[Diagnosis and treatment of hemophilia A acquired during postpartum ]

Acquired hemophilia A is a truly exceptional hemorrhagic diathesis, that consists of the emergence of polyclonal autoantibodies (inhibitor) IgG-type (subclasses 1 and 4, in most cases) against the coagulant function of the circulating factor VIII, which acts in the domains C2, A2 and A3 of the molecule, thus interfering their interaction with the factor IXa, the phospholipids and the Von Willebrand factor. Its morbidity and mortality are high, but nevertheless its low incidence (1-1.5 cases per million population per year) is the most frequent autoimmune disorder. This paper reports the clinical case of two patients; the first one, 36 years old, who the tenth day of postpartum required re-entry due to a diagnosis of hematoma of the abdominal wall that was surgically drained twice. The patient of case 2 was 39 years old and at six days of postpartum went to the emergency room due to bleeding, she was underwent to curettage and therapeutic transfusion of 3 UCH. Because of the persistence of bleeding, which was not possible to control with medical treatment and conservative measures, therapeutic hysterectomy was performed, with blood transfusion later. Due to the hemorrhagic complications of this condition and the serious clinical consequences derived from them, it is important to establish an early diagnosis; it is therefore critical to know the existence of this very rare disease to be able to avoid its consequences.

Posterior reversible encephalopathy syndrome complicating postpartum eclampsia in a Nigerian: case report

AIMS AND OBJECTIVES

This is a case of posterior reversible encephalopathy syndrome (PRES) associated with postpartum eclampsia in a primiparous Nigerian.

CASE PRESENTATION

A 20-year-old primiparous woman presented to the emergency unit of the department of obstetrics and gynaecology of our hospital with symptoms and signs consistent with postpartum eclampsia. While being managed for this, she developed weakness of the left limbs with associated altered sensorium. Significant findings on physical examination were hypertension, left-sided hemiparesis and cortical blindness. She had a computed tomographic (CT) scan of the brain which showed features consistent with posterior reversible encephalopathy syndrome. She was given full supportive care with control of her blood pressure and she made a significant improvement. She was discharged home about 3 weeks after admission with improvement in clinical condition and is currently being followed up in our neurology clinic.

CONCLUSION

PRES complicating eclampsia is a clinicoradiological diagnosis. In most cases neurological symptoms improve with good supportive care and adequate treatment of the underlying condition as was the case in this patient. However permanent neurological sequelae can result from delayed diagnosis and treatment; therefore a high index of suspicion, early diagnosis and treatment are essential.

[Enteral oxygenation in complex treatment of anaerobic septic shock in postpartum woman]

Purpose of the clinical case demonstration is to attract the professionals' attention to the method of enteral oxygen therapy successfully used in the complex intensive therapy of septic shock in young postpartum woman.

Friable coronary arteries are link between pathogenesis and treatment of spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is increasingly being diagnosed as the cause of an acute coronary syndrome, especially in young patients. We report the case of a 32-year-old woman with postpartum SCAD of the left main and left anterior descending coronary artery which required the implantation of two drug-eluting stents. We present a literature study that correlates the pathogenesis of SCAD to the treatment options. Non-atherosclerotic SCAD is clearly associated with connective tissue disorders, vasculitis, and the peripartum period with its hormonal and haemodynamic changes. The coronary arteries of these SCAD patients are friable and should be approached with caution. Percutaneous coronary intervention has a reported success rate of only 65% and may cause propagation of the dissection. Lately, more and more authors suggest the possibility of a conservative approach in the absence of remaining cardiac ischaemia, even in this era of percutaneous stent implantation.

Safety of treatment of obsessive compulsive disorder in pregnancy and puerperium

QUESTION

My patient is 3 weeks postpartum and has experienced repetitive checking and washing of her newborn as a result of obsessive concerns with the newborn's safety. Should I refer her for a psychiatric assessment to rule out obsessive compulsive disorder (OCD) or should I reassure her that her behaviour is normal?

ANSWER

Current data suggest that pregnancy and the postpartum period are times of high risk of OCD onset and exacerbation. The presenting symptoms of OCD overlap with normal concerns and behaviour during the perinatal period; however, an undiagnosed or untreated disorder could have adverse consequences for both the mother and her newborn. Therefore, it is strongly recommended that this patient undergo screening and psychiatric assessment in order to be appropriately managed.

Characteristics of postpartum pain associated with vaginal and caesarean births

BACKGROUND

It is desirable that nursing mothers should return to normal activities so as to encourage early care of the newborn. This desire will be met if the common postpartum maternal morbidities are identified and managed accordingly.

OBJECTIVE

To identify and characterize postpartum pain in the immediate postpartum period after vaginal or caesarean birth.

METHODS

Women who delivered in our hospital; over 18 years, delivered of a live neonate and were in hospital for at least 2 days were studied. The socio-demographic characteristics, site of pain and self report of pain were recorded. The mothers were interviewed to describe the nature of postpartum pain using the Short-Form McGill Pain Questionnaire.

RESULTS

A total of 116 patients participated in the study; 50/116 were nulliparous, and 100/116 received prenatal care. The incidence of pain was 82.8%. 55/74 women who had vaginal delivery and 41/42 post c-section women had pain. Only 51/96 women reported their pain and a good proportion of the women received some form of analgesia for the pain. Post c-section women were more likely to use affective descriptors than those who had vaginal delivery. The use of affective descriptors provoked higher VAS scores.

CONCLUSION

Pain in the immediate postpartum period is common and more severe in women who had caesarean section than vaginal delivery. There is need to improve current methods of managing postpartum pain in the sub-region.

Understanding and meeting the needs of women in the postpartum period: the Perinatal Maternal Health Promotion Model

A new model for the care of women in the postpartum focuses on the development of life skills that promote complete well-being. The year following childbirth is a time of significant transition for women. In addition to the physiologic changes associated with the postpartum period, a woman undergoes marked psychosocial changes as she transitions into a motherhood role, reestablishes relationships, and works to meet the physical and emotional needs of her infant and other family members. It is a time when women are vulnerable to health problems directly related to childbirth and to compromised self-care, which can manifest in the development or reestablishment of unhealthy behaviors such as smoking and a sedentary lifestyle. In addition to long-term implications for women, compromised maternal health in the postpartum period is associated with suboptimal health and developmental outcomes for infants. Maternal health experts have called for a change in how care is provided for women in the postpartum period. This article presents the rationale for a health promotion approach to meeting the needs of women in the postpartum period and introduces the Perinatal Maternal Health Promotion Model. This conceptual framework is built around a definition of maternal well-being that asserts that health goes beyond merely the absence of medical complications. In the model, the core elements of a healthy postpartum are identified and include not only physical recovery but also the ability to meet individual needs and successfully transition into motherhood. These goals can best be achieved by helping women develop or strengthen 4 key individual health-promoting skills: the ability to mobilize social support, self-efficacy, positive coping strategies, and realistic expectations. While the model focuses on the woman, the health promotion approach takes into account that maternal health in this critical period affects and is affected by her family, social network, and community. Clinical implications of the model are addressed, including specific health promotion strategies that clinicians can readily incorporate into antepartum and postpartum care.

[Illustrated literature review of peripartum cardiomyopathy]

Peripartum cardiomyopathy is defined by the development of heart failure with left ventricular systolic dysfunction at the end of pregnancy or in the months following childbirth. Its diagnosis remains difficult due to lack of specificity. Its pathophysiology is still imperfectly understood, but involves both genetic and pregnancy related factors. From a therapeutic viewpoint, the recommendations of the European Society of Cardiology on heart failure are used, but the stage of pregnancy must be taken into account for the treatment choice. The chances of recovery are greater than in other non-ischemic cardiomyopathies. However, an early diagnosis remains crucial to increase the probability of recovery particularly with bromocriptine, which has shown positive results in recent years.

Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of interventions to improve the mental health of women in the perinatal period and to evaluate any effect on the health, growth and development of their offspring, in low- and middle-income (LAMI) countries.

METHODS

Seven electronic bibliographic databases were systematically searched for papers published up to May 2012 describing controlled trials of interventions designed to improve mental health outcomes in women who were pregnant or had recently given birth. The main outcomes of interest were rates of common perinatal mental disorders (CPMDs), primarily postpartum depression or anxiety; measures of the quality of the mother-infant relationship; and measures of infant or child health, growth and cognitive development. Meta-analysis was conducted to obtain a summary measure of the clinical effectiveness of the interventions.

FINDINGS

Thirteen trials representing 20 092 participants were identified. In all studies, supervised, non-specialist health and community workers delivered the interventions, which proved more beneficial than routine care for both mothers and children. The pooled effect size for maternal depression was -0.38 (95% confidence interval: -0.56 to -0.21; I (2) = 79.9%). Where assessed, benefits to the child included improved mother-infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates.

CONCLUSION

In LAMI countries, the burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists. Such interventions benefit both women and their children, but further studies are needed to understand how they can be scaled up in the highly diverse settings that exist in LAMI countries.

Use of electroconvulsive therapy (ECT) in postpartum psychosis--a naturalistic prospective study

Postpartum psychosis (PPP) is a severe psychiatric condition requiring rapid restoration of health in view of significant risks to both mother and the infant. Electroconvulsive therapy (ECT) is often used for treatment of severe PPP. The aims of the study were to describe the indications for ECT among women admitted with PPP to a psychiatric hospital in India. It also aimed at assessing whether women with PPP who received ECT differed in their clinical history, diagnosis, severity of illness, psychopathology, drug dosage, and duration of hospital stay, compared to women who did not receive ECT. Infants of mothers who were breast-feeding their infants while receiving ECT were assessed for adverse effects. This was a naturalistic prospective study of 78 women admitted with PPP, 34 (43.6 %) of whom received ECT. Presence of catatonia, augmentation of medications, and suicidality were common indications for ECT. Catatonic symptoms were significantly higher among women who received ECT. There was no significant difference in duration of hospitalization or severity of psychopathology between women who did and did not receive ECT. Transient side effects to ECT were observed in few women, with no adverse effects noted in infants who were breast-fed. The current study supports the use of ECT as an effective and safe treatment for women with severe PPP.

Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis

OBJECTIVES

Women who experience postpartum psychosis (PP) seek guidance on further pregnancies and risk of illness; however, empirical data are limited. This study describes reproductive and mental health outcomes in women diagnosed with PP and examines clinical risk factors as predictors of further illness.

METHODS

A retrospective cohort design was used; 116 women who experienced episodes of mania or depression with psychotic features within six weeks of childbirth were recruited. All subjects underwent clinical diagnostic interviews and medical case notes were reviewed.

RESULTS

Only 33% of women had an antecedent history, of which 34% had bipolar disorder and 55% unipolar depression. Only 58% of those with PP in their first pregnancy had a subsequent pregnancy, and 18% of marriages ended following the PP episode. Clinical presentation at the time of initial episode did not influence the timing of the onset of symptoms, treatment, or recovery. Although 86% of patients received treatment within 30 days of onset, 26% of women reported ongoing symptoms at a year after delivery. The recurrence rate of PP was 54.4%; a longer duration of the index episode (p < 0.05) and longer latency between the index PP and next pregnancy predicted a subsequent PP. The rate of subsequent non-puerperal episodes was 69%, and all these episodes were bipolar.

CONCLUSIONS

Postpartum psychosis is difficult to predict in women with no antecedent history and is associated with a high rate of subsequent puerperal and non-puerperal illness. Risk of further illness needs to be conveyed in order to allow fully informed decisions to be made regarding future pregnancies.

Stroke and pregnancy: clinical presentation, evaluation, treatment, and epidemiology

Stroke is a neurological emergency that carries a risk of morbidity and mortality. Recent studies have shown that the incidence of stroke, although rare, is increasing in pregnant females. In this review, stroke and other vasculopathies in the pregnant and postpartum female are examined. A discussion of the symptoms and clinical presentation of stroke is provided and the current guideline for treatment of stroke in pregnancy. Finally, the data illustrating the recent increases in stroke incidence are outlined.

Auto-immune hepatitis following delivery

Auto-immune hepatitis first presenting in the early postpartum period is rare. Immunosuppressive effects of pregnancy result in delayed manifestation of auto-immune hepatitis, and in established cases, the spontaneous improvements are there. Auto-immune hepatitis should be considered in the differential diagnosis of liver dysfunction first presenting in the early postpartum period. A case of postpartum hepatitis of auto-immune aetiology is being presented here. It is disease of unknown aetiology, characterised by inflammation of liver (as evidenced by raised serum transaminases, presence of interface hepatitis on histological examination), hypergammaglobulinaemia (> 1.5 times normal), presence of auto-antibodies [(antinuclear antibodies (ANA)], smooth muscle antibody (SMA) and antibody to liver-kidney microsome type 1 (LKM1) in the absence of viral markers ie, hepatitis B (HBsAg) and C (AntiHCV) and excellent response to corticosteroid therapy.

Back to back: postnatal osteopathic care

There is growing recognition of the role that osteopathy can play in the treatment of women during pregnancy (King et al 2003; Sandler 1996; Green 2000). It is usual for the osteopathic training colleges to run a pregnancy clinic and give students the opportunity to focus on the particular changes the body will go through from a neuro-musculo-skeletal view point during this unique period of a woman's life. Also, osteopathy can help make a difference in a woman's overall antenatal care by using gentle procedures to help alleviate many common pregnancy related ailments. A recent literature review (Lavelle 2012) found that this included not only relief of pain for a variety of musculoskeletal conditions but also a reduction in the duration of labour and the avoidance of some complications of labour. To date, there has been less of a focus on what osteopathy can provide women postnatally; indeed, within the profession, there has been little research carried out in this area. However, many osteopaths are confident in the results they can achieve working with postnatal mothers, based on a sound working hypothesis of osteopathic principles.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy of unknown aetiology associated with significant mortality and morbidity and characterized by heart failure in late pregnancy or puerperium. Recently PPCM workshop committee has recommended inclusion of echocardiographic features of LV dysfunction to redefine PPCM. Subsequent pregnancies are associated with a very high mortality in these patients and hence should be avoided. Women with PPCM continue to have significant mortality despite the use of conventional drugs for managing heart failure. Use of newer drugs such as immunoglobulin, pentoxifylline, bromocriptine, and cabergoline along with newer interventions such as plasmapheresis, immunoadsorption, ventricular assist devices and last but not the least the heart transplantation hold promise for future.

[Pregnancy-Associated Breast Cancer: An analytical observational study]

BACKGROUND AND OBJECTIVE

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy and up to one year postpartum.

PATIENTS AND METHOD

A retrospective, analytical, observational study comparing 56 cases of breast cancer and pregnancy (PABC) diagnosed 1976-2008 with 73 patients with breast cancer not associated with pregnancy (non-PABC) was performed. Demographic data, prognostic factors, treatment and survival were reviewed and compared.

RESULTS

The prevalence of PABC in our center is 8.3/10,000. The highest frequency (62%) appeared during the postpartum period. The stages are higher in PABC, being 31.3% advanced (EIII and EIV) in PABC versus 13.3% in non-PABC (P < .05). Regarding prognostic factors, 27.3% in PABC had a tumoral grade 3 versus 15.8% of non-PABC. Among women with PABC, 33.3% had negative estrogen receptors, 48.7% negative progesterone receptors and 34.5% positive Her2Neu compared with 22.2, 24.1 and 31%, respectively of non-PABC patients. Finally, positive lymph nodes were found in 52.8% of PABC, versus 33.8% non-PABC (P < .05). Overall and disease-free survival rate at 5 years for PABC was 63.7 and 74.2%, respectively.

CONCLUSIONS

The poorer survival observed is possibly due to the presence of adverse prognostic features such as lymph node metastases, negative hormone receptors, tumoral grade iii, as well as a delay in diagnosis with a higher rate of advanced stages.

[Study of 14 cases of breast cancer and pregnancy]

INTRODUCTION

Breast cancer is diagnosed in pregnant women during pregnancy or the first year after childbirth, and is the second leading cause of death among women of reproductive age. We don't know the frequency of this disease or the characteristics of the women affected at the Juarez Hospital of Mexico. This paper analyzed the cases of pregnant women diagnosed with breast cancer treated in the Oncology Department over a period of 10 years (1990-2000).

METHODS

We performed a retrospective descriptive study of pregnant women diagnosed with breast cancer, treated at the hospital. Of the cases found, the following indicators were studied: maternal age, type of cancer, weeks of gestation at the time of diagnosis, resolution of pregnancy and perinatal outcome, and treatment monitoring. Descriptive statistics were performed using measures of central tendency and dispersion.

RESULTS

There were 14 cases of pregnant women with breast cancer. The mean age of patients was 28 years, with a mean of 23 weeks gestation at diagnosis. The resolution of pregnancy was favorable in 73% of cases. 78.6% of the patients were treated, 72.7% had follow-up for 2 years that found 62.5% of patients without tumor activity.

CONCLUSIONS

The frequency of pregnant women with breast cancer is low, affecting young people. The choice of treatment allowed the resolution of pregnancy and survival of women without tumor activity.

[Pregnancy and breast cancer]

INTRODUCTION

association of breast cancer and pregnancy is not common. The objective of this investigation was to evaluate the pregnancy, young age, stage, treatment, prognosis and mortality of women with breast cancer during pregnancy.

METHODS

retrospective analysis from March 1992 to February 2009, 16 patients were included with breast cancer and pregnancy. They were analized: histological characteristic of tumor, therapeutic response of the oncological treatment, evolution of the pregnancy. From of baby born: Apgar and weight. The woman's mortality with breast cancer during pregnancy was evaluated for age group and for interval of time between late pregnancy and diagnosis posterior of breast cancer and pregnancy.

RESULTS

characteristic predominant clinicohistological: stage III (81.2%), T3-T4 (75%), N+ 93.7%, invasive ductal carcinoma (87.5%), histological grade 2-3 (93.7%), receptor estrogeno positive (43.7%); RPpositive (25%); HER-2/neu positive (31.2%). 27 chemotherapy cycles were applied with 5-fluorouracil, epirubicin and cyclophosphamide during the second or third trimester of the pregnancy, there were not severe adverse effects for the mothers and the baby born exposed to chemotherapy. The mean time to disease recurrence was 18.8 months (range, 6-62 months). The rate of mortality for specific age (< 35 years) was of 31.3% (p = 0.358). From the 16 patients, 7 have died and 9 were live without evidence of disease.

CONCLUSIONS

the advanced stage and the number of affected axillary lymph node more than the age was predictors of worse pronostic influencing the relapse and mortality of the young patients with breast cancer and pregnancy.

[Diagnostics and correction of coagulopathy in pregnant women and puerperas with gestosis]

INTRODUCTION. Gestosis is a complication of normal pregnancy which for long years takes the 2-3rd place in maternal and perinatal mortality and women morbidity structure. 396 patients with moderate and heavy gestosis from 2007 to 2011 were studied. In 53 women (13.4%) it was accompanied by complex haemostasis disturbances and part of women had sepsis. Therefore the retrospective differential analysis of haemostasis disturbances with algorithm presented in this article was carried out. Haemostasis status, complete blood count, biochemical blood analysis data were analyzed. Correction of haemostasis disturbances in the postnatal period was performed according to legacy recommendations. As a result of retrospective differential diagnostics of haemostasis disturbances, the chronic disseminate intravascular clotting (DIC) syndrome, a HELLP-syndrome, thrombotic thrombocytopenic purpura (TTP) and a haemolytic uremic syndrome (HUS) were revealed. The received results indicate that in obstetrics there are essential difficulties with coagulopathy timely diagnostics, especially, TTP and HUS. The most difficult problem is differential diagnostics between a HELLP-syndrome, TTP and HUS. Clear algorithm of differential diagnostics appeared only in 2010. We analyzed all coagulopathy cases since 2007. TTP and HUS were diagnosed by 3rd days of the postnatal period, also specific therapy of these syndromes was late that was reflected in ICU length-of-stay, frequency of sepsis and need of uterectomy respectively.