Early Puerperium Research Articles

Monitoring pudendal nerve conduction during labor and early puerperium

Monitoring pudendal nerve conduction during labor and early puerperium

Plasma Concentrations of N-Terminal Pro-B-Type Natriuretic Peptide in Pregnant Women near Labor and during Early Puerperium

B-Type natriuretic peptide (BNP) is considered an important component of the adaptive mechanism that helps reduce the load on the myocardium through systemic vasodilatation, reduction in venous return, and reduction in vascular volume (1). Plasma concentrations of BNP have been shown to reflect cardiac dysfunction and volume overload in adults and children (2)(3)(4). BNP is synthesized in cardiac myocytes as a prohormone, proBNP. The active hormone, BNP, is cleaved and cosecreted from the myocyte along with its N-terminal propeptide (NT-proBNP) (5). NT-proBNP concentrations have been shown to provide information similar to BNP, and the validity of the assay as a clinical tool is well documented (3)(6)(7)(8)(9). Pregnancy represents a state of physiologic volume expansion as maternal blood volume increases ∼40%–45% above nonpregnancy volumes (10). Despite the growing data on the role of BNP in regulation of volume homeostasis, there are few studies regarding its role in pregnancy (11)(12)(13)(14). It has been shown that BNP concentrations are higher in preeclampsia and other hypertensive disorders of pregnancy than in normal pregnancy (11)(12)(14). It has also been suggested that BNP may have a role in regulation of amniotic fluid …

Prevention of postnatal depression

Postnatal depression is the most frequent psychiatric disorder seen after childbirth, with a prevalence rate of 10% to 15%. The women at risk need to be identified by a valid and reliable method, either using a screening instrument or an interview schedule. The preventive strategies need to have enough power to detect a clinically worthwhile effect to be considered useful in clinical practice. Many of the risk factors for developing postnatal depression are present during the pregnancy and immediate post-partum period. The risk factors for postnatal depression include depression or anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, maternity blues, low levels of social support, past history of depression and poor marital adjustment. The antenatal and postnatal period provides an ideal opportunity to screen women for these risk factors. The women identified to be at risk can be identified, and preventive interventions can be implemented. Routine clinical practice can be improved to identify some of the women at risk by better communication between health professionals. There are no antenatal screening tools that have been shown to be of benefit in predicting postnatal depression. Edinburgh Postnatal Depression Scale is widely used in the postnatal period to screen for depression. The psychosocial interventions to prevent postnatal depression have not been shown to be beneficial and there is a dearth of psychopharmacological trials to make firm conclusions about their efficacy in preventing postnatal depression. Individualised psychosocial interventions aimed at the at-risk populations and initiated in the postnatal period appear to have some benefit in preventing postnatal depression. The focus of this article will be the risk factors associated with postnatal depression, screening methods and tools to identify those at risk of developing the disorder and the psychosocial, psychological and psychopharmacological interventions to prevent postnatal depression.

Informative Value of Biochemical Plasma Parameters in Gestosis

Objective: to study the regularities of postpartum blood biochemical changes in varying severity gestosis. Subjects and methods: thirty-five females were examined in the puerperium. Blood was taken on postpartum days 1 and 3—4. The parameters of hepatic and renal function and lipid parameters were determined. Results. Higher levels of creatitine and urea and a more pronounced increase in the concentration of triglycerides and very low-density lipoproteins were observed in moderate gestosis than in normal physiological pregnancy. All the examinees were recorded to have low total protein levels within the first 24 hours after labor. Parturient women with moderate gestosis showed negative changes in protein concentrations throughout the study. Severe gestosis was characterized by multiple increases in bilirubin concentrations and, in case of death, these are also added by higher alanine aminotransferase and aspartate aminotransferase activities. Conclusion. Hypoproteinemia, hypocalcemia, elevated levels of triglycerides and very low-density lipoproteins and a simultaneous decrease in high-density lipoproteins are preserved in moderate gestosis in the early puerperium.

Sensitivity to activated protein C in patients with deep vein thrombosis during early puerperium period

In this study, we used an endogenous thrombin potential (ETP)-based assay to examine the response to activated protein C (APC) during early puerperium of 6 Japanese patients of deep vein thrombosis (DVT) and pulmonary embolism (PE) without a history of familial thrombophilia or antiphospholipid syndrome. The patient group comprised 6 Japanese women diagnosed for DVT or PE at Hamamatsu University School of Medicine, between July 1997 and April 2000. The control group comprised 30 healthy Japanese women in early puerperium. APC-sensitivity ratio (APC-sr), complete blood count (CBC), and other coagulant variables (thrombin-antithrombin-complex (TAT) and fibrin/fibrinogen-degration product (FDP)-D-dimer levels) were determined. Mean APC-sr was 2.0 +/- 0.3 in the control group and significantly higher (3.3 +/- 1.0) in the patient group (P < 0.05). The FDP-D-dimer level was significantly higher in the patient group than in the control group, but there was no significant difference in the TAT complex level. We conclude that sensitivity to APC is reduced in patients with DVT or PE during early puerperium. Although further clinical studies are needed to confirm, it appears that sensitivity to APC detected by ETP-based assay could become a useful marker to estimate the occurrence of DVT or PE.

Postnatal euphoria: are ‘the highs’ an indicator of bipolarity?

Research into postnatal mood disorders to date has concentrated on depressive syndromes of varying severity and full-blown acute puerperal mania. However, clinical experience, backed up by a review of the literature, indicates that milder hypomanic symptoms also occur in the early puerperium. Although these symptoms may often be regarded as clinically insignificant, there is evidence that the experience of minor puerperal elation may be a predictor of later postpartum depression. In addition, studying mild puerperal high mood may provide insights into the pathophysiology of more severe puerperal mania and psychosis. This paper critically reviews the literature on milder forms of high mood occurring in the puerperium and discusses the potential clinical and research significance of 'the highs'.

Anti-Müllerian hormone concentrations in maternal serum during pregnancy

In females, anti-Müllerian hormone (AMH) is expressed only by the ovary. AMH is secreted by the granulosa cells of ovarian follicles and appears to regulate early follicle development. AMH is detected in serum from women of reproductive age and its levels vary slightly with the menstrual cycle, reaching the peak value in the late follicular phase. This study investigated serum AMH levels throughout gestation and after delivery in healthy pregnant women. This cross-sectional study recruited pregnant women and healthy non-pregnant women, 84 in total. AMH, FSH and E2 were measured in the follicular phase, in the three trimesters of pregnancy and in early puerperium. Estradiol and FSH levels followed the expected patterns during gestation. During the follicular phase of the menstrual cycle AMH levels were 1.9 +/- 0.5 ng/ml. In the three trimesters of pregnancy and in early puerperium AMH levels were: 2.1 +/- 0.56, 2.4 +/- 0.64, 1.95 +/- 0.6 and 2.05 +/- 0.55 ng/ml respectively. No significant modifications were found in AMH levels during pregnancy and in the early puerperium. This study has obtained information on AMH and on the possible relationship with FSH. We hypothesize that the profile of the new marker of ovarian activity AMH may indicate that initial non-cyclic ovarian follicular activity during pregnancy is not abolished. Moreover FSH, does not seem to play a direct role on AMH synthesis and secretion.

Bilateral oophorectomy in a pregnant woman: hormonal profile from late gestation to post-partum: Case report

A 16 week pregnant woman presented with massive theca-lutein cysts requiring bilateral oophorectomy. Pregnancy progressed uneventfully and spontaneous lactation ensued after delivery. To study the role of the ovary on the hormonal profile at the end of gestation and in post-partum, we measured FSH, estradiol (E2), unconjugated estrone (E1), unconjugated estriol (E3), sex hormone-binding globulin, progesterone, dehydroepiandrosterone sulphate and prolactin at 37 weeks gestation and at 8 h, 4 days, 5 weeks, and 2 months post-partum. These hormones were within the range expected for ovary-intact pregnant and puerperal women until 4 days post-partum. At 5 weeks post-partum, FSH increased to a peri-menopausal range (31.4 IU/l) while estrogens remained within the normal puerperal range (E2=239 pmol/l; E1=102 pmol/l), contrasting with their rapid changes in non-pregnant women after bilateral oophorectomy. At 2 months, while partially breastfeeding, FSH, E2 and E1 were closer to menopausal range (68 IU/l, 136 and 70.2 pmol/l respectively), and hormone replacement was started. We conclude that the ovary is not required to maintain a normal hormonal profile in late pregnancy and early puerperium. However, the increase in FSH to peri-menopausal levels at 5 weeks post-partum, despite breastfeeding, suggests that the ovary is needed to maintain low FSH concentrations during lactation.

Sensitivity to activated protein C in patients with deep vein thrombosis during early puerperium period

Background. In this study, we used an endogenous thrombin potential (ETP)-based assay to examine the response to activated protein C (APC) during early puerperium of 6 Japanese patients of deep vein thrombosis (DVT) and pulmonary embolism (PE) without a history of familial thrombophilia or antiphospholipid syndrome. Methods. The patient group comprised 6 Japanese women diagnosed for DVT or PE at Hamamatsu University School of Medicine, between July 1997 and April 2000. The control group comprised 30 healthy Japanese women in early puerperium. APC-sensitivity ratio (APC-sr), complete blood count (CBC), and other coagulant variables (thrombin-antithrombin-complex (TAT) and fibrin/fibrinogen-degration product (FDP)-D-dimer levels) were determined. Results. Mean APC-sr was 2.0 ± 0.3 in the control group and significantly higher (3.3 ± 1.0) in the patient group (P < 0.05). The FDP-D-dimer level was significantly higher in the patient group than in the control group, but there was no significant difference in the TAT complex level. Conclusions. We conclude that sensitivity to APC is reduced in patients with DVT or PE during early puerperium. Although further clinical studies are needed to confirm, it appears that sensitivity to APC detected by ETP-based assay could become a useful marker to estimate the occurrence of DVT or PE.

Maternal Thyroid Function during Pregnancy and Puerperal Period

It has been noted that hypothyroidism in pregnant women can adversely affect the children's subsequent psychoneurotic development. Also, transient elevation of serum free thyroxine is occasionally seen in the first trimester of normal pregnancy. However, normal thyroid function during pregnancy and the puerperal period has not been clearly defined in Japan. The aim of this study was to assess maternal thyroid function during pregnancy and puerperal period in Japan. The concentrations of thyroid stimulating hormone (TSH), free triiodo-thyronine (free T(3)), free thyroxine (free T(4)) and thyroid binding capacity (TBC) of 522 normal pregnant and puerperal women (119 in the first trimester; 132 in the second trimester; 135 in the third trimester and 136 in the early puerperium) were measured by electrochemiluminescence immunoassay. We compared the measured data with those of healthy nonpregnant control. Twenty-six (21.8%) of 119 women in the first trimester had lower TSH levels and 23 (16.9%) of 136 women in the early puerperium had higher TSH levels than the normal range of healthy nonpregnant controls. Free T(3) gradually decreased during pregnancy, although it remained within the normal control range. Eight (6.7%) of 119 women in the first trimester had high free T(4) levels, which gradually decreased during pregnancy. Sixty (44.4%) of 135 women in the third trimester had low free T(4) levels. The values of TBC in the second trimester increased compared with the first trimester and did not change in the third trimester and decreased after delivery. There were no correlations between maternal TSH and levels of thyroid hormones (free T(3) or free T(4)), except for TSH and free T(4) in the first trimester. In conclusion, we showed that maternal thyroid function, especially TSH and free T(4), changed during the course of pregnancy. In assessing the thyroid function associated with pregnancy, one needs to keep in mind the tendency toward low free T(4) levels in the third trimester and high TSH levels in the early puerperal period.

Concentration of beta-carotene and vitamin A in blood serum of cows in peripartal period

In a herd of high-productive dairy cows of the Holstein breed, 40 cows were selected for an experiment. The animals were chosen at the period of advanced gravidity. Data on mean values of beta-carotene concentrations in blood serum of the cows show that significantly higher values (p&lt;0.01) were established in advanced gravidity (x=9.53? 3.49 ?mol/l) in comparison with the values on calving day (x=5.69?3.14 ?mol/l) and in early puerperium (x=2.25?1.00 ?mol/l). The average concentration of vitamin A in blood serum of cows varied approximately the same as the concentration of beta-carotene. The highest average concentration of vitamin A in blood serum of cows was determined in advanced gravidity (x=1.856?0.52 ?mol/l), and the lowest in early puerperium (x=0.988?0.31 ?mol/l) (p&lt;0.05). It can be concluded on the grounds of the results obtained in this work that the average concentration of beta-carotene and vitamin A in blood serum of cows in advanced gravidity and on the day of calving is within the limits of physiological values and in keeping with the values cited in literature, and that concentrations of beta-carotene and vitamin A in blood serum of cows two weeks after calving are significantly lower than the values obtained in advanced gravidity and on the day of calving and are lower than the physiological values most often reported in literature for this animal specie.

Cesarea scar hysterotomy. Assessment by 3D transvaginal-echography

Hysterotomy-made scars are a key factor for assessing further gestations in the same patient and so need to be monitored from the early puerperium through a whole year period following surgery. Other monitoring factors involve placenta previa, placenta acreta, ectopic cervical gestation, or uterus tearing both on parturition and at rest. Bidimensional (2D) transvaginal echography has proved a successful method in the detection of scar failures of the myometrium early in the puerperal period and afterwards, or in routine echographic exploration. Furthermore, tridimensional (3D) echography facilitates the monitoring of hysterotomy-made scars whereby total areas and depths of healed versus failing myometrium tissue can be quantified. The combined study of 2D and 3D echographic records may be useful to diagnose wound dehiscence from hysterotomy and to forecast the welfare of future gestations. In that respect, irregular cicatrization patterns can be identified from the early puerperium over the whole postpart...

Antenatal risk factors for postpartum depression: a synthesis of recent literature

Postpartum nonpsychotic depression is the most common complication of childbearing, affecting approximately 10–15% of women and, as such, represents a considerable health problem affecting women and their families. This systematic review provides a synthesis of the recent literature pertaining to antenatal risk factors associated with developing this condition. Databases relating to the medical, psychological, and social science literature were searched using specific inclusion criteria and search terms, in order to identify studies examining antenatal risk factors for postpartum depression. Studies were identified and critically appraised in order to synthesize the current findings. The search resulted in the identification of two major meta-analyses conducted on over 14,000 subjects, as well as newer subsequent large-scale clinical studies. The results of these studies were then summarized in terms of effect sizes as defined by Cohen. The findings from the meta-analyses of over 14,000 subjects, and subsequent studies of nearly 10,000 additional subjects found that the following factors were the strongest predictors of postpartum depression: depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, and a previous history of depression. Critical appraisal of the literature revealed a number of methodological and knowledge gaps that need to be addressed in future research. These include examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers, and the use of appropriate instruments assessing postpartum depression for use within different cultural groups.

Pressão arterial e freqüência cardíaca avaliadas pela MAPA em primigestas durante o trabalho de parto e puerpério imediato

OBJETIVO: analisar os valores da pressão arterial e da freqüência cardíaca durante o trabalho de parto e puerpério imediato de primigestas normais. MÉTODOS: foram incluídas no estudo 60 parturientes, às quais foi aplicada a monitorização ambulatorial da pressão arterial (MAPA) com uso do aparelho modelo SpaceLabs 90207, durante o trabalho de parto e nas primeiras 12 horas após o mesmo. A pressão arterial e a freqüência cardíaca foram registradas a cada 15 minutos durante o trabalho de parto e na primeira hora após o parto, e a cada 30 minutos até a 12ª hora após o parto. Esses parâmetros foram avaliados em três momentos do trabalho de parto (com dilatação cervical até 7 cm, entre 8 cm e dilatação total e durante o período expulsivo) e em dois momentos do puerpério (na primeira e décima segunda hora). Primeiramente os resultados foram analisados sem levar em consideração o tipo de procedimento anestésico, e depois, dividindo-os em grupos conforme o tipo de procedimento realizado: anestesia local, analgesia peridural lombar e anestesia subaracnóidea. Para comparação dentro de cada grupo foram realizados análise de variância (ANOVA) e teste t de Student pareado e, entre os grupos, o teste t não-pareado. Foi considerado o limite de significância estatística de 5%. RESULTADOS: quando os resultados foram avaliados sem levar em consideração o procedimento anestésico, os valores médios da pressão arterial sistólica, registrados durante o trabalho de parto, foram significativamente mais elevados que no puerpério. Durante o trabalho de parto esses valores foram significativamente mais elevados nos períodos de dilatação final e expulsivo que no período de dilatação inicial e, na 12ª hora, inferiores ao da primeira hora após o parto. Os valores médios da pressão arterial diastólica registrados durante o trabalho de parto foram significativamente mais altos que no puerpério. Estes valores não apresentaram alteração durante os diferentes períodos do trabalho de parto ou durante as primeiras doze horas do puerpério. A freqüência cardíaca aumentou progressivamente durante o trabalho de parto, diminuindo nas primeiras 12 horas após o parto. Quando a pressão arterial e a freqüência cardíaca foram avaliadas conforme o tipo de procedimento anestésico empregado, ambas mostraram-se com mesmo comportamento na anestesia local e peridural, embora naquelas submetidas à anestesia subaracnóidea, tanto a pressão arterial sistólica como a diastólica não apresentaram alteração durante o trabalho de parto. CONCLUSÕES: o trabalho de parto determinou aumento da pressão arterial sistólica e da freqüência cardíaca. Durante o trabalho de parto os valores das pressões arteriais sistólica e diastólica foram mais altos que nas primeiras 12 horas do puerpério, havendo queda significativa entre a primeira e a décima segunda hora do mesmo. Diferentes procedimentos anestésicos não interferiram nos valores das pressões arteriais sistólica e diastólica ou da freqüência cardíaca, durante o trabalho de parto e nas primeiras doze horas após o parto.

Lactating Vulva Mammary Tissue in a Nigerian

Forty one cases of ectopic mammary gland in the vulva have been reported since 1872. Ectopic mammary tissue is subject to the physiologic and pathologic changes that occur in the orthotopic breast. We report on a case of a 33 year old woman with a cystic mass in the right labium majus that developed rapidly in the early puerperium following her 5th confinement. Histology of the completely excised cyst revealed a secretory mammary tissue. There was no recurrence ten months after surgery while breastfeeding. Key Words: lactation, vulva, Mammary tissue, Nigerian Nig. Medical Practitioner Vol. 44(3) 2003: 50-51

Myocardial Infarction and 5,10-Methylenetetrahydro folate Reductase Gene Mutation

A 40-year-old woman with previous venous thrombosis in the lower limbs had recurrent myocardial infarction in the early puerperium. The only documented risk factor was an elevated level of plasma homocysteine, associated to a heterozygotic anomaly in the enzyme responsible for its metabolism, 5,10-methylenetetrahydrofolate reductase. The case and approaches to treatment are discussed.

Reference intervals for plasma levels of fibronectin, von Willebrand factor, free protein S and antithrombin during third-trimester pregnancy

Wickström K, Edelstam G, Löwbeer Ch, Hansson L-O, Siegbahn A. Reference intervals for plasma levels of flbronectin, von Willebrand factor, free protein S and antithrombin during third-trimester pregnancy. Scand J Clin Lab Invest 2004; 64: 31-40.During pregnancy, significant changes occur in the hemostatic system and in the plasma levels for several plasma proteins, especially towards term. In this study changes occurring during normal pregnancy and immediately postpartum were investigated to establish adequate reference intervals for important hemostatic parameters. Blood samples were collected during pregnancy weeks 33, 36, 39 and 1-3 h after delivery from 153 healthy pregnant women with at least one previous normal pregnancy. The plasma samples were analyzed for antithrombin, von Willebrand factor (vWf), free protein S and flbronectin. Fibroncctin and vWf are contact-promoting proteins responsible for adhesion and aggregation during primary hemostasis, but are also released from thrombocytes during activation of the coagulation process. Antithrombin is the most important primary physiological inhibitor of activated serine proteases related to the coagulation cascade. Protein S is a co-factor to protein C and in cooperation is also an important inhibitor of the coagulation cascade. During third-trimester pregnancy, vWf was higher than in non-pregnant women, and continued to increase postpartum. The flbronectin plasma level was mostly unchanged in comparison with non-pregnant values. Within this reference interval it gradually increased during the third trimester, but fell slightly postpartum. Antithrombin decreased slightly during the third trimester and even further, postpartum. Free protein S decreased markedly but to a stable level from week 33 to 39, decreasing even more postpartum. The present results are concordant with clinical knowledge of increased risk of thrombosis during pregnancy and early Puerperium, with increased levels of vWf and fibronectin and decreased levels of antithrombin and free protein S. Clearly, current reference values based on healthy non-pregnant subjects are not usable during late pregnancy and immediately postpartum.

Maternal serum interleukin-1β, -6 and -8 levels and potential determinants in pregnancy and peripartum

To measure maternal serum interleukins (IL) in pregnancy, delivery and early puerperium, and to identify their potential determinants. Prospective longitudinal measures of serum IL-1 beta, IL-6 and IL-8 in 38 healthy pregnant women at antenatal visits, through labor and delivery, with clinical correlates (infection, vaginal hemorrhage and anemia) recorded by questionnaire. Pregnancy IL levels remained consistently low. IL-1 beta increased shortly before delivery, then returned to pregnant levels, except where blood loss exceeded 500 ml. IL-6 and IL-8 rose at labor onset and exceeded pregnancy levels through postpartum day three. Postpartum IL-6 was higher after non-elective cesarean section than after spontaneous delivery (P < 0.0001), and where blood loss exceeded 500 ml. IL-6 and IL-8 were higher with systemic infection during delivery (P < 0.0001) and on postpartum day one (P < 0.05); IL-8 was higher in anemia (delivery: P < 0.005; postpartum day 1: P < 0.05). Differences due to delivery mode and systemic infection remained significant after correction for other conditions. Labor-dependent inflammation increases all IL levels at delivery. Further studies with larger sample sizes are required to establish reference values differentiating physiology from pathology as an aid to peripartum management.

Velocimetría Doppler transcraneal en gestantes y posteriormente puérperas normotensas

The physiological changes that take place in blood flow in the brain during pregnancy and the puerperium are still only poorly understood. The harmlessness of transcranial Doppler (TCD) makes it a suitable method of study. The purpose of this study was to determine the TCD velocimeter reading at the end of pregnancy and in the early puerperium of healthy expectant mothers. TCD was used to perform a bilateral study of the anterior (ACA), middle (MCA) and posterior cerebral arteries (PCA). Arterial blood pressure and haematocrit were also measured. Mean velocity (MV), the pulsatility index (PI), mean arterial blood pressure and haematocrit were employed as variables in the statistical analysis. Results from 44 normotensive pregnant women in the latter stages of gestation (week 33 to term) were compared with those of a control group made up of 58 women of a similar age, who were normotensive and not pregnant. The study was repeated in the group of pregnant women during the early puerperium (the first five days after labour) and the two different results were compared. Age and MAP were similar in the gestating and non-gestating groups. Haematocrit was significantly lower in the former (p < 0.001) and MV were significantly lower in the pregnant women in all the arteries (p < 0.001), whereas the PI were also significantly lower in four of the six territories that were studied (p < 0.005). During the puerperium, a significant rise in MV was observed in all the arteries (p < 0.001) and the PI increased in three of them (p < 0.05). In this phase, the mean arterial pressure rose (p < 0.05), although haematocrit levels dropped (p < 0.001). The low MV and PI seen at the end of pregnancy are compatible with cerebral vasodilatation. MV increase during the early puerperium and is probably linked to a relative hyperperfusion.

Preeclampsia grave síndrome HELLP posparto

This article describes a case of HELLP Syndrome in the early puerperium, which later became more complicated as the patient developed a post-caesarean section abdominal wall abscess.Both perinatal and maternal results were excellent.