Postpartum Setting Research Articles

Reciprocal Peer Support for Post-partum Patients with Diabetes: A Needs Assessment for the Diabetes Buddy Program.

While peer support has been investigated in multiple clinical contexts, its application to the postpartum setting is unknown. The aim was to assess acceptability of a postpartum peer support program for women with diabetes. Observational survey-based needs assessment of forty low-income women with diabetes, receiving care at a major medical institution. Mean age and gravidity were 30.7 years and 3.15 ± 1.67 respectively. 45 % expressed interest in a "buddy." There was no significant difference between groups desiring and not desiring this program. A majority of respondents desired telephone, text messaging, and in-person contacts (79.2, 72.1, 83.8 %), with 72.5 % of patients desiring diabetes-related activities during clinic waiting time. Many women desire a postpartum diabetes reciprocal peer program for support outside of clinician visits. Patients are receptive to educational services during their wait and outside of clinic time, a potentially valuable opportunity to share important health information.

Pneumocephalus associated with epidural and spinal anesthesia for labor.

Headache resulting from dural puncture in epidural and spinal anesthesia is usually secondary to a CSF leak. Pneumocephalus may also occur in this setting but has not been well-characterized. Although the risk factors for a CSF leak and pneumocephalus may overlap, their rates, clinical features, and treatments may be different. Our retrospective review of 182 patients with acute headache in the antepartum, peripartum, and postpartum settings yielded a 5:1 ratio of postdural puncture headache to pneumocephalus. The 3 patients with pneumocephalus had the defining characteristic of thunderclap headache during anesthesia. Early diagnosis is helpful as treatment with supplemental oxygen may hasten recovery. Pneumocephalus should be considered as a possible etiology of thunderclap headache in the setting of epidural and spinal anesthesia.

Serotonin Syndrome in Pregnancy

Millions of people take selective serotonin reuptake inhibitors (SSRIs) for depression and anxiety, so nurses and other clinicians need to be aware of the potential for serotonin toxicity and serotonin syndrome. These conditions can occur when women taking SSRIs are given additional medications in the labor and birth or postpartum settings. Symptoms can have an acute onset and can include delirium, fever and hypertension. Understanding the mechanism and symptoms of serotonin syndrome can lead to timely treatment of this unusual condition.

The Use of Pasteurized Donor Human Milk for Late Preterm Infant Supplementation

Poster Presentation Purpose for the Program Late preterm infants (LPIs) are born between 34 and 36 6/7 weeks of gestation. They comprise a unique population requiring enhanced awareness of transition, infection, nutrition, discharge readiness, and parent education that needs to begin shortly after birth. At Sharp Mary Birch Hospital for Women and Newborns we have on average of 60 to 80 late preterm births per month. Approximately 50% of those newborns go to the NICU, whereas the other half are cared for in the postpartum unit. Caring for LPIs in a postpartum setting comes with its own set of challenges. Although we had specific late‐preterm guidelines in our newborn guidelines of care, policies and order sets were all primarily developed with the term infant in mind, which caused inconsistencies in the care provided and on occasion led to hospital readmission of the late‐preterm infant. Proposed Change To develop more targeted guidelines, clear late preterm orders, streamlined supplementation protocols, and discharge criteria that are specific to late preterm infants. Implementation, Outcomes, and Evaluation The project had several phases. Our team completed the following: We developed educational materials for the nurses, families and physicians to raise awareness of the unique circumstances surrounding the LPI. We revised policies and procedures relating to newborn care, feeding, and supplementation of infants to reflect best practice for the LPI. We created a separate supplementation policy for LPIs and developed individual feeding management guidelines for LPIs with optional donor milk supplementation. We edited the Nursing Guidelines of Care to include more detailed information relating to LPIs. We restructured the newborn admission orders to include specific orders to address the unique nature of LPIs. Newborn orders now have a nested late‐preterm newborn orders subset. Implications for Nursing Practice Implementing these specific interventions had measurable positive effects on the late preterm newborn population at Sharp Mary Birch. Our utilization of donor milk was well received by staff and patients. Readmission rates to the NICU have steadily decreased. As a result of the improved care provided, the readmission rate of LPIs to the NICU had decreased 40% in the past 24 months based on the equivalent ratios 0.3 to 0.18 = 100% to 60%.

Pelvic Artery Embolization in the Management of Obstetrical Hemorrhage: Predictive Factors for Clinical Outcomes.

To evaluate clinical outcomes of pelvic artery embolization (PAE) for treatment of obstetric hemorrhage, and determine the predictive factors associated with failure. This retrospective study included all consecutive patients who underwent PAE for obstetric hemorrhage (not only in the post-partum setting), between January 2003 and January 2013 at three tertiary care centers. Medical records and imaging were reviewed to identify the study population and collect data on patient characteristics, PAE characteristics, and outcomes. Multiple parameters were compared between the failed and successful PAE groups, and univariate analysis was performed to determine the predictive factors for PAE failure. A total of 74 PAE procedures were performed in 68 patients. Primary clinical success rate was 78%. On univariate analysis, three factors were associated with PAE failure: hemodynamic instability (p < 0.022), hemoglobin level <95 g/dL (p < 0.024), and disseminated intravascular coagulation (DIC) (p < 0.046). Other factors, including maternal characteristics, antecedent history, angiographic finding, embolic agent, operator experience, procedure done after hours, and unilateral versus bilateral embolization, did not show any statistically significant association with PAE failure. Only one major complication was encountered, which was fetal demise in a pregnant patient with a uterine arteriovenous malformations. Out of the 68 patients, there were 61 total pregnancies at follow-up. PAE is an effective treatment for obstetric hemorrhage, with a low complication rate, and preserves fertility. Factors significantly associated with PAE failure include hemodynamic instability, hemoglobin level <95 g/dL, and DIC.

A prolonged second stage should prompt increased vigilance for postpartum maternal complications.

Gone are the days when the quality of our craft was judged solely at the moment a crying baby was placed in her mother's arms. The modern obstetrician is now charged with considering how each clinical decision may impact the reproductive health of our patients and communities in the long term, and nowhere is this more evident than in the recent campaign to prevent the first caesarean delivery. Amongst the modifiable variables that clinicians are asked to reconsider as they manage labour is the duration of the second stage, which some now recommend we allow to proceed for up to 4 hours in nulliparous women with epidurals, as long as descent or rotation have occurred (Spong et al. Obstet Gynecol 2012;120:1181–93). Whereas quality evidence suggests that 80–99% of women with a prolonged second stage will achieve a vaginal delivery (Laughon et al. Obstet Gynecol 2014;124:57–67), the question remains: at what cost? Although other researchers have measured the association between prolonged second stage and adverse neonatal or intrapartum maternal outcomes, Stephansson and colleagues provide answers to a missing piece: the association between prolonged second stage and adverse maternal outcomes in the postpartum setting. The authors levy the strength of a robust Swedish database in which clinical data, including the partograph, are collected prospectively from all maternity units in the region and forwarded to a central database on a daily basis. From a study population of 72 593 women they identify increased risks of any postpartum complication (infection, urinary retention, haematoma, or ruptured sutures), which increase for most strata with every additional hour of the second stage. As with any observational study, we must consider the ways in which bias, often entirely unintentional, may impact the reported associations. Is selection bias, information bias, or confounding present? If not, could the results arise from chance (Schulz et al. The Lancet Handbook of Essential Concepts in Clinical Research, 2006)? With this work, there is little risk of selection or information bias, as deliveries are recorded prospectively and prior to study design, and the only excluded cases are those in which partograph data are not available. There is however concern for residual confounding, as the authors themselves note. For example, chorioamnionitis was not included in the multivariate analysis because of underreporting in the discharge diagnoses, as described by the authors. This is associated with a prolonged second stage, and may also increase the risk of a postpartum diagnosis of infectious morbidity. Finally, could the results arise from chance? Given the robust size of the study population, the authors are able to identity very small but statistically significant differences between most of the subgroups. When interpreting Stephansson's data in the setting of a prolonged second stage, the clinician must consider not only odds ratios but also absolute risks. These data should not be used to discourage vaginal birth after caesarean, for example, as the absolute risk of complications remains low. Stephansson and colleagues should be commended for their contribution to our understanding of maternal morbidity following a prolonged second stage. No conflicts of interest to report.

Increasing LARC utilization: any woman, any place, any time.

Intrauterine contraceptive devices and the progestin implant are the most effective long-acting reversible contraception (LARC) methods available for preventing unintended pregnancy. LARC devices are safe, non-user-dependent methods that have the highest rates of continuation and satisfaction of all reversible contraceptives. Use of these contraceptives remains low in the United States due to several barriers including: misperceptions among both providers and patients; cost barriers; and patient access to the devices. Increasing the opportunities for women to access LARC methods in the primary care, postabortion, and postpartum setting can be achieved by addressing the system, provider, and patient barriers that exist.

Interventional Algorithms for the Control of Coagulopathic Bleeding in Surgical, Trauma, and Postpartum Settings: Recommendations From the Share Network Group.

Several clinical settings are associated with specific coagulopathies that predispose to uncontrolled bleeding. With the growing concern about the need for optimizing transfusion practices and improving treatment of the bleeding patient, a group of 9 Portuguese specialists (Share Network Group) was created to discuss and develop algorithms for the clinical evaluation and control of coagulopathic bleeding in the following perioperative clinical settings: surgery, trauma, and postpartum hemorrhage. The 3 algorithms developed by the group were presented at the VIII National Congress of the Associação Portuguesa de Imuno-hemoterapia in October 2013. They aim to provide a structured approach for clinicians to rapidly diagnose the status of coagulopathy in order to achieve an earlier and more effective bleeding control, reduce transfusion requirements, and improve patient outcomes. The group highlights the importance of communication between different specialties involved in the care of bleeding patients in order to achieve better results.

Postpartum acute renal failure: a multicenter study of risk factors in patients admitted to ICU.

BackgroundEven in developed countries, severe specific pregnancy complications may occur in the immediate postpartum period and require admission to the ICU. The characteristics and risk factors of acute renal failure (ARF) induced by these complications and their treatments are not well known.MethodsWe performed a retrospective multicenter study in three intensive care departments linked to level III maternity wards in the north of France. All patients admitted to ICU for postpartum complications over a 5-year period (2008 to 2012) were included. Clinical and biological data, delivery characteristics, type of complications, and treatments were compared by univariate and multivariate analyses according to the occurrence and severity of ARF.ResultsOne hundred eighty-two patients admitted to ICU for postpartum complications were included in the study. Sixty-eight patients (37%) developed an ARF: 49 with a low or medium severity and 19 with a severe ARF requiring renal replacement therapy. Hemolysis, elevated liver enzyme, and low platelet count (HELLP) syndrome on its own (p = 0.047) or combined with postpartum haemorrhage (p = 0.003), previous treatment by hyperoncotic albumin infusion (p = 0.001) and blockade of fibrinolysis by tranexamic acid (p = 0.03), was associated with secondary ARF. By multivariate analysis, the only independent factors were the association of HELLP syndrome with postpartum haemorrhage and the use of hyperoncotic albumin infusion.ConclusionsHELLP syndrome associated with postpartum haemorrhage induces a high risk of ARF in the complicated postpartum setting. A particular attention should be given to treatments that could worsen the kidney function in that situation.

Congenital tibial hemimelia

The congenital tibia hemimelia, also called tibial deficiency, is a rare disorder with unknown cause, showing many associated abnormalities or varying syndromes. The correct diagnosis can be easily established using radiographs and/or magnetic resonance imaging in the postpartum setting. However, treatment may be difficult and needs to take into consideration the given anatomic situation in the knee and ankle joint. Prosthetic fitting may be possible in mild cases. Nevertheless, the majority of patients need to undergo surgical reconstruction in order to restore a functional, mobile, and stable knee and ankle joint.

Postoperative and Postpartum Onset of Chronic Parkinsonism: Four Case Reports

Background: Certain environmental exposures have been linked to the development of parkinsonism. We report four cases in which the onset of chronic parkinsonism occurred immediately or soon after surgery or childbirth. Results: Exposure to certain anesthetic agents in susceptible individuals or the physiological changes associated with surgery or childbirth may have contributed to or precipitated the development of parkinsonism. Conclusion: Clinicians should be aware that postoperative or postpartum settings are potential precipitants of chronic parkinsonism. More research is needed to clarify contributing factors.

Influenza Infection Control Practices in Labor and Delivery Units During the 2009 H1N1 Influenza Pandemic

To assess the presence and usefulness of written policies and practices on infection control consistent with the Center for Disease Control and Prevention's (CDC) guidance in hospital labor and delivery (L&D) units during the 2009 H1N1 influenza pandemic. Online survey. Of 11,845 eligible nurses, 2,641 (22%) participated. This analysis includes a subset of 1,866 nurses who worked exclusively in L&D units. A cross-sectional descriptive evaluation was sent to 12,612 members from the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) who reported working in labor, delivery, postpartum, or newborn care settings during the 2009 H1N1 influenza pandemic. Respondents (73.8%) reported that CDC guidance was very useful for infection control in L&D settings during the pandemic. We assessed the presence of the following infection control written policies, consistent with CDC's guidance in hospital L&D units, during the 2009 H1N1 influenza pandemic and their rate of implementation most of the time: questioning women upon arrival about recent flu-like symptoms (89.4%, 89.9%), immediate initiation of antiviral medicines if flu suspected or confirmed (65.2%, 49%), isolating ill women from healthy women immediately (90.7%, 84.7%), ask ill women to wear masks during L&D (67%, 57.7%), immediately separating healthy newborns from ill mothers (50.9%, 42.4%), and bathing healthy infants when stable (58.4%, 56.9%). Reported written policies for five of the six practices increased during the pandemic. Five of six written policies remained above baseline after the pandemic. Respondents considered CDC guidance very useful. The presence of written policies is important for the implementation of infection control practices by L&D nurses.

Reimagining the General Health Questionnaire as a measure of emotional wellbeing: A study of postpartum women in Malta

Postpartum health has been subject to a focus on psychological morbidity, despite positive associations between postpartum recovery and maternal emotional wellbeing. There are currently many validated tools to measure wellbeing and related concepts, including non-psychiatric morbidity. The General Health Questionnaire, 12 items (GHQ-12) is one such instrument, widely used and validated in several languages. Its use in postpartum settings has been documented with disagreement about the instrument's utility in this population, particularly in relation to scoring method and threshold. The GHQ-12 has never been translated into Maltese. This study explored the psychometric properties of the GHQ-12 in a Maltese postpartum population to consider if the use of a different scoring method (visual analogue scale) in the GHQ-12 can determine postpartum wellbeing. One hundred and twenty-four postpartum women recruited from one hospital in Malta completed the translated and adapted GHQ-12 as a wellbeing measure (GHQ-12(WB)) at four postpartum time points. The psychometric properties of the GHQ-12(WB) were explored using confirmatory factor analysis, discriminant and divergent validity and reliability analysis. The GHQ-12(WB) demonstrated good divergent and known-groups validity and internal consistency. No models offered a good fit to the data. The overall consistent best-fit to the data was an eight item, two factor model (GHQ-8). Model fit improved across all models in terms of CFI at 13 weeks. Findings generally support the reliability and validity of the Maltese version of the GHQ-12(WB). Model fit changes over time reflect the dynamic nature of postpartum recovery. Further evaluation of the GHQ-8(WB) is recommended.

Use of the etonogestrel-releasing contraceptive implant

The single-rod, etonogestrel-releasing, subdermal implant (ENG implant) is the most effective, long-acting reversible method of contraception available. The failure rate of the ENG implant is 0.05%, which makes it more effective than female sterilization. It is discreet, easy to insert and remove, has no effect on future fertility and is associated with a number of noncontraceptive health benefits. The ENG implant is safe and effective when used in the postpartum and postabortion setting, and in women who have contraindications to estrogen. The most common reason cited for discontinuation is irregular and unpredictable bleeding. However, structured, preinsertion counseling can increase continuation and user satisfaction.

Multidisciplinary guidelines for the care of late preterm infants

Of the 500 000 premature babies born each year in the United States, nearly 75%—or 375 000—of them are born at 34 0/7 through 36 6/7 weeks of gestational age (GA). These infants are referred to as ‘late preterm infants' (LPI) by many who publish research and commentaries about their care, including the consensus panel at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).1 Late preterm infants are physiologically and metabolically immature at the time of birth, often lacking the self-regulatory ability to respond appropriately to the extra-uterine environment. Despite their appearance as small but ‘normal' babies, LPIs have higher rates of morbidity and mortality than their term counterparts, not only during birth hospitalization, but also throughout the first year after birth and beyond.2 In some hospitals, LPIs account for up to 20% of admissions to the NICU, and LPIs are more likely to be re-hospitalized within the first 2 weeks of discharge.3, 4, 5 The morbidity rate approximately doubles for every week below 38 weeks gestational age that a baby is born (38 weeks: 3.3% 37 weeks: 5.9% 36 weeks: 12.4% 35 weeks: 25% 34 weeks: 51.2%).6 Because of these inherent risks, LPIs require increased surveillance and monitoring of the mother–infant dyad to direct their healthcare needs. The level and intensity of care provided should be based on ongoing assessment of the infant's physiological status and availability of services and personnel within the birthing facility, so that any needed interventions can occur quickly to prevent permanent consequences. With appropriate awareness of potential risks, the care of many LPIs can be managed in the postpartum setting, and the Multidisciplinary Guidelines for the Care of Late Preterm Infants are focused on these infants. However, some infants may require transfer to a higher level of care for suitable management and monitoring. A multidisciplinary approach to caring for the LPI is recommended. Care should be implemented and coordinated by clinicians within their scope of practice and should be family-centered, developmentally supportive, and within the context of the family's culture and preferences. Communication should occur and education should be provided in ways that are appropriate for individual family needs, including families with limited or no English proficiency or health literacy. Care standards should always be of the highest quality but may require different methods of implementation.

Increased thyroid autoimmunity among women with multiple sclerosis in the postpartum setting

Background: Multiple sclerosis (MS) patients are predisposed to thyroid abnormalities, but the risk for pregnancy-related thyroid pathology among MS patients has not been evaluated. Objectives: The objectives of this research are to prospectively evaluate the prevalence of thyroid autoimmunity among MS patients in relation to pregnancy, and to investigate its impact on pregnancy outcome, postpartum depression and fatigue. Methods: Forty-six pregnant MS patients underwent repeat testing for serum thyroid antibodies (Abs), clinical evaluation and thyroid hormone measurement. Results were compared to 35 age-matched healthy mothers. Results: At six months postpartum 35.3% of MS patients presented elevated levels of thyroid Abs compared to 5.7% of controls, p = 0.01. Mean thyroid Ab concentrations among MS patients were significantly reduced during pregnancy and returned to maximal levels at six months postpartum. The proportion of individuals with postpartum thyroid dysfunction did not differ significantly between MS patients and healthy controls (3.4% vs 2.9%, p = 1.00). Elevated thyroid Ab levels did not increase the risk for adverse pregnancy outcome, fatigue or postpartum depression. Conclusions: Considering the tendency of MS mothers to develop thyroid autoimmunity postpartum and in association to treatments, we recommend screening MS patients for thyroid dysfunction (TSH) during early pregnancy and after delivery.

Abstract A31: Immune cell influx during postpartum mammary gland involution reveals immunosuppression and tumor promotion

Abstract Young women with breast cancer diagnosed in the postpartum period, defined as up to 5 years from last child delivery, have a poorer prognosis compared to women who have never been pregnant. Our lab has proposed that the poor prognosis associated with postpartum breast cancers is due to gland remodeling following pregnancy, known as postpartum involution. Using the mouse mammary gland as a model, our understanding of postnatal involution has greatly improved, however our understanding of the immune systems role during involution is limited. Recently M2 macrophages, that have tumor promotional characteristics, have been identified as essential for epithelial cell death during normal postpartum involution, demonstrating involution requires assistance from the immune system. We hypothesize that immune cells within the normal involuting gland set up an immunosuppressive environment that favors the growth and metastasis of breast cancer cells. To characterize the role of immune cells during involution and in the promotion of postpartum breast cancer, we created an immunocompetent mouse model using the Balb/c mouse. Using flow cytometry, we have determined that dendritic cells, GR1+ monocytic immature myeloid cells (iMCs), and T cells increase exponentially in the mammary gland during involution. Functional assays using myeloid cells isolated from the mammary gland indicate the iMCs isolated from involuting glands are capable of suppressing T cell activation ex vivo. The ability of iIMCs to suppress T cell activation indicates they are capable of immune suppression. To address whether iMCs are able to promote tumor progression in the postpartum breast cancer setting, D2A1 a triple negative mammary carcinoma cell line and Balb/c mouse were utilized. D2A1 cells injected into the involuting mammary fat pad have a significant growth advantage over D2A1 cells injected into the nulliparous gland, demonstrating that mammary gland involution promotes the growth of mammary carcinoma cells in this immune competent model. T cells identified by flow cytometry are significantly lower in number systemically and within the tumors of involution-injected mammary glands than T cells in nulliparous mice, indicating systemic immunosuppression. To demonstrate immunosuppressive function, iMCs were isolated from tumors and incubated with T cells ex vivo. iMCs from involution tumors were significantly more suppressive when compared to iMCs from nulliparous mice. These data suggest that transient exposure of latent cancer cells to the immune suppressed microenvironment of involution confers a prolonged poor prognostic signature. Further, we report evidence that postpartum involution can persistently alter breast cancer in young women. CD45+ immune cell infiltrate was elevated in mammary lobules during postpartum breast involution and in breast cancers diagnosed within 2 years of a completed pregnancy, suggesting an immunosuppressed population of immune cells is enriched in women diagnosed with postpartum breast cancer. While it is unknown if the immune cell infiltrate in normal involuting breast tissue or in postpartum breast cancers has immunosuppressive function, this may be expected based on our rodent data that shows postpartum breast cancers are characterized by high monocyte population with immune suppressive function. Our study demonstrates monocytes infiltrating the involuting mammary gland are capable of suppressing T cell function supporting the notion that immune suppression can promote a more aggressive tumor microenvironment, providing justification for targeting the immune-suppressive monocytes as a potential therapy for postpartum breast cancer patients. Citation Format: Holly Martinson, Sonail Jindal, Virginia Borges, Pepper Schedin. Immune cell influx during postpartum mammary gland involution reveals immunosuppression and tumor promotion. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Invasion and Metastasis; Jan 20-23, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;73(3 Suppl):Abstract nr A31.

Abstract P4-04-03: Monocytic immature myeloid cells permit tumor immune evasion during postpartum involution

Abstract Young women with breast cancer diagnosed in the postpartum period, defined as up to 5 years from last child delivery, have a poorer prognosis compared to women who have never been pregnant, and represent ∼30% of all young women's breast cancer cases. Our lab has proposed that the poor prognosis associated with postpartum breast cancer is due to gland remodeling following pregnancy, known as postpartum involution. Using rodent models and human breast tissue, it has been demonstrated recently that postpartum gland involution utilizes wound healing programs to remodel the gland to a non-secretory state. For example, macrophages with tumor promotional characteristics have been identified as essential mediators of epithelial cell death during postpartum involution. We hypothesize that the immune cells within the normal involuting gland set up an immunosuppressive environment to protect the host from negative sequel resulting from potential self-antigen exposure during epithelial cell death. A consequence would be the establishment of an immune microenvironment that favors the growth and metastasis of breast cancer cells. To characterize the role of immune cells during normal postpartum involution as well as in the promotion of mammary cancer, we developed an immunocompetent mouse model of postpartum breast cancer using the Balb/c mouse. By flow cytometry, we found that dendritic cells, GR1+ monocytic immature myeloid cells (IMCs), and T cells increase exponentially in the mammary gland during involution. Functional assays using myeloid cells from the mammary gland indicate the IMCs isolated from involuting glands are capable of suppressing T cell activation ex vivo, consistent with immune suppression in vivo. To begin to investigate whether IMCs are able to promote tumor progression in the postpartum breast cancer setting, D2A1 mammary carcinoma were injected into mammary fat pads of Balb/c mice. D2A1 cells injected into hosts with actively involuting mammary glands had a significant growth advantage over tumor cells injected into nulliparous host glands, demonstrating that mammary gland involution promotes the growth of mammary carcinoma cells in this immune competent model. T cells identified by flow cytometry are significantly lower in number systemically and within the tumors of the involution-group compared to the nulliparous-group, indicating systemic immunosuppression specific to the involution-group. To demonstrate immunosuppressive function, IMCs were isolated from tumors and incubated with T cells ex vivo. IMCs from involution tumors were significantly more suppressive then IMCs from nulliparous mice. These data indicate IMCs play an immunomodulatory role in the mammary gland during involution, which allows tumor cells to undergo immune evasion in the postpartum period. We are currently investigating how GR1+ IMCs suppress T cell activation and hope to determine if reprograming these cells could prevent the promotion of breast cancer during involution. (DOD-BC10904 and BC100910) Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-04-03.

How do we manage venous thromboembolism in pregnancy? A retrospective review of the practice of diagnosing and managing pregnancy‐related venous thromboembolism at two major hospitals in Australia and New Zealand

North American and European literature suggest that the incidence rate for pregnancy-related thromboembolism (VTE) ranges from 0.5 to 2 per 1000 pregnancies. However, there is a paucity of data regarding pregnancy-related VTE in Australia and New Zealand. To define the epidemiology, management and adverse effects of pregnancy-related VTE in Australia and New Zealand. Retrospective chart review of pregnant patients with objectively diagnosed pregnancy-related VTE at Monash Medical Centre and the North Shore Hospital from January 2007 to March 2011. Sixty women with VTE were identified, 31 and 29 in the antepartum and post-partum period respectively. VTE occurred as early as 8 weeks of gestation. There was a trend towards higher proportion of PE in the postpartum period. Most antenatal patients were started on enoxaparin and dosed according to weight at diagnosis. A wide variability in maintenance dosing strategies was observed. Three (5%, 95% CI: 1% to 14%) patients suffered major bleeds, all occurring post-partum. Recurrences occurred in two post-partum patients who received a truncated course of enoxaparin for distal deep-vein thrombosis. Although more women had an induction of labour, this did not translate into an increased Caesarean section rate. The epidemiology of pregnancy-related VTE is similar to that of other developed countries. All three bleeding events occurred in the immediate post-partum setting, highlighting the need for caution at this critical time. VTE recurrences occurred in those women with post-partum distal deep-vein thrombosis treated with an abbreviated course of enoxaparin.

Ovarian vein thrombosis in the nonpregnant woman: an overlooked diagnosis

Ovarian vein thrombosis in the nonpregnant woman: an overlooked diagnosis