Intraluminal carotid thrombus leading to postpartum stroke: a case study

BACKGROUND

Intraluminal non-occlusive thrombus (ILT) is a rare cause of ischemic stroke. Although in most cases ILT is associated with arterial wall disorders, it has also been documented in patients with thrombophilic conditions.

CASE REPORT

We present a case of carotid ILT in a 38-year-old puerperal woman with pregnancy-induced hypercoagulability. Following in vitro fertilization pregnancy, she experienced acute left-sided weakness 9 days after delivery. CT angiography revealed an intraluminal filling defect in the right carotid bulb, suggestive of a thrombus, along with ipsilateral MCA sub-occlusion. Mechanical thrombectomy was performed, achieving complete vessel recanalization without any endovascular intervention on the carotid ILT. Comprehensive evaluation excluded any underlying carotid vessel wall disease (such as atherosclerosis, inflammatory diseases, arterial dissection, focal dysplasia), inherited or acquired thrombophilia, and the sole prothrombotic risk factor identified was the puerperium. Histological thrombus analysis showed fibrin/platelet-rich material with significant macrophage infiltration (consistent with an intermediate/organized thrombus, suggesting potential embolization from a pre-existing carotid ILT). Anti-thrombotic treatment (acetylsalicylic acid 100 mg and enoxaparin 6000 UI) resulted in complete thrombus resolution at follow-up.

CONCLUSION

ILT should be considered a potential case of embolic stroke in pregnancy or puerperium. Vessel imaging is essential for diagnosis. Histological thrombus analysis can provide insights into the pathophysiological mechanisms of stroke.

Post-partum cerebral venous sinus thrombosis: A case report

INTRODUCTION

Cerebral venous sinus thrombosis (CVST) is a rare and life-threatening condition that may be encountered during pregnancy and puerperium. The diagnosis of CVST is a challenge because of its varied presentation.

CASE REPORT

A 28-year-old woman presented with headache, projectile vomiting, and generalized tonic-clonic seizures 10 days after delivery by cesarean section. She had an uneventful antenatal period of 38 weeks of gestation. High clinical suspicion and the availability of magnetic resonance venography helped in making a diagnosis of CVST. She was successfully managed with a low-molecular-weight heparin (LMWH) and anti-epileptic therapy with no residual complications.

DISCUSSION

Pregnancy induces several prothrombotic changes in the coagulation system that predispose to CVST. These changes persist for six to eight weeks after birth. Infection and cesarean section are the additional risk factors for CVST during puerperium. The symptoms of CVST depend on the sinuses and veins involved, raised intracranial pressure, and the extent of brain parenchymal injury.

CONCLUSION

Greater awareness of the disease and the availability of imaging modalities have contributed to the early diagnosis and favorable outcomes in these cases. LMWH is the main stay of treatment in this disease.

Psychiatric emergencies during pregnancy and puerperium in low - And middle-income countries

Pregnancy and puerperium are critical points in women's health, and various psychiatric emergencies may worsen or manifest (for the first time) during this period. In the presence of a psychiatric emergency, the pregnancy and puerperium outcomes may be compromised. In addition to the mother being at risk, the health of the fetus and the newborn may also be compromised if the psychiatric emergency is not managed appropriately. Early detection and collaborative approaches between mental health practitioners and obstetricians are of utmost importance in women who are at risk and those living with psychiatric illnesses during pregnancy and puerperium. Practitioners should also ensure that women with impaired capacity due to psychiatric disease are treated in a non-judgmental and respectful manner, even if their autonomies have been overridden.

The role of stress in perinatal depression and anxiety - A systematic review

Perinatal depression (PND) and anxiety affect around 20% of women, but available pharmacotherapy is not sufficiently effective in 20-60% of them, indicating a need for better understanding of these diseases. Since stress is a significant risk factor for PND, the aim was to examine the role of biological, environmental and psychological stress in PND and anxiety through a systematic literature search. Overall 210 studies were included, among which numerous rodent studies showed that perinatal stress induced depressive-like and anxious behavior, which was associated with HPA-axis alterations and morphological brain changes. Human studies indicated that the relationship between cortisol and perinatal depression/anxiety was not as clear and with many contradictions, although social and psychological stress were clearly positively associated with PND. Finally, oxytocin, synthetic neuroactive steroid and n-3 PUFA diet have been identified as potentially beneficial in the therapy of PND and anxiety, worth to be investigated in the future.

Functional status, social support, and anxiety among postnatal women of Eastern India

Introduction

Though becoming a mother is a joyous experience, the postpartum time can be difficult and stressful for women as they deal with significant physical alterations and adjustments to their daily routines. However, very few studies have focused on the functional well-being of the woman after childbirth. This study aims to find the level of functional status, social support, and anxiety among women attending immunization clinics.

Methods

A descriptive cross-sectional research design was adopted to recruit 220 women in this study from two immunization clinic centers in Bhubaneswar, Odisha. Data were collected using a self-reported sociodemographic profile, functional level scale after childbirth, modified multidimensional scale of perceived social support, and postnatal anxiety scale. Descriptive and inferential statistical tests were used for data analysis, including mean, percentage, and Fisher exact.

Results

59.5 % of women returned to a moderate level of functional status after six weeks postpartum. The majority of women, 98.6 % and 83.6 %, reported high levels of return to personal care and baby care, respectively, whereas 34.7 % had moderate levels of return to home activities and 90 % had low levels of return to community and social tasks. Also, 70 % of women had high perceived social support, and 87.7 % had no anxiety. In this study, normal delivery women had better functional status than their cesarean delivery counterparts. Moreover, functional status was significantly associated with anxiety at six postpartum weeks.

Conclusion

After six weeks of childbirth, most women only partially resumed their pre-pregnancy functional state. So, much more time, rest, and support from family members were needed to recover to a fully functional level. Nurses, midwives, and the family members of women should be aware of the critical role that social support plays in enhancing a woman's functional and psychological status during the postpartum period.

COVID-19 incidence in women of reproductive age: a population-based study in Reggio Emilia, northern Italy

BACKGROUND

Despite being at higher risk of severe disease and pregnancy complications, evidence on susceptibility to SARS-CoV-2 infection in pregnancy is still limited. The aim of the study is to compare the likelihood of undergoing a SARS-CoV-2 test and testing positive for COVID-19 in pregnancy and puerperium with that of the general female population of reproductive age.

METHODS

This is a retrospective population-based cohort study including 117,606 women of reproductive age (March 2020-September 2021) with 6608 (5.6%) women having ≥ 1 pregnancy. Women were linked to the pregnancy registry to be classified as "non-pregnant", "pregnant", and "puerperium"; then, according to the national case-based integrated COVID-19 surveillance system, all women undergoing a SARS-CoV-2 test during the study period were identified. The Incidence Rate Ratio was calculated to compare the likelihood of being tested for SARS-CoV-2 in pregnant, puerperium and non-pregnant women among all women included. The likelihood of having a COVID-19 diagnosis was calculated using two comparators (not-pregnant women and the person-time before/after pregnancy) by means of Cox proportional hazards models, adjusting for age and with the cluster option to control standard error calculation in repeated pregnancies. Only first infection and swabs before the first one positive were included.

RESULTS

The probability of being tested for SARS-CoV-2 was 4.9 (95% CI: 4.8-5.1) and 3.6 times higher (95%CI: 3.4-3.9) in pregnancy (including spontaneous miscarriages) and in the puerperium, respectively. The Hazard Ratio (HR) of covid-19 diagnosis during pregnancy vs. non-pregnancy was 1.17 (95% CI 1.03-1.33) with similar results when comparing the risk during pregnancy with that of the same women outside pregnancy (puerperium excluded), with an HR of 1.13 (95% CI 0.96-1.33); the excess decreased when excluding the test performed at admission for delivery (HR 1.08 (95%CI 0.90-1.30). In the puerperium, the HR was 0.62 (95% CI 0.41-0.92) comparing women with ≥ 1childbirth with all other women and excluding the first two weeks of puerperium.

CONCLUSIONS

Women during pregnancy showed a small increase in the risk of infection, compatible with a higher likelihood of being tested. A lower probability of infection during the puerperium was observed during the entire pandemic period, suggesting likely protective behaviors which were effective in reducing their probability of infection.

Exploring the impact of chronic medical conditions on maternal mental health: A National Inpatient Sample analysis

BACKGROUND

Pregnancy and postpartum period are associated with stress and pain. Chronic medical conditions can aggravate depressive and psychotic mental illnesses in the peripartum period.

AIM

The study aimed to investigate the association between different chronic medical conditions and mental illnesses during pregnancy and the postpartum period using the National Inpatient Sample (NIS).

METHODS

Pregnant women or women in the postpartum period were retrieved from the NIS 2016-2019 database using the International Classification of Diseases (ICD)-10 and set as our targeted population. Postpartum depression, puerperal psychosis, and mental illnesses related to pregnancy were also retrieved as our outcomes of interest. STATA 15 was used to analyze the data and investigate the relationship between chronic medical conditions and pregnancy-related mental illnesses.

RESULTS

2,854,149 admissions were retrieved from the database with a mean age of 29 ± 6 years old. Univariate and multivariate analyses showed a significant association between chronic medical conditions and postpartum depression, puerperal psychosis, and other mental illnesses. On univariate analysis, heart failure (odds ratio [OR] = 13.9; 95% confidence interval [CI] = 3.5-55.88; P < 0.001), alcohol misuse (OR = 5.3; 95% CI = 1.7-16.4; P = 0.004), and migraine (OR = 3.9; 95% CI = 2.8-5.3; P < 0.001) showed high association with postpartum depression. Epilepsy (OR = 54.37; 95% CI = 7.4-399.34; P < 0.001), systemic lupus erythematosus (OR = 24.66; 95% CI = 3.36-181.1; P = 0.002), and heart diseases (OR = 15.26; 95% CI = 3.6-64.5; P < 0.001) showed the highest association with puerperium psychosis. Alcohol misuse (OR = 8.21; 95% CI = 7.4-9.12; P < 0.001), osteoarthritis (OR = 6.02; 95% CI = 5.41-6.70; P < 0.001), and migraine (OR = 5.71; 95% CI = 5.56-5.86; P < 0.001) showed the highest association with other mental illnesses during pregnancy and the postpartum period.

CONCLUSION

Heart diseases, alcohol misuse, migraine, systemic lupus erythematosus, and epilepsy were the most important chronic medical conditions associated with mental diseases during pregnancy and the postpartum period. This investigation recommends integrating management of chronic diseases and mental health care together. Specifically, screening for mental illnesses should be a routine part of care for patients with chronic medical conditions, especially during pregnancy and early postpartum. By identifying and addressing mental health issues early on, healthcare providers can improve the overall health and well-being of these patients, ultimately leading to better maternal and fetal outcomes.

Uterine venous malformations in the puerperium: 2 Atypical cases and literature review

Uterine arteriovenous malformations (AVMs) is a rare but high-risk cause of uterine bleeding. The clinical management of this condition is challenging, as the ultrasound picture can sometimes be unambiguously interpreted. Moreover, in the puerperium in which acquired AVMs are most frequently formed, it is necessary to discuss the correct management in a multidisciplinary and personalized manner. We present two cases of AVMs developing in the puerperium, both with a vaginal delivery and spontaneous and complete secondment. The symptom of onset was an episode of bright red blood loss in the puerperium, on the 14th and 21st postpartum days, respectively. Transvaginal ultrasound showed a hypervascularized lesion in the myometrium with turbulent vascular flow, confirmed by transabdominal ultrasound and angiography. To date, there are no guidelines on the management of MAVs. In our cases we opted for a conservative approach, in order to preserve the fertility of the patient. These experiences reported have the purpose of enriching a literature still sparse on the subject and in the future to be able to represent a fulcrum for official recommendations.

Development and evaluation of the psychometric properties of a digital questionnaire for the self-management of health and well-being in the postpartum period

BACKGROUND

Despite the fact that the Global Strategy for Women's, Children's and Adolescents' Health (2016-2030) recognises the special importance of care for women during the postpartum period, thus highlighting the need to identify and measure any condition that may affect the welfare of pregnant women in any way, this is one of the most neglected stages in the health system. Given the absence in our area of global, efficient instruments, the objective of this study was to design a complete, specific measurement tool with good metric qualities in digital format for the evaluation of self-reported health and well-being during the puerperium, to conform to what was proposed by the ICHOM.

METHODS

A cross-sectional study was carried out to evaluate the psychometric characteristics of a digital measurement tool. The development of the tool was carried out in 4 steps, following the recommendations of the International Test Commission. It was tested on 280 puerperas attending primary healthcare appointments in the Basque Healthcare System (Osakidetza), and they did the newly created survey, answering all the questions that had been selected as the gold standard. The average age of the women was 34.93 (SD = 4.80). The analysis of the psychometric characteristics was based on mixed procedures of expert judgment (a focus group of healthcare professionals, an item evaluation questionnaire and interviews with users) and quantitative evaluations (EFA, CFA, and correlation with gold standard, ordinal alpha and McDonald's omega).

RESULTS

The final version of the tool comprised 99 items that evaluate functional state, incontinence, sexuality, breastfeeding, adaptation to the role of mother and mental health, and all of these questions can be used globally or partially. It was found that the scores were valid and reliable, which gives metric guarantees for using the tool in our area.

CONCLUSIONS

The use of this comprehensive concise tool with good psychometric properties will allow women to take stock of their situation, assess if they have the necessary resources, in psychological and social terms, and work together with midwives and other healthcare professionals on the most deficient areas.

Leukocyte telomere length in women with multiple sclerosis: Comparison with healthy women during pregnancy and puerperium

OBJECTIVES

Several studies indicated leukocyte telomere length (LTL) as a biomarker of multiple sclerosis (MS) evolution. This study aimed to investigate LTL in women with multiple sclerosis (MS) compared to that in healthy women (HW) across different reproductive phases, and to evaluate its relationship with MS activity.

METHODS

Blood samples were collected from women with MS and HW during the fertile phase, pregnancy, and puerperium. LTL was determined using quantitative fluorescence in situ hybridization (Q-FISH).

RESULTS

Blood samples from 68 women with MS (22 during fertile life, 23 during pregnancy, and 23 post-partum) and 52 HW (23 during fertile life, 20 during pregnancy, and 9 post-partum) were analyzed. During pregnancy, LTL in MS women and HW was 84.7 ± 10.5 and 77.6 ± 11.5, respectively (p < 0.005). Regression analysis showed that shorter LTL was associated with pregnancy in HW (p = 0.021); this relationship was not observed in MS women, for whom shorter LTL was related to a higher EDSS (p = 0.036). A longitudinal analysis was performed in eight MS women, showing LTL shortening from pregnancy to puerperium (p = 0.003), which was related to MS reactivation (p = 0.042).

CONCLUSION

Our results highlight the possible associations between LTL, reproductive biological phases, and MS activity after delivery.

Maternal depressiveness and infant growth outcomes: Findings from the MAASTHI cohort study in India

OBJECTIVE

The study aims to examine the association between depressiveness in mothers on infant obesity and stunting at one year of age.

METHODS

We enrolled 4829 pregnant women, followed them up at public health facilities in Bengaluru for one year after birth. We collected information on women's sociodemographic characteristics, obstetric history, depressive symptoms during pregnancy and delivery within 48 h. We took infant anthropometric measurements at birth and one year. We used chi-square tests, and calculated an unadjusted odds ratio using univariate logistic regression. We used multivariate logistic regression to examine the association between maternal depressiveness, childhood adiposity, and stunting.

RESULTS

We found that the prevalence of depressiveness was 31.8% in mothers who delivered in public health facilities in Bengaluru. Infants born to mothers with depressiveness at birth had 3.9 times higher odds of having larger waist circumference than infants born to mothers with no depressiveness (AOR: 3.96, 95% Confidence Interval: 1.24,12.58) and 1.9 times higher odds of having a larger sum of skinfold thickness (AOR: 1.99, 95% CI: 1.18,3.38). Additionally, we found that infants born to mothers with depressiveness at birth had 1.7 times higher odds of stunting than infants born to mothers with no depressiveness (AOR: 1.72; 95%CI: 1.22,2.43) after adjusting for confounders.

CONCLUSION

Our study highlights a high prevalence of depressiveness among mothers seeking antenatal care at a public hospital is associated with an increased risk of infant adiposity and stunting at one year. Further research is needed to understand the underlying mechanisms and identify effective interventions.

Herbs for lochia discharge used among postpartum women in Taiwan

ETHNOPHARMACOLOGICAL RELEVANCE

In the traditional Taiwanese culture of "postpartum confinement", the term "lochia discharge" is a synonym for assisting postpartum uterine involution. Postpartum women in Taiwan consult traditional Chinese medicine (TCM) pharmacies to obtain various TCM formulations that facilitate lochia discharge.

AIM OF THE STUDY

As an ethnopharmacy study, we aimed to conduct field investigations to explore the herbal composition of TCM formulations for lochia discharge provided by TCM pharmacies in Taiwan and to identify the pharmaceutical implications of these TCM formulations.

MATERIALS AND METHODS

Through stratified sampling, we collected 98 formulations for postpartum lochia discharge from TCM pharmacies, which used a total of 60 medicinal materials.

RESULTS

The most common plant families of the medicinal materials found in Taiwanese lochia discharge formulations were Fabaceae and Lauraceae. Abiding by the TCM theory of nature and flavor, most drugs were warm in nature and sweet in flavor, and predominantly focused on the traditional functions of qi tonifying and blood activating. Correlation and network analyses of the medicinal components of lochia discharge formulations identified 11 core herbs, which, in the order of most to least frequently used, include Angelica sinensis, Ligusticum striatum, Glycyrrhiza uralensis, Zingiber officinale, Prunus persica, Eucommia ulmoides, Leonurus japonicus, Lycium chinense, Hedysarum polybotrys, Rehmannia glutinosa, and Paeonia lactiflora. These 11 herbs formed a total of 136 drug combinations in the 98 formulations, with 2-7 herbs in each combination. In addition, in the center of the network were A. sinensis and L. striatum, which jointly appeared in 92.8% of the formulations analyzed.

CONCLUSIONS

To our knowledge, this is the first study to systematically review lochia discharge formulations in Taiwan. The results of this study could provide an important basis for subsequent research in the clinical efficacy of Taiwanese lochia discharge formulations and the pharmacological mechanisms of their herbal components.

Thrombin, protein C, and protein S values in mother-infant dyads in the postpartum period

INTRODUCTION

The objective of the study was to establish the normal range for the levels of antithrombin (AT), protein C (PC), and protein S (PS) in the first week post birth in mother-infant pairings, adjusting for obstetric and perinatal factors, based on 2 different laboratory methods.

METHODS

Determinations were carried out in 83 healthy term neonates and their mothers, establishing 3 postpartum age groups: 1-2 days, 3 days, and 4-7 days.

RESULTS

There were no differences in the levels of any of the proteins between the different age groups in neonates or mothers in the first week post birth. The adjusted analysis found no association with obstetric or perinatal factors. The AT and PC levels were higher in mothers compared to infants (P < .001), while the PS levels were similar in both. Overall, the correlation of maternal and infant protein values was poor, except for the levels of free PS in the first 2 days after delivery. Although we found no differences based on which of the 2 laboratory methods was applied, the absolute values did differ.

Specific changes and clinical significance of plasma D-dimer during pregnancy and puerperium: a prospective study

BACKGROUND

Pregnant and puerperal women are high-risk populations for developing venous thromboembolism (VTE). Plasma D-dimer (D-D) is of good value in the diagnosis of exclusion of VTE in the nonpregnant population. Since there is no consensus reference range of plasma D-D applicable to pregnant and puerperal women, the application of plasma D-D is limited. To investigate the change characteristics and the reference range of plasma D-D levels during pregnancy and puerperium and to explore the pregnancy- and childbirth-related factors affecting plasma D-D levels and the diagnostic efficacy of plasma D-D for excluding VTE during early puerperium after caesarean section.

METHODS

A prospective cohort study was conducted with 514 pregnant and puerperal women (cohort 1), and 29 puerperal women developed VTE 24-48 h after caesarean section (cohort 2). In cohort 1, the effects of the pregnancy- and childbirth-related factors on the plasma D-D levels were analyzed by comparing the differences in plasma D-D levels between different groups and between different subgroups. The 95th percentiles were calculated to establish the unilateral upper limits of the plasma D-D levels. The plasma D-D levels at 24-48 h postpartum were compared between normal singleton pregnant and puerperal women in cohort 2 and women from the cesarean section subgroup in cohort 1, binary logistic analysis was used to analyze the relevance between plasma D-D level and the risk of VTE developing 24-48 h after caesarean section, and a receiver operating characteristic (ROC) curve was used to assess the diagnostic efficacy of plasma D-D for excluding VTE during early puerperium after caesarean section.

RESULTS

The 95% reference ranges of plasma D-D levels in the normal singleton pregnancy group were ≤ 1.01 mg/L in the first trimester, ≤ 3.17 mg/L in the second trimester, ≤ 5.35 mg/L in the third trimester, ≤ 5.47 mg/L at 24-48 h postpartum, and ≤ 0.66 mg/L at 42 days postpartum. The plasma D-D levels of the normal twin pregnancy group were significantly higher than those of the normal singleton pregnancy group during pregnancy (P < 0.05), the plasma D-D levels of the GDM group in the third trimester were significantly higher than those of the normal singleton pregnancy group (P < 0.05). The plasma D-D levels of the advanced age subgroup at 24-48 h postpartum were significantly higher than those of the nonadvanced age subgroup (P < 0.05), and the plasma D-D levels of the caesarean section subgroup at 24-48 h postpartum were significantly higher than those of the vaginal delivery subgroup (P < 0.05). The plasma D-D level was significantly correlated with the risk of VTE developing at 24-48 h after caesarean section (OR = 2.252, 95% CI: 1.611-3.149). The optimal cut-off value of plasma D-D for the diagnosis of exclusion of VTE during early puerperium after caesarean section was 3.24 mg/L. The negative predictive value for the diagnosis of exclusion of VTE was 96.1%, and the area under the curve (AUC) was 0.816, P < 0.001.

CONCLUSIONS

The thresholds of plasma D-D levels in normal singleton pregnancy and parturient women were higher than those of nonpregnant women. Plasma D-D had good value in the diagnosis of exclusion of VTE occurring during early puerperium after caesarean section. Further studies are needed to validate these reference ranges and assess the effects of pregnancy- and childbirth-related factors on plasma D-D levels and the diagnostic efficacy of plasma D-D for excluding VTE during pregnancy and puerperium.

Comparison of risk assessments for venous thromboembolism during the puerperium

Objective

To compare the predictive value of different risk assessment methods for puerperium venous thromboembolism (VTE).

Methods

This study included 55 women with and 165 women without puerperal VTE. Using the cases, 11 assessment methods were compared.

Results

The area under the curve (AUC) value of the 11 assessments was highest for the modified Caprini risk assessment model for pregnancy (a modified risk scoring method from Caprini, AUC = 0.805). Pairwise comparison of the AUC values of the 11 assessment methods indicated no significant difference among the five methods with AUC values > 0.7. Among them, the modified Caprini, the risk scoring method recommended by the Swedish Guidelines (Swedish method), and the risk scoring method recommended by the Shanghai consensus (Shanghai method) performed better than the other six methods with AUC values < 0.7 (P < 0.05). The sensitivities of the five methods for predicting a high risk of VTE were 69.09-94.55% and the specificities were 25.45-77.58%. The sensitivity of the modified Caprini was higher than those of the risk management method from the Chinese consensus (Chinese consensus method), Royal College of Obstetricians and Gynaecologists risk assessment scale (RCOG), and Swedish method (P < 0.05), but the specificity was only 25.45%. No significant difference in sensitivity was detected among the Swedish, Shanghai, RCOG, and Chinese consensus methods, whereas the specificity of the Swedish method was higher than that of the Shanghai, RCOG, and Chinese consensus methods.

Conclusion

The predictive value of different risk assessment methods for puerperium VTE varies greatly. Considering the sensitivity and specificity, the Swedish method may have better clinical application value among the 11 methods.

Design of a postpartum hemorrhage and transfusion risk calculator

Background

Postpartum hemorrhage is the major cause of maternal deaths due to childbirth and also responsible for maternal morbidity.

Objectives

In this study we set out to look the incidence of postpartum hemorrhage in our population, to identify the most important risk factors for postpartum hemorrhage and thus develop a predictive risk calculator for postpartum hemorrhage and transfusion.

Study design

data was taken from patients who presented vaginal delivery or cesarean section from January 1 to December 31, 2016, the variables taken into account as risk factors were as follows: Gestational age, history of chronic or gestational hypertension, preeclampsia, previous abortions, parity, previous cesarean section, placenta previa, labor time, and postpartum hemorrhage as the event of interest. An objective quantification was performed on a weight scale in grams for the estimation of bleeding, considering postpartum hemorrhage those with >500 ml in vaginal delivery and >1000 ml of blood loss in cesarean section. Subsequently, a predictive risk calculator was developed using the Naïve Bayes algorithm.

Results

A success rate of 58% was obtained in the identification of patients at high risk of hemorrhage, and 36% for transfusion, with a sensitivity of 50.7% and specificity of 64.06%, identifying as risk factors for postpartum hemorrhage gestational age between 35 and 40 weeks, hypertension and preeclampsia, previous cesarean section, duration of labor <1 h or more than 10 h, placenta previa and previous history of postpartum hemorrhage.

Conclusion

A postpartum hemorrhage risk calculator has been designed, which due to its improved accuracy after incorporation of data becomes a useful tool that will require a larger study population to improve its performance in clinical practice and more similar studies to validate it.

Australian Pelvic Floor Questionnaire: translation, cultural adaptation, and validation

INTRODUCTION AND HYPOTHESIS

The aim was to translate, culturally adapt, and validate the APFQ (Australian Pelvic Floor Questionnaire) for the population of Brazilian pregnant and postpartum women.

METHODS

The translation and validation of the APFQ were performed according to Beaton's guideline recommendations, with a sample of 150 patients (75 pregnant, 75 postpartum). Cronbach's alpha assessed the scale's internal consistency and reproducibility with the intraclass correlation coefficient (ICC). To analyze the construct validity, two questionnaires were applied, and the Spearman correlation was performed. Confirmatory factor analysis (CFA) was executed to assess the fit of the data to the theoretical model. The ability to generate diagnosis was analyzed by sensitivity and specificity.

RESULTS

Only 1% of the sample scored in the prolapse domain, so it was removed from the validation analyses. Cronbach's alpha values greater than 0.70 were obtained for the bladder and bowel domains, and 0.69 for sexual function. As for reproducibility, the ICC was greater than 0.75 for all domains. Spearman's correlation was good for bowel (r=0.74), moderate for bladder (r=0.58), and poor for sexual function (r=0.23). CFA results showed a non-optimal adherence: despite the Chi-squared value being significant (p<0.001), the CMIN- which is the adherence of the data to the model- value is less than 3. Sensitivity above 80% was obtained, whereas specificity of 43%, 16%, and 12% was obtained for bowel, bladder, and sexual functions respectively.

CONCLUSION

The APFQ was translated, culturally adapted, and validated for Brazilian pregnant and postpartum women. It showed good indexes of internal consistency, construct validity, reproducibility, and sensitivity. However, the prolapse domain could not be validated.

[Nephrotic syndrome due to preeclampsia: Presentation, management and clinical evolution observed in 5 years experience]

INTRODUCTION

Nephrotic syndrome (NS) is rare during pregnancy. The main cause is severe pre-eclampsia (PR). Our aim was to describe the clinical presentation, analytical features, medical management, and progress of women with NS due to PE.

MATERIALS AND METHODS

A descriptive, retrospective study, conducted from 01/01/2017 to 01/01/2022 (5years). Women with a gestational age (GA) ≥20weeks were included in the study, hospitalised due to hypertensive disorders in pregnancy (HDP), with no evidence of kidney damage prior to gestation.

RESULTS

Of the 652 HDP, 452 PE and 21 NS were identified. Maternal age was 25±5.7 years, GA at diagnosis was 33.1±5.1 weeks. All the women had facial and peripheral oedema: 5 pleural effusion, 3 pericardial effusion, and 2 anasarca. Their p24 was 6.17±2.34grams (3.10-10.8), serum albumin 2.5±0.27g/dL (2.10-2.90), and serum cholesterol 281.4±21.7mg/dL (251-316). Thirteen developed maternal complications: acute kidney damage, pulmonary oedema, dilated cardiomyopathy, eclampsia, and HELLP syndrome. They all remained hypertensive postpartum, and required a combination of two to three antihypertensive drugs. They all received statins postpartum, and angiotensin converting enzyme (ACE) inhibitors to manage proteinuria. None developed hyperkalaemia or creatinine elevation. Hospital stay was 10.4±3.7days. All nephrotic range proteinuria parameters reversed prior to discharge. No deaths were recorded.

CONCLUSION

Presentation ranged from peripheral oedema to serous involvement. Severity of proteinuria varied. Use of ACE inhibitors did not precipitate hyperkalaemia or kidney failure. Maternal complications were frequent, but no deaths were recorded.

Predictors of Mortality and Functional Outcome in Pregnancy and Puerperium-Related Cerebral Venous Thrombosis

INTRODUCTION

Cerebral venous thrombosis (CVT) associated with pregnancy and puerperium has long been recognized, with poor information in terms of functional outcomes. Our objective was to analyze risk factors, clinical, imaging, and laboratory variables to predict functional outcome and death in this population.

METHODS

CVT registries from three referral centers from Pakistan, Turkey, and Mexico, recruiting prospective cases, were combined for CVT associated with pregnancy or puerperium. Datasets and variables were standardized. Demographic characteristics, presentation, risk factors, and functional outcomes in pregnancy/puerperium-related CVT were analyzed. Binary logistic regression was used to assess predictors of outcome. The main outcome was modified Rankin score >2 at 30 days and mortality at 30 days.

RESULTS

Five hundred fifty-three cases (median age 28 years [IQR 23-34]) of CVT associated with pregnancy and puerperium were included; 439 cases (79.4%) happened in the puerperium and 20.6% during pregnancy (53.5% occurred during the first trimester). Anemia (36.7%) and dehydration (22.9%) were the commonest obstetric risk factors identified. Predictors of poor outcome (mRS >2) were encephalopathy (OR 12.8, p < 0.001), cases from Mexican origin (OR 3.1, p = 0.004), fever/puerperal infection (OR 2.7, p = 0.02), and anemia (OR 2.2, p = 0.01). Cases from Mexican origin (OR 12.0, p = 0.003) and Encephalopathy (OR 7.7, p < 0.001), presented with the highest mortality association in the final adjusted model.

DISCUSSION/CONCLUSION

In CVT associated with pregnancy and puerperium, encephalopathy, fever/puerperal infection, and anemia are associated with bad functional outcomes, meanwhile encephalopathy and cases from Mexican origin with higher mortality in the acute (30-days) of CVT onset. Anemia and infection are potential reversible predictors of poor outcome that clinicians should be aware of in order to prevent poor outcomes in these patients.

Obstetric Sepsis: A Review Article

Introduction

The World Health Organization defines obstetric (maternal) sepsis as organ failure caused by infection during pregnancy, childbirth, post-abortion or postpartum period. It is the third most prevalent reason for maternal death. According to statistics, sepsis caused 11 percent of maternal fatalities worldwide.

Discussion

Physiological changes related to pregnancy may imitate the start of sepsis, which makes definitive diagnosis difficult. The definition of sepsis is gradually amended over decades. Various diagnostic tools and criteria are available.

Conclusion

Prevention, early diagnosis, and appropriate management can reduce sepsis related maternal mortalities and morbidities. To reduce unnecessary maternal mortality, future policy development in the area of evaluation and care of obstetric sepsis is essential.

Maternal mortality linked to COVID-19 in Latin America: Results from a multi-country collaborative database of 447 deaths

Background

This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a collaborative Latin-American multi-country database.

Methods

This was an observational study implemented from March 1st 2020 to November 29th 2021 in eight Latin American countries. Information was based on the Perinatal Information System from the Latin American Center for Perinatology, Women and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables into median with interquartile ranges.

Findings

We identified a total of 447 deaths. The median maternal age was 31 years. 86·4% of women were infected antepartum, with most of the cases (60·3%) detected in the third trimester of pregnancy. The most frequent symptoms at first consultation and admission were dyspnea (73·0%), fever (69·0%), and cough (59·0%). Organ dysfunction was reported in 90·4% of women during admission. A total of 64·8% women were admitted to critical care for a median length of eight days. In most cases, the death occurred during the puerperium, with a median of seven days between delivery and death. Preterm delivery was the most common perinatal complication (76·9%) and 59·9% were low birth weight.

Interpretation

This study describes the characteristics of maternal deaths in a comprehensive multi-country database in Latin America during the COVID-19 pandemic. Barriers faced by Latin American pregnant women to access intensive care services when required were also revealed. Decision-makers should strengthen severity awareness, and referral strategies to avoid potential delays.

Funding

Latin American Center for Perinatology, Women and Reproductive Health.

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases

Background

Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood. The goal was to summarize and define the etiology, risk factors, clinical presentation, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during pregnancy/puerperium (SHRP) complicated by the hypertensive disorder.

Methods

Literature search of all full-text articles included PubMed (1946–2021), PubMed Central (1900–2021), and Google Scholar. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no restriction of language to collect the cases. Additional cases were identified by reviewing references of retrieved studies. PRISMA guidelines for the data extraction and quality assessment were applied.

Results

Three hundred and ninety-one cases were collected. The median maternal age was 31 (range 17–48) years; 36.6% were nulliparous. Most (83.4%) occurred in the third trimester. Maternal and fetal mortality was 22.1% and 37.2%, respectively. Maternal and fetal mortality was significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia. The most important risk factors for SHRP were preeclampsia and HELLP syndrome. Most women had right lobe affected (70.9%), followed by both lobes in 22.1% and left lobe in 6.9%. The most common surgical procedure was liver packing. Liver transplantation was performed in 4.7% with 100% survival. Maternal mortality with liver embolization was 3.0%. Higher gestational age increases fetal survival.

Conclusion

The diagnosis and treatment of SHRP are often delayed, leading to high maternal and fetal mortality. SHRP should be excluded in hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain. Liver embolization and liver transplantation contribute to maternal survival. Maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, preeclampsia, and eclampsia have a significant negative influence on maternal survival.

Level of evidence

Level V

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00444-w.

Mesenteric cyst manifested as obesity, gastroesophageal reflux, urinary incontinence, and abdominal mass during pregnancy-Case report and literature review

INTRODUCTION AND IMPORTANCE

The mesenteric cyst (MC) is a rare entity, a benign lesion that causes the growth of an abdominal mass and other clinical presentations. The presentation of MC during pregnancy is even less frequent.

CASE PRESENTATION

A 34-year-old Mexican woman presented with a mesenteric cyst treated with laparotomy aspiration during the 16th week of pregnancy; the pregnancy was resolved by cesarean section without problems. Nevertheless, 17 months later, the lesion recurred. New assessment and surgical treatment with complete excision are performed without evidence of further recurrence.

CLINICAL DISCUSSION

This case is essential due to the low frequency of association between pregnancy and mesenteric cyst. Incomplete resection, aspiration, and marsupialization of the lesion carry a high risk of recurrence. Therefore, the opportune moment to perform a complete resection of the lesion and avoid complications should be evaluated during pregnancy.

CONCLUSION

MC should be considered a differential diagnosis in cystic lesions during pregnancy. Imaging studies, complete surgical resection, histological evaluation, and follow-up are necessary for adequate treatment.

Does gender difference matter in cerebral venous thrombosis?

Female specific risk factors (FSRFs) in cerebral venous thrombosis (CVT) may have difference in clinical, imaging and outcome parameters compared to those females with additional risk factors and males. We compare the clinical, MRI and outcome between male and female patients with CVT. We also compare female patients with and without female specific risk factors. 172 patients were included from a prospectively maintained CVT registry. The diagnosis was confirmed on magnetic resonance venography (MRV). Clinical details, risk factors, MRI and MRV findings were noted. The risk factors in the females were categorized as 1) Isolated FSRF (oral contraceptive, pregnancy, puerperium), 2) FSRF in addition to other risk factor, 3) non FSRF only, and 4) no risk factor groups. Outcome at 6 months was assessed using modified Rankin Scale (mRS) as death, poor (mRS 3-5) and good (mRS ≤ 2). There were 80 (46.5%) females; 24 (30%) had FSRFs and 18 (75%) of whom also had other risk factors leaving only 6(25%) females with isolated FSRF. The frequency of other prothrombotic risk factors, and clinical and imaging findings were similar in males and females except more frequent hyperhomocysteinemia in males (59% vs 41%; P = 0.036) and altered sensorium in females (66% vs 40%; P = 0.001). 17(9.9%) patients died, 12(7%) had poor and 143(83.1%) had good outcome, which were similar in both the gender, and in the females with and without FSRF. Isolated FSRF is rare in CVT, and there is no gender difference in terms of non FSRFs, clinico-radiological severity and outcome.

Covert postpartum urinary retention: causes and consequences (PAREZ study)

Introduction and hypothesis

Increased post-voiding residual volume (PVRV), known as covert postpartum urinary retention (PUR), is an asymptomatic condition with unknown long-term adverse effects. The objectives were to determine the frequency of this phenomenon 3 days after delivery and to examine the associated risk factors and consequences of the increased residuum on women´s health 6 weeks postpartum.

Methods

We carried out a prospective observational study including a total of 926 primiparous women, giving birth to singletons. All participants underwent ultrasound determination of PVRV on day 3 postpartum. Then, risk factors were determined using logistic regression analysis. After 6 weeks, participants were invited to return for PVRV determination and to complete urogynecological and general health questionnaires. Using these data, the consequences of increased PVRV were determined.

Results

A total of n=90 women were diagnosed with abnormal PVRV. Mean age in the studied population was 30.4 years, BMI prior to delivery 27.8, weight of the newborn 3,420 g, and percentage of cesarean sections 15.9%. Gestational week (p=0.043), vaginal tear (p=0.032), and induction of labor (p=0.003) were risk factors for covert PUR. Puerperal incidence of urinary tract infection was 1.1% (6 out of 526) and of urinary incontinence 29.2% (155 out of 530), with no differences between the groups. In the second examination, covert PUR was no longer present, and the values of residual urine decreased for all patients in the case group. No statistically significant differences were observed in questionnaire scores in general health and wellbeing perceptions between the groups.

Conclusions

We have found a few significant obstetrical–pediatric risk factors for abnormal PVRVs. Data from the follow-up suggest that covert PUR has no impact on morbidity and quality of life 6 weeks postpartum. Therefore, abnormal PVRV is a self-limited phenomenon with a tendency toward self-correction. Our findings support those of previous studies that advocate against screening for asymptomatic retention in the postpartum period, despite some similar previous recommendations.

Effect of retained placenta and clinical mastitis on reproduction parameters, immune response, and steroidogenic receptors gene expression in postpartum crossbred dairy cows

The purpose of this study was to evaluate the effect of retained placenta (RP) and clinical mastitis (CM) on the reproductive efficiency of crossbred dairy cows during the postpartum period and the effect in some innate immune system indicators. For this, two experiments were carried out. In the first, a total of 232 cows were evaluated and divided as: healthy control (n = 184), RP (n = 22), and CM (n = 26) groups. The RP and CM was evaluated until 30 days postpartum (DPP) and reproductive rates were measured. In experiment 2, cows were divided in control (n = 10), RP (n = 10), and CM (n = 30) groups. Between 40 and 50 DPP, clinical, gynecological examination and endometrial cytobrush were performed to evaluate subclinical endometritis (SE) and gene expression of interleukins 1β (IL-1β) and 6 (IL-6), chemokine ligand 5 (CCL5), estrogen α (ESR1), and progesterone (PGR) receptors by qRT-PCR analysis. In experiment 1, the conception rate at 1st artificial insemination (AI) was lower in RP and CM groups and pregnancy rate at 150 days decreased in CM group. Calving-to-1st AI interval and days open were shorter in healthy cows. In experiment 2, the occurrence of SE was 26.7% and higher in RP and CM groups. The expression of IL-1β increased in RP and CM groups, while IL-6 was less expressed in RP group. The CCL5, ESR1, and PGR were similar between groups. In conclusion, cows with RP and CM had their reproductive efficiency negatively affected and had they initial pro-inflammatory response improved by the increase of IL-β.

Effect of metritis on in-vitro uterine contractility in cows during the puerperium

Aim of this study was to determine the effect of metritis on in-vitro uterine contractility. Uteri obtained from 16 euthanized Holstein-Friesian cows were divided into two groups depending on whether metritis was absent (M-, n = 6) or present (M+, n = 10). Four longitudinal and four circular myometrial strips of all uteri were incubated in an organ bath. Spontaneous contractility was recorded in five consecutive 30-minute periods (T1-T5). This was followed by stimulation of one longitudinal and one circular strip with increasing concentrations of oxytocin, prostaglandinF_2α (PGF_2α), and calcium chloride (each during four 30-minute periods [T6-T9]). Strips in group M+ had higher minimum amplitude (minA) values at T1 and higher minA, mean amplitude (meanA), and area under the curve (AUC) values at T2 than strips in group M- (P ≤ 0.05). In the M+ group, the maximum amplitude (maxA), meanA, and AUC values of circular strips were higher than those of longitudinal strips during spontaneous contractility (T1, T4, and T5; P ≤ 0.05). The minA, meanA, and AUC values for strips in group M+ were higher than those in group M- when exposed to the highest concentration of PGF_2α (P ≤ 0.05). During stimulation with PGF_2α (T9), longitudinal strips had higher maxA values than the circular strips in group M+ (P ≤ 0.05). Spontaneous and stimulated contractility were temporarily increased in uteri with metritis compared to healthy uteri. Both myometrial layers, especially in uteri with metritis, reacted differently during spontaneous contractility and to stimulation with PGF_2α.

Comparison of two questionnaires to diagnose obstructive defecation syndrome during pregnancy and post-natally

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.

Maternal and Neonatal Outcomes of Critically Ill Pregnant and Puerperal Patients Diagnosed with COVID-19 Disease: Retrospective Comparative Study

BACKGROUND

We assessed maternal and neonatal outcomes of critically ill pregnant and puerperal patients in the clinical course of coronavirus disease 2019 (COVID-19).

METHODS

Records of pregnant and puerperal women with polymerase chain reaction positive COVID-19 virus who were admitted to our intensive care unit (ICU) from March 2020 to August 2021 were investigated. Demographic, clinical and laboratory data, pharmacotherapy, and neonatal outcomes were analyzed. These outcomes were compared between patients that were discharged from ICU and patients who died in ICU.

RESULTS

Nineteen women were included in this study. Additional oxygen was required in all cases (100%). Eight patients (42%) were intubated and mechanically ventilated. All patients that were mechanically ventilated have died. Increased levels of C-reactive protein (CRP) was seen in all patients (100%). D-dimer values increased in 15 patients (78.9%); interleukin-6 (IL-6) increased in 16 cases (84.2%). Sixteen patients used antiviral drugs. Eleven patients were discharged from the ICU and eight patients have died due to complications of COVID-19 showing an ICU mortality rate of 42.1%. Mean number of hospitalized days in ICU was significantly lower in patients that were discharged (P = 0.037). Seventeen patients underwent cesarean-section (C/S) (89.4%). Mean birth week was significantly lower in patients who died in ICU (P = 0.024). Eleven preterm (57.8%) and eight term deliveries (42.1%) occurred.

CONCLUSION

High mortality rate was detected among critically ill pregnant/parturient patients followed in the ICU. Main predictors of mortality were the need of invasive mechanical ventilation and higher number of days hospitalized in ICU. Rate of C/S operations and preterm delivery were high. Pleasingly, the rate of neonatal death was low and no neonatal COVID-19 occurred.

Cerebral venous sinus thrombosis in pregnancy and puerperium

Cerebral venous sinus thrombosis (CVST) is more common in women than in men, possibly due to gender-specific risk factors in young adults. The purpose of this study was to investigate whether the clinical and radiological findings, other risk factors, and clinical course of CVST associated with pregnancy and puerperium differ from those of other CVST cases. We retrospectively reviewed patients diagnosed with CVST in our hospital between September 2007 and December 2019. The risk factors, clinical and radiological characteristics, and follow-up data for female patients with CVST were compared between cases associated with pregnancy and puerperium with those of other cases. A total of 50 female patients with CVST were included in the study. Twenty-four (48%) cases occurred during pregnancy and puerperium. The mean age of the pregnant or puerperal patients was lower than that of the other patients (p = 0.007). There was no significant difference between the groups in terms of clinical and neuroradiological findings or presence of any additional risk factors including hereditary thrombophilia. There was also no difference in terms of in-hospital mortality rates and modified Rankin Scale (mRS) scores at 6 months between the groups. The clinical presentation of CVST and the frequencies of the presence of other risk factors including genetic thrombophilia in pregnant and puerperal patients were similar to those of non-pregnant female patients. Screening for additional risk factors, especially genetic thrombophilia, should therefore not be neglected in CVST occurring during pregnancy and puerperium.

Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review

Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.

Missed opportunities for venous thromboembolism prophylaxis during pregnancy and the postpartum period: evidence from mainland China in 2019

Background

Venous thromboembolism (VTE) has become one of the leading causes of maternal mortality. Thromboprophylaxis is recommended for the prevention of this condition; however, its use appears to be insufficient. Therefore, in this study, we aimed to identify the missed opportunities for VTE prophylaxis in hospitals that provide maternal healthcare in mainland China.

Methods

In this cross-sectional survey-based study, we collected case data on pregnant and puerperal women with deep vein thrombosis and pulmonary thromboembolism from January 1st to December 31st, 2019. Demographics, obstetric information, VTE risk assessment scores, and prophylaxis-related information were recorded. Thromboprophylaxis included mobilization, mechanical methods, and treatment with anticoagulants.

Results

Data corresponding to a total of 106 cases from 26 hospitals across China were collected, and 100 (94.3%) cases, 75 cases involving deep vein thrombosis and 25 cases involving pulmonary thromboembolism, were included in the final analysis. VTE occurred in 80% of the patients at the postpartum stage, while 20 patients developed the disease during the antenatal stage. Cesarean section, advanced maternal age, and obesity were the most common risk factors related to VTE during the postpartum stage, while a previous VTE-related history was a prominent risk factor among antenatal cases. Up to 75% of the patients had one or more missed opportunities for prophylaxis. The lack of the implementation of mechanical methods (60.8% vs. 24.5%, P < 0.001) and anticoagulant treatment (61.1% vs. 48.7%, P < 0.001) were more common in general hospitals compared to those of specialized hospitals. In women assessed as high-risk, anticoagulant treatment was lacking in 41 (54.7%) cases. More importantly, the lack of the implementation of mechanical methods was more common among women assessed as low-risk (56.0% vs. 38.7%, P < 0.001). Among the antenatal cases, the lack of treatment with anticoagulants (100.0% vs. 48.5%, P < 0.001) and implementation of mechanical methods (70.0% vs. 36.7%, P < 0.001) was highlighted. In addition, the lack of early mobilization was much more prominent among the PTE cases (10.5% vs. 37.5%, P < 0.001).

Conclusions

At least one prophylactic opportunity was missed in most of the enrolled Chinese women with VTE during the course of their maternal healthcare. Missed prophylactic opportunities varied with the type of hospitals, risk assessment, onset timing and disease type. Further efforts from patients, healthcare systems, and healthcare providers are needed for improving the implementation of preventative strategies.

Association between postpartum low-carbohydrate-diet scores and glucose levels in Chinese women

OBJECTIVES

Views on the relationship between a low-carbohydrate diet (LCD) and glucose levels are controversial, and no study, to our knowledge, has examined this association in postpartum women. We aimed to explore the association between postpartum LCD scores and glucose levels.

METHODS

We included 500 postpartum women from a prospective cohort study in Guangzhou, China, during 2017 and 2018. Dietary information during the first month after delivery was assessed via a validated food frequency questionnaire. The overall, animal, and plant LCD scores were determined based on percentages of energy from carbohydrate, protein, and fat. Higher scores reflected higher intakes of fat and protein and lower intakes of carbohydrate. At 6 to 8 wk postpartum, women with previous gestational diabetes mellitus underwent oral glucose tolerance tests (n = 104), and the others had fasting plasma glucose (FPG) tests (n = 396). Multivariable linear, quantile, and logistic regressions were conducted.

RESULTS

Of the 500 participants, 71 (14.20%) developed impaired fasting glucose. Animal LCD score was positively associated with FPG levels (β = 0.007, P = 0.017), but quantile regression showed that LCD scores were related to FPG only in women with lower FPG levels; they had no significant association in those with higher FPG levels. No significant interaction effect on FPG was found between LCD scores and history of gestational diabetes mellitus (P_interaction > 0.40). Furthermore, the relationships between the three LCD scores and risk of developing impaired fasting glucose were not statistically significant.

CONCLUSIONS

Animal LCD score during puerperium may be positively associated with FPG levels in the early postpartum period in Chinese women, but no interactions with history of gestational diabetes mellitus were observed. Stronger associations were observed in women with lower FPG levels.

Giving women WOICE postpartum: prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument

Background

There are no accurate estimates of the prevalence of non-severe maternal morbidities. Given the lack of instruments to fully assess these morbidities, the World Health Organization (WHO) developed an instrument called WOICE. We aimed to evaluate the prevalence of non-severe maternal morbidities in puerperal women and factors associated to impaired clinical, social and mental health conditions.

Method

A cross-sectional study with postpartum women at a high-risk outpatient clinic in southeast Brazil, from November 2017 to December 2018. The WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. Data collection was supported by Tablets with REDCAP software. Initially, a descriptive analysis was performed, with general prevalence of all variables contained in the WOICE, including scales on anxiety and depression (GAD-7 and PHQ-9- impaired if ≥10), functionality (WHODAS- high disability scores when ≥37.4) and data on violence and substance use. Subsequently, an evaluation of cases with positive findings was performed, with a Poisson regression to investigate factors associated to impaired non-clinical and clinical conditions.

Results

Five hundred seventeen women were included, majority (54.3%) multiparous, between 20 and 34 years (65.4%) and with a partner (75,6%). Over a quarter had (26.2%) preterm birth. Around a third (30.2%) reported health problems informed by the physician, although more than 80% considered having good or very good health. About 10% reported any substance use and 5.9% reported exposure to violence. Anxiety was identified in 19.8% of cases, depression in 36.9% and impaired functioning in 4.4% of women. Poisson regression identified that poor overall health rating was associated to increased anxiety/depression and impaired functioning. Having a partner reduced perception of women on the presence of clinical morbidities.

Conclusion

During postpartum care of a high-risk population, over one third of the considered women presented anxiety and depression; 10% reported substance use and around 6% exposure to violence. These aspects of women’s health need further evaluation and specific interventions to improve quality of care.

Bell's palsy during pregnancy and the post-partum period: A contemporary management approach

Bell's palsy during pregnancy and the immediate post-partum period represents a unique clinical entity requiring an individualised management approach. Whilst the exact link between Bell's palsy and pregnancy is still unclear, the majority of cases occur in the third trimester and immediate post-partum period. These patients have been demonstrated to experience worse long term outcomes and are less likely to receive early corticosteroid therapy. This review suggests a contemporary management algorithm to ensure that these patients receive early therapy that is safe for the patient and foetus and meets the unique physical needs of the expecting or new mother.

[Principles of intensive medical care in pregnant patients]

As the incidence of diseases during pregnancy or in the puerperium necessitating intensive medical care is very low, intensive care physicians are faced with a multitude of unfamiliar challenges in the treatment of this patient collective. The physiological and pathophysiological alterations during pregnancy induce some specific features with respect to the intensive medical treatment of pregnant or postpartum patients. Therefore, the first article in this CME series summarizes the most important principles and current recommendations on the care of pregnant or postpartum patients who need intensive medical treatment, always under consideration of the well-being of mother and child. The second article describes the diagnostics and treatment of special selected pathologies.

Receptor for advanced glycation end-products (RAGE) plays a critical role in retrieval behavior of mother mice at early postpartum

Receptor for advanced glycation end-products (RAGE) is a pattern recognition molecule belonging to the immunoglobulin superfamily, and it plays a role in the remodeling of endothelial cells under pathological conditions. Recently, it was shown that RAGE is a binding protein for oxytocin (OT) and a transporter of OT to the brain on neurovascular endothelial cells via blood circulation. Deletion of the mouse RAGE gene, Ager (RAGE KO), induces hyperactivity in male mice. Impairment of pup care by mother RAGE KO mice after stress exposure results in the death of neonates 1-2 days after pup birth. Therefore, to understand the role of RAGE during the postpartum period, this study aims to examine parental behavior in female RAGE KO mice and ultrasonic vocalizations in pups. RAGE KO mothers without stress before delivery raised their pups and displayed hyperactivity at postpartum day (PPD) 3. KO dams showed impaired retrieval or interaction behavior after additional stress, such as body restraint stress or exposure to a novel environment, but such impaired behavior disappeared at PPD 7. Postnatal day 3 pups emitted ultrasonic vocalizations at >60 kHz as a part of the mother-pup relationship, but the number and category of calls by RAGE KO pups were significantly lower than wild-type pups. The results indicate that RAGE is important in the manifestation of normal parental behavior in dams and for receiving maternal care by mouse pups; moreover, brain OT recruited by RAGE plays a role in damping of signals of additional external stress and endogenous stress during the early postpartum period. Thus, RAGE-dependent OT may be critical for initiating and maintaining the normal mother-child relationship.

Correlation between depressive symptoms and sexual dysfunction in postpartum women during the COVID-19 pandemic

OBJECTIVE

To evaluate the relation between sexual function and depressive symptoms in puerperal women during the pandemic period.

STUDY DESIGN

Prospective cohort with 125 women evaluated in the immediate postpartum period (before the pandemic - T1) in Hospital de Clínicas de Porto Alegre, 3 months (pandemic onset - T2) and 6 months (pandemic peak - T3) after birth by email and WhatsApp. The Female Sexual Function Index (FSFI) and the Edinburgh Postnatal Depression Scale (EPDS) were applied.

RESULTS

Fifty puerperal women participated in the three periods of the study. The median age was 25 years. There was an inverse correlation between the ​​ FSFI and EPDS values at T2 (p < 0.001) and T3 (p < 0.001), demonstrating that the worsening sexual response was secondary to the higher prevalence of depressive symptoms in the puerperium in the COVID-19 pandemic. There was an increase in EPDS scores in the three periods: at T1, the EPDS scores ​​were 5.0 (2.0-9.0), increasing to 7.0 (4.0-14.0) at T2 and 6.5 (3.0-13.0) at T3 (p = 0.004). There was no difference between the FSFI index at the three evaluated times.

CONCLUSIONS

Puerperal women are a susceptible subgroup for sexual dysfunction and depressive symptoms, which are correlated to each other and worsen in periods of stress, therefore, it is mandatory to investigate depressive symptoms in puerperal women with sexual complaints, especially during the COVID-19 pandemic.

The beneficial effects of fractional CO2 laser treatment on perineal changes during puerperium and breastfeeding period: a multicentric study

Childbirth is a great change in woman life because of hormonal, physical and psychological alterations that are associated with this process. Dyspareunia and perineal pain are commonly reported symptoms in the postpartum period, mainly due to perineal trauma, lacerations, episiotomy, and forceps or vacuum use at delivery. Among non-pharmacological treatment, a new trend is gaining popularity, which is the energy-based therapy, including fractional micro-ablative CO₂ laser. We conducted a multicentric retrospective study to assess the efficacy and the possible side effects of CO₂ laser treatment on transient vulvovaginal atrophy and perineal postpartum pain related to puerperium and breastfeeding period. All patients were submitted to 3 or 4 sessions of CO₂ laser treatment. As per protocol, an initial, intermediate (after 2 sessions) and final (3 months after the last cycle) evaluation of the symptoms were made, using a VAS (Visual Analogue Scale 0-10). We also compared this group of patients with a control group with no treatment. At the final evaluation, patients showed a significant improvement for dyspareunia (VAS from 7.95 to 3.14, p < 0.0001). A significant improvement was also registered in pain at the vaginal orifice (VAS from 6.94 to 2.05, p = 0.0001), dryness (VAS from 6.6 to 2.9, p = 0.0022), itching (VAS from 4.5 to 1.16, p = 0.0053), heat (VAS from 3 to 0, p = 0.0119) and burning (VAS from 5.5 to 1.6, p = 0.0013) if compared with the control group. Quality of life for the women during the breastfeeding and puerperium is important and training is mandatory to avoid side effects in order to improve the CO₂ laser performance.

Functioning of women in the postpartum period: an International Classification of Functioning, Disability and Health-based consensus of physical therapists

BACKGROUND

Physical therapists provide treatment for pain and other common complaints for women in the postpartum period, thereby contributing to the improvement of their functioning. However, before applying any interventions, physical therapists should assess their patients to identify the desired therapeutic goals. In this context, the International Classification of Functioning, Disability and Health (ICF) may be a useful tool for documenting functioning data and operationalizing collaborative goal setting.

OBJECTIVE

To identify ICF categories and the respective domains that should be considered in the evaluation of women postpartum.

METHODS

A consensus-building, three-round e-mail survey was conducted using the Delphi method. The sample included Brazilian physical therapists with expertise in women's health. Meaningful content was analyzed in accordance to the ICF linking rules. The kappa coefficient and content validity index (CVI) were calculated.

RESULTS

The panel consisted of 45 participants with a median age of 33 years and more than 10 years of experience in women's health. A total of 1261 meaningful contents were identified from the responses in the first round. After consensus was achieved, a final list of 62 items was prepared, including 53 categories (11 were on structures; 15 on body functions; 12 on activities and participation; 15 on environmental factors) and nine personal factors (CVI=0.89).

CONCLUSION

From the perception of physical therapists, an ICF-based postpartum assessment to describe functioning and disability must comprise 53 ICF categories and nine personal factors.

The predictive value of D-dimer test for venous thromboembolism during puerperium in women age 35 or older: a prospective cohort study

Background

This study aimed to investigate the predictive value of the D-dimer level for venous thromboembolism (VTE) events during puerperium of women age at 35 years or older, as well as to identify other risk factors associated with the occurrence of VTE.

Methods

It was a prospective observational cohort study, from January 2014 to December 2018, which involved 12,451 women age 35 or older who delivered at least 28 weeks of gestation at Women’s Hospital of Zhejiang University, School of Medicine. The maternal and fetal demographic characteristics, pregnancy complications, imaging finding and results of laboratory test within postpartum 24 h including D-dimer level, platelet counts and fibrinogen level were collected for analyses.

Results

30(2.4‰) women were identified as VTE, including 1 pulmonary embolism event and 29 deep venous thrombosis events. The receiver operating characteristic (ROC) curve analysis suggested the best cutoff point for D-dimer level within postpartum 24 h of women age 35 or older was 5.545 mg/L, with a specificity of 70.0% and a sensitivity of 75.4%. Besides, there was no statistical correlation between platelet counts and VTE, as well as between fibrinogen level and VTE. On multivariate analysis, D-dimer≥5.50 mg/L (OR = 5.874, 95%CI: 2.678–12.886) and emergency cesarean section (OR = 11.965, 95%CI: 2.732–52.401) were independently associated with VTE in puerperium of women age 35 or older.

Conclusions

We concluded that D-dimer≥5.50 mg/L was an independent predictor of VTE in puerperium with maternal age 35 or older and D-dimer testing was a necessary examination for perinatal women.

Puerperal complications: pathophysiological mechanisms and main imaging findings

OBJECTIVE

Puerperium is the period during which the physiological changes that have taken place during pregnancy revert and the uterus involutes until it reaches its normal size. This is a period of intense systemic changes, and diagnosing complications in this period is a challenge for both gynecologists and radiologists. This paper reviews the complications that can occur during puerperium, classifying them according to the pathophysiological mechanisms involved: the prothrombotic state, hemodynamic and hormonal changes, rapid uterine growth, changes associated with endothelial damage (preeclampsia, eclampsia, and HELLP syndrome), and postoperative complications in patients undergoing cesarean sections.

CONCLUSION

Puerperal complications represent a diagnostic challenge. Understanding the pathophysiological mechanisms underlying these complications is fundamental for choosing the most appropriate imaging technique to ensure the correct diagnosis in each case.

Reperfusion Therapy for Acute Stroke in Pregnant and Post-Partum Women: A Canadian Survey

BACKGROUND/OBJECTIVE

A Canadian Stroke Best Practices consensus statement on Acute Stroke Management during pregnancy was published in 2018. The state of individual practice, however, is unknown.

METHODS

A survey on treatment of acute stroke in pregnant and post-partum women was distributed via the Canadian Stroke Consortium email list. Descriptive statistics (frequencies and proportions) were calculated for demographic and response variables and free-text responses were coded for thematic content.

RESULTS

Thirty-five participants completed the survey; 12 had experience with intravenous tissue plasminogen activator (IV-tPA), endovascular therapy (EVT), or both in pregnant patients. None had treatment-related complications. The majority (92%) of those who had not yet encountered the issue in practice expressed some reservation about giving IV-tPA to an otherwise eligible pregnant woman. In a theoretical scenario where an otherwise eligible pregnant woman was a candidate for both IV-tPA and EVT, 58% of respondents would have opted for EVT alone. Amongst this cohort comprised mainly of stroke sub-specialists, more than a third had treated pregnant patients with reperfusion therapy.

CONCLUSIONS

The reported safety experience with both IV-tPA and EVT was reassuring. Overall, there was a hesitancy towards use of IV-tPA in pregnancy that is discordant with the recent consensus statement. Possible barriers to uptake identified through thematic analysis were concerns regarding risks of bleeding in the pregnant patient, presence of EVT as a perceived alternative, and the need for express consent from the patient and family.

Managing migraine in pregnancy and breastfeeding

The disproportionate prevalence of migraine among women in their reproductive years underscores the clinical significance of migraine during pregnancy. This paper discusses how migraine evolves during pregnancy, secondary headache disorders presenting in pregnancy and puerperium, and acute and preventive options for migraine management during pregnancy and lactation. Migraine is influenced by rising estrogen levels during pregnancy and their sharp decline in puerperium. Migraine, and migraine aura, can present for the first time during pregnancy and puerperium. There is also a higher risk for the development of preeclampsia and cerebrovascular headache during these periods. New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider. This paper reviews the diagnostic utility of neuroimaging studies and the risks of each during pregnancy. Untreated migraine can itself lead to preterm delivery, preeclampsia, and low birth weight infants. Behavioral interventions and lifestyle modifications are the cornerstone for migraine treatment during pregnancy. In addition, one should consider the risks and efficacy of each treatment during pregnancy on an individual basis. The protective nature of breastfeeding for migraine is debated, but there is no evidence to suggest breastfeeding worsens migraine. Acute and preventive migraine treatment options are available for nursing mothers. Neuromodulation and neurostimulation devices are additional options for treatment during pregnancy and lactation, while the safety of using calcitonin gene-related peptide receptor antagonists during these times remains to be determined.

ENG-releasing subdermal implants in postpartum teenagers - an open-label trial study protocol

Background

Higher than expected adolescent pregnancy high rates continue globally, with repeated unplanned pregnancy (UP) in this age group is a public health problem. In Brazil, 16% of pregnancies occur in adolescents under 18 years old, with high maternal morbidity and mortality rates in this age group. Effective and safe contraception is required to reduce UP rates. The objective of our study is to evaluate acceptance of etonogestrel (ENG)-releasing subdermal contraceptive implant after childbirth, before discharge, as well as clinical performance up to one year after placement. Comparison between teenagers who opt for ENG-implant versus other contraceptive methods after childbirth will be also evaluated, specifically regarding UP, continuation and discontinuation rates and reasons, body composition, pelvic ultrasound characteristics and user satisfaction.

Methods

A non-randomized open-label trial will be conducted with teenagers after childbirth and followed up to one year at the Women’s Hospital, University of Campinas (UNICAMP), Campinas, Brazil. The study group will consist of patients who accepted to use ENG-implant and placed before discharge. The comparison group will include adolescents who choose to use other contraceptive methods at the first postpartum visit (42 ± 3 days after childbirth). All women will follow-up at 40–60 days postpartum, as well as, at 6 and 12 months post-enrollment. Patient satisfaction, contraceptive effectiveness, reasons of discontinuation, continuation rate and body composition will be evaluated. Transvaginal ultrasound and electric bio impedance tests will be performed at all follow-up appointments. A 5% significance level was assumed, as well as, a sampling error (absolute) for 10% prevalence. The sample size was calculated at n = 100, obtaining an estimate of 50 to 70 adolescents who would accept the method offered, according to the prevalence and sample error assumed.

Discussion

Long-acting reversible contraceptive (LARC) methods include subdermal implants and intrauterine contraceptives, are considered first line contraception for teenagers. Immediate postpartum use is a safe option, which significantly reduces rates of repeated UP and all the undesirable consequences inherent to this process.

Trial registration

This study was approved by the Ethics and Research Commission of UNICAMP (CAAE: 92869018.5.0000.5404) and the Brazilian Registry of Clinical Trials (REBEC): http://www.ensaiosclinicos.gov.br/rg/RBR-4z7bc6, (number 2.901.752).

Acute right iliofemoral deep vein thrombosis mimicking acute appendicitis in the postpartum period: a case report

The risk of venous thromboembolism increases during pregnancy and postpartum. The incidence in the first six weeks following delivery is approximately 0.15%. Deep vein thrombosis may present with acute appendicitis-like symptoms such as right iliac fossa pain, nausea and vomiting. A 22-year-old woman was admitted with complaints of abdominal pain and vomiting 20 days after spontaneous vaginal delivery. Physical examination and radiological findings were compatible with acute appendicitis. Preoperative re-examination and re-evaluation of computed tomography revealed concomitant deep vein thrombosis on the right side. The patient underwent laparotomy and a normal appendix and ovaries were found. She had an uneventful recovery. Anticoagulant treatment was administered for six months. Early and correct diagnosis should be established to avoid complications of deep vein thrombosis and prevent unnecessary surgical interventions. Physicians should be aware of deep vein thrombosis in women who present acute appendicitis-like symptoms, especially during pregnancy and in the postpartum period.

Risk scores, prevention, and treatment of maternal venous thromboembolism

BACKGROUND

At present, the preventive treatment for pregnancy-related venous thromboembolism (VTE) in China is in its infancy, and there is no uniform or standardized industry guide. Drug prevention and treatment of pregnancy-related VTE rely highly on foreign guidelines; however, due to the differences in ethnicity and national conditions, there are many controversies over the indications for drug treatment, drug selection, and dose selection for anticoagulant therapy.

AIM

To investigate the risk scores, prevention, and treatment of maternal VTE to promote the prevention and standardized treatment of maternal thrombosis.

METHODS

A retrospective analysis was performed on 7759 patients who gave birth at our hospital from June 2018 to June 2019. Risk factors for pregnancy-related VTE, prenatal and postpartum VTE risk scores, prophylactic anticoagulant therapy, side effects after medication, and morbidity were analysed.

RESULTS

The risk factors for VTE were mainly caesarean delivery, obesity, and advanced maternal age. Regarding pregnancy-related VTE risk scores, there were 7520 patients in the low-risk group with a prenatal score < 3 points and 239 in the high-risk group with a score ≥ 3, and 44 patients received drug prevention and treatment during pregnancy. There were 4223 patients in the low-risk group with a postpartum score < 2 points and 3536 in the high-risk group with a score ≥ 2 points, and 824 patients received drug prevention and treatment for 10 d. Among the patients who did not present with VTE before delivery, we found one case each of pulmonary embolism secondary to lower extremity venous thrombosis, intracranial venous sinus thrombosis, and asymptomatic lower extremity venous thrombosis during the postpartum follow-up.

CONCLUSION

VTE poses a serious threat to maternal safety, and the society should increase its vigilance against pregnancy-related VTE.

Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018

BACKGROUND

Postpartum depression explains various groups of depressive symptoms and syndromes that can take place during the first 6 weeks following birth. The postpartum period is a critical time where both mild and severe mood disorders can occur. The familiar forms are baby blues and postpartum depression. Understanding the prevalence and associated factors of postpartum depression is mandatory for early detection and treatment.

METHODS

Institution based cross-sectional study was conducted from 1st May to June 30, 2018. The study participants were eligible women who came to Debre Berhan referral hospital and health centers for postnatal care and vaccination service. The Edinburgh postnatal depression scale was used to assess postpartum depression. A systematic random sampling technique was used to collect the data after determining the skip fraction (k = 2). The collected data were coded and entered into Epi-info version 7 and transported to SPSS version 20 for analysis. Both bivariate and multivariate binary logistic regression were done to identify associated factors. During bivariate analysis, variables with p-value < 0.05 were included in multivariate analysis. Odds ratios and their 95% confidence intervals were computed and variables with p-value less than 0.05 were considered to declare significantly associated factors (multivariate analysis).

RESULTS

A total of 308 mothers who attended postpartum care we're included, which was a 100% response rate. The prevalence of postpartum depression was found to be 15.6% (95%CI = 11.7, 19.8). Being widowed/widower, having poor social support, having a current hospitalized child, and experienced a death of family member or close relative were significantly associated with postpartum depression.

CONCLUSIONS

The prevalence of postpartum depression was lower than most studies done in different areas. Major life events and traumas are associated with an increased risk of postpartum depression. Health professionals should be aware of the mother's circumstances during the puerperium, they should initiate support to reduce the risk of depression in the postpartum period. Health care professionals working postpartum care clinics should give special attention to mothers who are widowed/widower, have poor social support, have a current hospitalized children, and experienced a death of family member or close relative.