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Outpatient epilepsy care can often be straightforward. This is because around 65% of patients are seizure-free on their antiseizure medicines (ASMs). Management decisions that can simplify patient care prominently include minimizing ASM dosing complexity, preferably with monotherapy and once daily dosing. Choosing ASMs with lower side effect profiles and interaction potential is also ideal. Proactively addressing comorbidities of epilepsy and its treatment can improve quality of care. Some ASMs can negatively affect bone health so routine calcium and vitamin D supplementation is useful. Psychiatric care is comprehensively discussed in Chapter 9. The relative lack of need for ASM level monitoring is discussed. The decision to stop ASM therapy and how to do it is discussed. Lastly, the chapter concludes with a concise and thorough discussion of specific management considerations for women with epilepsy. Topics include the hormone cause of the catamenial pattern as well as ASMs and contraception, pregnancy, and breast feeding.
In the Middle Ages, the dismemberment of Agrippina, Emperor Nero’s mother, was not simply a gruesome family affair, but it had links to the emerging practice of dissection and the anatomical difference between the sexes. According to classical authors, after an unsuccessful assassination attempt involving a self-sinking boat, Agrippina was slayed by Anicetus upon Nero’s orders.1 In Roman History, Cassius Dio added that Agrippina opened her dress and asked Anicetus to strike at her womb “for this bore Nero.”2 Nero wished to see her corpse to verify the death, “so he laid bare her body, looked her all over and inspected her wounds.”3 The emperor examining the wound of the womb is transformed in the Middle Ages into the image of the ruler ordering the dissection of the female body.4 Jacobus de Voragine described such episode in the Golden Legend (c. 1260).5 Jean de Meun, in his continuation to The Romance of the Rose (c. 1275), wrote that Nero “had his mother dismembered so that he might see the place where he was conceived.”6 Jean de Meun is documented between 1265 and 1269 in Bologna, where post-mortem medical examination was practiced from the thirteenth century onward.7 Giovanni Boccaccio reports the story at length, including the wound of the womb, and mentions that in some sources “after her death Nero inspected the corpse, criticizing some parts of her body and praising others.”8
The present study assessed if salivary crystallization pattern (ferning pattern formed as a result of the higher levels of salt content in the dried sample) could be used for estrus detection and for diagnosis of pregnancy/non-pregnancy in dairy cows. Saliva and blood samples were collected from non-pregnant cycling cows (Sahiwal breed; n = 20) on alternate days from the day of estrus till next estrus. Then, all the cows were inseminated and saliva and blood sampling were continued further for a period of 22 d post-insemination. Pregnancy diagnosis was carried out on day 45 post-insemination and eight cows were found to be pregnant. The salivary crystallization pattern and estradiol:progesterone ratio during estrous cycle and during pregnancy were compared among these cows. Six types of salivary crystallization patterns were discerned; distinct patterns such as branch-like, fern-like, fir-like and combinations of these. Fern-like pattern was observed in all the cows on the day of estrus (first measurement day) and furthermore, all of the cows that subsequently became pregnant had fern-like salivary crystallization pattern at the time of insemination. Saliva of all the pregnant cows showed branch-fir type of crystallization pattern on day 16 post-breeding while only 50% of non-pregnant cows showed this pattern on day 16 of estrous cycle. The appearance of fern-like pattern was positively and significantly related to estradiol:progesterone ratio (r = 0.86; P < 0.001). The findings were validated on a separate group of cycling cows (n = 32). We can conclude that salivary crystallization pattern might serve as a non-invasive and cost effective and easy-to-use cow-side tool for estrus detection and early pregnancy/non-pregnancy diagnosis in cows upon validation on a larger sample size.
This book is the first comprehensive study of images of rape in Italian painting at the dawn of the Renaissance. Drawing on a wide range of primary sources, Péter Bokody examines depictions of sexual violence in religion, law, medicine, literature, politics, and history writing produced in kingdoms (Sicily and Naples) and city-republics (Florence, Siena, Lucca, Bologna and Padua). Whilst misogynistic endorsement characterized many of these visual discourses, some urban communities condemned rape in their propaganda against tyranny. Such representations of rape often link gender and aggression to war, abduction, sodomy, prostitution, pregnancy, and suicide. Bokody also traces how the new naturalism in painting, introduced by Giotto, increased verisimilitude, but also fostered imagery that coupled eroticism and violation. Exploring images and texts that have long been overlooked, Bokody's study provides new insights at the intersection of gender, policy, and visual culture, with evident relevance to our contemporary condition.
It is currently debated whether vitamin D requirements during pregnancy differ from those during non-gravid states. In current analyses, we aimed to determine the best model for the association between PTH and serum 25-hydroxyvitamin D (25(OH)D) and the threshold for circulating 25(OH)D at which serum parathyroid hormone (PTH) is suppressed. This multicenter prospective cross-sectional study was conducted on 227 Iranian pregnant women aged 15–45 years in their third trimester of pregnancy. The locally weighted smoothing scatter plot (LOWESS) was used to determine the curvilinear shape of the 25(OH)D/PTH relationship. Linear and non-linear methods were employed to determine the best fit and cut-point for serum 25(OH)D concentration. The median serum 25(OH)D and corresponding serum PTH concentration were 17⋅26 (13⋅44–23⋅08) ng/ml and 19⋅46 (15⋅08–25⋅04) pg/ml in our study population, respectively. The LOWESS curve suggested a non-linear and monotonic with a negative slope relation between PTH (pg/ml) and serum 25(OH)D (ng/ml). The optimal model for the association between PTH and serum 25(OH)D was a one-term fractional polynomial (FP1) (AIC = 1640⋅463). The FP1 analysis identified the 25(OH)D threshold of 12⋅48 ng/ml at which serum PTH rapidly rose. The expected degree of PTH stimulation seems to have a linear trend as 25(OH)D falls below 40 ng/ml. 25(OH)D (ng/ml) and PTH (pg/ml) had a non-linear and monotonic relationship with a negative slope. Our data suggest that a 25(OH)D threshold of 12⋅48 ng/ml is sufficient for parathyroid hormone suppression, which could be used to screen for deficient individuals.
Despite advances in medical care, we still come across pregnancy in Eisenmenger syndrome. Eisenmenger syndrome represents the severe end of the spectrum for disease in pulmonary artery hypertension associated with CHD. Due to very high maternal and perinatal morbidity and mortality, pregnancy is contraindicated among these women. Current guidelines also recommend that the women who become pregnant should opt for early termination of pregnancy. Here, we present a case series of 11 women of Eisenmenger syndrome and their pregnancy outcome.
It was a retrospective analysis of 12 pregnancies among 11 women with Eisenmenger syndrome who were managed in a tertiary care referral centre of Northern India.
The mean age of these women was 28 ± 4 years (range 22 to 36 years). Almost 80% of them (9/11) were diagnosed with Eisenmenger syndrome during pregnancy. The commonest cardiac lesion was Ventricular Septal defect (54.5%) followed by Atrial Septal defect (27.3%) and Patent Ductus arteriosus (9.1%). Only three women opted for medical termination of pregnancy, rest eight continued the pregnancy or presented late. Pregnancy complications found include pre-eclampsia (50%), abruption (22%), and fetal growth retardation (62.5%). There were three maternal deaths (mortality rate 27%) in postpartum period.
This case series highlights the delay in diagnosis and treatment of CHD despite improvement in medical care. Women with Eisenmenger syndrome require effective contraception, preconceptional counselling, early termination of pregnancy, and multidisciplinary care.
During pregnancy, a variety of psychological and physical changes occur in women, which may have different impacts on risk decision-making involving different processes systems. Based on the dual-process theories of decision-making, using the Columbia Card Task (CCT) as the experimental paradigm, which can trigger deliberative versus affective decision-makings respectively, this study recruited 240 pregnant women and non-pregnant women aged 20-40 as the experimental group and control group respectively, investigated how pregnancy impacted on women’s risk decision-making, as well as the possible roles played by a series of psychological factors (impulsivity; sensation seeking; emotional state) and physiological factors (gestational age; human Chorionic Gonadotropin, hCG; progesterone) in the above process. The results were as follows: (a) Compared with non-pregnant women, pregnant women tended to choose fewer cards, indicating a higher risk aversion consistent with a more conservative strategy, both in cold and hot CCTs; in both cold and hot CCTs, compared with pregnant women in the second trimester of pregnancy, pregnant women in the first and the third trimesters of pregnancy had a higher risk aversion tendency. (b) Pregnant women had lower levels of all dimensions of sensation seeking than did non-pregnant women, pregnant women in the third trimester of pregnancy had lower levels of Disinhibition (DIS) and Boredom Susceptibility (BS) of sensation seeking than pregnant women in the first and the second trimesters of pregnancy, but there was no significant difference in levels of emotional state or impulsivity between pregnant woman and non-pregnant women. (c) DIS of sensation seeking played a fully mediating role in the impact of pregnancy on hot CCT performance. (d) Both hCG and progesterone levels were negatively correlated with pregnant women’s hot CCT performances. (e) Positive emotion played a partial mediating role in the effect of progesterone on hot CCT performance of pregnant women.
The plaintiff in Means v. United States Conference of Catholic Bishops sought to hold the US Conference of Catholic Bishops responsible for promulgating Ethical and Religious Directives for Catholic Health Care Services that dictated the substandard care she received after her water sbroke when she was eighteen weeks pregnant. The Sixth Circuit dismissed her case for lack of personal jurisdiction and failure to state a claim under state negligence law, reasoning that the defendants’ promulgation and adoption of the Directives was passive conduct providing no basis for foreseeing harm to patients. Leslie Griffin’s feminist judgment grants Means’ request to recognize that the defendants owed her a duty not to promote an ethical theory that foreseeably harms patients by actively interfering with their access to needed medical treatment. Maya Manian’s commentary situates the case in the ongoing conflict between religious freedom and access to appropriate miscarriage management, treatment for ectopic pregnancies, abortion care, tubal ligation surgery, and access to contraception—highlighting that abortion care is interconnected with health care more broadly.
In Burton v. State, a case from 2010, the Florida District Court of Appeals overturned a trial judge’s order requiring a pregnant woman with two children and two jobs who experienced premature rupture of membranes and onset of contractions at 25 weeks pregnant to submit to any medical treatment that her obstetrician deemed necessary—including detention in the hospital, administration of intravenous medications, and surgical delivery by cesarean section. Burton was prohibited from obtaining a transfer to another hospital where she might have gotten a second opinion because the trial court determined that moving her was not in the best interest of the child she carried. Nadia Sawicki’s feminist concurrence agrees with the majority’s determination that the trial court failed to apply the correct legal standard but writes separately to highlight that the trial court’s order was not supported by competent and substantial evidence. Greer Donley’s commentary highlights how the state’s efforts to dictate Burton’s health care “treatment” not only deprived her of dignity and bodily autonomy but also disregarded her right to make end-of-life decisions for her potential child.
This longitudinal randomized controlled trial examined the impact of a doula home visiting intervention for young, low-income mothers on parenting and toddler social-emotional development and tested whether intervention effects were moderated by maternal emotional and behavioral health characteristics. 156 mothers were offered home visits from a home visitor starting in mid-pregnancy through several years postpartum, with a community doula also working with the mother during pregnancy and after the birth. 156 received case management. Interviews, video recordings of mother-child interactions, and toddler assessments were conducted at 3 weeks, 3 months, 13 months, and 30 months of age. Intent-to-treat analyses conducted with the full sample showed some intervention effects. Moderation analyses, however, showed that most effects were concentrated among mothers engaged in high levels of risk-taking (delinquent behaviors, school suspensions, smoking, alcohol use, sexual risk-taking). Among higher risk-taking mothers, the intervention was related to less intrusiveness during early infancy, less psychological and physical aggression during toddlerhood, more sensitive parenting attitudes, and greater toddler social relatedness. Maternal depressive symptoms were only a moderator for toddler behavior problems. These findings suggest that doula home visiting may be a particularly effective model for enhancing sensitive, non-aggressive parenting among young mothers with a history of risk-taking behavior.
This opinion held that a viable fetus was a “child” under the state’s criminal child endangerment statute. The defendant was accused of using illegal drugs during her pregnancy and the South Carolina Supreme Court held that her alleged drug use could serve as the basis for a child endangerment charge. This opinion is cited as severely eroding the reproductive rights and bodily autonomy of women.
Pre-eclampsia is a serious complication of pregnancy, and maternal nutritional factors may play protective roles or exacerbate risk. The tendency to focus on single nutrients as a risk factor obscures the complexity of possible interactions, which may be important given the complex nature of pre-eclampsia. An evidence review was conducted to compile definite, probable, possible and indirect nutritional determinants of pre-eclampsia to map a nutritional conceptual framework for pre-eclampsia prevention. Determinants of pre-eclampsia were first compiled through an initial consultation with experts. Secondly, an expanded literature review was conducted to confirm associations, elicit additional indicators and evaluate evidence. The strength of association was evaluated as definite RR<0.40 or ≥3.00, probable RR 0.40-0.69 or 1.50-2.99, possible RR 0.70-0.89 or 1.10-1.49 or not discernible RR 0.90-1.09. The quality of evidence was evaluated using GRADE. Twenty-five nutritional factors were reported in two umbrella reviews and 22 meta-analyses. Of these, 14 were significantly associated with pre-eclampsia incidence. Maternal vitamin D deficiency and higher serum iron emerged as definite nutritional risk factors for pre-eclampsia incidence across populations, while low serum zinc was a risk factor in Asia and Africa. Calcium and/or vitamin D supplementation were probable protective nutritional factors. Healthy maternal dietary patterns were possibly associated with lower risk of developing pre-eclampsia. Potential indirect pathways of maternal nutritional factors and pre-eclampsia may exist through obesity, maternal anaemia and gestational diabetes mellitus. Research gaps remain on the influence of household capacities and sociocultural, economic and political contexts, as well as interactions with medical conditions.
Trans people who transition medically are typically hoping to live their lives simply as members of the sex with which their gender corresponds but may wish to make full use of the capabilities of their physical bodies, which may differ from typical male or female bodies. This chapter, co-authored by a trans man who is a transgender health advocate and a trans woman who is a physician, provides an overview of the kind of physical changes that are experienced by trans people, both those who transition from female to or toward male and those from male to or toward female, and alerts gynecologists and other medical healthcare professionals to the trans person’s perspective in clinical encounters.
Counseling patients through their journey to conceive can be challenging. When a therapist becomes pregnant, the therapeutic alliance alters. This chapter explores the unique dynamics between the pregnant fertility counselor and reproductive clients. Questions around the “who, what, where, when, why and how” of pregnancy disclosure are used as a tool to help think about the various elements to the therapeutic alliance. Intense feelings can be triggered for a patient who is struggling with infertility or pregnancy loss, but can also trigger emotional reactions for the fertility counselor. The transference and countertransference that arises with the self-disclosure of a pregnancy is likely to unfold complicated dynamics and emotions. The positive and negative implications that a pregnancy disclosure can have from the patient’s point of view, as well as that of the therapist, are addressed. Additionally, the postpartum experience and the return back to work after parental leave are also discussed. While this chapter focuses on the pregnant therapist, the issues raised pertain to all pregnant reproductive medical staff treating infertility patients.
Trauma occurs when the ability to envisage our future and feel safe in the world is no longer possible. While trauma is often a one-time horrific occurrence, it can also be chronic in nature. Indeed, reproductive trauma can encompass both types of anguish: the frightening and painful loss of a miscarriage, with massive bleeding and the potential need for surgery, or the seemingly endless cycle of hope and despair during fertility treatments. Sadly, for our patients, it is not uncommon to experience both infertility and pregnancy loss, and like a soldier on the battlefield, it can be protracted, leaving deep psychological wounds. This chapter not only explores the trauma that occurs in reproductive patients, but also how we, as fertility counselors, cope with being on the battlefield with them.
Although maternal stressor exposure has been associated with shorter telomere length (TL) in offspring, this literature is based largely on White samples. Furthermore, timing of maternal stressors has rarely been examined. Here, we examined how maternal stressors occurring during adolescence, pregnancy, and across the lifespan related to child TL in Black and White mothers.
Mothers (112 Black; 110 White; Mage = 39) and their youngest offspring (n = 222; Mage = 8) were part of a larger prospective cohort study, wherein mothers reported their stressors during adolescence (assessed twice during adolescence for the past year), pregnancy (assessed in midlife for most recent pregnancy), and across their lifespan (assessed in midlife). Mother and child provided saliva for TL measurement. Multiple linear regression models examined the interaction of maternal stressor exposure and race in relation to child TL, controlling for maternal TL and child gender and age. Race-stratified analyses were also conducted.
Neither maternal adolescence nor lifespan stressors interacted with race in relation to child TL. In contrast, greater maternal pregnancy stressors were associated with shorter child TL, but this effect was present for children of White but not Black mothers. Moreover, this effect was significant for financial but not social pregnancy stressors. Race-stratified models revealed that greater financial pregnancy stressors predicted shorter telomeres in offspring of White, but not Black mothers.
Race and maternal stressors interact and are related to biological aging across generations, but these effects are specific to certain races, stressors, and exposure time periods.
Selenium (Se) is essential for selenoprotein synthesis, being thus important for immune and thyroid function, and for antioxidant defence. Some studies have shown that low levels of Se may associate with hypertensive disorders of pregnancy (HDP). Nevertheless, evidence supporting Se supplementation in pregnant or childbearing-age women is still lacking. In this context, this work aimed to systematically review the most recent scientific evidence to understand the relationship between Se levels and HDP. We performed a systematic review (protocol number: CRD42022310424) with literature of the last decade. PubMed, Scopus, Web of Science, registers and grey literature were searched to identify studies reporting measurement of Se levels in normotensive and hypertensive pregnant women (supplemented or not with Se). Study quality was assessed using the National Heart, Lung, and Blood Institute Study Quality Assessment Tools. Among the thirty included studies, a majority, 61 % (n 19) of the ‘good’ or ‘fair’ studies, reported a negative association between Se and HDP, and some studies, 39 % (n 11) of the ‘good’ or ‘fair’ studies, reported a lack of association. This review provides an important amount of quality evidence suggesting that low Se levels associate with the occurrence of HDP. Nevertheless, the gathered information is not enough to underlie a recommendation for Se supplementation in pregnancy to protect against HDP. Thus, this review emphasises the need for further well-designed randomised controlled trials that may provide blunt evidence regarding the benefits of Se supplementation during pregnancy.
Bicuspid aortic valve is the most common congenital heart malformation and predisposes patients to thoracic aortic aneurysms and aortic dissections. Current peripartum guidelines are extrapolated from other heritable causes of thoracic aortic disease and do not account for unique characteristics of bicuspid aortic valve patients. We therefore evaluated the prevalence of maternal and fetal complications of women with early-onset complications of bicuspid aortic valve disease in the UTHealth Bicuspid Aortic Valve Research Registry. We found that the rate of cardiovascular complications was high and that relatively few women received guideline-recommended care.