Early Puerperium Research Articles

Cortisol levels in saliva and mood changes in early puerperium

Cortisol levels in saliva were measured in 22 women, daily from the 2nd to 7th day after they had given birth and in 7 control women for 6 consecutive days. During the same period the mothers filled out a mood self-rating scale. The cortisol levels of the mothers were higher than those of the controls and progressively decreased after birth except for the 4th day post-partum when there was an increase. Five mothers had post-partum blues, but their cortisol levels were not different from those of other mothers. However, there was a significant correlation between cortisol level and the mood of mothers who bottle fed their babies.

Cardiopulmonary bypass in the early puerperium: Possible new role for aprotinin

A case of successful emergency reoperation for mitral valve replacement 2 hours after a cesarean section is reported. The use of aprotinin (Trasylol; Bayer AG, Leverkusen, Germany) greatly simplified the surgical procedure and was in our opinion the most important factor in an uncomplicated outcome.

Post partum blues: Depressive disease or pseudoneurasthenic syndrome

Depressive mood disorders following childbirth can be quantified with self-rating and observer-rating scales. During two months, in the period from November 1989 to March 1990, women admitted to the obstetric unit of the University of Würzburg were examined on days 3 and 5 post-partum with the Hamilton Psychiatric Rating Scale for Depression, the Montgomery-Åsberg-Depression-Rating-Scale and the Befindlichkeits-Scale by von Zerssen. Results reveal that during the early puerperium, scores on these scales rarely reach the same severity as in major depressive disorder. The clinical picture is no different from emotional-hyperaesthetic hyposthenia following other kinds of physical illness such as endocrine disorders.

Increased whole blood platelet aggregation in normal pregnancy can be prevented in vitro by aspirin and dazmegrel (UK38485).

To determine the effect of normal pregnancy and the early puerperium on whole blood platelet aggregation and to assess the role of thromboxane A2 (TXA2) in platelet aggregation in pregnancy. A prospective descriptive study. TCD Medical School, St James's Hospital, Dublin. Twenty healthy primigravidae who remained normotensive during pregnancy and the puerperium. 20 ml blood samples were obtained serially at 12, 20, 28, 32 and 36 weeks gestation, during established labour and at 1 h, 24 h, 48 h and 6 weeks after delivery. Whole blood platelet aggregation in response to aggregating agents ADP, PAF (platelet aggregating factor) collagen, adrenaline and arachidonic acid (AA) at each stage of pregnancy and peuerperium was measured using a particle counting technique. The in vitro effect of aspirin and dazmegrel (thromboxane synthetase inhibitor UK38485) on platelet aggregation in pregnancy was also investigated. Platelet aggregation in response to collagen, adrenaline, ADP and AA were increased in the last trimester, during labour and at 1 h after delivery but decreased 24-48 h after delivery. Platelet aggregation in response to AA, collagen and adrenalin was reduced by both aspirin and dazmegrel. The earliest and most marked increases in platelet aggregation during normal pregnancy were found in response to AA and collagen. These platelet changes were prevented when whole blood was pre-incubated with either aspirin or dazmegrel. This suggests that enhanced production of TXA2 is responsible for increased platelet reactivity in normal pregnancy.

Disturbances in dexamethasone suppression test and lower availability of Ł-tryptophan and tyrosine in early puerperium and in women under contraceptive therapy

This study investigates the function of the hypothalamic-pituitary-adrenal (HPA)-axis and the availability of L-tryptophan and tyrosine to the brain in postpartum women and in women taking long-term oral contraceptives. To this end, we have measured the following parameters in 50 women (i.e. 9 normal controls, 10 women taking oral contraceptives, and 31 postpartum females): plasma cortisol, L-tryptophan, tyrosine and the amino acids (CAA) known to compete with them for transport through the blood-brain barrier. We have determined the effects of 1 mg of dexamethasone on the above-mentioned biological markers in postpartum females. Plasma cortisol and tyrosine were significantly higher and lower, respectively, in puerperium and in women under contraceptive therapy as opposed to normal controls. L-Tryptophan was significantly lower in postpartum females, whilst the L-tryptophan/ CAA ratio did not differ across the three study groups. Postpartum females revealed a significant negative relationship between the availability of L-tryptophan to the brain and postpartum mood, as measured by Zung's Depression and Anxiety Scales and State Anxiety Inventory. Dexamethasone had a significant suppressive effect on L-tryptophan/CAA and tyrosine/CAA ratios, with cortisol non-suppression appearing in 82% of the postpartum females.

The course of labor in intrauterine fetal death

The results of the course of birth in 71 intrauterine cases of foetal death are presented. There were spontaneous deliveries in 82% of the cases and in 4% a vacuum extraction was performed. The relatively high rate (14%) of Caesarean sections was in most cases, due to maternal indication. The introduction of prostaglandins was a significant progress factor in birth induction of these disturbed pregnancies. All 36 patients (51%) were treated with sulprostone (mostly intravenously). Furthermore, intrapartal, directly postpartal complications and complications of early puerperium are discussed.

Ogilvie's syndrome

Four cases of Ogilvie's syndrome (acute colonic pseudo-obstruction) are reported. All occurred in the early puerperium following cesarean section and cesarean hysterectomy. In three of the patients, the diameter of the distended cecum was less than 9.0 cm and so management was conservative while in the fourth patient it was more than 9.0 cm, and so surgical intervention was carried out. A cecal diameter of 9.0 cm or above is an indication for surgical intervention to prevent possible colonic perforation. Other indications for surgery include established cecal perforation and failed conservative management. It is important that an early diagnosis is made and management instituted in order to prevent complications and associated high mortality.

Experiences of childbirth in Natal Indian women

Through fifteen in-depth case studies of primipara, Natal Indian women's experiences of childbirth have been described. Common problems were identified, including lack of a family support person throughout labour, lithotomy position for delivery, episiotomies and their sequelae, breast-feeding difficulties and lack of professional support in the early puerperium at home. Preparation for common medical interventions in labour, breast-feeding and parenting appeared inadequate. Pertinent sociocultural aspects have been identified. These include continuing family support and culturally prescribed behaviour pertaining most importantly to the early puerperium and affecting the maternal-neonatal dyad. In the early adaptation to motherhood informants continued their role as daughter or daughter-in-law and would only actively continue their role as wife later or at the end of the puerperium. These traditional patterns of behaviour persist despite marked changes in educational level, language spoken and employment status. In the light of this research and founded on scientific evidence, a number of recommendations are made and areas for further research are identified.

Duplex ultrasound of the common femoral vein in pregnancy and puerperium

The common femoral veins of 34 apparently normal women were examined by ultrasound during or just after pregnancy. The cross sectional areas of these veins were measured at rest in the supine position and during a Valsalva manoeuvre. The veins were also assessed by pulsed Doppler ultrasound. We believe that Doppler examination is superior to calibre response assessment during the Valsalva manoeuvre in excluding an isolated iliac occlusion in women in late pregnancy and in early puerperium.

Prospective Study of Postpartum Blues

Potential biologic and psychosocial causative factors for the postpartum blues were tested in a prospective study of 182 women followed up from the second trimester of pregnancy until postpartum week 9. Personal and family history of depression, depressive symptoms, stressful life events, and social adjustment were all assessed during the second trimester. Levels of progesterone, prolactin, estradiol, free and total estriol, and free and total cortisol were measured on several occasions during late pregnancy and early puerperium. Obstetric and child-care stressors and the postpartum blues were assessed after delivery. Predictors of the postpartum blues were personal and family history of depression, social adjustment, stressful life events, and levels of free and total estriol. Our results support the hypothesis that the postpartum blues is within the spectrum of affective disorders.

Studies on the Leucogram of Female Camels (C. dromedarius) at Various Reproductive Phases

Contents: The leucocytic picture in 90 mature, healthy dromedary‐cows, representing the different reproductive phases, as well as, the non‐cyclic one, was determined. The non‐cyclic camels possess high total leucocytic count (15.5 × 10 3 /cm 3 ) compared with other ruminants. Moreover, neutrophilic domination (58.7%) with increased N/L ratio (1.5) in camels is not typical for other quadrupeds. At oestrus, there was a mild neutrophilia, eosinopenia and lymphopenia (61.1%, 0,4% and 37,4%, respectively versus respective values of 58.7%, 0, 7% and 39, 7% in non‐cyclic camels). However, the total number of leucocytes was reduced (13.7 vs. 15.5 × 103/cm3). A steady neutrophilia, eosinophilia and lymphopenia was associated with advancement of gestation in camels. An exceptional transient leucocytosis (P<0.05), with elevation in the lymphocyte proportion, occurred during the 9thand 10thmonth. At the preparturient period, a significant (P < 0.01) leucopenia, with neutrophilia (P < 0.01), lymphopenia (P < 0.05), and eosinopenia were reported. During early puerperium, the dromedary's leucogram revealed a typical moderate hematologic response to stress, manifested by lymphopenia (P < 0.01), eosinopenia (P < 0.05) and neutrophilia (P < 0.01) resulting in leucocytosis (P < 0.05).

Pulsatile Secretion of Luteinizing Hormone and Prolactin in Lactating and Nonlactating Women and the Response to Naltrexone

To investigate the mechanisms responsible for the postpartum suppression of reproductive function, LH and PRL levels were determined at 10-min intervals for 8 h in 10 lactating women, in 10 nonlactating women treated with bromocriptine, and in 5 nonpuerperal women. The lactating women were studied on postpartum day 7 (n = 5) or between days 28 and 35 (n = 5). All nonlactating women were studied on day 7. Five of them were treated with the opioid antagonist naltrexone to evaluate the role of endogenous opioids. By using a specific LH assay which does not cross-react with hCG, we were able to measure pulsatile LH secretion in the early puerperium for the first time. On day 7, LH levels were below the detection limit in both lactating and nonlactating women, hence no pulses could be detected. Chronic opioid blockade in bromocriptine-treated non-lactating women did not result in increased LH levels. Pulsatile LH secretion was present between days 28 and 35 of lactation, although pulse amplitude (P less than 0.05) and mean LH level (P less than 0.05) were lower than in nonpuerperal women. Mean LH in lactating women was negatively correlated with mean PRL (-0.87, P less than 0.05). Deconvolution analysis of the PRL responses to suckling revealed that PRL was secreted in distinct bursts, separated by intervals of secretory quiescence. Mean duration of PRL bursts was 40 +/- 4 min and the maximum secretory rate was reached around the end of suckling. We conclude that pulsatile LH secretion is completely suppressed during early lactation and partially suppressed during late lactation. Because the duration of suckling was similar, the relatively strong suppression during the early puerperium must be due to additional inhibitory factors. It has been suggested that endogenous opioids are involved in this process, but our results in puerperal women do not support this hypothesis.

Risk-Benefit Assessment of Anaesthetic Agents in the Puerperium

A critical evaluation of anaesthetic agents in the puerperium is difficult because systematic, relevant studies are still lacking. Current knowledge of the effects of different agents used in labour and caesarean section indicates that significant residual effects on the mother and newborn are limited. In the early puerperium, based on physiological and/or hormonal changes, the mother could be more sensitive to inhalational anaesthetic agents and local analgesics. To date there is no evidence that any anaesthetic agent is excreted in breast milk in clinically significant amounts when given as a single dose. The only exception is perhaps in the case of very premature neonates whose mothers have had multidrug therapy before labour. Even then the importance of breast milk should be carefully assessed against possible adverse drug effect. However, repeated administration of long-acting benzodiazepines and continuous epidural administration of pethidine (meperidine) can have adverse effects on the neonate. The essential conclusion of this review is that breast-feeding is best. The different anaesthetic agents are excreted in the milk in amounts so low that detrimental effects on the neonate should not be expected.

Increased 6-Hydroxycortisol Excretion in Pregnant Women: Implication of Drug-Metabolizing Enzyme Induction

The effect of pregnancy on hepatic drug-metabolizing enzyme activity was investigated in nine healthy pregnant women using the ratio of 6-hydroxycortisol (6-OHF), to total 17-hydroxycorticosteroid (17-OHCS) in 24-hour urine as an index of the hepatic monooxygenase activity. The values of 6-OHF and the ratio (713 +/- 250 micrograms/d and 0.323 +/- 0.242; mean +/- SD) before delivery were significantly higher than they were during early puerperium (395 +/- 145 micrograms/d and 0.114 +/- 0.055) and approximately three months after delivery (237 +/- 67 micrograms/d and 0.066 +/- 0.034). Although the values three months after delivery were comparable to those found in the nonpregnant group (n = 10; 228 +/- 48 micrograms/d and 0.081 +/- 0.031), 6-OHF values one week after delivery were significantly higher than those observed in the control group. These observations suggest that drug-metabolizing enzyme induction may occur during pregnancy.

Gestational diabetes mellitus: The prevalence of glucose intolerance and diabetes mellitus in the first two months post partum

To determine the prevalence of abnormal carbohydrate metabolism in the early postpartum period in women with gestational diabetes mellitus, we performed 2-hour oral glucose tolerance tests between 5 and 8 weeks post partum in 246 women with recent gestational diabetes mellitus. Patients were stratified into three study groups based on their fasting serum glucose level during pregnancy: (1) group A1: all fasting serum glucose levels during pregnancy less than 105 mg/dl without insulin therapy; (2) group A2: any fasting serum glucose levels greater than 105 and less than 140 mg/dl before insulin therapy; (3) group B1: any pregnancy with fasting serum glucose levels greater than 140 mg/dl. Overall, 48 (19%) of the patients had an abnormal oral glucose tolerance test in the early postpartum period; 25 (10%) had impaired glucose tolerance and 23 (9%) had diabetes mellitus. The prevalence of postpartum diabetes mellitus (2% in group A1, 9% in group A2 and 44% in group B1) increased in parallel with the degree of maternal metabolic decompensation during pregnancy (p less than 0.05 for A1 versus A2; p less than 0.001 for A2 versus B1). The prevalence of impaired glucose tolerance was likewise greater in the B1 group (26%) than in either the A1 or the A2 group (p less than 0.05). Gestational age less than 24 weeks at diagnosis of gestational diabetes mellitus was an additional risk factor for postpartum glucose intolerance. Our findings support the use of an oral glucose tolerance test in the early puerperium, especially for patients with elevated fasting serum glucose levels during pregnancy.

Oxytocin Infusion During Second Stage of Labour in Primiparous Women using Epidural Analgesia

OBJECTIVE--To determine whether the high rate of forceps delivery associated with the use of epidural analgesia could be reduced through giving an intravenous infusion of oxytocin during the second stage of labour. DESIGN--A randomised, double blind, placebo controlled trial. SETTING--Delivery suites in three hospitals. SUBJECTS--226 Primiparous women with adequate epidural analgesia in whom full dilatation of the cervix had been achieved without prior stimulation with oxytocin. INTERVENTION--An infusion of oxytocin or placebo starting at the diagnosis of full cervical dilatation at an initial dose rate of 2 mU/min increasing to a maximum of 16 mU/min. MAIN OUTCOME MEASURES--The outcome of labour was assessed in terms of the duration of the second stage, mode of delivery, fetal condition at birth, postpartum blood loss, and the incidence of perineal trauma. RESULTS--Treatment with oxytocin was associated with a shorter second stage (p = 0.01), a reduction in the number of non-rotational forceps deliveries (p = 0.03), and less perineal trauma (p = 0.03) but was not associated with any reduction in the number of rotational forceps deliveries performed for malposition of the occiput. No adverse effects on fetal condition at birth or in the early puerperium were seen in association with the use of oxytocin. CONCLUSIONS--The use of an oxytocin infusion may reduce the high rate of operative delivery associated with epidural analgesia provided that the fetal occiput is in an anterior position at the onset of the second stage of labour but within the dose range studied does not seem to correct malposition of the fetal occiput.

The Choice of Suture Materials and Techniques for Repair of Perineal Trauma

Summary A systematic review of the 14 relevant controlled trials was conducted because there is no agreement about the choice of material and technique for repair of perineal trauma sustained during childbirth. Derivatives of polyglycolic acid (marketed as Dexon and Vicryl) appear to be the absorbable material of choice for both deep and skin closure. Compared with catgut their use is associated with about a 40% reduction in short-term pain and need for analgesia. The main drawback is that some material often needs removal during the puerperium. Glycerol-impregnated catgut is ruled out because of its link with longterm dyspareunia. Compared with the non-absorbable materials (silk and nylon) polyglycolic acid skin sutures were associated with less shortterm perineal pain, and had no clear disadvantages. Continuous, subcuticular stitching appears preferable to interrupted, transcutaneous suturing, particularly in terms of perineal pain in the early puerperium.

Emotional Changes in Pregnancy and Early Puerperium Among the Yoruba Women of Nigeria

A randomly selected clinic population of 400 pregnant women in Ile-Ife, Nigeria, were interviewed for complaints of psychological disorders during the last trimester of pregnancy and the post-partum period. The study shows a considerable degree of psychological disturbances during pregnancy which later decreased significantly during the post-partum. While the complaints of worrying, guilt-feeling, nausea and vomiting and "heat in-the-head", were significantly more common in younger women, insomnia and anorexia were more common in older women. The incidence of psychological complaints among the women decreased with increasing parity. There was no significant difference in the incidence between women with monogamous and polygamous marriages.

Influence of parity on plasma lipid levels

Plasma levels of total cholesterol (TC), HDL cholesterol (HDLC) and LDL cholesterol (LDLC), triacylglycerols (TG) and apoprotein (apo) A-I, A-II and B were measured in 516 women in the early puerperium. Different lipid plasma values (TC: 5.98 ± 1.17 mmol l , LDLC: 3.79 ± 1.12 mmol l , apo B: 108 ± 24 mg/dl) and ratios ( LDLC HDLC : 2.85 ± 1.09 ) were significantly (p < 0.02) lower after the first pregnancy (n = 209) than after five or more pregnancies (n = 15) (TC: 6.50 ± 2.10 mmol l , LDLC: 4.36 ± 1.97 mmol l , apo B 130 ± 50 mg/dl, LDLC HDLC : 3.44 ± 0.89 ). The opposite was true for the HDLC TC ratio which was significantly lower (p < 0.02) after five or more pregnancies (20.0 ± 3.5) than after the first pregnancy (24.1 ± 6.6). We also found a significant correlation (p < 0.02) between the TC, LDLC, apo B and LDLC HDLC ratio levels and parity. Other factors which could interfere with lipid metabolism (diet, body/mass index smoking, physical activity, alcohol intake) were not different between the various parity groups. Hence, we could not find a reason for the lipid elevation after the subsequent pregnancies. Although the higher lipid levels in puerperium of multipara should indicate a higher risk for progression of atherosclerosis, we need more studies before to conclude that multiparity influences the risk for coronary heart disease.

Metabolic Balance and Reproductive Performance in Finnish Dairy Cows

The relationships between energy level and reproductive performance were studied in 24 dairy cows, which were fed grass silage. Serum glucose and blood acetoacetate (AA) and beta-hydroxybutyrate (HB) were measured 10, 15, 30 and 50 days postpartum. The cows were examined clinically by rectal palpation 3 times a week during 8 weeks postpartum. The time required for the complete uterine involution and the onset of ovarian activity were recorded. The pregnancy rate at the first insemination and the interval from calving to conception were obtained for each cow. The correlations between blood glucose and ketone bodies were negative, but they were significant only at days 15 and 30 for AA and at day 30 for HB. A low energy level in early puerperium caused a delay in uterine involution and in the onset of ovarian activity. The low energy balance in puerperium prolonged the interval from calving to the first insemination and the interval from calving to conception. The earlier the ovarian activity started the shorter was the interval from calving to conception. The energy level in early puerperium had a greater influence on the interval from calving to conception, whereas in late puerperium it was more important with regard to the interval from calving to the first insemination. Blood glucose had also a significant effect on the reproductive performance. The adverse influence of ketone bodies on fertility depended on duration and timing of their increased levels; the longer and later in puerperium the cow has elevated ketone bodies, the lower is the fertility.(ABSTRACT TRUNCATED AT 250 WORDS)