Postpartum Management Research Articles

Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth

Each year approximately 350,000 women in the United Kingdom and millions more worldwide, experience perineal suturing following childbirth. The postpartum management of perineal trauma is a core component of routine maternity care. However, for those women whose perineal wound dehisces (breaks down), the management varies depending on individual practitioners preferences as there is limited scientific evidence and no clear guidelines to inform best practice. For most women the wound will be managed expectantly whereas, others may be offered secondary suturing. To evaluate the therapeutic effectiveness of secondary suturing of dehisced perineal wounds compared to non-suturing (healing by secondary intention, expectancy). We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and reference lists of retrieved studies. Randomised controlled trials of secondary suturing of dehisced perineal wounds (second-, third- or fourth-degree tear or episiotomy), following wound debridement and the removal of any remaining suture material within the first six weeks following childbirth compared with non-suturing. Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy. Two small studies of poor methodological quality including 52 women with a dehisced and/or infected episiotomy wound at point of entry have been included.Only one small study presented data in relation to wound healing at less than four weeks, (the primary outcome measure for this review), although no reference was made to demonstrate how healing was measured. There was a trend to favour this outcome in the resuturing group, however, this difference was not statistically significant (risk ratio (RR) 1.69, 95% confidence interval (CI) 0.73 to 3.88, one study, 17 women).Similarly, only one trial reported on rates of dyspareunia (a secondary outcome measure for this review) at two months and six months with no statistically significant difference between both groups; two months, (RR 0.44, 95% CI 0.18 to 1.11, one study, 26 women) and six months, (RR 0.39, 95% CI 0.04 to 3.87, one study 32 women). This trial also included data on the numbers of women who resumed sexual intercourse by two months and six months. Significantly more women in the secondary suturing group had resumed intercourse by two months (RR 1.78, 95% CI 1.10 to 2.89, one study, 35 women), although by six months there was no significant difference between the two groups (RR 1.08, 95% CI, 0.91 to 1.28).Neither of the trials included data in relation to the following prespecified secondary outcome measures: pain at any time interval; the woman's satisfaction with the aesthetic results of the perineal wound; exclusive breastfeeding; maternal anxiety or depression. Based on this review, there is currently insufficient evidence available to either support or refute secondary suturing for the management of broken down perineal wounds following childbirth. There is an urgent need for a robust randomised controlled trial to evaluate fully the comparative effects of both treatment options.

StartSmart: a randomized intervention to promote maternal weight control and reduce childhood obesity in the Mississippi Delta

Excessive gestational weight gain (GWG) can complicate a woman's pregnancy and put her and her child at risk for poor delivery and birth outcomes and chronic conditions such as obesity. Further, feeding and activity habits established early in life can significantly impact the development of obesity in children. Thus, interventions designed to optimize GWG and promote postpartum and early childhood weight management have the potential to significantly impact the health of moms and their babies. We developed StartSmart, an 18 month culturally‐tailored maternal weight management and early childhood obesity prevention program for first time African American (AA) moms‐to‐ be in the Mississippi Delta. The program was designed using foundational components from the Diabetes Prevention Program and the Australian INFANT trial. 150 women, in their early 2nd trimester, will be randomized to a child development home visiting program or child development home visiting program + StartSmart. Both interventions will be implemented by trained lay parent educators. The comparative impact of the programs on weight status, dietary intake, and health behaviors of mom and baby will be assessed. Results will determine if a novel, scalable lifestyle intervention can improve the health of AA women and their children at high risk for obesity and chronic disease. Funding was provided by the USDA Agricultural Research Service.

PM.94 The Management of a Twin Pregnancy in a Patient with MAGIC Syndrome

In 1985 Firestein et al, first described patients with co-existent relapsing polychondritis and Behçet’s Disease. They proposed the acronym MAGIC syndrome (Mouth And Genital ulcers with Inflamed Cartilage).This is a...

Migration of Bakri balloon through an unsuspected uterine perforation during the treatment of secondary postpartum hemorrhage

The current case describes an unreported complication of Bakri balloon placement: the migration of the Bakri balloon to the broad ligament through an unsuspected uterine rupture. Finally, a hysterectomy had been required. The Bakri balloon may be involuntary introduced in an unexpected uterine rupture, even if the balloon is placed with ultrasound guidance.

Consideration of Postpartum Management in HIV-Positive Haitian Women

A previous study at the GHESKIO HIV clinic confirmed that highly active antiretroviral therapy (HAART) prophylaxis reduced mother-to-child transmission (MTCT) and infant mortality in Haiti. This analysis looks at maternal outcomes in this cohort after delivery. Records of 508 HIV-positive Haitian women who delivered between 1999 and 2005 were analyzed. We examined mortality, loss to follow-up, time to death or HAART initiation, and time of decline of CD4 count to 350 cells/μL. One hundred seventy women reached a CD4 ≤200 or developed clinical AIDS and were started on long-term HAART. The median CD4 count at HAART initiation was 178 (interquartile range, 106-227). CD4 decline was stratified by CD4 at delivery to project the mean months to a CD4 of 350. With an initial CD4 of 350-499 cells/μL, it was 19 months (95% confidence interval: 14 to 28) while with a CD4 >500 cells/μL, it was 71 months (95% confidence interval: 59 to 88). At study close, 257 women remained in follow-up, with loss to follow-up 3 times less in those on HAART (3.2/100 person-years) than those not on HAART (9.8/100 person-years). The threshold for starting treatment was often missed in HIV-infected women after delivery. Success of follow-up of women after delivery was favorably influenced by being on HAART. Women with high (>500) initial CD4 counts had a protracted time (5-7 years) before they reach a threshold CD4 count, in contrast to those with CD4 <500 cells/μL. Strategies for postpartum treatment of women should be informed by the speed with which they are likely to progress.

Point-of-Care Testing of Coagulation and Fibrinolytic Status during Postpartum Haemorrhage: Developing a Thrombelastography®-Guided Transfusion Algorithm

Thrombelastography® is a monitor of coagulation and fibrinolytic status, with point-of-care applications in managing haemorrhaging patients. Advocates have suggested a possible role in managing obstetric haemorrhage. This study aims to develop a pregnancy-specific thrombelastography-guided transfusion algorithm, which could be integrated into the management of postpartum haemorrhage. In this prospective observational study, 57 healthy, term-parturients provided pre-caesarean whole blood specimens for thrombelastography analyses. Specimens were processed according to a standardised protocol involving simultaneous analyses using three assays: native (non-activated); kaolin-activated; and kaolin and tissue factor-activated (RapidTEG®). For each assay, the following thrombelastography parameters were measured: reaction time (minutes); clot formation kinetics time (minutes); maximum amplitude (mm); and a angle (degree). Subsequent reference values were used to establish assay-specific reference intervals. For all thrombelastography parameters studied, reference values obtained using a non-activated assay differed from the corresponding values obtained using activated assays, and also demonstrated greater inter-sample variability. From the assay-specific reference intervals obtained, it was possible to establish a pregnancy-specific thrombelastography-guided transfusion algorithm. Specific features of this transfusion algorithm included the preferential use of activated assays, the need for duplicates and a recommendation that an initial baseline thrombelastography measurement is established for subsequent serial comparisons. This transfusion algorithm has been developed to assist with assessment of coagulation and fibrinolytic status during postpartum haemorrhage.

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TRIPPD: A Practice-Based Network Effectiveness Study of Postpartum Depression Screening and Management

Postpartum depression is common but inadequately recognized and undertreated. Continuing depressive symptoms are associated with adverse outcomes for the woman, her infant, and family. We wanted to determine the effect of a practice-based training program for screening, diagnosis, and management of depression in postpartum mothers. In this practice-based effectiveness study, 28 practices were randomized to usual care (n = 14) or intervention (n = 14), and 2,343 women were enrolled between 5 and 12 weeks' postpartum. The intervention sites received education and tools for postpartum depression screening, diagnosis, initiation of therapy, and follow-up within their practices. Usual-care practices received a 30-minute presentation about postpartum depression. Screening information for the usual care was obtained from baseline surveys sent directly to the central site but was not available for patient care. Outcomes were based on patient-reported outcomes (level of depressive symptoms) from surveys at 6 and 12 months, plus medical record review (diagnosis and therapy initiation). Among the 2,343 women enrolled, 1,897 (80.1%) provided outcome information, and were included in the analysis. Overall, 654 (34.5% of 1,897) women had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 (P = .07) and 12 months' (P=.001) postpartum. Primary care-based screening, diagnosis, and management improved mother's depression outcomes at 12 months. This practical approach could be implemented widely with modest resources.

Management of pre‐eclampsia: issues for anaesthetists

Pre-eclampsia is a leading cause of maternal morbidity and mortality. Substandard care is often present and many deaths are preventable. The aim of this review is to summarise the key management issues for anaesthetists in the light of the current literature. A systematic literature search of electronic databases was undertaken including MEDLINE, EMBASE and the Cochrane Library using the key words obstetrics, pregnancy, pregnancy complications, maternal, pre-eclampsia, preeclampsia, cardiac function, haemodynamics, haemolysis, elevated liver enzymes, low platelets (HELLP), eclampsia, anaesthesia, anesthesia, neuraxial. Relevant Colleges and Societies websites were examined for pertinent guidelines. The disease is defined within the context of hypertensive diseases, and early recognition of pre-eclampsia and its complications, as well as multidisciplinary expert team management is highlighted. Accurate monitoring and recording of observations including the use of transthoracic echocardiography is discussed. The importance of the treatment of systolic blood pressure>180 mmHg and the use of intravenous antihypertensive medication as well as the use of parenteral magnesium sulphate for the treatment and prevention of eclampsia is emphasised . Restricted intravenous fluid therapy and avoidance of ergometrine is discussed. Neuraxial analgesia and anaesthesia, and general anaesthesia for birth is summarised as well as postpartum management including analgesia, thromboprophylaxis, management of acute pulmonary oedema and the use of pharmacological agents in the setting of breastfeeding.

Evaluating the concerns of pregnant women with epilepsy: A focus group approach

RationaleSome women with epilepsy stop or decrease their antiepileptic drug (AED) therapy during pregnancy because they fear fetal effects of the therapy. This places the patient and her fetus at risk for potential adverse outcomes due to increased seizure activity. The rationale of this behavior is not completely understood and is underexplored. The aim of this qualitative project was to determine the concerns of pregnant women with epilepsy via small focus groups. MethodsPregnant women with epilepsy were recruited to participate in small group sessions involving direct interviews which were analyzed by thematic content analysis. ResultsTen focus groups were conducted with a total of 21 second or third trimester pregnant women with epilepsy. Twelve women reported changes to their AED regimen during pregnancy, with six having made changes requested by their prescriber and six (29% of all study participants) self-altering their AED regimen. In contrast to the former group, the alterations made by the latter group were either dose-lowering or stopping AEDs altogether. Via content analysis, four pregnancy specific patient-related concerns arose: 1) the safety of drug therapy during pregnancy, 2) potential neonatal complications, 3) labor and delivery issues and 4) neonatal and post-partum management. An unanticipated benefit was the fostering of patient comfort and an opportunity for patient-to-patient collaboration. ConclusionsOur study adds insight into the concerns of pregnant women with epilepsy. By identifying these concerns, we may be able to provide more effective patient education, and we hope to ultimately improve outcomes in women with epilepsy.

Safety and efficacy of high-dose intravenous iron carboxymaltose vs. iron sucrose for treatment of postpartum anemia

The purpose of this study is to compare the safety and efficacy of intravenous (IV) high-dose iron carboxymaltose (ICM) with iron sucrose (IS) for the treatment of postpartum anemia. We performed a retrospective cohort study with 210 anemic inpatient women in the postpartum period who received IV high-dose ICM (15 mg/kg; maximum, 1000 mg) or IS (2×200 mg), respectively. Safety and tolerability of both groups were compared on the basis of reported systemic and local adverse events. The cohorts were matched for baseline characteristics and their initial hemoglobin (Hb) values. The secondary endpoint included drug efficacy assessment by measurement of Hb level increase up to 8 days after treatment. Rapid administration of high ICM doses was as well tolerated as IS with overall adverse events of 5% (ICM) vs. 6% (IS). The most common complaint was burning and pain at the injection site. ICM was as effective as IS in changing Hb levels from the baseline. There was no difference in the mean daily Hb increase between the groups. Women with severe anemia showed the most effective responsiveness. IV ICM is as safe as IS in the management of postpartum (IDA) iron deficiency anemia despite five times of higher dosage. Both drugs are effective and offer a rapid normalization of Hb after delivery. The single application of ICM shows advantages of lower incidence of side effects at the injection site, a shorter treatment period, and better patient compliance.

Metabolic alterations in pregnant women: gestational diabetes

Gestational diabetes mellitus (GDM) and controversy are old friends. The impact of GDM on maternal and fetal health has been increasingly recognized. Nevertheless, universal consensus on the diagnostic methods and thresholds has long been lacking. Published guidelines from major societies differ significantly from one another, with recommendations ranging from aggressive screening to no routine screening at all. As a result, real-world practice is equally varied. This article recaps the latest evidence-based recommendations for the diagnosis and classification of GDM. It reviews the current evidence base for intensive multidisciplinary treatment of GDM and provides recommendations for postpartum management to delay and/or prevent progression to type 2 diabetes.

Provider Management and Support for Breastfeeding Pain

To describe breastfeeding pain reported by breastfeeding women during the first-year postpartum and providers' management of the pain as recorded in medical records. Retrospective, descriptive. Mid-South metropolitan obstetric and gynecologic medical practice. A convenience sample of 117 breastfeeding women. Data were collected using a retrospective review of medical records of breastfeeding mothers during their infants' first year of life. Participants reported a breastfeeding rate of 56.4%, and of those 23% reported breastfeeding pain during the first year. Major reasons for pain were mastitis (67.5%), candida (32.4%), engorgement (18.0%), nipple tenderness (8.1%), and clogged milk ducts (4.5%). Medications were used most frequently to treat mastitis and candida. However, limited documentation of breastfeeding support beyond prescribing medications was found. Nonpharmacological measures were rarely recommended, and few referrals were documented to specialized providers such as lactation consultants or community support groups. Routine infant feeding choices, breastfeeding discussions, and breastfeeding counseling were rarely documented and multiple non-evidence-based strategies were noted. Inadequate breastfeeding support and management were evident, and non-evidence-based recommendations were routinely practiced. It is recommended that primary care providers adopt evidence-based practices for breastfeeding and breastfeeding pain that support women in successfully reaching their breastfeeding goals.

Comportamento reprodutivo de vacas de corte manejadas em pastagem natural com duas cargas animais e duas idades à desmama

Este trabalho foi realizado para avaliar o desempenho produtivo e reprodutivo de 52 vacas de corte mestiças Charolês × Nelore em pastagem natural. O experimento foi iniciado em 4/8/2003, quando as vacas em gestação foram distribuídas uniformemente por peso e condição corporal em duas cargas animais (280 e 360 kg PV/ha). O desmame precoce foi realizado em 26 vacas quando os bezerros(as) atingiram em média 100 dias de idade e o desmame convencional, em 26 vacas quando os bezerros(as) atingiram em média 180 dias de idade. As vacas submetidas ao desmame precoce tiveram maior ganho médio diário em comparação àquelas submetidas ao desmame convencional (0,471 vs. 0,255 kg/dia, respectivamente). Houve interação significativa entre as idades de desmame e os períodos para a condição corporal das vacas. As vacas submetidas ao desmame precoce apresentaram melhor condição corporal na época do desmame convencional (3,5 vs. 2,8) e ao final do acasalamento (3,0 vs. 2,8). A carga animal não afetou significativamente o ganho médio diário nem a condição corporal das vacas. A taxa de prenhez das vacas do desmame precoce (60,0%) foi significativamente superior à do desmame convencional (12,0%), no entanto, as cargas animais não diferiram entre si (7,7% vs. 15,4%, respectivamente). Nos bezerros submetidos ao desmame precoce, o ganho médio diário e o peso vivo aos 180 dias foram significativamente inferiores aos observados nos bezerros do desmame convencional. O manejo da pastagem com as duas cargas animais no pós-parto das vacas e as duas idades de desmame dos bezerros não influenciam o peso médio e o ganho médio diário dos bezerros até os 14 meses de idade.

Chronic Hypertension in Pregnancy

Hypertension is the most common medical disorder during pregnancy. Chronic hypertension is a serious medical complication in pregnancy with increased maternal and perinatal morbidity and mortality. Those who develop uncontrolled severe hypertension, those with target organ damage, and those who are poorly compliant with prenatal visits are at high risk for poor perinatal outcome. Maternal complications include abruptio placenta, stroke, and superimposed pre-eclampsia. Fetal complications include prematurity, low birth weight, and perinatal death. Careful antepartum, intrapartum and postpartum management of women with high-risk chronic hypertension in pregnancies may reduce morbidity and mortality.

Diagnosis of Urolithiasis and Rate of Spontaneous Passage During Pregnancy

Due to imaging limitations little is known about the true rate of spontaneous stone passage during pregnancy. We evaluated the accuracy of urolithiasis diagnosis during pregnancy and the rate of spontaneous passage. We retrospectively reviewed the records of patients diagnosed with urolithiasis during pregnancy from 1997 to 2009. Patients were evaluated for a confirmed stone event, defined as a stone visualized on imaging or at surgery, or passed with visualization. We identified 112 women diagnosed with urolithiasis during pregnancy, including 5 with multiple episodes for a total of 117 events. Stones were visualized by imaging in 63 of 117 events. Another 22 patients without imaging confirmation passed a stone spontaneously. In 1 patient the stone was diagnosed at surgical removal during pregnancy and postpartum imaging identified another 4 patients. Thus, 90 of 117 events (77%) represented confirmed stones. Of the 90 patients 27 (30%) underwent temporizing or definitive surgical intervention during pregnancy. Postpartum definitive surgical management was necessary in 29 women (25%). Overall only 43 of 90 women (48%) spontaneously passed the stone. Mean followup of those with confirmed stones was 51 months. Urolithiasis recurred in 26 of the 90 patients (29%). The most common primary component of analyzed stones was calcium phosphate (81%). We found that almost a quarter of pregnant women diagnosed with urolithiasis are diagnosed inaccurately. The inappropriate diagnosis of urolithiasis may contribute to the misconception that most stones pass with conservative management during pregnancy.

Postpartum headache: diagnosis and management

Postpartum headache is described as a complaint of headache and neck or shoulder pain in the first 6 weeks after delivery. It is one of the most common symptoms with up to 39% of parturients experiencing headache in the first postpartum week. Regional anaesthesia has become the preferred choice for analgesia and anaesthesia in obstetric patients. With increasing awareness among our non-anaesthetic colleagues that post-dural puncture headache (PDPH) is a complication of regional anaesthesia, it is common for obstetric anaesthetists to be asked to review women with postpartum headache. It is very important therefore that anaesthetists are familiar with the possible differential diagnoses of postpartum headache and the management options available. In this article, we will discuss the causes of postpartum headache, their diagnosis, and management. In particular, we will focus on PDPH as this continues to be a significant cause of postpartum headache which poses particular challenges for the obstetric anaesthetist.

D-dimer testing versus multislice computed tomography in the diagnosis of postpartum pulmonary embolism in symptomatic high-risk women

[1] Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116(6):748–57. [2] Royal College of Obstetricians and Gynaecologists. Postpartum Haemorrhage, Prevention and Management (Green-top 52). www.rcog.org.ukhttp://www.rcog. org.uk/womens-health/clinical-guidance/prevention-and-managementpostpartum-haemorrhage-green-top-52 Published 2009. [3] Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynecol Obstet 2001;74(2):139–42. [4] Vitthala S, Tsoumpou I, Anjum ZK, Aziz NA. Use of Bakri balloon in post-partum haemorrhage: a series of 15 cases. Aust N Z J Obstet Gynaecol 2009;49(2):191–4.

Dry Period Management and Optimization of Post‐Partum Reproductive Management in Dairy Cattle

Dry period and early post-partum management are decisive factors for fertility in lactating dairy cows. Previous studies have shown that decreased dry matter intake (DMI) and increased non-esterified fatty acids (NEFA) negatively affect fertility and subsequent milk production. The traditional dry period decreases DMI prior to parturition, resulting in a decrease in energy intake. A negative energy balance increases NEFA concentration, and increased NEFA may impair the immune system, especially by decreasing neutrophil function prior to parturition. Earlier studies have shown that post-partum health disorders, including retained placenta and metritis, were correlated with periparturient neutrophil function. In addition, decreased DMI is also linked to a reduced body condition score (BCS) in dairy cows. These events in the periparturient period negatively affect fertility. Some manipulation, such as shortening the dry period, may be a solution to increased DMI in the periparturient period, preventing post-partum disorders and subsequent fertility issues. This article aims to explain the effects of shortening the dry period on reproduction and early post-partum treatments to improve fertility. In addition, timed artificial insemination protocols will be discussed for use during the post-partum period to improve fertility in dairy cows.

TRANSVERSE LIE

Transverse lie is dangerous not only to fetus but may endanger the life of mother if timely intervention is not done. Good antenatal care is of tremendous importance for proper management of transverse lie. Objectives: 1). To determine the predisposing factors to transverse lie. 2). To find out maternal and perinatal outcome in transverse lie. Facts were analyzed to find out the avoidable factors which make the maternal and perinatal outcome worse. Setting: Gynae and obstetric unit-II DHQ Hospital Faisalabad. Study Design: It was a descriptive study. Duration: Six months from 15th September, 2006 to 15th March, 2007. Materials and methods: Sixty cases of transverse lie were included in this study. These sixty patients were analyzed in great details, regarding predisposing factors, clinical features, intrapartum and postpartum management including the maternal and perinatal outcome. Results: Predisposing factors were found in 42% of the primpara but in only 34% of the multipara. The mode of delivery was surgical and lower segment caesarean section was undertaken in 80% of cases. Maternal outcome in order of frequency were difficult surgery in 23.3%, obstructed Labour in 15%, delayed recovery from anaesthesia in 3.3% and uterine rupture in 1.6%. Fetal outcome in order of frequency were intrauterine death in 18.3%, hand prolapse in 20% and cord prolapse in 8.9%. Conclusions: Known predisposing factors to transverse lie withstand a closer and more accurate assessment of their incidence. The maternal and perinatal outcome can be improved by early diagnosis during antenatal care and hospital delivery, without any delay.