"Anybody's child": severe disorders of mother-to-infant bonding

BACKGROUND

This paper describes severe, disorders of maternal affection and behaviour and suggests that there is an early process of mother-to-infant bonding which can go seriously wrong.

METHOD

Forty-four self-selected women who had suffered from at least one episode of postnatal mental illness described an unexpected and often catastrophic failure to love one or more of their babies.

RESULTS

These women reported absent affection, sometimes hate, rejection, neglect or impulses to harm, in relation to at least one of their children. These feelings often began immediately or very shortly after the birth, and with one exception, were specific to one child; such characteristics are best encapsulated by the term 'maternal bonding disorder'. Twenty-nine of the women were multiparae; first-borns were not significantly more likely to be the focus for such feelings. There was no direct evidence of predisposing maternal personality traits or previous experiences. Postnatal mental illness and recalled severe pain during labour were significantly associated with such disorders which, in their severe forms, did not occur in the absence of postnatal mental illness.

CONCLUSIONS

The nature of the link between postnatal mental illness and disorders of maternal bonding remains unclear. Because, in multiparae, the disorder often 'missed' the first child, factors such as maternal personality traits or early childhood experiences cannot be regarded as sufficient causes.

Osteomyelitis pubis occurring after spontaneous vaginal delivery: a case presentation

BACKGROUND

Osteomyelitis pubis is an uncommon disorder. The clinical presentation is similar to that of osteitis pubis, which is a self-limiting condition. However, osteomyelitis pubis necessitates intensive intravenous antibiotic therapy and, frequently, surgery to effect a cure.

CASE

A 33-year-old gravida II para 1001, Filipina vaginally delivered a 3802 gm baby on April 5, 1994. The delivery was complicated by shoulder dystocia. Her postpartum course was complicated by an abscessed tooth and pubic pain that was exacerbated by ambulation. On the twentieth postpartum day, she came to the emergency department with massive cellulitis of the mons veneris and labia majora. The results of an x-ray examination and bone scan were consistent with osteomyelitis of the pubis. The patient did not respond to multiple intravenous antibiotics, and surgical debridement was required.

CONCLUSIONS

A diagnosis of osteomyelitis pubis should be considered for any patient who experiences pubic pain that is exacerbated by walking. Proper therapy consists of intravenous antibiotics and surgical debridement, as necessary, in patients who do not respond to antibiotics.

Deep vein thrombosis in pregnancy and the puerperium: a comprehensive review

Although uncommon during pregnancy and the postpartum period, deep vein thrombosis (DVT) and its sequela, pulmonary thromboembolism, remain leading sources of maternal mortality and morbidity. The majority of literature concerning DVT in pregnancy and the postpartum period exists in the medical journals, with only a small amount in nursing journals. This article provides the nursing community a comprehensive review of literature concerning the incidence of both DVT and pulmonary embolism in pregnancy and the postpartum period, identification of risk factors, the effectiveness of available screening and diagnostic tools, and finally, options for treatment and prophylaxis.

Peripartum cardiomyopathy

Peripartum cardiomyopathy is an uncommon condition of unknown aetiology. Diagnosis requires exclusion of other causes of congestive cardiac failure and the demonstration of global ventricular dysfunction on echocardiography. Treatment consists od diuretics, vasodilators, digoxin and anticoagulants. Prognosis is related to recovery of ventricular function. The availability of cardiac transplantation has improved the outlook for those with persistent dysfunction.

[Acute fatty liver of pregnancy complicated by pancreatitis]

A woman with acute fatty liver of pregnancy developed fulminant hepatic failure after delivery, a time when spontaneous recovery was expected. Pancreatitis and multiple organ failure was documented and intensive treatment in a critical care unit was needed to support organ function. She underwent plasmapheresis due to extreme hyperbilirubinemia and coma. She recovered completely.

Treatment of spontaneous coronary artery dissection: report of three cases

Spontaneous coronary artery dissection is an extremely rare cause of myocardial infarction. It has been reported mainly in young women during or after pregnancy. The prognosis and treatment of coronary dissection are not clear. We report three cases of spontaneous coronary artery dissection in young women. One of them was pregnant and one was 2 weeks after delivery. The dissection involved the left anterior descending artery (LAD) in two cases and the left main coronary artery in one case. There was no evidence of atherosclerosis on angiography or intracoronary ultrasound in any of the patients. Two of the women were treated by stent implantation with excellent results. This is the first known report of successful coronary stenting of spontaneous coronary artery dissection. The pregnant woman was not a candidate for stent implantation and underwent implantation of the left internal mammary to the LAD without cardiopulmonary bypass. She completed her pregnancy uneventfully.

Postpartum thyroid dysfunction

Four disorders of the postpartum period are associated with thyroid dysfunction. The most common is PPT. Although recovery from thyroid dysfunction often occurs in PPT, many patients eventually develop permanent hypothyroidism. Postpartum Graves' Disease is less common than PPT, but it is not unusual. Whereas antithyroid drugs are indicated for postpartum Graves' Disease, they are not useful in PPT. Although they are rare, lymphocytic hypophysitis and postpartum pituitary infarction are important entities because they cause deficiencies of many critical hormones. The autoimmune nature of PPT, postpartum Graves' disease, and lymphocytic hypophysitis highlights the unique effects of pregnancy on the immune system.

Arterial ischemic strokes associated with pregnancy and puerperium

Physiological changes occurring during pregnancy and puerperium may increase the risk of stroke. However, the incidence rate of ischemic stroke is of 3.8 to 5 in 100,000 pregnancies, i.e. quite similar to that of ischemic strokes occurring in non pregnant women of child bearing age. Whereas eclampsia, choriocarcinoma and amniotic emboli occur only during pregnancy or puerperium, peripartum cardiomyopathy and benign cerebral angiopathy are less specific. All other causes of cerebral ischemia may also occur during pregnancy and puerperium. The management of an ischemic stroke should not differ between pregnant and non pregnant women of child bearing age. Strokes associated with pregnancy require a complete diagnostic work-up including angiography if necessary. Low doses of aspirin (60-80 mg/d) can be used after 3 months of pregnancy. Heparin is the anticoagulant of choice during pregnancy, but warfarin may be used between 13 and 36 weeks of gestation; heparin and warfarin can be used during breast feeding. There is no neurological reason to recommend a systematic use of cesarean section. Subsequent prescription of oral contraceptive therapy is not recommended except in patients with a definite cause of ischemic stroke which is not influenced by hormones.

Co-ordinated care for women with postnatal depression

In many cases, postnatal depression is not identified or treated early enough, often as a result of poor co-ordination between the health professionals involved. This article outlines a project to develop multidisciplinary working to improve the care provision for women with postnatal depression.

Anal canal pressures are low in women with postpartum anal fissure

BACKGROUND

Anal sphincter hypertenia is commonly thought to underlie development of anal fissure, yet anal fissure is particularly common after childbirth, a time when anal canal pressure may be reduced. This paradox was investigated by a prospective study of the effect of parturition on the pelvic floor.

METHODS

Anal manometry was performed 6 weeks before and after delivery in 209 primigravid women with no pre-existing history of anorectal disease. Postpartum studies only were performed on a further 104 primiparae. Anal fissure was diagnosed by history and direct examination.

RESULTS

Some 29 women (9 per cent) developed postpartum anal fissure. Antepartum anal canal resting and squeeze pressures were similar in women who did and those who did not develop fissure. Resting and squeeze anal canal pressures decreased post partum in both groups. Postpartum constipation was more common in those with fissure (62 per cent) than in those without (29 per cent) (chi 2 = 10.6, 1 d.f., P < 0.01). The mode of delivery or use of epidural analgesia did not affect the incidence of fissure.

CONCLUSION

Postpartum anal fissure is associated with reduced anal canal pressures, and surgical interference with the anal sphincter mechanism should be avoided.

Post partum psychosis: a clinical study

In this study of 192 cases of post partum psychosis, the mean age of cases was 24.2 years. A past history of post partum psychosis was present in 16 cases (8.3%). As per the RDC categories, a majority of patients had unspecified functional psychosis and developed psychosis after the birth of first child. There was a positive correlation between the birth of female child and psychosis. The majority of cases developed psychosis within first 2 weeks after delivery. There were several other statistically significant differences when these cases were compared with non-puerperal, disease-matched controls.

Postpartum bilateral subdural hematomas following spinal anesthesia: case report

BACKGROUND

Intracranial subdural hematoma is an exceptionally rare complication of spinal anesthesia. We report a case of this infrequent event and consider the influence of cerebral atrophy as a predisposing factor.

METHODS AND RESULTS

This 18-year-old woman with severe headaches was admitted to the hospital 42 days after delivery. She had a history of normal pregnancy and uneventful labor and delivery. The epidural anesthesia was satisfactory. Computed tomography showed bilateral chronic subdural hematomas that were surgically removed. An early follow-up scan showed marked resolution of the hematomas and a small sized brain with large subarachnoid space. A late follow-up scan confirmed the diagnosis of brain atrophy.

CONCLUSIONS

Persistence of headache and gradual progression despite treatment must be regarded as a sign of intracranial complication following spinal anesthesia. In this case, cerebral atrophy is considered to be a contributory factor for the development of subdural hematoma following dural puncture.

Placenta praevia accreta with delayed hysterectomy

A case of placenta praevia accreta is described. Delivery was achieved by Caesarean section and the placenta was left in place because of the risk of haemorrhage. Successful internal iliac artery embolization was performed 9 days postpartum to control uterine bleeding. Hysterectomy was performed at 55 days postpartum because of bleeding and sepsis.

Postpartum cerebral vasospasm treated with hypervolemic therapy

In a 23-year-old woman, gravida 1, para 1-0-0-1, headaches and seizures developed 1 week after an uncomplicated delivery. Cerebral angiography revealed severe, diffuse cerebral vasospasm. Her symptoms resolved with hyperosmolar, hypervolemic therapy and nimodipine. Magnetic resonance angiography on postpartum day 23 confirmed persistent, severe vasospasm, and repeat magnetic resonance angiography on postpartum day 33 demonstrated interval improvement. This report documents the time course of a case of postpartum vasospasm and its response to hypervolemic, hyperosmolar therapy and nimodipine.

[Perinatal maternal emergencies]

The perinatal period (from the 28th week of pregnancy to the 28th day after delivery) is a short but special period which endangers the mother's and child's life. There has been no elective statistical assessment of this period but surveys conducted in western countries show that most of the maternal emergencies requiring admission to an intensive care unit are actually those of the perinatal period; some are specific of pregnancy: gravidic toxemia, delivery hemorrhage, acute fatty liver of pregnancy; others such as septic or embolic shock, cardiomyopathy, are found also in non-pregnant women but are favored by pregnancy. Among the numerous eventualities it was necessary to take a selection: ours results from three sorts of considerations: i) the severity of some of these perinatal emergencies: preeclampsia, eclampsia, Hellp syndrome, subcapsula hepatic rupture, septic or hemorrhagic shock are among the most serious ones; ii) the high frequency of some of them: post partum hemorrhage is, in France, the first cause of maternal mortality and the second cause of maternal morbidity whereas infection which can bring a septic shock is found to complicate one to eight per cent of the deliveries; iii) several emergency conditions raise pathophysiological problems which are still not entirely solved, for instance, gravidic toxemia, acute fatty liver of pregnancy, amniotic embolism. They will be especially studied here. Maternal perinatal emergencies remain a major public health problem. It is a necessity to realize the importance of the stakes, to encourage a team spirit, to combine the abilities of obstetricians, intensive care physicians, anaesthesists, echographists, biologists, so that this race against time can be won.

Acute puerperal mastitis in the augmented breast

Acute puerperal mastitis is an inflammatory condition of the breast with an onset 2 to 3 weeks postpartum and often complicated by abscess formation in the affected breast if treatment is delayed. This case demonstrated a periprosthetic seroma in a patient who developed acute puerperal mastitis in the augmented breast that has not been described previously. Treatment of acute puerperal mastitis includes antistaphylococcal antibiotic coverage within the first 48 hours, with ultrasound examination in the presence of persistent induration, swelling, or tenderness to diagnose breast abscess. Plastic surgeons performing breast augmentation need to be aware of this entity.

Acute myocardial infarction during pregnancy and puerperium: a review

The purpose of this review is to analyze the possible parameters that lead to the development of what is a rare event--acute myocardial infarction (AMI) during pregnancy and puerperium. Through the Index Médicus, 109 publications on the subject were obtained. Since the first well-documented case by Katz in 1922, 136 patients have been reported, and from these reports the following data have been gathered: the average age was 32.1 years. This event is more frequent during the third trimester and puerperium of the first and second pregnancies. In 42.6% of the patients no coronary risk factors were observed, but when present, hypertension and cigarette smoking were the most common. The anterior wall along or in combination with any other anatomic area was affected in 73% of cases. Coronary angiograms, when taken, appeared normal in 47%. The maternal mortality rate was 26/136 (19.1%) and was higher during the third trimester, labor, and puerperium. Eight patients (8/26) (30.7%) had sudden death. In 5 of these, (62.5%) coronary thrombosis was found. In 18/26 deaths, an autopsy was performed; 9/18 (50%) had coronary thrombus formation and in 7/18 (39%) variable degrees of atherosclerosis were detected. On the other hand, the fetal mortality rate was 16.9%; however, in only 52% was death coincidental with that of the mother. Coronary artery spasm associated with a probable hypercoagulability state was the most likely mechanism in the majority of these patients, followed by atherosclerotic heart disease and coronary dissection-the last being secondary most likely to hormonal changes. During the AMI these patients should be studied by a medical team composed of a cardiologist, gynecologist, and anesthesiologist. A complete cardiologic work-up should be made to decide individually about further pregnancies.