Rezidivrisiko durch hormonale Kontrazeptiva bei Brustkrebsüberlebenden überprüft

Ostroot MK et al. Breast cancer recurrence risk after hormonal contraceptive use in survivors of reproductive age. Eur J Obstet Gynecol Reprod Biol 2021; 258: 174–178. doi: 10.1016/j.ejogrb.2020.12.035

Prenatal Androgen Excess Impairs Sexual Behavior in Adult Female Mice: Perspective on Sexual Dysfunction in PCOS

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders worldwide, affecting 5-20% of reproductive aged women [1]. PCOS is characterised by androgen excess, oligo- or anovulation, and polycystic ovarian morphology [1]. PCOS patients also experience sexual dysfunction, including decreased sexual desire, increased sexual dissatisfaction and gender dysphoria [2-4]. The origins of PCOS-related sexual difficulties remain unidentified, but may be related to impaired central mechanisms regulating sexual behaviours. Prenatally androgenized (PNA) mice recapitulate the PCOS phenotype and exhibit alterations in the neuronal network regulating reproductive function [5], providing a powerful, pathology-based model to unravel the biological origins of sexual dysfunction in PCOS. Here, we aimed to determine whether female sexual behaviours are impaired in the PNA mouse model of PCOS. To model PCOS, female dams received injections of dihydrotestosterone (PNA) or oil vehicle (VEH) daily from gestational day 16-18. Adult female offspring were ovariectomized and implanted with a silastic capsule of estradiol to examine the female-typical sexual behaviour: lordosis as well as partner preference. We also examined a potential masculinisation of the brain by replacing the estradiol implant by a testosterone implant then testing the female for male-like sexual behaviours. PNA females exhibited significantly reduced lordosis behaviour compared to VEH females (p<0.01). In contrast, partner preference and male-like sexual behaviour were not different between PNA and VEH females. In addition, using Open-field test and elevated-plus maze, we observed no effect of prenatal androgen exposure on locomotion and anxiety. These results highlight, for the first time, that prenatal exposure to the non-aromatisable androgen, DHT, impairs female receptivity only without masculinisation. These findings support the use of the PNA mouse model of PCOS to identify the neuronal targets of prenatal androgen action and to determine the mechanisms by which prenatal androgen excess impairs lordosis. Taken together, this study introduce a novel perspective on the origins of sexual dysfunction in women with PCOS and indicate the need for further investigation into the mechanisms of androgen excess on the female brain and sexual function. [1] Lizneva D et al, Fertil Steril. 2016;106:6-15. [2] Fliegner M et al, Geburtshilfe Frauenheilkd. 2019;79:498-509.[3] Kowalczyk R et al, Acta Obstet Gynecol Scand. 2012;91:710-4.[4] Mansson M et al, Eur J Obstet Gynecol Reprod Biol. 2011;155:161-5. [5] Ruddenklau A, Campbell RE. Endocrinology. 2019 Oct 1;160(10):2230-2242.

Análise dos desfechos materno-fetais em gestantes com ganho ponderal inadequado atendidas no ambulatório de pré-natal da Universidade Brasil, em Fernandópolis, São Paulo, Brasil

Sendo o peso pré-gestacional reconhecido com um dos principais determinantes do ganho ponderal na gestação e o acompanhamento do ganho ponderal nesse período um procedimento acessível e de baixo custo, é de grande utilidade sua análise e controle para possíveis intervenções primárias de prevenção, com promoção à saúde do binômio mãe-feto. Considerando as implicações da obesidade na gestação, esse trabalho objetivou analisar o histórico pré-natal do estado nutricional e possíveis correlações com intercorrências para a saúde materna e a via de parto no Ambulatório de Pré-natal da Universidade Brasil, Fernandópolis, São Paulo, Brasil. Forma avaliados 356 prontuários, considerando as variáveis: índice de massa corpórea na primeira consulta do pré-natal; diagnóstico de diabetes mellitus gestacional; síndromes hipertensivas gestacionais; e a via de parto no período de maio de 2015 a fevereiro de 2017. Dentre a amostra selecionada, 34,2% das gestantes encontravam-se em estado de sobrepeso e 11% de obesidade. A prevalência de diabetes mellitus gestacional foi de 4,2%, dentre as quais 33,3% foram classificadas em sobrepeso e 53,8% em obesidade. Em relação a síndromes hipertensivas gestacionais, o diagnóstico ocorreu em 10,1% da amostra, sendo que desta, 47,2% estavam acima do peso. Já sobre a via de parto, houve prevalência de 46% de partos operatórios, dentre os quais 56% ocorreram em gestantes com sobrepeso ou obesidade. Mediante a transversalidade desta temática, já que o excesso de peso na gestação se correlaciona com o aumento de problemas de saúde materna, além do seu impacto econômico para o país, pode-se concluir que atingir ou permanecer em estado nutricional de eutrofia é fundamental para o desenvolvimento saudável do binômio mão-feto e uma boa assistência pré-natal.Descritores: Gravidez; Peso Corporal; Diabetes Mellitus; Hipertensão; Parto.ReferênciasSilva LS, Pessoa FB, Pessoa DTC. Análise das mudanças fisiológicas durante a gestação: desvendando mitos. Rev FMB. 2015;8(1):1-16.Santos AL, Radovanovic CAT, Marcon SS. Assistência pré-natal: satisfação e expectativas. Rev Rene. 2010;11(Esp.):61-71.Sawada M, Masuyama H, Hayata K, Kamada Y, Nakamura K, Hiramatsu Y. Pregnancy complications and glucose intolerance in women with polycystic ovary syndrome. Endocr J. 2015;62(11):1.017-2.Laporte-Pinfildi ASC, Zangirolani LTO, Spina N, Martins PA, Medeiros MAT. Atenção nutricional no pré-natal e no puerpério: percepção dos gestores da Atenção Básica à Saúde. Rev Nutr. 2016;29(1):109-23.Gonçalves CV, Mendoza-Sassi RA, Cesar JA, Castro NB, Bortolomedi AP. Índice de massa corporal e ganho de peso gestacional como fatores preditores de complicações e do desfecho da gravidez. Rev Bras Ginecol Obstet. 2012;34(7):304-9.Santos JGC, Silva JMC, Passos AMPR, Monteiro BKSM, Maia MM, Silva RA et al. Peso materno em gestantes de baixo risco na atenção pré-natal. Int J Nutrology. 2017;10(2):5-15.Lima EM. Assistência nutricional no pré-natal: avaliação do processo nas Unidades de Saúde da família no município de Vitória de Santo Antão, PE. Vitória de Santo Antão: Universidade Federal de Pernambuco; 2015.Asbee SM, Jenkins TR, Butler JR, White J, Elliot M, Rutledge A. Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling. Obstet Gynecol. 2009;113(2 Pt 1):305-12.Godoy AC. Ganho de peso gestacional – recomendações e adequação entre mulheres brasileiras [dissertação] . Campinas: Universidade Estadual de Campinas, UNICAMP; 2015.World Health Organization. Obesity: Preventing and managing the global epidemic: report of a WHO Consultation. Geneva: WHO Consultation on Obesity; 2000.National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000;183(1):S1-22.Santos EMF, Amorim LP, Costa OLN, Oliveira N, Guimarães AC. Perfil de risco gestacional e metabólico no serviço de pré-natal de maternidade pública do Nordeste do Brasil. Rev Bras Ginecol Obstet. 2012;34(3):102-6.Valladares CG, Konka SB. Prevalência de diabetes mellitus gestacional em gestantes de um centro de saúde de Brasília - DF. Comun Ciênc Saúde. 2008;19(1):11-7.Maganha CA, Vanni DG, Bernadini MA, Zugaib M. Tratamento do diabetes mellito gestacional. Rev Assoc Med Bras. 2003;49(3):330-34.Assis TR, Viana FP, Rassi S. Estudo dos principais fatores de risco maternos nas síndromes hipertensivas da gestação. Arq Bras Cardiol. 2008;91(1):11-7.Melo ASO, Assunção PL, Gondim SSR, Carvalho DF, Amorim MMR, Benicio MHD'A et al. Estado nutricional materno, ganho de peso gestacional e peso ao nascer. Rev Bras Epidemiol. 2007;10(2):249-57.Vettore MV, Dias M, Domingues RMSM, Vettore MV, Leal MC. Cuidados pré-natais e avaliação do manejo da hipertensão arterial em gestantes do SUS no Município do Rio de Janeiro, Brasil. Cad Saúde Pública. 2011;27(5):1.021-34.Job HGC, Passini R Jr; Pereira BG. Obesidade e gravidez: avaliação de um programa assistencial. Rev Ciênc Méd. 2005;14(6):503-14.Brasil. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006: dimensões do processo reprodutivo e da saúde da criança. Brasília, DF: Ministério da Saúde; 2009 [citado 2019 Set 26]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnds_crianca_mulher.pdfCarneiro JRI, Braga FO, Cabizuca CA, Abi-Abib RC, Cobas RA, Gomes MB. Gestação e obesidade: um problema emergente. Rev HUPE. 2014;13(3):17-24.Chu SY, Bachman DJ, Callaghan WM, Whitlock EP, Dietz PM, Berg CJ et al. Association between obesity during pregnancy and increased use of health care. N Engl J Med. 2008;358(14):1444-53.

Management of a Complicated Internal Herniation After Roux-en-Y Gastric Bypass in a 28-Week Pregnant Woman

Background Small bowel obstruction (SBO) due to internal hernia (IH) is a well-known late complication after laparoscopic Roux-en-Y gastric bypass (LRYGB), with an incidence between 0.5 and 10% as reported by Iannelli et al. (Obes Surg. 17(10):1283–6, 2007). It is reported most frequently 1–2 years after surgery because of the greater weight loss at that time, with rapid loss of the mesenteric fat consequently as discussed by Stenberg et al. (Lancet. 387(10026):1397–404, 2016). Currently, women constitute more than 50% of the patients undergoing bariatric surgery and most of them are of childbearing age as reported by the World Health Organization (2015). SBO, due to IH, is a rare complication during pregnancy, mostly occurring during the third trimester as discussed by Torres-Villalobos et al. (Obes Surg 19(7):944–50, 2009), and can result in fetal and maternal morbidity and even mortality as reported by Vannevel et al. (Obstet Gynecol. 127(6):1013–20, 2016). Moreover, the physiologic changes of pregnancy can mask the symptoms of SBO after LRYGB, leading to significant diagnostic and therapeutic delays as detailed by Wax et al. (Am J Obstet Gynecol 208(4):265–71, 2013). Therefore, an early surgical exploration is necessary in this particular and uncommon situation as discussed by Webster et al. (Ann R Coll Surg Engl 97(5):339–44, 2015). Methods A 32-year-old female patient, with Ehlers-Danlos syndrome and chronic pain, was in the 28th week of her first pregnancy after bariatric surgery. She had had an antecolic LRYGB 6 years ago in another institution, resulting in a 35-kg weight loss. She presented to the emergency department with severe and persistent epigastric pain associated with nausea and vomiting during 24 h. On physical examination, her abdomen was painful and tender at the epigastrium and left hypochondrium, and her vital signs were normal. The blood tests were in the normal range except the white blood cell count at 12′000 G/l. The obstetric and neonatal team was involved, and fetal heart monitoring was normal. Abdominal ultrasonography ruled out other causes of pain. An abdominal MRI was performed and displayed a distended proximal small bowel, free abdominal fluid, and bowel mesenteric edema in the left upper quadrant with compression of the superior mesenteric vein. Internal hernia with intestinal suffering was suspected, and the patient consented for emergency laparoscopy. Results The laparoscopic exploration, reduction of the internal hernia, and closure of the mesenteric defects are demonstrated step-by-step in the presented intraoperative video. The postoperative course was uncomplicated for both patient and fetus. Oral feeding was resumed at day 1, with no residual symptom, and the patient was discharged on postoperative day 3. At 1-month follow-up, she had no complaint and her pregnancy had resumed a normal course. She delivered a healthy baby at 36 weeks without any complication. Conclusions Internal herniation after LRYGB represents a rare, high-risk complication during pregnancy. A low threshold for imaging, preferably by abdominal MRI, is recommended. Multidisciplinary management, including obstetricians and bariatric surgeons, is necessary in order to avoid maternal and fetal adverse outcomes. During surgery, recognition of the anatomy is often difficult, and parts of the bowel are distended and fragile. Starting to run the bowel backwards from the ileocecal valve is a crucial surgical step for reducing internal hernias during LRYGB, and reduces both the risk to worsen the situation and of bowel injury, making its management less hazardous.

Frauenheilkunde – Gynäkologische Operationen: Modernes perioperatives Management spart Kosten

Harrison RF et al. Impact of implementation of an enhanced recovery program in gynecologic surgery on healthcare costs. Am J Obstet Gynecol 2020; 222: 66.e1–66.e9 Das Konzept des „Enhanced Recovery after Surgery“ (ERAS®) beschreibt eine multimodale perioperative Behandlungsstrategie zur Reduktion der mit chirurgischen Eingriffen einhergehenden physiologischen Belastungen. Auch gynäkologische Patientinnen profitieren hiervon: Sie erleiden seltener Komplikationen, benötigen weniger Analgetika und erholen sich schneller. Welche Kosten verursachen die ERAS-Programme in der Gynäkologie?