Pregnancy and domestic violence
By Grace Roxas, Contributing Writer
A dark view of childbearing that equates it with having one foot in the grave may well apply to findings that women are more prone to violence at home at that most delicate stage in their lives than at any other time.
In a lecture before the Perinatal Association of the Philippines annual convention in September, University of the Philippines associate professor Dinah Nadera cited a number of scientific studies here and abroad showing a direct correlation between pregnancy and an increase in domestic violence.
She said: "There could be many explanations. From the psychoanalytic viewpoint, this can be linked to the sexual satisfaction of the partner. Or it may have something to do with finances."
Pregnancy-associated homicide or death during or within one year of pregnancy has spiked up through the years. Studies abroad found that a mother's young age, race, and the absence of prenatal care prefigure her risk for this extreme outcome of domestic violence.
For health-care providers, addressing this risk falls within the ambit of taking care of the total psychological well-being of the expectant mother, an aspect not always focused on in prenatal care, said Nadera.
She added: "Obviously, domestic violence will have an effect on the outcome of the pregnancy. And if we can prevent it and a lot of the psychological trauma and issues going on here, we can also ultimately prevent pregnancy-associated homicide."
She noted that postpartum depression is the only malady that tends to be associated with pregnancy. The other psychiatric conditions that may appear before childbirth, like general depression, anxiety, eating disorder, and psychosis, tend to be underdiag-nosed, because their symptoms are often linked to the physiological state of being pregnant.
Even if properly diagnosed, patients may be deliberately undertreated for fear of harming the fetus with the use of drugs.
Depression is likely to be experienced by 10 to 30 percent of mothers, according to studies. Nadera said that it could be the main unrecognized trigger for a self-directed extreme form of domestic violence-suicide, now a leading cause of maternal death in developed countries and among women of reproductive age in India and China.
She observed: "What's the interface now? Since depressed mothers are much more disabled and less likely to take care of their own needs, it's only logical that they cannot also take care of their young."
She also cited recent evidence that good perinatal health can drastically reduce the prevalence of schizophrenia because of its link with difficult childbirth.
However, it may not always be easy for a pregnant woman to seek psychological help in this country. Nadera noted that most local health-care personnel are usually uncomfortable handling mental-health cases due to a perceived lack of adeptness in the field.
They might benefit, she added, from learning about several screening processes for psychological morbidity developed by the World Health Organization. These tools won't take more than 20 minutes to use and are easy for the patient to answer.
In countries like India, the use of such tools has helped establish the independent link between maternal psychological disorders and low birth weight.
Next is establishing a multisectoral referral network to address the patient's specific needs. To prevent domestic violence, she recommends working with police child-protection units and women's desks. Various partnerships can be forged with women's and reproductive-health advocacy groups, psychiatrists, and nongovernment organizations sheltering unwed mothers.
She urged perinatal practitioners to go to the communities to promote mental health, saying: "We don't want you to stop in the clinic or be contained in a health center or lying-in facility. If we can give good reproductive, not sex, education to adolescents in school, then we can also improve pregnancy outcomes and preparedness for mothering." M
Womb stress marks a child for life
We are actually shaping the life inside the womb, not really after birth," said obstetrician/gyne-cologist Pilar Lagman-Dy of St. Luke's Medical Center. "Prenatal program-ming has permanent effects that alter responses to later life and can modify susceptibility to different diseases."
A fetus is highly vulnerable to adverse programming at different times for different tissues in his evolving body. Risky circumstances include having either too much or too little of a natural hormone or a nutrient, having abnormal chemicals in the body, and abnormal physical forces such as high blood pressure
Fetal malnourishment
Birth weight and other physical characteristics at birth are said to relate to a person's health status throughout his lifetime. Lagman-Dy cited several foreign studies establishing a link between increased risk of coronary heart disease and low birth weight (LBW) that is due to undernutrition in utero.
One such study, conducted in the United Kingdom, found as much as a 50-percent greater incidence of heart disease among LBW infants than their counterparts with normal weight.
Other studies have found similar links between infants born small and higher risks for central-nervous-system defects and obesity later on. A Columbia University study found that those born underweight are twice as likely to develop schizophrenia as those not exposed to fetal undernutrition.
The higher risk for obesity among underweight children shows how attempts to make it up to the baby after birth can have unwanted consequences. Lagman-Dy explained that babies born small tend to overcompensate after birth by eating too much, even though they are biologically wired to take in only so much nutrition.
She noted that undernutrition usually happens during the first trimester or when the mother is least likely to be aware yet of her pregnancy. "It should perhaps be a guiding principle for pediatricians to control the weight of children born small instead of attempting to reverse what happened in the womb," she said in a lecture at the annual convention of the Perinatal Association of the Philippines in September.
Even brief interludes of undernutrition may permanently damage or reduce the cell number, especially during vulnerable periods, or affect other structural changes such as the balance and distribution of different cell types and the formation of normal blood channels and hormone receptors.
Lagman-Dy noted that fetal cellular mechanisms may differ from adult processes as a fetus reacts differently to suboptimal conditions. A malnourished fetal environment, for example, may lead to a reflex action called brain sparing, where scanty nutrition is mostly diverted to the brain at the expense of other vital organs.
A vital organ thus deprived, such as the liver, may then have problems regulating cholesterol levels for the adult later on. With cholesterol problems more pronounced in overweight adults, the concomitant tendency to obesity due to fetal undernourishment gangs up on the LBW grown-up as well.
Since undernutrition is also a form of stress, it can also result in the faulty functioning of enzymes responsible for keeping stress hormones at bay, similar to what happens in a typical onslaught of stress. This can lead to a higher susceptibility to stress and hypertension during adulthood.
A stressed-out mother is not only at risk of bombarding the baby's brain with harmful cortisol but also for premature labor.
Positive programming
With undernutrition a major culprit in adverse fetal programming, Lagman-Dy said, pregnant women should focus on gaining weight, between 25 to 35 additional pounds depending on the existing body weight, based on an additional daily intake of about 300 calories a day and a balanced diet rich in carbohydrates. She suggested eating small meals six to 10 times during the day, especially in the first trimester of pregnancy.
If a pregnancy is still being anticipated, a would-be mother should get at least 400 micrograms of folic acid daily to prevent neural-tube defects. Preconception care may also entail avoiding medicines that harm embryos and for diabetics, making sure that insulin supply is sufficient.
The effects of drugs and alcohol on the fetus range from facial and heart defects, mental retardation, and behavioral problems; withdrawal symptoms from drug addiction to outright fetal death, and should therefore be totally avoided.
Exercising will ease labor and speed up recovery after delivery. Swimming and walking are highly recommended but should not be done to the point of exhaustion. A pregnant woman should avoid sports that expose the belly to trauma like badminton and contact sports. Using seatbelts should not be a problem because the uterus and amniotic fluid prevents the seatbelts from injuring the fetus. M
Boosting cervical-cancer prevention
The ASO4 adjuvant system facilitates a strong and sustained response to HPV vaccination.
Dr. Hugues Bogaerts, vice president of GlaxoSmithKline (GSK), called vaccines "one of the greatest achievements of biomedical science and public health." In recent years, vaccines have gone beyond the realm of infectious-disease prevention and now play a role in the prevention of neoplastic diseases.
Bogaerts is responsible for his company's worldwide medical affairs for prophylactic human-papillomavirus (HPV) vaccines.
HPV infection, according to the Asia-Oceania research organization on Genital Infection and Neoplasia (AOGIN), is "the necessary cause of cervical cancer," the second most common cancer in women both locally and worldwide, with a five-year mortality rate of 56 percent in the Philippines.
Unless cervical-cancer prevention improves in the coming years, experts at AOGIN estimate that more than one million women a year around the world will have the disease by 2050.
AOGIN held its second biennial conference on September 7 to 10 at the Shangri-La Mactan Resort and Spa in Cebu. The organization, established in 2005 to provide "a vehicle in this region to educate on the importance of preventing cervical cancer," is currently campaigning for HPV vaccination as an effective means of cutting down the alarming rates of cervical cancer worldwide.
Bogaerts, who talked about "Adjuvants in Vaccines" at the conference, enthused: "If we have 26-plus diseases that are vaccine-preventable, I think that by adding the first vaccine that was specifically designed to prevent a cancer, we will reconfirm that in the next century we will be able to have a great impact on public health through vaccination."
Anticancer vaccine
Viruses have long been known to play an important part in the pathogenesis of neoplastic diseases. Knowing that fact has yet to lead scientists to the cure for cancer, but it has given doctors a prophylactic agent for actively preventing certain cancers: vaccines. The prevention of liver cancer, for instance, has long been acknowledged as an added benefit of immunization against the hepatitis-B virus (HBV).
But while experts have associated only 80 percent of liver-cancer cases in the Philippines with HBV, HPV DNA can be identified in nearly all known cervical-cancer cases. About 70 percent of those cases result from persistent or recurrent infections with HPV types 16 and 18.
"You can only win by getting a vaccine," said Prof. Diane Harper of Dartmouth Medical School, emphasizing the role of HPV vaccination in the prevention of what AOGIN considers a major women's health concern around the world. AOGIN estimates that 50 to 80 percent of women will acquire genital HPV infection in their lifetime.
GSK recently developed a vaccine specifically for the prevention of infection with the cancer-causing HPV types 16 and 18. Because most HPV infections resolve spontaneously without producing any symptoms, the vaccine is aimed specifically at preventing cervical cancer, and has been called an anticancer vaccine.
To make a significant impact on public health, a vaccine should, apart from providing effective protection against target pathogens, confer long-term protection. Adjuvants boost the immune response to the antigens contained in vaccines and help provide more effective and longer-lasting immunity.
For the past 50 years, vaccine formulations have employed aluminum salts as adjuvants. More recently, the ASO4 system has been shown to provide better adjuvant activity. The system facilitates the activity of "toll-like receptors," which in turn act like the "barcode readers" of the immune system, playing an important part in the recognition of the molecular signature of pathogens. "By triggering toll-like receptors, ASO4 facilitates a strong and sustained humoral response to the HPV antigens in our vaccines and it does this better than aluminum hydroxide," explained Bogaerts.
The adjuvant system has already been used and shown effective in improving the immune response to the HBV and experimental herpes simplex vaccines.
In terms of the new bivalent HPV vaccine, studies have shown the new formulation to provide complete protection for at least 4.5 years. The vaccine also promises to provide long-term protection that can be given earlier in life as prophylaxis or when the recipient reaches the peak of sexual life. The augmented effects of the vaccine further mean lower doses and less frequent administrations.
The new vaccine is currently awaiting approval, and is to be marketed by GSK under the brand name Cervarix. M
Intrauterine devices back in vogue
Grace Roxas, Contributing Writer
After falling briefly into disrepute from adverse events and malpractice suits sometime after its advent in the 1960s, intrauterine devices (IUDs) are back in vogue worldwide as one of the most effective contraceptive options for women. However, it remains a relatively pricey option for Filipinas and women from other developing countries.
In recent years, numerous clinical studies are turning this consideration of cost on its head as they affirm the IUD's value beyond contraception-as an alternative to surgical procedures and to less invasive though still expensive solutions for managing the most common, benign gynecological disorders.
In a lecture before the Philippine Society of Reproductive Endocrinology and Infertility (PSREI), obstetrician/gynecologist Lilia Luna zeroed in on the levonorgestrel-intrauterine system (LNG-IUS), an IUD that releases daily small amounts of levonorgestrel (LNG), a synthetic derivative of the hormone progestogen, into the uterine cavity.
The device directly targets the endo-metrium, building up high local LNG concentrations to uniformly suppress the proliferation of the uterine mucous membrane over a five-year span. The clean and atrophic endometrium that results is thus no longer hospitable to sperm survival and fertilization.
The Gynecology Forum published a report this year favorably comparing the contraceptive ability of LNG-IUS with copper-releasing IUDs. Pregnancy rates of women using the LNG-containing device ranged from zero to 0.2 as against the 0.5 to 3.2 rates among those using the copper-release alternatives.
According to Luna, it is already a well-established contraceptive used by 8.5 million women to date and subjected to nearly 1,400 scientific reports, none of which mentioned serious side effects or safety concerns.
These reports have also extensively dwelt on the LNG-IUS's utility for menstrual disorders, notably menorrhagia-heavy menstrual bleeding over several consecutive cycles-both of the idiopathic variety or as a manifestation of benign pelvic tumors like leiomyomas.
"It (LNG-IUS) has enormous potential to improve women's health in developing countries, where protection against pregnancies and reproductive health are both important to quality of life," she said. "Although menorrhagia is supposed to be a benign gynecological disorder, it can also cause considerable distress in a sufferer so that its adequate control will inadvertently improve her quality of life."
She cited studies that show convincing reduction in menstrual blood loss and increase in hemoglobin level and serum ferritin among idiopathic and leiomyoma-linked menorrhagia patients using the device. Premenstrual syndrome and dysmenorrhea were also addressed.
Luna says that LNG's deactivation of the endometrium is also key to its curative benefits for gynecological complaints. The exact mechanism of the LNG-IUS's therapeutic effect for menorrhagia is still unknown, although there are a couple of likely explanations. The LNG-induced inactivity and insensitivity of the uterine mucous membrane to the proliferative effects of the major female sex hormone estradiol can significantly reduce the amount and duration of menstrual bleeding. The synthetic progestogen stimulates the synthesis of an insulin-like growth-factor-binding protein that suppresses the estradiol mediator in the endometrium.
Another possible cause of the induced endometrial change and reduced blood loss is the change in the uterine artery blood flow accompanying the continuous intrauterine release of LNG.
The antiestrogenic effect of LNG extends the usefulness of IUD to women entering menopause and undergoing hormone-replacement therapy (HRT). Luna said LNG counteracts the continued proliferative and possibly neoplastic effect of unopposed estrogen in the endometrium of peri- and postmenopausal women taking estrogen.
She added: "LNG can be a way for a woman to conveniently move on from a period where she needs contraception-where cycles are irregular and she may or may not be having menstrual disorders-and to that particular period where she may be having menopausal symptoms and therefore in need of HRT."
Increased blood loss may also be a problem with menopausal women. The IUD is slower to ramp up action against menopause-related bleeding than oral contraceptives, which have a high initial level of efficacy, but eventually reaches a plateau of efficacy.
A nonsurgical, more economical alternative?
Luna said that rapid development in medical technology has given clinicians multiple options for managing menorrhagia, with more leeway to decide based on the financial capability to the patient.
She said that when cost is a major concern, clinicians might want to look at findings indicating that menorrhagia patients treated through LNG-IUS, at a cost 40 percent lower than hysterectomy, enjoyed the same level of health-related quality of life after five years as those who went under the knife.
In some studies, a number of patients who were on the surgeon's wait list were subsequently ruled out for surgery after responding well to LNG-IUS. One study showed 64 percent of women canceled their surgery schedule after six months, with 82 percent doing the same after a year.
The device has also been shown to perform equally well compared with thermal balloon ablation, another intrauterine procedure, and it definitely outstrips oral treatments like tranexamic acid and flurbifrofen.
However, it was found to be slightly less effective than endometrial resection. And although it was found to be as effective as surgery in treating excessive bleeding and anemia for submucous leiomyoma, it is contraindicated in women with preexisting fibroids that distort the uterine cavity.
Overseas, LNG-IUS may have reached some measure of acceptability as an alternative to surgery. Based on data from Britain, IUD use showed a nearly steady rise from 1996 to 2004, while there was noted a decline in sterilization and endometrial resection.
The trend in acceptability may also have a lot to do with patient preference. With more options, she is also having more say, not only on the basis of treatment cost, but on whether she wants to subject her body to an effective yet invasive procedure such as hysterectomy.
"Nowadays, women do not like to get rid of their uterus, much less the ovary," said obstetrician/gynecologist Joan Tan-Garcia.
Hysterectomy is particularly unacceptable, of course, to women who still want to bear children. And while there are modern endoscopic uterine-sparing procedures like uterine-artery embolization, Luna noted than not many local practitioners are skilled to practice it so that they most often resort to hysterectomy, myomectomy, or laparoscopy.
Clinicians can opt for another strategy, the medically induced suppression of the endometrium. But Luna said that the use of agents like long-acting progesterone, gesti-none, and danazol has not been successful.
Administration of long-acting gonadotrophin-releasing hormone (GnRH) analogs as well as the antiprogestogen mifepristone can profoundly reduce menstrual bleeding. However, they come with concerns of safety and financial cost, said Luna.
The safety profile of antiprogestogens for long-term use is clouded by risks of endometrial hyperplasia and transitory increase in liver enzymes.
GnRH agonists are expensive compared with LNG-IUS and its beneficial effect in reducing the size of the myoma and of the uterus is reversed four to 10 weeks after cessation of therapy. Aside from the prohibitive price, its association with bone loss also deters long-term use.
Tan-Garcia agreed that the IUD is a good nonsurgical treatment for women who cannot afford the GnRH agonist, but maintained that there is still room for GnRH.
Still, Luna said that caution should be taken. She concluded: "I would like to emphasize that we don't have business putting anything in without making sure what the cause of the abnormal bleeding is. For the exact data to prove how LNG can possibly help, we await the future." M
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