bothered by at least one kind of PFD: bladder, bowel, and sexual dysfunction were more frequently reported. There were no significant differences in PFD prevalence between pregnancy and postpartum, except for bladder disorders, which were more prevalent in pregnancy. Familiarity for PFDs, pelvic floor contraction inability, cigarette smoking, body mass index more than 25 (calculated as weight in kilograms divided by the square of height in meters), and age more than 35 years were confirmed risk factors for the development of PFDs during pregnancy and postpartum. CONCLUSION Almost half of the women included in the study suffered from PFD-related symptoms with important consequences on quality of life. Validated questionnaires are fundamental in early diagnosis and treatment of PFDs.
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Affiliation(s)
| | | | | | | | - Arianna Casiraghi
- Gynecology Division, Vita-Salute San Raffaele University, Milan, Italy
| | - Patrizia Vergani
- Gynaecology Division, Milano-Bicocca University, Milan, Italy
- Obstetric Division, Monza and Brianza Mother and Child Foundation, Monza, Italy
| | | | - Giulia Magoga
- ULSS2 Marca Trevigiana, Oderzo Hospital, Oderzo, Italy
| | - Marta Cicuti
- ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
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Patient-Focused Websites Related to Postpartum Pelvic Floor Health: A DISCERN Quality Analysis. Female Pelvic Med Reconstr Surg 2021; 28:240-243. [PMID: 34628445 DOI: 10.1097/spv.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the quality of patient-focused websites addressing postpartum pelvic floor health. METHODS The Google search engine was used to perform a search of the following 3 terms: (1) "postpartum pelvic floor (PPF)," (2) "postpartum leaking urine (PLU)," and (3) "postpartum leaking stool (PLS)." The top 20 results from each search term were evaluated using the DISCERN quality appraisal tool and Journal of the American Medical Association (JAMA) benchmark criteria by 2 independent researchers. Websites were also categorized by type. Cohen κ was performed to determine interrater reliability between reviewers. The Kruskal-Wallis test was used to evaluate the differences in DISCERN and JAMA criteria scores. RESULTS The weighted mean κ between the investigators for each search term was κ = 0.47 (range = 0.163 [PPF] to 0.759 [PLU]), suggesting moderate agreement between reviewers. There was a significant difference in mean DISCERN scores between the terms, with "postpartum leaking urine" yielding the highest mean score. When comparing DISCERN scores by category, society- and government-sponsored websites (mean = 55 ± 13) scored significantly higher than other categories. Using JAMA criteria, mean scores ranged between 1.83 and 2.83/4, but there were no significant differences between websites. CONCLUSIONS The overall quality of health information available on the internet regarding postpartum pelvic health is low. Higher-quality search results are found within society- and government-sponsored websites as well as under the search term "postpartum leaking urine." It is important for health care providers to guide their patients to websites with reliable information about postpartum pelvic floor recovery.
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Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study. Sex Med 2021; 9:100417. [PMID: 34419692 PMCID: PMC8498962 DOI: 10.1016/j.esxm.2021.100417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Epidural analgesia has become a universal intervention for relieving labor pain, and its effect on the pelvic floor is controversial. AIM To investigate the effect of epidural analgesia on pelvic floor dysfunction (PFD) in primiparous women at 6 months postpartum. METHODS We performed a prospective cohort study involving 150 primiparous women in preparation for vaginal delivery, with 74 (49.3%) receiving epidural analgesia. Baseline demographic and intrapartum data were collected. At 6 months postpartum, PFD symptoms, including stress urinary incontinence, overactive bladder, defecation disorder, pelvic organ prolapse, and 4 kinds of sexual dysfunction (arousal disorder, low sexual desire, dyspareunia, and orgasm disorder), were evaluated. Pelvic floor muscle (PFM) function and postpartum depression were also assessed. Multivariate logistic regression was applied to identify factors associated with the PFD symptoms affected by epidural analgesia. MAIN OUTCOME MEASURE PFD symptoms and sexual dysfunction were evaluated through Pelvic Floor Distress Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI-12). PFM function was examined with palpation and surface electromyography (sEMG). Postpartum depression was assessed using Self-Rating Depression Scale (SDS). RESULTS At 6 months postpartum, women who delivered with epidural analgesia had a higher incidence of dyspareunia (43.2% vs 26.3%, P <0.05) and longer first, second, and total stage of labor durations (P <0.01) than those who without. No significant difference in other PFD symptoms or PFM function was found between the 2 groups (P >0.05). Multivariate logistic regression revealed that epidural analgesia (OR = 3.056, 95% CI = 1.217-7.671) and SDS scores (OR = 1.066, 95% CI = 1.009-1.127) were independent risk factors for dyspareunia. CONCLUSION At 6 months postpartum in primiparous women, epidural analgesia was associated with an increased risk of postpartum dyspareunia and longer labor durations, which deserves attention for rehabilitation after delivery. Future studies with a larger sample size are needed to evaluate the impact of epidural analgesia on other PFD symptoms. Du J, Ye J, Fei H, et al. Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study. Sex Med 2021;9:100417.
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Influence of Bowel Habit and Hormonal Changes on the Development of Hemorrhoidal Disease During Pregnancy and the Postdelivery Period: A Prospective Cohort Study. Dis Colon Rectum 2021; 64:724-734. [PMID: 33591046 DOI: 10.1097/dcr.0000000000001822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hemorrhoidal disease in women during pregnancy is common in clinical practice. However, prospective data on its real prevalence and women's demographics are scarce. OBJECTIVE The aim of this study was to determine the prevalence of hemorrhoidal disease during pregnancy and to assess its impact on quality of life. In addition, this study aimed to identify the relationship between patients' characteristics, bowel habits, hormonal changes, and the presence of symptomatic hemorrhoids. DESIGN This is a prospective longitudinal cohort study. SETTING This study was conducted in the Obstetrics Department for pregnancy follow-up. PATIENTS The patients evaluated were a cohort of pregnant women. INTERVENTION The study was designed to follow a homogeneous cohort of women for 15 months. Visits took place in the first and third trimesters of pregnancy, and 3 and 6 months after delivery. Women's demographics (age, medical history, bowel habit, Bristol stool scale) and serum determination of pregnancy-related hormones (estrogen, progesterone, and relaxin) were determined. MAIN OUTCOME MEASURES The primary outcome was the development of hemorrhoidal disease. RESULTS Overall, 109 women (mean age, 31.2 ± 5.4 years) were included in the study. The prevalence of symptoms and physical findings of hemorrhoidal disease was present in 11% in the first trimester, 23% in the third trimester, 36.2% at 1 month after delivery, and 16.9% at 3 months after delivery. A medical history of hemorrhoidal disease was significantly associated with the diagnosis of hemorrhoids in the first trimester (p < 0.0001) and third trimester (p = 0.005). Symptoms of constipation were associated with this clinical disorder in the first trimester (p = 0.011) and the third trimester of pregnancy (p = 0.022). No association was found between hormonal changes and the development of hemorrhoidal disease. LIMITATIONS A larger sample would provide more information. CONCLUSIONS The prevalence of women with hemorrhoidal disease increases during pregnancy and after delivery. A history of hemorrhoidal disease and constipation is significantly associated with the diagnosis of symptomatic hemorrhoidal disease. See Video Abstract at http://links.lww.com/DCR/B504. INFLUENCIA DEL HBITO INTESTINAL Y LOS CAMBIOS HORMONALES EN EL DESARROLLO DE LA ENFERMEDAD HEMORROIDAL DURANTE EL EMBARAZO Y EL PERODO POSTERIOR AL PARTO UN ESTUDIO DE COHORTE PROSPECTIVO ANTECEDENTES:La enfermedad hemorroidal en mujeres durante el embarazo es común en la práctica clínica. Sin embargo, hay escasos datos prospectivos sobre su prevalencia real y la demografía de las mujeres.OBJETIVO:El objetivo fue determinar la prevalencia de enfermedad hemorroidal durante el embarazo y evaluar su impacto en la calidad de vida. Además, identificar la relación entre las características de los pacientes, los hábitos intestinales, los cambios hormonales y la presencia de hemorroides sintomáticas.DISEÑO:Estudio prospectivo de cohorte longitudinal.AJUSTE:Este estudio se realizó en el Departamento de Obstetricia para el seguimiento del embarazo.PACIENTES:Una cohorte de mujeres embarazadas.INTERVENCIÓN:El estudio se diseñó para realizar un seguimiento de una cohorte homogénea de mujeres durante 15 meses. Las visitas se realizaron en el primer y tercer trimestre del embarazo, y a los 3 y 6 meses después del parto. Se determinaron los datos demográficos de las mujeres (edad, antecedentes médicos, hábito intestinal, escala de heces de Bristol) y la determinación sérica de hormonas relacionadas con el embarazo (estrógeno, progesterona y relaxina).PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el desarrollo de enfermedad hemorroidal.RESULTADOS:Se incluyó en el estudio a 109 mujeres (edad media, 31,2 ± 5,4 años). La prevalencia de síntomas y hallazgos físicos de enfermedad hemorroidal estuvo presente en 11% en el primer trimestre, 23% en el tercer trimestre, 36,2% 1 mes después del parto y 16,9% 3 meses después del parto. Un historial médico previo de enfermedad hemorroidal se asoció significativamente con el diagnóstico de hemorroides en el primer trimestre (p <0,0001) y tercer trimestre (p = 0,005). Los síntomas de estreñimiento se asociaron con este trastorno clínico en el primer trimestre (p = 0,011) y el tercer trimestre del embarazo (p = 0,022), respectivamente. No se encontró asociación entre los cambios hormonales y el desarrollo de enfermedad hemorroidal.LIMITACIONES:Una muestra más grande proporcionaría más información.CONCLUSIONES:La prevalencia de mujeres con enfermedad hemorroidal aumentó durante el embarazo y el posparto. El antecedente de enfermedad hemorroidal y estreñimiento se asociaron significativamente con el diagnóstico de enfermedad hemorroidal sintomática. Consulte Video Resumen en http://links.lww.com/DCR/B504.
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Barbosa M, Christensen P, Møller-Bek K, Brogaard L, Glavind-Kristensen M. Can ultrasound 10 days after obstetric anal sphincter injury predict anal incontinence at long-term follow-up? Int Urogynecol J 2021; 32:2511-2520. [PMID: 33730232 DOI: 10.1007/s00192-021-04733-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/09/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to investigate whether endoanal ultrasound (EAUS) performed 10 days after a primary repaired obstetric anal sphincter injury (OASIS) can predict the severity of anal incontinence (AI) in the long term. METHODS This prospective cohort study included women with a primary repaired 3b-degree tear, 3c-degree tear or fourth-degree tear at Aarhus University Hospital, Denmark, from 1 September 2010 to 31 May 2011. Clinical assessment and EAUS were performed on day 2, day 10, and day 20 after delivery. Functional outcomes were assessed using a questionnaire at the time of all clinical visits and at the long-term follow-up, 7 years after delivery. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score. RESULTS Ninety-six out of 99 women consented to participate. Five women had a secondary sphincter repair and were subsequently excluded from follow-up. Fifty-seven women underwent both EAUS 10 days after delivery and answered the long-term follow-up questionnaire. Median follow-up time was 7.7 years (IQR 7.4-7.8). Mean Wexner score was 4.4 ± 4.8 10 days after delivery and 2.5 ± 2.8 at follow-up; thus, the Wexner score improved over time (p = 0.01). Ultrasound sphincter defects were found in 82.6% of the women. Mean Starck score was 3.0 ± 1.8. The risk of AI was 0% (95% CI 0.0-30.8) if the Starck score was 0. No correlation was found between the Starck score and the Wexner score at follow-up. CONCLUSIONS We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.
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Affiliation(s)
- Malou Barbosa
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Peter Christensen
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Karl Møller-Bek
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Lise Brogaard
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marianne Glavind-Kristensen
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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García-Ramos R, Santos-García D, Alonso-Cánovas A, Álvarez-Sauco M, Ares B, Ávila A, Caballol N, Carrillo F, Escamilla Sevilla F, E. Freire, Gómez Esteban J, Legarda I, López Manzanares L, López Valdés E, Martínez-Torres I, Mata M, Pareés I, Pascual-Sedano B, Mir P, Martínez Castrillo J. Management of Parkinson’s disease and other movement disorders in women of childbearing age: Part 1. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Rotstein E, Åhlund S, Lindgren H, Lindén Hirschberg A, Rådestad I, Tegerstedt G. Posterior compartment symptoms in primiparous women 1 year after non-assisted vaginal deliveries: a Swedish cohort study. Int Urogynecol J 2021; 32:1825-1832. [PMID: 33646348 PMCID: PMC8295137 DOI: 10.1007/s00192-021-04700-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/10/2021] [Indexed: 11/26/2022]
Abstract
Introduction and hypothesis This is a prospective cohort follow-up study based on the hypothesis that primiparous women with non-assisted vaginal deliveries and a second-degree perineal tear have more posterior compartment symptoms 1 year after delivery than those with no or first-degree tears. Methods A follow-up questionnaire, including validated questions on pelvic floor dysfunction, was completed 1 year postpartum by 410 healthy primiparas, delivered without instrumental assistance at two maternity wards in Stockholm between 2013 and 2015. Main outcome measures were posterior compartment symptoms in women with second-degree perineal tears compared with women with no or only minor tears. Results Of 410 women, 20.9% had no or only minor tears, 75.4% had a second-degree tear, and 3.7% had a more severe tear. Of women presenting with second-degree tears, 18.9% had bowel-emptying difficulties compared with 20.0% of women with minor tears. Furthermore, almost 3% of them with second-degree tears complained of faecal incontinence (FI) of formed stool, 7.2% of FI of loose stool compared with 1.2% and 3.5% respectively in women with no or only minor tears. Conclusions Symptomatic pelvic floor dysfunction is common among primiparous women within 1 year following uncomplicated vaginal delivery, and there are no significant differences between second-degree perineal tears and minor tears. These symptoms should be addressed in all women after delivery to improve pelvic floor dysfunction and quality of life.
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Affiliation(s)
- Emilia Rotstein
- Karolinska Pelvic Floor Centre, Karolinska University Hospital Huddinge, Stockholm, Sweden.
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 171 77, Solna, Sweden.
| | - Susanne Åhlund
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Helena Lindgren
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynaecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gunilla Tegerstedt
- Karolinska Pelvic Floor Centre, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 171 77, Solna, Sweden
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García-Ramos R, Santos-García D, Alonso-Cánovas A, Álvarez-Sauco M, Ares B, Ávila A, Caballol N, Carrillo F, Escamilla Sevilla F, Freire E, Gómez Esteban J, Legarda I, López Manzanares L, López Valdés E, Martínez-Torres I, Mata M, Pareés I, Pascual-Sedano B, Mir P, Martínez Castrillo J. Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: Parte 1. Neurologia 2021; 36:149-158. [DOI: 10.1016/j.nrl.2020.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023] Open
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Abstract
Background: Fecal incontinence (FI) has been shown to be a common symptom in Western countries; however, there is few researches focusing on its epidemic condition in Chinese women. We conducted this national population-based epidemiology study to estimate the prevalence and risk factors of FI among adult Chinese women living in urban regions. Methods: This is a subgroup analysis of a national population-based epidemiology study of FI. Total 28,196 adult women from urban regions of six provinces and municipalities participated in this research from 2014 to 2015. They finished the questionnaire under the direction of trained interviewers. FI was defined as accidental leakage of flatus and/or liquid or solid stool at least once in the past. The FI prevalence trend and risk factors were identified by the Cochran-Armitage test, Chi-square test, and multivariable logistic regression. Results: The prevalence of FI in adult females in urban China was 0.43% (95% confidence interval: 0.35%–0.51%). Among women with FI, 42.96%, 82.96%, and 42.22% reported having leakage of solid, liquid stool, and gas, respectively. The overall FI prevalence and the incidence rate of solid stool/liquid stool/gas leakage increased with age. The mean Wexner score was 4.0% and 12.0% FI patients reported Wexner score ≥9. Body mass index ≥24 kg/m2, pelvic organ prolapses, chronic constipation, chronic cough, alcohol consumption, physical diseases including chronic bronchitis and cancer, gynecological diseases like gynecological inflammation are risk factors for FI. Vaginal delivery was the risk factor for FI in females with labor history. Conclusions: FI was not a common symptom in adult Chinese women living in urban areas and there were some potential modifiable risk factors. Trial Registration: Chinses Clinical Trial Registry: ChiCTR-OCS-14004675; http://www.chictr.org.cn/showproj.aspx?proj=4898
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Kuronen M, Hantunen S, Alanne L, Kokki H, Saukko C, Sjövall S, Vesterinen K, Kokki M. Pregnancy, puerperium and perinatal constipation - an observational hybrid survey on pregnant and postpartum women and their age-matched non-pregnant controls. BJOG 2020; 128:1057-1064. [PMID: 33030260 DOI: 10.1111/1471-0528.16559] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the prevalence of constipation during pregnancy and early puerperium. DESIGN Observational survey. SETTING Secondary and tertiary hospital in Finland. POPULATION Pregnant (n = 474) and postpartum (n = 403) women and a control group of 200 non-pregnant women who did not give birth in the past year. METHODS Women reported bowel function and other gastrointestinal symptoms on a structured questionnaire using an 11-point numerical rating scale (0 = no symptom, 10 = most severe symptom) and binominal yes/no questions during the second and third trimesters and few days and 1 month after childbirth. MAIN OUTCOME MEASURE Prevalence of constipation based on the Rome IV criteria. RESULTS The data consist of five cohorts of women: second trimester (n = 264), third trimester (n = 210), after vaginal delivery (n = 200) or caesarean section (n = 203), and a control group (n = 200). The prevalence of constipation was 40% in pregnant women and 52% (P < 0.001) in postpartum women, which was a higher prevalence than that in the control group, where 21% had constipation (P < 0.001). A few days after delivery, the prevalence of constipation was lower after vaginal delivery (47%) than caesarean section (57%, P < 0.039). One month postpartum, the prevalence of constipation was low: 9% after vaginal delivery (P = 0.002 compared with the control group) and 15% after caesarean section. Other gastrointestinal symptoms were common; pregnant women had the highest prevalence (34%) of nausea/vomiting. CONCLUSION The prevalence of constipation was two- to three-fold higher in pregnant women and a few days after delivery than in non-pregnant women. During puerperium, bowel function returned to or below that reported in non-pregnant women. TWEETABLE ABSTRACT Constipation is common in pregnancy and after delivery, but bowel function returns early in puerperium.
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Affiliation(s)
- M Kuronen
- Department of Anaesthesiology and Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - S Hantunen
- School of Medicine, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - L Alanne
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - H Kokki
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - C Saukko
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - S Sjövall
- Department of Anaesthesia, Satakunta Central Hospital, Pori, Finland
| | - K Vesterinen
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - M Kokki
- Department of Anaesthesiology and Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland
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Kirca AŞ, Kanza Gül D. Effects of self-acupressure on pregnancy-related constipation: A single-blind randomized controlled study. Explore (NY) 2020; 17:463-468. [PMID: 32782111 DOI: 10.1016/j.explore.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVES This study aimed to demonstrate that acupressure could be used to relieve the symptoms of constipation during pregnancy. DESIGN Single-blind randomized controlled trial SETTING: Private Medipol Nisa Hospital, Istanbul, Turkey INTERVENTION: This trial including 120 women aged ≥20 years was conducted from November 2019 to February 2020. The participating women who were in the 1st, 2nd or 3rd trimester of their pregnancy, had singleton pregnancy and had a complaint of constipation were randomized into the acupressure (n = 75) and control groups (n = 75). The women in the acupressure group applied 15 min of self-acupressure to the TH-6 acupuncture point twice a day for one week. The women in the control group received no intervention treatment. MAIN OUTCOME MEASURES Constipation levels of the participants in the two groups were assessed before and after the procedure using the Constipation Severity Instrument RESULTS: In the present study, after the application of self-acupressure, the severity of constipation decreased significantly in the acupressure group compared to the control group (before treatment: 41.36 ± 6.5 vs. 37.56 ± 6.17 respectively, after treatment: 26.08 ± 7.93 vs. 36.88 ± 5.93, respectively, p < 0.01) CONCLUSION: Although it is safe to use medical drugs in constipation associated with pregnancy, can't reduce it to the extent desired. This study's evidence indicates that self-administered acupressure can effectively alleviate the symptoms of constipation in clinical practice.
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Affiliation(s)
- Ayça Şolt Kirca
- Kırklareli University School of Health, MidwiferyDepartment Kırklareli, Turkey.
| | - Derya Kanza Gül
- Medipol University School of Medicine Health, Gynecology and Obstetric Department, Istanbul, Turkey.
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Verkuijl SJ, Meinds RJ, Trzpis M, Broens PMA. The influence of demographic characteristics on constipation symptoms: a detailed overview. BMC Gastroenterol 2020; 20:168. [PMID: 32493265 PMCID: PMC7268616 DOI: 10.1186/s12876-020-01306-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/18/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Diagnosing constipation remains difficult and its treatment continues to be ineffective. The reason may be that the symptom patterns of constipation differ in different demographic groups. We aimed to determine the pattern of constipation symptoms in different demographic groups and to define the symptoms that best indicate constipation. METHODS In this cross-sectional study the Groningen Defecation and Fecal Continence questionnaire was completed by a representative sample of the adult Dutch population (N = 892). We diagnosed constipation according to the Rome IV criteria for constipation. RESULTS The Rome criteria were fulfilled by 15.6% of the study group and we found the highest prevalence of constipation in women and young adults (19.7 and 23.5%, respectively). Symptom patterns differed significantly between constipated respondents of various ages, while we did not observe sex-based differences. Finally, we found a range of constipation symptoms, not included in the Rome IV criteria, that showed marked differences in prevalence between constipated and non-constipated individuals, especially failure to defecate (∆ = 41.2%). CONCLUSIONS Primarily, we found that certain symptoms of constipation are age-dependent. Moreover, we emphasize that symptoms of constipation not included in the Rome IV criteria, such as daily failure to defecate and an average duration of straining of more than five minutes, are also reliable indicators of constipation. Therefore, we encourage clinicians to adopt a more comprehensive approach to diagnosing constipation.
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Affiliation(s)
- Sanne J. Verkuijl
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30 001, 9700 RB Groningen, the Netherlands
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Rob J. Meinds
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30 001, 9700 RB Groningen, the Netherlands
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30 001, 9700 RB Groningen, the Netherlands
| | - Paul M. A. Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30 001, 9700 RB Groningen, the Netherlands
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Beluska-Turkan K, Korczak R, Hartell B, Moskal K, Maukonen J, Alexander DE, Salem N, Harkness L, Ayad W, Szaro J, Zhang K, Siriwardhana N. Nutritional Gaps and Supplementation in the First 1000 Days. Nutrients 2019; 11:E2891. [PMID: 31783636 PMCID: PMC6949907 DOI: 10.3390/nu11122891] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/13/2019] [Accepted: 11/19/2019] [Indexed: 12/23/2022] Open
Abstract
Optimized nutrition during the first 1000 days (from conception through the 2nd birthday) is critical for healthy development and a healthy life for the newborn. Pregnancy and the postpartum period are accompanied by physiological changes, increased energy needs, and changing requirements in the nutrients critical for optimal growth and development. Infants and toddlers also experience physiological changes and have specific nutritional needs. Food and nutrition experts can provide women of childbearing age with adequate dietary advice to optimize nutrition, as well as guidance on selecting appropriate dietary supplements. Considering the approaching 2020-2025 Dietary Guidelines for Americans (DGA) will be making specific recommendations for children, it is important to provide accurate scientific information to support health influencers in the field of nutrition. The purpose of this review is to summarize the nutrition and supplementation literature for the first 1000 days; to highlight nutritional and knowledge gaps; and to educate nutrition influencers to provide thoughtful guidance to mothers and families. Optimal nutrition during pregnancy through early childhood is critical for supporting a healthy life. Nutrition influencers, such as dietitians, obstetricians/gynecologists, and other relevant health professionals, should continue guiding supplement and food intake and work closely with expectant families and nutrition gatekeepers.
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Affiliation(s)
- Katrina Beluska-Turkan
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
| | - Renee Korczak
- Premier Nutrition, LLC, Bernardsville, NJ 07924, USA;
| | - Beth Hartell
- PearTree Nutrition, LLC, Seattle, WA 98115, USA;
| | - Kristin Moskal
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
| | | | | | - Norman Salem
- DSM Nutritional Products, Columbia, MD 21045, USA;
| | - Laura Harkness
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
| | - Wafaa Ayad
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
| | - Jacalyn Szaro
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
| | - Kelly Zhang
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
| | - Nalin Siriwardhana
- Church & Dwight, Co., Inc., Product Development Nutritional Sciences, Princeton, NJ 08540, USA; (K.B.-T.); (K.M.); (L.H.); (W.A.); (J.S.); (K.Z.)
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Larsson C, Hedberg CL, Lundgren E, Söderström L, TunÓn K, Nordin P. Anal incontinence after caesarean and vaginal delivery in Sweden: a national population-based study. Lancet 2019; 393:1233-1239. [PMID: 30799061 DOI: 10.1016/s0140-6736(18)32002-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/15/2018] [Accepted: 08/21/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Elective caesarean delivery is increasing rapidly in many countries, and one of the reasons might be that caesarean delivery is widely believed to protect against pelvic floor disorders, including anal incontinence. Previous studies on this issue have been small and with conflicting results. The aim of present study was to compare the risk of developing anal incontinence in women who had a caesarean delivery, in those who had a vaginal delivery, and in two age-matched control groups (nulliparous women and men). METHODS In this observational population-based study, we included all women in the Swedish Medical Birth Register who gave birth by caesarean delivery or vaginal delivery during 1973-2015 in Sweden and were diagnosed with anal incontinence according to ICD 8-10 in the Swedish National Patient Register during 2001-15. Exclusion criteria were multiple birth delivery, mixed vaginal and caesarean delivery, and four or more deliveries. We compared the diagnosis of anal incontinence between women previously delivered solely by caesarean delivery and those who solely had delivered vaginally. We also compared it with two age-matched control groups of nulliparous women and men from the Swedish Total Population Register. Finally, we analysed risk factors for anal incontinence in the caesarean delivery and vaginal delivery groups. FINDINGS 3 755 110 individuals were included in the study. Between 1973 and 2015, 185 219 women had a caesarean delivery only and 1 400 935 delivered vaginally only. 416 (0·22 %) of the 185 219 women in the caesarean delivery group were diagnosed with anal incontinence compared with 5171 (0·37%) of 1 400 935 women in the vaginal delivery group. The odds ratio (OR) for being diagnosed with anal incontinence after vaginal delivery compared with caesarean delivery was 1·65 (95% CI 1·49-1·82; p<0·0001). When the combination vaginal delivery and caesarean delivery was compared with the nulliparous control group, the OR of being diagnosed with anal incontinence was 2·05 (1·92-2·19; p<0·0001). For the nulliparous women compared with men, the OR for anal incontinence was 1·89 (1·75-2·05; p<0·0001). The strongest risk factors for anal incontinence after vaginal delivery were high maternal age, high birthweight of the child, and instrumental delivery. The only risk factor for anal incontinence after caesarean delivery was maternal age. INTERPRETATION The risk of developing anal incontinence increases after pregnancy and delivery. Women with known risk factors for anal incontinence should perhaps be offered a more qualified post-partum examination to enable early intervention in case of injury. Further knowledge for optimal management are needed. FUNDING County Council of Jämtland.
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Affiliation(s)
- Charlotta Larsson
- Department of Surgical and Perioperative Sciences, University of Umeå and Hospital of Östersund, Östersund, Sweden
| | | | - Ewa Lundgren
- Department of Surgery, Hospital of Östersund, Östersund, Sweden
| | - Lars Söderström
- Department of Research and Development, Hospital of Östersund, Östersund, Sweden
| | - Katarina TunÓn
- Department of Clinical Science, Obstetrics and Gynecology Umeå University, Umeå, Sweden
| | - Pär Nordin
- Department of Surgical and Perioperative Sciences, University of Umeå and Hospital of Östersund, Östersund, Sweden.
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Zhai J, Li Y, Lin J, Dong S, Si J, Zhang J. Chinese herbal medicine for postpartum constipation: a protocol of systematic review and meta-analysis. BMJ Open 2019; 9:e023941. [PMID: 30647039 PMCID: PMC6340430 DOI: 10.1136/bmjopen-2018-023941] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Constipation is one of the most common gastrointestinal symptoms in postpartum mothers. The choice of treatments for postpartum constipation remains a challenging clinical problem. Chinese herbal medicine has become increasingly popular as an alternative therapy for constipation. This systematic review aims to evaluate the efficacy and safety of Chinese herbal medicine for postpartum constipation. METHODS AND ANALYSIS We will search PubMed (1946 to present), EMBASE (1974 to present), Cochrane Central Register of Controlled Trials (all years), Web of Science (1900 to present), Chinese Biomedical Literatures Database (1978 to present), China National Knowledge Infrastructure (1979 to present) and WANFANG data (1998 to present) to identify any eligible study. No restriction will be put on the language, publication date or status of the study. The primary outcome will be the spontaneous bowel movement. Secondary outcomes will be stool consistency, quality of life, transit time, relief of constipation symptoms and adverse events. We will perform the meta-analysis when more than one trial examines the same intervention and outcomes with comparable methods in similar populations. If the heterogeneity is not significant statistically (p>0.10 or I2<50%), the fixed-effect model will be built to estimate the overall intervention effects. Otherwise, the random-effect model will be used to provide more conservative results. ETHICS AND DISSEMINATION No ethical issues are foreseen because no primary data will be collected. The results will be published in a peer-reviewed scientific journal. PROSPERO REGISTRATION NUMBER CRD42018093741.
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Affiliation(s)
- Jingbo Zhai
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yan Li
- School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jingyi Lin
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shuo Dong
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jinhua Si
- Library, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Junhua Zhang
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Subki AH, Fakeeh MM, Hindi MM, Nasr AM, Almaymuni AD, Abduljabbar HS. Fecal and Urinary Incontinence Associated with Pregnancy and Childbirth. Mater Sociomed 2019; 31:202-206. [PMID: 31762703 PMCID: PMC6853745 DOI: 10.5455/msm.2019.31.202-206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction: Fecal incontinence (FI) and urinary incontinence (UI) are major problems faced by women worldwide, with pregnancy and delivery representing two major risk factors for these conditions. The prevalence of FI and UI varies across studies. In our region, only a few publications have addressed this topic. Aim: The aim of this study was to determine the prevalence of FI and UI in Saudi pregnant women, their characteristics, and a specific clinical pattern that could identify patients that are at a risk for incontinence. Materials and Methods: This was a questionnaire-based crosssectional study conducted over a 3 months period in 2017, among pregnant women attending King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Results: Our study included 393 pregnant women. FI was reported by 24 patients (6.1%), and fecal urgency was reported by 30.5%. UI was reported by 84 patients (21.4 %). When patients with no UI were compared with patients with UI, the only statistically significant factor was BMI (p = 0.043). There were no statistically significant differences when comparing patients with FI versus no-FI, and fecal urgency versus no-fecal urgency. However, laceration (OR: 1.696, p = 0.036), episiotomy (OR: 1.413, p = 0.029), constipation (OR: 1.944, p < 0.001), hypertension (OR: 1.993, p = 0.022), and Bristol stool scale score (p = 0.002) were statistically significant factors for determining fecal control. Conclusion: FI and UI are frequently associated with pregnancy and delivery, but their prevalence is underestimated. The role of the practitioner is crucial in preventing and treating these conditions, and in impeding their harmful effects on the postpregnancy quality of life of Saudi women.
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Affiliation(s)
- Ahmed Hussein Subki
- Department of Internal Medicine, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Maged Mazen Fakeeh
- Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Muhab Mohammed Hindi
- Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali Mohammed Nasr
- Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Adel Dakhel Almaymuni
- Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hassan S Abduljabbar
- Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Ferdinande K, Dorreman Y, Roelens K, Ceelen W, De Looze D. Anorectal symptoms during pregnancy and postpartum: a prospective cohort study. Colorectal Dis 2018; 20:1109-1116. [PMID: 29972721 DOI: 10.1111/codi.14324] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 06/06/2018] [Indexed: 02/08/2023]
Abstract
AIM The aim was to determine the prevalence and risk factors of anal symptoms prepartum and postpartum. METHOD A prospective observational cohort study was carried out in Ghent University Hospital, Belgium. Ninety-four pregnant women between their 19th and 25th week of pregnancy were included. An anal symptom questionnaire was filled in at four different times: in the second and third trimester, immediately postpartum and 3 months postpartum. Descriptive data were obtained from patient files. A proctological diagnosis was presumed on the basis of combined symptoms (i.e. rectal bleeding, anal pain and swelling). Constipation was defined by the Rome III criteria. Risk factors were identified using multivariate analysis. RESULTS Sixty-eight per cent of the patients developed anal symptoms. The most prevalent symptom was anal pain. Constipation was reported by 60.7% during the study period. Seven women (7.9%) suffered from faecal incontinence. The most prevalent diagnoses were haemorrhoidal thrombosis (immediately postpartum), haemorrhoidal prolapse (in the third trimester and immediately postpartum) and anal fissure (not episode related). The two independent risk factors for anal complaints were constipation, with a 6.3 odds ratio (95% CI 2.08-19.37), and a history of anal problems, with a 3.9 odds ratio (95% CI 1.2-13). The Bristol Stool Chart was shown to be a reliable indicator in pregnancy and postpartum as significant correlations were observed in all study periods. CONCLUSION Two-thirds of pregnant women have anal symptoms during pregnancy and postpartum, especially haemorrhoidal complications and anal fissure. The most important risk factor is constipation. The prevention of constipation in pregnant women is therefore highly recommended.
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Affiliation(s)
- K Ferdinande
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent University, Gent, Belgium
| | - Y Dorreman
- Department of Gynaecology and Obstetrics, Ghent University Hospital, Ghent University, Gent, Belgium
| | - K Roelens
- Department of Gynaecology and Obstetrics, Ghent University Hospital, Ghent University, Gent, Belgium
| | - W Ceelen
- Department of GI Surgery, Ghent University Hospital, Ghent University, Gent, Belgium
| | - D De Looze
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent University, Gent, Belgium
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Prediction of the Risk of Early Gestational Complications in Women with Chronic Gastritis. Fam Med 2018. [DOI: 10.30841/2307-5112.5.2018.166700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Schei B, Johannessen HH, Rydning A, Sultan A, Mørkved S. Anal incontinence after vaginal delivery or cesarean section. Acta Obstet Gynecol Scand 2018; 98:51-60. [PMID: 30204238 DOI: 10.1111/aogs.13463] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 08/13/2018] [Accepted: 08/17/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Uncertainties remain as to whether a cesarean section is protective for the short-term and long-term development of anal incontinence. Our aim was to explore whether women who had delivered only vaginally were at greater risk of anal incontinence than nulliparous women and women who had undergone cesarean sections only. MATERIAL AND METHODS Background information, medical history, and data on anal incontinence (defined as fecal or flatus incontinence weekly or more) reported by women participating in a large population-based health survey in Norway (the Nord-Trøndelag Health Study 3) during the period October 2006 to June 2008 were collected and linked to data from the Medical Birth Registry of Norway. The prevalence of anal incontinence was calculated and multivariate logistic regression analyses were applied. RESULTS The mean age of the 12 567 women was 49.9 years. The age and educational level of women who had cesarean sections only were similar to those who had a vaginal delivery and obstetric anal sphincter injuries (OASIS). Nulliparous women and those who had a vaginal delivery and no OASIS were older and had higher educational achievements than women who had delivered by cesarean section exclusively, and women with OASIS. One in four women with OASIS reported anal incontinence compared with one in six of the other women (P < .001). Age, educational level, diarrhea, constipation, birthweight, and OASIS increased the risk of anal incontinence in all women. Parity was associated with anal incontinence in parous women only. No differences were found for fecal urgency. CONCLUSIONS Women with vaginal deliveries complicated by OASIS are at increased risk of anal incontinence. However, no increased risk of anal incontinence was found in nulliparous women or women who had cesarean sections only or vaginal deliveries not complicated by OASIS.
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Affiliation(s)
- Berit Schei
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Hege Hølmo Johannessen
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Sarpsborg, Norway
| | - Astrid Rydning
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Abdul Sultan
- Croydon University Hospital, Croydon, UK.,St George's , University of London, London, UK
| | - Siv Mørkved
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Research Department, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Johannessen HH, Stafne SN, Falk RS, Stordahl A, Wibe A, Mørkved S. Prevalence and predictors of anal incontinence 6 years after first delivery. Neurourol Urodyn 2018; 38:310-319. [DOI: 10.1002/nau.23854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/07/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Hege H. Johannessen
- Department of Physical Medicine and Rehabilitation; Østfold Hospital Trust; Sarpsborg Norway
| | - Signe N. Stafne
- Department of Public Health and Nursing; Norwegian University of Science and Technology; Trondheim Norway
- Department of Physiotherapy; St. Olavs Hospital Trondheim University Hospital; Trondheim Norway
| | - Ragnhild S. Falk
- Oslo Centre of Biostatistics and Epidemiology; Oslo University Hospital; Oslo Norway
| | - Arvid Stordahl
- Department of Surgery; Østfold Hospital Trust; Sarpsborg Norway
| | - Arne Wibe
- Department of Clinical and Molecular Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Department of Surgery; St. Olavs Hospital; Trondheim University Hospital; Trondheim Norway
| | - Siv Mørkved
- Department of Public Health and Nursing; Norwegian University of Science and Technology; Trondheim Norway
- Department of Research and Development; St. Olavs Hospital Trondheim University Hospital; Trondheim Norway
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Åhlund S, Rådestad I, Zwedberg S, Edqvist M, Lindgren H. Haemorrhoids - A neglected problem faced by women after birth. SEXUAL & REPRODUCTIVE HEALTHCARE 2018; 18:30-36. [PMID: 30420084 DOI: 10.1016/j.srhc.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the prevalence and severity of haemorrhoids after birth among first-time mothers in relation to management during the second stage of labour and to describe the women's experiences with haemorrhoids. METHOD A mixed method explanatory sequential design was used. Nulliparous women were allocated to an intervention group for whom the second-stage of labour practice followed the MIMA model (Midwives management during second stage of labour) or to a control group for whom standard-care practice was followed. Data were collected three weeks and 1.5 years after birth. RESULT A total of 496 (82.1%) women responded to the questionnaire three weeks after birth, 120 (70%) responded to the questionnaire 1.5 years after the birth. The women in the intervention group had fewer symptoms from haemorrhoids three weeks after birth compared to the women in the control group (adj. OR 0.6 95% CI 0.4-0.9). Half of the women in the intervention and control group (50.8%) who reported problems with haemorrhoids three weeks after birth still experienced problems after 1.5 years. The majority of all women did not seek medical care due to their symptoms. The women who described that they experienced haemorrhoids as a problem after birth felt neglected by the healthcare system. CONCLUSION A substantial percentage of women had symptoms from haemorrhoids after birth. Many of these women felt that their problems were neglected. Women who experienced a slow birth of the baby's head and spontaneous pushing suffered less from haemorrhoids 3 weeks after birth.
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Affiliation(s)
- Susanne Åhlund
- Department of Women's and Children's Health, Karolinska Institute, Sweden.
| | - Ingela Rådestad
- Department for Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
| | - Sofia Zwedberg
- Department of Women's and Children's Health, Karolinska Institute, Sweden; Department for Health Promoting Science, Sophiahemmet University, Stockholm, Sweden; Department of Obstetrics, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Malin Edqvist
- Department of Women's and Children's Health, Karolinska Institute, Sweden; Department of Obstetrics, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Helena Lindgren
- Department of Women's and Children's Health, Karolinska Institute, Sweden
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Continence technologies whitepaper: Informing new engineering science research. Proc Inst Mech Eng H 2018; 233:138-153. [DOI: 10.1177/0954411918784073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]. ACTA ACUST UNITED AC 2018; 46:419-426. [PMID: 29500142 DOI: 10.1016/j.gofs.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 12/11/2022]
Abstract
Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.
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Abstract
The gut microbiome is a critical component of an individual's metabolism and overall health. The prenatal period is marked by unique inflammatory and immune changes that alter maternal gut function and bacterial composition as the pregnancy advances. The composition of the maternal gut microbiome contributes to obstetric outcomes with long-term health sequelae for mother and child. Estrogen and progesterone also have an impact on gut function, especially during the prenatal period. These physiologic changes in pregnancy allow for adjustments in maternal metabolism and weight necessary to support the pregnancy. Normal hormonal, metabolic, and immunologic changes to the maternal gut microbiome throughout the prenatal period are reviewed, including relevant implications for nurses providing care for pregnant women.
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Samavati R, Ducza E, Hajagos-Tóth J, Gaspar R. Herbal laxatives and antiemetics in pregnancy. Reprod Toxicol 2017; 72:153-158. [DOI: 10.1016/j.reprotox.2017.06.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/24/2017] [Accepted: 06/05/2017] [Indexed: 11/27/2022]
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Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG. MR Imaging of Perianal Crohn Disease. Radiology 2017; 282:628-645. [PMID: 28218881 DOI: 10.1148/radiol.2016151491] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Shannon P Sheedy
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - David H Bruining
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Eric J Dozois
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - William A Faubion
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Joel G Fletcher
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Saldana Ruiz N, Kaiser AM. Fecal incontinence - Challenges and solutions. World J Gastroenterol 2017; 23:11-24. [PMID: 28104977 PMCID: PMC5221273 DOI: 10.3748/wjg.v23.i1.11] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 10/14/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023] Open
Abstract
Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient’s self-esteem and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.
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Thein-Nissenbaum J. The postpartum triathlete. Phys Ther Sport 2016; 21:95-106. [PMID: 27497835 DOI: 10.1016/j.ptsp.2016.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 01/02/2023]
Abstract
The postpartum period in a woman's life is filled with numerous changes, including physical changes, changes in sleep habits, and learning how to best care for a newborn. A common goal among postpartum women is to either begin or resume an active lifestyle, which often includes physical activity such as running, biking and swimming. The postpartum athlete may discover barriers that prevent her from returning to or beginning an exercise routine. These obstacles include muscle weakness, fatigue, depression and physical changes that require exercise modification. The physical therapist is well-suited to properly assess, treat and manage the care of the postpartum athlete. Postpartum athletes wishing to begin or resume training for triathlons require special consideration, as the triathlete must balance training to compete in three different sports. The purpose of the paper is to identify the unique physical and physiological changes that occur to the female during the postpartum period. In addition, injuries that are more commonly seen during the postpartum period will be discussed. Recommendations for beginning or resuming an exercise program will be reviewed. Lastly, sport-specific training for the postpartum triathlete, including challenges presented with each triathlon component, will be discussed.
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Affiliation(s)
- Jill Thein-Nissenbaum
- University of Wisconsin- Madison, School of Medicine and Public Health, 1300 University Avenue, Madison, WI 53706, USA.
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O’Connor DL, Blake J, Bell R, Bowen A, Callum J, Fenton S, Gray-Donald K, Rossiter M, Adamo K, Brett K, Khatri N, Robinson N, Tumback L, Cheung A. Consensus canadien sur la nutrition féminine : adolescence, reproduction, ménopause et au-delà. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:555-609.e19. [DOI: 10.1016/j.jogc.2016.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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O'Connor DL, Blake J, Bell R, Bowen A, Callum J, Fenton S, Gray-Donald K, Rossiter M, Adamo K, Brett K, Khatri N, Robinson N, Tumback L, Cheung A. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:508-554.e18. [PMID: 27368135 DOI: 10.1016/j.jogc.2016.01.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide health care professionals in Canada with the basic knowledge and tools to provide nutrition guidance to women through their lifecycle. OUTCOMES Optimal nutrition through the female lifecycle was evaluated, with specific focus on adolescence, pre-conception, pregnancy, postpartum, menopause, and beyond. The guideline begins with an overview of guidance for all women, followed by chapters that examine the evidence and provide recommendations for the promotion of healthy nutrition and body weight at each life stage. Nutrients of special concern and other considerations unique to each life stage are discussed in each chapter. EVIDENCE Published literature, governmental and health agency reports, clinical practice guidelines, grey literature, and textbook sources were used in supporting the recommendations made in this document. VALUES The quality of evidence was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. CHAPTER 2: GENERAL FEMALE NUTRITION: Summary Statements Recommendations CHAPTER 3: ADOLESCENCE NUTRITION: Summary Statements Recommendations CHAPTER 4: PRE-CONCEPTUAL NUTRITION: Summary Statement Recommendations CHAPTER 5: NUTRITION IN PREGNANCY: Summary Statements Recommendations CHAPTER 6: POSTPARTUM NUTRITION AND LACTATION: Summary Statements Recommendations CHAPTER 7: NUTRITION DURING MENOPAUSE AND BEYOND: Summary Statement Recommendations.
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The Relationship between Constitution of Traditional Chinese Medicine in the First Trimester and Pregnancy Symptoms: A Longitudinal Observational Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:3901485. [PMID: 27087821 PMCID: PMC4818819 DOI: 10.1155/2016/3901485] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/03/2016] [Indexed: 11/17/2022]
Abstract
Objective. We report on the distribution of traditional Chinese medicine (TCM) constitution in the first trimester and on the association between TCM constitution and maternal symptoms related to pregnancy. Methods. Participants were followed up until delivery to observe primary measures (gestational hypertension and gestational diabetes mellitus) and secondary measures (signs of miscarriage, miscarriage, nausea and vomiting, and sleepiness and defecation during pregnancy). Descriptive analysis, t-tests, chi-square tests, and logistic regression analysis were used in this study. Results. 61.8% of the participants had unbalanced constitutions. We did not find a significant association between the TCM constitution and gestational hypertension, gestational diabetes, miscarriage, signs of miscarriage, and defecation during pregnancy. And we found that women with unbalanced constitutions in early pregnancy had a greater likelihood of severe nausea and vomiting and poor sleep during pregnancy in the logistic regression analysis. Conclusions. These results have implications for female health care providers and policy makers. Identification of TCM constitution may be helpful for understanding nausea and vomiting and poor sleepiness during pregnancy, especially in the condition that can not be explained by modern medical science, and be helpful for making program to improve these uncomfortable symptoms.
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Mukudai S, Ichi Matsuda K, Bando H, Takanami K, Nishio T, Sugiyama Y, Hisa Y, Kawata M. Expression of Sex Steroid Hormone Receptors in Vagal Motor Neurons Innervating the Trachea and Esophagus in Mouse. Acta Histochem Cytochem 2016; 49:37-46. [PMID: 27006520 PMCID: PMC4794553 DOI: 10.1267/ahc.15037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/22/2016] [Indexed: 12/11/2022] Open
Abstract
The medullary vagal motor nuclei, the nucleus ambiguus (NA) and dorsal motor nucleus of the vagus (DMV), innervate the respiratory and gastrointestinal tracts. We conducted immunohistochemical analysis of expression of the androgen receptor (AR) and estrogen receptor α (ERα), in relation to innervation of the trachea and esophagus via vagal motor nuclei in mice. AR and ERα were expressed in the rostral NA and in part of the DMV. Tracing experiments using cholera toxin B subunit demonstrated that neurons of vagal motor nuclei that innervate the trachea and esophagus express AR and ERα. There was no difference in expression of sex steroid hormone receptors between trachea- and esophagus-innervating neurons. These results suggest that sex steroid hormones may act on vagal motor nuclei via their receptors, thereby regulating functions of the trachea and esophagus.
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Affiliation(s)
- Shigeyuki Mukudai
- Department of Anatomy and Neurobiology, Kyoto Prefectural University of Medicine
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine
- Department of Otolaryngology-Bronchoesophagology, Kyoto Second Red Cross Hospital
| | - Ken Ichi Matsuda
- Department of Anatomy and Neurobiology, Kyoto Prefectural University of Medicine
| | - Hideki Bando
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine
| | - Keiko Takanami
- Department of Anatomy and Neurobiology, Kyoto Prefectural University of Medicine
- Ushimado Marine Institute, Graduate School of Natural Science and Technology, Okayama University
| | - Takeshi Nishio
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine
| | - Yoichiro Sugiyama
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine
| | - Yasuo Hisa
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine
- Faculty of Health and Medical Sciences, Kyoto Gakuen University
| | - Mitsuhiro Kawata
- Department of Anatomy and Neurobiology, Kyoto Prefectural University of Medicine
- School of Health Sciences, Bukkyo University
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Li Z, Pergolizzi JV, Huttner RP, Zampogna G, Breve F, Raffa RB. Management of opioid-induced constipation in pregnancy: a concise review with emphasis on the PAMORAs. J Clin Pharm Ther 2015; 40:615-9. [DOI: 10.1111/jcpt.12331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Z. Li
- Temple University School of Pharmacy; Philadelphia PA USA
| | - J. V. Pergolizzi
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
- Department of Pharmacology; Temple University School of Medicine; Philadelphia PA USA
- Association of Chronic Pain Patients; Houston TX USA
| | - R. P. Huttner
- Women's Health Center of Hunterdon County; Flemington NJ USA
| | | | - F. Breve
- Temple University School of Pharmacy; Philadelphia PA USA
| | - R. B. Raffa
- Temple University School of Pharmacy; Philadelphia PA USA
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