Postpartum Status Research Articles

Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months

We characterized breastfeeding concerns from open-text maternal responses and determined their association with stopping breastfeeding by 60 days (stopping breastfeeding) and feeding any formula between 30 and 60 days (formula use). We assessed breastfeeding support, intentions, and concerns in 532 expectant primiparas and conducted follow-up interviews at 0, 3, 7, 14, 30, and 60 days postpartum. We calculated adjusted relative risk (ARR) and adjusted population attributable risk (PAR) for feeding outcomes by concern category and day, adjusted for feeding intentions and education. In 2946 interviews, 4179 breastfeeding concerns were reported, comprising 49 subcategories and 9 main categories. Ninety-two percent of participants reported ≥ 1 concern at day 3, with the most predominant being difficulty with infant feeding at breast (52%), breastfeeding pain (44%), and milk quantity (40%). Concerns at any postpartum interview were significantly associated with increased risk of stopping breastfeeding and formula use, with peak ARR at day 3 (eg, stopping breastfeeding ARR [95% confidence interval] = 9.2 [3.0-infinity]). The concerns yielding the largest adjusted PAR for stopping breastfeeding were day 7 "infant feeding difficulty" (adjusted PAR = 32%) and day 14 "milk quantity" (adjusted PAR = 23%). Breastfeeding concerns are highly prevalent and associated with stopping breastfeeding. Priority should be given to developing strategies for lowering the overall occurrence of breastfeeding concerns and resolving, in particular, infant feeding and milk quantity concerns occurring within the first 14 days postpartum.

Clinical features of spontaneous coronary artery dissection

BackgroundSpontaneous coronary artery dissection (SCAD) is an infrequent but increasingly recognized cause of acute coronary syndrome (ACS). Previous case reports demonstrated that this condition occurs in young females with a low atherosclerotic risk factor burden and may be associated with peripartum or postpartum status. The purpose of this study was to review patients with angiographically confirmed SCAD to provide additional insight into the diagnosis and treatment of this condition. Methods and resultsWe screened medical records of all patients with ACS from March 2001 to November 2012. From these patients, we selected patients with SCAD based on coronary angiographic review. Of a total of 1159 ACS patients, 10 patients (0.86%) were diagnosed with SCAD. The mean age of these patients was 46 years, and 9 were female. ST-elevation myocardial infarction (STEMI) was observed in 9 patients and 5 patients had no coronary risk factors. One patient was treated conservatively with medication alone and 3 patients underwent thrombectomy. Balloon angioplasty was performed in 2 patients, and a bare metal stent was placed in one of these patients later. In the remaining 4 patients, bare metal stents were implanted emergently. Follow-up coronary angiography showed appropriate repair of SCAD in all 10 patients. ConclusionsIn our experience, the clinical features of SCAD appear to be similar to those reported previously. SCAD appears to be rare, but it should be considered in ACS patients, especially in younger females.

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

Comparison of long-term controlled internal drug release-based protocols to synchronize estrus and ovulation in postpartum beef cows1

Two experiments were conducted to examine the necessity of adding a GnRH injection to a 14-d controlled internal drug release (CIDR)-based protocol for synchronization of estrus and ovulation in postpartum beef cows. The experiments were designed to characterize long-term CIDR-based protocols in cyclic and noncyclic postpartum beef cows on the basis of estrous response, follicular dynamics, and serum steroid hormone concentrations. In Exp. 1 and 2, crossbred lactating beef cows (n = 40 and 38, respectively) were randomly assigned to 1 of 2 treatments by age, days postpartum (DPP), BCS, and estrous cyclicity status: 1) cows received a CIDR from d 0 to 14 followed by GnRH 9 d after CIDR removal (d 23) and PGF2α on d 30 (CIDR Select) or 2) CIDR administration from d 0 to 14 followed by PGF2α 16 d later (d 30; Show-Me-Synch). Estrus detection was performed using HeatWatch transmitters applied from CIDR removal to AI. Cows in Exp. 1 were artificially inseminated based on detected estrus whereas cows in Exp. 2 were inseminated at a fixed time. In both experiments, follicle turnover on d 25 of treatment was greater among CIDR Select-treated cows (P < 0.001) compared with Show-Me-Synch-treated cows. In Exp. 1, CIDR Select-treated cows tended to have a reduced (P = 0.06) variance for the interval to estrus after PGF2α than Show-Me-Synch-treated cows. Also, cows assigned to the CIDR Select protocol had greater concentrations of progesterone (P < 0.05) on the day before PGF2α administration as well as greater concentrations of estradiol-17β (P < 0.01) 48 h after PGF2α administration. In Exp. 2, mean dominant follicle diameter on d 23 and at fixed-time AI (FTAI) did not differ between treatments (P > 0.10), but Show-Me-Synch-treated cows had larger follicles at d 28 (P < 0.001) and tended to have larger follicles at PGF2α (d 30; P = 0.06) compared with cows assigned to CIDR Select. In summary, the administration of GnRH on d 23 of a long-term CIDR-based estrus synchronization protocol increased follicle turnover; however, both long-term CIDR-based protocols yielded similar physiological outcomes among estrous-cycling and anestrous postpartum beef cows.

Effect of Prenatal and Postpartum Food Security Status on Breastfeeding Initiation and Duration in Massachusetts WIC Participants 2001–2009

This study examined the association between household food insecurity during pregnancy and initiation/duration of breastfeeding in Massachusetts WIC women. Full term, live singleton births of mother's certified into WIC prenatally who had complete food security, breastfeeding and covariate data (maternal race, age, education, smoking status, BMI, HH income and size, birth weight and sex) were included (n=27,112). Multivariate logistic regression was used to estimate the association between food security status and breastfeeding initiation and among initiators, food security status continued breastfeeding for 3, 6 and 12 months. Low prenatal food security was associated with lower likelihood of breastfeeding initiation compared to food secure women (OR=0.87, p&lt;.0001). Prenatal very low prenatal food security was not significantly associated with initiation rates (p &gt;; .05). Low postpartum HH food security status was associated with a greater likelihood of breastfeeding at least three and six months compared to those who were food secure during the postpartum period (OR=1.08 and 1.11, p&lt;0.05). There was no association between prenatal food security and breastfeeding duration. Prenatal and postpartum food security status may influence the decision to initiate breastfeeding and sustain breastfeeding.

Post-partum atypical haemolytic-uraemic syndrome treated with eculizumab: terminal complement activity assessment in clinical practice.

Atypical haemolytic-uraemic syndrome (aHUS) is a disease of uncontrolled complement alternative pathway activation. Eculizumab induces terminal complement blockade (TCB), and is safe and effective for aHUS treatment as evidenced by its recent approval by the US Food and Drug Administration and the European Commission. A 26-year-old woman was admitted 1 week after her first childbirth for aHUS with creatinine 6.2 mg/dL (550 µmol/L), haemoglobin 3.6 g/dL (36 g/L), lactate dehydrogenase 2155 U/L (upper normal limit 248), 9% schizocytes and platelet count 49 × 103/µL (49 × 109/L). She had a medical history of Crohn's disease 5 years earlier and a skin melanoma 3 years earlier. Family history was remarkable with her father's brother presenting two renal graft losses related to aHUS despite plasma exchange (PE). The patient and her uncle both carried combined heterozygous mutations in genes coding for Factor H (p.Lys1186Thr) and Factor I (p.Ile322Thr). Daily PE was started with 60 mL/kg fresh frozen plasma substitution for 80 kg body weight with an initial positive haematological response without improvement of renal function requiring haemodialysis. Due to family history and suspected genetic background that was confirmed later, the patient was switched to eculizumab [1–3], 900 mg on Day 3 post-admission (PA). Placental retention was subsequently diagnosed and treated but a second 900 mg eculizumab infusion 10 days-PA was not effective in controlling aHUS (decreasing platelet count). Daily PE was re-started without supplemental eculizumab. During eculizumab treatment, complement activity measured with a validated sensitized sheep erythrocytes lysis assay (CH50) is expected to be <10% as observed in hereditary C5 deficiency [4]. We considered that complete TCB would be achieved for a serum CAE (complement activation enzyme immunosorbent assay, Diasorin®) [5] value <0.5 U/mL, (normal range 63–145 U/mL), corresponding to CH50 <10%. Patient serum CAE was 77 U/mL before the first eculizumab administration. Following the first three eculizumab administrations, complete TCB was maintained for a maximum of 4 days. On Day 39-PA, because of a continuous drop in platelet count from 161 to 81 × 103/µL despite intensive PE and as other causes of thrombocytopenia than aHUS were ruled out, eculizumab was resumed at a higher dose (1200 mg) and administrated whenever CAE activity increased over 0.5 U/mL. Under complete and sustained TCB, the outcome was rapidly positive (Figure 1): blood count normalized and the patient recovered normal renal function [serum creatinine stabilized to 0.8 mg/dL(75 µmol/L) without proteinuria after 6 months-PA] on the approved eculizumab dosing regimen. Far from aHUS trigger, eculizumab was tapered from 18 months-PA, and the patient had no signs of aHUS at the last follow-up 2 months after interrupting eculizumab. Fig. 1. Treatment regimen and clinical course of a patient with complement factor H and complement factor I gene mutations presenting post-partum (aHUS). Time is represented from the day of admission that corresponded to the first PE. Patient was switched to ... This is the first case of post-partum aHUS treated with eculizumab and the first description of TCB functional assessment to guide eculizumab dose and frequency of administration so as to obtain permanent complete complement blockade. This pragmatic therapeutic option seems to be adequate to rescue acute phases of aHUS, when the expected improvement does not occur under the recommended dose regimen of eculizumab. The degree of uncontrolled complement activation likely is influenced by the genetic background and the magnitude of the biological stress such as post-partum status [2, 6].

19 THE EFFECT OF FOLLICLE-STIMULATING HORMONE IN A MODIFIED CO-SYNCH SYNCHRONIZATION PROTOCOL ON SUBSEQUENT PREGNANCY RATES OF CROSSBRED LACTATING BEEF CATTLE

Heritability of reproductive traits is relatively low, leaving only management strategies as an alternative to affect reproductive efficiency in beef cattle. The use of assisted reproductive technologies such as fixed-timed AI (FTAI) offers the ability to increase reproductive efficiency through selection of superior genetics and manipulation of calving dates through estrous-synchronization protocols. Application of these technologies has not been fully embraced by cattlemen due to variation in success rate, primarily associated with the apparent lack of control of follicular waves. While it has been reported that an endogenous increase in FSH precedes the emergence of follicular waves in cattle, we could find no reports on the effects of exogenous FSH on FTAI pregnancy rates. Artificial insemination remains the most important reproductive technology that could positively affect cattlemen. Therefore, this experiment was conducted to test the hypothesis that incorporation of FSH into the CO-Synch synchronization protocol would increase FTAI pregnancy rates in beef cattle. Crossbred beef cows (n = 182) with a mean body weight (BW) of 596 ± 6.6 kg and mean body condition score (BCS) of 5.4 ± 0.07 from 3 different locations were stratified across treatment groups by BW, BCS, and days postpartum or cyclicity status based on plasma progesterone concentrations. Females were estrus synchronized using the 7-day CO-Synch+CIDR protocol. All females received a CIDR insert and 100 µg of gonadotropin-releasing hormone (GnRH; Factrel) on Day 0, followed by CIDR removal, 25 mg of prostaglandin (Lutalyse) IM and fitted with an estrus-detection patch (Estrotect) on Day 7. On Day 2, all females (n = 92) in the FSH treatment group were administered 20 mg of FSH (Folltropin) IM and the remaining females (n = 90) served as nontreated controls. Fixed-timed AI was performed at 72 h following CIDR removal when all females were administered 100 µg of GnRH and the estrus-detection patch was evaluated. The overall FTAI pregnancy rate was 55% (100/182) and there was no difference (P = 0.41) in pregnancy rates across locations so the data were pooled and reanalyzed. Pregnancy rates were not affected (P = 0.54) by treatment group and were 52% (48/92) for the FSH-treated females and 58% (52/90) for the nontreated control group. Similarly, based on evaluation of the estrus-detection patch, there was no difference (P = 0.68) in the percentage of females responding to the synchronization protocol [61% (55/92) v. 68% (61/90)] and no difference (P = 0.55) in the pregnancy rate of responding females [62% (34/55) v. 69% (42/61)] for the FSH-treated and nontreated control groups, respectively. In conclusion, administration of FSH 10 days prior to FTAI in CO-Synch+CIDR synchronized crossbred beef cows did not increase subsequent pregnancy rates. However, exogenous FSH administration should be evaluated further to determine its effects, if any, on follicular dynamics related to FTAI in the lactating beef cow.

Uneven implementation of the National Perinatal Depression Initiative: findings from a survey of Australian women's hospitals

Australia is a leader in recognising that perinatal mental health problems are prevalent and constitute a significant burden of disease among women. In 2009, the Australian government launched the National Perinatal Depression Initiative (NPDI) to address this. To investigate implementation of Australia's NPDI. Data were collected by a structured online survey assessing: screening for depression and depression risk in women receiving antenatal and postnatal care; staff training about perinatal depression; barriers and enablers to implementing the NPDI recommendations. All Australian members of Women's Healthcare Australasia (WHA) were invited to complete the survey in March 2011. Of 30 Australian WHA members, 14 (46.6%) completed the survey. The sample included a representative distribution of small, medium and large hospitals. All respondents had introduced some NPDI recommendations. Most (80%) reported using the Edinburgh Postnatal Depression Scale (EPDS) to screen for antenatal depression and for risk of developing depression but at varied gestational ages, and with differing cut-off scores for follow-up or referral. Only one assessed depression status postpartum. Responsibility for screening and feedback was predominantly assigned to midwives, most of whom were offered <4 h training. Implementation barriers included insufficient personnel; per-client time requirements; insufficient clarity about screening protocols; difficulties modifying the medical record; few referral options and a lack of training resources. Implementation of the NPDI is uneven among Australian maternity hospitals. Little is known about perinatal mental health screening practices in the private sector and hospitals with <1000 births annually.

Couples’ postpartum health status

This study was conducted in Taiwan on couples for a month in the postpartum period to investigate the correlated factors that affect their health status. Most studies have focused on the postpartum health status of mothers, but few of them mention about the postpartum health status of fathers. A cross-sectional design. This study was carried out on a cross-section of couples, and the data were collected through telephone interviews conducted by a research assistant using structured questionnaires. A total of 201 couples who had given birth to a healthy single baby at a medical centre in southern Taiwan were recruited between 1 August 2007-31 November 2007. The two most important factors correlated with mothers' health statuses, during the month-long postpartum period, were mothers' educational and postpartum stress levels. The result also showed that baby's Apgar score at the first minute was the main factor related to father's health status during the month-long postpartum period. Educational programmes should incorporate factors that affect couples' health status during the one month postpartum period to promote postnatal couples' health. To improve the couples' health status during the one month postpartum period, we need to strengthen the stress-coping skills of mothers and provide them with coping resources to support their maternal roles, to provide social support to fathers and to incorporate issues of marital intimacy and parental attachment into the couples' educational programmes. Also, a father's presence at his infant's birth is encouraged to enhance parental attachment.

Clinical Features, Management, and Prognosis of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection. SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare clinical entity of unknown cause that typically affects young women without coronary risk factors.1–5 Initial reports were scarce and based on autopsy findings after episodes of sudden cardiac death, suggesting that the condition had a dismal prognosis.1,2 An intimal tear was seldom found in autopsy series and, therefore, primary disruption with bleeding of vasa vasorum and intramedial hemorrhage was proposed as the underlying mechanism.1,2 Alternatively, an intimal tear may lead to separation of coronary wall layers and, eventually, to a double lumen. Pressure-driven expansion of the false lumen induces axial propagation of the disease and true lumen compression, resulting in myocardial ischemia.2–4 In some patients, weakening of the arterial wall (hormonal changes, cystic medial necrosis, proteolytic enzymes from periadventitial eosinophils)2 may provide an underlying vulnerable coronary wall. Coronary angiography is widely used in the diagnosis of SCAD and the classical intimal flap represents the hallmark of this disease. Most patients present with an acute coronary syndrome but have a favorable prognosis.2–5 However, available evidence on this condition is limited to multiple case reports and small retrospective case series with short follow-up.1–5 Therefore, 8 decades after its first pathological description,1 the diagnosis and management of SCAD remains elusive. Tweet et al6 present the characteristics, management, and outcome of a uniquely large cohort of patients with SCAD seen at the Mayo Clinic during the last 3 decades. Eighty-seven consecutive patients with SCAD were included. In all cases a dissection plane was visible on angiography, but associated atherosclerosis was absent. Mean age was 43 years, and 82% were female. Predisposing conditions included extreme exertion (44% of males) and postpartum status (18% of females). Half …

Reason for removal of US etonogestrel subdermal implant is significantly associated with age, BMI and postpartum status

Reason for removal of US etonogestrel subdermal implant is significantly associated with age, BMI and postpartum status

Postpartum and Depression Status are Associated With Lower [11C]raclopride BPND in Reproductive-Age Women

The early postpartum period is associated with increased risk for affective and psychotic disorders. Because maternal dopaminergic reward system function is altered with perinatal status, dopaminergic system dysregulation may be an important mechanism of postpartum psychiatric disorders. Subjects included were non-postpartum healthy (n=13), postpartum healthy (n=13), non-postpartum unipolar depressed (n=10), non-postpartum bipolar depressed (n=7), postpartum unipolar (n=13), and postpartum bipolar depressed (n=7) women. Subjects underwent 60 min of [¹¹C]raclopride-positron emission tomography imaging to determine the nondisplaceable striatal D₂/₃ receptor binding potential (BP(ND)). Postpartum status and unipolar depression were associated with lower striatal D₂/₃ receptor BP(ND) in the whole striatum (p=0.05 and p=0.02, respectively) that reached a maximum of 7-8% in anteroventral striatum for postpartum status (p=0.02). Unipolar depression showed a nonsignificant trend toward being associated with 5% lower BP(ND) in dorsal striatum (p=0.06). D₂/₃ receptor BP(ND) did not differ significantly between unipolar depressed and healthy postpartum women or between bipolar and healthy subjects; however, D₂/₃ receptor BP(ND) was higher in dorsal striatal regions in bipolar relative to unipolar depressives (p=0.02). In conclusion, lower striatal D₂/₃ receptor BP(ND) in postpartum and unipolar depressed women, primarily in ventral striatum, and higher dorsal striatal D₂/₃ receptor BP(ND) in bipolar relative to unipolar depressives reveal a potential role for the dopamine (DA) system in the physiology of these states. Further studies delineating the mechanisms underlying these differences in D₂/₃ receptor BP(ND), including study of DA system responsivity to rewarding stimuli, and increasing power to assess unipolar vs bipolar-related differences, are needed to better understand the affective role of the DA system in postpartum and depressed women.

Slow Recovery of Blood Glucose in the Insulin Tolerance Test during the Prepartum Transition Period Negatively Impacts the Nutritional Status and Reproductive Performance Postpartum of Dairy Cows

In peripartum dairy cows, insulin resistance (IR) increases to adjust the direction of energy to lactation after calving. To investigate the effect of prepartum IR on postpartum reproductive performance, the insulin tolerance test (ITT) was applied to 15 cows at 3 weeks (Pre21) and 10 days (Pre10) before the predicted calving date. Blood glucose area under the curve (AUC(glu)) within 120 min after administration of 0.05 IU/kg-BW insulin was calculated. The occurrence of first ovulation, days to first artificial insemination (AI) and first AI conception rate were recorded. Nutritional status postpartum was evaluated by blood chemical analysis. Based on AUC(glu) changes from Pre21 to Pre10, cows were classified into either the AUC-up group (AUC(glu) increase, n=5) or the AUC-down group (AUC(glu) decrease, n=10). There was no difference in the decrease in blood glucose at 30 min after insulin injection between groups, although glucose recovery from 30 to 60 min during the ITT was slow at Pre10 in the AUC-up group. The AUC-up group had a higher number of days to first AI and high glucose, total protein, globulin, γ-glutamyltransferase, triacylglycerol levels and a low albumin-globulin ratio at the 14th day postpartum. The present study infers that prepartum slow glucose recovery rather than insulin sensitivity might increase the potential for subclinical health problems postpartum and thus suppress reproductive performance. During the prepartum transition period, glucose dynamics in the ITT can be considered as a new indicator for the postpartum metabolic status and reproductive performance of dairy cows.

Associations of prepartum plasma cortisol, haptoglobin, fecal cortisol metabolites, and nonesterified fatty acids with postpartum health status in Holstein dairy cows

The association between negative energy balance and health has led to the testing of blood analytes such as nonesterified fatty acids (NEFA) to identify opportunities for improving the management of transition dairy cows. The objective of this study was to evaluate whether prepartum analytes associated with stress (cortisol) or inflammation (haptoglobin) could also identify dairy cattle at increased risk for health complications after calving. Prepartum blood and fecal samples were collected once weekly from 412 Holstein dairy cows on 2 commercial dairy farms (at wk −3, −2, and −1 relative to calving) and analyzed for concentrations of NEFA, haptoglobin (Hp), and cortisol in plasma and cortisol metabolites in feces. Retained placenta (RP), displaced abomasum (DA), subclinical ketosis (SCK), high Hp concentration (HiHp), and death were recorded up to 30 d in milk (DIM), and animals were subsequently categorized into 3 health categories: (1) no disorder of interest (NDI); (2) one disorder (RP, DA, SCK, or HiHp); or (3) more than one disorder (RP, DA, SCK, HiHp) or death. With the exception of prepartum NEFA, no associations were detected between prepartum concentrations of our analytes of interest and the occurrence of one disorder (RP, DA, SCK, or HiHP) by 30 DIM. Haptoglobin concentration tended to be greater during wk −2 and −1 in cows that developed more than one disorder or that died by 30 DIM; however, when calving assistance was included as a covariate in the analysis prepartum, Hp was no longer a significant risk factor for this postpartum health outcome. Primiparous cows with plasma cortisol concentrations >22.2nmol/L during wk −2 had reduced odds [odds ratio (OR) 0.41; 95% confidence interval (CI) 0.17–0.98] of developing more than one disorder or death by 30 DIM, whereas multiparous cows with plasma cortisol >34.1nmol/L during wk −2 tended to have greater odds (OR 2.53; 95% CI 0.87–7.37) of developing more than one disorder or death by 30 DIM. Individual variation in daily cortisol secretion patterns and stress responses to the restraint and handling associated with sample collection make prepartum plasma cortisol data and its relationship to postpartum health difficult to interpret. Among multiparous cows, for every 500-unit (ng/g of fecal dry matter) increase in fecal cortisol metabolite concentration during wk −2, cows had increased odds (OR 1.41; 95% CI 1.12–1.79) of developing more than one disorder or dying after calving. For multiparous cows, every 0.15mmol/L increase in plasma NEFA concentration during any of the 3 wk before calving was associated with an approximately 2-fold increase in the odds of developing more than one disorder or dying by 30 DIM. Fecal cortisol metabolite concentration during the prepartum period did not predict which cows would go on to develop more than one disorder or die within 30 DIM as accurately as prepartum NEFA concentration; therefore, this analyte is not a suitable substitute for NEFA for assessing opportunities to improve herd health.

Interaction of maternal age and mode of delivery in the development of postpartum depression in Yerevan, Armenia

To investigate determinants of development of postpartum depression among women in Yerevan, Armenia. A case-control study of all reproductive age (18-45) women having 1-3 months old children registered in 7 Primary Health Care (PHC) facilities, in Yerevan. We used Edinburgh Postnatal Depression Scale (EPDS) and a structured questionnaire to assess possible postpartum depression status of mothers and exposure status through telephone interviews. The study had a 96.7% response rate for 63 cases and 272 controls. The prevalence of possible postpartum depression was 14.4%. The risk of possible postpartum depression associated with age less than 25 years at childbirth was increased only among women who delivered their child through C-section (OR=7.8; 95% CI: 1.5-40.7). Meanwhile, this risk was much lower among women who delivered through vaginal delivery (OR=0.9; 95% CI: 0.4-1.8). EPDS had not been translated and validated in Armenia. Study population included only women having 1-3 months old children. The study suggested that the effect of younger age at last childbirth on the risk of possible postpartum depression development was higher for women who gave birth through C-section compared to those with vaginal delivery. Despite the stressful and crisis conditions existing in Armenia over the past 2 decades the prevalence of possible postpartum depression does not differ much from that in other societies.

Predictors of an Unsatisfactory Conventional Cervical Cytology Smear

ObjectivesCervical cytology smears reported as unsatisfactory for interpretation represent an unrealized screening opportunity and may have significant laboratory and patient costs. Identifying patients at higher risk for an unsatisfactory smear could alert clinicians to take extra care in the acquisition of the smear. Few studies have examined patient characteristics that could predict an unsatisfactory cervical cytology smear. The purpose of this study was to determine the effect of patient age, day of the menstrual cycle, postmenopausal status, postpartum status, and the use of oral contraceptives on the rate of unsatisfactory cervical cytology smears. MethodsWe performed a case–control study of all unsatisfactory cervical cytology smears at a large tertiary care teaching hospital over one year compared with a random sample of smears that were satisfactory for interpretation. Data were obtained from the cytology requisitions. Continuous variables were tested with unpaired t tests, and dichotomous variables were analyzed with chi-square tests. Multivariate significance was tested with binary logistic regression analysis. ResultsOf all cervical cytology smears, 1.1% were reported as unsatisfactory. In univariate analyses increased age, earlier date in the menstrual cycle, and postpartum status were associated with unsatisfactory smears. However, following Bonferroni correction for multiple comparisons and multivariate regression analysis, only increased age remained a significant predictor of an unsatisfactory cervical cytology smear. ConclusionOlder women are at greater risk of having an unsatisfactory cervical cytology smear. Clinicians and public health officials must be aware of this risk and must encourage optimal collection techniques for women in this demographic group.

Incidence and Severity of Invasive Streptococcus pneumoniae, Group A Streptococcus, and Group B Streptococcus Infections Among Pregnant and Postpartum Women

The epidemiology of streptococcal infection in pregnant and postpartum women is poorly described in recent literature. We used data from multistate surveillance for invasive Streptococcus pneumoniae, group A Streptococcus (GAS), and group B Streptococcus (GBS) infections to estimate disease incidence and severity in these populations. Cases were reported through the Centers for Disease Control and Prevention Active Bacterial Core surveillance, an active population- and laboratory-based system. A case was defined as illness in a woman aged 15-44 years with streptococcus isolated from a normally sterile body site during 2007-2009. Pregnant or postpartum status was recorded at the time of culture. Incidence was calculated as cases per 1000 woman-years with use of national Census data; 95% confidence intervals were calculated on the basis of λ distribution. We used multivariable logistic regression to explore associations between pregnant or postpartum status and hospital length of stay, a marker of disease severity. We identified 1848 cases in women; 6.0% of women were pregnant, and 7.5% were postpartum. Pregnant women had a higher mean incidence of GBS disease, compared with nonpregnant women (0.04 cases per 1000 woman-years [range, 0.03-0.05 cases per 1000 woman-years] vs 0.02 cases per 1000 woman-years [range, 0.02-0.02 cases per 1000 woman-years]). Postpartum women had elevated mean incidence of all 3 pathogens, compared with nonpregnant women (S. pneumoniae: 0.15 cases per 1000 woman-years [range, 0.09-0.25 cases per 1000 woman-years] vs 0.052 cases per 1000 woman-years [range, 0.049-0.056 cases per 1000 woman-years]; GAS: 0.56 cases per 1000 woman-years [range, 0.42-0.70 cases per 1000 woman-years] vs 0.019 cases per 1000 woman-years [range, 0.017-0.021 cases per 1000 woman-years]; GBS: 0.49 cases per 1000 woman-years [range, 0.36-0.64 cases per 1000 woman-years] vs 0.018 [range, 0.016-0.020 cases per 1000 woman-years]). Neither pregnancy nor postpartum status was associated with longer length of stay among women infected with any of the 3 pathogens. Although invasive streptococcal infections do not appear to be more severe in pregnant or postpartum women, postpartum women have a 20-fold increased incidence of GAS and GBS, compared with nonpregnant women.

Low urinary iodine postpartum is associated with hypothyroid postpartum thyroid dysfunction and predicts long-term hypothyroidism

Postpartum thyroid dysfunction (PPTD) is characterized by an early hyperthyroid phase followed, with peak prevalence at 6 months, by a hypothyroid phase which carries a risk of long-term hypothyroidism. Iodine has a major effect on thyroid function. Western Australia has previously been shown to be iodine replete. To examine the iodine status of women with and without PPTD and the relationship of iodine status postpartum with long-term hypothyroidism. Case-control with follow-up. A total of 149 women at 6 months postpartum (74 PPTD, 75 controls) with 98 (46 PPTD, 52 controls) followed up at 12 years. Urinary iodine concentration (UIC) and thyroid function at 6 months postpartum; thyroid function at 12-year follow-up. At 6 months postpartum, median UIC (quartiles) for observed TSH ranges were: for TSH < 0·4 mU/l 130·0 μg/l (82·0, 170·0); for TSH 0·4-4·0 mU/l 123·0 μg/l (80·5, 168·0); for TSH > 4·0 mU/l 85·0 μg/l (40·0, 141·5), P = 0·018. The odds ratio (OR) of hypothyroid PPTD with each unit of decreasing log iodine was 2·54, (95%CI: 1·47, 4·35), and with UIC < 50 μg/l, OR 4·22, (95%CI: 1·54, 11·55). In the long term, decreased log UIC significantly predicted hypothyroidism at 12-year follow-up (P = 0·002); as did UIC < 100 μg/l (P = 0·03) and UIC < 50 μg/l (P = 0·02). The association was independent of antibody status. Low UIC measured at 6 months postpartum is associated with hypothyroid PPTD and independently predicts long-term hypothyroidism. We believe that it results from more severe preceding destructive thyroiditis, with discharge of thyroidal iodine, and thereby predicts a greater risk of long-term hypothyroidism.

Prepartum dietary energy intake affects metabolism and health during the periparturient period in primiparous and multiparous Holstein cows

An experiment was conducted to determine the effect of prepartum plane of energy intake on metabolic profiles related to lipid metabolism and health in blood and liver. Primiparous (n=24) and multiparous (n=23) Holsteins were randomly assigned by expected date of parturition to 1 of 3 prepartum energy intakes. A high energy diet [1.62 Mcal of net energy for lactation (NEL)/kg; 15% crude protein] was fed for either ad libitum intake or restricted intake to supply 150% (OVR) or 80% (RES) of energy requirements for dry cows in late gestation. To limit energy intake to 100% of National Research Council requirements at ad libitum intake, chopped wheat straw was included as 31.8% of dry matter for a control diet (CON; 1.21 Mcal of NEL/kg of dry matter; 14.2% crude protein). Regardless of parity group, OVR cows had greater concentrations of glucose, insulin, and leptin in blood prepartum compared with either CON or RES cows; however, dietary effects did not carry over to the postpartum period. Prepartum nonesterified fatty acids (NEFA) were lower in OVR cows compared with either CON or RES cows. Postpartum, however, OVR cows had evidence of greater mobilization of triacylglycerol (TAG) from adipose tissue as NEFA were higher than in CON or RES cows, especially within the first 10 d postpartum. Prepartum β-hydroxybutyrate (BHBA) was not affected by diet before parturition; however, within the first 10 d postpartum, OVR cows had greater BHBA than CON or RES cows. Prepartum diet did not affect liver composition prepartum; however, OVR cows had greater total lipid and TAG concentrations and lower glycogen postpartum than CON or RES cows. Frequency of ketosis and displaced abomasum was greater for OVR cows compared with CON or RES cows postpartum. Controlling or restricting prepartum energy intake yielded metabolic results that were strikingly similar both prepartum and postpartum, independent of parity group. The use of a bulky diet controlled prepartum energy intake in multiparous and primiparous cows, improved metabolic status postpartum, and reduced the incidence of health problems. When metabolic profiles are considered collectively, cows overfed energy prepartum exhibited an “overnutrition syndrome” with characteristics of clinical symptoms displayed by diabetic or obese nonruminant subjects. This syndrome likely contributed to metabolic dysfunction postpartum.