Women In Postpartum Period Research Articles

Inherited thrombophilia and pregnancy associated venous thromboembolism

Pulmonary embolism is the leading cause of maternal mortality in developed countries and accounts for 20% of pregnancy related deaths in the United States.1 2 The risk of pulmonary embolism...

Impact of Pregnancy on Serum Thyroglobulin and Detection of Recurrent Disease Shortly After Delivery in Thyroid Cancer Survivors

Since pregnancy can stimulate thyroid growth, we examined the effect of pregnancy on recurrence and serum thyroglobulin (Tg) shortly after delivery in thyroid cancer survivors. Retrospective analysis of thyroid cancer survivors who became pregnant after completing initial therapy. 36 women (age 34 +/- 4 years) who became pregnant a median of 4.3 years after initial therapy for differentiated thyroid cancer were evaluated a median of 4 months after delivery. As part of their initial therapy, 23 women underwent total thyroidectomy with radioactive iodine remnant ablation (RRA), six had total thyroidectomy without RRA, and seven underwent lobectomy without RRA. Following total thyroidectomy with or without RRA, no evidence of recurrence was detected in the early postpartum period in women with negative prepregnancy ultrasound and either undetectable or low suppressed Tg levels. However, disease progression was documented as enlargement of a previously stable cervical lymph node in one of three patients and a marked rise in serum Tg without evidence of structural disease progression in a patient with previously stable distant metastases. When analyzed based on initial therapy, the mean suppressed Tg after delivery was not significantly different than the prepartum value. However, eight women had Tg values after delivery more than 20% higher than the baseline Tg before pregnancy (three with known disease, five with no clinical evidence of disease). In thyroid cancer survivors, pregnancy is unlikely to cause clinically significant disease recurrence in the early postpartum period when structural imaging studies confirm the absence of residual disease but can occasionally be associated with progression of known metastatic lesions. Even though the serum Tg did not differ significantly before and after pregnancy, the long-term implications of minor rise in serum Tg seen in some individual patients cannot be assessed without longer studies in larger cohorts.

Postpartum Dietary Changes in Women With Previous Gestational Diabetes Mellitus

ABSTRACT OBJECTIVE Women with gestational diabetes mellitus (GDM) are at high risk of developing type 2 diabetes. This study was conducted to determine whether nutrition education upon diagnosis of GDM resulted in dietary change and whether this change was sustained postpartum. METHODS Women with GDM or impaired glucose tolerance of pregnancy (≤ 32 weeks gestation) (n = 19) were recruited, and 4-day food records were collected pre-dietary intervention, 2 weeks post-dietary intervention, and 6 weeks and 6 months postpartum. Physical activity was assessed, and glucose tolerance and lipid profiles were also determined postpartum. RESULTS After nutrition education there was a significant increase in protein (% kcal), milk and milk products (servings) and dietary fibre (g) intake, as well as meal frequency (number of meals/day). However, these changes were not subsequently sustained throughout the postpartum period. Physical activity levels did not change, and at 6 months postpartum, 26% of subjects had impaired glucose tolerance and 97% had at least 1 abnormal lipid variable. CONCLUSIONS Women with GDM made changes in eating patterns during pregnancy, but these were not maintained postpartum. Further intervention is recommended during the postpartum period for women with GDM to sustain changes made during pregnancy.

Postpartum major depression at six weeks in primary health care: prevalence and associated factors.

Major depression is a common and disabling complication of the postpartum period in women. It is thought to occur three times more commonly in the developing than in developed countries. The objectives of this study were to determine the prevalence of and factors associated with major depression among women attending a peri-urban primary health care unit in Kampala, Uganda, at six weeks postpartum. Five hundred and fourty four women attending a peri-urban health centre were investigated in a cross-sectional study. These women were screened using the twenty five-item Self Reporting Questionnaire (SRQ-25), while major depression was confirmed using the Mini International Neuro-psychiatric Interview (MINI). Associations were sought between major depression and the respondents' demographics and various psychological, social and obstetric factors. The point prevalence of major depression at six weeks postpartum was 6.1%. Psychiatric disorder was significantly associated with young age, being single, negative life events, unplanned pregnancy, unwanted sex of baby and current physical illness in both mother and newborn. There is indication for routine screening of at risk women in the peri-natal period to avoid, recognize and manage postpartum psychiatric morbidity and its consequence on mothers and their developing children.

Efficacy Similar for SSRIs, TCAs In Postpartum Depression

Efficacy Similar for SSRIs, TCAs In Postpartum Depression

Changes in Health Status Experienced by Women with Gestational Diabetes and Pregnancy-Induced Hypertensive Disorders

To examine changes in health status among women with gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH). We examined perceived health status changes from the prepregnancy, as recalled at 12-20 weeks gestation, to the postpartum period in women with GDM (n = 64) vs. unaffected gravidas (n = 1233) and women diagnosed with PIH (n = 148) vs. unaffected gravidas. We used patient survey and medical record data from a prospective cohort study. Health status measures included the Short Form-36 scales for physical function, vitality, and self-rated health and the Center for Epidemiologic Studies-Depression Scale (CES-D). Multivariate logistic regression models controlled for age, parity, race, education, prepregnancy body mass index (BMI) and exercise levels, food insufficiency, and GDM or PIH during a prior pregnancy. Women with PIH more often reported a significant decline in vitality (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.02-2.23) and self-rated health (OR 2.12, 95% CI 1.19- 3.77) and an increase in depressive symptoms from prepregnancy to postpartum compared with unaffected women (OR 1.84, 95% CI 1.11-3.05). Decline in self-rated health was partially mediated by cesarean birth and preterm delivery. Similar proportions of women with GDM and unaffected women reported declines in health status measures. Women with PIH, but not GDM, more often experience significant declines in health status from prepregnancy to postpartum than unaffected women.

Increase of Serum Angiopoietin-2 During Pregnancy Is Suppressed in Women With Preeclampsia

Numerous recent reports demonstrated that changes in serum levels of angiogenesis-related factors were associated with preeclampsia. Here, we determined the serum concentration of angiopoietin-2 (Ang-2), a natural antagonist of angiopoietin-1 (Ang-1) involved in promoting angiogenesis in the presence of angiogenic stimuli such as vascular endothelial growth factor (VEGF), in women with preeclampsia. The levels of serum Ang-2 and Tie-2, a receptor for Ang-1 expressed on endothelial cells, were determined by enzyme-linked immunosorbent assay. The concentrations of serum Ang-2 were significantly elevated in healthy pregnant women (18.9 ng/mL) as compared to nonpregnant women or women in postpartum period. Increase in the levels of serum Ang-2 was significantly suppressed in preeclamptic women (4.5 ng/mL). The serum Ang-2 concentrations inversely correlated with gestational age in healthy pregnant women, but not in preeclamptic women. The serum Ang-2 concentrations positively correlated with placental weight or mean blood pressure (BP) in healthy pregnant women, but not in preeclamptic women. The serum Ang-2 concentrations inversely correlated with proteinuria in preeclamptic women. The serum concentrations of Tie-2 were not significantly different between preeclamptic and nonpreeclamptic women. These results suggest the potential requirement of circulating Ang-2 in proper formation of placental vasculatures during pregnancy. Although we cannot exclude the possibility that suppression in the increase of serum Ang-2 levels during pregnancy in preeclampsia as a consequence rather than a cause, measurement of serum Ang-2 concentration in pregnant women may serve as a useful marker in the diagnosis and potentially in predicting subsequent development of preeclampsia.

Higher rates of post-partum complications in HIV-infected than in uninfected women irrespective of mode of delivery.

To inform the debate on the use of elective caesarean section (CS) delivery in HIV-infected women, we investigated the occurrence of clinical events in the immediate post-partum period in women delivering in 13 European centres. Two separate matched case-control studies (vaginal and elective CS deliveries) among infected women (cases) and uninfected controls delivering between 1992 and 2002. The prevalence of minor and major post-partum complications was assessed overall for infected and uninfected women; within mode of delivery group (vaginal/CS) the complication rates of infected cases were compared with uninfected controls in a matched analysis. Overall complication rates were 29.2% (119 of 408) for HIV-infected women, 19.4% (79 of 408) for uninfected women, 42.7% (135 of 316) for CS deliveries and 12.6% (63 of 500) for vaginal deliveries. There were no major complications in women delivering vaginally; but, compared with controls, HIV-infected cases were at increased risk of puerperal fever [odds ratio (OR), 4.5; 95% confidence interval (CI), 1.55-13.07), especially after medio-lateral episiotomy. In the CS group, there were six major complications (five among cases, one control) (OR, 5.1; 95% CI, 0.58-45) and cases had an increased risk of minor complications (OR, 1.51; 95% CI, 1.22-2.41) compared with controls, mainly anaemia not requiring blood transfusion. HIV-infected pregnant women are at increased risk of post-partum complications regardless of mode of delivery, but modification of clinical practice, particularly use of prophylactic antibiotics, would reduce this risk. Infected women should be informed about risks of vertical transmission and post-partum complications, and be involved in mode of delivery decisions.

Noninfectious uveitis and pregnancy

PurposeTo report the course of uveitis disease activity during pregnancy and the postpartum period in women with noninfectious uveitis. DesignObservational case series. MethodsThe medical records of women with noninfectious uveitis and pregnancy during follow-up at a large eye hospital were retrospectively reviewed. Patients with pregnancy were included in the study if follow-up was adequate to document the presence or absence of flare-ups in uveitis activity during the pregnancy and/or postpartum period. ResultsSeventy-six pregnancies among 50 women were included in the study. Thirty-three pregnancies were in women with Vogt–Koyanagi–Harada disease, 19 were in women with Behcet disease, and 24 were in women with idiopathic uveitis. A flare-up in uveitis activity occurred within the first 4 months of pregnancy in 49 of 76 cases (64%) and later in pregnancy in 17 cases (22%); no flare-up occurred during pregnancy in 21 cases (28%). An early pregnancy flare-up was typical of Vogt-Koyanagi-Harada disease and idiopathic uveitis. A flare-up within 6 months of delivery occurred in 38 of 59 cases (64%) that had adequate examination data available from the postpartum period. The postpartum flare-up was especially typical of Behcet disease. ConclusionsMany women with noninfectious uveitis will experience a flare-up in disease activity within the first 4 months of pregnancy. Later pregnancy appears to be a time of relative disease inactivity. Many will experience a rebound in activity within 6 months of delivery.

Thrombotic Disorders: Diagnosis and Treatment

Hematologists are increasingly involved in the diagnosis and management of patients with venous and arterial thromboembolic disorders. There have been major advances in recent years in our understanding of the central role of hypercoagulability in the pathogenesis of thrombosis. This has led to new approaches to the diagnosis of patients at risk for thrombosis and the development of more rational antithrombotic strategies. In Section I, Dr. Andrew Schafer reviews current concepts of acquired and inherited hypercoagulable states. It is now recognized that most, if not all, patients with venous thromboembolism have a genetic basis for the disorder ("thrombophilia"). The level of lifelong, baseline hypercoagulability in any individual may be determined by the type(s) and number of thrombophilia(s) that are inherited. Clinical episodes of thrombosis are precipitated by acquired thrombogenic triggers, which may be overt (e.g., pregnancy) or subclinical. In Section II, Dr. Mark Levine discusses the complex problem of thrombosis in patients with cancer. The goals of treating acute venous thromboembolism in cancer patients are to prevent recurrence, minimize the risk of anticoagulant-induced bleeding, and improve quality of life. New developments have improved treatment of venous thromboembolism in these patients, including outpatient therapy and secondary prevention with low-molecular-weight heparin. In Section III, Dr. Barbara Konkle reviews the diagnosis and management of thrombotic complications associated with pregnancy and hormonal therapy. Patient management is discussed based on data on thrombotic risks associated with hormonal treatment of infertility, pregnancy and the post-partum period in women with and without underlying thrombophilic risk factors. In Section IV, Dr. Clive Kearon discusses the management of anticoagulation before and after elective surgery. In the past, there has been no consensus on the perioperative management of anticoagulation for patients who require long-term warfarin therapy. This review considers the expected risks and benefits of different approaches to anticoagulation in patients who require warfarin because of atrial fibrillation, a mechanical heart valve, or a history of venous thromboembolism.

Inherited thrombophilia and gestational venous thromboembolism.

Inherited thrombophilias are associated with an increased risk of venous thromboembolism (VTE) and the risk is further increased during pregnancy. However, not all pregnancies or all thrombophilias carry the same risk. Deficiencies in coagulation inhibitors and especially in antithrombin are rare but are associated with a higher risk than the most frequent factor V Leiden or prothrombin (factor II) 20210A mutations. Differences may be observed depending on heterozygosity or homozygosity of the defects and on the presence of combined thrombophilias. Although we now have more information on the global risk of thrombosis in thrombophilia, the magnitude of the risk is unknown in women who do or do not have a history of VTE, and in those who are the propositus or family members. Additional risk factors may be taken into account such as age of the mother, cesarean section, obesity, and immobilization during pregnancy. Recommendations of the American College of Chest Physicians (ACCP) concerning prophylaxis during pregnancy published in 2001 are mostly 1C recommendations; they are based on observational studies and subject to changes when more information becomes available. There is now a consensus about prevention in the postpartum period in women with thrombophilia. In contrast, prophylaxis in the antepartum period is often determined on an individual basis. We give some indications of the appropriate prophylaxis on the basis of the ACCP recommendations and personal experience.

Pregnancy-induced changes in lower extremity superficial veins: An ultrasound scan study

Objective: The purpose of this study was to follow changes in superficial veins of the lower extremities during pregnancy and the postpartum period in women with varicose veins. Methods: This was a prospective study with the use of duplex scanning during the first and third trimesters of pregnancy and postpartum period. Competent veins were defined as veins with an absence of reflux, and incompetent veins were defined as veins with reflux. The diameter of the competent or incompetent greater saphenous vein (GSV) and lesser saphenous vein (LSV) was measured. The diameter of the largest varicose dilatations was measured in all three networks: GSV and its tributaries, LSV and its tributaries, and nonsaphenous varicose veins. Results: Sixty-six women were studied prospectively (mean age, 32.2 ± 4 years; 85 affected extremities). The diameter of competent and incompetent GSVs and competent LSVs increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). The diameter of the largest varicose dilatations of the GSV and its tributaries and nonsaphenous networks increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). No statistically significant variation of the diameter was demonstrated for any of these veins between the first trimester and the postpartum period. Conclusion: The diameters of competent and incompetent superficial veins increased during pregnancy and decreased during the postpartum period to return to their baseline values. (J Vasc Surg 2000;32:570-4.)

Postpartum care of the woman with diabetes.

The postpartum period in women with diabetes or GDM allows both the physician and mother to relax from the intensive medical and obstetric management that has permitted, in most cases, a successful and joyous outcome. The role of the physician, however, must switch to a proactive and preventive mode to formulate a reproductive health plan for women with diabetes and GDM. The plan should be individualized to address glycemic management and surveillance, nutritional management, contraception prescription, future pregnancy planning, and lifestyle changes. Essential to the development of a reproductive health plan is the active participation of the patient, who through education gains an understanding of the far-reaching effects her active participation will have on her subsequent health and possibly on that of her future children.

Postpartum Uterine-Artery Velocity Waveforms in Women with Sickle Cell Disease

Objective: To investigate the changes in uterine Doppler velocimetry during the postpartum period in women with homozygous sickle cell (SS) disease and to correlate these findings with values in the third trimester and with neonatal outcomes. Methods: We studied the postpartum changes in uterine Doppler velocimetry in 16 women with SS disease in relation to third-trimester systolic/diastolic (S/D) ratios and neonatal outcome. All patients had repeated measures of uterine S/D ratios biweekly in the third trimester from 28 weeks of pregnancy until delivery, and at 24 h, and 3 and 6 weeks postpartum. Results: Overall the mean S/D ratio in the first 24 h for these 16 women was 2.72 ± 0.72 and increased progressively to a mean S/D ratio of 6.88 ± 0.96 at 6 weeks postpartum, with the reappearance of a diastolic notch by the 3rd postpartum week. Twelve women who had normal (≤2.6) uterine S/D ratios during pregnancy delivered appropriate-for-gestational-age (AGA) infants. The remaining 4 women had abnormal uterine S/D ratios, and in 3 of these pregnancies, small-for-gestational-age (SGA) infants were delivered. The mean S/D ratios for the subgroups with abnormal value at each of the three postpartum periods were significantly higher than for the 12 SS patients with normal third-trimester values. Postpartum S/D ratios for the 3 women with SGA births were also significantly higher at 24 h and 6 weeks postpartum when compared to SS patients with AGA infants. Conclusion: We concluded that postpartum S/D ratios are higher in women with SS disease that have abnormal values in the third trimester and that they are associated with SGA births. In SS patients the nonpregnant pattern of uterine artery velocity waveforms which reappears postpartum may reflect an increase in the uteroplacental circulatory impedence due to reversal of the alterations in the spiral arteries induced by trophoblastic invasion during pregnancy or subinvolution of the placental bed. Additional studies are needed to further elucidate these important hemodynamic changes in women with hemoglobinopathies and to identify patterns predictive of neonatal outcomes in these high-risk patients.

Frequency of pregnancy-related venous thromboembolism in anticoagulant factor-deficient women: implications for prophylaxis.

It has been reported that women with an inherited deficiency of antithrombin, protein C, or protein S have an increased risk for developing venous thromboembolic disease during pregnancy and the postpartum period. However, because the available data on risk are flawed, it is difficult to define a rational, efficacious, and safe policy about prophylaxis for venous thromboembolism in these women. To determine the frequency of venous thromboembolism during pregnancy and the postpartum period in women with heritable deficiencies of anticoagulant factors. Retrospective cohort study. University outpatient clinics in the Netherlands and Italy. 129 otherwise asymptomatic female family members of patients with a history of venous thromboembolism and an established deficiency of antithrombin, protein C, or protein S. Medical history, with specific attention to episodes of venous thromboembolism and obstetric history, was taken. The anticoagulant factor status of the study participants was determined. If a patient had an episode of venous thromboembolism, subsequent pregnancies in that patient were not analyzed. Of the 129 women who participated in the study, 60 had anticoagulant factor deficiency and 69 did not. In the nondeficient group, 198 pregnancies occurred; 1 of these (0.5%) was complicated by an episode of venous thromboembolism during the postpartum period. In the deficient group, 169 pregnancies occurred; 7 of these (4.1%) were complicated by an episode of venous thromboembolism during the third trimester of pregnancy (2 pregnancies [1.2%]) and the postpartum period (5 pregnancies [3.0%]). The risk for venous thromboembolism was increased eightfold in deficient women compared with nondeficient women (hazard ratio, 8.0 [95% CI 1.2 to 184]). Anticoagulant factor-deficient women have an increased risk for venous thromboembolism during pregnancy and the postpartum period. Although data from an appropriate randomized clinical trial are lacking, the frequency of venous thromboembolism seen in deficient women might justify the use of anticoagulative prophylaxis during the third trimester of pregnancy and the postpartum period.

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

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

Peculiarities of the course of labor and the postpartum period in women whose pregnancy was threatened with termination

To clarify the peculiarities of the course of labor, the postpartum period, and the condition of newborns, we analyzed 102 labor histories of women whose pregnancies were complicated by the threat of termination in different terms. Morphological examination of the placenta was performed concurrently in these women in labor. The age of the examined women ranged from 18 to 35 years.

HEART DISEASE AS A COMPLICATION OF PREGNANCY, WITH EMPHASIS ON INDICATIONS FOR RECOMMENDING THERAPEUTIC ABORTION OR AVOIDANCE OF CONCEPTION

Mere diagnosis of a valvular heart lesion without circulatory incapacity is inconsequential in considering the prognosis for a pregnant woman.There are grave dangers of heart failure during pregnancy, labor or the postpartum period in women who have had congestive failure prior to pregnancy or during a previous pregnancy and delivery. Decisions as to whether or not to recommend avoidance of pregnancy or therapeutic abortion should depend not alone upon the prospect of death during gestation or at the time of delivery, but also upon the possibility of increased impairment of heart function and physical incapacity of the mother in the postpartum period. Because of the extensive surgical procedure there are few indications for interrupting pregnancy after the third lunar month; and because the major circulatory loads do not increase after the eighth month, rarely should labor be prematurely induced after that time.The exertion of labor, although generally inconsequential, in some cases may produce sustained oxygen debt. In cases in which labor in a previous pregnancy has been accompanied by heart failure, cesarean section should be considered as a means of lessening the possibility of serious failure or death, although this is not a frequent consideration. In the resemblance of circulatory changes that occur, during delivery and immediately postpartum, to those changes produced by the closure of an arteriovenous shunt or patent ductus arteriosus, lies a suggestion as to some of the causative factors in heart failure during or soon after delivery. Probably of great importance is the decrease in blood volume and hemoconcentration at delivery followed by the return of water to the circulatory system, with consequent transient increase in blood volume, in the postpartum period. Additionally, the rise of venous pressure after use of oxytocic drugs suggests that rapid infusion of blood from an engorged uterus may cause an abrupt and perhaps poorly tolerated hypervolemia. Death by heart failure in pregnancy and the puerperium has become extremely rare in recent years due to the frequent observations, meticulous diagnosis of impending failure and improved care of cardiac patients jointly by the obstetrician and the internist. In addition to digitalis therapy and sodium restriction, patients exhibiting evidence of impending heart failure may require bed rest through the entire third trimester of pregnancy. Oxygen should be administered during labor in such patients and anoxia guarded against during anesthesia.